NORMAL CHEST

X-RAY
Dr. Abhushan Siddhi Tuladhar
MBBS, MD
Associate Professor
Department of Radiodiagnosis
NMCTH
RADIODENSE

RADIOLUCENT
TODAY WE WILL DISCUSS ON

 NORMAL CHEST X-RAY

 COLLAPSE AND CONSOLIDATION

 BRONCHOGENIC CARCINOMA
CHEST X-RAY VIEWS

 PA VIEW IN FULL INSPIRATION

 LATERAL VIEW
 AP VIEW
 LORDOTIC VIEW
 DECUBITUS VIEW
 SUPINE
 OBLIQUE
 EXPIRATORY VIEW
 APICOGRAM
PA VIEW
LATERAL VIEWS
Lateral decubitus view
AP VIEW
 Scapulae overlie the
upper lungs
 Clavicles project more
cranially over the lung
apices
 Disc spaces of lower
cervical spine more
clearly seen
 Cardiac shadow enlarged
with blur cardiac borders
 VIEWING THE PA FILM
1. Request form name, age, date, sex, clinical
information
2. Technical centering, patient positioning,markers,
exposures
3. Trachea position, outline
4. Heart and
mediastinum size, shape, displacement
5. Diaphragms outline, shape, relative position
6. Pleura costophrenic,cardiophrenic angles
7. Lung fields Local, generalised
abnormalities, comparison of
translucency and vascular
markings of the lungs
8. Hidden areas Apices, mediastinum,
hila, bones
9.Hila density, position, shape
10.Below diaphragm gas shadow, calcifications
11. Soft tissues mastectomy, gas shadows
12. Bones lesions, fractures
REQUEST FORM

 Identification
 Date
 Clinical information
 Previous x-rays, CT, reports etc. for
comparison
TECHNICAL ASPECTS

 CENTERING – clavicles
equidistant from
spinous process at
T4 /T5 level
If spinous process appears closer to the right clavicle (red arrow), the
patient is rotated toward their own left side

If spinous process appears closer to the left clavicle (red arrow),

the patient is rotated toward their own right side
EXPOSURE / PENETRATION

 Underexposed films =
white
 Overexposed films = dark

 120-170 KVP at FFD of 6 ft

 Upper 4 dorsal vertebrae
seen
Overpenetrated Film
• Lung fields darker than
normal—may obscure
subtle pathologies
• See spine well beyond the
diaphragms
• Inadequate lung detail
 Underpenetrated Film
•Hemidiaphragms are obscured
•Pulmonary markings more prominent than they actually are
DEGREE OF INSPIRATION

 On full inspiration
 Anterior ends of 6 ribs
 Posterior ends of 10 ribs
Quality Control

 Inspiration 1

 Should be able to count 3

4
9-10 posterior ribs
5

6
 Heart shadow should
not be hidden by the 7

diaphragm 8

10
 Poor inspiration
can crowd lung
markings
producing pseudo-
8
airspace disease

About 8 posterior ribs are showing

With better inspiration, the

“disease process” at the lung
bases has cleared
9

9-10 posterior ribs are showing

MARKERS
R
 To differentiate right
and left side
 For anatomical
orientation
 Has role in dextocardia,
situs inversus
PATIENT POSITIONING

 Tilted
 Oblique
 Improper position
 Motion blur
TRACHEA

 Position
 Outline
 Carinal angle 60-750
 Right paratracheal
stripe
MEDIASTINUM / HEART

 Size
 Shape
 Displacement
 Mediastinal masses
 Cardiomegaly and chamber enlargement
 Valvular heart diseases, ASD, VSD, TOF
 Thymic shadow
 Cardiac Silhouette

1. R Atrium 4. Superior Vena Cava 7. Pulmonary Valve

2. R Ventricle 5. Inferior Vena Cava 8. Pulmonary Trunk
3. Apex of L Ventricle 6. Tricuspid Valve 9. R PA 10. L PA
DIAPHRAGMS

 Right higher than left

 – ? liver pushing right dome
 - heart pressing left dome
 > 3 cm is abnormal
 Full inspiration anterior 6 ribs
posterior 10 ribs
 Supine – higher
 Cardiophrenic angles
 Costophrenic angles
 Obscured in pleural diseases, pleural effusion
 Collapse / consolidation
 Diaphragmatic humps /slips/ tenting
 Gas under diaphragm
 Diaphragmatic hernia
 Eventration
FISSURES

 Horizontal fissure (MINOR FISSURE) runs

anteriorly and slightly downwards from hilum
to 6th rib in axillary line
 Oblique fissure (MAJOR FISSURE) runs from
T4/5 level, passes through hilum
 Right ends just behind the CP angle
 Left is steeper and ends 5 cm behind CP angle
ACCESSORY FISSURES

 Azygous fissure
 Superior accessory fissure
 Inferior accessory fissure
 Left sided horizontal fissure
COSTOPHRENIC ANGLES

 Acute angles and well

defined
 Obliterated in effusion,
thickening, mass
LUNG FIELDS

 Compare two lung fields

 Areas of abnormal translucency
 Uneven distribution of lung markings
 Abnormal shadows
 Location, extent
 Shape, size, outline, margin of the lesions
 Calcifications, cavitations
 Further lesions, displacement of normal
landmarks
 Composite shadow – superimposed normal
shadows of vessels, bones or cartilages
 Divided into upper, middle and lower zones in
each lung by lower border of first 2 ribs and
then by next 2 ribs.
 UPPER ZONES

MID ZONES

LOWER ZONES

RIGHT LEFT
HIDDEN AREAS

 Lung apices – obscured

by ribs, costal cartilages,
clavicles, soft tissues –
Pancoast tumour,
tuberculosis, cavities -
Apicogram helps
 Mediastinum and hila
 Diaphragms
 Bones / costal cartilages
HILA

 Left hilum 2.5 cm higher than right

 Hilar shadow of two sides should be of equal
density and similar size
 Should have well defined concave lateral
borders
 Hilar shadow is the shadow where upper
pulmonary veins meet lower pulmonary arteries
 Width of pulmonary artery 10-16 mm in male
 9- 15 mm in female
BELOW THE DIAPHRAGMS

 Pneumoperitoneum
 Abnormal gas shadows – dilated bowel loops
 Abscesses
 Chiladiti syndrome
SOFT TISSUES

 Chest wall
 Shoulders
 Neck
 Breast shadows - mastectomy
 Nipple shadows
 Skin folds – confused with pneumothorax
 Anterior axillary fold shadows – consolidation
 Sternocleidomastoid muscle – cavity in apices
 Companion shadow – over clavicles
BONES

 All bones should be surveyed

 Fractures / dislocations
 Diseases of bones
 Lung diseases affecting bones
 Can be confused with lung lesions
 Sternum / clavicles / scapulae / ribs / spine
LEFT UPPER LOBE COLLAPSE CONSOLIDATION
COLLAPSE AND CONSOLIDATION

 COLLAPSE
 Partial or complete loss of volume of lung
 Diminished volume of air / reduction of lung
volume
MECHANISMS OF COLLAPSE

1. Relaxation or passive collapse – pleural eff.

2. Cicatrization collapse – pulmonary fibrosis
3. Adhesive collapse – respiratory distress
syndrome
4. Resorption collapse – foreign body, Ca lung
RADIOLOGICAL SIGNS OF COLLAPSE

 DIRECT  INDIRECT SIGNS

1. Displacement of 1. Elevation of diaphragm

interlobar fissures 2. Mediastinal displacement
2. Loss of aeration 3. Hilar displacement
3. Vascular and bronchial 4. Compensatory
signs hypertrophy
 Lobar collapse
The lobes collapse in characteristic fashion:
 1. The upper lobes collapse upwards, medially and
anteriorly
 2. The middle lobe goes downwards and medially
 3. The lower lobes collapse posteriorly, medially
and downwards.
 Lateral view. The
The lesser fissure Collapse of the R upper lobe. upper lobe
moves upwards Opacity in the upper lobe, collapses
but remains silhouette sign upper mediastinum upwards,
pivoted at the R & upward displacement of the anteriorly, and
hilum medially lesser fissure. towards the
mediastinum.
Posteroanterior radiograph of the chest demonstrates the Golden S
sign. Note the convexity (arrowhead) from the mass and the
concavity (arrow) of the minor fissure
UPPER LOBE
COLLAPSE
 Lt upper lobe collapse

•Mediastinal shift to left

•Density left upper lung field
•Loss of aortic knob and left hilar silhouettes
Rt. middle lobe collapse. There is a Lateral view shows the middle
density next to the heart, below lobe collapse more clearly. The
the R hilum, which is roughly triangular opacity anteriorly is the
triangular in shape collapsed lobe
RML Atelectasis
 Lt lower collapse

Left diaphragm not visible 

Increased density over lower spine
 Plate atelectasis

 linear subsegmental atelectatic shadows at the

lung bases
CONSOLIDATION

 Implies replacement of air in one or more

acini by fluid or solid material
 Does not imply a particular pathology or
etiology
 Causes – pneumonia ,cardiogenic pulmonary
edema, non-cardiogenic pulmonary edema,
hemorrhage, aspiration, alveolar cell
carcinoma, lymphoma
AIR BRONCHOGRAM IN CONSOLIDATION

 When consolidation is associated with a

patent airway an air-bronchogram is seen
 Produced by the radiographic contrast
between the column of air in the airway and
surrounding opaque acinus
 Air bronchogram
 Visualization of air-filled bronchi surrounded by
air-less lung.

Normal lung. Bronchi not seen Bronchi visible because the air in the
surrounding alveoli has been
replaced by fluid.
Chest x-ray of a patient with right upper lobe
consolidation. Note the beautiful air-
bronchogram
 Indicates that the lesion is intrapulmonary.

 Seen in
 Pneumonia
 Pulmonary edema
 Hyaline membrane disease
 Alveolar cell carcinoma
 Lymphoma
 Radiation pneumonitis
Bilateral upper lobe consolidation
•Pulmonary edema
 Air alveologram
 Tiny areas of radiolucency within the surrounding air-
less lung
BRONCHOGENIC CARCINOMA

1. Squamous cell carcinoma – 30-50%

2. Adeno carcinoma (incl. Alveolar cell Ca) -
15-35%
3. Large cell carcinoma – 10-15%
4. Small cell carcinoma 20-30%
Ca LUNG RADIOLOGICAL FEATURES

1. Hilar enlargement – central lung mass, hilar

lymyphnode enlargement, mediasinal
lymphadenopathy
2. Airway obstruction – segmental or lobar collapse,
consolidation, secondary infection
3. Peripheral mass – peripheral mass, poorly defined,
lobulated or umbilicated or spiculated margin,
satellite lesions, doubling time (1- 18 months) (> 2
years in beingn lesions), cavitations – necrosis –
abscess, pancoast tumour in lung apices, metastatic
lesions (peripheral, subpleural and multiple)
4. Mediastinal involvement – mediastinal
lymphadenopathy, mediastinal widening, SVC
obstruction, esophageal invasion, phrenic nerve
palsy (elevated hemidiaphragm), pericarditis,
pericardial effusion
5. Pleural involvement – pleural effusion
6. Bone involvement – ribs, spine, osteolytic
lesions
ROLE OF RADIOLOGY IN Ca LUNG

1. Making diagnosis
2. Staging of tumour
3. Assessing treatment
MEDIASTINAL MASSES
Felson’s classification scheme
• On the lateral radiograph the anterior
and middle compartments can be
separated by drawing an imaginary line
anterior to the trachea and posterior to
the pericardium.

The middle and posterior

compartments can be separated by an
imaginary line passing 1 cm posteriorly
to the anterior border of the vertebral
bodies.

Thus, posterior mediastinum in this

defn essentially includes paravertebral
lesions.
Anterior Mediastinum

 The anterior mediastinum contains the

following structures:
 thymus,
 lymph nodes,
 ascending aorta,
 pulmonary artery,
 phrenic nerves and
 thyroid.
 The four T's make up the mnemonic for
anterior mediastinal masses:
 Thymus
 Teratoma (germ cell)
 Thyroid
 Terrible Lymphoma
Hilum Overlay Sign: hilar vessels are seen
through a mediastinal mass
Middle Mediastinum

 The middle mediastinum contains the

following structures:
 lymph nodes,
 trachea,
 esophagus,
 azygos vein,
 vena cavae,
 posterior heart and the aortic arch.
 The majority of middle mediastinal masses
consist of
 foregut duplication cysts (eg oesophageal
duplication or bronchogenic cysts) or
lymphadenopathy.

 Aortic arch anomalies can also present as middle

mediastinal masses.
Posterior Mediastinum

 The posterior mediastinum contains the

following structures:
 sympathetic ganglia,
 nerve roots,
 lymph nodes,
 parasympathetic chain,
 thoracic duct,
 descending thoracic aorta,
 small vessels and
 the vertebrae.
 Most masses in the posterior mediastinum
are neurogenic in nature.

 These can arise from the sympathetic ganglia

(eg neuroblastoma) or from the nerve roots
(eg schwannoma or neurofibroma).
SCHWANNOMA
 INTERESTING
CHEST
X-RAYS
Hemothorax
PA view: RML consolidation and loss of right heart silhouette
Lateral View: RML wedge shaped consolidation

RML pneumonia
 RUL infiltrate / consolidation, bordered by minor fissure inferiorly
Patchy LLL infiltrate that obscures the left hemidiaphragm; right and left heart
borders obscured

RUL and LLL pneumonia

Multiple bilateral cavitary lesions with air-fluid levels c/w pulmonary
abscesses

Tuberculosis
Well demarcated paucity of pulmonary vascular markings in right apex

Left spontaneous pneumothorax

RML consolidation that appears wedge shaped on lateral view

RML pneumonia
RLL infiltrate / consolidation

RLL pneumonia
Obscuring of the right and left heart borders; infiltrate at the bases

Bilateral aspiration pneumonia

Diffuse bilateral fluffy interstitial infiltrates

Pneumocystis carinii pneumonia

LUL pneumonia
Severe pulmonary TB
 Left lung opacity

Later diagnosed as lung cancer

Cardiomegaly, increased pulmonary vascular markings,
fluid in the horizontal fissure

CHF
What do the arrows indicate?
Kerley B Lines

Short (1 -2 cm) white

lines at the lung
bases, perpendicular
to the pleural surface
representing
distended interlobular
septa
ELEVATED RIGHT HEMIDIAPHRAGM
RIGHT HYROPNEUMOTHORAX
LEFT PLEURAL EFFUSION
LARGE RIGHT PLEURAL EFFUSION
AND COPD
PNEUMOTHORAX
TENSION PNEUMOTHORAX WITH
MEDIASTINAL SHIFT
RIGHT UPPER LOBE CONSOLIDATION / PNEUMONIA
BENIGN SOLITARY PULMONARY NDULE
THANK YOU.