Bonus Learning

Chest X-Rays and Pathology

When medical doctors are first taught to read chest x-rays.
Taught to scan an image and look for ALL abnormalities, don’t stop on the first
abnormality, mentally note all that you see on the first scan then go back and 1 by
1 to determine which of the below categories does the abnormality fall in?
1. Is something too white?
2. Is something too dark?
3. Is something too large?
4. Is something in the wrong place?
Next steps that physicians are taught:
1. What projection is this? AP or PA, this makes a difference on the size of the
heart because of OID on the AP. That could be easily mistaken as
cardiomegaly.
a. They are told if the scapulas are in the lung field, it is more than likely an AP (we know this
isn’t always true, but I thought it was interesting when I read that in a physician’s guide to
chest x-rays)
2. Orientation is the next thing they check to make sure the image is marked
correctly and displayed correctly. Dextrocardia (heart on the right side) is a
real thing, however, more commonly it is pathology shifting the mediastinal
structures.
3. Rotation - They are first and foremost taught to identify any asymmetry in the sc
joints To determine if there is rotation, and the side of the lung that is “whiter” is the
side further away from the IR.
4. Penetration- I thought this was an interesting way to determine penetration.
They are taught to look at the lower part of the cardiac shadow for vertebral
bodies. They are suppose to look barely visible in the lower part. If they are darker
than “barely visible”, it was over penetrated and low density lesions might be
missed. If you can’t see them at all, the image is under-penetrated and the lungs
will be too white.
5. Degree of Inspiration - The 10th posterior rib should be above the diaphragm. If
more than 10, the lungs are hyper-inflated and that could point to emphysema. If
underinflated, the heart will appear larger, appearing as cardiomegaly.
Lateral Chest X-Ray
Little trick I learned from the
Doctor’s guide for chest x-rays that
isn’t in your textbooks.
On a lateral chest x-ray, an easy
way to determine which hemi-
diaphragm you are looking at is that
the RIGHT hemi-diaphragm will be
visible all the way across the width
of the chest, as to where the left
appears to stop at the posterior
border of the heart.
Common Chest Pathologies
Pleural Effusion

Pleural Effusion: fluid buildup

between the lungs and the pleura that lines
the lungs.

Caused by:
Poor pumping of the heart (CHF)
Cancer
Pneumonia
Pulmonary embolism

Biggest indication on chest x-ray is

whiteness at the base of a lung, collapsing
the lung tissue.

Chest tube will be needed to drain fluid.

 Characteristics of a pneumothorax:
Pneumothorax
- Caused by air being trapped
between the visceral and parietal
pleura of lung.

- Pleural line

- No lung markings
Atelactasis - When there is a failure to aerate the lung through the alveoli
Characteristics of atelectasis on a chest x-
ray:

- Air bronchograms - tubular outlines of

the smaller airways
- Silhouette signs - obliteration of
normally clear outlines between lung
fields and adjacent structures.
- Crowding of pulmonary vessels
- Under inflation
- Hemidiagram is elevated
- Trachea deviates to side of
atelectasis
- Mediastinum deviates to side of
atelectasis
Consolidation - caused by infiltrates

Consolidation - a term you will hear a

lot when reading chest x-ray reports.

This is a term to denote when normal

air filled spaces are filled with
products of disease. These are the
“infiltrates”
- Blood
- Infection(Pus)
- Tumors
- Aspiration of fluid

Characteristics of consolidation are

large dense white area in lung that
you can still see some airspace (very
tiny and low density though)
COPD - Chronic Obstructive Pulmonary Disease
Emphysema and
Chronic Bronchitis are Characteristics on x-ray:
the most common Elongated lung fields.
causes of COPD.
Blunting (flattened)
Bronchitis - increased diaphragm.
mucus and
inflammation. Hyperlucency (black
areas) due to enlarged
Emphysema - air spaces.
Destruction and
enlargement of air
spaces.
Congestive Heart Failure Characteristics on x-ray:

Chest x-ray findings include

A chronic condition pleural effusions,
cardiomegaly (enlargement of
in which the heart the cardiac silhouette), Kerley
doesn't pump blood B lines (horizontal lines in the
as well as it should. periphery of the lower
posterior lung fields), upper
Heart failure can lobe pulmonary venous
congestion and interstitial
occur if the heart edema.
cannot pump
(systolic) or fill
(diastolic)
adequately.