CHEST X-RAY

Chest :
Goals : Recognize normal. Decide if there is
pathology.
Recognize life threatening cases which necessitate
immediate management and intervention.
The normal chest. Anatomy, quality, proper
positioning, penetration, supine versus standing,
infants, cardiothoracic ratio etc.
What to examine: Remember : heart size and shape,
lungs, mediastinum, diaphragm, thoracic cage.
Patterns of diseases : Lungs, increased density.
Pneumonia, pleural effusions, tumors, atelactasis,
cysts.
Radiolucent lesions : Emphysema, bullae,
pneumothoax, hypogenetic lung etc.
 CHEST , CV , RADIOLOGY

Anatomy:
– The heart is normal in size and shape.
– The lungs are clear.
– The mediastinum, diaphragm and thoracic
cage are intact.
 Recognizing
A Technically
Adequate Chest X-ray
Factors to Evaluate


Penetration

Inspiration

Rotation

Angulation
 Penetration

Barely see the

thoracic spine
through the heart.
Pitfall Due to Underpenetration

If the film is underpenetrated, the left hemidiaphragm (and

left lung base) will not be visible and the pulmonary
markings will appear more prominent than they actually are
 Inspiration

About 10 posterior ribs visible is an

excellent inspiration, 7 anterior ribs.
In many hospitalized patients 9 posterior
ribs is an adequate inspiration
 Anterior vs. Posterior Ribs

Anterior ribs
Posterior ribs will be visible
are those that but are
are most harder to see.
apparent on They run
more or less
the chest x- at a 45 degree
ray. They run angle
more or less downward
toward the
horizontally. feet.

How to tell the difference between

the anterior and the posterior ribs
Ten posterior ribs showing is an
excellent inspiration

Ten posterior ribs showing is an excellent

inspiration
Pitfall Due to Poor Inspiration

Poor inspiration will crowd lung markings and make

it appear as though the patient has airspace disease
Same patient

Better inspiration and the “disease”

at the lung bases has cleared
 Rotation
If the spinous
process of the
vertebral body is
equidistant from
the medial ends of
each clavicle, there
is no rotation
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 
Pitfall Due to Marked Rotation

Severe rotation may make the pulmonary arteries

appear larger on the side farther from the film
 AP versus PA
The Effect of Magnification

– In a PA film, the heart is closer to the film

and thus less magnified.
– The standard chest x-ray is the PA film.
– In an AP film, the heart is farther from the
film and is more magnified.
– Portable chest x-rays are almost always
done AP.
 AP versus PA
The Effect of Magnification

AP portable film makes the On this PA film done on

heart look larger than it the same patient an
does. hour later
 Angulation

Angulation
If the x-ray beam is angled toward the
head (mostly because the patient is
semi-recumbent), the film so obtained
is called an “apical lordotic” view
Anterior structures (like the clavicles)
will be projected higher on the film than
posterior structures
 Pitfall Due to Angulation

A film which is apical lordotic (beam is angled up toward head) will

have an unusually shaped heart and the sharp border of the left
hemidiaphragm will be absent
 Important Points

– Factors to determine the quality of chest

x-ray are:
– Penetration – see spine through the heart
– Inspiration – at least 8-9 posterior ribs
– Rotation – spinous process between
clavicles
– Angulation – clavicle over 3rd rib
What is technically wrong with
each of the following images?
What is most wrong with this image
(check any that apply)?

Penetration
Inspiration
Rotation
Angulation
Correct
The image is apical
lordotic- look at the
high position of the
clavicles. It is also
underpenetrated.
You can’t tell if its
rotated and the
degree of
inspiration is
adequate.
What is most wrong with this image
(check any that apply)?

Penetration
Inspiration
Rotation
Angulations
Correct

The patient has

taken a poor
inspiration. He is
also rotated toward
his own right. It is
slightly
underpenetrated and
he is not angulated.
What is most wrong with this image
(check any that apply)?

Penetration
Inspiration
Rotation
Angulation
Correct
The film is
underpenetrated. You
can’t see the spine
through the heart . The
degree of inspiration is
probably adequate.
Rotation can not be
evaluated and there is a
slight amount of
angulation. Incidentally,
there is a large
bronchogenic ca in the
left lung.
What is most wrong with this image
(check any that apply)?

Penetration
Inspiration
Rotation
Angulation
Correct

The primary technical

problem here is the
patient is rotated
considerably toward
her own left side. Notice
how the hemidiaphragm
appears elevated on the
side to which the
patient is rotated (red
arrow).
 One of the easiest
Cardio-thoracic observations to make is the
Ratio cardio-thoracic ratio which
is the widest diameter of the
heart compared to the
widest internal diameter of
the rib cage

<50%
The Cardiac Contours

Aortic knob
Ascending Aorta

Main pulmonary
“Double density” artery
of LA enlargement Indentation for
LA
Right atrium
Left ventricle

But only the top five are really important

in making a diagnosis.
Normal Increased Flow
Recognizing
Congestive
Heart Failure
Congestive Heart Failure
Common Causes of


Coronary artery disease

Hypertension

Cardiomyopathy

Valvular lesions

AS, MS

L to R shunts
Congestive Heart Failure
Clinical


Usually from left heart failure

Shortness of breath

Paroxysmal nocturnal dyspnea

Orthopnea

Cough

Right heart failure

Edema
 Congestive heart failure.
3 stages:
– congestion : upper lobe diversion “
cephalization”, arterial bronchial ratio “ blood
vessels become larger than near by bronchus”
distinctness, “peri vascular haze”.
– Interstitial edema: B and C lines of Kerley fluid
in the fissures and pleural effusions.
– Air space edema “ alveolar edema”.
 Congestive Heart Failure
Secondary Four Signs of Pulmonary interstitial
edema


Thickening of the interlobular septa

Kerley B lines

Peribronchial cuffing

Wall is normally hairline thin

Thickening of the fissures

Fluid in the subpleural space in
continuity with interlobular septa

Pleural effusions
 Kerley B Lines


B=distended interlobular septa

Location and appearance

Bases

1-2 cm long

Horizontal in direction

Perpendicular to pleural surface
Multiple Kerley B lines
at the left lung base
These are faint whites
lines perpendicular to
the pleural surface and 1-
2cm long
 Kerley A and C Lines


A=connective tissue near bronchoarterial
bundle distends with fluid

Location and appearance

Near hilum

Run obliquely

Longer than B lines

C=reticular network of lines

C Lines probably don’t exist
Intersecting
network of lines
are Kerley A lines
in proper clinical
setting
Numerous small circular
“doughnuts” seen in lung
represent fluid in
bronchial walls when
seen in conjunction with
other signs of CHF
Fluid in the minor
fissure
Fissures may be seen
normally but are usually
no thicker than the point
of a sharpened pencil
CHF


There is diffuse
airspace
(alveolar)
disease which
has somewhat
of a “bat-wing”
appearance
CHF


There are
Kerley A
and B lines
at the right
lung base
and a small
right
effusion
CHF


There are Kerley B lines
visible at both lung bases
 Important Points


The four reliable signs of CHF are:

Kerley B lines

Fluid in the fissures

Peribronchial cuffing

Pleural effusion

NOT cardiomegaly

NOT cephalization

The Solitary Pulmonary Nodule
An Approach
 Uncalcified lesion with
extrapulmonary malignancy


Nodule could be

Solitary metastasis

New primary

Benign nodule

Manage with biopsy; resection may be considered
if no other lesions are demonstrated
Solitary Pulmonary Nodule
Five groups


Benign by virtue of clinical course

Benign by virtue of characteristic ca++

Benign by virtue of stability on serial films

Uncalcified and growing or no old films

Extrapulmonary malignancy
Solitary Pulmonary Nodule
Factors in determining malignancy


Calcification

Growth

Location

Size

Margin

Cavitation
Solitary Pulmonary Nodule
Calcification


Laminated granuloma

Target histoplasmoma

Popcorn hamartoma

No other calcification is benign
Solitary Pulmonary Nodule
Calcification


CT 33% more accurate in finding
calcification than plain films

Same rules for benign calcifications
apply to CT

Malignancies enhance >20 HU after IV
contrast
 Solitary Pulmonary Nodule
Growth


A nodule that is stable for 2 years is almost
always benign

Doubling time-a 25% increase in diameter of
nodule = 1 double in volume

Most malignancies double in 6 weeks to 16
months

Some, like osteosarcoma, choriocarcinoma and
testicular ca can double faster
 Solitary Pulmonary Nodule
Location


More cancers are located in the upper than
lower lobes
Solitary Pulmonary Nodule
Size


Small lesions tend to be benign

Over 80% of lesions > 5cm are malignant
 Solitary Pulmonary Nodule
Margin


Ca tends to have ill-defined borders

Hamartomas and tuberculomas are usually
well-defined

A notch in the margin (Rigler’s notch) is
sign of benignancy
 Solitary Pulmonary Nodule
Cavitation


Both benign and malignant lesions
cavitate

Ca tends to be thick-walled and nodular
 Solitary Pulmonary Nodule
Truisms


SPN in a patient with known
extrapulmonary malignancy is more often 1°
lung ca than met

Malignant nodules are more symptomatic
than benign ones but most malignant
nodules are asymptomatic
William Herring, M.D. © 2002

Recognizing
A Pneumothorax

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 Remember


There are two layers of pleura- parietal and
visceral-the pleural space between them

Normally there is no air in the pleural
space

The visceral pleura is inseparable from the
lung parenchyma and moves with the lung
Visceral
pleura

Parietal Pleural
pleura space

© Frank Netter, MD Novartis®

The Visceral Pleural White Line


When air enters the pleural space, the
parietal and visceral pleura separate
making the visceral pleura visible

The thin white line of the visceral pleura
is called the visceral pleural white line

You must see the visceral pleural white
line to make diagnosis of pneumothorax!
A pneumothorax
will be visible as a
thin white line -
the visceral pleural
white line. Absent
lung markings
superior to the
white line.
 Lung Markings


Absence of lung markings is not sufficient
to make diagnosis of pneumothorax!
 Simple Pneumothorax


In a simple pneumothorax, there is no
shift of the heart or mediastinal
structures (trachea)

Air in left hemithorax balances the air
in the right hemithorax
 Tension Pneumothorax


Progressive loss of air into pleural space
causing a shift of the heart and mediastinal
structures away from side of pneumothorax

Opposite lung is compressed

Respiratory function severely compromised
 Shift of
Complete right- heart and
sided trachea to
pneumothorax left

Lung is
compressed
against
mediastinum
Simple or Tension Pneumothorax

Tension pneumothorax-heart is shifted slightly

to right by large left-sided pneumothorax
 Tension Pneumothorax

© Frank Netter, MD Novartis®

Air enters Right hemithorax either from tear in lung or hole in chest
wall on inspiration; does not exit on expiration
Simple pneumothrax


The visceral pleural
white line is seen and
there are no lung
marking distal to it.
This is a simple
pneumothorax since
there is no shift.
Skin fold or Pneumothorax


A fold of the patient’s skin may become
trapped between the patient and cassette

Skin folds are common

Especially in patient’s who have lost a great
deal of weight

This skin fold can mimic a
pneumothorax
 This is an edge

Dense

Lucent

Skin Fold

The key difference is that a skin fold is an edge

consisting of a density (light) and then a lucency (dark)
 Skin Fold Pneumothorax

Here they are again side-by-side: the skin fold is an edge,

the pneumothorax is a line
 SKIN FOLD NOT
PNEUMOTHORAX

This is a skin fold. It is an edge,

not a line.
 This is a line

Lucent

Dense

Lucent
Pneumothorax

Whereas the visceral pleural line is a

thin white line with a lucency (darker) on both sides of it
Skin Fold Pneumothorax

How can we tell them apart?

Yahya Shawar, M.D. © 2009
Take home points

Pneumonia

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 RADIOLOGIC PATTERNS
Air space - consolidation.
The denotes alveolar disease . Bacterial
pneumonia.
Cloudy , patchy and cotton wool.
Interstitial lacey, spider’s web, steel wool
and linear.
Viral and fungal pneumonia.
Gram Positive Pneumonias


Pneumococcal pneumonia

Staphylococcal pneumonia

Streptococcal pneumonia

Nocardiosis
Day 1 Day 2
Rapid Clearing
 © R3

Pneumococcal pneumonia
Rapidly Clearing Alveolar Infiltrate

1. Pneumococcal
pneumonia
2. Hemorrhage
3. Pulmonary edema
4. Aspiration
DDX
Staph Aureus Pneumonia
X-ray


Rapid spread through lungs

Empyema, especially in children

No air bronchogram

Pneumothorax, pyopneumothorax

Abscess formation, pneumatocoele

Bronchopleural fistula
 Infiltrates with Effusion

1. Staph pneumonia
2. Strep pneumonia
3. TB
4. Pulmonary infarct

DDX
Day 1 Day 4

Staph pneumonia
Staph pneumonia
Staph pneumonia with pneumatocoele
 © R3

Strep pneumonia in newborn

 Nocardiosis


Gram-positive, acid-fast bacterium

Occurs in immunocompromised

Multiple nodules with or without
cavitation

Empyemas occur
 © R3

Nocardiosis – nodules with cavitation

INTERSTITIAL VIRAL PNEUMONIA
Gram Negative Pneumonias


Pseudomonas

Klebsiella

Enterobacter

Serratia

Anaerobic
 Pseudomonas Aeruginosa
General


Gram negative rod

Frequently hospital-acquired

Frequently related to inhalators or
nebulizers

Many patients on multiple antibiotics and/or
steroids
Pseudomonas Aeruginosa
Predisposed


COPD

CHF

Alcoholism

Kidney disease

Those with trachs
Pseudomonas Aeruginosa
X-ray Findings


Resembles staph pneumonia

Predilection for lower lobes

Usually affects both lungs

Contains multiple small lucencies

Lung abscess > 2 cm may also occur

Widespread nodular shadows another
manifestation
Pseudomonas
Pseudomonas lung abscess
Klebsiella, Enterobacter, Serratia
General


Encapsulated, gram negative rods

Most are hospital-acquired

Most occur in chronic alcoholics

Aspirated into lungs

Most are unilateral and right sided
 Klebsiella Pneumonia
X-ray Findings


Produces excessive amounts of
inflammatory exudate

Affected lung gains volume and fissures bulge

Bulging fissure sign

Abscess and cavity formation common

Pleural effusion and empyema common
Klebsiella with bulging fissure
Anaerobic lower lobe cavitary pneumonia
Other Pneumonias


Cryptococcus

Varicella

Pneumocystis

Actinomycosis

Mycoplasma pneumonia

Coccidiomycosis
 Cryptococcosis
(Torulosis)


Caused by Cryptococcus neoformans

Found in soil contaminated with pigeon
excrement

Granulomatous disease

Diabetics, immunocompromised

Frequently produces meningitis
 Cryptococcosis
X-ray


Well circumscribed peripheral mass (40%)

Lobar/segmental consolidation (35%)

Cavitation (15%)

Hilar/ mediastinal adenopathy
Nodular Infectious Diseases

1. Nocardiosis
2. Coccidiomycosis
3. Cryptococcosis
4. Varicella
 Take Home


SARS produces patchy airspace dz

Pneumococcal pneumonia can clear in
48 hrs

Staph produces loculated effusions and
pneumatocoeles

Nocardiosis has multiple nodules with
or without cavitation

 Take Home


Pseudomonas - lower lobes; multiple
small lucencies

Klebsiella - heavy exudate; bulging
fissure

Actinomycosis – extends through
pleura

 Take Home


Mycoplasma – lower lobe; dormitory
settings

Coccidiomycosis – thin-walled cavity

for patchy perihilar parenchymal infiltrates on a plain
CXR, which correspond to alveolar lesions of
advanced pulmonary sarcoidosis
 Pleural Effusion-Types

Transudate
– Exudate
– Empyema
– Hemothorax
– Chylothorax
 Transudate
Transudate
  capillary hydrostatic pressure or 
osmostic pressure
– CHF
– Hypoalbuminemia
– Cirrhosis
– Nephrotic syndrome
 Exudate
Usually 2 neoplastic or inflammatory
dzs involving pleura [Fluid Protein] 
[serum protein] > 0.5
[Fluid LDH]  [serum LDH] >0.6
Fluid LDH > 2/3 highest normal
serum LDH
 Side-specificity
Side-specificity
–Mostly left-sided
–Pancreatitis
–Dressler’s syndrome
Distal thoracic duct obstruction
–Mostly right-sided
–Heart failure
–Abdominal disease related to liver
or ovary
–Proximal thoracic duct obstruction
Appearances of Pleural Effusions
Subpulmonic effusion
Blunting of Costophrenic angle
Meniscus sign
Layering
Loculated
Laminar effusion
Opacified hemithorax
Air-fluid levels
Fluid rises
higher
along the
edge of a
pleural
effusion
producing
an upside
down “U”
or
meniscus Meniscus Sign
shape
A straight edge,
indicative of a fluid
interface, in this
case an air-fluid
interface, is seen on
the right.

In order to have an
air-fluid level in the
pleural space, there Hydropneumothora
must be a x
pneumothorax
present.