Chest X-ray

For a PA projection, the film cassette is placed against the anterior chest and the x-ray travel from back to front. In the case of a lateral film, the cassette is placed against the left lateral chest wall.

The AP CXR is the standard bedside chest radiograph or portable CXR Take note 1. use of shorter tube to film distance and AP direction of the beam magnification of the heart and superior mediastinum shadows of up to 1015% 2. Less than full inspiration achieved, accentuate the normal lung marking mimicking the appearance of interstitial pulmonary edema or chronic interstitial lung disease. 3. Usually vascular markings on a chest radiograph are more prominent in the bases due to gravity; however if taken in supine position, the usual effect of gravity on the distribution to blood flow is lost and redistribution to the apices can be seen mimicking the early changes of venous hypertension seen in congestive heart failure

PA CXR interpretation
1. 2. 3. Check the name, medical number, and date L or R marking Always get an old film to compare

Quality of the film

1. Patient rotation must be such that the beam is properly centered and the patient is not rotated medial ends of each clavicle should be equidistand poorly centered films ==> false impression of mediastinal shift, hilar prominence, or a hyperlucent hemithorax

2. Level of inspiration on full inspiration, the midpoint of the right hemidiaphragm should reach the level of 9th-10th rib posteriorly/ 6th - 7th rib anteriorly less than full ==> false impression of volume loss, increased intersitial markings or cardiomegaly

3. Film exposure Exposure on a PA film is optimal when it allows for the faint visualisation of the thoracic spine and its intervertebral discs while still allowing for the visualisation of the normal lung markings behind the left side of the heart. When the vertebral bodies and the lung markings behind the left side of the heart are poorly visualised the film is said to be underexposed or underpenetrated

Systemic review 1. 2. 3. 4. mediastinum and hila pleura and diaphragms extrathoracic bones and soft tissues lungs

Extrathoracic soft tissues neck supraclavicular fossa soft tissues of the lateral chest wall, the pectoralis muscles breast shallow

Rib cage Pleura -

clavicle scapula acromioclavicular joint glenohumeral joint

ribs (anterior and posterior) vertebral column (spinous processes, transverse processes and height of each vertebra) diaphragm - doomed shaped with peak near midpoint right diaphragm is usually higher than the left by no more than 1 rib interspace area below the diaphragm, gastric air bubble on the left. the distance from the top of the bubble to the dome is usually less than 1-2cm, more than that may suggest a subpulmonic efflusion inspect upper abdomen for spleen or liver shadow, air in the colon, or free air under the diaphragm

parietal pleura lines the diaphragm, the outer surface of the mediastinum and the inner surface of the chest wall visceral pleura lines the surface of the lungs inspect the diaphragm and lateral chest wall for pleural thickening or calcifications the costophrenic angle is examined for blunting or medial displacement (pleural fluid or scarring) minor fissure can sometimes be seen on a PA film as a thin line extending from the right hilum to the lateral chest wall at the level of the axillary portion of the 5th/6th rib

Mediastinum can be deviated due to pleural effusion, pneumothorax or atelectasis note tracheal air column, top-narrowing at the level of vocal cords and slight deviation to the right at the level of aorta arch the normal carinal angle is about (45-75). Abrnormal widening of the carinal angle can be seen with left atrial enlargement and subcarinal adenopathy

Contours of the mediastinum left superior borden of the mediastinum is primarily attributed to the left subclavian artery the curve below aortic arch is left pulrymonary artery the concavity between the aortic arch and the left pulmonary artery called the aortopulmonary window. when the space is opacified (ie the borden becomes convex) it may indicate the presence of mediastinal adenopathy the lower left mediastinal contour is formed by the left heart border, which is composed of the left atrial appendage and the left ventricle the superior mediastinal border is formed by the right brachiocephalic vein and the superior vena cava. note the right paratracheal stripe which is usually <3mm in diameter, and can become thickened as a result of right paratracheal adenopathy

at the level of the right pulmonary artery the mediastinal border is formed by the superior vena cava, and then more inferiorly by the right atrium. note the cardiac silhouette for its shape and size. normal cardiac shadow spans <50% of the total transverse diameter of the chest

Lung parenchyma compare corresponding areas of the right and left lungs, looking for asymmetry due to an increased or decreased density. examine the apices, the retrocardiac area and portion of the lungs that projects below the diaphragm the normal lung markings are primarily the result of blood vessels. these marking gradual taper and are usually visible up to 1-2cm from the visceral pleura. due to gravity, there is greater blood flow to the bases than the apices of the lung and therefore the vessels in the bases are more prominent.

Lateral Chest Xray