Chest Radiographs

SAMUEL M. Y. GAMADEY
16TH SEPTEMBER,2010
 CHEST X RAY

A Chest X-ray (CXR) is normally taken erect and PA

(posterior anterior) at a distance of 5 or 6 feet (150 or
200cm).
PA VIEW
LATERAL VIEW

PA RADIOGRAPH LATERAL RADIOGRAPH

LATERAL DECUBITUS LORDOTIC POSITION

LATERAL DECUBITUS RADIOGRAPH AP LORDOTIC RADIOG.

 Chest Radiography : Basics
Principles

A Structure is rendered visible on a radiograph by the

juxtaposition two different densities
 Silhouette Sign
Loss of expected interface normally
created by the juxtaposition of two
structures of different densities

No boundary can be seen between two

structures of similar densities.
 ERECT FILMS
Erect position is the most ideal technique for chest x
ray because
It reproduces the normal state of the lungs &
mediastinum.

Air rises to the apical region, making it easy to

recognise a pneumothorax.

Fluid runs downwards, producing a level at the

base with a curved line (meniscus).

The diaphragms are lower showing more of the

lung bases and the heart size can be accurately
assessed.
 POSTERIOR – ANTERIOR VIEW
The film is taken PA because:

It is easier to clear the scapulae from the lung fields by

moving the shoulders forward

There is less magnification of the heart because the heart

is lying adjacent to the film

When the patient is too sick to stand unaided or unable to

keep still the X-ray is taken supine.
PA VIEW AP VIEW
 EXPIRATORY FILM:
This is taken when the patient has breathed out.
This may help to show bronchial obstruction with air trapping
(e.g. inhaled foreign body in a child):

LATERAL FILM:
A lateral film should never be part of a standard chest
examination especially for medical purposes or for follow up
of a known lesion. The PA film should be examined. If there
is an abnormality, a lateral film may then be useful for further
assessment & localisation of abnormalities seen or
suspected on the PA film.
 OBLIQUE VIEWS:
These are helpful in assessing rib lesions & some
pneumothoraces.

LORDOTIC VIEWS
They can be obtained to better visualize structures in the
thoracic apex obscured by overlying bony structures.

DECUBITUS VIEW
The decubitus view can be done to locate fluid in the chest
cavity. The patient will have to lie on either the right or left
side for two minutes and a shoot through x-ray is taken.
 Poor Quality CXR
Supine position
– Decreases lung volume, increased heart size
– Basilar infiltrates & interstitial spaces accentuated
– Increases venous return to the heart
Semi-upright position
– Enlarges normal structures
– Changes air-fluid levels
Failure to hold breath
– Lung structures & diaphragm blurred
Expiration film
– Basilar infiltrates & interstitial spaces accentuated
– Increased heart size
Why order a CXR?
SYMPTOMS:
Bad or persistent cough
Chest pain
Chest injury
Coughing up blood
Fever
Shortness of breath
Why order a CXR?
Pleural effusion Lung cancer
Pneumothorax Chest pain (MI?)
Hemothorax Hypertension
Pulmonary embolus Screening
Trauma Pneumonia
Monitoring chest COPD
drainage
Asthma
TB
 The 12-Step Program

}
1: Name
2: Date Pre-read
3: Anatomical markings
4: What type of view(s)

}
5: Penetration
6: Inspiration
7: Rotation Quality Control
8: Angulation

}
9: Soft tissues / bony structures
10: Mediastinum
11: Diaphragms Findings
12: Lung Fields
 Quality Control

5. Penetration
– Should faintly see ribs
through the heart

– Barely see the spine

through the heart so
that lesions behind or
in front of the heart will
not be missed.

– Should see pulmonary

vessels nearly to the
edges of the lungs
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

A body section view may be done in addition to a routine
PA chest to outline the lower regions of the chest in very
obsessed patients.
 Quality Control

6. Inspiration
1
2

– Should be able to 3

count 9-10 posterior 4

ribs 5

– Heart shadow should 7

not be hidden by the

8
diaphragm
9
10
 Poor inspiration can crowd
lung markings producing
pseudo-airspace disease
8

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

 Quality Control

7. Rotation

– Medial ends of
bilateral clavicles are
equidistant from the
midline or vertebral
bodies
 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
 Quality Control

8. Angulation
1
2

– Clavicle should lay 3

over 3rd rib

Pitfall Due to Angulation

Apical lordotic Same patient, not lordotic

A film which is apical lordotic (beam is angled up toward

head) will have an unusually shaped heart and the usually
sharp border of the left hemidiaphragm will be absent
 Findings

9. Soft tissue and bony

structures
– Check for
Symmetry
Deformities
Fractures
Masses
Calcifications
Lytic lesions
 Findings

10. Mediastinum
– Check for
Cardiomegaly
Mediastinal and
Hilar contours for
increase densities
or deformities
Measurement of the
cardiothoracic ratio.
Maximum transverse diameter of the heart on
a normal PA film is not more than 15.5cm in
adult males and 14.5cm in adult females.
When the cardiothoracic ratio is used it
should not exceed 50%.

A+B = the transverse diameter of the heart.

C= the transverse diameter of the thorax
which is measured at the level of the
diaphragms from the inner ribs
A+B divided by C = the cardiothoracic ratio
(CTR)
 Findings

11. Diaphragms

– Check sharpness of
borders

– Right is normally
higher than left

– Check for free air,

gastric bubble, pleural
effusions
 Findings

L
12. The Lung Fields!
– To help you determine
abnormalities and their
location…

Use silhouettes of
other thoracic
structures

Use fissures
 Lung Anatomy
Right Lung
– Superior lobe
– Middle lobe
– Inferior lobe
Left Lung
– Superior lobe
– Inferior lobe
Lung Anatomy on Chest X-ray
The right upper lobe
(RUL) occupies the
upper 1/3 of the right
lung.
Posteriorly, the RUL is
adjacent to the first three
to five ribs.
Anteriorly, the RUL
extends inferiorly as far
as the 4th right anterior
rib
Lung Anatomy on Chest X-ray
The right middle
lobe is typically the
smallest of the
three, and appears
triangular in shape,
being narrowest
near the hilum
Lung Anatomy on Chest X-ray
The right lower lobe is the
largest of all three lobes,
separated from the others
by the major fissure.
Posteriorly, the RLL
extend as far superiorly as
the 6th thoracic vertebral
body, and extends
inferiorly to the diaphragm.
Review of the lateral plain
film surprisingly shows the
superior extent of the RLL.
Lung Anatomy on Chest X-ray
These lobes can be
separated from one another
by two fissures.
The minor fissure separates
the RUL from the RML, and
thus represents the visceral
pleural surfaces of both of
these lobes.
Oriented obliquely, the major
fissure extends posteriorly
and superiorly approximately
to the level of the fourth
vertebral body.
Lung Anatomy on Chest X-ray
The lobar architecture
of the left lung is
slightly different than
the right.
Because there is no
defined left minor
fissure, there are only
two lobes on the left;
the left upper
Lung Anatomy on Chest X-ray
Left lower lobes
Lung Anatomy on Chest X-ray
These two lobes are
separated by a major
fissure, identical to that
seen on the right side,
although often slightly
more inferior in location.
The portion of the left
lung that corresponds
anatomically to the right
middle lobe is
incorporated into the left
upper lobe.
Chest Radiographic Patterns of
Diseases
Air Space Opacity
Interstitial Opacity
Nodules and Masses
Lymphadenopathy
Cysts and Cavities
Lung Volumes
Pleural Diseases
 AIR SPACE OPACITY /ALVEOLAR
SHADOWING
The alveoli are filled with fluid or solid tissue
and appear as small separate rounded
6mm opacities in the early stages.

The vessels are obscured and there may be

an air bronchogram and silhouette sign.

When the alveoli fill with fluid or other

substances, it is called consolidation
Components
Air bronchogram : air – filled bronchus
sorrounded by airless lung.
Confluent opacity extending to pleural
surfaces.
Segmental distribution
Blood (hemorrhage)
Water (edema) i.e. hydrostatic or non –
cardiogenic
Cells (tumor)
Protein/fat: alveolar proteinosis and lipoid
pneumonia
Pus (pneumonia)
Air bronchograms. The bronchi in the upper lobes are visible as dark
lines because the surrounding alveoli are filled with exudate due to
pneumonia.
LUL PNEUMONIA
 Interstitial opacity
This is due to a disease in the
interstitium .i.e. the tissue in which
the blood vessels and bronchi lie
within the lungs. This leads to a non
homogenous pattern of shadowing
which may take many forms.

The normally visualised blood vessels

become ill defined or obscured and may
be diffuse or localised.
 Hallmarks :

Small, well – defined nodules

Lines i.e. interlobular septal thickening or
fibrosis
Reticulation .
Idiopathic interstitial pneumonias
Infections ( TB , Viruses)
 Edema
Hemorrhage
Non – infectious inflammatory lesions e.g.
scarcoidosis
Tumor

Interstitial disease Reticulo nodular pattern

Normal interstitium
Close up of interstitial shadowing in a patient with fibrosing alveolitis.
There is a nodular pattern super-imposed on a fine network of lines.
Loss of vessels.
 Nodules and Masses
Nodule: any pulmonary lesion represented
in a radiograph by a sharply defined,
discrete nearly circular opacity 2 – 30 mm
in diameter
Mass: larger than 3cm
 Qualifies :
Single or multiple
Size
Border definition
Presence or absence of calcification
Location
 Well Defined

Calcifications

Ill Defined Mass

The solitary nodule
 Lymphadenopathy
Chronic abnormal enlargement of the lymph nodes

Non – specific presentations

1. Mediastinal widening
2. Hilar prominence

Specific patterns :
1. Particular station enlargement
Right paratracheal
lymphadenopathy
Left Hilar Lymphadenopathy
 Cysts and Cavities
Cyst: abnormal pulmonary parenchymal
space, not containing lung tissues but
filled with air and/or fluid, congenital or
acquired , with a wall thickness greater
than 1mm

Epithelial lining often present

 Cavity: abnormal pulmonary parenchymal
space , not containing lung but filled with
air and / or fluid .

It is caused by tissue necrosis, with a

definitive wall greater than 1mm in
thickness and comprised of inflammatory
and / or neoplastic elements.
 Cysts and cavities
Characterize:
1. Wall thickness at the thickest portion
2. Inner lining
3. Presence/ absence of air/fluid level
4. Number and location
Benign Lung Cyst :PCP Pneumatocele
Uniform Wall Thickness
1mm
Smooth Inner lining
Malignant Cavities: Squamous Cell Cavities
Maximum Wall Thickness 16mm
Irregular Inner Lining
Pleural Effusion
 Right
Side
Pleural
Effusion
Fracture of posterior rib #
 Fibrosis
cavitation
Calcifications

Consolidation
Granuloma

Hilar Lymphadenopathy (Tuberculoma)

Miliary Shadowing

Pericardial Effusion

Pleural
effusion
Manifestation of pulmonary tuberculosis
Pericardial effusion
 Atelectasis - Collapse/ incomplete expansion.

Endobronchial– mucus plug/ tumor.

Extrinsic compression– mass/ effusion/ ascites.
Scarring-- post TB/ Radiation/ inflammation.
Linear/curved/wedge(apex-hilum) density with hilar/tracheal/media-
stinal/diaphragm deviation with volume loss +/- compensatory
hyper- inflation.
Right upper and lower lobe
atelectasis
Right middle lobe pneumonia
 Type of pneumonia
Lobar - entire lobe consolidated and air bronchograms
common

Lobular - multifocal, patchy.

Interstitial - starts perihilar ,can become confluent and/or

patchy as disease progresses, no air bronchograms

Aspiration pneumonia

Diffuse pulmonary infections - nosocomial

(Pseudomonas, debilitated, mechanical vent, high
mortality rate, patchy opacities, cavitation, immuno-
compromised host(bacterial, fungal, Pneumocystic Carinii
Pneumonia)  
 Major differentiating factors between atelectasis and
pneumonia

Atelectasis   Pneumonia

  
Volume Loss normal or increased volume
Associated Ipsilateral Shift no shift/ contralateral shift
Linear, Wedge-Shaped air space process
Apex at Hilum not centered at hilum

   Air bronchograms can occur in both.

Dextrocardia
Aortic Aneurysm
Putting It Into Practice
Case 1
A single, 3cm relatively thin-walled cavity is noted in the left
midlung. This finding is most typical of squamous cell
carcinoma (SCC). One-third of SCC masses show cavitation
Case 2
LUL Atelectasis: Loss of heart borders/silhouetting.
Notice over inflation on unaffected lung
Case 3
Right Middle and Left Upper Lobe Pneumonia
Case 4
Cavitation:cystic changes in the area of consolidation due to
the bacterial destruction of lung tissue. Notice air fluid level.
Cavitation
Case 5
Tuberculosis
Case 6
COPD: increase in heart diameter, flattening of the
diaphragm, and increase in the size of the retrosternal air
space. In addition the upper lobes will become hyperlucent
due to destruction of the lung tissue.
Chronic emphysema effect on the lungs
Case 7
Pseudotumor: fluid has filled the minor fissure creating a
density that resembles a tumor (arrow). Recall that fluid and soft
tissue are indistinguishable on plain film. Further analysis,
however, reveals a classic pleural effusion in the right pleura.
Note the right lateral gutter is blunted and the right diaphram is
obscurred.
Case 8
Pneumonia:a large pneumonia consolidation in the right
lower lobe. Knowledge of lobar and segmental anatomy is
important in identifying the location of the infection
Case 9
CHF:a great deal of accentuated interstitial
markings, Curly lines, and an enlarged heart.
Normally indistinct upper lobe vessels are
prominent but are also masked by interstitial
edema.
24 hours after diuretic therapy
Case 10
Chest wall lesion: arising off the chest wall and not the lung
Case 11
Pleural effusion: Note loss of left hemidiaphragm. Fluid
drained via thoracentesis
Case 12
Lung Mass
Case 13
Small Pneumothorax: LUL
Case 15
Right Middle Lobe Pneumothorax: complete lobar collapse
Post chest tube insertion and re-expansion
Case 16
Metastatic Lung Cancer: multiple nodules seen
Case 17
Right upper lower lobe pulmonary nodule
Case 18
Tuberculosis
Case 19
Perihilar mass: Hodgkin’s disease
Case 20
Widened Mediastinum: Aortic Dissection
Case 21
Pulmonary artery stenosis with cardiomegally
likely secondary to stenosis.
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
RML consolidation that appears wedge shaped on lateral view

RML pneumonia
RLL infiltrate / consolidation

RLL pneumonia
Patient BIBA to ER s/p airplane crash.

Widened mediastinum

Concern for aortic injury

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
 Left lung opacity

Later diagnosed as lung cancer

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

CHF
Kerley B lines
The End

Thank you