Taibah University

College of Medical Rehabilitation Sciences

Respiratory Therapy Department
Patient Assessment Course (RT 244)

Radiology of the chest

Dr. Naseer Ahmad

Taibah University
 Overview
• Technical aspects of chest
radiography
• Systematic approach to
reading CXR
• Basic CXR anatomy

3
 Thoracic Imaging
• X-ray (CXR)
• Computed Tomography (CT)
• Magnetic Resonance Imaging(MRI)
• Ultrasonography (US)
• Nuclear Medicine
• PET/CT
• Radionuclide ventilation perfusion imaging
 Indications of chest x-ray
• Evaluation of symptoms • Screening for lung
• Evaluation of signs cancer
• Pre-employment and
prior to surgery
• Evaluation of placement
of devices and tubes
• Screening after
procedures (central line,
lung biopsy, chest tube,
thoracentesis)
Density of tissue and radio opacity
 A systematic approach to reading a CXR

ChestX-ray

Image Credit: Lung Health Image Library/Gary Hampton 13

 Put it in right order
Patient’s right side Patient’s left side

Aortic knob
Gastric bubble
should be on the
left
Mark on film

Heart: two thirds to the left

 Chest x-ray viewing guide
Quality Be Systematic
Correct CXR
• Name • Orientation
• Date of • Penetration/
birth/Age Exposure
• Date • Inspiration
• Left and • Rotation
right, mark • Angulation
Abnormality
• What (pathology)
• Where (site)
• Extent (size)
• Diagnosis
 Patient Position
• PA, AP, lateral or decubitus view
• Rotation – Sternal end clavicles equal from
vertebral body
• If AP what position
 Techniques – Projection
Chest X-ray views
Relation of x-ray beam to patient
• Posteroanterior - PA
• Anteroposterior - AP
• Lateral
– Right lateral
– Left lateral
• Decubitus or lateral decubitus
(anterior or posterior)
– Right decubitus
– Left decubitus
• Oblique
• Lordotic or apical
 PA View
• Standard, radiology
department
• X-rays posterior to
anterior
• Standing position
 AP View
• Cassette placed behind • Since AP radiographs
patient are taken from shorter
• X-rays anterior to distances, they appear
posterior more magnified and
• Sitting in chair, semi- less sharp compared to
erect in bed, supine standard PA films
• AP marked on film
• Heart enlarged, poorer
inspiration
 AP
• All x-rays in the ICU are
portable and are AP
view

Portable AP
 Views
Lateral View Oblique view
 Decubitus View
Lateral Decubitus View
• PA on side
• Small pleural effusions
• Pneumothorax
 Assess CXR Technical Quality
• Inspiratory effort
– 9-10 posterior ribs (5 -6 anterior)
• Penetration
– thoracic intervertebral disc space just visible
• Positioning / rotation
– medial clavicle heads equidistant from
spinous process

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 Penetration/Exposure
Proper Exposure
• How dark or light a film
is
• Is the film over or under
penetrated
• if under penetrated you
will not be able to see
the thoracic vertebrae.
 Inspiratory or expiratory
• Good inspiratory effort:
– If anterior end of 6th or 7th rib reaches
mid-clavicular line of diaphragm, it is
Inspiratory Xray.
• Poor inspiraory effort
Inspiratory film CXR
– 9 posterior ribs are visible.
– 5 anterior ribs are visible.
• Expiratory
– Less than 9 posterior ribs are visible.
– Less than 5 anterior ribs are visible.
Poor Inspiration
 Inspiratory effort
• If more ribs are apparent above the hemi-
diaphragm, the inspiratory volume is large or
the patient is hyper inflated. If fewer ribs are
apparent above the hemi diaphragm, the
inspiratory volume is small or the patient has
restricted lung volumes.
Image credit: Curry International Tuberculosis Center, University of California, San Francisco 8
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Image credit: Curry International Tuberculosis Center, University of California, San Francisco 8
 2
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3

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Image credit: Curry International Tuberculosis Center, University of California, San Francisco 8
 2
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Image credit: Curry International Tuberculosis Center, University of California, San Francisco 8
 Rotation
• Check for rotation

– Does the thoracic spine

align in the center of the
sternum and between
the clavicles?
– Are the clavicles level?
• Centering and
symmetry of thorax
The sternoclavicular
joints should be an
equal distance from
the spines of the
thoracic vertebrae.
• Heart The mediastinal
shadow should be slightly
to the left of center and in
contact with the
diaphragm.
• The cardiothoracic index
should be about one-third
to one-half. Look for the
aortic arch (aortic knob),
to the left
• A cardiophrenic angle is
the intersection of the
vertical curvature of the
heart shadow and the
horizontal curvature of
the hemi diaphragm. Look
for sharp cardiophrenic
angles on the right and
left side of the heart.
 Mediastinum - Heart
Size
• No larger than half width
of chest
Position
• Two thirds on the left
Borders
• Clear
Systematic approach
Airway
 Airway

Trachea
• Deviated
• Carina
• Artificial airway
 Bone

• Ribs
• Scapulae
• Clavicles
• Vertebrae
 Check the Heart
• Size
• Shape
• Silhouette-margins should be
sharp
• Diameter (>1/2 thoracic diameter
is enlarged heart)

Remember: AP views make heart appear larger

than it actually is.
 Hilar region
The hila (lung roots) are complicated structures mainly consisting of the major
bronchi and the pulmonary veins and arteries. These structures pass through
the narrow hila on each side and then branch as they widen out into the lungs.
The hila are not symmetrical but contain the same basic structures on each side.

Hilum—Normally, the hilum is 1 to

2 cm higher on the left than on the
right side of the mediastinum.

D.D of enlarged hilum

• Enlarged pulmonary
artery
• Enlarged lymph nodes
• Mass
 Diaphragm
• Shape
• Height: right –6rib ant,
left – 7 ant
• The right
hemidiaphragm is
higher than the left Margins should
• Cardiophrenic angle be
• sharp
• Costophrenic angle • Clear
• Pin point
 Diaphragm
• Look at the diaphram:
for tenting
free air
abnormal elevation
• Margins should be
sharp
(the right hemidiaphram is
usually slightly higher than
the left)
 Lung Fields
• Black with lung markings
• Other opacity indicated pathology
• Fissures
• Zones
• Air bronchograms
• Consolidation
 Radiologic lung zones

The Chest Xray is usually divided into three zones

 Lung Zones
Dividing the lungs into zones
allows more careful
attention to be paid to each
smaller area. If this is not
done it is easy to ignore
important abnormalities.
Note that the lower zones
reach below the diaphragm.
This is because the lungs
pass behind the dome of the
diaphragm into the posterior
sulcus of each hemithorax.
Normal lung markings can be
seen below the well defined
edges of the diaphragm.
 Pleural spaces
Normal pleura and pleural
spaces
Trace round the entire edge
of the lung where pleural
abnormalities are more
readily seen
Start and end at the hila
Is there pleural thickening?
Is there a pneumothorax?
The lung markings should be
visible to the chest wall
Is there an effusion? The
costophrenic angles and
hemidiaphragms should be
well defined
.
 Check the Lung Fields
• Infiltrates
• Increased interstitial markings
• Nodules/Masses
• Patchy opacity
• Air bronchograms
• Increased vascularity
• Cyst
• Cavity
 Lung findings
• Darker areas • Lighter areas
Radiolucent – Opacities
– Pneumothorax – Atelectasis
– Cysts/bulla – “infiltrates”
– Air bronchograms • Blood
• Pus
• Water
– Nodules or mass
Bronchitis
 Pneumothorax
• Black jet opacity
• Visceral pleural
line
• Collapsed lung
• With or without
mediastinal shift
Pneumothorax in ICU

Deep sulcus

Deep sulcus
 Consolidation/pneumonia

Caused by filling of alveoli with fluid, pus, blood, cells (tumor), etc.
May be diffuse, or isolated to segments or lobes of the lung
May be associated with air bronchograms (air-filled bronchus surrounded by
opacified lung)
Mass
 Interstitial Opacity
• Acute or chronic onset
• Signs of heart failure
• interstitial edema ( reticular
pattern)
• Pulmonary vascular congestion
• enlarged heart size in most
cases
• Butterfly opacity (central)

D.D of interstitial opacity

• Cardiogenic Pulmonary
edema
• ARDS
• interstitial lung diseases
CHF: cardiogenic pulmonary edema
• Tumour
 Interstitial opacity
• Acute onset
• Insult
• respiratory failure not explained
• decreased arterial PaO2/FiO2 ratio
below 200
• interstitial edema ( reticular
pattern)
• May be areas of consolidation
• Normal heart size
• Peripheral opacity

D.D of interstitial opacity

• Cardiogenic Pulmonary
edema
• ARDS
• interstitial lung diseases
• Tumour ARDS
Pleural effusion

White homogeneous opacity

Obliterating costophrenic angle
Rising to axilla
 Everything else

Breast shadows
Surgical emphysema