BASIC OF

THORAX
IMAGING
Radiology Department of Hasan Sadikin
Hospital
Medical Faculty of Padjadjaran University
INTRODUCTION
ANATOMY
POSITIONING
15 STEPS TO READ CHEST X-RAY
LATERAL CHEST X RAY
PATHOLOGIC FINDINGS IN CHEST X-RAY
INTRODUCTION
 Introduction

Plain chest radiograph is one of the

most commonly performed imaging
procedures
Up to 50% of studies in radiology
practices.
Countless volumes of radiology
textbooks have been dedicated
solely to thoracic imaging.
 Introduction
Indication :
Screening.

Preoperative underlying pulmonary and

cardiovascular diseases.
Febrile patient pulmonary sources of fever

Trauma patient.

Contraindication (relative):
Pregnant women especially 1st & 2nd

trimester.
Neonates and children.
ANATOMY
Lung Anatomy
 Right Lung
Lung Anatomy
o 3 lobes

(divided by major
fissure and minor
fissure)
o 10 segments
Left Lung :
o 2 lobes

(divided by major
fissure)
o 8 segments
o Lingula segments ~
medial lobe of the
right lung
 Lung Anatomy

Minor (horizontal )fissure divides the

superior lobe and the middle lobe of the
right lung.
There is no minor fissure in the left lung.
 Lung Anatomy
In the right lung, the major fissure (oblique)
divides the inferior lobe with the middle and
superior lobes.
In the left lung, the major fissure (oblique)
divides the inferior lobe with the superior lobe.
 RIGHT LUNG SEGMENTATION

Superior Lobe Apical segment (1)

Posterior segment (2)
Anterior segment (3)
Middle Lobe Lateral segment (4)
Medial segment (5)
Inferior Lobe Apicobasal segment (6)
Mediobasal segment (7)
Anterobasal segment (8)
Laterobasal segment (9)
Posterobasal segment (10)
 LEFT LUNG SEGMENTATION

Superior Lobe Apicoposterior segment (1)

Anterior segment (2)
Lingula Superior segment (3)
segments Inferior segment (4)
Inferior Lobe Apical segment (5)
Anteromedial basal
segment (6)
Laterobasal segment (7)
Posterobasal segment (8)
 RESPIRATORY TRACT ANATOMY

Trachea :
Begins at the lower border of the cricroid

cartilage at the level of C6 vertebra.

Extend to the carina at the level of the

sternal angle (T5 level)

T4 level on expiration
T6 level on inspiration
The trachea is 15 cm and 2 cm in diameter.
 RESPIRATORY TRACT ANATOMY

Trachea :
The trachea in children is very pliable.

It may be deviated to the right in normal

expiratory film.
It only deviates to the left if the aortic arch

is on the right side.

RESPIRATORY TRACT ANATOMY
RESPIRATORY TRACT ANATOMY
 RESPIRATORY TRACT ANATOMY

Primary lobule
The smallest functional unit of the lung

Comprises all the structures distal to a

respiratory bronchiole including 16-40

alveoli.
Normal adult has approximately 23

million primary lobules.

 RESPIRATORY TRACT ANATOMY

Acinus
Consists of all structures distal to the

terminal bronchiole, including vessels,

nerves, and connective tissue.
It has a diameter 4-8mm

Contains approximately 10-20 primary

lobules
 RESPIRATORY TRACT ANATOMY

Secondary Lobule
The smallest structural unit of lung

parenchyma that is surrounded by a

connective tissue septum.
Contains 3-12 acini and measures 1,0-2,5

cm in diameter.
RESPIRATORY TRACT ANATOMY
RESPIRATORY TRACT ANATOMY
TRACHEOBRONCHIAL SYSTEM

23
 Acinus

Lobulus primer

3/30/17 www.brainybetty.com 24
Alveoli
Alveoli pore:
Canals of Lambert
between alveoli and
terminal bronchiole
Pores of Kohn
between alveoli.

25
Radioanatomi Posteroanterior Chest X Ray
POSITIONING
CHEST X-RAY POSITION

POSTER0ANTERIOR
ANTEROPOSTERIOR
RIGHT/LEFT LATERAL
RIGHT ANTERIOR OBLIQUE
LEFT ANTERIOR OBLIQUE
RIGHT POSTERIOR OBLIQUE
LEFT POSTERIOR OBLIQUE
TOP LORDOTIC
RIGHT/LEFT LATERAL DECUBITUS
POSTEROANTERIOR

Indication:
Routine

Screening TB

Pre-operative
Technique:
The patient stand between the film and the x-ray tube.

The patient faced the film.

The hands are put in the waist with the elbow flexed to

the anterior (to open scapula so it doesnt

superimposed with the lung)
The distance of the film to the x-ray tube :

Lung 1.5m
Heart 2.0m
Centre : 6th 7th thoracic spine
50-60 KV
10-20 MAs
 ANTEROPOSTERIOR

Indication:
(cannot be taken with
PA )
Severely ill patient

Children

Infant and neonates

Obese

Pregnant

Ascites

Intraabdominal tumor
Technique:

1. The patient lie on the table with the arms put

beside the body or put up.
2. The film was placed behind the back.
3. Centre : 6th -7th thoracic spine
Distortion in Anteroposterior
chest x-ray

Heart enlargement
Mediastinal widening
Crowded bronchovascular marking at the
basal zone.
 How to differentiate PA & AP
PA
V shaped clavicles

No lung superposition

with the scapula

No mediastinal

widening
Distinct anterior

aspect of the costa. AP

Straight clavicles
Less crowded Lung superposition with the scapula
Mediastinal widening
bronchovascular Distinct posterior aspect of the costa

marking Crowded bronchovascular marking especially at

the basal zone.

PA vs AP CXR
Lateral Chest X-Ray

Indication:
Look at mediastinal

abnormalities.
Look at anomalies that

wasnt clear at
posteroanterior position.
Heart assessment.

To look for minimal fluid

collection in the pleural

cavity (75cc) that can not
be seen in the PA chest x-
ray
Lateral Chest X-Ray

Technique:
1. The patient stand
between the film and
the x-ray tube.
2. The lateral side of the
anomalies (right/left)
was closed to the film.
3. Both arms was lifted
up.
4. Centre: 6th -7th thoracic
spine
R
L AORTIC ARCH
TRACHEA

OBLIQUE FISSURE

POSTERIOR RIBS
RT. HEMI
DIAPHRAGM

LT. HEMI DIAPHRAGM

COLON GAS
Thorax Lateral
 Oblique Position
Indication:
To look at anomalies that were not clear at PA and

lateral position.

Type:
Right anterior oblique (RAO)
Left anterior oblique (LAO)
Right posterior oblique (RPO)
Left posterior oblique (LPO)

The side that is mentioned is the side that was close

to the film
RAO: The right side and the anterior side was
close to the film
LPO: The left side and the posterior side was
close to the film.
 Oblique Position
Indication:
To look at anomalies that were not clear at PA

and lateral position.

Techniques:
1. The patient stand between the film and the
x ray tube.
2. The side that is mentioned is the side that
is close to the film
3. The angle of obliquity is approximately 450.
4. The arm that was close to the film was put
over the head, while the other hand was put
on the waist with the elbow flexed to the
RAO LAO
Lateral Decubitus

Indication:
To look for
minimal fluid
collection in the
pleural cavity
(15-20cc) that
can not be seen
in the PA chest
x-ray

Technique:
1. The patient lying in the table with the lateral
side close to the table.
1. RLD : The right side of the body is close to the
table
2. LLD : The left side of the body is close to the table
2. Both arms are lifted.
3. Centre: 6th 7th thoracic spine
LLD/RLD
Top Lordotic

Indication:
To look for
anomalies at
the apex of
the lung.
Technique:
1. The patient stand between the film and the x-ray tube.

2. The patient is facing the x-ray tube.

3. The distance between the patient and the film is 30cm

4. The patient then rest the back of his shoulder to the

film.
5. The upper border of the film is approximately 1 inch
above the shoulder.
6. Centre: manubrium of the sternum
TOP LORDOTIK
15 STEPS TO READ CHEST X-RAY
 15 STEPS TO READ CHEST X-RAY

}
1: Name & Age
2: Date
3: Medical record number Administration
4: Previous examination
5: Position/View: PA/AP/Marker

}
6: Penetration
7: Rotation
8: Inspiration Quality
9: Magnification
10: Angulation

}
11: Trachea, heart, sinuses, diaphragm
12: Hilum, bronchovascular marking
13: Lung field, hemithorax Diagnostic
14: Soft tissue, bone
15: Conclusion
 Administration

Identity: Name & Age

Date
Medical record number
Previous examination
Position/view:
PA/AP/Marker
Quality

Penetration
Rotation
Inspiration
Magnification
Angulation
Penetration

Higher kV higher penetration ability of

the x-ray. (quality of the x-ray)
Higher mAs higher quantity of the x-
ray higher amount of x ray that
penetrate the body
Higher kV lower contrast resolution
The ability to differentiate between high
density and low density object will be
decreased with higher kV.
Penetration
So to get a good penetration film with a
good contrast resolution, we should use
low kV with high mAs. But there is a
problem because the radiation dose will
be higher with lower kV and higher mAs.

Our goal is to get the best quality of the

image with the lowest radiation dose to
the patient.
Penetration
Fine vascular markings within the lung
should be seen.
Faint outlines of at least mid and upper
thoracic vertebra
3rd thoracic vertebra in conventional
radiograph
All of the thoracic vertebra in digital
radiograph
Faint outlines of posterior ribs through
heart and mediastinal structures.
Penetration

Conventional Digital
Penetration
Rotation
It should be symetrical.
Look at the distance from the medial end
of both the clavicles to the spine process
in the midline.
Inspiration
Level inspirasimaksimal
Apex of the diaphragm at the level 5th-6th
anterior ribs.
9th 10th posterior ribs at the level of right
cardiophrenic sulcus.
2
3 1
4
5
6

10
How to differentiate anterior
ribs from posterior ribs
 Example of poor inspiration

Spurious findings : cardiomegaly, mass at

the aortic arch, patchy opacification in
 Example of poor inspiration

Spurious findings : cardiomegaly, mass at

the aortic arch, patchy opacification in
 Magnification
Influence the heart size assessment.
Depend on the patient position toward
the film.
PA chest x-ray is more accurate in
depicting the heart size than AP chest
x-ray.
Reason:
The distance between the heart and
the film is closer in PA chest x-ray.
Not significant in patient < 4 years
old.
Magnification

AP PA
Distortion in AP Chest X-
Ray
 Angulation

In erect chest x ray (without cephalad or

caudal angulation) the beam of the x-ray is
paralel to the floor and perpendicular to the
thorax the clavicle is projected below the
posterior aspect of the first rib.
In top lordotic (cephalad angulation) the
clavicle (anterior structure) is projected above
the posterior aspect of the first rib (posterior
structure).
In top lordotic, the normal S shaped clavicle
will be seen as straight structure.
The assessment of thoracic structure will be
influenced by the angulation.
Trachea
Lucent structure contain air.
Centrally located.
Normal diameter : 1,5 cm
Look for deviation.
Extend to the carina at the level of the
sternal angle (T5 level)
T4 level on expiration
T6 level on inspiration
Tracheal bifurcation (carina) normal
angle <900
>900 in left atrial enlargement.
Trachea
Heart
Size : Cardiothoracic Ratio (CTR)
Shape
Position
Size

CTR : a + b
c+d
a
b
c
c d
Size

Normal CTR
Adult (PA) < 50%
Adult (AP) < 55%
Normal CTR (PA)
Neonates (<1month) < 60%
Infant (1 month 1 year) < 55%
Children (>1 year) < 50%
Sinuses or Sulci

Costophrenicus
Cardiophrenicus
Diaphragm
Right
diaphragm is
higher than the
left diaphragm.
Normal : 2.5 cm
> 3 cm:
abnormal
Shape :
Tenting
Scalloping
Diaphragm

Diaphragm flattening
N>1,5cm
<1,5 flattening
Lung

Lungs contain
air that will
give negative
contrast
black (lucent)
Compare the
right lung with
the left lung
 Lung Zone
Apex
From the apex to the
clavicle
Upper lung field
From the clavicle to the
2nd anterior rib
Middle lung field
From the 2nd anterior
rib to the 4th anterior rib
Lower lung field
From the 4th anterior rib
to the diaphragm
 Other Division of the Lung Zone

Divided by the upper

and lower border of
the hilum.
Upper zone
Above the upper border
of the hilum
Middle zone
From upper border of
the hilum to the lower
border of the hilum
Lower zone
Below the lower border
of the hilum
 Hilum (plural: Hila)
Latin: Hilus (plural: hili)

The area where the

vessels (artery and
vein), bronchus, and
lymphatic vessels
come in to and come
out from the lung.
Normal left hilum is
higher than the right
hilum (about 1 rib)
The diameter is
about 9-16 mm or
not bigger than
trachea
PULMONARY ARTERY
PULMONARY VEIN
Bronchovascular Marking
Extend from the central to the
peripheral area.
Decreasing in quantity and calibre
from the central to the peripheral.
Increased bronchovascular marking if
> 2/3 of the hemithorax.
More crowded in the basal region.
Bronchovascular Marking
Cranialization or cephalization :
Upper zone bronchovascular marking is
more prominent than the lower zone
Ratio 3-5:1
Bronchovascular Marking

NORMAL INCREASED
Soft Tissue and Skeletal

SKELETAL:
Ribs
Clavicles
Scapula
SOFT TISSUE
Breast shadow
Skin fold.
Expertise
International : peripheral to central
RSHS: central to peripheal
 Contoh Ekpertise
Trakea di tengah
Cor tidak membesar
Sinuses dan diafragma kanan/kiri normal
Pulmo:
Hili normal
Corakan bronkovaskuler normal
Tidak tampak bercak lunak

Kesan:
- Tidak tampak TB paru/kelainan paru
lainnya
LATERAL CHEST X RAY
 How to read lateral chest x ray
Quality
Retrosternal space
Retrocardiac space
Posterior sinus
Anterior sinus
Diaphragm
Hilar area
Lung field
How to read lateral chest x ray

Quality
From apex to the sinus.
From sternum to the
posterior ribs.
Chin and arms
elevated sufficiently
No rotation
No motion (sharp
outlines)
Visualize rib outlines
and lung marking
through the heart
shadow
How to read lateral chest x ray

Retrosternal
space
Covered by heart

shadow < 1/3

bottom
Abnormal >

Retrocardiac
space
Clear triangular

shaped
How to read lateral chest x ray

Anterior sinus
Sharp

Sometimes

covered by
mediastinal fat
Depend on the

exposure of the
film.
Posterior sinus
Sharp
How to read lateral chest x ray

Diaphragm
Right diaphragm is

higher.
Right diaphragm is

seen from the

posterior to the
anterior.
Anterior aspect of left

diaphragm is covered
by the heart shadow.
Gastric bubble below

the left diaphram.

How to read lateral chest x ray

Hilar area
Mass will make

this area more

opaque
Vascular

opaque
Bronchi lucent
How to read lateral chest x ray

Lung field
Clear lung at the

anterio and
posterior of the
heart.
Decrease density

from superio to
inferior in the
posterior
mediastinum.
 Contoh Ekpertise
Retrosternal dan retrocardiac space
cerah.
Sinus anterior tajam.
Sinus posterior tajam.
Diafragma jelas.
Tidak tampak infiltrat.
PATHOLOGIC FINDINGS IN
CHEST X-RAY
 INDICATION OF CHEST X-RAY
Signs and symptoms potentially related to the
respiratory, cardiovascular, and upper
gastrointestinal systems, and the musculoskeletal
system of the thorax.
Screening for neoplasma or metastasis
Follow-up of known thoracic disease
Monitoring of patients with life-support devices and
other devices in the thorax region
Evaluate foreign body
Screening in trauma patient
Surveillance for active tuberculosis or occupational
lung disease
Preoperative radiographic evaluation
 PATHOLOGIC FINDINGS IN
CHEST X-RAY

o Heart Failure and pulmonary edema

o Pleural Effusion
o Pulmonary Contusion
o Atelectasis
o Diaphragmatic Hernia
o Flail chest

o Corpus Alienum Aspiration

o Hemothorax
o Pneumonia
o Pneumothorax
o Rib fracture
o Pneumonia Aspiration
 Heart Failure and Pulmonary
Edema
Heart is enlarged to the left with the
apex downward toward the
diaphragm.
Hilar hazyness.
Infiltrates in the 2/3 medial of both
lung
bat wing appearance
butterfly appearance
Heart Failure and Pulmonary
Edema
Pleural Effusion
Pulmonary Contusion
Pulmonary Contusion with Ribs
Fracture
Atelectasis
Atelectasis
Atelectasis
Diaphramatic Hernia
Flail Chest
Corpus Alienum Aspiration
Hemothorax
Right Middle Lobe Pneumonia
Right Inferior Lobe Pneumonia
Tension Pneumothorax
Rib Fracture
Aspiration Pneumonia
Aspiration Pneumonia with
Thymic Shadow in an Infant
Thank You