BASICS OF

CHEST
RADIOGRAPHY
Ezekiel T. Arteta, MD
General Principles
• Have a systematic approach
• Interpret the CXR in conjunction with the clinical findings
• Always compare with previous CXR if available to assess for change
• Ask yourself “does my interpretation make sense?”
SYSTEMATIC CHEST X-RAY
INTERPRETATION
• IDENTIFICATION
• TECHNIQUE
• INTERPRETATION
IDENTIFICATION
• Correct patient
• Correct date and time
• Correct Examination
• AP vs PA view
• Right vs Left side
• Comparison film
PA vs AP View
Feature AP PA
Position of Horizontal Oblique
Clavicles
Scapula Over the lung Away from lung
field field
Spinolaminar Not significant Inverted “V”
Angle
TECHNICAL ASPECTS
• INSPIRATION
• PENETRATION
• ROTATION
• MOTION
TECHNICAL ASPECTS: Inspiration
• The volume of air in the hemithorax will affect the configuration
of the heart with question of cardiac enlargement with a shallow
level of inspiration.
• The vascular pattern in the lung fields will be accentuated with a
shallow inspiration.
TECHNICAL ASPECTS: Inspiration
• Apex of the right
hemidiaphragm is visible
below the tenth posterior rib.
TECHNICAL ASPECTS: Inspiration
TECHNICAL ASPECTS: Penetration
• Refers to adequate photons traversing the patient to expose the
radiograph.
• The lack of penetration renders the area “whiter” than with an
adequate film
• Can simulate pneumonia or effusion.
• Faint visualization of the intervertebral disk spaces of the thoracic
spine.
• Discrete branching vessels can be identified through the cardiac
shadows and the diaphragms.
• Faint visualization of
the intervertebral
disk spaces of the
thoracic spine.
• Discrete branching
vessels can be
identified through
the cardiac shadows
and the diaphragms.
TECHNICAL ASPECTS: Penetration
TECHNICAL ASPECTS: Penetration
TECHNICAL ASPECTS: Rotation
• Distorts mediastinal anatomy and makes assessment of cardiac
chambers and the hilar structures especially difficult
• Significant rotation may alter the expected contours of the heart
and great vessels, the hila, and hemidiaphragms.
TECHNICAL ASPECTS: Rotation
• If spinous process closer to the left clavicle = ROTATION TOWARDS
THE RIGHT SIDE
• If spinous process closer to the right clavicle = ROTATION
TOWARDS THE LEFT SIDE
DISTORTED
MEDIASTINUM DUE TO
TORTOUS AORTA AND
ROTATION.
Systematic
Systematic Approach
• Name/marker/rotation/ penetration
• Lines/metal work
• Heart
• Mediastinum
• Hilum
• Lungs (Zones: Upper / Middle / Lower)
• Diaphragm and Pleura
• Soft tissues
• Bones
Lines / Metal Work

Look for:

•Sternal wires (implies previous

thoracic surgery)
•Tip of endotracheal tube (2cm
above carina)
•Feeding tube
•Tip of Central Venous Line/ IJ
catheter
Heart
• Positioned two thirds to
the left unless have
dextrocardia
• Occupies up to 50% of the
maximum internal thoracic
diameter on a standard PA
erect view
• Cannot comment on heart
size on AP view because of
magnification of heart
Mediastinum
• The trachea should be centrally
located or slightly to the right
• The aortic arch is the first
convexity on the left side of the
mediastinum
• The pulmonary artery is the next
convexity on the left, and the
branches should be traceable as
it fans out through the lungs
• The lateral margin of the superior
vena cava lies above the right
heart border
Hila
• The hila consist primarily of the major bronchi
and the pulmonary veins and arteries
• The hila are not symmetrical, but contain the
same basic structures on each side
• The hila may be at the same level, but the left
hilum is commonly higher than the right (up
to 1 cm)
• Both hila should be of density
Lungs
• Normally, there are visible markings throughout the lungs due to
the pulmonary arteries and veins, continuing all the way to the
chest wall
• Both lungs should be scanned, starting at the apices and working
downward, comparing the left and right lung fields at the same
level (as is done with auscultation)
• On a PA radiograph, the minor fissure can often be seen as a faint
horizontal line dividing the RML from the RUL.
• The major fissures are not usually seen on a PA view because they
are being viewed obliquely.
Diaphragm
• The left dome is normally slightly lower than the right due to
elevation by the liver, located under the right hemidiaphragm.
• The costophrenic recesses are formed by the hemidiaphragms and
the chest wall.
• On the PA radiograph, the costophrenic recess is seen only on each
side where an angle is formed by the lateral chest wall and the
dome of each hemidiaphragm (costophrenic angle).
Diaphragm
• The highest point of the right diaphragm is usually 1–1.5 cm higher
than that of the left.
• Each costophrenic angle should be sharply outlined.
Diaphragm
• Assessment of diaphragmatic flattening
• The highest point of a hemidiaphragm should be at least 1.5 cm above a
line drawn from the cardiophrenic to the costophrenic angle.
Pleura
• The pleura and pleural spaces will only be visible when there is an
abnormality present
• Common abnormalities seen with the pleura include pleural
thickening, or fluid or air in the pleural space.
Bones and Soft Tissues
• Look at each rib in turn
• Clavicles
• Scapulae and humeri if visible
• Lower cervical and thoracic spine
• Look carefully at the soft tissues for
asymmetry (i.e. mastectomy)
Bones and Soft Tissues
• Thick soft tissue may obscure underlying structures:
• Thick soft tissue due to obesity may obscure some underlying
structures such as lung markings
• Breast tissue may obscure the costophrenic angles
• Lucencies within soft tissue may represent gas (as
observed with subcutaneous air)
Anatomy
Radiological Signs of Chest
Disorders
Silhouette Sign
• Indicates airspace disease
• Loss of the expected
interface normally created
by juxtaposition of two
structures of different
density
• No boundary can be seen
between two structures of
similar density Right Lower Lobe Pneumonia
Air Bronchogram Sign
Air Bronchogram Sign
• This sign indicates that the underlying opacity must be
parenchymal rather than pleural or mediastinal in location.
 Continuous Diaphragm Sign
• Continuous lucency outlining the base
of the heart, representing
pneumomediastinum.
• Air in the mediastinum tracks
extrapleurally, between the heart and
diaphragm .
• Pneumopericardium can have a similar
appearance but will show air
circumferentially outlining the heart.
Deep Sulcus Sign
• This sign refers to a deep
collection of intrapleural air
(pneumothorax) in the
costophrenic sulcus as seen
on the supine chest
radiograph.
Common Abnormal Findings
Consolidation
The lung is said to be consolidated when the alveoli and small
airways are filled with dense material.

This dense material may consist of:

• Pus (pneumonia)
• Fluid (pulmonary edema)
• Blood (pulmonary hemorrhage)
• Cells (cancer)
Atelectasis
• Almost always associated with a linear increased density due to
volume loss
• Indirect indications of volume loss include vascular crowding or
mediastinal shift toward the collapse
• Possible observance of hilar elevation with an upper lobe collapse,
or a hilar depression with a lower lobe collapse
Pneumonia
Typical findings on the chest radiograph include:

• Airspace opacity

• Lobar consolidation

• Interstitial opacities
Pleural Effusion
On an upright film, an effusion will cause blunting on the lateral costophrenic
sulcus and, if large enough, on the posterior costophrenic sulcus.
• Approximately 200 ml of fluid are needed to detect an effusion in a PA film,
while approximately 75 ml of fluid would be visible in the lateral view

In the AP film, an effusion will appear as a graded haze that is denser at the
base

A lateral decubitus film is helpful in confirming an effusion as the fluid will

collect on the dependent side
Pneumothorax
• Appears in the chest radiograph as air without lung markings
• In a PA film it is usually seen in the apices since the air rises to the
least dependent part of the chest
• The air is typically found peripheral to the white line of the visceral
pleura
• Best demonstrated by an expiration film
Pulmonary Edema
There are two basic types of pulmonary edema:
• Cardiogenic pulmonary edema caused by increased hydrostatic
pulmonary capillary pressure
• Noncardiogenic pulmonary edema caused by either altered
capillary membrane permeability or decreased plasma oncotic
pressure
Congestive Heart Failure
Common features observed on the chest radiograph of a CHF
patient include:
• Cardiomegaly (cardiothoracic ratio > 50%)
• Cephalization of the pulmonary veins
• Appearance of Kerley B lines
• Alveolar edema often present in a classis perihilar bat wing pattern
of density
Emphysema
Common features seen on the chest radiograph include:
• Hyperinflation with flattening of the diaphragms
• Increased retrosternal space
• Bullae
• Enlargement of PA/RV (cor pulmonale)
Lung Mass

A lung mass will typically present as a lesion with sharp margins and
a homogenous appearance, in contrast to the diffuse appearance of
an infiltrate.
Patterns of Chest Disease
Patterns of Chest Disease
• Airspace disease
• Airway disease
• Interstitial Disease
• Pleural disease
• Thoracic cage disease
Airspace Disease
Interstitial Disease
• Opacities produced by
processes that thicken
the interstitial
compartments of the
lung (water, blood,
tumor, cells, fibrous
tissues, or
combination)
Patterns of
Interstitial
Lung
Disease
Linear
• A linear pattern is seen when there is thickening of the interlobular
septa, producing Kerley lines
• The interlobular septa contain pulmonary veins and lymphatics
 Kerley A Lines
• Linear opacities that are either 2 to 6
cm long, <1 mm thick lines, that are
obliquely oriented and course through
the substance of the lung toward the
hila.
• Caused by distension of lymphatic
channels within edematous septa
coursing from peripheral lymphatics to
central hilar nodes.
• Less specific for pulmonary venous
hypertension
Reticular
• A reticular pattern results from the summation or superimposition
of irregular linear opacities.
• The term reticular is defined as meshed, or in a form of network.
• Can be described as fine, medium or coarse, as the width of the
opacities increase
• Fine = 1 – 2 mm
• Medium = 3 – 10 mm (honeycombing)
• Coarse = greater than 1 cm
• Diseases that most commonly produce this appearance include
interstitial pulmonary edema and usual interstitial pneumonitis.
Nodular
Type Size
Miliary <2 mm
Micronodule 2-7 mm
Nodule 7-30 mm
Mass >30 mm
Reticulonodular
Pulmonary Lucencies
• Cyst
• Well-circumscribed intrapulmonary gas collection with a smooth thin wall
>1 mm thick.
• Likely represent postinflammatory or posttraumatic lesions
• Cavity
• Form when a pulmonary mass undergoes necrosis and communicates with
an airway, leading to gas within its center.
• Wall is usually irregular or lobulated, greater than 1 mm thick
Benign Lung Cyst : PCP Pneumatocele
• Uniform wall thickness
• 1 mm
• Smooth inner lining
Benign Cavities :
Cryptococcus
Malignant Cavities: Squamous Cell Ca
Pulmonary Lucencies
• Bleb
• A small gas-containing space within the visceral pleura or subpleural lung,
<1 cm in diameter
• Usually formed in the apical portion of the lung
• Bulla
• An airspace measuring > 1 cm – usually several centimeters – in diameter
• Sharply demarcated by a thin wall that is no greater than 1 mm in
thickness
• Usually accompanied by emphysematous changes in the adjacent lung
• Bullous emphysema is bullous destruction of the lung parenchyma