Chest X-ray

Interpretation

Dr Mohamed Osman
MRT, PHO, MBBS and MPHN
Why order a
CXR?
SYMPTOMS:
 Bad or persistent cough
 Chest pain
 Chest injury
 Coughing up blood
 Fever
 Shortness of breath
 S/P fall
Why order a CXR?
 Pleural effusion  Lung cancer
 Pneumothorax  Chest pain
 Hemothorax (MI?)
 Pulmonary embolus  Hypertension
 Trauma  Screening
 Monitoring chest  Pneumonia
drainage  COPD
 TB  Asthma
 Essentials Before Getting
Started
 Exposure
– Overexposure
– Underexposure
 Sex of Patient
– Male
– Female

Overexposure causes a film to be too dark. Under these circumstances, the thoracic spine,
mediastinal structures, and retrocardiac areas are well seen, but small nodules and the fine
structures in the lung cannot be seen.
 Essentials Before Getting
Started
 Path of x-ray beam
– PA
– AP
 Patient Position
– Upright
– Supine
 Essentials Before Getting
Started
 Breath
– Inspiration
– Expiration
 Systematic Approach
 Bony Framework
 Soft Tissues
 Lung Fields and Hila
 Diaphragm and Pleural Spaces
 Mediastinum and Heart
 Abdomen and Neck
 Systematic Approach
 Bony Fragments
– Ribs
– Sternum
– Spine
– Shoulder girdle
– Clavicles
 Systematic Approach
 Soft Tissues
– Breast shadows
– Supraclavicular areas
– Axillae
– Tissues along side of
breasts
 Systematic Approach
 Lung Fields and Hila
– Hilum
 Pulmonary arteries
 Pulmonary veins
– Lungs
 Linear and fine nodular
shadows of pulmonary
vessels
– Blood vessels
– 40% obscured by other
tissue
 Systematic Approach
 Diaphragm and
Pleural Surfaces
– Diaphragm
 Dome-shaped
 Costophrenic angles
– Normal pleural is not
visible
– Interlobar fissures
 Systematic Approach
 Mediastinum and
Heart
– Heart size on PA
– Right side
 Inferior vena cava
 Right atrium
 Ascending aorta
 Superior vena cava
 Systematic Approach
 Mediastinum and
Heart
– Left side
 Left ventricle
 Left atrium
 Pulmonary artery
 Aortic arch
 Subclavian artery and
vein
 Systematic Approach
 Abdomen and Neck
– Abdomen
 Gastric bubble
 Air under diaphragm
– Neck
 Soft tissue mass
 Air bronchogram
 Summary of Density
 Air
 Water
 Bone
 Tissue

Tissue
 Pitfalls to Chest X-ray
Interpretation
 Poor inspiration
 Over or under penetration
 Rotation
 Forgetting the path of the x-ray beam
 Lung Anatomy
 Trachea
 Carina
 Right and Left Pulmonary
Bronchi
 Secondary Bronchi
 Tertiary Bronchi
 Bronchioles
 Alveolar Duct
 Alveoli
 Lung Anatomy
 Right Lung
– Superior lobe
– Middle lobe
– Inferior lobe
 Left Lung
– Superior lobe
– Inferior lobe
Lung Anatomy on Chest X-ray
 PA View:
– Extensive overlap
– Lower lobes extend
high
 Lateral View:
– Extent of lower lobes
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.
 The Normal Chest X-ray
 PA View:
1. Aortic arch
2. Pulmonary trunk
3. Left atrial appendage
4. Left ventricle
5. Right ventricle
6. Superior vena cava
7. Right hemidiaphragm
8. Left hemidiaphragm
9. Horizontal fissure
 The Normal Chest X-ray
 Lateral View:
1. Oblique fissure
2. Horizontal fissure
3. Thoracic spine and
retrocardiac space
4. Retrosternal space
 Compare symmetry


Normal Chest X-Ray Review organs (bones,

lungs, heart) in sequence
 Left to Right then…
Top to Bottom
 Random free search

Recognition of abnormal
first requires knowledge
of normal. Over
diagnosis of normal
variation may be more
serious than omission &
may lead to needless &
harmful therapy.
The Normal Chest X-Ray
 Systematically evaluate
chest wall,
mediastinum, lungs,
pleural space, heart,
large arteries, ribs &
diaphragm.
 Also evaluate neck,
Whataxilla,
does air under diaphragm
thyroid gland &
signify?
abdomen
What is best position for this
diagnosis?
The Normal Chest X-Ray

 You can recognize air,

water & bone density
on chest x-ray
 Lung fields appear
dark because of air.
– 99% of the lung is air.
The Normal Chest X-Ray

 The pulmonary vasculature,

interstitial space, constitutes
1% of the lung
 Gives a lacy lung pattern.
 Most disease states replace air
with a pathological process
which usually is a liquid
density and appears white.
 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
 Missed Diagnoses
10% of all x-ray interpretations have errors

What is wrong with Nothing!!

this lung tissue??? But the clavicle is
fractured!

Especially if there are

multiple problems,
don’t focus on the
most obvious
abnormality!
 Systematic CXR
Interpretation
 IDENTIFICATIO  TECHNIQUE
N – Complete exam?
 All views
– Correct patient
 Entire anatomical area
– Correct date & included?
time – Projection
– Correct  Is the film AP or PA?

 The width of heart &

examination
mediastinum larger on
 Right vs. Left side AP film
 Comparison film – Position
 Systematic CXR
Interpretation
 TECHNIQUE, cont.
 TECHNIQUE, cont.  Inspiration
– Penetration  Normal, erect,
 Over-penetrated dark
inspiratory CXR shows
films can obscure 9.5-10.5 ribs.
subtle pathologies  Less inspiration
 Under-penetrated
appears diffusely
white films may given denser
impression of diffuse  Diaphragms elevated
increased density causing heart &
mediastinum to appear
enlarged
Systematic CXR
Interpretation
 TECHNIQUE, cont.
 Rotation
 Determined by

distance between
spinous process &
medial clavicle
 Affects heart size &

shape, aortic tortuosity,

mediastinal widening,
density of lung fields
 Systematic CXR

Interpretation
INTERPRETATION  INTERPRETATION
 Extraneous material  Bones
 Contrast
 Fracture, dislocation
 Lines, tubes, clips
 Mineralization
 All properly located?
 Lung fields
 Soft tissues  Asymmetry
 Asymmetry  Consolidation
 Calcifications
 Nodules, lesions
 Diaphragms & Below  Heart
 Free air  Size & shape
 Dilated bowel
 Cardiothoracic ratio
 Abnormal position
 Systematic CXR
Interpretation
 INTERPRETATION
 INTERPRETATION  Pulmonary vascularity
 Mediastinum  Taper at periphery
 Width
 Narrow toward upper
 Masses
lobes with erect film
 Contour  Asymmetry

 Hila  Interstitial markings

 Asymmetry  Very fine
 Vessel aneurysm  If indistinct, prominent
 Trachea & carina suspect edema, fibrosis
 Interpretation Of The CXR:

1.Demographic date : name , DOP, hospital

2.Image quality: assess the quality of the image: a mnemonic you may find
useful is ‘RIPE
3.The ABCDEFGH approach can be used to carry out a structured
interpretation of a chest X-ray.
4.Differential diagnosis
5.diagnosis
6.Management
 Image quality: assess the quality of the image: a
mnemonic you may find useful is ‘RIPE
 Rotation
 The medial aspect of each clavicle should be equidistant from the spinous
processes.
 The spinous processes should also be in vertically orientated against the
vertebral bodies.
 Inspiration
 The 5-6 anterior ribs, lung apices, both costophrenic angles and the lateral rib
edges should be visible.
 Projection
 Note if the film is AP or PA: if there is no label, then assume it’s a PA film (if
the scapulae are not projected within the chest, it’s PA).
 Exposure
 The left hemidiaphragm should be visible to the spine and the vertebrae
should be visible behind the heart.
Rotation
Inspiration
Projection
Exposure
The above radiograph shows good penetration
with the spine and bronchovascular structures
behind the heart visible.

This radiograph is over penetrated, with loss of

lung markings

This radiograph is under penetrated with

increased lung markings.
 The ABCDEFGH approach can be used to carry out
a structured interpretation of a chest X-ray

 A: Airway
• B: Bones
 C: Circulation
 D: Diaphragm
 E: Edges (lung borders )
 F: Fields (infiltrates , air bronchograms)
• G: Gastric bubble
• H: hilum of the lung
Airway structures on the chest X-Ray
(
Red Arrows: trachea, Green Arrow: carina, Pink Arrows: left and right main bronchus )
B: Bones
C: Circulation
D: Diaphragm
Putting It All Together
 Liquid Density
Liquid density Increased air density

Generalized Localized

Infiltrate
Diffuse alveolar Localized airway obstruction
Consolidation
Diffuse interstitial Diffuse airway obstruction
Cavitation
Mixed Emphysema
Mass
Vascular Bulla
Congestion
Atelectasis
 Stages of Evaluating an
Abnormality
1. Identification of abnormal shadows
2. Localization of lesion
3. Identification of pathological process
4. Identification of etiology
5. Confirmation of clinical suspension
 Complex problems
 Introduction of contrast medium
 CT chest
 MRI scan
 Case 1
Patient Data
Age: 35 years
Gender: Female
Fall from bicycle resulting in an injury of the anterior
chest by the handlebar. The patient complains of a
sharp pain in the chest, aggravated by deep breathing.
 Case 2
 General Data: E. J. 29 –years- old Male Baseco, Port Area,
Manila
 Patient was walking alone after a drinking session when
suddenly was approached by an unknown assailant and
allegedly stabbed on the back by a “knife
 Physical Examination BP = 110/ 60 mm. Hg RR = 23 cpm CR =
89 bpm
  Decreased Breath Sounds left
 • Dullness on Percusssion
Answer case 2
 Case 3
Patient Data
Age: 60 years
Gender: Male
Presentation
 Motorbike accident. Chest pain and shortness of
breath
Case 1
Substernal Thyroid Goiter. Frontal chest radiograph shows a large
superior/anterior mediastinal mass (white arrows) displacing the
trachea (black arrow) to the right of midline.
CONSOLIDATION

 Alveolar space filled

with inflammatory
exudate
– WBC, bacteria, plasma,
and debris
 Congestive Heart

Failure
Increased heart size:
cardiothoracic ratio >0.5  Large hila with
indistinct
markings
 Fluid in
interlobar
fissures
 Pleural effusions,
alveolar edema
ARDS
 Congestion
 Interstitial and
alveolar edema
 Collapsed or
distended alveoli
 Bilateral
SARCOIDOSIS
 Granulomatous
Inflammation
 Bilateral &
symmetrical hilar &
mediastinal LAD
 Generalized fibrosis
ATELECTASIS
 No ventilation to lobe
beyond the obstruction
 Trapped air absorbed by
pulmonary circulation
 Segmental/lobar density
 Compensatory hyper-
inflation of normal lungs.
 TENSION
PNEUMOTHORAX
PLEURAL EFFUSION
COPD
Let’s See How
Much You Paid
Attention
 Right
Lower
Lobe
Pneumoni
a
ET tube in right mainstem bronchus
Right side
tension
pneumotho
rax
Fracture of posterior rib #7
 Right
Side
Pleural
Effusion
Left Sided Pneumothorax
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
Right Middle and Left Upper Lobe Pneumonia
Case 3
Cavitation:cystic changes in the area of consolidation due to the
bacterial destruction of lung tissue. Notice air fluid level.
Cavitation
Case 4
Tuberculosis
Case 5
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 6
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 7
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 8
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 9
Chest wall lesion: arising off the chest wall and not the lung
Case 10
Pleural effusion: Note loss of left hemidiaphragm. Fluid
drained via thoracentesis
Case 11
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.
 Any

Questions?
GOOD LUCK