Interpretation of

Chest X-ray
 DENSITIES
Blackest Air< fat< liver< blood< muscle< bone<contrast<metal Whitest
 Technical Aspects

• Identification – name, file number, date & time

• Projection – PA or AP
• Position – Upright or Supine
• Inspiratory effort – ?poor inspiration
• Exposure - ?overexposed ?underexposed
– thoracic intervertebral disc space just visible
• Positioning/rotation
– medial clavicle heads equidistant to spinous process

M C Alraies 3
 PA or AP view

AP (Antero-posterior)
(portable)
PA ( Postero-anterior)

FILM
X-ray Beam
FILM

4
 LATERAL view
• To visualize a lesion in the left
thorax-left lateral view.
• To visualize a lesion in the
right thorax- right lateral view.
Decubitus View
• "decubitus" means "lying down“
• To confirm free flowing effusion.
 Oblique View — Ribs view
• Detailed study of the ribs
• Tracheal bifurcation
• Hila of the lungs.

Left Anterior Oblique — Right Anterior Oblique —

Left anterolateral chest Right anterolateral chest
next to film next to cassette

Lordotic Views
Especially good for viewing
the apices of the lungs
Expiratory View
• Useful in detecting unilateral obstructive emphysema (as from a
unilateral obstruction of a bronchus).
• Occasionally a small pneumothorax is only visible on expiration
Normal standards for following are in PA view only
1. Heart size
2. Mediastinal width
3. Position of diaphragm
4. Meniscus of pleural effusion
5. Vascular shadows
Is this a PA or AP film? Is this a PA or AP film?

• Heart appear larger

• Mediastinum widens
• Diaphragm are higher
• Pleural fluid layers posteriorly
• Pulmonary vascularity increase
and equal in upper and lower fields
Is this film centered? Is this film centered?
Is the exposure appropriate? Is the exposure appropriate? Is the exposure appropriate?

Over-exposed Under-exposed
Is this a good inspiration film? Is this a good inspiration film?
 Ribs
Posterior ribs are used as reference
• Identify the first rib
• # of ribs helps you determine how much lungs
are inflated and location of a lesion
• Anterior ribs are more perpendicular to X-ray
beam and thus not seen very well.
• 9 ribs = good inflation.
• 10 or more ribs = ? Hyper-inflated
 Ant. ribs

Post. ribs
Anatomy
0utline of Mediastinum
Area between right and left pleural cavity
• Superior : thoracic inlet
• Inferior : thoracic outlet (diaphragm)
• Antero-lateral : sternum and ribs
• Posterior : thoracic vertebrae
Superior mediastinum
Bounded superiorly by the thoracic inlet and inferiorly by a horizontal line
through the sternal angle.
Includes thyroid gland, aortic arch and great vessels, proximal portions of the
vagus and recurrent laryngeal nerves, esophagus and trachea.
 Anterior mediastinum
Sternum anteriorly, and the anterior cardiac surface posteriorly
Includes fat, ascending aorta, lymph nodes, internal mammary
artery and vein, thymus.
5Ts – Thyroid, Thymoma, TB, T cell lymphoma, Teratoma
 Posterior mediastinum
Borders: Anterior surface of the spine & posteriorly the ribs.
Structures include the descending aorta, adjacent osseous
structures (the spine and ribs) and nerves, roots, spinal cord,
and the azygous and hemiazygous veins
 Middle Mediastinum
Borders composed of the anterior mediastinal compartment ventrally, and the
anterior surface of the spine posteriorly.
Structures include the esophagus vagus nerve, recurrent laryngeal nerve, heart,
proximal pulmonary arteries and veins (hilar), trachea and root of the
bronchial tree, and superior and inferior vena cava
Cardiothoracic ratio Hilum Vascular markings

Left and right diaphragm Paratracheal stripe

right
Gastric
bubble
left
Lobar anatomy
 Right Lung Left LUNG

Upper lobe
Upper lobe
Lower Middle Lower
lobe lobe lobe

Right Lung Left Lung

2 fissures (oblique and 1 fissure (oblique)
horizontal). 2 lobes (upper and
3 lobes (upper, middle, lower)
lower) 8 segments
10 segments
 Right Lung
RUL RML RLL
 Left Lung
LUL LLL
Upper

Lingula
Segmental Anatomy
 Right Lung
RUL RML

Apical Lat

Med
Post

Ant
 Right Lung
RLL
Sup
Ant

Lat

Med

Post
 Left Lung
LUL Lingula

Sup
Apicopost

Inf.

Ant
 Left Lung
LLL

Ant
sup

Lat

Post
 SILHOUETTE SIGN

The
The Silhouette
Silhouette Sign
Sign

Silhoutte Adjacent lobe/segment

Right Diaphragm
Right Heart margin
Ascending Aorta
Aortic knob
Left Heart margin
Descending Aorta
Left Diaphragm
RLL/Basal segments
RML/Medial segment
RUL/Anterior segment
LUL/Posterior segemnt
Lingula/Inferior segment
LLL/post segment
LLL/Basal segments
Normal X-ray
Bronchiectasis Pulmonary edema Pleural effusion
COPD
ILD
RUL consolidation RUL collapse
Lingular consolidation RML lateral segment collapse
RUL posterior segment consolidation
Right lung collapse Massive right pleural effusion
Left Hydro-pneumothorax Left lower lobe collapse

Multiple cavities with air fluid level

Right lower lobe collapse
Cardiomegaly Bilateral Pleural effusion
Fluid in fissures (pseudotumor)
RLL consolidation RML consolidation
Left pneumothorax Left tension pneumothorax
LLL pneumonia
Pulmonary Embolism
Pulmonary Hypertension
Gas under diaphragm
Dextrocardia, situs inversus
Milliary TB
Sarcoidosis
RUL Mass
Right diaphragm paralysis
 Bronchiectasis

Cystic cylindrical Varicose

Azygos fissure and lobe
Thank You