1. NORMAL CHEST X RAY

2. How to obtain a good quality chest radiography (1)
3  aspects are very important for good quality:
The penetrating power of the x-ray beam (adjustment of x-ray tube voltage )
The x-ray tube current (milliampere)
The exposure time adjustment

3. How to obtain a good quality chest radiography (2)
The adjustment of the x-ray tube voltage controls the contrast: the difference of density levels of the different organs and tissues in the thorax
The x-ray tube current and the exposure time controls the intensity of x-ray beams

4. How to obtain a good quality chest radiography (3)
Adjustment of voltage
High voltage: a range of 100 /120 kV: optimal contrast between lungs and bones, and good visualisation of mediastinum and vessels
Exposure time
<0.05 seconds: decrease of motion artefact caused by the beating of the heart or respiratory movement

5. How to obtain a good quality chest radiography (4)
A long distance between the tube focus and the film improves the image clarity
and decreases the geometric blur

6. How to obtain a good quality chest radiography (5)
Other criteria
Quality of the x-ray grid: the flat metallic plate with very narrow lead trips close to the film: increase in the image clarity and reduction of the scattered radiation from the patient
Good quality electrical power supply
Efficient and frequent maintenance of x-ray equipment
Quality of films and good conditions of storage
Good screen-film system
Good techniques for x-ray film processing (developing, rinsing, fixing, washing and drying procedure). If possible
automatic film processor.

7. What about digital X ray system?(1) (Direct Digitalised System)
composed with:
Electronic flat-panel X ray detector
High resolution grayscale diagnostic display
High performance computer

8. What about digital X ray system ?(2)
Avantages:
-feasible imaging quality adjusted by computer processing
-easy and quick image processing
-X-ray film and its processing procedures in dark room no more needed.
-Lower dose radiation
- imaging transmission and intepretation via internet to referent radiologist is easily possible
Disadvantages:
- Costly initial investment (61000 to $)
- Significant trainning in digital technology needed for the radiological technicians and costly running maintenance

9. Possible compromise with computed radiography (CR system)
digital radiography using a Photo‐stimulable Phosphor plate (PSP, also called Imaging Plate, IP) enclosed in a cassette as a detector, instead of a film‐screen.
The IP is then introduced into a CR Reader which reads the film and converts the recorded signal into a digital grey scale image
Same avantages than digitalised system
Lower cost than DR system, because can be used with the existing X ray equipment. Only a CR reader and CR cassette reader (with Imaging Plates) need to be purchased..

10. Basic radiographic views:
Postero-anterior view
Lateral view
Additional/supplementary view:
radiography in expiration
radiography in supine and lateral position
Back view (antero-posterior view)
Opacification of the oesaphagus

11. The thorax is composed of:
Bone (vertebrae, ribs, scapula…). The main component is calcium, which absorbs the x-ray considerably: the bone image is very opaque (white on the radiography)
Blood and soft tissue (heart, mediastinum, vessels). The absorption of x-rays is less complete than bones: the image is less opaque (light grey)
Fat tissue. the absorption of x-rays is lower: the image is dark grey.
Air (in lungs) which does not absorb the x-ray at all. The image of the lungs is black

12. Picture of 4 different solutions on a chest x-ray film
calcium
water
oil
Air

13. calcium
Fluid / soft
tissu
air
Fat

14. Dosage of x-rays type of investigation Equivalent of chest x-ray
Equivalent of natural radiation
chest x-ray 1
3 days
TDM
1 month-1year
NMR: no radiation

15. Chest x-ray: criteria for quality
Deep inspiration
Adequate contrast / density
Good position of the patient
X-ray beam in postero-anterior view (the patient is standing)

17. Same patient with deep inspiration Poor inspiration
False opacity of the inferior lobes
Adequate inspiration if you can count
9 posterior or 6 anterior parts of ribs over the diaphragm

18. PA is the correct view false cardiomegaly AP versus PA view
clavicles are high and horizontal
The x-ray beam is antero posterior
Same patient with correct
postero-anterior x-ray beam
incidence
PA is the correct view
The technician should specify the position of the patient if AP view

19. The heart outline is bigger on D2
( bird’s-eye view of the patient)

20. Correct standing or sitting position for chest radiography

21. Standing or sitting position not always easy to obtain…

22. If the patient is in
supine position (too ill
to stand up), the cardiac
outline and mediastinum
is enlarged. The scapula
may be on the lung field.
The chest x-ray has
poor quality for analysis

23. The technician should specify the patient position if supine
Standing patient with
postero-anterior X ray beam
Patient in supine position
The technician should specify the patient position if supine

24. Dark film Lighy film no detail visible in the lung area
Under penetration
No detail visible
in the mediastinum area.

25. Correct density and good contrast:
- Pulmonary vessels visible in the lungs, behind the diaphragm
and behind the heart
Para-aortic line visible
- Vertebra visible behind the mediastinum

26. Conditions for adequate contrast / density
Correct x-ray factor (Kv, Mas, exposure time)
Good conditions of developing and good quality of processing chemicals
Correct temperature of developer
correct quality of film
In case of digitalised or computerised system, imaging quality is adjusted by computer processing and the 3 last conditions are no more needed.

27. Exact front view : the vertical line connecting the spinous process of thoracic vertebrae is in the middle of the two sterno-claviculars joints.

28. exact PA view left anterior oblique position

29. Front View l a o r a o D1 D2 D3
D3> D1>D2

30. Chest x-ray: to ensure top quality
deep inspiration
adequate contrast / density
correct position of the patient (exact front view)
x-ray beam in postero anterior view (the patient is standing)

31. Process for analysis of the chest radiography: the check list
Verification of name and date
Clinical history and findings
Verification of the factors for good quality
Assess
-thoracic wall and thoracic skeleton
- mediastinum
- each lung field, one after the other
Do not skip any item in the checklist !

33. Normal chest radiography
and some pitfalls…
( trouble-shooting)

34. Thoracic wall
And skeleton

35. Sternocleidomastoid muscle
Thoracic wall
Sus and retro clavicular field
External side of
Sternocleidomastoid muscle

36. thoracic wall 1 3
The clavicles are projected on the level of the 3rd or 4th posterior part of ribs 4

37. Cervical ribs: minor malformation

38. Be aware of foreign body or artefacts
on the chest x-ray
trap picture: opacity of the superior part of right lung due to a hair braid

39. Breast implant

40. The retro-clavicular fields are always difficult to analyse, because of bone superposition:
- Clavicles
- Anterior part of first rib
- Posterior part of third and fourth rib,
- Sterno-clavicular joint

41. There are 2 ways to correctly analyse the retro-clavicular fields:
Always compare right and left
Ask for a chest x-ray with the patient’s back against the film (AP view, lordotic position)

42. Always compare left and right
Right TB infiltrate

43. Patient with fever, cough,
AFB sputum positive…

44. You have no CT scan. So use your eyes and compare right and left!
If any doubt, request AP/ lordotic
chest X ray

45. Normal AP chest x-ray,
back close to the film
Normal chest x-ray ,
front close to the film

46. Chest x-ray, back close to the film And clavicles out of the field
by raising hands
Chest x-ray, front close to the film

47. Chest x-ray back close to the film

48. physiological blur of the inferior side of the ribs
Thoracic wall
physiological blur of the inferior side of the ribs
Rib view section

49. You must always « read » a chest x-ray with methodology:
Example: for the chest wall, you must look at every rib, one after the other
(6th and 9th ribs missing on this CXR)

50. Chest wall
Top of the axillar hole
Big pectoral muscle

51. thoracic wall
Scapula

52. What is wrong with this chest x-ray?
Congenital clavicles agenesy

54. Thoracic wall
Breast silhouette

55. Be careful with false opacities in the inferior lobes, consequences
of breast superposition.

56. Chest x-ray. Before and after right mastectomy

57. The right side is usually higher than the left side (3cm )
Thoracic wall
Diaphragm
The right side is usually higher than the left side (3cm )

59. Component elements of
Mediatinum and hilus

60. AO AO PA LA RV RA RV LV LV

61. Front view Lateral viewAO
SVC AO PA PA LV RA LA RV LV
Front view
Lateral view
SVC: superor vena cava
AO : aortic vessel
PA: pulmonary artery
RA:Right ventricle
LV left ventricle
LA: left auricle
RV: right venticle LA RA LV RV

62. Left pulmonary
artery
Right pulmonary
artery

63. The pulmonary vena are not physiologiccally visible
RSPV
LPSV
L A
RIPV
L V
The pulmonary vena are not physiologiccally visible

64. Mediastinum lines
X ray beam crossing thorax and mediastinum meets in some places pleural thickness, producing images on the CXR like lines defining mediastinum lines…

65. Too complicated And not so usefull… Mediastinum lines
1. Sub clavicle arterial line
2. Posterior mediastinum line
3. Brachio cepahalic vena line
4. para-azygos line
5. Anterior mediastinum line
6. Descending aortic line
7. Right and left paravertébral line
8. Inferior veina cava line
9. para-œsophageal line
10. para-trachéal line
Too complicated
And not so usefull… 6

66. Three of them are really important.
Right paratracheal line
Aorto pulmonary line
Para-aortic line
Three of them are really important.

67. Mediastinum enlargment due to fat tissu

68. Be aware of false enlargment of mediastinum if obesity, poor inspiration, oblique view or supine position

69. Trap: false mediastinum enlargment in the case of this older woman with cyphoscoliosis, in supine position

71. Component elements of lungs

72. On a normal chest x-ray, bronchi are not visible
(opacification with iodin hydrosoluble solution)

73. …but pulmonary arteries are visible.

76. Small fissura
Big fissura
Right view

77. Left fissura
Left view

78. Right superior lobe pneumonia
minor fissura
Right superior lobe pneumonia
minor fissura
Large oblique fissura posterior part

80. Right inferior pneumonia
Large oblique fissura

82. Middle lobe pneumonia Large fissura minor fissura
Small pleural effusion

84. External segment of middle lobe pneumonia

85. External segment of middle lobe pneumonia

86. Left superior lobe pneumonia

88. Left inferior pneumonia
Left scissura

91. Normal lateral view

92. Lateral view

93. AO PA LA RV LV

94. Front view Lateral viewAO
SVC AO PA PA LV RA LA RV LV
Front view
Lateral view LA RA LV RV

95. Heart and Mediastinum vessels
Superior vena cava
Heart and Mediastinum vessels
Ascending
Aorta
Pulmonary arteria
Right ventricle
Descending
aorta

96. Heart and
Mediastinum
vessels
Left
ventricle
Inferior
vena cava

97. Mediastinum vessels
Aortic arch

98. mediastinum vessels
Descending aorta

99. Right pulmonary artery
Mediastinum vessels
Right pulmonary artery
Left pulmonary artery

100. normal CXR
Lateral view is very useful for diagnosis of mediastinal adenopathies

101. trachea
20 mm

102. Right superior lobe bronchus Left superior lobe bronchus

104. The «clear spaces»
Retro sternal clear space
Retro cardiac clear space

105. The «clear spaces»
Retro tracheal space

106. enlargment of the clear spaces: Emphysema

107. Emphysema
Normal lateral view

108. The retro sternal space is filled: thymoma

109. The retro sternal space is filled: thymoma. Normal view on the right

110. Diaphragm
Right diaphragm
Left
diaphragm

111. Summary normal CXR

112. Normal frontal chest view Aortic arch (AA) Descending aorta (DA)
Proximal left pulmonary
artery (PLPA)
Left interlobar pulmonary
artery (LPA)
Aortopulmonary window (AW)
Left main bronchus (LB)
Left atrial appendage (LAA)
Left ventricle (LV)
Superior vena cava (SVC)
Right paratracheal stripe
(RPS)
Azygos vein (AV)
Right interlobar pulmonary
artery (RIPA)
Right atrium (RA)
Trachea (T)
Right diaphragm (RD)
Left diaphragm (LD) T T
SVC
SVC
A A
RPTS
A W AV
LPA
RIPA LB DA RA RD LV LD

113. Normal lateral chest view
Posteriorly: vertebral bodies (V) and intervertebral disc spaces (*)
Anteriorly: retrosternal clear space (RSCS)
Trachea (T)
Orifice of Right Upper Lobe bronchus (RUL) appears as circular lucency projecting over the continuation of the tracheal air column
Left pulmonary artery (LPA)
Right pulmonary artery (RPA)
Left auricle (LA)
Left ventricle (LV)
Right ventricle (RV)
Aortic arch (AA)
Postero costo phrenic angle (PCPA)
Right diphragm (RD)
Left diaphragm (LD)
Inferior vena cava (IVC)
Scapula (Sc)
Retro cardiac clear space (RCCS) T Sc AA
RSCS
RPA
LPA
RUL RV LA V
RCCS * LV
IVC LD RD
PCPA