1. Chest Radiography Interpretation
M Chadi Alraies, MD
Chief Medical Resident
Case Western Reserve University SVCH
M C Alraies

2. Reading CXR’s Have a structured method! Be consistent with that method
Don’t take short cuts
LOOK AT ALL YOUR PATIENTS XRAYS YOURSELF (and with your resident of course!)
PRACTICE…PRACTICE… PRACTICE

3. What is a Chest Radiograph?
SHADOW

4. Identification! Start at the beginning Are old films available?
Correct patient
Correct date and time
Correct examination
Are old films available?
DO THIS EVERYTIME – It buys you time and is vitally important.

5. Approach to the CXR: Technical Aspects
Projection – PA or AP
Position – Upright or Supine (Supine folks are sick)
Inspiratory effort
9-10 posterior ribs
Penetration
thoracic intervertebral disc space just visible
Positioning/rotation
medial clavicle heads equidistant to spinous process

6. Projection

7. Portable (AP or Antero-posterior)
FILM

8. PA (Postero-anterior)
FILM

9. Projection PA AP

10. Low Lung Volumes

11. Over Exposure
Proper Exposure

12. 9

14. Mental Break

15. Anatomy
RUL
RML

18. RUL (Right Upper Lung)

19. RML (Right Middle Lung)

20. RLL (Right Lower Lung)

21. Right Sided Fissures

22. LUL (Left Upper Lung)

23. LLL (Left Lower Lung)

24. Left Side Fissure
LUL
LLL

25. What to Evaluate Lungs Pleural surfaces Cardiomediastinal contours
Bones and soft tissues
Abdomen

26. Where to Look Apices Retrocardiac areas (left and right)
Below diaphragm

27. Apical TB

28. Left Retrocardiac Opacity

29. Normal Anatomy: Frontal CXR
Heart
Aorta
Pulmonary arteries
Airways
Diaphragm/costophrenic sulci

31. Normal Anatomy: Lateral
Heart
Aorta
Pulmonary arteries
Airways
Spine

32. Maximum x-ray Blackest Transmission (least dense tissue) Maximum x–ray
Absorption
(densest tissue)
Blackest
air
fat
soft tissue
calcium
bone
x-ray contrast
metal
Whitest

33. Chest Radiography: Basic Principles
A structure is rendered visible on a radiograph by the juxtaposition of two different densities

34. Silhouette Sign
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

35. Right Lower Lobe Pneumonia

36. Differential X-Ray Absorption
The absence of a normal interface may indicate disease;
The presence of an unexpected interface may also indicate disease
The presence of interfaces can be used to localize abnormalities

37. Chest Radiographic Patterns of Disease
Air space opacity
Interstitial opacity
Nodules and masses
Lymphadenopathy
Cysts and cavities
Lung volumes
Pleural diseases

38. LUL Pneumonia

39. Air Space Opacity Components:
air bronchogram: air-filled bronchus surrounded by airless lung
confluent opacity extending to pleural surfaces
segmental distribution

40. Air Space Opacity: DDX Blood (hemorrhage) Pus (pneumonia)
Water (edema)
hydrostatic or non-cardiogenic
Cells (tumor)
Protein/fat: alveolar proteinosis and lipoid pneumonia

41. Interstitial Opacity: Small Nodules

42. Interstitial Opacity:
Lines

43. Interstitial Opacity: Lines & Reticulation

44. Interstitial Opacity Hallmarks: small, well-defined nodules lines
interlobular septal thickening
fibrosis
reticulation

45. Interstitial Opacity: DDX
Idiopathic interstitial pneumonias
Infections (TB, viruses)
Edema
Hemorrhage
Non–infectious inflammatory lesions
sarcoidosis
Tumor

46. Well-Defined
Calcification
Ill-Defined
Mass

47. Nodules and Masses
Nodule: any pulmonary lesion represented in a radiograph by a sharply defined, discrete, nearly circular opacity mm in diameter
Mass: larger than 3 cm

48. Nodules and Masses Qualifiers: single or multiple size
border definition
presence or absence of calcification
location

49. Right Paratracheal
Lymphadenopathy

50. Right Hilar LAN

51. Right Hilar LAN

52. Left Hilar LAN

54. Subcarinal LAN *

55. AP Window LAN

56. Lymphadenopathy Non-specific presentations: Specific patterns:
mediastinal widening
hilar prominence
Specific patterns:
particular station enlargement

58. Cysts & Cavities
Cyst: abnormal pulmonary parenchymal space, not containing lung but filled with air and/or fluid, congenital or acquired, with a wall thickness greater than 1 mm
epithelial lining often present

59. Cysts & Cavities
Cavity: abnormal pulmonary parenchymal space, not containing lung but filled with air and/or fluid, caused by tissue necrosis, with a definitive wall greater than 1 mm in thickness and comprised of inflammatory and/or neoplastic elements

60. Benign Lung Cyst : PCP Pneumatocele
Uniform wall thickness
1 mm
Smooth inner lining

61. Benign Cavities :
Cryptococcus
max wall thickness 4 mm
minimally irregular inner lining

62. Indeterminate Cavities
max wall thickness 5-15 mm
mildly irregular inner lining

63. Malignant Cavities: Squamous Cell Ca
max wall thickness 16 mm
Irregular inner lining

64. Cysts & Cavities Characterize: wall thickness at thickest portion
inner lining
presence/absence of air/fluid level
number and location

65. Pleural Effusion

66. Pleural Effusion

67. Pleural Calcification

68. Pleural Disease: Basic Patterns
Effusion
angle blunting to massive
mobility
Thickening
distortion, no mobility
Mass
Air
Calcification

69. Thoracic Aorta Aneurysm

70. Chest breast implants

71. Rib fx’s
Mediast. OK
Pulmonary contusion
Subcu air
Chest tube
NG tube

72. MVC victim

73. Deep Right Mainstem Intubation
Carina
Tip of ET tube
Deep Right Mainstem Intubation

74. Tip of ET
Pneumomediastinum

75. Potential X ray findings
wide mediastinum
obliteration of aortic knob
Rt mainstem shift up and right
NG deviate to right
pleural cap
Major Vessel Injury

76. Pneumothoraces

78. Expiration reduces lung volume, making a small pneumo easier to see

87. Irregular linear opacities are present in both lungs, especially in the periphery and the bases of the lungs. The heart is slightly enlarged, but this is not related to the pulmonary abnormalities in this case.

90. Hodgkin’s Disease

91. Ao
SVC
Mediastinal Hematoma

92. Tracheal deviation to Rt. ET tube First rib fx Obliterated aortic knob
NG shift to Rt.
Chest tube

93. Lt. Internal Carotid Artery
Rt. Subclavian Art. ET
Lt. Subclavian Artery NG
Aortic Rupture

94. Tension Pneumothorax on CT
Mediastinum
Rt.
Lt. Ao

95. Hemothoraces

96. Hemothorax
Supine
Upright

97. Hemopneumothorax

99. Indistinct diaphragm

100. Elevated, irregular hemidiaphragm

101. Indistinct, elevated diaphragm
Clavicle fx
Suspicious
Close-up
Rib fxs
Indistinct, elevated diaphragm
Chest tube

102. Crushed right chest

103. After ventilated with PEEP