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Chest Radiography Interpretation

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Presentation on theme: "Chest Radiography Interpretation"— Presentation transcript:

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?

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)

8 PA (Postero-anterior)

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:

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

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