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The Chest X-Ray. Contents: Patient Data Techniques CXR Interpretation.

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Presentation on theme: "The Chest X-Ray. Contents: Patient Data Techniques CXR Interpretation."— Presentation transcript:

1 The Chest X-Ray

2 Contents: Patient Data Techniques CXR Interpretation

3 Technical Details Type(PA/AP/Lat./decubit us/Lordotic) Rotation Inspiration/expiration Penetration

4 Densities The big two densities are: (1) WHITE - Bone (2) BLACK - Air The others are: (3) DARK GREY- Fat (4) GREY- Soft tissue/water And if anything Man-made is on the film, it is: (5) BRIGHT WHITE - Man-made

5 Techniques - Projection P-A (relation of x-ray beam to patient)

6 A-P (relation of x-ray beam to patient)


8 Techniques - Projection (continued) Lateral Decubitus

9 Lordotic view

10 Film Quality (cont) Was film taken under full inspiration? -10 posterior ribs should be visible. A really good film will show anterior ribs too, there should Be 6 to qualify as a good inspiratory film.

11 Ribs

12 Rotation

13 Rotation (continued)

14 TECHNIQUE, cont. Rotation Determined by distance between spinous process & medial clavicle Affects heart size & shape, aortic tortuosity, density of lung fields

15 Is the film over or under penetrated ? if under penetrated you will not be able to see the thoracic vertebrae. If overpenetrated you will see the thorasic vertebrae beyond the heart with details. Penetration


17 Anatomy

18 Lung Anatomy Right Lung –Superior lobe –Middle lobe –Inferior lobe Left Lung –Superior lobe –Inferior lobe

19 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.

20 Lobes Right upper lobe:

21 Lung Anatomy on Chest X-ray The right upper lobe (RUL) occupies the upper 1/3 of the right lung.

22 Lobes (continued) Right middle lobe:

23 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

24 Lobes (continued) Right lower lobe:

25 Lung Anatomy on Chest X-ray These two lobes are separated by a major fissure, identical to that seen on the right side. The portion of the left lung that corresponds anatomically to the right middle lobe is incorporated into the left upper lobe.

26 Lobes (continued) Left lower lobe:

27 Lobes (continued) Left upper lobe with Lingula:

28 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

29 Lobes (continued) Lingula:

30 Lobes (continued) Left upper lobe - upper division:

31 Lateral CXR (continued)


33 The Silhouette Sign An intra-thoracic radio- opacity, if in anatomic contact with a border of heart or aorta, will obscure that border. An intra- thoracic lesion not anatomically contiguous with a border or a normal structure will not obliterate that border.


35 Systematic Approach Bony Framework Soft Tissues Diaphragm and Pleural Spaces Lung Fields and Hila Mediastinum and Heart Abdomen and Neck

36 Systematic Approach Bony Fragments –Ribs –Sternum –Spine –Shoulder girdle –Clavicles

37 Systematic Approach Soft Tissues –Breast shadows –Supraclavicular areas –Axillae Mdiastinum

38 Soft tissue

39 Now you are ready Look at the diaphram: for tenting free air abnormal elevation Margins should be sharp ( the right hemidiaphram is usually slightly higher than the left )

40 Hilum Made of: 1. Pulmonary Art.+Veins 2.The Bronchi 3.L.N. Left Hilus higher (max 1-2,5 cm) Identical: size, shape, density

41 Check the hilar region The hilar – the large blood vessels going to and from the lung at the root of each lung where it meets the heart. Check for size and shape of aorta, nodes,enlarged vessels

42 Mediastinum & Heart

43 Check the Heart Size Shape Silhouette-margins should be sharp Diameter (>1/2 thoracic diameter is enlarged heart) Remember: AP views make heart appear larger than it actually is.

44 Heart Size:

45 Heart Size of heart Size of individual chambers of heart Size of pulmonary vessels Evidence of stents, clips, wires and valves





50 Systematic Approach Diaphragm and Pleural Surfaces –Diaphragm Dome-shaped Costophrenic angles –Normal pleural is not visible –Interlobar fissures

51 Systematic Approach Abdomen and Neck –Abdomen Gastric bubble Air under diaphragm –Neck Soft tissue mass Bone structure


53 Lungs : Apices Behind the heart Behind the clavicles CP angles Parenchyma


55 Identify the lesion → localise the lesion → describe the lesion → give DD Never stop looking, carry on with your systematic approach!!


57 Consolidation Lobar consolidation: –Alveolar space filled with inflammatory exudate –Interstitium and architecture remain intact –The airway is patent –Radiologically: A density corresponding to a segment or lobe Airbronchogram, and No significant loss of lung volume

58 Atelectasis Loss of air Obstructive atelectasis: –No ventilation to the lobe beyond obstruction –Radiologically: Density corresponding to a segment or lobe Significant loss of volume



61 Left Sided Pneumothorax

62 Right Side Pleural Effusion


64 Right Lower Lobe Pneumonia





69 SARCOIDOSIS Granulomatous Inflammation Bilateral & symmetrical hilar & mediastinal LAD Generalized fibrosis

70 ARDS Congestion Interstitial and alveolar edema Collapsed or distended alveoli Bilateral


72 CONSOLIDATION Alveolar space filled with inflammatory exudate – WBC, bacteria, plasma, and debris


74 RLL pneumonia

75 LUL pneumonia

76 LLL pneumonia

77 Consolidation on CT

78 Hilar mass

79 The Enlarged Hila Causes: 1. Adenopathies (neoplasia, infection) 2. Primary Tumor 3. Vascular 4. Sarcoidosis


81 Multiple Masses

82 Pleural Effusion

83 ?

84 Heart failure

85 Pneumothorax

86 Air under the diaphragm


88 Cavitating lesion

89 Hiatus hernia

90 Miliary shadowing

91 Chest Tube, NG Tube, Pulm. artery cath

92 Dextrocardia


94 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


96 Cavitation:cystic changes in the area of consolidation due to the bacterial destruction of lung tissue. Notice air fluid level.

97 Cavitation


99 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.


101 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


103 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.

104 24 hours after diuretic therapy


106 Pleural mass


108 Pleural effusion: Note loss of left hemidiaphragm. Fluid drained via thoracentesis

109 Lung Mass


111 Metastatic Lung Cancer: multiple nodules seen


113 Right upper lower lobe pulmonary nodule


115 Perihilar mass: Hodgkin’s disease


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