1. “Must Know” chest RADIOGRAPH Radiology
Joanna R. Fair, M.D., Ph.D.
Vice Chair of Education
Department of Radiology
Many slides courtesy of UNM Radiology faculty
and Petra Lewis, M.D.
Associate Professor of Radiology
Dartmouth Medical School

2. Objectives Review normal chest radiograph anatomy
Describe findings of common emergent diagnoses on chest radiographs
Identify proper and improper positioning of tubes and lines on chest radiographs

3. Normal Anatomy

4. Chest radiograph scan pattern “ABCDE”
Airway
Trachea
R/L main bronchi
Bones
Shoulders
Spine
Ribs
Cardiac
Diaphragm
and all below
Everything else =
Lungs B B A E E A A B C B B D

5. Chest radiograph scan pattern “ABCDE”
Airway
Trachea
Bones
Spine
Sternum
Cardiac
Diaphragm
and all below
Everything else =
Lungs A B B C E D

6. Common ER Diagnoses on Chest Radiographs

7. Where is the abnormality?
No abnormality
Left lung
Right lung

8. Where is the abnormality?
No abnormality
Left lung
Right lung

9. Lingular pneumonia

10. Silhouette sign Silhouette sign with diaphragm
Well defined right lung opacity
Surrounded by air
Silhouette sign with diaphragm
Silhouette sign with heart

11. Middle lobe pneumonia

12. The BEST interpretation of this CXR is:
Normal
Emphysema
Left lower lobe pneumonia
Pulmonary edema
Interstitial edema

13. The BEST interpretation of this CXR is:
Normal
Emphysema
Left lower lobe pneumonia
Pulmonary edema
Interstitial edema
Kerley B lines

14. Interstitial pulmonary edema
Distension/blurring of upper lobe pulmonary veins
Peribronchial cuffing/indistinct hilar “fuzziness”
Kerley B lines
Pleural effusions
+/- Enlarged cardiac silhouette

15. Baseline

16. - Enlarged cardiac silhouette - Superior redistribution of vessels
- Early interstitial edema
(See next image for close-up)

17. Baseline Early CHF Vascular redistribution to upper lobes.
Fuzzy vessels
Sharp vessels
Sharp vessels
Baseline
Early CHF
Vascular redistribution to upper lobes.
Vessels less distinct, larger caliber.

18. CHF with lymphatic engorgement:
Kerley B lines
Another patient with CHF
Mag of RLL

19. Interstitial & alveolar pulmonary edema.

20. The MOST likely dx is: A. Pneumonia B. Pulmonary hemorrhage
C. Pulmonary edema
D. Aspiration
E. ARDS
Pulmonary edema but could be any

21. The MOST likely dx is: A. Pneumonia B. Pulmonary hemorrhage
C. Pulmonary edema
D. Aspiration
E. ARDS
Pulmonary edema but could be any
Could be any of these!

22. Bilateral Airspace Opacification
Edema
Pneumonia/aspiration
Hemorrhage
ARDS
Unusual conditions such as alveolar proteinosis

23. Asymmetric pulmonary edema

24. Pulmonary hemorrhage
goodpastures

25. ARDS

26. Pneumonia (aspiration)

27. Best diagnosis for the LEFT thorax is:
Pleural effusion
Hydropneumothorax
Pneumonia
Atelectasis
Left hydropneumothorax

28. Best diagnosis for the LEFT thorax is:
Pleural effusion
Hydropneumothorax
Pneumonia
Atelectasis
Left hydropneumothorax

29. Pleural Effusions Best seen on CT or ultrasound
CXR: Lat > PA upright > AP supine
Confirm presence/mobility with ipsilateral decubitus film/US
Horizontal line = air/fluid level = hydropneumothorax
Supine
Diffuse ground glass opacity lower zones
Diaphragm obscured
Very large effusions  mass effect

30. Pleural Effusions
Huge left pleural effusion,.supine left effusion

31. Pleural Effusions
Decub view s PA
Left effusion
Left lateral decubitis

32. What is the MOST likely diagnosis?
Left pneumothorax
Right pneumothorax
Left lower lobe pneumonia
Right lower lobe pneumonia
Right pneumothorax

33. What is the MOST likely diagnosis?
Left pneumothorax
Right pneumothorax
Left lower lobe pneumonia
Right lower lobe pneumonia
Right pneumothorax

34. Pneumothorax
Expiratory or upright or lateral decubitus film more sensitive
White line with absent lung markings distally
Apex on upright film
Play with contrast/brightness
Skin folds may confuse
Look for signs of tension

35. Pneumothorax inspiratory/expiratory films
Inspiratory –expiratory pair (expiratory on right) left ptx. Notice how the expiratory film shows the ptx better
Inspiratory
Expiratory
Easier to see

36. BEST diagnosis for the RIGHT is:
Middle lobe pneumonia
Tension pneumothorax
Upper lobe atelectasis
Aortic rupture
Right tension ptx

37. BEST diagnosis for the RIGHT is:
Middle lobe pneumonia
Tension pneumothorax
Upper lobe atelectasis
Aortic rupture
Right tension ptx

38. Tension pneumothorax Medical emergency Often total lung collapse
Pneumothorax plus
Mediastinal shift
Diaphragmatic depression
Hypotension, pulsus paradoxus, hypoxia

39. Tension pneumothorax

40. Trauma film. Your most IMMEDIATE concern would be for:
Left lower lobe pneumonia
Fractured clavicle
Left pleural effusion
Aortic injury
Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 31553

41. Trauma film. Your most IMMEDIATE concern would be for:
Left lower lobe pneumonia
Fractured clavicle
Left pleural effusion
Aortic injury
Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 31553

42. Mediastinal Hematoma Wide mediastinum Left apical pleural cap
Abnormal aortic contour
Deviation of trachea or NGT to right

43. Where is all that air? subQ emphysema pneumomediastinum
possible pneumothorax

44. Lines and tubes

45. Which of these lines is NOT inserted correctly?
Dobhoff (feeding) tube
ET tube
PICC line
Subclavian line

46. Which of these lines is NOT inserted correctly?
Dobhoff (feeding) tube
ET tube
PICC line
Subclavian line

47. NG tube Incorrect Coiled in esophagus Correct
Tip and side port below GE junction
Incorrect
Coiled in esophagus

48. Dobhoff (feeding) tube
Correct
Tip in duodenum
Tip in stomach (may be OK)
Must be below GE junction; prefer duodenum

49. Dobhoff (feeding) tube
Dobhoff both main bronchi
Dobhoff tip in esophagus
Incorrect
In both main bronchi
Incorrect
Tip in distal esophagus

50. Central line Correct Right IJ tip mid-distal SVC Incorrect
Normal right IJ; LIJ in aorta,
Correct
Right IJ tip mid-distal SVC
Incorrect
Left IJ in aorta

51. Central line Incorrect IJ into right subclavian Incorrect PICC coiled
Right subclav in IJ
Incorrect
IJ into right subclavian
Incorrect
PICC coiled

52. Right subclavian line placement
What happened here?
Right subclavian line placement
with PTX

53. Chest tube Chest tube OK Side port inside thorax
Chest tube ports outside thorax
Chest tube OK
Side port inside thorax
Side port outside thorax

54. ET tube ETT position OK Best at level of aortic arch Incorrect
ETT normal
ETT RMB
ETT position OK
Best at level of aortic arch
Incorrect
In right main bronchus

55. Line placements: SummaryNG
Both ports in stomach
Dobhoff tube
Tip must be below GE junction, pref. in duodenum ET
Few cm above carina in adult
At level of aortic arch

56. Line placements: Summary (2)
PICC/IJ/SCV
Tip in distal SVC
Chest tubes
Both ports in chest
Basal and posterior for effusions
Anterior and apical for ptx

57. Radiology Ordering Tips
More history = better interpretation
Radiologists available 24/7 (check AMION)
Call with ?s about protocols or interpretations
Some studies (nuc med, fluoroscopy, IR) require a phone call if after hours or on weekends