1. CHEST X-RAY IN COMMON RESPIRATORY DISEASES
DR.S.SOMASUNDARAM., MD.,DNB., FRCR (UK)
HEAD OF DEPT. OF RADIOLOGY
CARE NATIONAL HOSPITAL

2. Why order a CXR? SYMPTOMS: Persistent cough Fever Chest pain
Chest injury
Hemoptysis
Shortness of breath

3. COMMON CHEST PATHOLOGIES
Pneumonia
Pleural effusion
Pneumothorax
Hemothorax
Pulmonary embolism
Trauma TB
Lung cancer
Pulm.edema.
Hypertension
COPD
Asthma
Emphysema
Bronchiectasis

4. Views for standard chest radiography

5. POSTERIOR ANTERIOR VIEW
The patient's chest is placed against the film cassette.
The x-rays enter the patient posteriorly and exit ventrally.
The PA view minimizes cardiac magnification which can be a complication of other views.

7. LATERAL VIEW A lateral view is ordered in conjuction with a PA view.
By convention, the left side of chest is placed against the film cassette.
Since the right side of the body is closer to the source of the x-rays, the right side is magnified greater than the left side. This will help separate structures. For example, the right costophrenic margin appears larger than the left costophrenic margin in this image.

9. APICOLORDOTIC VIEW
It is similar to a PA view except the x-ray beam is angled cranially.
It is performed to evaluate upper lobe pathology.
This view removes the clavicular shadows seen in the PA view.

10. ANTERIOR POSTERIOR(AP) VIEW
It is performed on patients who are unable to stand for the PA exam.
AP radiographs are performed at bedside. The film cassette is placed under the patients back and a portable x-ray machine is positioned over the patients chest.
Difficult to interpret due to many potential technical problems.
May cause cardiac magnification as demonstrated in this comparison.

13. Normal Chest X-Ray Compare symmetry
Review organs (lungs, heart,bones, ) in sequence
Left to Right then… Top to Bottom
Random free search

14. Normal Chest X-Ray
Recognition of abnormal first requires knowledge of normal. Over diagnosis of normal variation may be more serious than omission & may lead to needless & harmful therapy.

15. FISSURES
Right major fissure separates the right upper lobe, and right middle lobe from the right lower lobe.
Right minor (horizontal) fissure separates the right upper lobe from the right middle lobe.

16. Left major fissure separates the left upper lobe from the left lower lobe
Also note that the lower lobes extend behind the outline of the diaphragm on a PA view.

17. Right upper lobe Right middle lobe Right lower lobe
Segments: apical, posterior, anterior
Right middle lobe
Segments: lateral, medial
Right lower lobe
Segments: medial basal, anterior basal, lateral basal, posterior basal and apical basal.

18. Left upper lobe Left lower lobe
Segments: apicoposterior, anterior, superior lingular, inferior lingular
Left lower lobe
Segments: apical basal, anteromedial basal, lateral basal, posterior basal

19. CARDIAC ANATOMY

20. PA CARDIAC VIEW The right cardiac border is formed by the right atrium
the left cardiac border is formed by the left ventricle.
The right ventricle and left atrium are superimposed structures and are not border forming.
The Superior vena cava: forms a right paramedian border.

22. LATERAL CARDIAC VIEW
On the lateral projection, the anterior cardiac border is the right ventricle while the posterior cardiac border is composed of both the LV and LA.
The right atrium is not a border-forming structure.

23. LATERAL CARDIAC VIEW
The inferior vena cava is seen best on lateral projection.
The posterior border is evident in contrast to the air-filled lungs.

24. Hilar Anatomy
The "hilum" is composed of the pulmonary artery and its branches, and adjacent airway and pulmonary veins.
Since airways do not produce a significant shadow on plain film radiography, the majority of the detectable "hilar" structures are vascular.

26. HILAR ANATOMY
On the left side, the left pulmonary artery is directed posterolaterally, toward the left scapula and goes over the left main stem bronchus. The left pulmonary artery is therefore located higher than the right pulmonary artery.

27. HILAR ANATOMY
On the lateral projection, the left pulmonary artery is posterior to a line drawn down the tracheal air column.

28. HILAR ANATOMY
The right pulmonary artery (RPA) courses underneath the right main stem bronchus.
The right hilar shadow is inferior to the left on the PA projection ( 70%). Hilar shadows are equal in height (30%).
The right hilum is never superior to the left hilum.

29. Tracheobronchial Anatomy

30. TRACHEA
The trachea appears as an air-shadow coursing down the midline of the chest and terminating at the carina. The left and right mainstem bronchus may be evident as well as the lobar bronchi.

32. PULMONARY VENOUS ANATOMY
Pulmonary veins course more horizontally than pulmonary arteries, are ultimately directed toward the left atrium and best seen on a lateral projection.
Pulmonary venous anatomy should not to be confused with a retrocardiac infiltrate.

33. MEDIASTINUM

35. ANTERIOR MEDIASTINUM
Borders include the sternum anteriorly, and the ventral cardiac surface posteriorly.
Includes fat, ascending aorta, lymph nodes, internal mammary artery and vein, adjacent osseous structures (ribs and sternum), thymus. Knowledge of the mediastinal contents can aid in your differential diagnosis.

36. This thymoma has spread throughout the Anterior Mediastinal compartment.

37. MIDDLE MEDIASTINUM
Borders composed of the anterior mediastinal compartment ventrally, and the anterior surface of the spine, posteriorly.
Structures include the esophagus, vagus nerve, recurrent laryngeal nerve, heart, proximal pulmonary arteries and veins (hilar), trachea and root of the bronchial tree, and superior and inferior vena cava

39. POSTERIOR MEDASTINUM
Borders: Anterior surface of the spine posteriorly to the ribs.
Structures include the descending aorta, adjacent osseous structures (the spine and ribs) and nerves, roots, spinal cord, and the azygous and hemiazygous veins.

41. SUPERIOR MEDASTINUM
It is located above a horizontal line drawn from the angle of Louis posteriorly to the spine.
Structures include the thyroid gland, aortic arch and great vessels, proximal portions of the vagus and recurrent laryngeal nerves, esophagus and trachea.

43. AORTOPULMONARY WINDOW

44. AORTOPULMONARY WINDOW
A "space" located underneath the aortic arch and above the left pulmonary artery.
Contains fat.
On the PA projection, it appears as a concave shadow. If adenopathy is present, it manifests as a convex shadow.

46. DIAPHRAGM
The left and right diaphragm appear as sharply marginated domes.
The peripheral margins of the diaphragm define the costophrenic sulci.
The right diaphragm is higher than left due to the position of the liver. Will appear larger on a lateral chest film

48. OSSEOUS STRUCTURES Ribs Anterior and posterior ribs. Spine Pedicles
Transverse processes
Spinous Processes
Sternum

50. X-ray densities
Density is related to the structures ability to block photons. Air, for example, allows a greater number of photons to pass through and subsequently exposes more film generating a black image. More dense structures, such as bone or metal, reflect or absorb photons. Therefore, the film absorbs less photons and appears white.
Five different densities are represented on plain films: air, fat, soft tissue (fluid), bone & metal (contrast material)

51. X-ray densities

52. Sensitivity and specificity of plain films.
Plain films are not very sensitive.
A great deal of pathology is missed on plain films.
They are also not very specific since the majority of possible pathology falls under the catagory of fluid or soft tissue density making it difficult to differentiate.

53. Chest X-Ray Findings
On a chest x-ray lung abnormalities will either present as areas of increased density or as areas of decreased density.
Lung abnormalities with an increased density - also called opacities - are the most common. A practical approach is to divide these into four patterns:
Consolidation
Interstitial
Nodules or masses
Atelectasis

54. 4-Pattern approach
Consolidation - any pathologic process that fills the alveoli with fluid, pus, blood, cells (including tumor cells) or other substances resulting in lobar, diffuse or multifocal ill-defined opacities.
Interstitial - involvement of the supporting tissue of the lung parenchyma resulting in fine or coarse reticular opacities or small nodules.

55. Nodule or mass - any space occupying lesion either solitary or multiple.
Atelectasis - collapse of a part of the lung due to a decrease in the amount of air in the alveoli resulting in volume loss and increased density.

56. Basic Pulmonary Pathology
Concept of the silhouette sign
able to distinguish anatomical margins when two structures of different density abut one another. When two structures of similar density abut one another, their margins are lost.

57. Consolidation key-findings on the X-ray
Ill-defined homogeneous opacity obscuring vessels
Silhouette sign: loss of lung/soft tissue interface
Air-bronchogram
Extention to the pleura or fissure, but not crossing it
No volume loss

58. PNEUMONIA
Pneumonia causes pus (bacterial, viral, fungal) to accumulate in the lungs causing increased density of the lung.
It is possibly confused with blood, water or even tumor.
Clinical history is necessary to help differentiate pneumonia from other possible pathology.

59. Radiographic appearance predicated on infiltrate location, i. e
Radiographic appearance predicated on infiltrate location, i.e. broncho-pneumonia vs. lobar pneumonia.

61. CONSOLIDATION Air bronchogram Lobar consolidation
Alveolar space filled with inflammatory exudate
WBC, bacteria, plasma, and debris
Air bronchogram
Lobar consolidation
Diffuse consolidation
Multifocal ill-defined consolidations

62. Lobar CONSOLIDATION

64. Segmental consolidation
increased density with ill-defined borders in the left lung
the heart silhouette is still visible, which means that the density is in the lower lobe
air-bronchogram

65. Strep.pneumonia
 ill-defined area of increased density in the right upper lobe without volume loss.
air-bronchogram (arrow)

66. Pulm.Hemorrhage

68. Congestive Heart Failure
Cardiomegaly.
determined by comparing the width of the heart to the width of the thoracic cavity on a PA film. If the heart is greater than 50% of the width of the thoracic cavity, then the heart is enlarged.

69. Congestive Heart Failure
The upper lobe vessels become more prominent due to vascular congestion or interstitial edema - results from transudation of fluid through the capillary walls into the interstitium around the vessels which can render normally indistinct vessels distinct, and creates a shaggy appearance around the heart border on a chest film.

72. Congestive heart failure
bilateral perihilar consolidation with air bronchograms and ill-defined borders
an increased heart size
subtle interstitial markings
Batwing distribution.

73. ARDS Congestion Interstitial and alveolar edema Bilateral
No pleural effusion

74. Bronchopneumonia

75. Bronchopneumonia

76. CAVITATION
The infection causing the pneumonia may lead to cavitation or destruction of the lung tissue, forming abscesses.
The three most common organisms that cause pulmonary abcesses are staph aureus, strep pyogenes, and Klebsciella.
Gram negatives are also very common causes of abscesses.

79. ATELECTASIS
Sharply-defined opacity obscuring vessels without air-bronchogram
Volume loss resulting in displacement of diafragm, fissures, hili or mediastinum

80. RT.upper lobe ATELECTASIS
Triangular density
Elevated right hilus
obliteration of the retrosternal clear space (arrow)

81. Right middle lobe atelectasis
Blurring of the right heart border (silhouette sign)
Triangular density on the lateral view as a result of collapse of the middle lobe

82. Right lower lobe atelectasis
-Abnormal right border of the heart. -The right interlobar artery is not visible, because it is not surrounded by aerated lung but by the collapsed lower lobe, which is adjacent to the right atrium.

83. Left upper lobe atelectasis
Large density on the left with loss of cardiac silhouette.
Luft sichel means a sickle of air ,outlining the aortic knuckle.

84. Left lower lobe atelectasis
There is a triangular density seen through the cardiac shadow. This must be an abnormality located posterior to the heart. The contour of the left diaphragm is lost when you go from anterior to posterior.

85. Atelectatic bands

86. Pleural effusions
Pleural efusions may be caused by a number of possible etiologies. Some of the most common causes are congestive heart failure, trauma, or blood.
One cannot determine the nature of the pleural fluid based solely on the plain film (blood, pus, transudate, or exudate, etc).

87. Pleural effusions
The pleural fluid collects first in the posterior gutters. As the amount of fluid increases, plain films will reveal a blunting of the posterior and lateral gutters
The build up of fluid will apply pressure to the lung causing a decrease in air intake.
Treament - drain pleural fluid.

88. PLEURAL EFFUSION

89. Large PLEURAL EFFUSION

90. PSEUDOTUMOR The fissures are in continuity with the pleural space.
Fluid can fill the fissures.
This phenomenon is often refered to as pseudotumor due to its strong resemblance to a tumor.

91. Fluid has filled the minor fissure creating a density that resembles a tumor (arrow).

92. LATERAL DECUBITUS VIEW
It is often difficult to determine the size of a pleural effusion based on a plain film.
The patient lies on their affected side and gravity causes the pleural fluid to coalesce in the lateral margin.
A Decubitus chest film can detect as little as 5 cc's of fluid.

94. Pulmonary Nodules
Can be benign, malignant primary or metastatic nodules.
Carcinoma can resemble other pathology such as pneumonia.
Criteria for malignancy: presence of calcification, size, margins-not defined, growth, patient age/sex, and smoking history.
Metastatic disease is hematogenously disseminated from another primary source such as colon or ovary which usually present as multiple nodules.

96. If the nodule is highly calcified, it is a benign process and is not life-threatening and typically is a granuloma.

97. What should you do if you discover a nodule?
The first step is to review the patient's old chest films.
No change over a two-year period then the nodule is more than likely benign.
If there are no old chest films, then a CT should be ordered. If the nodule is enlarging over time, then the nodule should be worked up.

98. Left Sided Pneumothorax

99. Left Sided Pneumothorax

100. TENSION PNEUMOTHORAX

101. COPD

102. SARCOIDOSIS

103. Cardiac Pathology
A buldge on left cardiac boarder is indicative of possible Mitral Valve Stenosis. Left Ventricle Enlargement is evident on a PA view by distension of the lower left cardiac boarder.

105. Let’s See How Much You Paid Attention

114. THE END