MRCS

Chest X-ray (CXR)

Normal Chest Radiograph

There is a very easy system to remember when reporting chest x rays- RIPABCDE! Firstly, is this radiograph (never say x-ray!) of good enough quality to comment on health and disease from?

Film Adequacy
Rotation: Are the clavicular heads symmetrical either side of the manubrium? In this film the right clavicular head is slightlly further away from the manubrium than the left (there is minimal rotation to the right). Otherwise one can simply say, there is no significant rotation. Inspiration: There should be at least 5 anterior ribs (note the ribs labelled above are posterior ribs) visible within each lung field. If not there is said to be inadequate inspiration. NB patients with less or significantly more ribs anteriorly may be suffering from restrictive and obstructive lung diseases respectively. Penetration and Position: As shown in the above radiograph, one should just about be able to make out the borders of the vertebral bodies behind the sternum. If this is just a white

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Chest X-ray (CXR)

haze then the film is probably under-penetrated; if one can clearly see the whole of the vertebral column descending all the way down into the abdomen then the film is overpenetrated. Otherwise one simply says, There is appropriate penetration/exposure. Check whether all the lung fields are included in the radiograph too, especially the apices costophrenic margins. (editors note: apologies if some of the radiographs on this page are inadequate! At this point also mention any tubes/ pacemakers etc. in situ. Here are some examples Nasogastric Tube in situ Chest Drain in situ

Central Line in situ

Pacemaker in situ

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Chest X-ray (CXR)

ABCDE System
Having commented on the films adequacy and anything remarkable in situ, move on to comment on any pathology present. In order to be thorough consistently, it is useful to have a recollectable system:

Airway: Is the airway (trachea) central? If anything, allow for some deviation to the right
but the trachea, as seen in this radiograph, should be dead central. Common causes of a deviated trachea: pulmonary collapse, tension pneumothorax, massive pleural effusion, lung cancer, kyphoscliosis.

Breathing: Be clinical in checking the whole of the lung margin (purple) aswell as field
(green) in a snake like pattern on both sides.

This should take up the bulk of your inspection as there are many things to watch out for.

PURPLE ROUTE
Firstly, as you follow the mediastinal lung margins consider whether the distance between each side is wider than normal.

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Chest X-ray (CXR)

Knowledge of the underlying anatomy is key to understanding why the mediastinum may become wider. Bounded laterally by the pleural cavities, the mediastinum is a threedimensional space with four compartments that are best appreciated in sagittal section (see above). The superior and inferior parts are bounded by a horizontal line passing backwards from the level of the manubriosternal joint, which passes between the 4th and 5th thoracic vertebrae posteriorly. The inferior mediastinum itself is broken up into three compartments, the anterior and posterior compartments being separated by the fibrous pericardium which defines the middle compartment of the inferior mediastinum. From front to back the main structures present in the superior mediastinum are: thymus gland, superior vena cava and draining brachiocephalic veins, aortic arch, trachea and oesophagus. The anterior mediastinum (in no particular direction) contains the internal thoracic arteries (from subclavian arteries), inferior pole of thymus gland and lymphatics. Aforementioned, the middle mediastinum contains the fibrous pericardium and heart contained within. Since the aorta arches posteriorly, the arrangement of structures in the posterior mediastinum is trachea (bifurcating at T4), oesophagus, aorta (from front to back). Common causes for widened mediastinum are: hilar lymphadenopathy (sarcoidosis, lymphoma, metastases, TB), Aortic Aneurysm or rupture, pericardial cyst and oesophageal dilatation (achalasia, hiatus hernia). Moving down from the mediastinum down the left heart border, there are four moguls corresponding to: aortic knuckle, pulmonary artery, left atrium and left ventricle:

Normal Left Heart Border

You will commonly see an exaggerated left atrial mogul, caused by conditions in which there is sustained increase in chamber pressure: Hypertension, Mitral Valve disease, Atrial Fibrillation, Congestive Cardiac Failure

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Chest X-ray (CXR)

Left Atrial Dilatation

Right Atrial Dilatation

NB, if either heart border is obliterated/ blurred, then this is likely to be due to pulmonary consolidation rather than cardiac pathology. The same rule of thumb applies to the hemidiaphragms

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Chest X-ray (CXR)

SAILS SIGN- Left Hemi-Diaphragmatic Obliteration (Left Lower Lobar Pneumonia:

Right Middle Lobe Pneumonia (no clear RHB)

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Chest X-ray (CXR)

Superior Segment of RLL Pneumonia (no clear RHB)

Following our purple route further, landmarks NOT to forget are the costophrenic angles. Nearly all the chest radiographs so far have sharp and obvious angles to show the diaphragmatic pleura meeting the pleura of the chest wall. If more than about 250 mls of fluid accumulates within the pleural space, there is often blunting of these radiographic angles:

Left Sided Pleural Effusion (Blunting of left Costophrenic Angle)

Causes for pleural effusion can be categorised into exudative (where the protein content exceeds 35 g/L) and transudative (less than 25 g/L of protein). If 25-35 g/l of protein and serum protein content is greater than 0.5 then the effusion is exudative. Exudative Causes: Pneumonia, Malignancy (metastatic/lung primary, PE, Rheumatoid Arthritis. Transudative causes: cardiac failure, fluid overload, hypoproteinaemia (liver disease/ nephrotic syndrome), Meigs syndrome. Always look for clues elsewhere on the radiograph as to what the cause could be (paraoneumoinc effusion? Enlarge Heart? Hilar Lymphadenopathy?).

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Chest X-ray (CXR)

Finally on purple route, you must check for pneumothorax (air in the pleural space). When following the pleural line, make sure there are lung markings reaching it, and not stopping short (at the parietal pleura the other side of a pneumothorax!).

Left sided Pneumothorax

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Chest X-ray (CXR)

A TENSION PNEUMOTHORAX is characterised by mediastinal shift and is diagnosed clinically, not through the radiology department. The radiograph below represents a clinical emergency, requiring immediate decompression through the insertion of a cannula in the 2nd intercostal space in the mid-clavicular line

Tension Pneumothorax

GREEN ROUTE
There are different types of shadowing within the lung, each associated with different pathologies.

Noduar Shadowing
Neoplastic Causes: Carcinoma, Adenoma, Hamartoma, Metastases (NB the majority of malignant lung disease is metastatic). Infectious Causes: Varicella Pneumonia, Septic Emboli. Granulomas: Miliary TB, Sarcoidosis, Wegeners Granulomatosis, Histoplasmosis.Pneumoconioses: e.g. Caplans Syndrome.

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Chest X-ray (CXR)

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Alveolar Shadowing- ARDS

Note the fluffy cloud-like appearance of the shadowing. This is a non-cardiogenic cause of pulmonary oedema- note the normal heart size and no pleural effusion (see Cardiac section for heart failure radiographs) associated. Usually alveolar shadowing is secondary to left ventricular failure (causing pulmonary oedema)- common causes: Pneumonia, Haemorrhage, Drugs (heroin, cytotoxics), renal and/or liver failure.

Reticular Shadowing- Post Primary TB

Note the predilection for upper lobes in Tuberculous parenchymal fibrosis. Reticular shadowing is usually due to acute interstitial changes: Sarcoidosis, asbestosis, silicosis, Wegeners Granulomatosis, Fibrosing Alveolitis.

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Be specific with what you see when reporting. Do not only mention the type of shadowing. Comment on the location of the shadowing present- upper zones? (sarcoidosis, TB, silicosis), lower zones? (asbestosis, drug reactions), central zones? (Pulmonary oedema, lymphoma) together with any associated lung volume abnormality- increased?(emphysema, cystic fibrosis) or decreased? (fibrotic lung disease, sarcoidosis).

NB It is seldom possible to reach a diagnosis on the basis of the chest radiograph alone. If there is unexpected diffuse shadowing of the lung field or a suspicious isolated lesion a CT chest is usually the investigation of choice. Chest X rays are a better screening tool than diagnostic tool.

Cardiac: Most importantly look at the size of the heart, which should be no wider than
half the transthoracic width (usually <15cm), with two- thirds of the heart lying to the left of the midline. NB one cannot comment on the size of the heart in an AP film as it is artificially enlarged. If there is an enlarged heart, check for other signs of heart failure: Upper Lobe Diversion (of blood vessels), Kerley B Lines and Pleural Effusions:

Diaphragm:
Elevated Hemidiaphragm- Right Phrenic Nerve Palsy

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The right side is usually higher (liver in right upper quadrant of abdomen pushing from underneath) but not by too much! The right hemidiaphragm is usually situated at the level of the 6th anterior rib +/- 1 rib so if in doubt count. The most common cause for an elevated hemidiaphragm is eventration of the higher hemidiaphragm. Eventration is membraneous replacement of the diagphragmatic muscular tendon, which is weaker and allows abdominal viscera to move upwards (colon, spleen, stomach, greater omentum etc.). If elevation of the hemidiaphragm is a new finding then phrenic nerve paralysis MUST be ruled out (the most common pathology for unilateral phrenic nerve paralysis is malignancy in the mediastinum). Elevated Hemidiaphragm- Mucous Plug with Left Lung Collapse

Another common pulmonary cause for elevation of the hemidiarphragm is lung collapse.

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The other important area to assess is whether there is any air visible UNDER the diaphragma sign of pneumoperitoneum.

Pneumoperitoneum- Bowel Perforation

Although a perforated abdominal viscus is the most common cause (usually perforated peptic ulcer), air may come from many other places within the abdominal cavity: post lapartomy/laparoscopy, gall bladder or a subphrenic abscess.

Everything Else!: Apparently normal chest x-ray? Check common neglect areas: lung
apices? (TB), bones? (clavicular fracture, glenohumeral dislocation, humeral fracture, vertebral crush fracture), soft tissue mass? (axillary mass/ breast shadow mass).

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Chest X-ray (CXR)

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Further Radiology
HIstoplasmosis- calcified nodes; clumpy calcification; calcified nodules in lungs

Splenic Rupture- pleural effusion after blunt trauma

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Chest X-ray (CXR)

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Squamous Cell Cancer- Mass Density in anterior segment of LUL; thick calcification

Pancoast Tumour- Apical Density with 2nd Rib Destruction

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Chest X-ray (CXR)

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Canon Ball Metastases- multiple; bilateral; round opacities

Wedge Shaped Opacity-Vascular (infarct, Aspergillosis) or Bronchial (consolidation. Atelectasis)