Basic Interpretation of Chest Radiography

By Dr. Chia Kok King

Five Radiographic Opacities

Air Fat Soft tissue Bone Metal

least opaque most lucent Black

to to to

most opaque least lucent White

Radiographic Opacities & Contrasts

Air Fat Water Bone Metal

Air Mineral oil Water Tums ???

Film Quality
1. 2. 3. 4. 5. PA or AP view. Upright/Erect or Supine Breath : Inspiration or Expiration X-ray penetration : Under- or OverRotation

PA vs AP views

PA view
Scapula is seen in periphery of thorax Clavicles project over lung fields Posterior ribs are distinct Position of markers

AP view
Scapulae are over lung fields Clavicles are above the apex of lung fields Position of markers Anterior ribs are distinct

Inspiration vs Expiration

Penetration
With correct exposure you should barely see the intervertebral disc through the heart

If you see them very clearly the film is overpenetrated

If you do not see them it is underpenetrated

Penetration

Rotation

Pitfalls to Chest X-ray Interpretation

Poor inspiration Over or under penetration Rotation Forgetting the path of the x-ray beam

Normal Chest X-ray

Cardiac Structures
Position
More central in younger infants and children More on the L side in older infants and teens

Size
CARDIO-THORACIC RATIO! Cardiac diameter :
normal individuals < 15.5 cm in males; <14.5 cm in females. A change in diameter of greater than 1.5 cm between two X-rays is significant.

Cardio-thoracic ratio
seen on postero-anterior (PA) view only >50% is considered abnormal in an adult; more than 66% in a neonate. Possible causes of a ratio greater than 50% include:
cardiac failure pericardial effusion left or right ventricular hypertrophy
*AP views make heart appear larger than it actually is.*

Normal Chest X-ray

1. Soft tissue structures
Shadows, most commonly, breast

2. Bony structures
Count the ribs 8 10 ribs should be visible on inspiration Clavicle placement at 2-3 intercostal space (if not, may be rotated)

Normal Chest X-ray

3. Diaphragm
Contour Rounded with sharp pointed costophrenic and costocardiac angles Right diaphragm is usually 1-2 cm higher

Normal Chest X-ray

4. Lungs
Start at the top and compare the R and L Trachea should be midline over the thoracic vertebrae and air filled Lung parenchyma becomes lighter as you go down the lung. If not, it may indicate a lower lobe or pleural effusion

Anatomy

Anatomy

Lobes
Right upper lobe:

 Right middle lobe:

 Right lower lobe:

 Left lower lobe:

 Left upper lobe with Lingula:

 Lingula:

 Left upper lobe - upper division:

Abnormal Chest X-ray

Radiopacity (whiteness) = increased density Radiotranslucency (blackness) = decreased density

Radiopacity
Alveolar Pattern Fluffy, soft, poorly demarcated opacifications < 1cm in diameter Possible causes: 1. Pulmonary edema 2. Viral pneumonia 3. Pneumocystis 4. Alveolar cell carcinoma Interstitial Pattern Consolidation of interstitial tissue

Looks like branching lines radiating toward the periphery of the lung
Possible causes: 1. Interstitial pneumonitis 2. Pulmonary fibrosis

Vascular pattern If there is an increase in size of the pulmonary arteries as they extend out into lung pulmonary hypertension

If there is a decrease in size, truncation, or obliteration of a pulmonary artery embolus

Lack of vascular marking in the periphery pneumothorax

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 Air bronchogram, and No significant loss of lung volume

Consolidation

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 Compensatory hyperinflation of normal lungs

Atelectasis
No ventilation to lobe beyond the obstruction Trapped air absorbed by pulmonary circulation Segmental/lobar density Compensatory hyper-inflation of normal lungs.

Congestive Heart Failure

Increased heart size: cardiothoracic ratio >0.5

Large hila with indistinct markings Fluid in interlobar fissures Pleural effusions, alveolar edema

Congestive Heart Failure

Alveolar edema (Bats wings) Kerley B lines (Interstitial edema) Cardiomegaly Dilated prominent upper lobe vessels Pleural effusion

ARDS
Congestion Interstitial and alveolar edema Collapsed or distended alveoli Bilateral

Pneumothorax

Right side tension pneumothorax

Left Sided Pneumothorax

Pleural effusion

Right Side Pleural Effusion

RLL Pneumonia

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Fracture of posterior rib #7

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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

Right Squamous Cell Carcinoma

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Right Middle and Left Upper Lobe Pneumonia

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

Cavitation

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Tuberculosis

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COPD: increase in heart diameter, flattening of the diaphragm, and increase in the size of the retrosternal air space. In addition the upper lobes will become hyperlucent due to destruction of the lung tissue.

Chronic emphysema effect on the lungs

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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.

24 hours after diuretic therapy

Chest wall lesion: arising off the chest wall and not the lung

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

Lung Mass

The Enlarged Hila

Causes: 1. Adenopathies (neoplasia, infection) 2. Primary Tumor

3. Vascular
4. Sarcoidosis

Small Pneumothorax : LUL

Right Middle Lobe Pneumothorax: complete lobar collapse

Post chest tube insertion and re-expansion

Metastatic Lung Cancer: multiple nodules seen

Tuberculosis

Pleural Effusion

Pulmonary Fibrosis

Cavitating lesion

Miliary shadowing

5. 65 yo male admitted for sepsis. CHF or ARDS?

12. Is the central line correctly positioned?

13. Does ET tube need to be advance or pulled back? Arrow shows location of carina

14. OK for R/T feeding?