Terminology in Chest XRays

PA view- chest close to xray plate

xray tube 6 feet from patient
Pt erect
AP view- back close to plate
xray tube 3 feet from pt
pt supine
PA sharper
less magnified
Both generally taken in full inspiration
Oblique- taken with pt standing obliquely. Right oblique is with right chest
against the plate
Lateral decubitus side of supine pt on the plate with xray tube
horizontal
Apical Lordotic- xray tube angled at 45
Sternal & rib views
 HOW TO READ A CHEST X-RAY
Switch off all unnecessary lights.

1.Identify patient name,age,sex,hosp #. Date of xray and side marker (R or L)

2.. Check the adequacy and tech quality of film
Exposure- mid thoracic intervertebral disc should be clearly visible or a
finger held behind the black part of the film should be just visible.
Underexposed film is pale- lung appears consolidated/pulm edema.
Overexposed film is black suggest emphysema
Position Supine or erect. PA,APor lat
Rotation (centered)- Spinous process of upper thoracic vertebrae
should be central & Medial ends of clavicles must be equidistant from
the central spinous process
Lung volume (Degree of inspiration)- Right hemidiaphragm should reach
the anterior end of 6th / 7th rib or the 9th / 10th rib posteriorly on full
inspiration
> 6th rib in expiration indicates hyperinflation( emphysema)
< 5th rib indicates underinflation ( crying infant)
Film taken in expiration may simulate disease cardiomegaly,
pulmonary congestion
(CONTD.)
3. Check the extrathoracic soft tissue-
Start at the top with the supraclavicular areas, neck, shoulder,- look for subcutaneous emphysema.,
calcified glands Continue down each side of the chest Assess breast shadows. Finally check
under the diaphragm for air
4.. Check the bony cage Ribs,clavicles, scapulae,shoulder jts,thoracic spine
5..Check for medical equipment
like ET tube, CVP line -Tip of ET tube should be about 2 cm from carina
6. F. Check the superior mediastinum for widening or abnormal masses and identify the
trachea
thymus causes widening upto 2yrs
7. Check the heart- its positioned with 1/3 of its diameter to the right and 2/3 to the left of the
spinous process. A low diaphragm will cause a right shift and a high d a left shift. The hearts full
dia should be less than of the internal thoracic dia at its widest point ( cardiothoracic ratio)
8.Check the diaphragms, Cp & Cp angles.
R dia 3 cm higher than left. Outline should be smooth with highest point medial to the midline of
the hemithorax
Gastric bubble seen under L diaphragm
9.. Hilum
Hilar shadows- made up of pulm art and large veins. Left hilum normally 2 cm higher than right
10.Lungs
Lung pattern- all the markings in a normal lung are vascular. They disappear 2 cm or less from the
lung margin
Lung zones- Upper apex to 2nd costal cartilage,
Middle -2-4 cartilage
lower below 4th cartilage
Features of Anatomy seen on PA
VIEW
LATERAL VIEW
Normal PA view
PA VIEW
Each lobe is covered by visceral pleura.The
visceral pleura bordering adjacent
surfaces of 2 lobes form the septa,which
separates the lobes.
The space between 2 adjacent septae is
called the interlobar fissure- a fissure is a
narrow space; a septa is a divider. The 2
terms are used interchangeably
Right lung has 3 lobe-RUL,RML,RLL
separated by septa or fissures
R major fissure runs obliquely downwards
from 5th thoracic vertebra to the diapraghm
to a point just behind the ant cp angle.
Not normally seen in PA view as it is not
parallel to the x-ray beam
The Right minor fissure intersects the lateral
chest wall at the level of anterior portion of
4th rib(+/_2)
RUL made up of apical ,anterior & posterior
bronchopulmonary segments
RML made up of lateral and medial segments
RLL made of superior, medial basal, ant
basal, lateral basal and post basal
PA view
Left lung is made of
LUL & LLL
The LUL is made up of
apicoposterior and
anterior segments
The lower or lingular
division of the LUL is
made up of sup & inf seg
The LLL is made up of the
sup, medial basal, ant
basal, lat basal and
postbasal
NORMAL CXR
Trachea is central
Dome of R diapraghm is at the level of 6 th rib
L hemidiapraghm is 3cm lower than the R
Heart size is < 50% of the thoracic diameter. 2/3
of the heart lies to the L and 1/3 to the R of the
spine
Cardiac apex & gastric bubble are to the left
Horizontal fissure lies at the level of the 4 th costal
cartilage.
Mediastinum is < 25% of the chest width
HEART BORDERS

1.Aortic knuckle
2.Pulm. Artery
3.L.atrial appendage
4.L ventricle
5.R atrium
6.trachea
7.R dome of diaphragm
8.gas bubble in stomach
9.horizontal fissure
MRD:maximum R diameter
MLD :maximum L diameter.
ID : internal diameter
USEFUL RULES & SIGNS
The Silhouette Sign
Contiguous objects of the same density
are not seen separately
The 4 basic densities are air, fat, water and metal
The silhouette sign is seen when a border of the heart,
aorta, or diaphragm is obliterated
The heart and ascending aorta are anterior structure
Causes of confluent opacification of a hemithorax
There are four main causes of confluent opacification of
a hemithorax -
consolidation (that is, material within the air-spaces
and
pleural effusion - that is, material within the pleural
space, which could be serous fluid, blood, or pus.
Complete collapse of one lung with the mediastinum
shifting over the the abnormal side can also cause a
"white out" on the abnormal side.
Finally, after a pneumonectomy the mediastinum shifts
to the empty hemithorax and the residual pleural space
fills with fluid and fibrotic material leaving the patient with
a complete "white out" on the side that has been
operated on. Consolidation and pleural effusion are the
two most common, and it can be difficult to distinguish
between them - of course, they can coexist.
Collapse-RML
Silhouette sign
RML COLLAPSE-LATERAL
RML collapse..graphic
Collapse
Collapse of a lobe is caused by proximal
obstruction
for example, by a neoplasm, mucus plug,
such as in a postoperative patient, or
foreign body, such as in a child.
AIR BRONCHOGRAM
The bronchi are not normally seen on the
xray as they are thin walled, contain air
and are surrounded by air in the alveoli
Visualisation of air in the bronchi is known
as an air bronchogram
Air- filled bronchi can be seen if surrounded
by diseased lung which contains no air (eg
pneumonia, hyaline membrane
disease,RDS)
RDS
SAIL SIGN
The normal thymus lies in the sup, ant
mediastinum. In the infant , it may appear
to widen the mediastinum in a PA view,
being largest at about 2 years of age

The inferior border of the R thymic lobe is a

straight line. When it rests on the R
horizontal fissure it produces an
appearance referred to as the sail sign
sail sign
RUL collapse..graphic
Findings in
COLLAPSE/ATELECTASIS
Increased Radiopacity
Shift of fissure, hilum,
mediastinum
Crowding of vessels &
airways within the lobe
Crowding of ribs
Compensatory
emphysema
Elevation of the hemi
diaphragm ( tenting )
LLL COLLAPSE
LLL COLLAPSE
PNEUMONIA- RUL
CONSOLIDATION
Not very dense
opacity
Loss of contingous
borders
No volume loss
Air bronchogram
Loss of vascular
markings
Medial segment of R middle lobe
CONSOLIDATION
RM&LL PNEUMONIA
TB HILAR ADENOPATHY
APICAL TB
MILIARY TB
Pl. effusion R