Radiology Department of Hasan Sadikin Hospital

Medical Faculty of Padjadjaran University

• Plain chest radiograph is one of the most
commonly performed imaging procedures
• Up to 50% of studies in radiology practices.
• Countless volumes of radiology textbooks
have been dedicated solely to thoracic
imaging.
Indication :
• Screening.

• Preoperative  underlying pulmonary and

cardiovascular diseases.
• Febrile patient  pulmonary sources of fever

• Trauma patient.

Contraindication (relative):
• Pregnant women especially 1st & 2nd trimester.

• Neonates and children.

Right Lung
o 3 lobes

• (divided by major fissure

and minor fissure)
o 10 segments
Left Lung :
o 2 lobes

• (divided by major fissure)

o 8 segments
o Lingula segments ~ medial
lobe of the right lung
• Minor (horizontal )fissure divides the superior lobe
and the middle lobe of the right lung.
• There is no minor fissure in the left lung.
• In the right lung, the major fissure (oblique) divides the
inferior lobe with the middle and superior lobes.
• In the left lung, the major fissure (oblique) divides the inferior
lobe with the superior lobe.
Superior Lobe Apical segment (1)
Posterior segment (2)
Anterior segment (3)
Middle Lobe Lateral segment (4)
Medial segment (5)
Inferior Lobe Apicobasal segment (6)
Mediobasal segment (7)
Anterobasal segment (8)
Laterobasal segment (9)
Posterobasal segment (10)
Superior Lobe Apicoposterior segment (1)
Anterior segment (2)
Lingula segments Superior segment (3)
Inferior segment (4)
Inferior Lobe Apical segment (5)
Anteromedial basal segment (6)
Laterobasal segment (7)
Posterobasal segment (8)
Trachea :
• Begins at the lower border of the cricroid cartilage at
the level of C6 vertebra.
• Extend to the carina at the level of the sternal angle
(T5 level)
• T4 level on expiration
• T6 level on inspiration
• The trachea is 15 cm and 2 cm in diameter.
Trachea :
• The trachea in children is very pliable.

• It may be deviated to the right in normal expiratory

film.
• It only deviates to the left if the aortic arch is on the
right side.
Primary lobule
• The smallest functional unit of the lung

• Comprises all the structures distal to a respiratory

bronchiole including 16-40 alveoli.
• Normal adult has approximately 23 million primary
lobules.
Acinus
• Consists of all structures distal to the terminal
bronchiole, including vessels, nerves, and
connective tissue.
• It has a diameter 4-8mm

• Contains approximately 10-20 primary lobules

Secondary Lobule
• The smallest structural unit of lung parenchyma
that is surrounded by a connective tissue septum.
• Contains 3-12 acini and measures 1,0-2,5 cm in
diameter.
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 Lobulus primer

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Alveoli pore:
Canals of Lambert
• between alveoli and terminal
bronchiole
Pores of Kohn
• between alveoli.

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POSTER0ANTERIOR
ANTEROPOSTERIOR
RIGHT/LEFT LATERAL
RIGHT ANTERIOR OBLIQUE
LEFT ANTERIOR OBLIQUE
RIGHT POSTERIOR OBLIQUE
LEFT POSTERIOR OBLIQUE
TOP LORDOTIC
RIGHT/LEFT LATERAL DECUBITUS
Indication:
 Routine

 Screening TB

 Pre-operative
Technique:
 The patient stand between the film and the x-ray tube.
 The patient faced the film.
 The hands are put in the waist with the elbow flexed to
the anterior (to open scapula so it doesn’t superimposed
with the lung)
 The distance of the film to the x-ray tube :
 Lung  1.5m
 Heart  2.0m
 Centre : 6th – 7th thoracic spine
 50-60 KV
 10-20 MAs
Indication:
(cannot be taken with PA )
• Severely ill patient

• Children

• Infant and neonates

• Obese

• Pregnant

• Ascites

• Intraabdominal tumor
Technique:

1. The patient lie on the table with the arms put beside
the body or put up.
2. The film was placed behind the back.
3. Centre : 6th -7th thoracic spine
• Heart enlargement
• Mediastinal widening
• Crowded
bronchovascular
marking at the basal
zone.
PA
• V – shaped clavicles
• No lung superposition
with the scapula
• No mediastinal widening
• Distinct anterior aspect
of the costa.
• Less crowded
bronchovascular marking
AP
• Straight clavicles
• Lung superposition with
the scapula
• Mediastinal widening
• Distinct posterior aspect
of the costa
• Crowded bronchovascular
marking especially at the
basal zone.
Indication:
• Look at mediastinal
abnormalities.
• Look at anomalies that
wasn’t clear at
posteroanterior position.
• Heart assessment.

• To look for minimal fluid

collection in the pleural
cavity (75cc) that can not be
seen in the PA chest x-ray
Technique:
1. The patient stand between
the film and the x-ray tube.
2. The lateral side of the
anomalies (right/left) was
closed to the film.
3. Both arms was lifted up.

4. Centre: 6th -7th thoracic

spine
R
L AORTIC ARCH
TRACHEA

OBLIQUE FISSURE

POSTERIOR RIBS
RT. HEMI
DIAPHRAGM

LT. HEMI DIAPHRAGM

COLON GAS
Indication:
 To look at anomalies that were not clear at PA and lateral
position.

Type:
 Right anterior oblique (RAO)
 Left anterior oblique (LAO)
 Right posterior oblique (RPO)
 Left posterior oblique (LPO)

The side that is mentioned is the side that was close to the film
 RAO: The right side and the anterior side was close to the
film
 LPO: The left side and the posterior side was close to the
film.
Indication:
 To look at anomalies that were not clear at PA and
lateral position.

Techniques:
1. The patient stand between the film and the x ray tube.
2. The side that is mentioned is the side that is close to
the film
3. The angle of obliquity is approximately 450.
4. The arm that was close to the film was put over the
head, while the other hand was put on the waist with
the elbow flexed to the posterior.
5. Centre: 6th -7th thoracic spine
RAO LAO
Indication:
• To look for minimal
fluid collection in
the pleural cavity
(15-20cc) that can
not be seen in the
PA chest x-ray
Technique:
1. The patient lying in the table with the lateral side
close to the table.
1. RLD : The right side of the body is close to the table
2. LLD : The left side of the body is close to the table
2. Both arms are lifted.
3. Centre: 6th – 7th thoracic spine
Indication:
• To look for
anomalies at the
apex of the lung.
Technique:
1. The patient stand between the film and the x-ray tube.
2. The patient is facing the x-ray tube.
3. The distance between the patient and the film is 30cm
4. The patient then rest the back of his shoulder to the
film.
5. The upper border of the film is approximately 1 inch
above the shoulder.
6. Centre: manubrium of the sternum
TOP LORDOTIK
1: Name & Age
2: Date
3: Medical record number
4: Previous examination
5: Position/View: PA/AP/Marker
6: Penetration
} Administration

7: Rotation
8: Inspiration
9: Magnification
10: Angulation
11: Trachea, heart, sinuses, diaphragm
} Quality

12: Hilum, bronchovascular marking

13: Lung field, hemithorax
14: Soft tissue, bone
15: Conclusion
} Diagnostic
Identity: Name & Age
Date
Medical record number
Previous examination
Position/view: PA/AP/Marker
Penetration
Rotation
Inspiration
Magnification
Angulation
• Higher kV  higher penetration ability of the x-ray.
(quality of the x-ray)
• Higher mAs  higher quantity of the x-ray 
higher amount of x ray that penetrate the body
• Higher kV  lower contrast resolution
• The ability to differentiate between high density and low
density object will be decreased with higher kV.
• So to get a good penetration film with a good
contrast resolution, we should use low kV with high
mAs. But there is a problem because the radiation
dose will be higher with lower kV and higher mAs.

• Our goal is to get the best quality of the image with

the lowest radiation dose to the patient.
• Fine vascular markings within the lung should be
seen.
• Faint outlines of at least mid and upper thoracic
vertebra
• 3rd thoracic vertebra in conventional radiograph
• All of the thoracic vertebra in digital radiograph
• Faint outlines of posterior ribs through heart and
mediastinal structures.
Conventional Digital
• It should be symetrical.
• Look at the distance from the medial end of both
the clavicles to the spine process in the midline.
Level inspirasimaksimal
 Apex of the diaphragm at the level 5th-6th anterior ribs.
 9th – 10th posterior ribs at the level of right cardiophrenic
sulcus.
2
3 1
4
5
6

10
Spurious findings : cardiomegaly, mass at the aortic
arch, patchy opacification in both lower zones.
Spurious findings : cardiomegaly, mass at the aortic
arch, patchy opacification in both lower zones.
• Influence the heart size assessment.
• Depend on the patient position toward the film.
• PA chest x-ray is more accurate in depicting the
heart size than AP chest x-ray.
• Reason:
• The distance between the heart and the film is closer
in PA chest x-ray.
• Not significant in patient < 4 years old.
AP PA
• In erect chest x ray (without cephalad or caudal
angulation)  the beam of the x-ray is paralel to
the floor and perpendicular to the thorax  the
clavicle is projected below the posterior aspect of
the first rib.
• In top lordotic (cephalad angulation) the clavicle
(anterior structure) is projected above the posterior
aspect of the first rib (posterior structure).
• In top lordotic, the normal ‘S’ shaped clavicle will
be seen as straight structure.
• The assessment of thoracic structure will be
influenced by the angulation.
• Lucent structure  contain air.
• Centrally located.
• Normal diameter : 1,5 cm
• Look for deviation.
• Extend to the carina at the level of the sternal
angle (T5 level)
• T4 level on expiration
• T6 level on inspiration

• Tracheal bifurcation (carina) normal angle <900

• >900 in left atrial enlargement.
• Size : Cardiothoracic Ratio (CTR)
• Shape
• Position
CTR : a + b
c+d
a
b
c
c d
Normal CTR
• Adult (PA) < 50%
• Adult (AP) < 55%
Normal CTR (PA)
• Neonates (<1month) < 60%
• Infant (1 month – 1 year) < 55%
• Children (>1 year) < 50%
Costophrenicus
Cardiophrenicus
 Right diaphragm is
higher than the left
diaphragm.
 Normal : 2.5 cm
 > 3 cm: abnormal
 Shape :
 Tenting
 Scalloping
 Diaphragm flattening
 N>1,5cm
 <1,5  flattening
• Lungs contain air
that will give
negative contrast
 black (lucent)
• Compare the right
lung with the left
lung
Apex
From the apex to the
clavicle
Upper lung field
From the clavicle to the
2nd anterior rib
Middle lung field
From the 2nd anterior
rib to the 4th anterior rib
Lower lung field
From the 4th anterior rib
to the diaphragm
Divided by the upper and
lower border of the
hilum.
Upper zone
Above the upper border
of the hilum
Middle zone
From upper border of
the hilum to the lower
border of the hilum
Lower zone
Below the lower border
of the hilum
• The area where the
vessels (artery and
vein), bronchus, and
lymphatic vessels
come in to and come
out from the lung.
• Normal left hilum is
higher than the right
hilum (about 1 rib)
• The diameter is about
9-16 mm or not bigger
than trachea
• Extend from the central to the peripheral area.
• Decreasing in quantity and calibre from the
central to the peripheral.
• Increased bronchovascular marking if > 2/3 of
the hemithorax.
• More crowded in the basal region.
• Cranialization or cephalization :
• Upper zone bronchovascular marking is more
prominent than the lower zone
• Ratio  3-5:1
NORMAL INCREASED
 SKELETAL:
• Ribs
• Clavicles
• Scapula
SOFT TISSUE
• Breast shadow
• Skin fold.
 International : peripheral to central
 RSHS: central to peripheal
 Trakea di tengah
 Cor tidak membesar
 Sinuses dan diafragma kanan/kiri normal
 Pulmo:
 Hili normal
 Corakan bronkovaskuler normal
 Tidak tampak bercak lunak
Kesan:
- Tidak tampak TB paru/kelainan paru lainnya
• Quality
• Retrosternal space
• Retrocardiac space
• Posterior sinus
• Anterior sinus
• Diaphragm
• Hilar area
• Lung field
Quality
• From apex to the sinus.
• From sternum to the
posterior ribs.
• Chin and arms elevated
sufficiently
• No rotation
• No motion (sharp
outlines)
• Visualize rib outlines and
lung marking through
the heart shadow
Retrosternal space
• Covered by heart
shadow < 1/3 bottom
• Abnormal > ½

Retrocardiac space
• Clear triangular
shaped
Anterior sinus
• Sharp

• Sometimes covered by
mediastinal fat
• Depend on the
exposure of the film.
Posterior sinus
• Sharp
Diaphragm
• Right diaphragm is
higher.
• Right diaphragm is seen
from the posterior to
the anterior.
• Anterior aspect of left
diaphragm is covered by
the heart shadow.
• Gastric bubble below
the left diaphram.
Hilar area
• Mass will make this
area more opaque
• Vascular  opaque

• Bronchi  lucent
Lung field
• Clear lung at the
anterio and posterior
of the heart.
• Decrease density from
superio to inferior in
the posterior
mediastinum.
 Retrosternal dan retrocardiac space cerah.
 Sinus anterior tajam.
 Sinus posterior tajam.
 Diafragma jelas.
 Tidak tampak infiltrat.
 Signs and symptoms potentially related to the
respiratory, cardiovascular, and upper
gastrointestinal systems, and the musculoskeletal
system of the thorax.
 Screening for neoplasma or metastasis
 Follow-up of known thoracic disease
 Monitoring of patients with life-support devices and
other devices in the thorax region
 Evaluate foreign body
 Screening in trauma patient
 Surveillance for active tuberculosis or occupational
lung disease
 Preoperative radiographic evaluation
o Heart Failure and o Corpus Alienum
pulmonary edema Aspiration
o Pleural Effusion o Hemothorax
o Pulmonary Contusion o Pneumonia
o Atelectasis o Pneumothorax
o Diaphragmatic Hernia o Rib fracture
o Flail chest o Pneumonia Aspiration
 Heart is enlarged to the left with the apex
downward toward the diaphragm.
 Hilar hazyness.
 Infiltrates in the 2/3 medial of both lung
 “bat wing appearance “
 “butterfly appearance”