RADIOLOGY

Normal Chest Radiograph

Maria Louven Urbano-Grasparil, MD | 23 August 2018
S1T3
OUTLINE
I. Normal Chest Radiograph II. Lungs
A. Posteroanterior View A. Right Lung
B. Lateral View B. Left Lung
C. Anteroposterior View C. Fissures
D. Apicolordotic View III. Normal Cardiac Plain Film
E. Oblique Views Anatomy
F. Lateral Decubitus View

I. NORMAL CHEST RADIOGRAPH

A. PA (Posteroanterior View)

Lateral View

C. AP (Anteroposterior) View
• Performed on patients who are unable to stand
• Performed at beside
• May cause cardiac magnification
• Widened mediastinum
• Not winged-out scapula: May be difficult to look for infiltrates
• X-ray tube is 40 inches away from the patient

Chest PA View
• Patient’s chest is placed against the film cassette
• X-rays enter the patient posteriorly and exit anteriorly

PA vs AP View

• Minimizes cardiac magnification due to divergence

• Advantages
- Allows more accurate representation of heart size as the heart is
positioned closer to the detector and is therefore less magnified
- Pulmonary vasculature and soft tissue outlines are well-defined
(“crisper” borders) PA View AP View
• X-ray tube is 6ft (72 in) away from the patient • This is a PA film on the left compared with an AP supine film on the
• The nearer the x-ray tube, the higher the magnification right
• Posterior ribs are more horizontally oriented • The AP shows magnification of the heart and widening of the
• Anterior ribs are more obliquely oriented mediastinum.
• Bones obscure the apices of the lungs and heart • Whenever possible, the patient should be imaged in an upright PA
position.
B. Lateral View • AP views are less useful and should be reserved for very ill
• Requested in conjunction with PA view patients who cannot stand erect.
- Ancillary to have sort of “three-dimensional” view of the chest
- To know if a lesion is anteriorly or posteriorly located D. Apicolordotic (APL) View
• The left side of the chest is placed against the film cassette • Similar to PA view except that the x-ray beam is directed cranially
• The right side of the body is close to the source of x-rays - Source is angulated at 15 degrees: apices are seen very well
• The right side is magnified than the left side - Liliyad yung pasyente
• This is performed to evaluate upper lobe paraplegy
• Removes the clavicle shadows seen in PA view
• Ribs are more horizontally oriented
• Used to:
- Evaluate upper lung pathology
- Evaluate tuberculosis
▪ Aerophilic → predilection on the upper lobe

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 RADIOLOGY
Normal Chest Radiograph
- Identify the minor fissure in suspected cases of atelectasis of the LOBAR ANATOMY
right middle lobe • Right Lung
o 3 Lobes (1 Oblique/Major & 1 Horizontal/Minor Fissure)
▪ Right Upper Lobe
▪ Right Middle Lobe
▪ Right Lower Lobe
• Left Lung
o 2 Lobes (1 Oblique/ Major Fissure)
▪ Left Upper Lobe
▪ Left Lower Lobe

RIGHT LUNG
RIGHT UPPER LOBES
POSTEROANTERIOR LATERAL

E. Oblique view
• Auxillary views
• Left Anterior Oblique (LAO)
• Right Anterior Oblique(RAO)
• Left posterior oblique (LPO)
• Right posterior oblique (RPO)
• Breast shadow attenuating the lower part of thorax is more
radiopaque (lower lobe)
• Used to:
o Show foreign objects outside the chest
o Localize abnormalities such as pleural plaque

F. Lateral Decubitus View

• Used for detecting air (very minimal pneumothorax, seen on the
top side of the film) or fluids (pleural effusion, seen on the bottom
side of the film) Occupies the upper 1/3 of the On the lateral view, RUL
right lung. Extends inferiorly as occupies the superior part of
• Doc Grasparil: In detecting fluids, ultrasonography is better than
far as the 4th anterior rib the view. Adjacent to the first 3-
X-ray
5 ribs.
Doc: comprised of your apices

Notice the slightly radiolucent

trachea (encircled)

RIGHT MIDDLE LOBES

POSTEROANTERIOR LATERAL

• Left shows a patient in position for a right lateral decubitus

position.
• The right is an example at a decubitus film showing a mobile
pleural effusion (arrows)

II. LUNGS
• Radiolucent, appears black on the X-ray film

The RML occupies the anterior Smallest. It is located

half of the right lung field. anteroinferiorly. Appears
triangular and narrowest at the
Notice its intimate relationship hilum.
with the right cardiac border.
It does not occupy half of the
In this view, it occupies half of lung. It is wedge shape, and it
the right lung. occupies the anterior half of the
lung.

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 RADIOLOGY
Normal Chest Radiograph
RIGHT LOWER LOBES LEFT LOWER LOBES
POSTEROANTERIOR LATERAL

POSTEROANTERIOR LATERAL
The LLL occupies 2/3 of the lung The LL occupies ½ of the lateral
field. view. Most of it is situated
posteroinferiorly. The RLL is
Largest of all 3 lobes. Extends It occupies majority of the superimposed on the LLL;
inferiorly up to the diaphragm posterior space and a partion of narrowest superiorly.
Occupies almost 2/3 of the the antero inferior view. Extend
lower posterior of the right lung as far superiorly as the 6th
thoracic vertebral body, and FISSURES
extends inferiorly to the • Major fissure/oblique fissure – separates the lower lobe from the
[Link] is upper lobe superiorly and middle lobe anteriorly.
considerable overlap between
the more anterosuperiorly
• Minor fissure/horizontal/transverse fissure – only present in the right
lobe; separates the midle and lower lobes from the upper lobe.
located RUL and the RLL.
Similarly, the deep posterior
gutters extend considerably
inferiorly; with full inspiration, it
can extend as low as L2,
becoming superimposed over
the upper poles of the kidneys.

• If you see an opacity/lesion on the right middle lung field on the

PA view, in which lobe could the lesion be located?
Answer: Either RUL, RML, RLL
a lateral view of the right lung is needed to distinguish these
THREE lobes) unlike sa CT, kita mo agad kung upper, middle or
lower lobe. In a PA view, there’s just too much overlap. You cant
say na nasa right middle lobe yung lesion, you can only state that
there’s a mass on the right middle LUNG FIELD. (hindi lobe)
• If you see an opacity in the superior part of the right lung field
on frontal view, in which lobe could the lesion be?
Answer: RUL
LEFT LUNG
LEFT UPPER LOBES

POSTEROANTERIOR LATERAL
The LUL appears as if it’s the The right middle lobe is
entire left lung. superimposed on the inferior
portion of the left upper lobe.
Majority of LUL is situated
anterosuperiorly; narrowest LATERAL VIEW
inferiorly. • The major fissure extends posteriorly and superiorly approximately
to the level of the fourth vertebral body..

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 RADIOLOGY
Normal Chest Radiograph
III. NORMAL CARDIAC PLAIN FILM ANATOMY

• Orange arrows - normal pulmonary vessels

• Numerous blood vessels immediately near the mediastinum but
blood vessels taper/decrease as you go from inner to peripheral
areas; Consider pulmonary congestion if vessels are numerous in
periphery

Superior vena cava and inferior vena cava will drain into the right atrium.
Blood from RA will travel through the tricuspid valve to the right ventricle.
Through pulmonic valve, blood will go to pulmonary arteries then to the
lungs.

Do you really see it? NO. You see shadows which are WHITE .

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 RADIOLOGY
Normal Chest Radiograph

Blood will pass through the aortic valve to the aorta.

Blood will go back to the heart through the pulmonary veins to the left
atrium. Left atrium is superiorly located. Left ventricle is on the left side. Blood will go down to the descending aorta.

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 RADIOLOGY
Normal Chest Radiograph

Right border:
• Superior vena cava
• Right atrium
• Inferior vena cava
Left border:
We only see the borders. Left ventricle forms the left border of the heart. • Aortic knob
Left ventricle enlarges laterally and inferiorly. Right ventricle forms the • Main pulmonary trunk
right border of the heart and enlarges superiorly. Linear calcifications
may be seen in the aorta documented as atheromatous aorta or POSTERO-ANTERIOR VIEW
atherosclerotic aorta. Pulmonary Vessels

• The pulmonary vessels are linear streaks that branch.

• The lung can be divided vertically into three areas: the central,
middle and peripheral areas.
• The pulmonary vessels are normally most prominent in the central
area and tapers as they go to the periphery.
• If these vessels persist in the peripheral areas = Pulmonary
Congestion
• The left and right pulmonary arteries may be on the same level but
more often, the left is higher than the right.
- Why? Usually 90-95% of the population has this anatomy. It
is because of the left main stem bronchus, which passes
inferior to the pulmonary artery, pushing it up.
• If the right PA is higher → pathologic (something is pushing or
pulling it up)
- Mass/ Bulla/ Abscess below the RPA which pushes it up
- Loss of air (atelectasis) of the upper lobe pulls the RPA up
• Pulmonary veins are inferior and posterior to the arteries

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 RADIOLOGY
Normal Chest Radiograph
• The left atrium is below your carina. If the left atrium is enlarging,
the carinal angle widens.

LATERAL VIEW
Heart
• Review: SVC/IVC → RA → Tricuspid valve → RV → Pulmonic valve
→ Pulmonary Arteries → Lungs → Pulmonary Veins → LA → Mitral
valve → LV → Aortic valve → Aorta
• On lateral view, the anterior border of the heart is formed by the
RV.
• The heart is posterior to your sternum. Note in the next picture that
there is air between the heart and the sternum. If the RA enlarges, it
pushes the RV anteriorly and displaces the air.

• From the lungs, the blood goes back to the heart via the pulmonary
veins which are inferior and posterior to the arteries, and enters the
LA.
• The LV forms the posterior border of the heart on lateral view.
- If the LA enlarges, it pushes the LV towards the spine and the
LV (posterior border) touches the spine.

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 RADIOLOGY
Normal Chest Radiograph

CARDIAC BORDERS

(1) Left atrium (5) Right pulmonary artery

(2) Left ventricle (6) Left pulmonary artery
(3) Inferior vena cava (7) Aorta
(4) Right ventricle

DIAPHRAGM
• The left and right diaphragm appears as sharply marginated domes
• The peripheral margins of the diaphragm define the costophrenic
sulci
• The right diaphragm
- Higher than left due to the position of the liver
- Will appear larger on a lateral chest film

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 RADIOLOGY
Normal Chest Radiograph
REFERENCES
• Dr. Arquero’s powerpoint
• 2019 trans

OSSEOUS STRUCTURES
• Ribs, anterior and posterior ribs, spine, pedicles, transverse
processes, spinous processes, sternum

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