Chest Radiography

Interpretation:
Reading
Reading Chest
Chest Films
Films
Lisa Chen , M.D.
Assistant Clinical Professor
Pulmonary and Critical Care Division
Department of Medicine
San Francisco General Hospital
Michael Gotway, MD
Associate Clinical Professor, Radiology
University of California, San Francisco

Approach
Approach to
to the
the CXR:
CXR:
Technical
Technical Aspects
Aspects
Inspiratory
Inspiratory effort
effort
99-10
-10 posterior
posterior ribs
ribs

Penetration
Penetration
thoracic
thoracic intervertebral
intervertebral disc
disc space
space just
just visible
visible

Positioning/rotation
Positioning/rotation
medial
medial clavicle
clavicle heads
heads equidistant
equidistant to
to spinous
spinous
process
process

Low Lung Volumes

Over Exposure

Proper Exposure

10

What
What to
to Evaluate
Evaluate
Lungs
Lungs
Pleural
Pleural surfaces
surfaces
Cardiomediastinal
Cardiomediastinal contours
contours
Bones
Bones and
and soft
soft tissues
tissues
Abdomen
Abdomen

Where
Where to
to Look
Look
Apices
Apices
Retrocardiac
Retrocardiac areas
areas (left
(left and
and right)
right)
Below
Below diaphragm
diaphragm

Apical TB

Left Retrocardiac Opacity

Normal
Normal Anatomy:
Anatomy: Frontal
Frontal CXR
CXR
Heart
Heart
Aorta
Aorta
Pulmonary
Pulmonary arteries
arteries
Airways
Airways
Diaphragm/costophrenic
Diaphragm/costophrenic sulci
sulci
Junction
Junction lines
lines

Normal
Normal Anatomy:
Anatomy: Lateral
Lateral
Heart
Heart
Aorta
Aorta
Pulmonary
Pulmonary arteries
arteries
Airways
Airways
Spine
Spine

AA

RV
LV

Chest
Chest Radiography:
Radiography:
Basic
Basic Principles
Principles
X-ray
X-ray photon
photon fates:
fates:
completely
completely absorbed
absorbed in
in patient
patient
transmitted
transmitted through
through patient;
patient; strike
strike film
film
scattered
scattered within
within patient;
patient; strike
strike film
film

X-ray
X-ray absorption
absorption depends
depends on:
on:
beam
beam energy
energy (constant)
(constant)
tissue
tissue density
density

Maximum x-ray
Transmission
(least dense tissue)

Blackest
air
fat
soft tissue
calcium
bone
x-ray contrast

Maximum xray
Absorption
(densest tissue)

metal

Whitest

Chest
Chest Radiography:
Radiography:
Basic
Basic Principles
Principles
All
All cardiothoracic
cardiothoracic pathology
pathology and
and
normal
normal anatomy
anatomy is
is visualized
visualized (or
(or not)
not)
by
by 77 different
different densities
densities
How
How is
is this
this accomplished?
accomplished?
differential
-ray absorption
differential xx-ray
absorption

Differential
-Ray Absorption
Differential X
X-Ray
Absorption
A
A structure
structure is
is rendered
rendered visible
visible on
on aa
radiograph
radiograph by
by the
the juxtaposition
juxtaposition of
of two
two
different
different densities
densities

Silhouette
Silhouette Sign
Sign
Loss
Loss of
of the
the expected
expected interface
interface
normally
normally created
created by
by juxtaposition
juxtaposition of
of
two
two structures
structures of
of different
different density
density
No
No boundary
boundary can
can be
be seen
seen between
between
two
two structures
structures of
of similar
similar density
density

Right Lower Lobe Pneumonia

Differential
-Ray Absorption
Differential X
X-Ray
Absorption
The
The absence
absence of
of aa normal
normal interface
interface
may
may indicate
indicate disease;
disease;
The
The presence
presence of
of an
an unexpected
unexpected
interface
interface may
may also
also indicate
indicate disease
disease
The
The presence
presence of
of interfaces
interfaces can
can be
be
used
used to
to localize
localize abnormalities
abnormalities

Chest
Chest Radiographic
Radiographic
Patterns
Patterns of
of Disease
Disease
Air
Air space
space opacity
opacity
Interstitial
Interstitial opacity
opacity
Nodules
Nodules and
and masses
masses
Lymphadenopathy
Lymphadenopathy
Cysts
Cysts and
and cavities
cavities
Lung
Lung volumes
volumes
Pleural
Pleural diseases
diseases

Chest
Chest Radiographic
Radiographic
Patterns
Patterns of
of Disease
Disease
Cardiomediastinal
Cardiomediastinal contour
contour abnormalities
abnormalities
Bone
Bone and
and soft
soft tissue
tissue abnormalities
abnormalities
Below
Below the
the diaphragm:
diaphragm: abdominal
abdominal and
and
retroperitoneal
retroperitoneal disease
disease

Air
Air Space
Space Opacity
Opacity
Components:
Components:
air
-filled bronchus
air bronchogram
bronchogram:: air
air-filled
bronchus
surrounded
surrounded by
by airless
airless lung
lung
confluent
confluent opacity
opacity extending
extending to
to pleural
pleural
surfaces
surfaces
segmental
segmental distribution
distribution

Air
Air Space
Space Opacity:
Opacity: DDX
DDX
Blood
Blood (hemorrhage)
(hemorrhage)
Pus
Pus (pneumonia)
(pneumonia)
Water
Water (edema)
(edema)
hydrostatic
-cardiogenic
hydrostatic or
or non
non-cardiogenic

Cells
Cells (tumor)
(tumor)
Protein/fat:
Protein/fat: alveolar
alveolar proteinosis
proteinosis and
and
lipoid
lipoid pneumonia
pneumonia

LUL Pneumonia

Interstitial
Interstitial Opacity
Opacity
Hallmarks:
Hallmarks:
small,
-defined nodules
small, well
well-defined
nodules
lines
lines

interlobular
interlobular septal
septal thickening
thickening

fibrosis
fibrosis
reticulation
reticulation

Interstitial Opacity: Small Nodules

Interstitial Opacity:
Lines

Interstitial Opacity: Lines & Reticulation

Interstitial
Interstitial Opacity:
Opacity: DDX
DDX
Idiopathic
Idiopathic interstitial
interstitial pneumonias
pneumonias
Infections
Infections (TB,
(TB, viruses)
viruses)
Edema
Edema
Hemorrhage
Hemorrhage
Noninfectious
Noninfectious inflammatory
inflammatory lesions
lesions
sarcoidosis
sarcoidosis

Tumor
Tumor

Nodules
Nodules and
and Masses
Masses
Nodule:
Nodule: any
any pulmonary
pulmonary lesion
lesion
represented
represented in
in aa radiograph
radiograph by
by aa sharply
sharply
defined,
defined, discrete,
discrete, nearly
nearly circular
circular opacity
opacity
2-30
2-30 mm
mm in
in diameter
diameter
Mass:
Mass: larger
larger than
than 33 cm
cm

Nodules
Nodules and
and Masses
Masses
Qualifiers:
Qualifiers:
single
single or
or multiple
multiple
size
size
border
border definition
definition
presence
presence or
or absence
absence of
of calcification
calcification
location
location

Well-Defined

Calcification

Ill-Defined

Mass

Lymphadenopathy
Lymphadenopathy
Non-specific
Non-specific presentations:
presentations:
mediastinal
mediastinal widening
widening
hilar
hilar prominence
prominence

Specific
Specific patterns:
patterns:
particular
particular station
station enlargement
enlargement

Right Paratracheal
Lymphadenopathy

Right Hilar LAN

Right Hilar LAN

Left Hilar LAN

Subcarinal LAN

Subcarinal LAN

AP Window LAN

Cysts
Cysts &
& Cavities
Cavities
Cyst:
Cyst: abnormal
abnormal pulmonary
pulmonary
parenchymal
parenchymal space,
space, not
not containing
containing
lung
lung but
but filled
filled with
with air
air and/or
and/or fluid,
fluid,
congenital
congenital or
or acquired,
acquired, with
with aa wall
wall
thickness
thickness greater
greater than
than 11 mm
mm
epithelial
epithelial lining
lining often
often present
present

Cysts
Cysts &
& Cavities
Cavities
Cavity:
Cavity: abnormal
abnormal pulmonary
pulmonary
parenchymal
parenchymal space,
space, not
not containing
containing
lung
lung but
but filled
filled with
with air
air and/or
and/or fluid,
fluid,
caused
caused by
by tissue
tissue necrosis,
necrosis, with
with aa
definitive
definitive wall
wall greater
greater than
than 11 mm
mm in
in
thickness
thickness and
and comprised
comprised of
of
inflammatory
inflammatory and/or
and/or neoplastic
neoplastic
elements
elements

Cysts
Cysts &
& Cavities
Cavities
Characterize:
Characterize:
wall
wall thickness
thickness at
at thickest
thickest portion
portion
inner
inner lining
lining
presence/absence
presence/absence of
of air/fluid
air/fluid level
level
number
number and
and location
location

Benign Lung Cyst : PCP Pneumatocele

Benign Cavities :
Cryptococcus

max wall thickness 4 mm

Indeterminate Cavities

max wall thickness 5-15 mm

Malignant Cavities: Squamous Cell Ca

Pleural
Pleural Disease:
Disease: Basic
Basic Patterns
Patterns
Effusion
Effusion
angle
angle blunting
blunting to
to massive
massive
mobility
mobility

Thickening
Thickening
distortion,
distortion, no
no mobility
mobility

Mass
Mass
Air
Air
Calcification
Calcification

Pleural Effusion

Pleural Effusion

Subpulmonic Effusion

Pleural Calcification