CXR Reading
Dr Mahmoud A. Abuissa, MD
Consultant Internal Medicine
Ittihad Hospital
What is X-ray
X-rays- describe radiation which is part of the
spectrum which includes visible light
Unlike visible light, radiation passes through
stuff.
When you shine a beam of X-Ray at a person and
put a film on the other side of them a shadow is
produced of the inside of their body.
Different tissues in our body absorb X-rays
at different extents:
• Bone- high absorption (white)
• Tissue- somewhere in the middle
absorption (grey)
• Air- low absorption (black)
What to identify first
Correct patient
Correct date and time
Correct examination
Are old films available?
Technical aspects
Position and Projection
Inspiratory effort
Penetration
Positioning/rotation
Exposure
Position and projection
The standard chest examination consists of :
PA (posterioranterior)
lateral chest x-ray.
The films are read together.
PA vs AP
The PA (posterioranterior) film is obtained
with the patient facing the cassette and the x-
ray tube 6 feet away.
This distance diminishes the effect of beam
divergence and magnification of structures
closer to the x-ray tube
Whenever possible the patient should be
imaged in an upright PA position.
AP views are less useful and should be
reserved for very ill patients who cannot
stand erect.
Lateral decubitus position
This could be
helpful to assess
the volume of
pleural effusion
and demonstrate
whether a pleural
effusion is mobile
or loculated
Inspiratory effort
The patient should be examined in full
inspiration.
On good inspiration, the diaphragm should be
found at about the level of the:
8th - 10thposterior rib
5th - 6th anterior rib
A patient can appear to have a very abnormal
chest if the film is taken during expiration
Penetration
On a good PA film, the thoracic spine disc
spaces should be barely visible through the
heart but bony details of the spine are not
usually seen.
On the other hand penetration is sufficient
that bronchovascular structures can usually
be seen through the heart.
Rotation
access patient rotation by observing the
clavicular heads and determining whether
they are equal distance from the spinous
process of the thoracic vertebral bodies.
If there is rotation of the patient, the
mediastinum may look very unusual.
Check exposure
One needs to be able to identify both
costophrenic angles and lung apices
Follow a specific radiological Check List so as
not to miss any abnormalities:
Inside outside
Outside inside
A-B-C-D-E-F-G-H
A - Airway
Ensure trachea is visible and in midline
Trachea gets pushed away from abnormality
pleural effusion or tension pneumothorax
Trachea gets pulled towards abnormality
atelectasis
View the carina, angle should be between 60
–100 degrees
Increased
left atrial enlargement,
lymph node enlargement
left upper lobe atelectasis
Check for tubes, pacemaker, wires, lines
foreign bodies etc
If an endotracheal tube is in place, check the
positioning, the distal tip of the tube should
be 3-4cm above the carina
B- Bones
Check for fractures, dislocation,
Bone lesions in clavicles, ribs, thoracic spine
and humerus
At this time also check the soft tissues for
subcutaneous air, foreign bodies and surgical
clips
C – Cardiac shadow
Check heart size and heart borders
Cardiothoracic ratio
Check aorta
Widening, calcification
Check heart valves
Calcification, valve replacements
D&E – Diaphragm & effusions
Right hemidiaphragm
Should be higher than the left
If much higher, think of effusion, lobar
collapse, diaphragmatic paralysis
If you cannot see parts of the diaphragm,
consider infiltrate or effusion
If film is taken in erect or upright position
you may see free air under the diaphragm if
intra-abdominal perforation is present
Differentiating Rt and Lt hemi diaphragms
F – Fields (Lungfields)
Identify the location of infiltrates
by use of known radiological phenomena,
loss of heart borders or of the contour of the diaphragm
Remember that right middle lobe abuts the heart, but the right
lower lobe does not
The lingula abuts the left side of the heart
Identify the pattern of infiltration
Interstitial pattern (reticular) versus alveolar (patchy or
nodular) pattern
Lobar collapse
Look for air bronchograms, tram tracking, nodules, Kerley B
lines
Pay attention to the apices
Silhouette sign
Elimination of the silhouette or loss of
lung/soft tissue interface caused by a mass or
fluid in the normally air filled lung.
The sign is commonly applied to the heart,
aorta, chest wall, and diaphragm. The location
of this abnormality can help to determine the
location anatomically.
Nodules and Masses
Nodule:
any pulmonary lesion represented in a
radiograph by a sharply defined, discrete,
nearly circular opacity 2-30 mm in diameter
Mass:
larger than 3 cm
G – Gastric Air Bubble
Check correct position
Beware of hiatus hernia
Look for fee air under diaphragm
H – Hilum and Mediastinum
Check the position and size bilaterally
Enlarged lymph nodes
Calcified nodules
Mass lesions
Pulmonary arteries, if greater than 1.5cm think
about possible causes of enlargement
Pulmonary arteries
Mediastinum
Common Abnormalities
Cardiogenic Pulmonary Edema
Cephalization of the pulmonary vessels,
Kerley B lines or septal lines, "bat wing"
pattern, increased cardiac size.
Alveolar edema
Pleural effusion
Pulmonary embolism
Normal
Elevated Hemi- diaphragm
Hampton's hump
Westermarks sign
Pleural effusion
What do you tkink?
Pulmonary Fibrosis
Thanks