X-RAY CHEST
Prof. Dr. Sajid Abbas Jaffri
INTRODUCTION
• Chest X-ray is performed to evaluate the lungs, heart and
chest wall.
• Normal chest x-ray is taken with patient in upright
position, taking deep breath and holding it for few
seconds.
• Routine chest x-ray is taken in frontal view (called
posterior-anterior or PA view).
• Interpretation of the film in expiration is difficult because
the lung bases appear hazy and the heart looks enlarged
except pneumothorax , which is more clearly seen in an
expiratory film rather than inspiratory film.
NORMAL CHEST X-RAY
NORMAL CHEST X-RAY
NORMAL CHEST X-RAY
X-RAY WITH DEXTROCARDIA
X-RAY WITH DEXTROCARDIA
X-RAY WITH DEXTROCARDIA
FOLLOWING POINTS TO BE OBSERVED IN
CXR
• Position of the patient (look for kypho-scoliosis).
• Side of X-ray (look for right ‘R’ and left ‘L’ markers on the top of the film).
• Soft tissue shadow (outside skeleton such as skin and muscles).
• Bony configuration (look for ribs, clavicles, scapula and spine).
• Position of the trachea.
• Outline of the diaphragm (both right and left domes).
• Costophrenic and Cardiophrenic angles on both sides.
• Borders of the heart including upper mediastinum.
• Heart size.
• Lung fields (including hilar shadows, pulmonary vessels and fissure of the lungs).
• In females look for breast shadow.
• Look for any shadow in the neck, subcutaneous tissue in the chest wall, any
abnormality in humerus and subcutaneous emphysema.
• Any device or prosthesis or tube for example, pacemaker, ICD, mechanical valve, IT
tube, tracheostomy tube and CV line.
DIFFERENCE BETWEEN PA & AP VIEW
DIFFERENCE BETWEEN PA & AP VIEW
Postrior-anterior (PA) VIEW
Anterior-Posterior (AP) VIEW
POSITION OF THE PATIENT
• Observe the medial ends of both clavicles in
relation to the pedicles of thoracic vertebrae.
• The medial end of clavicle should be
equidistant from the spinous process at the
level of T4 and T5 thoracic vertebrae.
SIDE OF THE X-RAY (RIGHT OR LEFT)
• Always look on the top of the film for ‘R’ or ‘L’ marker,
which indicates the patients position (right or left).
• Other points that will help to find the side in addition
to the markers on the top of film are:
1. Diaphragm-- usually the right dome is 2.5 cm above
the left dome.
2. Fundal gas is on the left side.
3. Heart—normally, one third lies on the right side and
two third on the left. Look at the cardiac apex, which
is on the left side.
SOFT TISSUE SHADOW
(OUTSIDE SKELETON)
• This appears as opacity outside the bony
skeleton.
• In females, check for the breast shadow.
BONY CONFIGURATION
• Look for the cervical rib, may be small or
rudimentary.
• Check the ribs(normal, crowding, wide spaced,
erosions, notching, fracture or healed fracture
and resected rib).
• Check the clavicle, spine and vertebral
column, scapula and humerus.
• Look for kypho-scoliosis.
POSITION OF TRACHEA
• Trachea is seen as a dark column(due to air).
• Observe whether the trachea is central or
deviated to the right or left, normally trachea
lies midway or slightly deviated to the right.
OUTLINE OF DIAPHRAGM
(RIGHT & LEFT DOMES)
• Normally, right dome is at the level of anterior
end of the sixth rib and posterior end of the
10th rib near the vertebral column.
• Left dome is 2.5 cm below the right dome.
COSTOPHRENIC & CARDIOPHRENIC ANGLES
ON BOTH SIDES
• Angle between the diaphragm and the rib is
called costophrenic angle(may be obliterated
due to pleural effusion).
• Angle between the diaphragm and cardiac
border is called the cardiophrenic angle(may
be obtuse due to left ventricular enlargement
or pericardial effusion).
HEART SIZE
• Cardiothoracic ratio is used for measuring the
heart size. Maximum transverse diameter of
the heart is slightly less than half of the
maximum transverse diameter of chest (<0.5).
MEASURING HEART SIZE
CADIOTHORACIC RATIO
BORDERS OF THE HEART
• 1. Right border of the heart is formed by (above
downwards) the following:
a. Upper slightly curved portion– superior vena cava with
ascending aorta.
b. Lower more convex part– outer border of the right atrium.
• 2. Left border of the heart is formed by (above downwards)
the following:
a. Prominent aortic knuckle(formed by aortic arch).
b. Straight line due to pulmonary artery.
c. Left atrial appendage.
d. Left ventricle.
CARDIOMEGALY
PERICARDIAL EFFUSION
PROMINENT AORTIC KNUCKLE
STRAIGHTENING OF LEFT BORDER OF HEART
STRAIGHTENING OF LEFT BORDER OF HEART
X-RAY WITH MS
HILAR SHADOWS
Hilar shadow consist of:
• Pulmonary artery
• Pulmonary veins
• Hilar lymph nodes( normally they are too small and not
well visible).
• Left hilum is slightly higher(2.5 cm than the right).
• Air within major bronchus can be seen, but their walls
re not visible.
• Normally, shadow of pulmonary vessels is not well
visible.
BILATERAL HILAR LYMPHADENOPATHY
HILAR LYMPHADENOPATHY
DIFFERENTIAL DIAGNOSIS OF HILAR
LYMPHADENOPATHY
• Sarcoidosis
• Mycobacteria
• Fungal
• Viral
• Tularemia
• Lymphoma
LUNG FIELDS
Radiologically, lung fields are divided into three
zones all of which are seen in PA view.
• Upper zone is the part above a horizontal line
through the lower border of the anterior end of
second rib.
• Mid zone is the part between the lower border of
the upper zone and a horizontal line through the
lower border of the anterior end of fourth rib.
• Lower zone is the part below the mid zone.
AIR BRONCHOGRAM
• Normally, air in the bronchi through normal lung
parenchyma is not visible. When alveoli are filled
with fluid, air in the bronchi becomes visible, called
air bronchogram. It is present in:
• Consolidation
• Pulmonary oedema
Rarely:
• Hyaline membrane disease, Sarcoidosis, Lymphoma,
Alveolar cell carcinoma and Acute respiratory
distress syndrome.
AIR BRONCHOGRAMS
PNEUMONIA WITH AIR BRONCHOGRAM
CONSOLIDATION
• Consolidation means pneumonia, which is
defined as ‘ inflammation in the lung
parenchyma characterized by the
accumulation of secretion and inflammatory
cells in alveoli’.
• Radiologically non-homogenous opacity with
air bronchogram within it.
PNEUMONIA WITH AIR BRONCHOGRAM
CHICKENPOX PNEUMONIA
• Chickenpox pneumonia in adulthood can
cause the development of numerous calcified
nodules. To determine whether this is a likely
diagnosis:
a. Look at the distribution of the nodules: In chickenpox
they tend to be in the lower and mid zones.
b. Look at the density of the nodules: They are calcified
and so should be very white in appearance.
c. Look at their size. They are usually less than 3 mm in
diameter.
VERICELLA PNEUMONIA
PRIMARY TUBERCULOSIS
• It is the first attack of tuberculosis, which
usually involves the periphery of lung in mid
and upper zones called Ghon focus. When this
focus is associated with enlarged hilar or
mediastinal lymph nodes, it is called Ghon
complex or primary complex. Usually the
primary complex heals spontaneously and
often calcifies.
MILIARY TUBERCULOSIS
• It is the acute dissemination of pulmonary TB
through blood stream due to rupture of
tuberculous focus into a vein.
• Miliary TB usually occurs as a complication of
primary tuberculosis.
• Characterized radiologically by multiple small
millet-shaped nodules in the lung, all of which
are of same size and evenly distributed.
MILIARY MOTTLING
• It means multiple, small millet shaped
shadows, usually 1-2 mm, involving all the
zones of both lung fields.
MILLIARY MOTLING
FIBROSIS
Fibrosis is one of the rarer causes of white lung and you need to
differentiate it from consolidation or edema which is far more
common. If you suspect fibrosis:
1. Look at the old x-ray if possible: Fibrosis is fairly chronic process
so if present previously it is more likely to be fibrosis than
consolidation or edema.
2. Look at the distribution of the shadowing: This may help
differentiate from edema since the latter is more likely to be
bilateral, basal and peripheral. Therefore shadowing that is mid
zone or apical is more likely to be fibrosis.
3. Look at the size of the lung: Fibrosis may cause shrinkage of the
lungs which will not be caused by consolidation or edema. The
presence of small lung points strongly to fibrosis.
FIBROSIS
1. Look at the shape of mediastinum: Since fibrosis causes
shrinkage of the lungs, it will pull the mediastinum and
distort the outline.
2. Look at the nature of shadowing: Pulmonary fibrosis gives
reticular nodular shadowing which simply means a
meshwork of lines. Sometimes the meshwork is very fine,
giving a ground glass appearance, later it gives a more coarse
appearance and is to look like a honey comb.
3. Look at the heart border and diaphragm: Both of these may
appear blurred, if fibrosis is present.
4. Look at the vascular markings: These become less distinct in
areas of fibrosis.
FIBROSIS OF LUNG
FIBROSING ALVEOLITIS
LUNG FIBROSIS
HONEY-COMB LUNG
RETICULONODULAR PATTERN
RETICULONODULAR PATTERN
LUNG COLLAPSE
LUNG COLLAPSE
HOW TO DIFFERENTIATE COLLAPSE FROM
FIBROSIS
• COLLAPSE: X-ray shows homogenous opacity.
Evidence of bronchial obstruction (mass
lesion) may be seen, diaphragm may be
elevated.
• FIBROSIS: Non homogenous opacity, rib
crowding and ring shadow due to dilatation of
bronchi within fibrosis may be seen.
TYPE OF COLLAPSE
• Collapse is of two types:
• 1. ETIOLOGICAL:
• a) Compression collapse due to pleural effusion and
pneumothorax.
• b) Absorption collapse due to bronchial obstruction.
• 2. ANATOMICAL:
• a) Central– mass lesion ( produce more signs and
symptoms.
• b) Peripheral– usually a small collapse ( produce less
signs and symptoms.
TYPE OF COLLAPSE
• CENTRAL COLLAPSE: Bronchus is completely
obstructed. Breath sounds are diminished or
absent. Vocal resonance is diminished or absent.
Caused by bronchial carcinoma or adenoma,
enlarged lymph node or foreign body.
• PERIPHERAL COLLAPSE: Bronchus is patent.
Breath sounds are bronchial and vocal
resonance is increased. Caused by bronchial
cast or mucus plugging.
PLEURAL EFFUSION
• Accumulation of fluid in the pleural space.
• Homogenous opacity with concave upper
margin, obliterating the costophrenic and
cardiophrenic angles.
PLEURAL EFFUSION
(RIGHT SIDED)
PLEURAL EFFUSION
(LEFT SIDED)
PLEURAL EFFUSION
(BILATERAL)
PLEURAL EFFUSION
PLEURAL FFFUSION
MENISCUS SIGN
PLEURAL EFFUSION
PNEUMOTHORAX
PNEUMOTHORAX
• It is an accumulation of air in the pleural
space.
• Radiologically, increased translucency with
collapsed lung margin.
• In pneumothorax, some amount of fluid may
be present, obliterating the costophrenic
angle, which is due to pleural reaction.
TENSION PNEUMOTHORAX
TENSION PNEUMOTHORAX
• Increased translucency on the right side.
• Trachea and heart(mediastinum) are shifted to
the left side.
• Intercostal spaces are wide.
TENSION PNEUMOTHORAX
HYDROPNEUMOTHORAX
• It is the accumulation of air and fluid in pleural
space.
• Increased translucency with collapsed lung
margin on the right side.
• Horizontal fluid level with obliteration of right
costophrenic and cardiophrenic angles.
HYDROPNEUMOTHORAX
HYDROPNEUMOTHORAX
HYDROPNEUMOTHORAX
CHRONIC BRONCHITIS
• It is defined as the ‘presence of cough
productive of sputum, on most of the days for
at least three consecutive months for two
successive years, not due to other causes’.
CHRONIC BRONCHITIS
CHRONIC BRONCHITIS
CHRONIC BRONCHITIS
CHRONIC BRONCHITIS
EMPHYSEMA
• It is the permanent distension of alveoli with
destruction of their walls distal to the terminal
bronchioles.
EMPHYSEMA
EMPHYSEMA
• Lung fields are hyper-translucent.
• Low and flat diaphragm.
• Heart is elongated and tubular(tear drop
heart).
• Ribs are widely spaced.
• Blood vessels are less prominent.
• The pathognomonic sign is presence of bullae.
EMPHYSEMA
EMPHSEMATOUS BULLAE
EMPHYSEMA WITH GIANT BULLA
BRONCHIECTASIS
• It is the abnormal, permanent dilatation one
or more bronchi with destruction of bronchial
wall proximal to the terminal bronchiole.
BRONCHIECTASIS
BRONCHIECTASIS
• Saccular and cystic dilatation(ring-like shadow)
of many bronchiolar segments of right lower
lobe.
• Multiple ring-like translucent shadows
involving the lower zone right or both lung.
GAS UNDER DIAPHRAGM
GAS UNDER DIAPHRAGM
GAS UNDER DIAPHRAGM
CAUSES OF GAS UNDER DIAPHRAGM
• Perforated abdominal viscera
• Perforated Peptic Ulcer
• Ileal perforation( typhoid, tuberculosis, crohn’s
disease, actinomycosis, radiation enteritis ).
• Burst appendicitis.
• Penetrating injury to the abdomen.