Chest X-Rays:

Common Views: (Based on direction of rays through body) Some terms:

PA: most commonly used- smaller cardiac shadow and more lung field visualization Exposure: dose of radiation; just the upper vertebrae
AP: Usually for a patient unable to stand; portable X-ray; decubitus for early pleural effusion should be visible through cardiomediastinal shadow. If
Lateral: rays usually from right to left high, lung fields become black and vertebrae are clear

Unusual views: Centering: Clavicles at the same level and inner ends
Lardotic: for middle lobe collapse equidistant from midline
Apical
Penetrated (high exposure): for enlarged left atrium and aorta

Note: usually taken in full inspiration; main exception: small pnemothorax

Normal chest X-Ray:

CHARECTERISTICS:

PA view
Adequate exposure
Line dividing upper and middle zone Centered
passing through inferior borders of Skeletal: look for rib cage, thoracic vertebrae, shoulder bones.
anterior ends of 2nd costal cartilage At full inspiration, 10 posterior (red) and 6 anterior (blue) ribs
are visible.
Reticular lung fields
Line dividing middle and lower zones Hilar shadow: pulmonary arteries>veins, bronchi, hilar lymph
passing through inferior borders of nodes and lymphatics
anterior ends of 4th costal cartilage Pleura invisible unless calcified or thickened
Cardiac silhouette: max heart/max thorax diameter is called
CTR i.e. cardiothoracic ratio; Normal CTR in PA: 0.5:1, enlarged
if >0.57

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 Borders of cardiac silhouette:
Right from above- SVC, Right atrium, IVC
Left from above- Aortic knuckle, Pulmonary trunk, Left atrial
appendages, left ventricle

Costo-phrenic angle: Acute and clearly visible

Cardio-phrenic angle: Right sided: acute close to right; becomes
more acute in pericardial effusion. Left isn't very visible due to
epicardial pad of fat.

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Consolidation

CHARECTERICTICS:
Homogenous opacity (here: in left mid and lower zone)
Trachea is usually central. If not, check for associated effusion,
pnemothorax.
Look for air bronchogram: bronchi unusually visible due radiolucent air
against radiopaque consolidated lung.

Differential diagnosis:
Collapse: mediastinal shift
Bronchogenic Carcinoma: a/w pleural reaction, rib erosions, no air
bronchogram
TB: consolidation is usually not sharply defined, pleural reaction +
Pulmonary infarction

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Pleural effusion

CHARACTERISTICS:
Homogenous opacity, jet white,
curved(concave) upper border. Obliterated
costo-phrenic angle. Mediastinum shifted to
the opposite side.

Earliest detection is by USG

300ml is the min for x-ray

Differential diagnosis:
Empyema: a/w thick pleura and localized.
Thickened pleura: No mediastinal shift, ribs
maybe visible

Suspect malignant effusion if:

a/w collapse, convex bulge,
elevated hemi-diaphragm (due
to phrenic nerve palsy), erosion
of ribs, recurrent/rapid
collection

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Pneumothorax

CHARACTERISTICS:
Radiolucent area with absent Broncho-vascular markings
Collapsed lung visible as a sharply defined homogenous opacity
Mediastinum shifted to the opposite side s/o tension pneumothorax
Inferior displacement of diaphragm
Don’t wait for an x-ray if tension pnemothorax is clinically diagnosed- use a 14/16 G
needle into the 5th IC space in the anterior axillary line
For a small pnemothorax, X-ray is taken in expiration

Differentials for unilateral hyper translucency:

Bullae, lung cyst, obstructive emphysema, compensatory emphysema, contalateral
thickened pleura

Hydropneumothorax:

CHARACTERISTICS:
Horizontal fluid level with translucency and lack of Broncho -vascular markings above and
homogenous opacity below.
Mediastinum shifted to the opposite side
Collapsed lung maybe obscured by effusion

Clinically: shifting dullness, succussion splash, percussion changes

Differentials: large lung abscess, infected lung cyst

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Emphysema

CHARACTERISTICS:
Hyper translucency in both lung fields
Wide intercostal spaces
Low flat diaphragm
Narrow vertical(long and tubular) heart
Bullae: round areas with translucency with hair line shadows forming walls
No mediastinal shift

DD for tubular heart:

Emphysema, Addisons disease and panhypopituitarism, constrictive pericarditis

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Bronchiectasis

CHARACTERISTICS:
Multiple ring shadows of dilated bronchi
Areas of haziness s/o fibrosis
Better diagnosed on CT

D/D for honey combing:

BTX
Cystic fibrosis, tuberous sclerosis, histiocytosis, pneumoconiosis
Extrinsic allergic alveolitis

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Lung abscess

CHARECTERISTICS:
Cavity with thick shaggy inner wall
Fluid level maybe seen inside the cavity with hyper-translucency indicating air above the
level; Trachea normal in position

D/D: (for horizontal fluid level) D/D: (for cavities)

Hydropnemothorax Shaggy wall: Abscess, CA, tuberculous cavity
Achalasia cardia Thin wall: Caseous TB cavity, cyst, bullae,
Obstructed diaphragmatic hernia mycotic cavity
Infected lung cyst Small cavity with thick wall: CA

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Lung collapse aka Atelectasis

CHARECTERISTICS:
Homogenous opacity
Trachea shifted to the same side
Crowding of ribs

D/D for homogenous opacity of hemi-thorax:

Massive pleural effusion, Empyema Thoracis
Massive consolidation, Thickened pleura
Pleural mesothelioma
Lung agenesis
Pulmonectomy

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Fibrosis of lung

CHARECTERISTICS:
(Right upper lobe) Haziness in lung field
Trachea shifted to the same side
Rib crowding

D/D: (localized haziness)

Primary TB
Resolving Bacterial Pneumonia
Localized bronchiectasis (lower lobes usually)

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The Pulmonary TB page

Names:
Types:
Primary:
Primary
Ghons focus: sub-pleural usually in the lower/middle lobes
Primary progressive
Ghons complex: Ghons focus + hilar lymphadenopathy + interconnecting laryngitis
Post-primary (secondary)
Post-primary:
Miliary
Ashmans focus: Deep apical
'Cryptic' miliary
Simons: Sub-pleural upper lobes
Bronchitis and Laryngitis
Outside the lungs:
Rich: cerebral
Pleurisy, effusion, pnemothorax
Simond: hepatic
Wigard: blood vessels

TB features on X-ray: Literally anything D/D for apical shadows:

Apical lordotic view helps TB
Aspergillosis
Features of active TB on X-ray: Pancoast tumor
Cavity Berriliosis
Soft shadows
Progression of shadows

D/D for miliary mottling:

Acute miliary TB: generalized, uniform size and upper zones are always involved
Tropical eosinophilia: mid and lower zones, non-uniform, hilar lymph nodes ++
Miliary carcinomatosis: rare
Pnemoconiosis
Extrinsic allergic alveolotis: upper zone
Sarcoidosis: larger shadows, hilar lymph nodes ++
Histoplasmosis, coccidioidomycosis

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Pulmonary edema

CHARECTERISTICS:
Batwing/Butterfly appearance of confluent shadows extending from hilum

The Kerley lines:

Kerley lines are described as types A, B or C. Occur in chronic pulmonary edema due to chronic
venous hypertension.

Kerley A(Apex) lines are linear opacities extending from the periphery to the hila caused by
distention of anastomotic channels between peripheral and central lymphatics (arrow)
Kerley B(Base) lines are small, horizontal, peripheral straight lines demonstrated at the lung bases
that represent thickened interlobular septa on CXR. They represent edema of the interlobular septa
and though not specific, they frequently imply left ventricular failure as they relate to left atrial
pressure. (white arrowhead)
Kerley C(Central) lines are reticular opacities at the lung base, representing Kerley’s B lines end on
(‘en face’).(black arrowhead)

From <[Link]

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Bronchogenic Carcinoma

CHARECTERISTICS:
Homogenous opacity with sharp borders, sometimes with a cavity
No air bronchogram
Mediastinal widening/shifting possible
Rib destruction possible

D/D: Random fact:

Consolidation Dock sign is the rib notching seen in
Lung cyst coarctation of aorta
Aortic aneurysm
Granuloma

Other CA findings:
Dense hilar opacity
Localized emphysema, atelectasis of a segment, lobe or whole lung
Linear streaks radiating from hilum or miliary mottling: lymphangitis arcinomatosa
If phrenic nerve is involved: diaphragmatic elevation

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Mitral stenosis

CHARECTERISTICS:
Straightening of left heart border consisting of: aortic knuckle, dilated pulmonary artery(convex), prominent left atrial appendage and normal left
ventricle.
Double contour of right heart border; one due to right atrium and inner due to enlarged left atrium.
Enlarged cardiac size (RVH)
Dilated pulmonary artery at hilum with pruning at periphery is s/o pulmonary artery HTN; Kerley lines absent
Kerley lines s/o pulmonary edema in left atrial failure

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Pericardial effusion

CHARECTERISTICS:
Grossly enlarged (globular) cardiac silhouette: water bottle configuration
Cardiac landmarks obliterated
Very acute right cardio-phrenic angle: Rotch sign

D/D for enlarges cardiac shadow with normal cardio-phrenic angle and landmarks:
Cardiomyopathy (dilated)
RVH: increased transverse diameter
LVH: increased oblique diameter with boot shaped heart
Double contour of right border: LAH
CCF
LV aneurysm

D/D for pleural + pericardial effusion:

TB
CCF, cirrhosis of liver
Lymphoma and cute leukemias
Septicemia
Neoplastic/post-irradiation

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