Chest X-rays
Notes by Hanin Bashaikh
Chest X ray
• Is the most commonly performed diagnostic x-
ray examination.
Images
• Heart, lungs, airways, blood vessels and the bones
of the spine and chest.
• Easily and readily available.
• It’s non-invasive.
• Cheap.
Normal Chest X-Ray
The 12-Step Program there are many
different systems to read the CXR and this one of the most
commonly used
•
•
•
1: Name.
2: Date.
3: Old films.
} Pre-read
• 4: What type of view(s).
}
• 5: Penetration.
• 6: Inspiration.
• 7: Rotation. Quality Control
• 8: Angulation.
• 9: Soft tissues / bony structures.
}
• 10: Mediastinum.
• 11: Diaphragms.
• 12: Lung Fields.
Findings
Pre-Reading
• 1. Check the name
• 2. Check the date make sure that this is a new x-ray especially if
the patient presented acutely.
• 3. Obtain old films if available to compare
• 4. Which view(s) do you have?
• PA / AP, lateral, decubitus, AP lordotic
Techniques - Projection
• P-A (relation of x-ray beam to patient) Radiation comes from
behind the patient and the x-ray film is anterior to the patient.
Techniques - Projection
(continued)
•Lateral the x-ray machine will be on the patient’s side. If you didn’t ask the radiology
technician to make right lateral imaging, they will automatically do a left lateral.
Techniques - Projection
(continued)
•Lateral Decubitus the patient will be laying on the side, and we can use it when we
are looking for fluids in the chest and weather it is free fluids or not.
Quality Control
• 5. Penetration
• In adequate penetration you
will:
• Should see ribs through
the heart.
• Barely see the spine
through the heart.
• Should see pulmonary
vessels nearly to the
edges of the lungs.
Over penetrated Film:
• Lung fields darker than
normal—may obscure
subtle pathologies.
• See spine well beyond the
diaphragms.
• Inadequate lung detail.
Underpenetrated Film
•Hemidiaphragms are obscured.
•Pulmonary markings more prominent than they actually are.
Pulmonary Markings
Hemidiaphragms
Quality Control
• 6. Inspiration 1
2
• Should be able to count 3
9-10 posterior ribs.
4
• Heart shadow should not 5
be hidden by the 6
diaphragm. 7
9
10
Poor inspiration can
crowd lung
markings producing
pseudo-airspace
8 disease
About 8 posterior ribs are showing
With better inspiration, the
“disease process” at the
lung bases has cleared
9
9-10 posterior ribs are showing
Quality Control
• 7. Rotation
• Medial ends of bilateral
clavicles are equidistant
from the midline or
vertebral bodies.
• The patient should be
central, and the spinous
processes of the
vertebrae are centered.
If spinous process appears closer to the right clavicle (red
arrow), the patient is rotated toward their own left side
If spinous process appears closer to the left clavicle (red arrow),
the patient is rotated toward their own right side
Quality Control
• 8. Angulation 1
2
• Clavicle should lay over 3
3rd rib.
• اللي فهمته ان الروتيشن يمين
. االنقيوليشن قدام ورا،يسار
Pitfall Due to Angulation
Apical lordotic Same patient, not lordotic
A film which is apical lordotic (beam is angled up toward
head) will have an unusually shaped heart and the usually
sharp border of the left hemidiaphragm will be absent
Findings
• 9. Soft tissue and bony
structures
• Check for
• Symmetry compare two
sides
• Deformities
• Fractures
• Masses
• Calcifications
• Lytic lesions
Findings
• 10. Mediastinum
• Check for
• Cardiomegaly
• Mediastinal and
Hilar contours (left
hilum is higher
than the right
hilum) for increase
densities or
deformities.
Findings
• 11. Diaphragms
• Check sharpness of
borders (cardiophrenic
and costophrenic
borders).
• Right is normally higher
than left.
• Check for free air, gastric
bubble, pleural effusions.
Findings
• 12. The Lung Fields!
• To help you determine
abnormalities and their
location…
• Use silhouettes of other
thoracic structures.
• Use fissures.
Lung Fields: Using Structures /
Silhouettes
Silhouette / Structure Contact with Lung
Upper right heart
Anterior segment of RUL
border/ascending aorta
Right heart border RML (medial)
Upper left heart border Anterior segment of LUL
Left heart border Lingula (anterior)
Apical portion of LUL
Aortic knob
(posterior)
Anterior hemidiaphragms Lower lobes (anterior)
Lung Fields: Using Structures /
Silhouettes
Upper right heart
border / Aortic knob
ascending aorta (Apical portion
(anterior RUL) of LUL )
Upper left
Right heart border heart border
(medial RML) (anterior
LUL)
Left heart
border
Anterior (lingula;
hemidiaphragms anterior)
(anterior
lower lobes)
Lung Fields: Fissures
• The fissures can also help you to determine the
boundaries of pathology
Major Oblique Fissure Separates the LUL from the LLL
Separates the RUL/RML from
Right Major Fissure
the RLL
Separates the RUL from the
Right Minor Fissure
RML
Lobes
• Right upper lobe:
Lobes (continued)
• Right middle lobe:
Lobes (continued)
• Right lower lobe:
Lobes (continued)
• Left lower lobe:
Lobes (continued)
• Left upper lobe with Lingula:
Lobes (continued)
• Lingula:
Heart
• Right border: Edge of (r) Atrium.
• Left border: (l) Ventricle + Atrium.
• Posterior border: Left Ventricle.
• Anterior border: Right Ventricle.
Heart (continued)
Heart (continued)
Hilum
Made of:
1. Pulmonary Artery + Veins.
2. The Bronchi.
• The left Hilum is higher (max 1-2,5 cm)
Because the heart pushes the left hilum
up.
• Identical: size, shape, density.
Hilum
Cases
be systematic
Clinical presentation:
• Fever.
• Cough.
• Breathlessness.
• Hypoxia.
• Spo2 92% ON HFNC 50L/min 70% 02.
Bilateral consolidation, the diagnosis is pneumonia
Dark lines: air
bronchograms
RUL pneumonia
Presents with right pleuritic chest pain
RML pneumonia
You can’t see the right heart border
RLL pneumonia
[Link] see the right heart border but you
can’t see the right hemidiaphragm
Very dark! Dark lines: air
bronchograms
RML pneumonia
LUL pneumonia
LLL pneumonia
You can’t see left hemi diaphragm
We can see right hemidiaphragm, but we can’t see right
heart border > RML pneumonia
PA view: RML consolidation and loss of right heart silhouette
Lateral View: RML wedge shaped consolidation
Consolidation
Minor
fissure
RUL and LLL pneumonia
RUL infiltrate / consolidation, bordered by minor fissure inferiorly
Patchy LLL infiltrate that obscures the left hemidiaphragm; right and left
heart borders obscured
Tuberculosis Next 4 slides
There is fibrosis in the upper area (consolidation with loss of lung volume).
Hilum is not clear; they are pulled upwards because loss of volume. This is a
patient with TB (chronic).
DDx: ILD that affects upper lobes: silicosis.
Patchy
consolidations
- Depending
on the
history:
a) Acute
symptoms:
Lung infection.
b) Chronic
symptoms: TB.
This patient was admitted with cough, weight loss, and fever.
TB
Habitation
TB
Cavitation
Air-fluid level
Tuberculosis
Multiple bilateral cavitary lesions with air-fluid levels c/w
pulmonary abscesses
DDx: Infections (bacterial/fungal) – Malignancies – Vasculitis–
Trauma (Infarction/contusion).
Multiple cavitating
lesions
Multiple lung cavitation.
ANCA+ Wegener granulomatosis.
Miliary mottling / Miliary TB
Miliary TB (Many small dots).
الدخن
ILD
• The following 2 slides Reticulonodular changes.
This patient has become breathless gradually among the two
past years, the lung looks smaller, and there are multiple lines
that cross each other (reticular changes in both lungs), so this is
what you see in pulmonary fibrosis.
Lines and dots (reticulonodular).
Bilateral dense prominent hilum,
DDX: Sarcoidosis, TB, Histoplasmosis, lymphoma.
Hilar Lymphadenopathy - BL
Bilateral Hilar Adenopathy but look at the changes in the lungs=
sarcoidosis. Reticular pattern.
The edge is not
Smooth.
Lung mass, look at the edges its irregular speculated
Mass with a
smooth edge.
Calcificated
costal
cartilages
Mediastinum
Mediastinal vs lung mass
If the lesion is in the mediastinum, it
will be pushed against the lung
Lesion
Deviated
trachea
(Pushed to the
right)
Retrosternal Goiter
Multiple
opacities
(Cotton ball
malignancies)
metastasis
from the
kidney-liver-
breasts-
thyroid.
Multiple Masses
Bullae full of air
Hyperinflated lungs (more than 10 Final diagnosis is reached by spirometry
posterior ribs) emphysema If the damage is in the lower lobes=
alpha antitrypsin
Bullae full of air,
not enough lung Alpha-1 antitrypsin deficiency
matrix
• The next 2 slide cardiomegaly
Cardiothoracic ratio is more than 50%
• The next slide is Heart failure/Pulmonary oedema
Causes of Pulmonary Oedema
• Cardiogenic.
• Non-Cardiogenic: neurogenic.
Biventricular pacemaker
Rt atrium
Lt ventricle
Pacemaker with 2 wires (one in the right ventricle and one in the left ventricle)
This type of pacing is called “Biventricular pacing” and the therapy is
“resynchronization therapy”
ICD CRT (implantable cardioverter defibrillator/cardiac resynchronization
therapy) Thick wire to concentrate the electrical current
ICD (implantable cardioverter defibrillator)
Dual chamber pacemaker Rt Atrial and Rt Ventricular
Median Sternotomy if you look carefully you can also see a coronary
stent
Cardiac resynchronization look carefully you see 3 cardiac wires
pacing the rt and lt ventricle
Pleural effusions
Pleural effusion
Suggestive of infection (Pneumonia with parapneumonic
infection)
case
Unilateral Pleural effusion
Unilateral: Infection, malignancy. Usually diseases such as liver
diseases or nephrotic syndrome tend to drain through the openings
of the diaphragm into the right pleural space
Left Pleural effusion with mediastinal shift (huge effusion)
Loss of septations
Left empyema
Air-Fluid level (air is introduced into the pleura from inside the lung
or outside or even from gas producing bacteria in severe infections)
A: Mild bilateral effusion. B: Left border pleural effusion. C: Large
left unilateral effusion. D: Localized effusion.
Cavitating lesion
With thick wall (strongly suggestive of malignancy)
A: Cavity filled with something (bleeding?/fungi?)
B: Small arrows (black and white) points at small communication
between the cavity and airways.
Thick wall cavity in a child who On CT scan, it appears with a
had pneumonia (Post pneumonic
cavity) thin wall
Breathless Immunocompromised
patient
Diagnosis: Pneumonia.
Bilateral changes of the lung (ground glass appearance).
Think of organisms that are common among immunocompromised
patients. And remember that they have different reaction to infections.
Diagnosis: Bronchiectasis (mucus in the airways).
Another bronchiectasis predominantly on the right
lobe
Bilateral bronchiectasis
Bilateral = think more of systemic disease
Post TB LT lung destruction with associated
bronchiectasis (There is loss of left lung volume)
Bronchiectasis predominantly affecting upper lobes
• Chronic Cough.
• Sputum production.
Diagnosis: Bronchiectasis.
28 y/o female with sudden onset SOB while jogging this morning
Well demarcated paucity of pulmonary vascular markings in right apex
Left spontaneous pneumothorax
Tension Pneumothorax
How will you treat: Insert needle in the
right lung in the 5th intercostal space
45-year-old with UC
Sudden onset SOB
Frpm hx the DDx: PE, pneumothorax. CT pulmonary angiogram
So we perform CT. Huge clots in the left and right pulmonary
trunks.
Patient brought by the ambulance to the
ER s/p airplane crash
Widened mediastinum
DDx: Aortic dissection.
Next step is CT scan
Lung Collapse
Different lobes
What are the causes?
Lung Collapse
Different lobes
What are the causes?
Right upper lobe collapse
Lung Collapse
Different lobes
What are the causes?
Air under the diaphragm
DDx: Perforated viscus.
Chronic cough, upper
GI symptoms
Air-fluid level behind the heart
Someone flipped
the film. Look
carefully!
Dextrocardia
Rt Mastectomy
COVID 19 Pneumonia
The 12-Step Program
•
•
•
1: Name
2: Date
3: Old films
} Pre-read
• 4: What type of view(s)
• 5: Penetration
•
•
•
•
6: Inspiration
7: Rotation
8: Angulation } Quality
9: Soft tissues / bony structures
Control
}
• 10: Mediastinum
• 11: Diaphragms
• 12: Lung Fields
Findings
The End
Questions?
