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Hi everybody, welcome to our module on chest x-rays. Chest x-rays are extremely frustrating to
learn at the medical student level, and there are a couple of reasons for this. First of all, it's
difficult to see the different structures, so if you've ever looked at the thorax with a CAT scan or
MRI, you know that you can distinguish the chambers of the heart and the vessels.

It's much harder to do this by chest x-ray. In addition, there are many, many normal variants, so
it's hard to know what's abnormal and what's normal, and then of course there are many, many
pathologic findings. Some reasonable goals for medical students are to know the basic chest
anatomy, because you're often tested on this in class or on the boards, and then know the
classic examples of pathology.

If you just focus on these two things, then when you move into your clinical years, you can start
learning normal variants and the other examples of pathology that are not so classic. So let's
start by reviewing some normal anatomy by chest x-ray. One of the first structures you should
be able to identify is the trachea, and this is the trachea here.

It's this black portion in the neck, and you can see that it's travelling downward from the neck
towards the diaphragm. And notice that this trachea stays midline. It doesn't deviate to the left
or the right side.

That's important to note. In patients who have pneumothorax, you can see a tracheal shift to
one side or the other. Next thing I want to point out in this x-ray is that the heart is normal size.

So how do I know that? Well, if we draw a line in the middle of the chest x-ray and we draw
another line at the edge of the ribs, the heart should finish before that halfway point between
those two lines. So this is the distance from the midline to the edge of the rib cage. This is the
halfway point, and the heart is smaller than that halfway point.

If the heart extended beyond this halfway point, that would be an enlarged heart. You should
be able to pick out normal enlarged hearts by chest x-ray. Next, let's review the vascular
structures in the middle of the chest x-ray.

And unlike on CAT scan or MRI, it's very difficult to delineate the borders of these structures.
You just kind of have to know where they sit. So this is the SVC right here.

It's the uppermost structure on the right side of the chest x-ray. Next comes the right atrium.
This is the border of the right atrium right here.

And then next comes the IVC. The right ventricle, you may know, is an anterior structure. So it
just sits sort of right here in the front of the cardiac silhouette on the chest x-ray.
And then if we go up the left side, the first thing we come to is the left ventricle. This is the
border of the left ventricle right here. The left atrium is a little bit higher up.

That's followed by the pulmonary artery. And then finally, we see a structure called the aortic
knob, which is not shown that well in this example, but it's a little bulge right here. And that's
just a part of the thoracic aorta that's seen normally on chest x-ray.

And you should be able to identify all these basic structures of the chest on a chest x-ray. Okay,
now let's go through some classic examples of pathology. And the first thing we're going to talk
about is pulmonary edoema.

So over here on the left side of the screen is a normal chest x-ray. And you can see that the lung
fields are mostly black without a lot of white stuff in them. Over here on the right is a chest x-
ray of a patient who has pulmonary edoema.

And notice that there's a lot of this puffy white stuff filling the lung fields on both sides. And
that's what pulmonary edoema looks like. Another important clue to pulmonary edoema is that
this heart is enlarged.

So if we draw a line in the middle of the chest x-ray, and we draw a line here at the ribs, you can
see that the heart extends beyond the halfway point. So when you see an enlarged heart along
with these fluffy infiltrates, you're probably looking at an example of pulmonary edoema.
Another classic finding of pulmonary edoema on the chest x-ray are curly or septal lines.

There are curly A, B, C, and D lines. But the most important are the curly B lines. And so if we
look here at this chest x-ray on the right, there's an arrow pointing at a faint white line here like
this.

And that is fluid filling the space between alveoli and between bronchi. And those are called
septal or curly B lines. And they're hard to see at first.

But once you get used to looking for them, you can usually identify them in chest x-rays that
have those fluffy white things like we saw in the last example. The curly B lines are usually there
as well. Okay, next let's talk about pleural effusions.

And this is a chest x-ray showing a large left-sided pleural effusions. So the first thing you have
to know in understanding x-rays of pleural effusions is the costophrenic angle. So what's that?
So the costophrenic angle is right here.

I'm drawing it with my white marker here. It's where the diaphragm meets the ribs. And what
you see in pleural effusions is blunting of the costophrenic angle.

It basically means you can't see it anymore. And that's because fluid has filled this space and it
becomes white here. So you can't delineate where the rib cage ends and the diaphragm starts.

This patient here has a large left-sided pleural effusion. So you have blunting of the
costophrenic angle. We can't see where the diaphragm meets the ribs cage over here.

It's blunted or blocked. And then we've got white stuff filling this space here. And this is an
upright chest x-ray.

So gravity's pulling the fluid down. And therefore, it's creating this solid white area in the
bottom part of the left lung. And that's a left-sided pleural effusion.

So when you first glance at this chest x-ray, you may think this black area over here between
the ribs is lungs. But in fact, it is too black. Look over here in the left lung of this patient.

You don't see complete blackness between the rib cages. You see little white lines. And those
are small pieces of lung tissue that are lighting up on the chest x-ray.

Those are absent over here in the right lung. It's completely black in this space between these
two ribs, for example. And that's because there is no lung there.

This is actually the lung right here. It's been deflated. And it's like a balloon that's collapsed.

And we just have blank space over here. And that's why it looks so dark. So in order to pick up a
pneumothorax, you have to identify that the lung is collapsed down here and that you've got
this clear black area between the ribs over here.

Small pneumothoraces are very difficult to pick up. But this is an example of a very large classic
appearing pneumothorax that you should be able to recognise for your board exams. Next
classic x-ray is lobar pneumonia.

So let's look over here in the right lung. And we see this area that is hazy and white. I'm circling
it here with my pen.

If you compare that to the left side, you'll see that the left side is clear. So this is a patient who
has a right upper lobe infiltrate. That's how it would usually be described, or right upper lobe
pneumonia.

And you should be able to identify classic examples of lobar pneumonia as a medical student.
This is an example of a chest x-ray showing interstitial fibrosis. And so what you see here is
diffuse white stuff in all the lung fields.

But this is different from that fluffy white stuff we saw in pulmonary edoema. This white stuff
has spaces between it. It's described as honeycombing.

And that's what you see in patients who have pulmonary fibrosis. And you should get good at
recognising this pattern when it's as classic as this example is here on the screen. This is an
example of hilar lymphadenopathy, like you might see in a sarcoidosis or tuberculosis patients.

So the hilar lymph nodes are here on either side of the trachea. I'm circling one of them. And
now I'm circling the other one.

And they are large and bright white in this chest x-ray. And that's what you see in patients who
have sarcoidosis or TB. And you should be able to recognise hilar lymphadenopathy for your
boards.

And then finally, this is an example of a pulmonary nodule. So pulmonary nodules can be very
subtle. And they're difficult to pick up if you don't have a lot of experience reading chest x-rays.

But this one is fairly easy to see. If you look out here in the left lung field, you see this circular
region here that has whiteness in it. And you don't see anything like that over here on the right
lung.

So this would be a coin lesion, it's called, or a pulmonary nodule. And this is a patient who could
have a lung cancer. And that concludes our module on chest x-rays.

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