X-RAY CHEST NOTES

Introduction: A New Way to See X-Rays

This lecture presents a unique method for interpreting X-rays, developed
over 20 years of learning and teaching.
The approach is based on three core "mantras" followed by a systematic
method for examination.
The goal is to build confidence and fundamentally change your perspective
on reading X-rays.

Mantra 1: Air is Black, Everything Else is White

X-Rays as Shadows:
An X-ray is not a photograph (which works by reflection); it is a
shadowgram.
Analogy: Playing with shadow puppets using a flashlight. The shape of
the shadow resembles the object, but its size and clarity depend on its
distance from the light source.
Similarly, an X-ray plate captures the shadows of structures that block
the X-ray beam. Pathologies and anatomical structures are interpreted
from these shadows.
The Principle of Density:
If an X-ray beam passes through a room with only air and hits the plate,
the plate will turn completely black. There is no obstruction.
If an object, like a hand, is placed in the beam's path, it creates a
shadow.
The surrounding air remains black.
The structures of the hand appear in shades of white and grey.
 The whiteness of a structure is directly proportional to its density.
The more solid (denser) a structure is, the whiter it will appear.
Bones: Very dense, appear bright white.
Soft Tissues: Less dense, appear grey.
Air: Least dense, appears black.
The Five Basic Densities in an X-Ray:
[Link]: Black
[Link]: Dark Grey
[Link] & Soft Tissue: Light Grey
[Link]: Off-White
[Link]: Bright White (e.g., pacemaker, wires, swallowed coin)
Application to Chest X-Ray (CXR):
Black Structures (Air-filled):
Trachea
Lungs
White/Grey Structures (Non-Air):
Heart (soft tissue/fluid)
Liver (below the diaphragm)
Bones (ribs, vertebrae, clavicles)
Metal (e.g., a pacemaker and its wires will be bright white)
Identifying Pathology:
An abnormality exists if a structure appears different from its expected
density.
A normally black area that appears white is abnormal.
A normally black area that appears even blacker is also abnormal.
Too much white or too much black are both signs of pathology.
Clinical Examples based on Mantra 1
 (Example 1: Rt. Upper Lobe Consolidation)

1. The "White Problem" - Consolidation:

Observation: One lung appears normal (black), while a section
of the other lung is abnormally white.
Interpretation: The air in that part of the lung has been
replaced by something denser and more solid (e.g., pus, fluid).
Terminology: This is called Consolidation.
Example 1: An extra white patch in the right upper lung field.
Diagnosis: Right Upper Lobe Consolidation.
Example 2: An extra white patch in the left lower lung field.
Diagnosis: Left Lower Lobe Consolidation.
 (Example 2: left lower Lobe Consolidation)

2. The "Black Problem" - Pneumothorax:

Observation: When comparing the two lungs, one lung is significantly
blacker than the other. It looks like a shiny, empty black.
Interpretation: This is not a "healthier" lung with more air. The lung
itself has collapsed, and the pleural space is filled with air. This is
evident by the complete absence of lung markings (vessels, bronchioles)
in the outer part of the chest cavity. You can often see the border of the
collapsed lung.
Terminology: This is Pneumothorax.
Note: If the pneumothorax is causing a shift of the trachea and heart to
the opposite side, it is a Tension Pneumothorax, a medical emergency.
Practical Tip: To better identify a pneumothorax, physically tilt the X-
ray film. The human eye is better at detecting superior-inferior
differences than lateral ones, making the lung edge more apparent.
 (Example: Pneumothorax) ( tilted film for better detection of superior and
inferior differences than lateral one)

3. The "Bilateral Black Problem" - Emphysema:

Observation: Both lungs appear abnormally and uniformly black
(hyperlucent), large, and over-expanded (hyperinflated). The heart may
appear small and elongated (tubular heart).
Interpretation: Unlike a pneumothorax, lung markings are still present
throughout. This is characteristic of air-trapping diseases.
Diagnosis: This pattern is typical of Emphysema (a type of COPD).

Emphysema
Mantra 2: Borders are Formed, and Borders are Lost
Principle of Contrast:
Analogy: A white ghost is only visible at night because of the contrast
between its white form and the black background.
To see any object, there must be a contrast between it and its
surroundings.
In an X-ray, a border (or line) is formed wherever two structures of different
densities meet.

Formation of Borders (Normal & Pathological):

Normal Borders: We can see the diaphragm because it separates the
air-filled lungs from the solid liver. We can see the heart because it is a
solid organ surrounded by air-filled lungs.
Pathological Borders: The appearance of a new structure with a
different density creates a new, visible border.
Example 1 (Foreign Body): A metal coin (bright white) in the
trachea (black) is clearly visible because of the sharp border created
by the extreme density difference.
Example 2 (Cavity): A cavitary lesion in the lung is visible because a border
forms between the wall of the cavity and the surrounding lung tissue.
 (example 1 : foreign body) (example 2: cavity, left lung field)

Loss of Borders (The Silhouette Sign):

Principle: When two structures of the same density come into contact, the
border between them disappears. They merge into a single shadow.
Analogy: A person's dark silhouette sitting on a dark hill at sunset. You can't see
the person's lower body because it merges with the hill's shadow (no contrast).

Application to CXR: This is crucial for localizing pneumonia.

Right Heart Border: This border is normally formed by the contact between
the heart (fluid/soft tissue density) and the Right Middle Lobe (RML) (air
density).
Left Heart Border: This border is formed by the contact between the heart
and the Left Lower Lobe (LLL) (specifically, the lingula).

( loss of right heart border) (loss of left heart

Pathology:
If the RML fills with fluid (consolidation), it becomes the same density as
the heart. The border between them disappears.
Loss of the Right Heart Border = Right Middle Lobe (RML)
Consolidation.
If the LLL consolidates, the left heart border disappears.
Loss of the Left Heart Border = Left Lower Lobe (LLL) Consolidation.
Similarly, loss of the diaphragmatic border indicates consolidation in the
corresponding lower lobe (RLL or LLL).
Mantra 3: Follow the Windpipe, See Where It Goes
The Principle: The trachea should normally be in the midline. A deviation
indicates a significant pathological process.

Method:
Imagine a vertical line down the center of the chest
X-ray.
Check if the trachea (the black tube in the upper
mediastinum) is centered on this line.
If it is deviated, determine the cause.
Two Types of Tracheal Deviation:
PUSH Effect: Something is pushing the trachea to the
opposite side. This is caused by a space-occupying
lesion with mass effect.
Causes: Tension Pneumothorax, Large Pleural
Effusion, Large Tumor/Mass.
PULL Effect: Something is pulling the trachea
towards the same side. This is caused by a loss of
lung volume.
Causes: Lung Collapse (Atelectasis), Lobectomy
(surgical removal of a lobe), Pneumonectomy.
Examples:
A large left-sided pneumothorax will push the trachea to the right.
A large right-sided tumor will push the trachea to the left.
A collapse of the left lung will pull the trachea to the left.

(left- sided pneumothorax pushing trachea to the right)

A large right-sided tumor will push the trachea to the left

A collapse of the left lung will pull the trachea to the left.
 A Systematic Approach to Reading a Chest X-Ray
Before interpretation, always assess the quality of the film.

Step 0: Quality Check (IRP)

I - Inspiration:
A CXR should be taken on full inspiration. An expiratory
film can be misleading (heart appears larger, lungs seem
congested).

(expiratory misleading x-ray film) (x-ray film with full inspiration)

How to Check: Count the posterior ribs in the mid-

clavicular line down to the cardiophrenic angle (where
heart meets diaphragm). A good inspiratory film will
show at least 10 ribs. An expiratory film may only show 8
R - Rotation:
The patient should be positioned straight, not rotated.
Rotation distorts anatomy.
How to Check: The medial ends of the two clavicles should be
equidistant from the vertebral spinous processes. If one is
closer than the other, the film is rotated.

(non equidistant medial end of clavicles)

 3. - Penetration:
The X-ray exposure (power) must be correct.
Under-penetrated (too white): Can mimic pathology like
pneumonia. The vertebrae behind the heart are not visible at
all.
Over-penetrated (too black): Can hide subtle pathologies
and mimic emphysema.
How to Check: On a well-penetrated film, you should be able
to faintly see the outlines of the thoracic vertebrae
through the heart shadow.

( under penetrated, too white) (over penetrated, too black)

Step-by-Step Interpretation
Trachea: Check for any deviation (push or pull).
 Right Side Trace:
Lung Border: Trace the entire border of the right lung. A break suggests
consolidation.
Costophrenic Angle: Follow the border down to the sharp angle where the ribs
meet the diaphragm. If this angle is blunted or filled in, it indicates a Pleural
Effusion. Look for a curved upper border (Meniscus Sign).
Diaphragm: Check under the right hemidiaphragm. The presence of a black
crescent of air (Gas Under the Diaphragm) indicates bowel perforation and is a
surgical emergency.
Right Heart Border: Check if it is sharp and visible. If it is lost, suspect RML
consolidation.

Right side trace; costophrenic angles; meniscus sign (pleural effusion).

(Gas under the diaphragm) (RML consolidation as right heart borderis not visible)
 3. Left Side Trace: Repeat the same process for the left lung border, left
costophrenic angle, left hemidiaphragm, and left heart border (loss suggests LLL
consolidation).
4. Hila: Examine the hila (the central area where bronchi and major blood vessels
enter the lungs). If they appear enlarged or prominent, especially bilaterally
(Bilateral Hilar Enlargement), it suggests an inflammatory process (e.g., infection,
autoimmune disease, cancer).

5. Lung Fields:
Compare the lung fields zone by zone, looking for any asymmetry.
Check for any areas that are abnormally white (consolidation, mass) or
abnormally black (pneumothorax, bullae).
Special Pattern: Pulmonary Edema (Alveolar Edema): If both lung fields are
diffusely white, appearing like cotton wool or as if water was sprinkled on them, this
suggests fluid has filled the alveoli. This is a classic sign of pulmonary edema (e.g.,
from heart failure or ARDS).
 (alveolar oedema)
6. Review Bones: A quick look at the ribs, clavicles, and visible vertebrae for
fractures or lesions.
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