This ppt is about basic of chest X-ray.

1. Collected by:
Tapendra Koirala

2. - Borrowed from somebody.

3. Checklist for a systematic approach
1. Patient identity
2. Image data
3. Image quality
4. The obvious abnormality - description/location
5. Systematic check of anatomy
6. Review areas
7. Consider the clinical question (ie diagnosis)

4. Patient identity
 I know you are good on this!

5. Which film? PA or AP

6. AP vs PA projection
 The heart, being an anterior structure within the chest, is magnified
by an AP view.
 Magnification is exaggerated further by the shorter distance between
the X-ray source and the patient, often required when acquiring an
AP image. This leads to a more divergent beam to cover the same
anatomical field.
 As a rule of thumb, you should never consider the heart size to be
enlarged if the projection used is AP. If however the heart size is
normal on an AP view, then you can say it is not enlarged.

8. AP v PA - Scapular edges
 Radiographers will often label a chest X-ray as either PA or AP.
 If the image is not labelled, it is usually fair to assume it is a standard
PA view.
 If, however, you are not sure, then look
 at the medial edges of each scapula.
 If they are wide apart and are not parallel– then film is most likely PA
OR
 If the scapulae overlie the lung fields then the film is AP. If they do not it is
probably PA.

9. Once that is decided…
 Position the x-ray upright and face Left (L) to your Right & vice
versa.

10. Inspect the immage Quality
 Components
 Rotation
 Inspiration
 Penetration
@ Rest In Peace (RIP)

11. 1. Rotation
 Check whether the medial end of clavicle are equidistant from the vertebral
spinous processes.
 Film must be well centered to comment on:
 Mediastinal shift
 Cardiomegaly
 Comparative study of radiolucency
Is the film well centralized?

12.  If the medial end of left clavicle is nearer to spinous
process then the film is considered to be rotated
towards left and vice versa.
• Heart size can be assessed accurately with a well-centred
posterior-anterior (PA) chest X-ray.
• If the patient is rotated to the left the heart may appear enlarged
and if rotated to the right its size may be underestimated.

13. 2. Inspiration and lung volume
 Chest X-rays are conventionally acquired in the inspiratory phase of
the respiratory cycle
 The radiographer asks the patient to, 'breathe in and hold your
breath!‘
 When interpreting a chest X-ray it is important to recognise if there
has been incomplete inspiration
 If the image is acquired in the expiratory phase, the lungs are
relatively airless and their density is increased
 Also, the raised position of the diaphragm leads to exaggeration of
heart size, and obscuration of the lung bases

14. Assessing inspiration
 To assess the degree of inspiration it is conventional to count ribs
down to the diaphragm.
 The diaphragm should be intersected by the 6th to 8th anterior ribs in
the mid-clavicular line or 9-11th ribs posteriorly
 Less is a sign of incomplete inspiration.

15. Assessing for hyperexpansion
 While checking for adequate inspiration you may notice that a
patient's lungs are hyperexpanded (>8th anterior rib intersecting the
diaphragm at the mid-clavicular line). This is a sign of obstructive
airways disease.
 It is possible to assess for hyperexpansion by counting ribs, or by
checking for flattening of the hemidiaphragms.

16. Normal expansion
 This patient has taken a good breath in such
that the diaphragm is intersected by the 6th
rib in the mid-clavicular line.
 In film in the left shows an imaginary line
(dotted) between the costophrenic and
cardiophrenic angles.
 The distance between this line and the
diaphragm (green line) should be greater
than 1.5cm(asterisk) in normal individuals.
 In practice this is rarely measured and a
quick assessment of diaphragm shape is all
that is necessary.

18. 3. Penetration/Exposure
2. Is it a well exposed film?
 In a well exposed film only the spinous processes of first four thoracic vertebra
are seen. Others are hidden by cardiac shadow.
 If more than 4 vertebra are seen over exposed (lungs appear more
translucent)
Penetration is the degree to
which X-rays have passed
through the body.
OR
• A well penetrated chest X-ray is one where the vertebrae are just visible behind the heart.
• The left hemidiaphragm should be visible to the edge of the spine. Loss of the hemidiaphragm
contour or of the paravertebral tissue lines may be due to lung or mediastinal pathology.

19. Why is this important?

20. Under penetration
The left hemidiaphragm is not visible to the spine
Lung tissue behind the heart cannot be assessed
Re-windowing the image using digital software
can compensate
Well penetration (same pt.)
The diaphragm (long arrows) is visible to the spine.
The left paravertebral soft tissues are visible (short
arrows) , and the right side of the spine is clear
(arrowheads). There is no abnormality of lung tissue
behind the heart.

21. Is there any artifacts?
 Medical/surgical artifact
 Instruments (eg. NG tube, chest tube etc.)
 Patient artifact
 Ornaments, Skinfolds
 Hair artifact
 Radiologic artifact
 Quality issues (rotation, penetration, inspiration etc.) Hair artifact

22. In summary
 Image quality influences conclusions
 Check the image for - Labeling , Projection, Rotation, Inspiration,
Penetration and Artifact
 Quality is influenced by radiographic technique and patient factors
 Check to see if a poor quality X-ray demonstrates a life threatening
abnormality before dismissing it
 Above all, Can the clinical question still be answered?
If the film taken can still answer
the question then why to re-order
another?

23.  Once you’ve made sure that you are reading a good quality film then
proceed further.

24. Inspect the lung field
1. Study the lung field in 3 zones: Upper, Middle, and Lower
1. Upper: area above the anterior end of 2nd rib
2. Lower: area below the anterior end of 4th rib
3. Middle: area between above two fields
2. Compare the lung fields on both the side in each of 3 zones
• Should be equally radiolucent bilaterally
3. Study the apices (area behind clavicle earliest TB lesion found)
4. Look for bony asymmetry
5. Look for cardio & costophrenic angles; should be sharply defined
1. Any obliteration is pathological
2. Right diaphragm is 1 to 1.5 cm higher than Left diaphragm

25. 1
2
3
1. Upper: area above the
anterior end of 2nd rib
2. Lower: area below the
anterior end of 4th rib
3. Middle: area in between

26.  Inspect Hila
 Left slightly higher than the right
 Identify the course of trachea up to the carina for any deviation

27. Inspection of cardiac silhouette
 Study the cardiac borders
 Left cardiac border made up of: Aorta, pulmonary conus, left atrial appendage, and
left ventricle
 Right cardiac border: SVC and Rt. Atrium
 Measure the cardiothoracic ratio
 Draw a vertical line through spinous processes
 Then draw perpendicular lines ‘a’ and ‘b’ from the point of maximal width on left and
right border to the vertical line
 a+b gives the maximum transverse diameter of the heart
 Measure ‘c’ ie the largest diameter of chest
 Transverse line that joins the inner border of ribs at the widest portion of chest

28. a
b
c
CT ratio= (a+b)/c

29. Inspection of Bones
 Ribs
 Look for crowding/spreading and bony lesions
 Clavicle
 Scapula
 Shoulder joints

30. Inspection of soft tissue
 Muscles
 Subcutaneous tissues of the chest and the neck
 Breast (in female)

31. Key points - Review areas
 Apices - Pneumothorax?
 Bones/soft-tissues - Fractures/density?
 Cardiac shadow- Consolidation/mass?
 Diaphragm - Pneumoperitoneum?
 Edge of the image - Unexpected findings?
 Mnemonic - ABCDE

32. Review areas - Bones
Bone abnormalities can be very
subtle on chest X-rays. Here the
first right rib is destroyed by a
metastatic bone lesion(?).
Compare this poorly defined area
of increased soft tissue density
with the normal first left rib.
Review areas - Cardiac shadow
The area behind the heart is too
dense and the left hemidiaphragm
is not well-defined to the midline.
This is evidence of consolidation
affecting the left lower lobe.
There is also a reactive effusion.
Review areas - Diaphragm
Check every chest X-ray for
pneumoperitoneum.
Occasionally lung pathology is
visible through the 'window' of the
gastric bubble, which is normal in
this case.
Review areas - Edge of the image
Well done if you noticed the small left pleural
effusion.
Did you spot the missing right humerus?!
This patient had a history of a previous malignant
bone lesion of the right humerus which had been
resected. Note the surgical clips.
Review areas - Apices
A pneumothorax is often a very subtle
finding, and may only be seen on a
second review of each lung apex.
You should also check the lung apices
for tumours.

33. Chest X-ray checklist; A-H
A Airway (midline, no obvious deformities, no paratracheal masses)
B Bones and soft tissue (no fractures, subcutaneous emphysema)
C Cardiac size, silhouette and retro-cardiac density normal
D Diaphragms (right above left by 1 cm to 3 cm, costophrenic angles sharp, diaphragmatic contrast
with lung sharp)
E Equal volume (count ribs, look for mediastinal shift)
F Fine detail (pleura and lung parenchyma)
G Gastric bubble (above the air bubble one shouldn't see an opacity of any more than 0.5 cm
width)
H
Hilum (left normally above right by up to 3 cm, no larger than a thumb)
Hardware (in the intensive care unit: endotracheal tube, central venous catheters)

34. If there is an elephant in the image, don't ignore it! Describe it in detail and
then use your system to continue scrutinizing the image.

35. A sample CXR presentation
 This is the CXR of [child’s name].
 The film is an AP view with good inspiratory effort. There is an isolated fracture of the 8th rib on
the right.
 There is no tracheal deviation or mediastinal shift.
 There is no pneumo- or hemothorax.
 The cardiac silhouette appears to be of normal size.
 The diaphragm and heart borders on both sides are clear, no infiltrates are noted.
 There is a central venous catheter present, the tip of which is in the superior vena cava.
 This shows improvement over the CXR from [number of days ago] as the right lower lobe
infiltrate is no longer present.

36. Thank You
Good luck ! with the X-rays.

37. Random collections

39. Table: Common causes of pleural effusion
Infection
Neoplasm
Cardiovascular disease (congestive heart failure)
Cirrhosis
Hypoproteinemia
Pancreatitis
Uremia
Subdiaphragmatic abscess
Trauma (hemothorax, chylothorax)
Occupational (asbestos)
Collagen vascular disease (systemic lupus erythematosus)
Hypothyroidism (often with pericardial effusion)
Pulmonary embolism

40. • The appearance of an effusion depends on the patient's position at
the time of the radiologic examination and on the mobility of the
effusion.
• In an upright person, fluid collects mainly in the lower pleural space,
as long as it is freely mobile, creating a homogeneous opacity with a
curvilinear upper border that is sharply marginated and concave to
the lung.
• Fluid can collect in the fissures, creating a ‘pseudotumor’ that
conforms to the edges of the fissures and resolves with clearing of
lung edema.

41. • In supine patients, freely mobile fluid layers posteriorly, creating
hazy, veillike opacification of the affected hemithorax with
preserved vascular shadows.
• Depending on the size of the effusion, this can be a subtle finding;
when bilateral, it may not be detected at all, especially when
small, or it may be confused with pulmonary edema
• Other findings of pleural effusions in supine patients include
• blunting of the costophrenic angle (although this is often a false-
positive finding) (6),
• capping of the lung apex, thickening of the minor fissure, and
• widening of the paraspinal soft tissues.

42. • Lateral decubitus views can be useful in verifying
pleural effusions when the supine examination is
equivocal, and they can allow determination of whether
pleural fluid is mobile or not.
• The lateral decubitus view is much more sensitive than
the upright view for the detection of pleural effusions; it
can demonstrate as little as 5 mL of pleural fluid

43. Causes of a large unilateral pleural effusion
“ITCH”
Infection (empyema)
Tumor (primary bronchogenic cancer, metastasis, mesothelioma,
lymphoma)
Chylous (ruptured thoracic duct, lymphoma)
Hemorrhage (trauma, either iatrogenic or otherwise)

44. Re-expansion pulmonary edema. A: PA chest radiograph of a 78-year-old woman with metastatic breast cancer shows a large left pleural effusion
associated with collapse of the left lung and shift of the mediastinum to the right. These findings suggest tension hydrothorax. B: PA chest radiograph after
placement of a left chest tube and adequate drainage of pleural fluid shows re-expansion pulmonary edema on the left.

45. Empyema. A: PA chest radiograph of a 60-year-old man
with right lower lobe pneumonia shows a large right
hydropneumothorax with air fluid level. There is an
incidental calcified granuloma in the right mid lung

46. Tuberculous empyema. PA chest radiograph shows a large left pleural
effusion. A large unilateral pleural effusion is worrisome for empyema,
hemothorax, malignancy, or chylothorax.

48. In the supine patient, the highest part of the chest cavity lies anteriorly or
anteromedially at the base near the diaphragm, and free pleural air rises to
this region. If the pneumothorax is small or moderate in size, the lung is not
separated from the chest wall laterally or at the apex and therefore the
pneumothorax may not be appreciated
In the upright patient, air rises in the pleural space and separates the lung
from the chest wall, allowing the visceral pleural line to become visible as a
thin curvilinear opacity between vessel-containing lung and the avascular
pneumothorax space. The pleural line remains fairly parallel to the chest wall.

49. Skin fold mimicking pneumothorax

50. Radiographic signs of pneumothorax in the supine patient
• Relative increased lucency of the involved hemithorax
• Increased sharpness of the adjacent mediastinal margin and diaphragm
• Deep, sometimes a tonguelike costophrenic sulcus
• Visualization of the anterior costophrenic sulcus
• Increased sharpness of the cardiac borders
• Visualization of the inferior edge of the collapsed lung above the diaphragm
• Depression of the ipsilateral hemidiaphragm
Radiologic signs of tension pneumothorax
• Contralateral displacement of the mediastinum
• Inferior displacement of the diaphragm
• Hyperlucent hemithorax and
• Ipsilateral collapse of the lung