It's a PowerPoint presentation on chest x-ray interpretation for medical students.

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Dr Abdul Bari

2. CONTENTS
Anatomy
Rotation
AP vs PA view
Signs on chest x rays
Patterns of lung diseases
Radiolucency
Specfic diseases
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3. CHEST ANATOMY
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4. CHEST ANATOMY
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15. LOBES OF LUNGS
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19. • The ribs play a role in assessing the adequacy of inspiration taken by the patient. The anterior end of approximately 5-7 ribs
should be visible above the diaphragm in the mid-clavicular line. Less than this indicates an incomplete breath in, and more than
7 ribs or flattening of the diaphragm, suggests lung hyper-expansion.
• On this normal X-ray the anterior end of the 7th rib (asterisk) intersects the diaphragm at the mid-clavicular line.
• This chest X-ray also demonstrates the subcostal grooves (red highlights) on the underside of the ribs. These grooves contain
the neurovascular bundles that accompany each rib. To avoid damaging the nerves or vessels, the superior edge of a rib is used
as the landmark for needle insertion during procedures such as chest drain insertion.
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21. PA vs AP Views
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22. Rotation
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24. Shilloute sign
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25. SIGNS ON XRAY
Silhoute sign
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26. Air bronchogram
SIGNS ON XRAY
Air bronchogram sign
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27. Air bronchogram SIGNS ON XRAY
Air bronchogram sign
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28. • SIGNS ON XRAY
Air bronchogram
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29. Silhoute sign SIGNS ON XRAY
Air bronchogram sign
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32. Hilar enlargment
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34. HILAR ENLARGMENT
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35. PATTERNS ON CHEST X RAYS
Airspace (alveolar) shadowing
Reticular pattern
Nodular pattern
Reticulo-Nodular pattern
Mass lesion
White lung
Black lung
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37. Alveolarinfiltrates
Alveolar shadowing
No interstitium visible
Ground glass opacification
Homogenous areas – with or
without air bronchogram
Silhouette sign positive
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49. RETICULAR AND LINEAR PATTERNS
ON CHEST X-RAYS
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52. The reticular interstitial pattern refers to a complex network of
curvilinear opacities that usually involved the lung diffusely.
They can be subdivided by their size (fine, medium or coarse). The
subdivision refers to the size of the lucent spaces created by the
intersection of lines:
1. Fine "ground-glass" (1-2 mm): seen in processes that thicken
the pulmonary interstitium to produce a fine network of lines,
e.g. interstitial pulmonary oedema
1. Medium "honeycombing" (3-10 mm): commonly seen in pulmonary
fibrosis with involvement of the parenchymal and peripheral
interstitium
1. Coarse (>10 mm): cystic spaces caused by parenchymal
destruction, e.g. usual interstitial pneumonia, pulmonary
sarcoidosis, pulmonary Langerhans cell histiocytosi
RETICULAR AND LINEAR PATTERNS
ON CHEST X-RAYS
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53. RETICULAR pattern
RETICULAR PATTERN
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54. Edema
• Cardiac failure
• Fluid overload
• Neprhopathy
Infections
• Viral
• Mycoplasma
• PCP
Drug reactions
Acute reticular pattern
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55. Acute
reticular
pattern
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56. Chronic reticular pattern
Post infectious scarring
Tuberculosis
Histoplasmosis
PCP
Coccidooid-
omycosis
Chronic interstitial edema
Chronic mitral diseases
Collagen vascular diseases
Rheumatoid arthritis
Scleroderma
MCTD
IPH
Sarcoidosis & Eosinophilic pneumonia
Idiopathic
Idiopathic pulmonary fibrosis
Lymphanioleiomyomatosis
Neoplasms
Lympangitis
carcinomatosis
Inhalation
H -pneumonitis
Silicosis – coal worker disease,
chronic aspiration
Drug reactions
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57. A reticulonodular interstitial pattern is produced by either,
overlap of reticular shadows, or by the presence of reticular
shadowing and pulmonary nodules. While this is a relatively
common appearance on a chest radiograph, very few diseases
are confirmed to show this pattern pathologically. Examples
include:
Reticulo-nodular pattern
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58. Reticulo-nodular pattern
Reticulo-nodular pattern
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59. Peripheral: thickening of the
peripheral interstitium (either
medially or laterally) produces Kerley
lines
Linear
Linear interstitial patterns are seen in processes that thicken the axial
(bronchovascular) interstitium or the peripheral pulmonary
interstitium
Axial: diffuse thickening along the bronchovascular tree seen as parallel
opacities radiating from the hila (seen transversely) or peri-bronchial
cuffing
(seen en-face)
Axial interstitial thickening is difficult to
distinguish from airways disease that result
in bronchial wall thickening
, (e.g. bronchiectasis, asthma)
and most often seen in
interstitial pulmonary oedema.
Linear pattern
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60. Linear pattern
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61. NODULAR PATTERN
Nodular opacities represent small rounded lesions within the pulmonary
interstitium.
In contrast to airspace nodules, interstitial nodules are homogeneous (they lack
air bronchiolograms
or air alveolograms)
and well defined, as their margins are sharp and they are surrounded by
normally aerated lung.
In addition, unlike airspace nodules, which tend to be uniform in
diameter (approximately 8 mm), these opacities can be divided
into
1. Miliary opacities ( < 2 mm),
2. Micronodules (2 to 7 mm),
3. Nodules (7 to 30 mm), or
4. Masses ( > 30 mm).
A micronodular or miliary pattern is seen predominantly in granulomatous
processes
e.g., miliary tuberculosis or histoplasmosis) hematogenous pulmonary
metastases (most commonly thyroid and renal cell carcinoma), and
pneumoconioses (silicosis)
Nodules and masses are most often seen
in metastatic disease to the lung.
Nodular pattern
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62. Nodular pattern
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64. Nodular pattern
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65. Nodular vs reticulonodular pattern
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66. SPECIFIC
DISEASES
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67. Bronchiectasis
Normal appearing CXR in most
Tubular shadows
Tram line shadows
Gloved finger appearance
Mucocele
Ringed shadows with thickened bronchial walls
Air fluid level
Watch for dextrocardia
Diffuse lung fibrosis
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69. Bronchiectasis
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70. Bronchiectasis
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71. Tramlines
Ring shadows
Bronchiectasis
Ring shadows
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72. Tram track
appearance
Bronchiectasis
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73. Bronchiectasis
Bronchiectasis
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74. Bronchiectasis
Bronchiectasis
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75. Non-
cardiogenic
pulmonary
edema
ARDS
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76. Diffuse alveolar pneumonia
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77. Diffuse alveolar pneumonia
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78. Pneumonia – Lobar Pneumonia
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79. Pneumonia – interstitial pneumonia (viral)
Streaky or reticular
shadowing extending to
peripheries
Fine nodular pattern
Ground glass opacities
Dense widened hilar
structure
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80. Pneumonia – interstitial pneumonia (viral)
1. Peri-bronchial
thickening
2. Reticular
pattern
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81. Pneumonia – interstitial pneumonia (viral)
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82. Pneumonia – interstitial pneumonia (viral)
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83. Pneumonia – pneumocystis pneumonia
Reduced depth of inspiration
Basal reticulo-nodular pattern
Ground glass opacities
Sparing of periphery
Loss of vascular distinction
Progression to white lung
Pneumatocele
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84. Pneumonia – pneumocystis pneumonia
Reduced
depth of
inspiration
Basal reticulo-
nodular pattern
Ground
glass
opacities
Sparing of
periphery
Loss of vascular
distinction
Progression
to white
lung
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85. Pneumonia – pneumocystis pneumonia
Reduced
depth of
inspiration
Basal reticulo-
nodular pattern
Ground
glass
opacities
Sparing of
periphery
Loss of vascular
distinction
Progression
to white
lung
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86. Pneumonia – pneumocystis pneumonia
Reduced
depth of
inspiration
Basal reticulo-
nodular pattern
Ground
glass
opacities
Sparing of
periphery
Loss of vascular
distinction
Progression
to white
lung
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87. Pulmonary aspergillosis
Focal lesions
with broad
pleural
contact
Central lucency
surrounded by
white shadow
May mimic
infarction
Semilunar
(crescent
sign) air
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88. Pulmonary aspergillosis
Focal lesions
with broad
pleural
contact
Central lucency
surrounded by
white shadow
May mimic
infarction
Semilunar
(crescent
sign) air
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89. tuberculo
Spread of tuberculosis
Schematic diagram of the spread of infection in pulmonary tuberculosis.
Endobronchial
dissemination (a): In addition to the classic endobronchial spread of infection from a cavity to the lower
lung fields (often diagonally to the opposite lung), one more often encounters spread to the
posterobasal segments of the upper lobes. Miliary dissemination
(b): diffuse hematogenous spread of the pathogen results when an infected lymph node erodes into
adjacent blood vessels
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90. Primary tuberculosis
Peripheral focus of
consolidation
Upper & middle lung
field
Increased shadowing
towards hilum
Associated effusion (
rare)
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91. Primary tuberculosis
A peripheral focus of consolidation
(anterior end of the 2nd rib [white
arrows]) is seen in combination with lymphangitic markings and thickened
lymph
Peripheral focus
of consolidation
Upper & middle
lung field
Increased shadowing
towards hilum
Associated
effusion ( rare)
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92. Primary tuberculosis – Ghon focus
Peripheral focus
of consolidation
Upper & middle
lung field
Increased
shadowing
towards hilum
Associated
effusion ( rare)
Ghon focus
Calcified few lymph nodes
in right
ant region
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93. Miliary tuberculosis
Multiple diffusely
distributed, uniform
nodules
Measures 1 – 2mm
No predilection towards
any particular lobe
Lack of interstitial
septal pattern
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94. Miliary tuberculosis
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95. Difference bw primary and post primary TB
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96. EMPHYSEMA
Hyperlucency
Right hemidiapghram
below anterior 7th
rib
Multiple blebs
Avascular zones
Prominent pulmonary
artery
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97. EMPHYSEMA
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98. 1. Hyperlucency
2. Low set flat
diaphragm
3. Vertical heart
4. Avascular
zones
Emphysema
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99. 1. Hyperlucency
2. Low set flat
diaphragm
3. Vertical heart
4. Pre and
infracardiac lungs
5. Barrel shape
6. Avascular zones
7. Bleb walls
Emphysema
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100. Cardiac failure
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101. Pulmonary edema – interstitial edema
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102. Pulmonary edema – interstitial edema
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103. Pulmonary edema - alveolar
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104. 1. Cardiome
galy
2. Full hilum
3. Interstitial
markings
4. Prominent
pulmonar
y vein
5. Pleural
effusion
on left
Pulmonary edema
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105. Air (black) in pleural space. No lung markings in pleural space.
Recognition of atelectatic lung (lung margin). The lung recoils to a resting state
as the negative pressure in the pleura is lost (relaxation atelectasis).
Shift of mediastinum to the opposite side. The mediastinum is held in the
middle by balance between pleural pressures. When the negative pressure on
the side of the pneumothorax is lost, the mediastinum gets pulled by the normal
negative pressure from the opposite side. Progressive shift subsequently could
result from a push secondary to tension pneumothorax.
Larger hemithorax. When negative pressure in the pleura is lost, the chest wall
reaches the TLC position. Note the following chest tube the hemithorax returns
to FRC position.
Opposite lung gets the entire cardiac output and the vascular markings
become prominent.
Pneumothorax
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106. 1. No vascular
markings
on right
2. No shift of
mediastinu
m to left
3. Deep
sulcus
4. Atelectatic
right lung
5. Increased
haziness
on left:
Diversion
of entire
cardiac
output
Pneumothorax
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107. 1. No
vascular
marking
s on
right
2. Shift of
mediasti
num to
left
3. Deep
sulcus
4. Atelectat
ic right
lung
5. Increase
d
haziness
on left:
Diversio
n of
entire
cardiac
output
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Pneumothorax

108.  Homogenous
density
 Meniscus
maximum in
axilla
 Loss of
cardiophrenic
angle
 Loss of
diaphragmatic
and right
cardiac
silhouette
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Pleural effusion

109. 1. Homogeno
us density
2. Loculated
3. Loss of
cardiophren
ic angle
4. Loss of
lateral
portion
of diaphrag
matic silho
uette
Loculated effusion
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110. 1. Homogenous
density right
hemithorax
2. Mediastinal
shift to right
3. Right
hemithorax
smaller
4. Right heart
and
diaphragmatic
silhouette are
not identifiable
Collapse
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111. Mediastinal adenopathy
• Particularly in
anterior mediastinum
• Bilateral and
asymmetric
• Large and bulky
Endobronchial
Atelectasis
Alveolar form
Lung mass
Indistinct edges
Air bronchogram
Pleural effusions
Bony lesions
Lymphoma
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112. Pericardial effusion
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113. left ventricular failure
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114. 1. Lymph nodes
1. Bilateral
symmetrical hilar
nodes
2. Potato nodes
3. Mediastinal nodes
(not in anterior
mediastinum)
4. Egg shell
calcification
2. Alveolar infiltrates
3. Miliary nodules
4. Lung fibrosis
1. Upper lobe
distribution
2. Cavitation
Sarcoidosis
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115. 1. Lymph nodes
1. Bilateral symmetrical hilar
nodes
2. Potato nodes
3. Mediastinal nodes (not in
anterior mediastinum)
4. Egg shell calcification
2. Alveolar infiltrates
3. Miliary nodules
4. Lung fibrosis
1. Upper lobe distribution
2. Cavitation
sarcoidosis
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116. 1. Lymph nodes
1. Bilateral symmetrical hilar
nodes
2. Potato nodes
3. Mediastinal nodes (not in
anterior mediastinum)
4. Egg shell calcification
2. Alveolar infiltrates
3. Miliary nodules
4. Lung fibrosis
1. Upper lobe distribution
2. Cavitation
sarcoidosis
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117. Bilateral,
symmetrical hilar
adenopathy with
or without
mediastinal
adenopathy and
the main
differential for
this appearance
is lymphoma
Pulmonary sarcoidosis 117
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118. •Lung parenchymal involvement may present with fibrosis
evident as reticulation, typically in the
upper and mid zones
Sarcoidosis may manifest as a nodular pattern similar in
appearance to miliary TB or consolidation, which tends to
be peripheral and patchy.
Pulmonary sarcoidosis 118
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119. Frontal CXR of a patient with sarcoidosis. Note the area of consolidation due to
air space sarcoid (black arrow)
and the numerous nodules (white arrows) that mimic metastases as they are larger
than the nodules usually
associated with sarcoid. The nodules also look like metastases on the CT images
but note the lining up of the
nodules along the left major fissure in the bottom CT image giving a clue to
their true nature.
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120. • Note the consolidation (white arrow) and marked
• mediastinal and hilar lymphadenopathy (black arrows).
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121. • The numerous cysts give a Reticulation type pattern on CXR as for LAM,
but nodules that will subsequently develop into cysts may be seen.
• LCH is a smoking related disease and the distribution of disease tends to
be in the upper and
mid zones with sparing of the lung bases (LCH)
LANGERHAN CELL HISTIOCYTOSIS
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122. 1. Generalized reticular
and linear pattern
2. Nodular pattern
3. Middle and Upper zone
predominance
4. Egg shell calcification
5. Miliary nodules
Silicosis
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123. Idiopathic pulmonary fibrosis
Ground glass opacity
Reticular shadowing subpleural
and posterior basal predominance
Disseminated small
nodules
Honey combing
Reduced depth of
inspiration
Traction bronchiectasis 123
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124. Idiopathic pulmonary fibrosis
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125. Honey
combing
Idiopathic pulmonary fibrosis
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126. Hypersensitivity
pneumonitis
Numerous poorly
defined small < 5mm
nodules in both lungs
sparing apices and
bases
Ground glass opacities
(may resemble
pulmonary edema)
Fine reticular shadow
Symmetric extensive
shadowing with normal
heart
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127. Hypersensitivity
pneumonitis
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128. Lymphangitis carcinomatosis
Reticular or reticulo-
nodular pattern
Absence of volume loss
Prominent septal lines
(d/d fibrosis)
Identification of
primary tumor or
mediastinal
lymphadenopathy 128
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129. Lymphangitis carcinomatosis
Reticular or reticulo-nodular pattern
Absence of volume loss
Prominent septal lines (d/d fibrosis)
Identification of primary tumor or mediastinal
lymphadenopathy 129
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