Chest xray

1. Chest X-Ray Interpretation in
Clinical Medicine
Presenter:
Dr. Pratap singh chauhan
Dept. Of Medicine,
NSCB MCH Jabalpur

2.  Technique, Basic Anatomy &
Concepts
 Chest X-Ray indices
 Commonly encountered
conditions

3. (180 cm)

4. AP View
(Antero-posterior)

5. RIGHT LATERAL VIEW

6. BASIC ANATOMY

10. Left hilar point should be
always above Right.

12. Horizontal Fissure

13. Vanishing Tumor

14. Left and Right
oblique fissures

15. Accessory Azygous FissureAccessory Azygous Fissure

18. Aortic
Knuckle

21. Determining orientation:
• Label
• Cardiac shadow
• Aortic Knuckle
• Gastric air bubble
• Level of Diaphragm

22. PA vs AP View:
• Superior Mediastinum appears widened on AP view due to maginification.
• Cardiac shadow appears enlarged due to magnification.
• Medial border of scapula significantly covers lung fields in AP view.
• AP projection images are of lower quality than PA images.

23. Why magnification in AP view

24. Inclusion:
Must be visible:
• First rib
• Costo-phrenic
angles.
• Lateral ends of
ribs.

25. Depth of Inspiration:

26. • The diaphragm should be intersected by the 5th to 7th
anterior ribs in the mid-clavicular line. Less is a sign of
incomplete inspiration.
• If the image is acquired in the expiratory phase, the
lungs are relatively airless and their density is
increased, particularly at bases, sometimes falsely
labelled as basal pneumonitis.

28. Hyperexpansion:
• If > 7th Anterior rib intersects diaphragm in midclavicular
line.
• Also can be assessed by apparent flattening of
diaphragm.

29. This should
be > 1.5 cm

31. Rotation:
Ends of
clavicles
should be
equidistant.

32. Left rotation may produce
false cardiomegaly.

33. Penetration/Exposure:
• Vertebra not clearly visible through heart shadow.
• Left hemi-diaphragm can not be traced to vertebral border.
• Pulmonary vessels can not be traced till the end.
• Vertebra clearly visible through heart shadow.
• Left hemi-diaphragm can be traced to vertebral border.
• Pulmonary vessels can be traced till the end.
Under
Penetration
Good
Penetration

35. Air Bronchogram:
• Normally bronchial walls are not visible on X-ray.
• Air containing Lung parenchyma and Bronchi with air form
homogenous darkness.
• When the internal tubular outline of a bronchus is visible
within a thoracic opacity…that is an air bronchogram.
• It is most commonly associated with a simple pneumonia.
Sometimes it occurs with pulmonary oedema.
• Hyperdensity due to pneumonia provides background (or
foreground) to create contrast for visualization of air column
within bronchi.
• It is usually very good news for the patient. An air
bronchogram excludes a bronchial obstruction

38. Silhouette Sign:
• The silhouette sign is a misnomer! It should be called the 'loss
of silhouette' sign.
• Normal adjacent anatomical structures of differing densities
form a crisp 'silhouette,' or contour. Loss of a specific contour
can help determine the position of a disease process.
• E.g.
Loss of clarity of the right heart contour (formed by the right atrium)
implies disease of the right middle lobe which lies next to the right
atrium.

39. Loss of Silhouette of Right heart border: Pathology in right
middle lobe which is next to right atrium

40. Cardio-Thoracic Ratio:
Normal < 50 %

41. Opacities on Chest X-Ray:
Lung abnormalities with an increased density - also called
opacities - are the most common.
A practical approach is to divide these into four patterns:
• Consolidation
• Interstitial
• Nodules or masses
• Atelectasis (Collapse)

43. • Consolidation
Lobar consolidation
Diffuse consolidation
Multifocal ill-defined consolidations
• Interstitial
Reticular interstitial opacities
Fine Nodular interstitial opacities
• Nodule or mass
Solitary Pulmonary Nodule
Multiple Masses
• Atelectasis

44. Clinical Data

45. For consolidation key-findings on the
X-ray are:
• ill-defined homogeneous opacity obscuring
vessels
• Silhouette sign: loss of lung/soft tissue interface
• Air-bronchogram
• Extention to the pleura or fissure, but not
crossing it
• No volume loss
Volume Loss:
• Pulling of Trachea
• Pulling of Hemidiaphragm
• Associated Pneumothorax

46. For collapse key-findings on the X-ray
are:
• Sharply-defined opacity obscuring vessels without
air-bronchogram.
• Volume loss resulting in displacement of
diaphragm, fissures, hili or mediastinum

47. Right upper lobe collapse

48. Right upper lobe collapse with Pulled diaphragm

49. Right Lower Lobe collapse
• Abnormal right border of the heart.
• The right interlobar artery is not visible, because it is surrounded
by the collapsed lower lobe

50. Usually right middle lobe atelectasis does not result in noticeable
Findings.
Right Middle Lobe collapse
• Blurring of the right heart border (silhouette sign)
• Triangular density on the lateral view as a result of collapse of
the middle lobe

51. Right Middle Lobe collapse

52. Left Upper Lobe collapse
• Minimal volume loss with elevation of the left diaphragm
• Band of increased density in the retrosternal space, which is the
collapsed left upper lobe
• Abnormal left hilus, i.e. possible obstructing mass

53. Left Lower Lobe collapse
• Triangular density seen through the cardiac shadow(posterior to heart)
• This is confirmed on the lateral view.
• Contour of the left diaphragm is lost from anterior to posterior.
• Lower lobe vessels not visible as surrounded by the atelectatic lobe.

54. THANK YOU
One Chest X-ray delivers radiation dose of 0.1 msv to patient .
Yearly permissible radiation dose in 1 msv.
Limit X-Ray chest to less than 10 times a year.