1. HOW READ CHEST XR -11
ANAS SAHLE ,MD

2. Brief review

3. POSITION
PA AP
QUALITY
ROTATION PENETRATION INSPIRATION
LESION
OPACIT
OPACITY
Homo
Heterogenous Wellill defined Zone
Centralperipher
Silhouet sign
al
Y Necrotic
PATCHY
HILUMMEDIASTINAL
NODULE Central deviasionwided
MASS
COSTO-PHRENIC ANGEL
Freeoblitern
CAVITARY
OTHER
INFILTIRATION
Bone soft tissuediaphragm

4. Consolidation
Infection
causes Non-infection causes
Broncho-
WEGNER Cardiac
Pneumonia Lymphoma alveolar COP Sarcoid
disease failure
carcinoma

5. Solitary Pulmonary Nodule(SPN)
Appearance
Margin Calcification cavitation
Comparison with a
Size
previous x-ray to >8mm
<8mm
Assess growth over
time. Location
Upperhillar zone Lowerbasesup-pleural
Associated abnormalities
Lymph node enlargement Rib destruction/erosion

6. Cavitary lesion
Air +
Air-fluid level Air only
tissue
Wall thickness
Straight Wavy Thick Thin
1. Fungal ball.
2. Rupture hydatid cyct site
3. Necrotic tumor
ruptured
4. Blood glot Hydatid
Abscess Irregular Regular
Peripheral Central
inner wall inner wall
cyst
Emphesemato
Cavitating Chronic us pneumatoc
neoplasm abscess ele
bulla

7. LINEAR PATTERN
LINEAR PATTERN
LEFT VENTRICULAR FAILURE Perihilar and peripheral basal septal lines,
changes acutely and resolves with diuretics
Normal ageing Coarsening of lung markings in lower zones, no
change on review of recent films
Lymphangitis Coarse nodular and linear thickening of
markings, known malignancy, often associated
with pleural effusion, rapid clinical
deterioration of patient

8. LINEAR PATTERN
LINEAR PATTERN
Atelectasis Short thin lines, often basal, new on review of
previous films
Subsegmental Longer thicker bands, often perihilar or basal,
collapse suggest recent infection or infarction
Scarring Any length, persist over time unchanged
Fibrosis Volume loss is key, persists over time

9. Causes of fibrosis
Mid zone lung Lower zone lung Upper zone lung
tuberculosis Drug indused fibrosis sarcoidosis
(most common)
Chronic extrinsic allergic UIP
alveolitis
Radio-therapy Asbestose-related fibrosis
Ankylosing spondylitis
Progressive massive
fibrosis
histoplasmosis

10. CASE-1
• A 50-year-old male smoker is evaluated for chronic shortness of breath.
• On physical examination his vital signs are:
– pulse 110 bpm;
– Temperature normal;
– respirations 30/min with use of accessory muscles and pursed-lip breathing;
– blood pressure 110/78 mm Hg.
• Other pertinent findings are:
– heart exam: apex beat (impulse) is medial to the mid-clavicular line
– generalized decreased breath sounds on lung exam;
• ABGs (FiO2 0.21):
– pH 7.38; PCO2 47 mm Hg; PO2 67 mm Hg.
• PFTs/spirometry:
– FVC 2.80 L (67% of predicted);
– FEV1 1.56 (50% of predicted);
– FEV1/FVC% 56%;
– TLC 134% of predicted;
– RV 170% of predicted;
– DLCO 43% of predicted.
– There is no reversibility with bronchodilators.

11. CASE-1

12. POSITION •PA CXR
QUALITY •Good Technical Quality
•Bilateral linar (vascular)infitration .
•Laminar opacity from right hilum.
LESION •Hyper-lucency area at lower right zone.
MEDIASTINALHilum •Central trachea and mediasteinal.
•Dangle heart.
ANGELS •Hazy left angleirregular
diaphragm(flat)
•No
OTHER

13. CASE-1
• 1. What is the most likely diagnosis?
• a. Bronchial asthma with status asthmaticus
• b. Emphysema
• c. Chronic bronchitis
• d. Tuberous sclerosis
• 2. Associated with the above condition is
• a. Obstructive sleep apnea
• b. Increased IgE levels
• c. Respiratory failure with increased A-aDO2
gradient
• d. Clubbing

14. CASE-2
• A 38-year-old man is admitted with progressive shortness of breath
• and cough.
• He denies any fever, chills, or purulent sputum production.
• He wants to be evaluated to determine the reasons for his symptoms.
• On exam, he is afebrile and has decreased breath sounds with hyper-
resonant upper lung field more obvious on the right.
• ABGs on RA: pH 7.35; PCO2 38mm Hg; PO2 78 mm Hg.
• Spirometry:
– (FVC) 1.72 (70% of predicted);
– (FEV1)1.34 L (60% of predicted);
– FEV1/FVC% 76%;
– TLC 4.1 L (100% of predicted);
– TLC by helium dilution method 3.4 (71%);
– DLCO 70% of predicted.
– There is no bronchodilator response.

15. CASE-2

16. POSITION •PA CXR
QUALITY •Poor Technical Quality
•Large bulla extend at right upper and
middle zone.
LESION •Vascular marking crowded at lower
zone.
•Hyperlucensy area at left upper zone.
MEDIASTINALHilum •Central trachea and mediasteinal.
ANGELS •Free
•No
OTHER

17. CASE-2
• 1. What is the most likely diagnosis?
• a. Severe emphysema
• b. Bulla
• c. Pneumothorax
• d. Bronchiectasis
• 2. What is the next management option?
• a. Place a chest tube urgently
• b. Increase bronchodilator dosage and frequency
• c. Start chest physical therapy
• d. Perform CT scan of chest

18. CASE-3
• A 39-year-old man, a smoker since age 16, is seen
in the clinic with complaints of fever, cough, and
production of yellowish sputum.
• He has been chronically short of breath, but
these symptoms have increased over the last
week after he developed a flulike illness.
• On exam, he is febrile and looks ill.
• Lung exam reveals diffuse wheezing with
egophony and whispering pectoriloquy on the
right side.
• ABGs show PO2 of 55 mm Hg on room air,
• sputum is negative for TB.

19. CASE-3

20. POSITION •PA CXR
QUALITY •Poor Technical Quality
•Multiple air-fluid level at right middle
zone.
LESION •Area of hyperlucensy at right and left
upper zone.
MEDIASTINALHilum •Central trachea and mediasteinal.
ANGELS •Free
•No
OTHER

21. CASE-3
• 1. The next step in the management of this patient
would be
• a. Arrange with intervention radiology to do a needle
aspiration
• b. Consult thoracic surgery for lung reduction surgery
• c. Start antibiotic and O2 therapy
• d. Admit patient in an isolation room
• 2. Appropriate measures at the first follow-up
should include
• a. Pneumococcal and influenza vaccine
• b. Allergy testing
• c. Detailed occupational history
• d. Genetic counseling

22. CASE-4
• A 31-year-old African American man is admitted
with increasing cough, fever, and sputum
production.
• He gives a history of repeated infections and
“pneumonias” since childhood.
• Lung exam reveals:
– diffuse rhonchi
– bilateral crackles, more so in the left lung field.
• Routine labs are normal except for a poly-
morphonuclear leuko-cytosis.

23. CASE-4

24. POSITION •PA CXR
QUALITY •Poor Technical Quality
•Bilateral nodulo-reticular pattern
crowded at lower,middle zone and cyct-
LESION like apperance.
MEDIASTINALHilum •Central trachea and mediasteinal.
ANGELS •Free
•No
OTHER

25. CASE-4
• 1. What is the most likely diagnosis?
• a. Bronchiectasis
• b. Cystic fibrosis
• c. Sarcoidosis
• d. Allergic bronchopulmonary aspergillosis
• 2. What is the next management option?
• a. Bronchoscopy
• b. Steroid Rx
• c. Antibiotics and postural drainage
• d. Surgical consult

26. DISCUSSION
• The history is suggestive of bronchiectasis,
and the bilateral cystic-appearing lesions on
the CXR are consistent with that diagnosis.
• Cystic fibrosis is generally predominant in the
upper zone.
• Sarcoidosis rarely presents with this history,
and the fibrotic changes in sarcoidosis are
usually in the upper lobes.
• Allergic bronchopulmonary aspergillosis is
seen with an underlying asthmatic condition.

27. CASE-5
• A 24-year-old male law student presents with
a 3-wk history of increasing dyspnea.
• He has a history of chronic sputum production
of about 100 cc of purulent material each day
for many years.
• In the past, he was hospitalized for a left
pneumothorax.
• He is on inhaled bronchodilator as an
outpatient.

28. CASE-5

29. POSITION •PA CXR
QUALITY •Good Technical Quality
•Bilateral cyct-like opacity apperance.
•At middle zone near hilum and extend
LESION to left upper zone (fibrosis).
MEDIASTINALHilum •Central trachea and mediasteinal.
ANGELS •Freeflated diaphragm.
•No
OTHER

30. CASE-5
• 1. Physical exam will most likely show
• a. Clubbing
• b. Koilonychia
• c. Oncholysis
• d. Pectus excavatum
• 2. Spirometry will most likely show
• a. FVC 60%; FEV1 40%; ratio 66%
• b. FVC 60%; FEV1 62%; ratio 90%
• c. Normal
• d. Normal except mild decrease in FEF25–75
• 3. The most helpful treatment option would be
• a. Increase bronchodilator therapy
• b. Start broad-spectrum antibiotic therapy
• c. Initiate anti-pseudomonas antibiotic regimen
• d. Start oral steroids

31. DISCUSSION
• The history and chest x-ray are consistent with
cystic fibrosis with bilateral cystic upper zone
predominance.
• Physical exam would reveal clubbing;
spirometry would show a mixed obstructive
with restrictive picture.
• The best option would be to initiate anti-
pseudomonas antibiotics.