Basics of Chest X Ray Reading

CHEST RADIOLOGY
Dr. Harish Kumar Singhal
Associate Professor
University College of Ayurved
Dr. S. R. Rajasthan Ayurved University, Jodhpur
Email:-drharish_md@yahoo.co.in

THE CHEST X-RAY
 A chest X-ray is the common noninvasive investigation that helps not only in the
diagnosis of respiratory disease but also in cardiovascular disease too, hence,
should be performed routinely in these disorders.
 Important extension of clinical examination particularly in respiratory symptoms.
5/7/2021
DR. HARISH KUMAR SINGHAL 2

POINTS TO BE NOTED WHILE ASSESSING THE CHEST
 Assessment of Quality
 Bones and Soft tissues
 Cardiac Shadow
 Diaphragm
 Effusion
 Fields and Fissures
 Great vessels
 Hila and mediastinum and Hidden areas
 Impression
5/7/2021

VIEW & CENTRALISATION OR CENTERING
 View
 Whether it is PA view or AP view.
 In PA view, the beam of rays falls from behind the patient and the heart size appears
more or less normal; while in AP view the beam of rays falls from the front and the
heart shadow appears as apparently enlarged.
 Pitfall:AP radiographs magnify the heart and mediastinum.
 Centralisation or Centering
 Look at the clavicles, if they are at the same level, then X-ray is centralised; and if not
then it is poorly centralised.
5/7/2021

PENETRATION/EXPOSURE & SEX
 Penetration/exposure
 If the bony cage, ribs and vertebral bodies are just visible through the cardiac shadow,
then exposure/penetration is adequate.
 If they are too clearly visible, then it is over-penetrated and if not visible, then it is
under penetrated (under exposed).
 Pitfall: In over-penetrated X-rays you are likely to miss low density lesions.
 Sex
 If breast shadows are visible, then X-ray belongs to the female patient.
5/7/2021

ROTATION
 Is the patient rotated?
 The medial end of each clavicle should be equidistant from a vertical line drawn
through the spinous processes of the T1–T5 vertebral bodies.
 Pitfalls:
 Rotation can distort the mediastinal and hilar appearances mimicking a mass
 One lung may appear blacker than the other
5/7/2021

5/7/2021
Penetration/exposure & Sex

POSITION OF TRACHEA
 Position of theTrachea
 This is seen as a dark column representing the air within the trachea.
 Note whether trachea is central or displaced.
 This is seen in reference to central bony vertebral column behind it.
 The trachea may be deviated to the same side or opposite side in a number of
conditions.
5/7/2021

5/7/2021
Position of Diaphragm & Trachea

WHERE IS TRACHEA ?
 Tracheal deviation can be the result
of it being pushed by a mass lesion
in the mediastinum, most often an
enlarged thyroid gland, as in the
case shown here.
 The lung volumes in this case are
normal, and the ribs and
diaphragms are in their normal
positions.
5/7/2021

5/7/2021
Patient had right upper lobectomy and
postoperative radiotherapy. Both of these
have led to volume loss in the remaining
right lung. The trachea has been pulled to
the right as a result. The lung is of
increased blackness on the right compared
to the left because the remaining lung is
hyperinflated. The right diaphragm has
also changed shape, and this appearance
is known as diaphragmatic tenting. It looks
as though a tent pole has been put
underneath to push it upwards.

 Patient had a pneumonectomy
several years ago.
 The left hemithorax is white, and
the mediastinum has shifted to the
left.
 The left-sided ribs are also crowded
together compared to the right side,
and the patient has developed a
slight curvature of the spine.
 The right lung becomes
hyperinflated, and some of the lung
crosses over the midline.
5/7/2021

DIAPHRAGM
 Are both domes of the diaphragm clearly seen and well-defined?
 If part of a dome is obscured — suspect pathology in the adjacent lower lobe.
 A flat diaphragm indicates hyperexpansion (COPD, emphysema, bronchiolitis)
and a higher placed diaphragm indicates pleural effusion, collapse or
diaphragmatic paralysis.
 Normally, right hemidiaphragm is placed slightly superiorly due to the liver.
 Air under diaphragm is normal on left side (gastric bubble)
 Both the costophrenic and cardiophrenic angles are clear.
5/7/2021

EFFUSION
 Are the costophrenic angles
clear and well defined?
 Pleural effusion obscures
these angles.
5/7/2021

5/7/2021
Air under right
dome
of diaphragm
(indicated by an
arrow).

5/7/2021
(A) X Ray shows an abnormally elevated right dome of diaphragm with
flattening, gave a suspicion of diaphragmatic pleurisy or subpulmonic effusion,
which revealed clearly a subpulmonic effusion (splash of fluid producing
peripheral convex opacity with concavity toward lung) when chest X-ray (B) was
taken in decubitus position

5/7/2021
Note the horizontal straight
line between
hypertranslucent area
above and an opaque are
below.
Hydropneumothorax

5/7/2021
Small left effusion
filling the costophrenic
angle. It has a curved
upper margin.

5/7/2021
• A much larger right pleural
effusion. The fluid now encases
the lung and the increased
whiteness can be seen around the
apex of the lung. Compare this
almost totally white lung with the
appearance following a
pneumonectomy.
• In the case of a large pleural
effusion, the mediastinum may be
pushed away from the midline by
the large volume of fluid

5/7/2021
Right Empyema

5/7/2021
Minimal pleural effusion.
There is just
obliteration of costophrenic
angle.

5/7/2021
Hydropneumothorax–
left side

BONES AND SOFTTISSUES:
 Note the central vertebral column and the horizontal ribs.
 Look for scoliosis, relative crowding of ribs (collapse or fibrosis) or wide
separation of ribs (pleural effusion, pneumothorax), osteoporosis, fractures,
metastatic lesions, cervical rib, bony erosion of the ribs.
 Look for subcutaneous emphysema, edema or foreign bodies
 Pitfall: Nipple shadow (bilateral) may mimic intra-pulmonary nodule
5/7/2021

DEGREE OF INSPIRATION
 To judge the degree of inspiration, count the number of ribs above the
diaphragm.
 The anterior end of the 6th rib should be above the diaphragm as should be the
posterior end of 10th rib.
 If more ribs are visible then the lung is hyperinflated.
 If fewer ribs are visible, then patient has not held the breath during full
inspiration.
 It is important to note this because poor inspiration will make the heart size to
look larger and cause the trachea to appear deviated to right.
5/7/2021

5/7/2021

THE CARDIAC SHADOW
 It occupies the central part of the chest. Its right and left borders are
defined;
 The right border is smooth, formed from above downwards by the superior
vena cava, right atrium and inferior vena cava.
 The left border is formed from above downwards by aortic knuckle,
pulmonary conus (artery), left atrial appendage, and left ventricle.
 The cardiothoracic ratio is <50 per cent i.e. the heart shadow is less
than half of the maximum transthoracic diameter. If the cardiac shadow
occupies >50 per cent of the transthoracic diameter, then heart is said to be
enlarged.
5/7/2021

5/7/2021

ABNORMALITIES OFTHE CARDIAC SHADOW
 Causes of prominent aortic knuckle
 • Aortitis
 • Aortic aneurysm
 • Atherosclerosis of the aorta
 • Post-stenotic dilatation.
 Pulmonary conus is prominent in;
 • Idiopathic dilatation of pulmonary artery
 • Post-stenotic dilatation
 • Pulmonary hypertension
5/7/2021

 The pulmonary artery shadow
 It is absent in pulmonary valvular stenosis, pulmonary artery atresia,Fallot’s
tetralogy
 Left atrial enlargement
 It produces double atrial shadow and prominence of shadow of left atrial appendage and
straightening of the left border.
 It is seen in mitralised heart.
 The right atrial enlargement produces straightening of the right border of the heart
with double atrial shadow.
 Ventricular enlargement
 It produces enlargement of cardiac shadow in different directions.
 The right ventricular enlargement produces enlargement of cardiac shadow outwards; while
left ventricular enlargement causes the heart shadow to enlarge down and out giving an
appearance of boot-shaped heart.
5/7/2021

5/7/2021
Situs inversus
1. Apex of heart lies on the right
side
2. Aortic knuckle is absent on the
left is present on the right side
3. Left dome of the diaphragm is
elevated due to presence of
liver on left. There is absence
of stomach air bubble below
left dome

LEFT TO RIGHT SHUNT
 The X-ray of ASD (atrial
septal defect). There is mild
cardiomegaly with large
pulmonary artery and
enlarged arteries in the hila
with plethora in the lung
fields.
 Aortic knuckle is small. The
radiological appearance is
suggestive of left to right
shunt (ASD)
5/7/2021

MITRAL STENOSIS
5/7/2021
Heart size enlarged
with prominent upper
lobes veins, left atrial
enlargement, double
atrial shadow on the right
side near the heart
border, the apex is
dipping into the
diaphragm indicate
mitralised heart

5/7/2021
 Left Border of Heart -
 Straightening of the left border is due to left atrial enlargement.
 Right Border of Heart-
 See for a double atrial shadow which is best seen in well penetrated film and is due to left
atrial enlargement (mitralised heart).
 The left atrium also causes the right heart border to shift further over to the right than
usual.
 For left atrial shadow,hold the X-ray in right hand in horizontal or oblique position infront of
you in bright light, the double shadow, i.e. double right border will be visible as peripheral less
opaque and inner dense opaque area.
 See carina by following the tracheal shadow to its bifurcation into right
and left bronchi
 The angle between the two bronchi is <90°.Widening of this angle suggest left atrial
enlargement.
 Prominent pulmonary conus indicates pulmonary hypertension.
 Lung fields and pulmonary vasculature-
 Prominent upper lobe veins (inverted mostache sign), haziness of lung field from hilum towards
periphery and the transverse Kerley’s B line indicating interstitial oedema indicate pulmonary
venous hypertension and acute pulmonary oedema or congestive heart failure.

5/7/2021
Radiological Features
• Heart shadow is enlarged
• Look at the left border of heart
for a bulge. If a bulge is
noticed, follow it to determine
whether it imperceptibly
merges with the heart border,
Left Ventricular Aneurysm

5/7/2021
Radiological findings
• The heart is boot-shaped
with prominent pulmonary
conus (X-ray set for
comparison).
• There is increased
bronchovascular marking
Left ventricular Hypertrophy

5/7/2021
Radiological Features
• Cardiac shadow is enlarged.
Look at the X-ray and confirm the
enlargement of cardiac shadow
by measurements.
• Money-bag appearance. In
contrast to chamber enlargement,
the heart shadow is globular in
shape with straightening of both
the borders of the heart.
• Both the hila are covered by the
heart shadow.
Lung fields. In contrast to
ventricular enlargement where lung
fields are congested and vascular
markings prominent near the hilum,
the lung vasculature is normal or
oligaemic in pericardial effusion.
Pericardial Effusion

5/7/2021
Lozenge- shaped
areas of blackness which
represent pockets of air
in the soft tissue.
In severe cases,
orientation of the planes
is lost and dark and white
lines are produced which
cross a part or whole of
the film.
Surgical Emphysema

HILA AND MEDIASTINUM AND HIDDEN AREAS:
 Are the hila normal – position, size and density?
 The left hilum should be at the same level or higher than the right – never lower
than the right.
 The hilar density on each side should be similar.
 Both the hila are similar in size and concave in shape. They have more or less
same density.
 Abnormal hilum means either one hilum is bigger than the other or denser than
the other.When hilum enlarges, its concave shape is lost – a first sign of hilar
enlargement.
5/7/2021

CAUSES OF HILAR ENLARGEMENT
 Unilateral
 Due to lymph node enlargement
 Infective e.g. tuberculosis, histoplasmosis
 Sarcoidosis
 Neoplasm e.g. lymphoma, metastasis from bronchial carcinoma
 Due to vascular enlargement
 Pulmonary artery aneurysm
 Poststenotic dilatation of pulmonary artery
5/7/2021

 Bilatéral lymphnodes
enlargement
 Infections e.g.
tuberculosis,
histoplasmosis, AIDS,
Recurrent chest infections
 Neoplasms e.g. lymphoma,
metastases
 Occupational lung diseases
e.g. silicosis, berrylliosis
 Sarcoidosis (a common
cause)
5/7/2021

MEDIASTINAL SHADOW/ENLARGEMENT
 The mediastinum comprises the central area between the two lungs and their
pleural coverings.
 Laterally on either side, it is bounded by mediastinal pleura. It extends from the
thoracic inlet (above) to the diaphragm (below) and from the sternum (front) to
the spine (back).
 The structures present in the mediastinum include, lymphnodes, heart and great
vessels (aorta and its branches), superior vena cava, thymus, oesophagus and fatty
areolar tissue.
5/7/2021

CAUSES OF MEDIASTINALWIDENING (ENLARGEMENT)
 Lymphadenopathy
 Tuberculosis,sarcoidosis, lymphomas, leukemias, metastasis
 Aortic enlargement
 Aneurysm
 Unfolding of aorta
 Thymus
 Thymoma,Thymic hyperplasia
 Cysts
 Dermoid; teratoma
 Bronchogenic cyst
 Pleuropericardial cyst
 Meningocoele
 Oesophagus
 Cardia achalasia
 Hiatus hernia
 Enterogenous cyst
5/7/2021

SITE OF ENLARGEMENT/WIDENING
 Look at the X-ray and note whether widening is at the top, in the middle or lower
part of mediastinum.
 Widening at the top could either be due to thyroid, thymus or innominate artery.
 Widening of the middle or bottom of the mediastinum could be due to lymphadenopathy,
aortic aneurysm, dilatation of oesophagus (cardia achalasia) or a hiatal hernia.
 If widening is at the top, then look at the position of the trachea.
 If you suspect an enlarged thyroid then look at the outline of the shadow.
 Look at the right side of trachea.A white edge of trachea is 2-3 mm wide, its further
widening suggest either enlarged superior vena cava or a paratracheal mass.
 If you suspect widening of the aorta, follow the outer edge of the aorta downward,
you may be able to detect a continuous edge which widens to form the edge of
enlarged mediastinum.This would suggest that the widening is due to dilatation of the
aorta.
5/7/2021

5/7/2021
Chest X-ray (PA view) showing widening
of the mediastinum due to aortic arch
aneurysm

HIDDEN AREAS
5/7/2021
• Apical Zones
• Hilar Zones
• Retrocardial Zones
• Zone below the diaphragm

THE LUNG FIELDS
 For radiological purposes, the lung fields are divided into 3 zones.
 Upper zone: extends from the apex to a transverse line drawn through the lower
borders of the anterior ends of the 2nd costal cartilages.
 Mid-zone: extends from this line to another line drawn through the lower borders of
the 4th costal cartilage.
 Lower zone: extends from this second line to the bases of the lungs or to the dome of
diaphragm.
 Each zone is examined on both sides and compared with each other for
any abnormal finding (infiltrates, consolidation, mass, pneumothorax, etc.)
 Vessels should taper and become almost invisible towards the periphery of lung
field.
 Look for thickening or fluids in major and minor fissures.
5/7/2021

NORMAL CHEST X - RAY
5/7/2021

5/7/2021

CHEST X-RAY IN PULMONARY
DISORDERS
5/7/2021

INFILTRATE
A. It is an abnormal shadow in the lung which does not have any pattern—a vague
term.
B. If these infiltrates involve the alveoli such as in pneumonia and lymphoma, a
homogeneous dense opacity is produced.When this opacity is confined to a
lobe, it is called lobar consolidation and this is seen in bacterial pneumonia.
C. An air bronchogram is also seen. Multiple such opacities when present in the
lung constitute bronchopneumonia.
D. The alveolar exudates may coalesce to produce nodular opacities or large fluffy
cotton-wool like shadows.
5/7/2021

A
5/7/2021
Apical
tuberculosis.
There is
infiltration in
right upper zone
without
cavitation

B
5/7/2021
Consolidation right middle lobe
(chest X-ray PA view)

C
5/7/2021
Bilateral consolidation of lower lobes

D
5/7/2021
Bilateral pulmonary tuberculosis.
Note the bilateral
infiltrates producing nodular opacities

E
5/7/2021
Bilateral fungal infection.
Note the fluffy cotton-
wool shadows

5/7/2021
Bulging lower border of
consolidated right upper
lobe is suggestive of
Klebsiella pneumonia.

COLLAPSE—CONSOLIDATION
OF RIGHT UPPER LOBE
5/7/2021
Lobar/segmental distribution of
pneumonia. Commonly seen with
pneumococcal pneumonia.

5/7/2021
 Right upper zone and lower zone
consolidation; Left upper zone and middle
zone consolidation; Sparing of right middle
zone suggesting
Pneumocystis(carinii)pneumonia:

5/7/2021
Hyperinflated lungs
Bronchiolitis

5/7/2021
Bilateral consolidation with cavities
Staphylococcal pneumonia

5/7/2021
Congenital
diaphragmatic
hernia

5/7/2021
Extensive destruction
of lung
parenchyma with
formation
of cavities bilaterally
is visible
indicating
staphylococcal
pneumonia.

5/7/2021

 Thankyou……………
5/7/2021

Basics of Chest X Ray Reading

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Basics of Chest X Ray Reading

Similar to Basics of Chest X Ray Reading (20)

More from Dr Harish Kumar Singhal

More from Dr Harish Kumar Singhal (10)

Recently uploaded

Recently uploaded (20)

Basics of Chest X Ray Reading