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1 the normal cxr
This document provides an overview of how to view and interpret a normal chest x-ray (CXR) and discusses some key radiological concepts: 1. It describes the technical aspects of a PA view CXR including proper centering, inspiration level, and visibility of structures like the trachea. 2. The mediastinum, heart, diaphragm, lungs, bones, and soft tissues are identified and their normal appearances discussed. 3. Important radiological signs like the silhouette sign and air bronchogram that are used to interpret abnormal films are introduced.
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1 the normal cxr
- 1. The Normal CXR By Dr. Hayam Yousif Radiologist Muhammad Jalal Abdulsamad
- 4. The Plain Film •The PA view • Exposure is made on full inspiration
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- 8. PA view AP view • The posterior chest wall is well shown • The scapulae overlie the upper lungs and the clavicles are projected more cranially over the apices • The neural arches are • The disc spaces of the visualised lower cervical spine are more clearly seen
- 9. AP film PA film
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- 12. Viewing the PAFilm Request form Name Age Date Sex Clinical information
- 13. Viewing the PAFilm Technical aspects Centering Penetration the vertebral body and spaces should be just visible through the cardiac shadow. Degree of inspiration on full inspiration the anterior ends of 6th ribs or the posterior ends of 10th are above the right hemidiaphragm.
- 14. Trachea it isin the midline then deviates slightly to the right side at level of aortic knuckle Narrowing Displacement Intraluminal lesion
- 15. The mediastinum andheart The central dense shadow seen on PA CXR comprises the mediastinum, heart, spine and sternum The cardiac shadow lies to the left of the midline and 1/3 to the right although it is quite variable The transverse cardiac diameter normal for female < 14.5 cm and for males < 15.5 cm. The normal cardiothoracic ratio is < 50% on PA film and < 60% in AP film. An increase in excess of 1.5 cm in the transverse diameter on comparable serial films is significant.
- 16. All borders ofthe heart and mediastinum should be clearly defined In babies and young children the normal thymus is a triangular sail shaped structure with well defined borders which may be wavy.
- 18. Superior Vessels Vena Cava Aortic Arch Ascending Aorta Pulmonary Artery Right Left Atrium Atrium Inferior Left Ventricle Vena Cava
- 19. Aortic Knob/Arch Descending Ascending Aorta Aorta Left Atrium Right Left Ventricle Ventricle Inferior Vena Cava
- 20. Diaphragm In most patientsthe right hemidiaphragm is higher than the left. May lie at the same level, and in small percentage the left side is higher. A difference of > 3 cm in height is significant Loss of outline indicates that the adjacent tissue does not contain air.
- 21. The fissures The mainfissures The horizontal fissure is seen often incompletely on PA film The oblique fissures are seen on lateral film commence posteriorly at the level of T4 or T5 passing through the hilum. The left is steeper and finishes 5cm behind the anterior costophrenic angle, where as the right ends just behind the angle. Accessory fissures, the azygos fissure is comma shaped and nearly always right sided.
- 23. Right Oblique Fissure Horizontal Fissure Left Oblique Fissure
- 24. RUL LUL RML RLL LLL
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- 27. Costophrenic angles The normalcostophrenic angles are acute
- 29. The lungs By comparingthe lungs, areas of abnormal translucency or uneven distribution of lung markings are more easily detected.
- 30. The hila In 97%of subjects the left hilum is higher than the right. The hila should be of equal density and similar size with clearly defined concave lateral borders. The lower lobe vessels are larger than those of the upper lobes in erect position. The right main bronchus is shorter, steeper and wider than the left.
- 31. Below the diaghragm Pneumoperitoneum Dilatedbowel Abscess Calcified lesion Chilaiditi’s syndrome
- 32. Soft tissue Chest wall:breast shadow, skin folds, shadow of sternomastoid muscle Shoulders Lower neck
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- 36. Image credit: CurryInternational Tuberculosis Center, University of California, San Francisco 22
- 37. Viewing the lateralfilm • Routinely the left side is adjacent to the film
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- 39. • Aortic arch • Right pulmonary artery • Left pulmonary artery • Trachea & bronchi Image credit: Curry International Tuberculosis Center, University of California, San Francisco 23
- 46. • The clearspaces Retrosternal space normally this space is less than 3 cm deep Retrocardiac space
- 47. • Vertebral translucency Thevertebral bodies become more translucent caudally
- 48. • Diaphragm outline Bothdiaphragms are visible The posterior costophrenic angles are acute and small amounts of pleural fluid may be detected.
- 49. • The fissures Loculatedinterlobar effusions Displacement Thickening
- 50. • The trachea Thispasses down in a slightly posterior direction.
- 51. • The sternum should be studied carefully in cases of malignancy or when there is a history of trauma.
- 52. Interpretation of abnormalfilm • Radiological signs The silhouette sign is the loss of an interface by adjacent disease, when air in the alveolar space is replaced by fluid or soft tissue, there is no longer a difference in radiodensity between that part of the lung and the adjacent structures. Therfore the silhouette is lost and the silhouette sign is present.
- 53. Silhouette sign
- 54. • The airbronchogram is an important sign showing that the lesion is intrapulmonary. The bronchus , if air filled but not fluid, become visible when air is displaced from the surrounding parenchyma. The air bronchogram is seen as scattered linear translucencies.
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