This document provides a comprehensive overview of basic chest X-ray interpretation, outlining radiographic views, anatomy, and common lung conditions. It discusses techniques for identifying various issues such as pleural effusion, pneumonia, and pneumothorax, including the importance of film quality and systematic approaches to interpretation. Key points and clinical implications, such as potential findings correlated with patient symptoms, are also highlighted.

1. BASIC CHEST X-RAY INTERPRETATION
DR.S.SHRINUVASAN
ASSISTANT PROFESSOR,SLIMS

2. CONTENTS
 INTRODUCTION TO X- RAYS
 Radiographic views
 SYSTEMATIC APPROACH
 Radiographic anatomy
LUNGS/MEDIASTNUM
 Common lung conditions

3. X-rays- describe radiation which is part of the
spectrum which includes visible light, gamma
rays and cosmic radiation.
Unlike visible light, radiation passes through
stuff.
When you shine a beam of X-Ray at a person
and put a film on the other side of them a shadow
is produced of the inside of their body.

4. Different tissues in our body absorb X-rays at different
extents:
•Bone- high absorption (white)
•Tissue- somewhere in the middle absorption (grey)
•Air- low absorption (black)

5. PA VS AP

7. VIEWS
 Decubitus - useful for differentiating pleural
effusions from consolidation (e.g. pneumonia) and
loculated effusions from free fluid in the pleural
space.
 Lordotic view - used to visualize the apex of the
lung to pick-up abnormalities such as a Pancoast
tumour.
 Expiratory view - helpful for the diagnosis of
pneumothorax .

8. BE
SYSTEMATIC

10. Film Quality
 First determine is the film a PA or AP view.
All x-rays in the PICU are portable and are AP
view

11. IMAGE QUALITY

12. CHECK FOR ROTATION
 Does the thoracic spine
align in the center of the
sternum and between
the clavicles?
 Are the clavicles level?

13. Was film taken under full inspiration?
-10 posterior ribs should be visible.
A really good film will show anterior ribs too, there should
Be 6 to qualify as a good inspiratory film.

14. QUALITY (cont.)
 Is the film over or
under penetrated if
under penetrated you
will not be able to see
the thoracic vertebrae.

15. THE THORAX
 The thorax is divided into
TWO LATERAL COMPARTMENTS
each containing a lung and associated pleura
CENTRAL COMPARTMENT
the mediastinum, which contains
the other thoracic structures.

16.  The lung root contains:
 * Main bronchus.
 * Pulmonary artery.
 * Pulmonary vein.
 * Bronchial arteries.
 * Lymph nodes

17. RADIOGRAPHIC ANATOMY
A: Right 1st rib.
B: Trachea.
C: Right main bronchus.
D: Posterior rib.
E: Left main bronchus.
F: Right costophrenic angle.

18. LATERAL VIEW

19. CHECK THE HEART
 Size
 Shape
 Silhouette-margins should be sharp
 Diameter (>1/2 thoracic diameter is enlarged heart)
Remember: AP views make heart appear larger than it
actually is.

21. MEDIASTINUM
 The mediastinum is the central part of the thoracic
cavity which lies between thepleural sacs.
 It extends from the superior thoracic aperture to the
diaphragm and from the sternum and costal
cartilages to the thoracic vertebrae.
 An arbitrary line formed between the sternal angle to
the inferior border of T4 divides the mediastinum
into superior and inferior parts

22.  The inferior mediastinum is subdivided by
thepericardium into anterior, middle and posterior
parts. The heart and great vessels lie
within the middle mediastinum.
 The heart has a base, apex, three surfaces and four
borders. The base of the heart is located posteriorly
and formed mainly by the left atrium.

24. MEDIASTINUM
A: Aortic knuckle.
B: Superior vena cava (SVC).
C: Left pulmonary artery.
D: Right pulmonary artery.
E: Left heart border: left
ventricle.
F: Right heart border: right
atrium.
G: Inferior heart border: right
ventricle.

25. Cardiac Silhouette
1. R Atrium
2. R Ventricle
3. Apex of L Ventricle
4. Superior Vena Cava
5. Inferior Vena Cava
6. Tricuspid Valve
7. Pulmonary Valve
8. Pulmonary Trunk
9. R PA 10. L PA

26. The '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.

27.  Silhouettes' and their adjacent tissues
 Left heart border (left ventricle) - Lingula
 Right heart border (right atrium) - Right middle
lobe
 Left hemidiaphragm - Left lower lobe
 Right hemidiaphragm - Right lower lobe
 Aortic knuckle - Left upper lobe/middle mediastinum
 Descending aorta - Left lower lobe
 Right paratracheal stripe - Right upper lobe/anterior
mediastinum
 Paraspinal lines - Medial lung/Posterior mediastinum

29. Simulated silhouette signs
1 - Left heart border - Lingula disease
2 - Hemidiaphragm - Lower lobe lung disease
3 - Paratracheal stripe - Paratracheal disease
4 - Chest wall - Lung, pleural or rib disease

31. 5 - Aortic knuckle - Anterior mediastinal or left
upper lobe disease
6 - Paraspinal line - Posterior thorax disease
7 - Right heart border - Middle lobe disease
8 - Density above horizontal fissure* - Anterior
segment of the right upper lobe

32. Key points - Review areas
 Apices - Pneumothorax?
 Bones/soft-tissues - Fractures/density?
 Cardiac shadow- Consolidation/mass?
 Diaphragm - Pneumoperitoneum?
 Edge of the image - Unexpected findings?
 Mnemonic - ABCDE

33. REVIEW AREAS

37. OPACIFICATION OF A
HEMITHORAX
 Pleural effusion
 Consolidation
 Collapse
 Massive tumour
 Fibrothorax
 Combination of above lesions
Pneumonectomy
 Lung agenesis

38. PLEURAL EFFUSION
 Pleural effusion is excess fluid that accumulates
between the two pleural layers , the fluid-filled space
that surrounds the lungs.
 Excessive amounts of such fluid can impair
breathing by limiting the expansion of the lungs
during ventilation.

39.  Four types of fluids can accumulate in the pleural
space:
 Serous fluid (hydrothorax)
 Blood(haemothorax)
 Chyle (chylothorax)
 Pus(pyothorax or empyema)

43.  Conditions associated with transudative pleural effusions
 Congestive Heart Failure (CHF)
 Hepatic cirrhosis
 Hypoproteinemia
 Nephrotic syndrome
 Acute atelectasis
 Myxedema
 Peritoneal dialysis
 Meig's syndrome
 Obstructive uropathy

44.  Conditions associated with exudative pleural effusions
 Malignancy
 Infection
 Trauma
 Pulmonary infarction
 Pulmonary embolism
 Autoimmune disorders
 Pancreatitis
 Ruptured esophagus ( or Boerhaave's syndrome)
 Rheumatoid Pleurisy
 Drug-induced Lupus
 Tuberculosis

45. PNEUMONIA

46.  Pneumonia is an inflammatory condition of the
lung—affecting primarily the microscopic air sacs
known as alveoli. It is usually caused by infection
with viruses or bacteria and less commonly other
microorganisms, certain drugs and other conditions
such as autoimmune diseases

48. COLLAPSE
 Atelectasis is defined as the collapse or closure of
the lung resulting in reduced or absent gas exchange.
It may affect part or all of one lung. It is a condition
where the alveoli are deflated, as distinct from
pulmonary consolidation

51. CAUSES OF HYPERTRANSRADIANT
 Mastectomy — absent breast ± absent pectoral muscle shadows.
 Poland's syndrome — unilateral congenital absence of pectoral
 muscles ± rib defects.
 PLEURA
PNEUMOTHORAX
 LUNG
 EMPHYSEMA
 UNILATERAL BULLAE — vessels are absent rather than attenuated. May mimic
pneumothorax.
 MACLEOD'S SYNDROME — the late sequela of childhood bronchiolitis.
Small lung with small main and peripheral arteries. Air trapping occurs on
expiration

52. PNEUMOTHORAX
 A pneumothorax
is an abnormal
collection of air or
gas in the pleural
space that separates
the lung from the
chest wall and
which may interfere
with normal
breathing

53.  A Primary Pneumothorax is one that occurs without
an apparent cause and in the absence of significant lung
disease
 Secondary Pneumothorax occurs in the presence of
existing lung pathology.
 In a minority of cases, the amount of air in the chest
increases markedly when a one-way valve is formed by
an area of damaged tissue, leading to a Tension
Pneumothorax.
 This condition is a medical emergency that can cause
steadily worsening oxygen shortage and low blood
pressure. Unless reversed by effective treatment, these
sequelae can progress and cause death.

56. Chronic Obstructive Pulmonary Disease

61. PULMONARY EDEMA
 Pulmonary edema is fluid accumulation in the air
spaces and parenchyma of the lungs. It leads to
impaired gas exchange and may cause respiratory
failure.
 It is due to either failure of the left ventricle of the
heart to adequately remove blood from the
pulmonary circulation ("cardiogenic pulmonary
edema"), or an injury to the lung parenchyma or
vasculature of the lung ("noncardiogenic pulmonary
edema")

62.  The key findings of cardiogenic pulmonary edema
Kerley B lines (septal lines)
 Seen at the lung bases, usually no more than 1 mm thick and 1 cm
long, perpendicular to the pleural surface
 Pleural effusions
 Usually bilateral, frequently the right side being larger than the left
 If unilateral, more often on the right
 Fluid in the fissures
 Thickening of the major or minor fissure
 Peribronchial cuffing
 Visualization of small doughnut-shaped rings representing fluid in
thickened bronchial walls

64.  Non-cardiogenic pulmonary edema
 Bilateral, peripheral air space disease with air bronchograms
or central bat-wing pattern
 Kerley B lines and pleural effusions are uncommon
 Typically occurs 48 hours or more after the initial insult
 Stabilizes at around five days and may take weeks to
completely clear
 On CT
 Gravity-dependent consolidation or ground glass opacification
 Air bronchograms are common

66. The clinical question

67. Clinical information provided
 Recent increase in shortness of breath
 No fever or productive cough
 Left shoulder and arm pain
 Heavy smoker
 Weight loss

68. Findings
Left apical shadowing
Raised left hemidiaphragm
Increased extra-thoracic
soft tissue density (*) with
displacement of the
scapula on the left
(arrowheads) - compare
with right

69.  Interpretation in view of clinical details
 Cancer - Smoker with weight loss and left apical
consolidation/mass and no clinical features of
infection
 Phrenic nerve palsy - Increased shortness of
breath and raised left hemidiaphragm
 Brachial plexopathy - Arm pain and axillary soft
tissue swelling

70. THANK
YOU