in this tutorial i am speaking about chest x-ray quality that include :
1- Inclusion
2- inspiration/lung
3- volume
4- projection
5- penetration
6- Rotation
7- artifact
i try to make it easy and simple for medical students and junior doctors to help them in clinical life.
in this tutorial i am speaking about chest x-ray quality that include :
1- Inclusion
2- inspiration/lung
3- volume
4- projection
5- penetration
6- Rotation
7- artifact
i try to make it easy and simple for medical students and junior doctors to help them in clinical life.
A chest x ray is a fast and painless imaging test that uses certain electromagnetic waves to create pictures of the structures in and around your chest. This test can help diagnose and monitor conditions such as pneumonia, heart failure, lung cancer, tuberculosis, sarcoidosis, and lung tissue scarring, called fibrosis
Learn Chest X-Ray With Its Normal Positioning & Radio-AnatomyDr.Santosh Atreya
Learn Chest X-Ray With Its Normal Positioning & Radio-Anatomy..For some image description please go through the text book "David Sutton" because i have described these image during my presentation Verbally..There are many animations used inside this presentation so to see all the pictures which are placed layer by layer with the help of animations you simple need to download this presentation first.... Thanx.
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A chest x ray is a fast and painless imaging test that uses certain electromagnetic waves to create pictures of the structures in and around your chest. This test can help diagnose and monitor conditions such as pneumonia, heart failure, lung cancer, tuberculosis, sarcoidosis, and lung tissue scarring, called fibrosis
Learn Chest X-Ray With Its Normal Positioning & Radio-AnatomyDr.Santosh Atreya
Learn Chest X-Ray With Its Normal Positioning & Radio-Anatomy..For some image description please go through the text book "David Sutton" because i have described these image during my presentation Verbally..There are many animations used inside this presentation so to see all the pictures which are placed layer by layer with the help of animations you simple need to download this presentation first.... Thanx.
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
Contact us if you are interested:
Email / Skype : kefaya1771@gmail.com
Threema: PXHY5PDH
New BATCH Ku !!! MUCH IN DEMAND FAST SALE EVERY BATCH HAPPY GOOD EFFECT BIG BATCH !
Contact me on Threema or skype to start big business!!
Hot-sale products:
NEW HOT EUTYLONE WHITE CRYSTAL!!
5cl-adba precursor (semi finished )
5cl-adba raw materials
ADBB precursor (semi finished )
ADBB raw materials
APVP powder
5fadb/4f-adb
Jwh018 / Jwh210
Eutylone crystal
Protonitazene (hydrochloride) CAS: 119276-01-6
Flubrotizolam CAS: 57801-95-3
Metonitazene CAS: 14680-51-4
Payment terms: Western Union,MoneyGram,Bitcoin or USDT.
Deliver Time: Usually 7-15days
Shipping method: FedEx, TNT, DHL,UPS etc.Our deliveries are 100% safe, fast, reliable and discreet.
Samples will be sent for your evaluation!If you are interested in, please contact me, let's talk details.
We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
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Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
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Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
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disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
5. Systematic approach - Patient and image data
Check the patient's identity
Note the image date and time
Note the image projection: Check if a posterior anterior
(PA) or anterior posterior (AP) projection was used, and
note if the patient was standing, sitting or supine? Was
the mobile X-ray machine used?
The image annotations are often useful:
This is a mobile chest X-ray
taken with the patient supine,
at 11.25 am in the resuscitation
room. The patient's name, ID
number and date of birth are
annotated. Note the side
marker is correct.
7. Systematic approach - Image quality
Assess the image quality: The chest X-ray should be
checked for rotation, inspiration and penetration
(Mnemonic-RIP-Rest In Peace ).
Comment on the presence of medical artifacts
Can the clinical question still be answered?
8. Systematic approach - The obvious abnormality
It is often appropriate to start by describing the most
striking abnormality. However, once you have done this,
it is vital to continue checking the rest of the image.
Remember that the most obvious abnormality may not
be the most clinically important.
The elephant in the
image!
If there is an elephant
in the image, don't
ignore it! Describe it
in detail and then use
your system to
continue examining the
image.
9. Systematic approach - Describing abnormalities
'Shadowing', 'Opacification', 'increased density',
'increased whiteness' are all acceptable terms
'Lesion descriptors' may lead you towards a diagnosis
Be descriptive rather than jumping to a diagnosis
'Lesion descriptors'
6. Position Anterior/
Posterior/Lung zone etc.
7. Shape Round/ Crescentic/etc.
8. Edge Smooth/
Irregular/Spiculated
9. Pattern Nodular/
Reticular(netlike)
10.Density Air/ Fat/Soft tissue/
Calcium/Metal
1. Tissue involved Lung,
heart, aorta, bone etc.
2. Size Large/ Small/Varied
3. Side Right/ Left
Unilateral/ Bilateral
4. Number Single/ Multiple
5. Distribution Focal/
Widespread
10. Systematic approach - Describing abnormalities
'Shadows, opacities, densities'
Tissue involved: Lung
Size: Small (>2 cm)
Side: Bilateral
Number: Multiple
Distribution: Widespread
Position: Mainly middle
to lower zones
Shape: Round
Edge: Irregular
Pattern: Nodular
Density: Soft tissue
Diagnosis:
Description helps with diagnosis. Once you have put all the above terms
together, there can only be one diagnosis.
Metastatic disease
11. Systematic approach - Locating abnormalities
Consider its anterior-posterior position.
A lateral view may help, but 3D location may also be
possible on a posterior-anterior (PA) view if you have a
knowledge of chest X-ray anatomy and an understanding
of the 'silhouette' sign.
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.
12. Systematic approach - Locating abnormalities
The 'silhouette' sign: Loss of contour of :
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
13. Systematic approach - Locating abnormalities
The 'silhouette' sign: Loss of contour of :
5 - Aortic knuckle Anterior mediastinal or left upper lobe disease
6 - Paraspinal line Posterior thorax disease
7 - Right heart border Middle lobe disease
14. Systematic approach - Review areas
After a systematic look at the whole chest X-ray, it is worth
re-checking hidden areas that may conceal important
pathology.
Hidden areas:
• Apical zones
• Hilar zones
• Retrocardial zone
• Zone below the
dome of diaphragm
15. Systematic approach - Interpretation
Whatever the findings are,
they should only be
interpreted in view of the
clinical setting.
Remember to treat the
patient - not the X-ray!
Occasionally there will be
an unexpected finding
(Incidental Finding), which
may need to be considered
with caution, especially if
equivocal or if it does not
fit the clinical scenario.
Posteroanterior (PA) chest
radiograph shows an incidental
finding of a solitary pulmonary
nodule adjacent to the left hilum.
16. Chest X-ray quality - Inclusion
Check the image for: Inclusion, Projection, Rotation,
Inspiration, Penetration and Artifact.
Check to see if a poor quality X-ray demonstrates a life
threatening abnormality before dismissing it.
Check to see if the clinical question still be answered?
Inclusion:
A chest X-ray
should include
the entire thoracic
cage ( first ribs,
Costophrenic
angles, Lateral
edges of ribs ).
17. Chest X-ray quality - Projection
AP projection :
AP projection image is of
lower quality than PA image.
The scapulae are not retracted
laterally and they remain
projected over each lung.
Heart size is exaggerated
18. Chest X-ray quality - Rotation
Rotation:
The spinous processes should lie
half way between the medial
ends of the clavicles
Rotation affects heart size &
shape, aortic tortuosity, tracheal
position and density of lung fields
Rotation can obscure a
pneumothorax . Can also mimic a
mediastinal shift.
Rotation may cause an increase in the transradiancy (blackness)
of the lung on the side to which the patient is rotated.
Rotation will also alter the relative appearance on the hila and
can mimic hilar asymmetry.
20. Chest X-ray quality - Rotation
Frontal chest x-Ray (CXR) with subject rotated to
the left. Note an enlarged heart and small left
pleural effusion. The left hemithorax is darker
than the right due to the rotation.
21. Chest X-ray quality - Inspiration & lung volume
Assessing inspiration:
Count ribs down to
the diaphragm.
The diaphragm
should be
intersected by:
the 5th to 7th (right
6th anterior rib )
anterior ribs in the
mid-clavicular line or
The 8th–10th (9th)
posterior ribs . CXR in full inspiration
22. If the image is acquired in the
expiratory phase or with a
poor inspiratory effort:
1. The lungs are relatively airless
and their density is increased.
2. Increase in lower zone
opacity
3. The hila are compressed and
appear more bulky
4. Exaggeration of heart size
5. Obscuration of the lung
bases.
Chest X-ray quality - Inspiration & lung volume
poor inspiratory effort
full inspiration the same patient
23. Chest X-ray quality - Penetration
Differential Absorption:
Penetration of the x-ray
beam is dependent on
tissue density
Denser object = Less
beam striking the
film (more
absorption) = whiter
Less dense = More
beam striking the
film = blacker
24. Chest X-ray quality - Penetration
A well penetrated (exposed) chest X-ray :
The end plates of the lower thoracic vertebral bodies
should be just visible through the cardiac shadow.
The left hemidiaphragm should be visible to the edge
of the spine.
25. Chest X-ray quality - Penetration
Good penetration
You should be able to
just see the thoracic
spine through the heart
26. Chest X-ray quality - Penetration
An under-penetrated film looks diffusely opaque (too
white), structures behind the heart are obscured, and
left lower lobe pathology may be easily missed.
An over-penetrated film looks diffusely lucent, the lungs
appear blacker than usual and the vascular markings and
lung detail are poorly seen.
27. Chest X-ray quality - Artifact
Radiographic artifact
Rotation, incomplete inspiration
and incorrect penetration. Other
radiographic artifact includes
clothing or jewellery not
removed.
Patient artifact
Poor co-operation with
positioning or movement. Very
often obesity exaggerates lung
density. Occasionally normal
anatomical structures such as hair
or skin folds can cause confusion. Hair artifact
28. Chest X-ray anatomy - Airways
Assessing the airways
Start your assessment of
every X-ray by looking at the
airways.
The trachea should be central
or slightly to the right.
If the trachea is deviated:
If the patient is rotated, or if
there is pathology.
If the trachea is deviated:
If it has been pushed or
pulled by a disease process.
The trachea branches at the
carina, into the left and right
main bronchi, and these can
often be followed as they
branch beyond the hila and
into the lungs.
29. Chest X-ray anatomy - Airways
large left pleural
effusion, and
tracheal shift away
from the effusion
Tension pneumothorax
with tracheal deviation
to right
Tracheal shift to the
right due to thyroid
enlargement
Causes of tracheal deviation:
Ipsilateral (To pull): Collapse and Fibrosis
Contralateral ( To push): Apical mass , Pleural effusion
and Pneumothorax
30. Chest X-ray anatomy - Hilar structures
The structures contributing to
hilar shadows are:
Major: Pulmonary artery and veins
Minor: Fat, Lymph nodes and
Bronchial walls (not visible unless
abnormal)
Normal Hilum:
Position: Left hilum is slightly
higher than the right hilum, Only in
a minority of cases the right hilus is
at the same level as the left, but
never higher.
Shape: Concave
Size: Similar on both sides
Density: Almost same on both sides
Deoxygenated blood (blue
arrow) is pumped upwards out of
the right ventricle (RV) via the
main pulmonary artery (MPA).
This divides into left (LPA) and
right (RPA) which each pass via
the lung hila into the lung tissue
31. Chest X-ray anatomy - Hilar structures
The hilar points: the angle
formed by the descending upper
lobe veins, as they cross behind
the lower lobe arteries
Not every normal patient has a
very clear hilar point on both
sides, but if they are present then
they can be useful in determining
the position of the hila.
Identify main lower lobe
pulmonary arteries: They
can be compared to a
little finger pointing
downwards and medially.
32. Chest X-ray anatomy - Lung zones
The chest radiograph zones:
1. Apical zone: above the
clavicles
2. Upper zone: below the
clavicles and above the
cardiac silhouette (i.e. up to
lower margin of 2nd rib )
3. Mid zone: the level of the
hilar structures (i.e. from
lower margin of 2nd rib to
lower margin of 4th rib )
4. Lower zone: the bases ( i.e. from 4th rib to diaphragm )
33. Chest X-ray anatomy - Pleura and pleural spaces
Trace round the entire edge
of the lung where pleural
abnormalities are seen.
Start and end at the hila
Is there pleural thickening?
Is there a pneumothorax?
The lung markings should
be visible to the chest wall
Is there an effusion? The
costophrenic angles and
hemidiaphragms should be
well defined
34. Chest X-ray anatomy - Pleura and pleural spaces
Costophrenic recesses and
angles:
The costophrenic angles
are limited views of the
costophrenic recess
On a frontal view the
costophrenic angles
should be sharp.
The costophrenic angles
consist of the lateral
chest wall and the dome
of each hemidiaphragm.
35. Chest X-ray anatomy - Lung lobes and fissures
In the right lung there
is an oblique fissure
( of ) and a horizontal
fissure ( hf ) ,
separating the lung into
three lobes - upper,
middle, and lower.
Each lobe has its own
visceral pleural
covering.
36. Chest X-ray anatomy - Lung lobes and fissures
The left lung is
divided into two
lobes, upper and
lower.
These lobes have
their own pleural
covering and these
lie together to form
the oblique (major)
fissure ( of ).
37. Chest X-ray anatomy - Diaphragm
The hemidiaphragms are not
at the same level on frontal
erect inspiratory chest
radiographs, but are usually
within one rib intercostal space
height (2 cm) of each other.
The left hemidiaphragm is
usually lower than the right.
If the left hemidiaphragm is
higher than the right or the
right is higher than the left by
more than 3 cm, one of the
many causes of diaphragmatic
elevation should be considered.
38. Chest X-ray anatomy - Diaphragm
Hemidiaphragms - lateral
view:
The left and right
hemidiaphragms are
almost superimposed on
a lateral view.
Anteriorly the left
hemidiaphragm blends
with the heart and
becomes indistinct.
39. Chest X-ray anatomy - Heart size and contours
From superior to inferior:
1. Right paratracheal stripe:
made up of right
brachiocephalic vein and SVC
2. Arch of the azygous vein
3. Ascending aorta in older
individuals projects to the
right of the SVC
4. Superior vena cava (SVC)
5. Right atrium
6. Inferior vena cava (IVC)
The normal contours of the heart and mediastinum
(cardiomediastinal contour):
Right cardiomediastinal contour
40. Chest X-ray anatomy - Heart size and contours
From superior to inferior:
Left paratracheal stripe
Made up of left common
carotid artery, left subclavian
artery and the left jugular vein
Aortic arch +/- aortic nipple
(left superior intercostal vein)
Pulmonary artery
Auricle of left atrium
Left ventricle
The normal contours of the heart and mediastinum
(cardiomediastinal contour):
Left cardiomediastinal contour
42. Chest X-ray anatomy - Heart size and contours
Lateral view:
Anterior cardiomediastinal contour
From superior to inferior:
1. Superior mediastinum
1. great vessels
2. thymus
2. Ascending aorta
3. Right ventricular outflow track
4. Right ventricle
Posterior cardiomediastinal contour
From superior to inferior:
1. Left atrium and pulmonary veins
2. Right atrium
3. Inferior vena cava
43. Chest X-ray anatomy - Heart size and contours
Cardiothoracic ratio:
The cardiothoracic ratio
should be less than 0.5. i.e.
A+B/C<0.5
A cardiothoracic ratio > 0.5
suggests cardiomegaly in
adults
A cardiothoracic ratio > 0.6
suggests cardiomegaly in
newborn.
44. Chest X-ray anatomy - Heart size and contours
There are several structures in the superior mediastinum
that should always be checked. These include the aortic
knuckle, the aorto-pulmonary window, and the right
para-tracheal stripe.
45. Chest X-ray anatomy - Heart size and contours
It is a space
located between
the arch of the
aorta and the
pulmonary
arteries.
This space can be
lost as a result of
mediastinal
lymphadenopathy
(e.g. malignancy).
The aorto-pulmonary window:
Aortic knuckle (red arrow) &
Aortopulmonary window (green arrow)
46. Chest X-ray anatomy - Mediastinum
In lateral CXR, mediastinum divided into :
Superior mediastinum (S): above the
thoracic plane or the plane of Ludwig
(a horizontal line that runs from sternal
angle or angle of Louis) to the inferior
endplate of T4)
Inferior mediastinum: below the plane of
Ludwig
Anterior mediastinum (A): anterior to
the pericardium
Middle mediastinum (M): within the
pericardium
Posterior mediastinum (P): posterior to
the pericardium
In PA view, the mediastinum is that space
between the lungs and pleural surfaces
(yellow lines).
47. Chest X-ray anatomy - Bones and Soft tissues
Bones:
Ribs (anterior
and posterior)
Clavicles and
shoulders
Sternum
Vertebrae
Shoulder joints
Soft tissues :
Breast shadows
Skin folds
Muscles
Check for: Symmetry, Deformities, Fractures, Masses, Calcifications
and Lytic lesions .
49. Chest X-ray anatomy - Lateral view
Interpretation of lateral film
The clear spaces
Retrosternal space
Retrotracheal
space
Retro cardiac
Vertebral
translucency
Diaphragm outline
The fissures
The trachea
The sternum
50. Chest X-ray anatomy - Lateral view
Retrosternal space
Seen as a normal lucency
between the posterior aspect
of the sternum and anterior
aspect of the ascending aorta
This space should be visible
and less than 2.5cm in width.
Can be demonstrated at point
3cm below manibrium sterni
An increased retrosternal
airspace is a reliable sign of
pulmonary emphysema, while
obliteration indicates anterior
mediastinal mass e.g.
lymphoma.
51. Chest X-ray anatomy: Lateral view
Vertebral translucency
The ‘‘spine sign,’’ which
states that the normal
lateral chest film shows
increasing overall lucency
as one looks down the
thoracic vertebral bodies
from the neck to the
diaphragms.
Causes of failure to darken
gradually above the
diaphragms:
Pleural thickening
Lower lobe collapse
Mediastinal mass
52. Chest X-ray anatomy - Lateral view
Diaphragm outline
Right
hemidiaphragm
continues
anteriorly
left
hemidiaphragm
blends with the
heart and
becomes
indistinct
Anteriorly.
54. How to speak - Normal CXR
This is chest radiograph, PA view with
normal exposure, no rotation and without
any apparent bony abnormality. Trachea is
placed centrally & lung fields are clear with
normal broncho-vescicular markings.
Cardiovascular silhouette is within normal
limits with normal cardiothoracic ratio.
Mediastinum, costo-phrenic, cardio-phrenic
angles, dome of diaphragm & soft tissue
shadow within normal limits.
55. Chest X-ray Abnormalities - Trachea
Ensure trachea is visible and in midline
1. Tracheal displacement (discussed previously)
2. Trachea normally narrows at the vocal cords
3. View the carina, angle should be between 60 –100
degrees. Beware of things that may increase this angle,
e.g. left atrial enlargement, lymph node enlargement and
left upper lobe atelectasis
4. Follow out both main stem bronchi
5. Check for tubes, foreign bodies etc.
6. If an endotracheal tube is in place, check the positioning,
the distal tip of the tube should be 5-7cm above the
carina
57. Chest X-ray Abnormalities - Trachea
In this patient, the endotracheal tube is in the right
mainstem bronchus, and the left sided is not being
ventilated. That is why the left side is collapsed
58. Chest X-ray Abnormalities - The lung hilum
A. Hilar position:
If a hilum has moved, you should try to determine if it has
been pushed or pulled, just like you would for the
trachea.
The left hilum must never be lower than the right hilum.
Whenever a left hilum appears lower than the right hilum
– look for other evidence suggestive of:
Collapse of either the left lower lobe or of the right
upper lobe
Enlargement of the right hilum
59. Chest X-ray Abnormalities - The lung hilum
A. Hilar position:
Superior displacement and
horizontalization of the right hilum
(white curved arrow) due to
atelectasis of the right upper lobe
(black arrows). the hilum (red arrow)
Left lower lobe atelectasis. The blue
arrows point to the edge of a
triangular region of atelectatic left
lower lobe. Left Hilum displaced
inferiorly. the hilum (red arrow)
60. Chest X-ray Abnormalities - The lung hilum
B. Hilar enlargement:
May be unilateral or bilateral, symmetrical or asymmetrical
61. Chest X-ray Abnormalities - The lung hilum
Analyze the enlargement of
hilum (if present):
1. Lymph Node enlargement:
Lobulated appearance
(lumpy-bumpy opacity )
Presence of calcification
within the mass
indicates usually
tuberculosis.
Egg-shell calcification
indicates silicosis or
sarcoidosis. Calcified bilateral hilar
lymphadenopathy in
sarcoidosis
62. Chest X-ray Abnormalities - The lung hilum
2. Arterial enlargement:
Smooth margins
In pulmonary arterial
hypertension the
arteries in the outer
two-thirds of each
lung are smaller than
those at the hila
(peripheral pruning)
Primary pulmonary hypertension showing
right heart enlargement and enlargement
of the main pulmonary artery and its right
and left branches.
63. Chest X-ray Abnormalities - The lung hilum
3. Malignancy:
Spiculated irregular or
indistinct margins
Hilar enlargement due to
malignant lung lesion is
also associated with
superior mediastinal
lymphadenopathy. Look
at the lung fields (for
presence of tumor) and
bone/ribs for metastasis. This patient has a bulky right
hilum. This was shown to be
due to a bronchogenic tumour.
64. Chest X-ray Abnormalities - The lung hilum
C. Hilar density:
May be due to :
A mass or calcification in
the hilum
Dense Hilum Sign:
superimposition of
another abnormal
density (pneumonia or a
mass ) in the lung or
mediastinum that
projects over the hilum
on the frontal image.
Here is increased density and
enlargement of the right hilum with
a multilobular contour. The CT
scans show enlarged mediastinal
and right hilar lymph nodes.
65. Chest X-ray Abnormalities - The lung hilum
Dense Hilum Sign:
On the frontal (PA) image, the left hilum (red arrow)
appears denser than the right hilum (white arrow). This
may be caused by a hilar mass, but not necessarily. The
lateral view shows airspace disease (pneumonia) in the
superior segment of the left lower lobe (yellow arrow).
66. Chest X-ray Abnormalities - lung fields
Lung abnormalities:
Abnormal whiteness
(increased density):
Consolidation
Atelectasis
Nodule or mass
Interstitial
Abnormal blackness
(decreased density):
Cavity
Cyst
Emphysema
Assess the lungs by comparing the upper,
middle and lower lung zones on the left
and right
67. Chest X-ray Abnormalities - lung fields
Four patterns of
increased density:
Consolidation
Lobar
Diffuse
Multifocal ill-
defined
Atelectasis
Nodule or mass
Solitary Pulmonary
Nodule
Multiple Masses
Interstitial
Reticular
Fine Nodular
68. lung field abnormalities - Consolidation
The key-findings on the
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
May be Blunting of
costophrenic angle
X-ray are:
69. lung field abnormalities - Consolidation
Air bronchogram refers to the phenomenon of air-filled
bronchi (dark) being made visible by the opacification of
surrounding alveoli (grey/white).
74. lung field abnormalities - Consolidation
Bat's wing appearance:
A bilateral perihilar distribution of consolidation.
Reverse bat's wing appearance:
Peripheral or subpleural consolidation
75. lung field abnormalities - Consolidation
Reverse bat's wing appearance
In Chronic eosinophilic pneumonia
82. lung field abnormalities - Consolidation
Lymphoma: Imaging Findings:
Mediastinal widening due to
mediastinal lymphadenopathy
Parenchymal lung involvement:
Multiple nodules
Consolidation with an
air - bronchogram
Segmental or lobar
atelectasis
Pleural effusions (Mostly
small, unilateral, and
exudative)
Destructive rib or vertebral
body lesion
Chest X-ray reveals multiple
scattered consolidation
lesions involving both lungs
83. lung field abnormalities - Consolidation
Tuberculosis (TB): Primary pulmonary tuberculosis:
Imaging Findings:
Patchy or lobar consolidation
Cavitation (uncommon)
Caseating granuloma
(tuberculoma) which usually
calcifies (known as a Ghon
lesion)
Ipsilateral hilar and
mediastinal (paratracheal)
lymphadenopathy, usually
right sided.
Calcification of nodes
Atelectasis
Pleural effusions
Chest X-ray shows right upper lobe
and left midzone consolidation
and adenopathy.
84. lung field abnormalities - Consolidation
Tuberculosis: Post-primary pulmonary: Imaging Findings:
Almost always affect:
1. Posterior segments of the
upper lobes
2. Superior segments of the
lower lobes
Patchy consolidation
Poorly defined linear and
nodular opacities
Cavitation, Aspergillomas,
fibrosis and Bronchiectasis
pleural effusion
Hilar nodal enlargement
Lobar consolidation,
tuberculoma and miliary TB
Patchy bilateral opacification of the
upper lung lobes with cavitation most
marked on the left (arrow)
85. lung field abnormalities - Consolidation
Tuberculoma and Miliary Tuberculosis: Imaging Findings:
Tuberculoma and miliary
tuberculosis are rare
Miliary deposits are seen
both in primary and post-
primary tuberculosis. It
appear as 1-3 mm diameter
nodules, which are uniform in
size and uniformly distributed
Tuberculomas are usually
found as single nodules and
they may include a cavity or a
calcification with sharp
margins. They are usually
found in the upper lobes
Miliary Tuberculosis
86. lung field abnormalities - Consolidation
Aspergillomas:
Mass-like fungus balls of Aspergillus fumigatus, occur in patients
with normal immunity but with pre-existing cavities:
pulmonary tuberculosis
pulmonary sarcoidosis
bronchiectasis
bronchogenic cyst
pulmonary sequestration
Pneumocystis pneumonia (PCP)
associated pneumatocoeles
Imaging Findings: Air crescent sign :
Rounded or ovoid soft tissue attenuating
masses located in a surrounding cavity
and outlined by a crescent of air.
Differential diagnosis (DD); hydatid cyst,
bronchogenic carcinoma and PCP.
Rounded density with an
air crescent
88. lung field abnormalities - Consolidation
Aspiration Pneumonitis and Pneumonia: Imaging Findings:
Chest x-ray shows an
infiltrate, frequently in the
superior or posterior basal
segments of a lower lobe or
the posterior segment of an
upper lobe (The right lower
lobe is the most frequent
location).
Aspiration-related lung
abscess
Interstitial or nodular
infiltrates, pleural effusion,
and other changes may be
slowly progressive.
Typically localized pneumonia in
the right lower lobe.
89. lung field abnormalities - Consolidation
Consolidation due to Lung infarction:
Hampton’s Hump: consists of a pleural based shallow,
wedge-shaped consolidation in the lung periphery
with the base against the pleural surface
90. lung field abnormalities - Consolidation
Klebsiella pneumonia (Friedländer’s pneumonia):
Imaging Findings:
Usually involves one of
the upper lobes
Homogeneous,
nonsegmental, lobar
consolidation
Bulging Fissure Sign:
bulging of usually minor
fissure from heavy,
exudate ( arrow)
Lung abscess (es)
Pleural effusion (70%)
and/or empyema
91. Consolidation - Cardiogenic pulmonary edema
Cardiogenic pulmonary edema
Consolidation due to Congestive Heart Failure (CHF) :
92. Consolidation - Cardiogenic pulmonary edema
Stage I CHF – Redistribution:
Redistribution of the pulmonary veins. This is know as
cephalization (blue arrow) because the pulmonary veins
of the superior zone dilate due to increased pressure.
An increase in width of the vascular pedicle (red arrows)
93. Consolidation - Cardiogenic pulmonary edema
The vascular pedicle is bordered on the right by the
superior vena cava and on the left by the left subclavian
artery origin
94. Consolidation - Cardiogenic pulmonary edema
Stage II CHF - Interstitial edema Characterized by:
1. Kerley’s A lines: extend radially from the hilum to the
upper lobes; represent thickening of the interlobular
septa that contain lymphatic connections.
95. Consolidation - Cardiogenic pulmonary edema
2. Kerley’s B lines: are short horizontal lines situated
perpendicularly to the pleural surface at the lung base;
they represent edema of the interlobular septa.
96. Consolidation - Cardiogenic pulmonary edema
3. Thickening of the bronchial walls (peribronchial cuffing)
and as loss of definition of these vessels (perihilar haze).
97. Consolidation - Cardiogenic pulmonary edema
4. Fluid in the major or minor fissure (shown here)
produces thickening of the fissure beyond the pencil-
point thickness it can normally attain
98. Consolidation - Cardiogenic pulmonary edema
Stage III CHF - Alveolar edema Characterized by:
Alveolar edema with
perihilar consolidations
and air bronchograms
( Bat's wing or butterfly
pulmonary opacities )
(yellow arrows)
Pleural fluid (blue arrow)
Prominent azygos vein
and increased width of
the vascular pedicle (red
arrow)
An enlarged cardiac silhouette (arrow heads).
99. lung field abnormalities - Consolidation
Adult Respiratory Distress Syndrome ( ARDS )
ARDS versus Congestive Heart Failure:
Diffuse bilateral
patchy infiltrates
More uniform
opacification
Homogenously
distributed
No cardiomegaly
No cephalization
Usually no pleural
effusion or Kerley
B lines
100. lung field abnormalities - Consolidation
Bronchopneumonia characterised by:
Multiple small nodular or reticulonodular opacities which
tend to be patchy and/or confluent.
The distribution is often bilateral and asymmetric, and
predominantly involves the lung bases
101. lung field abnormalities - Consolidation
Wegener's granulomatosis characterized by:
Nodules or mass lesions, which may cavitate
Fleeting focal infiltrates (lung consolidation )
102. lung field abnormalities - Consolidation
It is a congenital abnormality. A
nonfunctioning part of the lung lacks
communication with the bronchial
tree and receives arterial blood
supply from the systemic circulation.
The plain X-ray often shows a
triangular or oval-shaped, basal,
posterior lung mass, or, less
commonly, as a cyst more on the left
An infected sequestration may be
associated with a parapneumonic
effusion, and may contain one or
more fluid levels.
Pulmonary sequestration: This is an uncommon cause of lobar
consolidation.
Chest radiograph showing left
lower lobe consolidation
(arrow)
103. lung field abnormalities - Consolidation
Eosinophilic pneumonia (EP):
Acute EP : A pattern consistent
with pulmonary edema, with
extensive airspace opacity,
interlobular septal thickening (ie,
Kerley B-lines), and pleural
effusions. The infiltrates are
diffuse and not peripherally
based.
Chronic EP : Nonsegmental
peripheral airspace consolidation
(“photographic negative shadow
of pulmonary oedema” - reverse
bat wing appearance) involving
mainly the upper lobes .
Chronic EP: The chest x-ray
shows bilateral peripheral
patchy infiltrates with relative
sparing of the lower lobes.
104. lung field abnormalities - Consolidation
Septic emboli:
Usually present as multiple ill-defined densities, which
are probably consolidations.
In about 50% cavitation is seen.
105. lung field abnormalities - Interstitial disease
On a CXR the most common pattern is reticular.
The ground-glass pattern is frequently not detected.
The cystic pattern is also difficult to appreciate.
High-resolution computed tomography (HRCT) has the ability
to better define diseases that have similar CXR patterns.
There are many causes. For example:
107. lung field abnormalities - Alveolar vs. Interstitial
Alveolar = air sacs
Radiolucent
Can contain blood,
mucous, tumor, or
edema (“airless lung”)
Interstitial = vessels,
lymphatics, bronchi, and
connective tissue
Radiodense
Interstitial disease:
prominent lung markings
with aerated lungs
108. lung field abnormalities - Interstitial disease
Linear Pattern:
There is thickening of the
interlobular septa (contain
pulmonary veins and
lymphatics ), producing
Kerley lines.
DD of Kerly Lines:
( Pulmonary edema is the
most common cause, Mitral
stenosis, Lymphangitic
carcinomatosis, Malignant
lymphoma, Congenital
lymphangiectasia, Idiopathic
pulmonary fibrosis, Pneumoconiosis and Sarcoidosis )
109. lung field abnormalities - Interstitial disease
Reticular Pattern:
Fine "ground-glass" (1-2
mm): e.g. interstitial
pulmonary oedema
Medium "honeycombing"
(3-10 mm): commonly seen
in pulmonary fibrosis
Coarse (> 10 mm): cystic
Spaces caused by
parenchymal destruction,
e.g. usual interstitial
pneumonia, pulmonary
sarcoidosis, pulmonary
Langerhans cell histiocytosis
111. lung field abnormalities - Interstitial disease
Nodular pattern:
A nodular pattern consists
of multiple round
opacities, generally
ranging in diameter from
1 mm to 1 cm
Nodular opacities may be:
Miliary nodules: <2 mm
Pulmonary
micronodule: 2-7 mm
Pulmonary nodule:
7-30 mm
Pulmonary mass:
>30mm
114. lung field abnormalities - Interstitial disease
A reticulonodular
pattern results from a
combination of reticular
and nodular opacities.
A differential diagnosis
should be developed
based on the
predominant pattern.
If there is no
predominant pattern,
causes of both nodular
and reticular patterns
should be considered.
Causes: the same disorders as reticular patterns
Reticulonodular pattern:
115. lung field abnormalities - Interstitial disease
Ground-glass appearance
A hazy area of increased
attenuation in the lung with
preserved bronchial and
vascular markings.
Aetiology:
Normal expiration
Partial filling of air spaces
Partial collapse of alveoli
Interstitial thickening
Inflammation
Oedema
Fibrosis
Neoplasm
Perihilar ground-glass
appearance in the shape of
bats-wings
116. lung field abnormalities - Interstitial disease
Cystic lung disease:
A lung cyst is an air filled structure with perceptible wall typically 1 mm
in thickness but can be up to 4 mm. The diameter of a lung cyst is
usually < 1 cm.
Aetiology:
Acquired :
Honeycombing in UIP
pattern
Cystic bronchiectasis
Sarcoidosis
Pneumocystis
pneumonia
Pulmonary laceration in
trauma
Primary :
Pulmonary Langerhans cell
histiocytosis
lymphangioleiomyomatosis with
or without tuberous sclerosis
lymphocytic interstitial
pneumonitis (LIP)
Tracheobronchial papillomatosis
Sjogren syndrome
Neurofibromatosis
117. lung field abnormalities - Interstitial disease
Hypersensitivity pneumonitis (HP) - (acute & Subacute):
PCX-ray may be normal
PCX-ray commonly shows
a bilateral diffuse micro nodular
infiltrate, usually dense towards
hila, have a predilection for the
midzones or lower zones. An
irregular and linear infiltrate
may be present in lower zones.
Acute severe attack : a pattern
of diffuse airspace disease or a
ground-glass pattern mimicking
that of pulmonary edema or,
more rarely, as consolidation.
Bilateral reticulonodular
interstitial infiltration
secondary to subacute
hypersensitivity pneumonitis.
118. lung field abnormalities - Interstitial disease
Hypersensitivity pneumonitis (HP) - (chronic):
Pulmonary fibrosis affects
upper zones predominantly,
loss of lung volume.
Reticular pattern and
honeycombing, more severe
in the upper lobes than in the
lower ones
Larger ring shadows 1-4 mm
in diameter are due to bullae,
blebs, cysts, or
bronchiectasis.
Parallel line shadows are
caused by bronchiectasis or
bronchial wall thickening
chronic HP—a pigeon fancier—
shows reticular-nodular
opacification.
119. lung field abnormalities - Interstitial disease
Sarcoidosis; classified by
chest x-ray into 5 stages :
stage 0: normal chest
radiograph
stage I: hilar or
mediastinal nodal
enlargement only
stage II: nodal
enlargement and
parenchymal disease
stage III: parenchymal
disease only
stage IV: end-stage lung
(pulmonary fibrosis)
120. lung field abnormalities - Interstitial disease
Radiographic varieties of Sarcoidosis :
Hilar and mediastinal lymphadenopathy: Garland triad, also known
as the 1-2-3 sign is bilateral hilar and right paratracheal
lymphadenopathy.
Dystrophic calcification of involved lymph nodes: Calcification can
be amorphous, punctate, popcorn like, or eggshell.
Parenchymal changes: including fine nodular; reticulonodular;
acinar (poorly marginated, small to large nodules or coalescent
opacities); and, rarely, focal (solitary nodule or mass).
Mycetomas: in stage IV sarcoidosis and apical bullous disease
In stage IV : when fibrosis supervenes, hilar retraction, decreased
lung volume, and honeycomb lung may be present. Bullous disease,
air trapping and diaphragmatic tenting may also be seen.
Pulmonary hypertension may develop: Prominent main pulmonary
artery, enlarged right and left pulmonary arteries, right ventricular
enlargement, and attenuation of peripheral vessels.
121. lung field abnormalities - Interstitial disease
Can be even normal in patients
with very early disease
In advanced disease:
Decreased lung volumes
Basal fine to coarse
reticulation due to more
extensive involvement of the
lower lobes
Honeycomb Lung and traction
bronchiectasis
The major fissure is shifted
inferiorly which is best seen on
the lateral chest radiograph.
Usual interstitial pneumonia (UIP):
Plain film features are nonspecific.
122. lung field abnormalities - Interstitial disease
Usual interstitial pneumonia (UIP):
Honeycombing:
The radiographic appearance of honeycombing comprises reticular
densities caused by the thick walls of the cysts.
Chest radiograph
demonstrates
coarse bibasilar
reticular
interstitial
disease
( honeycomping )
(red arrows)
123. lung field abnormalities - Interstitial disease
Bronchiectasis:
CXR may be normal
Volume loss
Increased pulmonary markings
Indistinct vessel margins due
to peribronchial fibrosis.
Tram lines: dilated and thickened
airways
Ring shadows: thickened and
abnormally dilated bronchial walls.
Clusters of cysts in Cystic type
Dextrocardia (Immotile cilia
syndrome)
Mucus plugging (finger-in-glove)
appearance
Atelectasis or diffuse lung fibrosis
Tram-Track sign
124. lung field abnormalities - Interstitial disease
Bronchiectasis:
Cystic bronchiectasis with
multiple cystic airspaces
Ring shadow ( red arrow) & Tram
lines ( yellow arrow)
125. lung field abnormalities - Interstitial disease
Bronchiectasis: Location:
Allergic bronchopulmonary
aspergillosis – central
Childhood viral infections –
Lower lobe predominance
Mounier-Kuhn syndrome –
First to fourth order bronchi
Mycobacterial avium complex
- Right middle lobe and lingual
Primary ciliary dyskinesia –
Fifty percent associated with
situs inversus, middle lobe,
and lingular predominance
Cystic fibrosis - Upper lobe,
particularly right upper lobe
Postprimary mycobacterial
tuberculosis (traction
bronchiectasis) – Apical
and posterior segments of
upper lobes
Sarcoidosis (traction
bronchiectasis) – Upper
lobe predominance
Usual interstitial
pneumonitis (commonest
cause of traction
bronchiectasis) - Lower
lobe predominance, worse
peripherally
126. lung field abnormalities - Interstitial disease
Pneumocystis pneumonia (PCP) - CXR findings:
Bilateral, diffuse, often perihilar,
fine, reticular interstitial
opacification, which may appear
somewhat granular.
Air-space consolidation
Cystic lung disease, spontaneous
pneumothorax, and isolated lobar
or focal consolidation, particularly
with an upper-lobe predominance.
Miliary nodularity, bronchiectasis,
endobronchial lesions, and
mediastinal lymphadenopathy
,which may show calcification
CXR may be normal
Typical bilateral air-space
consolidation of PCP in
acquired immunodeficiency
virus infection.
127. lung field abnormalities - Interstitial disease
Lymphangitic carcinomatosis:
The term given to tumour spread
through the lymphatics of the lung,
and is most commonly seen
secondary to adenocarcinoma e.g.
breast cancer, bronchogenic
adenocarcinoma, colon cancer,
stomach cancer, prostate cancer,
cervical cancer, thyroid cancer, etc.
CXR may be normal or Appears as
reticular or reticulonodular
opacification, often with associated
septal lines (Kerley A and B lines),
peribronchial cuffing, pleural
effusions, and mediastinal and/or
hilar lymphadenopathy
Lymphangitic carcinomatosis.
The radiograph
like in the case of interstitial
pulmonary oedema
128. lung field abnormalities - Interstitial disease
Silicosis:
1. Acute silicosis (silicoproteinosis):
Large bilateral perihiliar consolidation
or ground glass opacities.
2. Chronic simple silicosis
(common type ): CXR shows multiple
nodular opacities:
Well-defined and uniform in shape
and attenuation
From 1 to 10 mm in diameter
Predominantly located in the upper
lobe and posterior portion of the lung
Nodules may Calcify
Lymph node enlargement common:
Eggshell calcification of hilar nodes
(5%), DD: Sarcoidosis
Silicosis features a diffuse
micronodular lung disease
with an upper lobe
predominance
129. lung field abnormalities - Interstitial disease
Silicosis:
3. Complicated silicosis
(progressive massive fibrosis
(PMF), or conglomerate
silicosis): CXR shows large
symmetric bilateral opacities
that are:
1 cm or more in diameter and
with an irregular margin
Usually in mid-zone or
periphery of upper lobes
Compensatory emphysema
occurs in lower lung fields.
Progressive Massive Fibrosis
(PMF) with scarring and
retraction of hila upwards.
Progressive Massive Fibrosis. There are
conglomerate soft-tissue densities in
both upper lobes (black arrows) with
linear scarring leading from the lower
lobes (white arrows).
130. lung field abnormalities - Interstitial disease
Silicosis:
4.Complicated silicosis : Complicated
by tuberculous (Silicotuberculosis),
non-tuberculous mycobacterial, and
fungal infection, certain autoimmune
diseases, and lung cancer.
Eggshell node calcification in silicosis
Silicotuberculosis, with bilateral
conglomerate disease. Several
cavities are present in the left
upper lobe
131. lung field abnormalities - Atelectasis
CXR show direct and indirect signs of lobar collapse:
Direct signs include displacement of fissures and
opacification of the collapsed lobe.
Indirect signs include the following:
Displacement of the hilum
Mediastinal shift toward the side of collapse
Loss of volume in the ipsilateral hemithorax
Elevation of the ipsilateral diaphragm
Crowding of the ribs
Compensatory hyperlucency of the remaining lobes
Silhouetting of the diaphragm or heart border
132. lung field abnormalities - Atelectasis
Complete atelectasis: Characterized by:
Opacification of the entire hemithorax
An ipsilateral shift of the mediastinum.
133. lung field abnormalities - Atelectasis
Right upper lobe collapse:
Increased density in the upper medial
aspect of the right hemithorax
Elevation of the horizontal fissure
Loss of the normal right medial
cardiomediastinal contour
Elevation of the right hilum
Hyperinflation of the right middle and
lower lobe result in increased
translucency of the mid and lower
parts of the right lung
Right diaphragmatic tenting
Non-specific signs :
Elevation of the hemidiaphragm
Crowding of the right sided ribs
Shift of the mediastinum and trachea to the right
134. lung field abnormalities - Atelectasis
Right upper lobe collapse: The Golden S-sign (or reverse
S-sign of Golden): is seen on
PA view and the appearance
is that of right upper lobar
collapse with a central mass
expanding the hilum.
On the lateral projection it is
harder to identify. Elevation of
the horizontal fissure and
upper part of the oblique
fissure may be visible.
135. lung field abnormalities - Atelectasis
Right middle lobe collapse:
On lateral projection, right
middle lobe collapse is
usually relatively easy to
identify,
Appearing as a triangular
opacity in the anterior
aspect of the chest overlying
the cardiac shadow.
The horizontal fissure is
displaced inferiorly and the
inferior part of the oblique
fissure, displaced
anterosuperiorly.
136. lung field abnormalities - Atelectasis
Right middle lobe collapse:
On frontal CXR, the findings are more
subtle:
The normal horizontal fissure is no
longer visible (as it rotates down)
Blurring of the right heart border
(silhouette sign) (in atelectasis as
well as consolidation)
Non-specific signs may be subtle or
absent due to the small size of the
right middle lobe :
Elevation of the hemidiaphragm
Crowding of the right sided ribs
Shift of the mediastinum to the right
linear opacities in the lobe suggest that the collapse is chronic
(right middle lobe syndrome), with associated bronchiectasis.
137. lung field abnormalities - Atelectasis
Right lower lobe collapse:
On frontal CXR, the findings :
Increased opacity (triangular in
shape) at the medial base of the
right lung
Obliteration of the silhouette of
the right hemidiaphragm
The right hilum is depressed
Descending right lower lobe
pulmonary artery is not visualized
Right heart border maintained.
Non-specific signs :
Elevation of the hemidiaphragm
Crowding of the right sided ribs
Shift of the mediastinum to right
The collapsed right lower lobe
is a triangular opacity (orange
arrows).The right
hemidiaphragmatic outline is
lost (blue dashed line).
138. lung field abnormalities - Atelectasis
Right lower lobe collapse:
On lateral projection:
The right
hemidiaphragmatic
outline is lost posteriorly
The lower thoracic
vertebrae appear denser
than normal (they are
usually more radiolucent
than the upper
vertebrae) The collapsed right lower lobe a
triangular opacity (orange arrows).
The right hemidiaphragmatic
outline is lost (blue dashed line).
139. lung field abnormalities - Atelectasis
Left upper lobe collapse:
Hazy or 'Veil-like' opacification of
the left hemithorax
Right heart border not visible
The left hemidiaphragm is still
visible
Near-horizontal course of the left
main bronchus
The luftsichel sign (next)
Elevation of the hemidiaphragm
Non-specific signs :
'peaked' or 'tented‘
hemidiaphragm: juxtaphrenic
peak sign
Crowding of the left sided ribs
Shift of the mediastinum to left
Left upper lobe collapse: Notice
the ovoid density at the left hilum,
CT confirmed a large left hilar
mass, which occluded the left
upper lobe bronchus
140. lung field abnormalities - Atelectasis
Left upper lobe collapse:
The luftsichel sign:
In some cases the
hyperexpanded superior
segment of the left lower
lobe insinuates itself
between the left upper
lobe and the superior
mediastinum, sharply
silhouetting the aortic
arch and resulting in a
lucency medially ( red
arrow ).
141. lung field abnormalities - Atelectasis
Left upper lobe collapse:
On lateral projections:
left lower lobe is
hyperexpanded and
the oblique fissure
displaced anteriorly
(arrows).
Increase in the
retrosternal opacity.
142. lung field abnormalities - Atelectasis
Left lower lobe collapse:
1. Triangular opacity in the
posteromedial aspect of left lung
2. Edge of collapsed lung may
create a 'double cardiac contour'
3. left hilum will be depressed
4. loss of the normal left
hemidaphgragmatic outline
5. loss of the outline of the
descending aorta
6. Non-specific signs indicating
left sided atelectasis :
Elevation of the hemidiaphragm
Crowding of the left sided ribs
Shift of the mediastinum to left
143. lung field abnormalities - Atelectasis
Left lower lobe collapse:
7. The flat waist sign refers to flattening of
the contours of the aortic arch and
adjacent main pulmonary artery. It is
seen in severe left lower lobe collapse
and is caused by leftward displacement
and rotation of the heart.
8. On lateral projection:
The left hemidiaphragmatic outline is
lost posteriorly
The lower thoracic vertebrae appear
denser than normal (they are usually
more radiolucent than the upper
vertebrae)
144. lung field abnormalities - Nodules and Masses
A solitary pulmonary nodule:
Defined as a discrete, well-marginated, rounded opacity less than or
equal to 3 cm in diameter that is completely surrounded by lung
parenchyma, does not touch the hilum or mediastinum, and is not
associated with adenopathy, atelectasis, or pleural effusion.
146. lung field abnormalities - Nodules and Masses
Other causes :
Hyperdense pulmonary mass:
(a pulmonary mass with internal
calcification)
Cavitating pulmonary mass:
(gas-filled areas of the lung in
the center of the mass. They are
typically thick walled and their
walls must be greater than 2-5
mm. They may be filled with air
as well as fluid and may also
demonstrate air-fluid levels).
A Pulmonary mass:
It is an area of pulmonary opacification that measures more than
3 cm. The commonest cause for a pulmonary mass is lung cancer.
147. lung field abnormalities - Nodules and Masses
Hyperdense pulmonary mass:
They include:
Granuloma: most common
Pulmonary hamartoma
Bronchogenic carcinoma
Bronchogenic cyst
Carcinoid tumours
Pulmonary metastases
Dystrophic calcification:
Papillary thyroid carcinoma
Giant cell tumour of bone
Synovial sarcoma
Bone forming / cartilage
mineralisation:
Osteosarcoma
Chondrosarcoma
A solitary well marginated
homogeneous radiodensity is seen in
the right upper zone with focal central
area of increased density within.
148. lung field abnormalities - Cavities
Pulmonary cavities :
Are gas-filled areas of
the lung in the center
of a nodule, mass or
area of consolidation.
They are typically thick
walled and their walls
must be greater than
2-5 mm.
They may be filled with
air as well as fluid and
may also demonstrate
air-fluid levels.
150. lung field abnormalities - Cavities
Multicystic mass with air in cysts
CXR in type I ( large (2-10 cm)
cysts ) and II (small (< 2 cm)
cysts) CCAM may demonstrate a
multicystic (air-filled) lesion.
Type III ( microcysts ) CCAM
appear solid.
Large lesions may cause mass
effect with resultant, mediastinal
shift, and depression and even
inversion of the diaphragm.
The cysts may be completely or
partially fluid filled, in which case
the lesion may appear solid or
with air fluid levels.
Congenital cystic adenomatoid malformation (CCAM):
Multiloculated cystic lesion in
right hemithorax with marked
mediastinal shift to the left.
151. lung field abnormalities - Cavities
It can be pulmonary 10-15% or
Mediastinal 65-90%
Usually in the medial 1/3 of lungs
With a lower lobe predilection
Mediastinal cysts are visualized as
a mediastinal mass (image 1)
Intrapulmonary cysts usually present
as a solitary pulmonary nodule unless
the cyst contains air.
Cysts are usually fluid filled,
occasionally a communication may
develop following infection or
intervention, resulting in an air-filled
cystic +/- an air-fluid level (image 2)
Bronchogenic cyst: During development a portion of the tracheo
bronchial tree gets separated. CXR :
153. lung field abnormalities - Decreased density
Pulmonary emphysema:
1. Hyperinflation
Flattened hemidiaphragm (s):
most reliable sign
Increased and usually irregular
radiolucency of the lungs
Increased retrosternal airspace
Increased antero-posterior
diameter
Obtuse costophrenic angle on
posteroanterior or lateral film.
Widely spaced ribs
A narrow mediastinum
Sternal bowing
Low diaphragm
154. lung field abnormalities - Decreased density
Pulmonary emphysema:
2. vascular changes
Paucity of blood vessels,
often distorted
Pulmonary arterial
hypertension:
Prominence of the
pulmonary hilum and
enlargement of the main
pulmonary arteries.
Right ventricular
enlargement: encroachment
into the retrosternal space
on a lateral chest film
Pruning of peripheral
vessels
155. lung field abnormalities - Decreased density
Pulmonary emphysema:
Flat diaphragm are present when the maximum perpendicular
height (red line) from the superior border of the diaphragm to a
line drawn between the costophrenic and cardiophrenic angles in PA
view or between the costophrenic and sternophrenic angles in
lateral view is less than 1.5 cm.
156. lung field abnormalities - Decreased density
An iatrogenic pulmonary
condition of the premature infant
with immature lungs. PIE occurs
almost in association with
mechanical ventilation.
CXR features :
Subtle & often hidden by other
pathology
linear, oval, and spherical cystic
air-containing spaces throughout
the lung parenchyma.
Perivascular halos from air
collections
Intra-septal air
Subpleural cysts
Pulmonary Interstitial emphysema (PIE ):
CXR of the infant at 2 days of
age, showing bilateral severe
PIE and atelectasis of the right
middle and lower lung lobes.
157. Pleural disease - Pneumothorax
Pneumothorax:
Rotation of CXR can obscure a
pneumothorax . Rotation can
also mimic a mediastinal shift.
Expiratory images are thought
to better depicting minimal
(subtle) pneumothoraces.
In erect patients: Pleural gas
collects over the apex .
158. Pleural disease - Pneumothorax
In the supine position:
The juxtacardiac area, the
lateral chest wall, and the
subpulmonic region are the best
areas to search for evidence of
pneumothorax.
The deep sulcus sign: (very wide
and deep costophrenic angle)
An ipsilateral increased lucency
in the upper quadrant of the
abdomen.
Double Diaphragm Sign: both
the diaphragmatic dome and
anterior portions of the
diaphragm are visualized
159. Pleural disease - Pneumothorax
Double Diaphragm Sign
of Pneumothorax. Air in
the right hemithorax
displaces both the
dome (white arrow)
and the anterior
costophrenic angle
(yellow arrow) in this
patient with a large,
right-sided
pneumothorax. There is
also a deep sulcus sign
present (red arrow).
160. Pleural disease - Pneumothorax
A large pneumothorax as
being of greater than 2 cm
width at the level of the
hilum
The volume of a
pneumothorax approximates
to the ratio of the cube of
the lung diameter to the
hemithorax diameter
lateral decubitus studies:
Should be done with the
suspected side up
The lung will then 'fall'
away from the chest wall
Rib films are indicated
This chest X-ray shows a large
pneumothorax (P) which is >2 cm
depth at the level of the hilum.
161. Pleural disease - Pneumothorax
A bulla or thin wall cyst can be
mistaken for loculated
pneumothorax. The pleural
line caused by pneumothorax is
usually bowed at its center
towards lateral chest wall but
the inner margins of bulla or
cyst is generally concave rather
than convex.
Pneumothorax with pleural
adhesion may simulate bulla or
lung cyst. Differential diagnosis
by comparison with previous
chest radiography, lateral
decubitous or CT scanning
A chest radiograph shows
Right bullous formation
162. Pleural disease - Pneumothorax
A skin fold can be mistaken for a pneumothorax. Unlike
pneumothorax, skin folds usually continue beyond the chest
wall, and lung markings can be seen beyond the apparent
pleural line.
163. Pleural disease - Pneumothorax
Deep sulcus sign (red arrow) in a supine patient in the ICU.
The pneumothorax is subpulmonic.
164. Pleural disease - Pneumothorax
Hydropneumothorax:
With the patient upright,
there will be an air-fluid
level in the thoracic cavity
On supine radiographs, a
hydropneumothorax will
be more difficult to see
although a uniform
grayness to the entire
hemithorax with the
absence of vascular
markings suggest the
diagnosis
165. Pleural disease - Pleural thickening
Best seen at the lung edges where the pleura runs tangentially to
the x-ray beam. Causes:
Unilateral pleural thickening
• Peripheral shadowing on the right
• Loss of right lung volume
• Shadowing over the whole right
lung due to circumferential pleural
thickening
Benign pleural thickening
Recurrent inflammation
Recurrent pneumothoraces
Following a pleural empyema
Complication of haemothorax
Asbestosis & silicosis
Malignant pleural thickening
Primary pleural malignancy
• Mesothelioma
• Primary pleural lymphoma
Pleural metastases
Secondary pleural lymphoma
166. Pleural disease - Apical pleural cap
In normal asymptomatic individuals, the apical cap is an irregular
density generally less than 5 mm high located over the apex of the
lung.
Apical pleural cap (yellow arrows)
Causes:
Pleural thickening/scarring
Idiopathic: common
feature of advancing age
Secondary to tuberculosis
Radiation fibrosis
Pancoast tumour
Haematoma
Lymphoma
Abscess
Metastases
167. Pleural disease - Pleural plaques
Asbestos related pleural plaques:
Ill-defined opacities over both
mid and lower zones. Over the
diaphragmatic domes, linear
regions of calcification are
noted.
Most pleural plaques are
multiple, bilateral, and often
symmetrical and are located in
the mid-portion of the chest wall
between the seventh and tenth
ribs.
Plaques may be calcified (they are
irregular, well-defined, and
classically said to look like holly
leaves), however, most (85-95%)
are not
Visceral pleura, lung apices, and
costophrenic angles are typically
spared.
168. Pleural disease - Pleural effusion
Pleural effusion is an abnormal
collection of fluid in the pleural space.
Fluid may be (Transudate, Exudate,
Pus, Blood, Chyle, Cholesterol, Urine )
Erect frontal Chest X-ray:
1. Blunting of costophrenic angle
2. Blunting of cardiophrenic angle
3. The diaphragmatic contour is
partially or completely obliterated,
depending on the amount of the
fluid (silhouette sign).
4. Fluid within the horizontal or
oblique fissures
5. Concave meniscus seen laterally and
gently sloping medially (horizontal
in case of hydropneumothorax)
169. Pleural disease - Pleural effusion
Erect frontal Chest X-ray:
6. Massive pleural effusion:
Opacification of entire hemithorax and
shifting of mediastinum to the opposite
side (note: The mediastinal shift can be
less prominent or even absent in the
presence of underlying lung collapse or
contralateral hemithorax abnormality)
Causes “white-out” lung
Around 5-7 liters of pleural fluid
Generally, the pleural effusion is said to be
massive if it crosses the anterior border of
the 2nd rib. It is said to be moderate if it
crosses the anterior border of the 4nd rib
and is said to be mild or small if it is below
that.
Massive right pleural
effusion (1),
with shift of mediastinum
towards left (2)
170. Pleural disease - Pleural effusion
Erect frontal Chest X-ray:
7. Lamellar effusions: Shallow collections between lung
surface and visceral pleural sometimes sparing the
costophrenic angle. It represent interstial pulmonary fluid
Bilateral lamellar pleural effusions
171. Pleural disease - Pleural effusion
Subpulmonic effusion. Note the
increased distance between the air-
filled fundus of the stomach and
the left "hemidiaphragm" (arrow).
Erect frontal Chest X-ray:
8. Subpulmonic effusion:
Unilateral subpulmonary
effusion is more common
on right side.
Right: appear as a raised
diaphragm with
flattening and lateral
displacement of the
dome.
Left: The distance
between the lung and
the stomach bubble will
exceed 2 cm
172. Pleural disease - Pleural effusion
Erect frontal Chest X-ray:
9. Encysted (encapsulated) pleural effusion:
Loculation secondary to adhesions after an infected or
hemorrhagic effusion.
Peripheral soft-tissue opacity with smooth obtuse tapering
margins
173. Pleural disease - Pleural effusion
Erect frontal Chest X-ray:
10. Encysted (encapsulated) pleural effusion in the fissure:
Loculated effusion in the fissures
appears as a well-defined
elliptical opacity with pointed
margins.
Pseudotumor/vanishing tumor
(phantom tumor): Loculated
effusion in the fissures ,
secondary to congestive heart
failure, hypoalbuminemia, renal
insufficiency or pleuritis.
Radiologically simulating a
neoplasm. It disappears rapidly in
response to the treatment of the
underlying disorder
174. Pleural disease - Pleural effusion
Lateral Chest X-ray:
Small effusions appear as
a dependent opacity with
posterior upward sloping
of a meniscus-shaped
contour.
The opacity obliterates
the underlying portion of
the diaphragmatic
contour (silhouette sign).
Can detect an effusion as
small as 50–75 mL Note the concave meniscus
blunting posterior costophrenic
angle.
175. Pleural disease - Pleural effusion
Supine Chest X-ray:
Due to the effect of gravity, the
pleural fluid is distributed
throughout the posterior part of
the pleural during supine
position – this cause the
hemithorax to appear whiter or
paler grey compared to the
normal side.
Vessels are often visible through
the shadowing.
It is therefore especially difficult
to identify similar sized bilateral
effusions as the density of the
lungs will be similar.
Requires about 200 ml fluid
Right-sided effusion. a veil-like
increased density of the lower right
hemithorax (blue arrow). Note that the
pulmonary vascular structures are not
obscured or silhouetted by the vague
density but, rather, are still visible
through it (open arrow).
176. Pleural disease - Pleural effusion
lateral decubitus Chest X-ray:
A small amount of fluid (10-25 mL) can be depicted on this
projection.
The layering fluid can easily be detected as a dependent, sharply
defined, linear opacity separating the lung from the parietal
pleural and chest wall, and
the parietal pleura–chest wall margin can be identified as a line
connecting the inner apices of the curvature of the ribs.
Note in the film
on right shows the
findings of sub
pulmonic effusion
(red arrow). In the
lateral decubitus
film fluid layers
along the ribs
(yellow arrow).
177. Pleural disease - Pleural effusion
Complete white-out of a hemithorax:
Trachea pulled toward the opacified
side:
Pneumonectomy
Total lung collapse
Pulmonary agenesis
Pulmonary hypoplasia
Trachea remains central in position:
Consolidation
Pulmonary oedema/ARDS
Pleural mass: e.g. mesothelioma
Chest wall mass: e.g. Ewing sarcoma
Pushed away from the opacified side:
Pleural effusion
Diaphragmatic hernia
Large pulmonary mass
178. Pleural disease - Pleural effusion
How do you determine the etiology of effusion from chest x-ray?
Bilateral: consider transudative effusions first. You will need
clinical information.
Bilateral effusions with cardiomegaly: Congestive heart failure
Bilateral pleural effusions associated with ascites in a alcoholic:
Cirrhosis
Unilateral: most of them are exudative
Massive unilateral effusion: Malignancy
Pleural effusion with apical infiltrates: Tuberculosis
Pleural effusion with nodes or mass or lytic bone lesions:
Malignancy
Loculated effusions are empyemas
Pleural effusion with a missing breast suggesting resection for
cancer: Malignancy
Pleural effusion following chest trauma: Hemothorax
In patients with mediastinal lymphoma: Chylothorax
179. Chest X-ray Abnormalities- Costophrenic angle
Costophrenic (CP) angle blunting:
On a frontal CXR the costophrenic angles should form acute angles
which are sharp to a point.
Often the term costophrenic "blunting" is used to refer to the
presence of a pleural effusion. This, however, is not always correct
and costophrenic angle blunting can be related to other pleural
disease, underlying lung disease or Lung hyper-expansion.
1- left CP
angle blunting
in effusion
2- bilateral CP
angles
blunting in
emphysema
180. Elevated hemidiaphragm: If the left hemidiaphragm is higher
than the right or the right is higher than the left by more than 3 cm
Can result from:
Above the diaphragm
Decreased lung volume
Atelectasis/collapse
Lobectomy/pneumonectomy
Pulmonary hypoplasia
Diaphragm
Phrenic nerve palsy
Diaphragmatic eventration
Contralateral stroke: usually middle cerebral artery distribution
Below the diaphragm
Abdominal tumour, e.g. liver metastases or primary malignancy
Subphrenic abscess
Distended stomach or colon
Chest X-ray Abnormalities - Diaphragm
181. Diaphragmatic hernia: defect in the diaphragm can result
from:
Congenital:
Bochdalek hernia: most common, More frequent on left
side, located posteriorly and usually present in infancy
Morgagni hernia: smaller, anterior and presents later,
through the sternocostal angles
Acquired:
Traumatic diaphragmatic rupture
Hiatus hernia
Iatrogenic
Chest X-ray Abnormalities - Diaphragm
182. Morgagni hernia
are: Anteromedial
parasternal defect,
small, Usually
unilateral, more
often right-sided
(90%)
Chest X-ray Abnormalities - Diaphragm
Bochdalek Hernia : Frontal
view of the chest shows a
large air-containing and
walled structure in the region
of the left lower lobe (white
arrow). It is originating from
below the diaphragm. The air-
containing structure is seen
posteriorly on the lateral view
(red arrow).
183. Hiatus hernias occur when there is herniation abdominal contents
through the oesophageal hiatus of the diaphragm into the thoracic
cavity. Appears as retrocardiac opacity with air-fluid level
Chest X-ray Abnormalities - Diaphragm
PA and lateral view of hiatal hernia. Can you see the air-
filled "mass" posterior to the heart
184. Free gas under diaphragm (Pneumoperitoneum): It is a
finding in the chest X-ray seen in case of perforation of
hollow viscus.
Chest X-ray Abnormalities - Diaphragm
CXR shows Minor
opacity in the left
lower zone. Large
volume of free
subdiaphragmatic
gas ( yellow arrow).
185. Chest X-ray Abnormalities - Diaphragm
Chilaiditi syndrome: is a rare condition in which a portion of the
colon is abnormally located (interposed) in between the liver and the
diaphragm. It is one of the causes of pseudopneumoperitoneum.
Features that suggest a Chilaiditi syndrome (i.e. Chilaiditi sign):
Gas between liver and diaphragm
Rugal folds within the gas suggesting that it is within the bowel.
186. Cardiophrenic angle lesions:
The more common:
Pericardial fat pad
Pericardial cyst
Morgagni's hernia
Lymphadenopathy
Pericardial fat necrosis
Pericardial lipomatosis
Other less common:
Thymoma
Hydatid cyst
Right middle lobe collapse
Chest X-ray Abnormalities - Diaphragm
Pericardial
cyst: X-ray
shows a well
circumscribed
mass in
contact with
right cardiac
margin.
187. Cardiomegaly and heart failure:
The heart is enlarged if the cardiothoracic ratio (CTR) is greater than
50% on a PA view. If the heart is enlarged, check for other signs of
heart failure such as pulmonary oedema, septal lines (or Kerley B
lines), and pleural effusions.
Chest X-ray Abnormalities - Heart
CXR shows:
• Cardiomegaly CTR = 18/30 (>50%)
• Upper zone vessel enlargement (1)
- a sign of pulmonary venous
hypertension
• Pulmonary oedema (2) - bilateral
increased lung markings (classically
peri-hilar and shaped like bats wings
- more widespread in this case)
• Septal (Kerley B) lines (3)
• Pleural effusions (4)
188. left atrial enlargement:
The double density sign: Right side of
the dilated left atrium is visible next to
the right heart border (right atrium). It
may extend out beyond the right heart
border, an appearance known as atrial
escape.
Oblique measurement of greater than
7cm (blue arrow).
Convex left atrial appendage; produces
“straightening” of the left heart border
- normally it is flat or concave.
Splaying of the carina to greater than a
90 degree angle (yellow lines).
Posterior displacement of the left
main stem bronchus on lateral
radiographs.
Chest X-ray Abnormalities - Heart
189. left ventricular enlargement: CXR shows:
Left heart border is displaced leftward, inferiorly, or posteriorly
Rounding of the cardiac apex
The aorta is prominent
Lateral view: Retrocardiac space become narrowed or disappeared,
esophageal space disappeaered
Chest X-ray Abnormalities - Heart
190. Chest X-ray Abnormalities - Heart
If we draw a
tangent line
from the apex
of the left
ventricle to
the aortic knob
(red line) and
measure along
a perpendicular
to that tangent
line (green line)
The distance
between the
tangent and the
main pulmonary
artery (between
two small green
arrows) falls in a
range between
0 mm (touching
the tangent line)
to as much as
15 mm away from
the tangent line
left heart border:
191. Chest X-ray Abnormalities - Heart
left heart border abnormalities:
The main pulmonary artery may
project beyond the tangent line
(greater than 0 mm). This can occur if
there is increased pressure or
increased flow in the pulmonary
circuit.
The main pulmonary artery may
project more than 15 mm away from
the tangent line. This can occur in
left ventricle enlargement and/or
aortic knob enlargement e.g.
atherosclerosis, aortic incompetence,
and mitral incompetence.
192. Right atrial enlargement: Features are non-specific but include :
Right heart enlargement (the right atrium and ventricle cannot be
separately identified on a radiograph) causes filling-in of the
retrosternal clear space and prominence of the right heart border
A prominently convex lower right heart border
Enlarged, globular heart
Narrow vascular pedicle
Chest X-ray Abnormalities - Heart
193. Right ventricular enlargement: :
Frontal view demonstrates:
Rounded left heart border
Uplifted cardiac apex
Chest X-ray Abnormalities - Heart
CXR showing right
ventricular
hypertrophy (arrows,
note filling of the
retrosternal space by
an enlarged right
ventricle in the lateral
view) and enlarged
central pulmonary
arteries (arrowhead).
Lateral view demonstrates:
Filling of the retrosternal
space
Rotation of the heart
posteriorly
194. Ventricular aneurysm:
A ventricular aneurysm is usually the sequel to a myocardial
infarct, thus cases of calcified ventricular aneurysm are
rare.
Typically the left cardiac border changes shape and bulges.
Chest X-ray Abnormalities - Heart
195. Ventricular
Pseudoaneurysm:
It is caused by a
contained
rupture of the LV
free wall.
A chest
radiograph may
show
cardiomegaly
with an abnormal
bulge on the
cardiac border.
Chest X-ray Abnormalities - Heart
196. Pericardial effusion:
It occurs when excess fluid collects in
the pericardial space (a normal
pericardial sac contains approximately
30-50 mL of fluid).
CXR Suggestive but not usually
diagnostic.
Globular enlargement of the cardiac
shadow giving a water bottle
configuration
Widening of the subcarinal angle
without other evidence of left atrial
enlargement may be an indirect clue
Chest X-ray Abnormalities - Heart
197. Pericardial effusion:
lateral CXR may show:
Loss of retrosternal clear space
A vertical opaque line
Produced by pericardial fluid
(yellow arrows) separating a
vertical lucent line directly
behind sternum Produced by
epicardial fat (white arrows)
anteriorly from a similar lucent
vertical lucent line Produced by
pericardial fat (red arrows)
posteriorly; this is known as
the Oreo cookie sign
Chest X-ray Abnormalities - Heart
Real
Oreo
cookies
198. Pulmonary Arterial Hypertension: Features include:
Elevated cardiac apex due to right ventricular hypertrophy
Enlarged right atrium
Prominent pulmonary outflow tract
Enlarged pulmonary arteries
Pruning of peripheral pulmonary vessels
Chest X-ray Abnormalities - Heart
199. Transposition of the Great Vessels:
The classic appearance described as an egg on a string sign
Most common cyanotic congenital heart lesion
The aorta arises from the morphologic right ventricle and the
pulmonary artery arises from the morphologic left ventricle
Narrowing of the superior mediastinum on radiographs
Patent ASD, VSD, Foramen ovale, systemic collaterals to sustain life
The right atrial border is convex, and the left atrium is enlarged
CXR Abnormalities - Congenital heart disease
200. Total Anomalous Pulmonary Venous Return:
Occurs when the pulmonary veins fail to drain into the left atrium
and instead form an aberrant connection with some other
cardiovascular structure
2% of cardiac malformations
SNOWMAN SIGN: resembles a snowman
CXR Abnormalities - Congenital heart disease
201. Partial Anomalous Pulmonary Venous Return:
Scimitar syndrome
Anomalous pulmonary vein drains any or all of the lobes of the
right lung, and empties into the inferior vena cava, portal vein,
hepatic vein, or right atrium
Vein appears like a scimitar, a sword with a curved blade that
traditionally was used by Persian and Turkish warriors.
Hypoplasia of right lung, hypoplasia of right pulmonary artery, and
anomalous arterial supply of the right lower lobe from abdominal
aorta.
CXR Abnormalities - Congenital heart disease
202. Tetralogy of Fallot:
10%–11% of cases of congenital heart disease
Components: Ventricular septal defect, Infundibular pulmonary
stenosis, Overriding aorta, Right ventricular hypertrophy
Blood flow to the lungs is usually reduced
The heart has the shape of a wooden shoe or boot (in French,
coeur en sabot)
CXR Abnormalities - Congenital heart disease
203. Aortic Coarctation:
5%–10% of congenital cardiac lesions
Eccentric narrowing of the lumen of aorta at the level where the
ductus or ligamentum arteriosus inserts anteromedially
Classic radiologic signs:
Figure-of-three sign
Reverse figure-of-three sign
Rib notching on CXR pathognomonic
CXR Abnormalities - Congenital heart disease
204. Mediastinal abnormalities - Mediastinal widening
Superior mediastinum:
Should have a width less than 8 cm
on a PA CXR.
A widened mediastinum can be
associated with:
AP CXR view
Unfolded aortic arch
(not pathological) or a thoracic
aortic aneurysm
Mediastinal masses
Oesophageal dilatation
Ruptured aorta
Mediastinal lipomatosis:
increased deposition of normal
unencapsulated fat
Unfolded aorta: widened and
'opened up' appearance of
the aortic arch. It is seen with
increasing age
205. Mediastinal abnormalities - Aortic Dissection
Aortic Dissection: CXR
findings include:
1. Mediastinal widening; it is
noted in 60% of patients
2. Irregularity of the aortic
contour
3. Double aortic contour
4. Double-calcium sign:
Inward displacement of
atherosclerotic calcification
by more than 10 mm
5. Pleural effusion (more
common on the left side;
suggests leakage)
CXR shows; double density
aortic arch (black/white
arrows), Mediastinal widening,
and Cardiac enlargement
206. Mediastinal abnormalities - Aortic Dissection
Aortic Dissection:
CXR findings include:
6. Tracheal
displacement to
the right
7. Pericardial effusion
8. Cardiac
enlargement
9. Displacement of a
nasogastric tube
10. Left apical pleural
capping (opacity)
11. Normal CXR in 12%
of patients
CXR shows: rightward deviation of the trachea (red
arrow); left apical pleural capping (blue arrow); aortic
“double-calcium” sign (between white arrows);
depression of the left bronchus (purple arrow); pleural
effusion (green arrow); widened mediastinum and
loss of the aorto-pulmonary window (not labeled).
207. Mediastinal abnormalities - Pneumomediastinum
Radiographic features of Pneumomediastinum
Small amounts of air
appear as linear or
curvilinear lucencies
outlining mediastinal
contours and form:
1. Subcutaneous
emphysema
2. Air anterior to
pericardium:
(Pneumoprecardium)
Pneumo-
precardium
subcutaneous
emphysema
208. Mediastinal abnormalities - Pneumomediastinum
Radiographic features of Pneumomediastinum
3. air around
pulmonary
artery and
main
branches:
ring around
artery sign
4. air outlining
major aortic
branches:
tubular
artery sign
Tubular Artery Sign (Red
arrows)
Ring around artery
sign
209. Mediastinal abnormalities - Pneumomediastinum
Radiographic features of Pneumomediastinum
5. Continuous diaphragm sign: due to air
trapped posterior to pericardium
6. Spinnaker Sail Sign (angel wing sign) is
seen on neonatal postero-anterior
CXR when thymic lobes are displaced
laterally by air, (Very typical sign in
neonatal age).
Spinnaker Sail
Sign (angel wing
sign)
Continuous diaphragm
sign
210. Mediastinal abnormalities - Pneumomediastinum
Radiographic features of Pneumomediastinum
Naclerio V sign:
It is seen as a V-shaped air collection.
One limb of the V is produced by
mediastinal air outlining the left
lower lateral mediastinal border.
The other limb is produced by air
between the parietal pleura and
medial left hemidiaphragm.
Lateral Chest X-Ray
Retrosternal air
Lateral Decubitus Chest X-Ray
Air will not move with change in position
Neck Films
Air outlining fascial planes of the neck
Naclerio V sign
211. Mediastinal abnormalities - Masses
Clues to locate mass to mediastinum
Masses in the lung
Mediastinal masses
May contain air
bronchograms
A lung mass abutts
the mediastinal
surface and creates
with lung an acute
angles.
Not contain air bronchograms
The margins with the lung will be obtuse.
Mediastinal lines (azygoesophageal recess,
anterior and posterior junction lines) will be
disrupted.
There can be associated spinal, costal or
sternal abnormalities.
LEFT: A lung mass abutts the
mediastinal surface and creates
acute angles with the lung.
RIGHT: A mediastinal mass will
sit in the mediastinum, creating
obtuse angles with the lung.
212. Mediastinal abnormalities - Masses
Clues to locate mass to mediastinum
LEFT: there is a lesion that has an acute border
with the mediastinum. This must be a lung mass.
RIGHT: shows a lesion with an obtuse angle to the
mediastinum. This must be a mediastinal mass.
Localize mass within the mediastinum
In lateral CXR, mediastinum is divided into superior and Inferior.
Inferior mediastinum is divided into anterior, middle, and posterior
214. Mediastinal abnormalities - Masses
Cervicothoracic sign:
As the anterior
mediastinum ends at the
level of the clavicles, the
upper border of an anterior
mediastinal lesion cannot
be visualised extending
above the clavicles.
Any lesions with a
discernible upper border
above that level must be
located posteriorly in the
chest, i.e. apical segments
of upper lobes, pleura, or
posterior mediastinum
Anterior
( A )
vs
posterior
( B )
lesion
215. Mediastinal abnormalities - Masses
Thoracoabdominal sign:
Posterior costophrenic
sulcus extends more
caudally than anterior
basilar lung
Lesion extending
below the dome of
diaphragm must be in
posterior chest
whereas lesion
terminating at dome
must be anterior.
Margin of mass is apparent and
below diaphragm, therefore this
must be in the middle or posterior
compartments where it is surrounded
by lung This example is a ‘Lipoma’
216. Mediastinal abnormalities - Masses
Hilum overlay sign:
When a mass arises from
the hilum, the
pulmonary vessels are in
contact with the mass
and as such their
silhouette is obliterated.
If hilar vessels are
sharply delineated it can
be assumed that the
overlying mass is
anterior or posterior
“Hilum overlay” sign. Note that
the vessels of the left hilum
(yellow arrow) can be “seen
through” the mass (red arrows)
projected over the left hilum.
217. Mediastinal abnormalities - Masses
Hilum convergence sign:
If branches of pulmonary artery converge toward central
mass, is an enlarged pulmonary artery (image A).
If branches of pulmonary artery converge toward heart
rather than mass, is a mediastinal tumor (image B).
218. Mediastinal abnormalities - Paratracheal stripe
Right paratracheal stripe:
Made up of right tracheal wall,
Paratracheal lymph nodes,
adjacent pleural surfaces,
mediastinal fat, right
brachiocephalic vein and SVC
It normally measures less than
4 mm and thickening is
non-specific but may represent:
lipoma
Paratracheal
lymphadenopathy
Thyroid malignancy,
parathyroid neoplasms
Tracheal carcinoma or stenosis
Pleural effusion or thickening
Widening of the right
paratracheal stripe (arrow)
Abnormal right paratracheal
stripe caused by a large ectopic
parathyroid adenoma
219. Mediastinal abnormalities - Paratracheal stripe
Left paratracheal stripe:
Made up of pleural surface of
the left upper lobe, tracheal
border and mediastinal fat.
It is seen less frequently.
It may not be visible if the left
upper lobe contacts the left
subclavian artery or left common
carotid artery.
Abnormal widening may be due:
Pleural effusion
Mediastinal
lymphadenopathy or
malignancy
Mediastinal haematoma
Widening of the left paratracheal
stripe (arrows), with mass effect
on the trachea. A 47-year-old
patient with metastatic thyroid
carcinoma
220. CXR Abnormalities - Soft tissue abnormalities
Breast tissue:
left-sided mastectomy:
Increased density
over the right lung
Decreased density
of the left lung
Breast asymmetry
Gynaecomastia:
Mobile AP
Cardiac monitoring
leads
Dense breast tissue
Male patient
Breast cancer:
PA Chest Xray:
Increased soft tissue
density with mass
effect projected on
left breast and axilla
221. CXR Abnormalities - Soft tissue abnormalities
Subcutaneous emphysema:
There is often striated lucencies in the soft tissues that may outline
muscle fibres. If affecting the anterior chest wall, subcutaneous
emphysema can outline the pectoralis major muscle, giving rise to the
ginkgo leaf sign.
Large left pneumothorax (white arrow) with mediastinal shift indicating
tension. Left upper lobe cavitating lesion, the lesion which was recently
biopsied. Extensive left chest wall (yellow arrow), ginkgo leaf sign (red
arrow), and neck surgical emphysema.
222. CXR Abnormalities - Bones
Bones:
The bones are used as
useful markers of CXR
quality (rotation,
adequacy of inspiration
and CXR penetration).
Plain radiograph may miss
up to 50% of rib fractures
Multiple fractures of the 4th right rib
(yellow arrows), other visible fractures
of 3rd, 5th, 6th and 7th right ribs (red
arrows)
Old rib
fractures:
increased
density (whiter
areas) due to
callus
formation (red
arrows)
223. CXR Abnormalities - Bones
Bones:
Malignant bone disease may
manifest as either single or
multiple lesions.
Bones may become denser
(whiter) due to a sclerotic
process (often seen in prostate
cancer), or less dense (blacker)
due to a lytic process (as is
often the case in renal cell
cancer).
Primary bone tumours, both
benign and malignant, are
relatively uncommon
Expansile lytic metastasis of right
7th rib from carcinoma thyroid
(red arrow).
224. CXR Abnormalities - Bones
Bones:
Cervical ribs: are usually bilateral
but asymmetrical. Cervical rib is
usually asymptomatic, but it can
cause thoracic outlet syndrome.
Sclerotic metastases from
carcinoma prostate.
Cervical rib (bilateral) with Cervical
7th transverse process directing
inferiorly
225. Chest X-ray - Tubes
On a radiograph acquired with
the neck in the neutral position,
a distance of 5-7 cm above the
carina is generally considered
acceptable for adults.
In most individuals the carina is
located between the levels of
the 5th and 7th thoracic
vertebral bodies. This is an
inaccurate method for locating
the carina If the carina is not
clearly visible.
Intubation of a bronchus may
lead to lung or lobar collapse
Endotracheal (ET) tube position:
226. Chest X-ray - Tubes
Tracheostomy tubes
are positioned so that
their tips are located
at a midpoint
between the upper
end of the tube and
the carina.
It should occupy
one-half to two-thirds
of the tracheal lumen
to minimize airway
resistance.
Tracheostomy Tube:
227. Chest X-ray - Tubes
Chest X-rays are used to
determine NG tube
position if aspiration of
gastric fluid is
unsuccessful.
The tip of the tube must
be visible below the
diaphragm and on the
left side of the abdomen
- 10 cm or more beyond
the gastro-oesophageal
junction.
Nasogastric (NG) tube:
228. Chest X-ray - Tubes
Catheter positioning:
The tip of a CVC is within the SVC at or just above the level of
the carina (approximately 1-1.5 cm above the level of the carina)
for most short-term uses.
Central venous catheter (CVC):
Right
subclavian
vein
catheter
Right
internal
jugular
vein
catheter
229. Chest X-ray - Tubes
Catheter positioning:
CVCs placed for the purpose of long term chemotherapy may be
placed more inferiorly at the cavo-atrial junction - the junction of
the SVC and right atrium (RA).
Catheters used for haemodialysis may be placed at the cavo-atrial
junction or even in the RA itself.
Central venous catheter (CVC):
Long term catheter - PICC line:
This peripherally inserted central
catheter (PICC) is correctly located
with its tip at the level of the cavo-
atrial junction - approximately the
height of two vertebral bodies
below the level of the carina
230. Chest X-ray - Tubes
Catheter positioning:
Left-sided catheters approach the SVC at a shallow angle such that
they may abut the right lateral wall of the SVC. They may need to
be inserted further so the distal end obtains a vertical orientation.
This may mean locating the tip below the level of the carina.
Central venous catheter (CVC):
231. Chest X-ray - Tubes
For treatment of a pneumothorax the tube tip is aimed towards the
upper pleural cavity and for treatment of a pleural effusion towards
the lower part of the pleural cavity
Chest Drains:
Chest
drain -
treatment
for
pleural
effusion
Chest drain
- treatment for
pneumothorax