CXR is a commonly performed imaging test that uses ionizing radiation to visualize the inside of the body. It is useful for diagnosing and treating conditions. A standard CXR involves exposing the chest to a small dose of radiation for less than half a second to produce images. It requires no special preparation and carries minimal risk when used appropriately. The CXR must be evaluated systematically by examining bones, the heart, lungs, mediastinum, diaphragm and soft tissues to identify any abnormalities.

4. C X RC X R

5. IntroductionIntroduction
 XR is a noninvasive test that helps Dx & RxXR is a noninvasive test that helps Dx & Rx
 CXR is the most commonly done XRCXR is the most commonly done XR
 XR involves exposing to a small dose of IR to make pix.XR involves exposing to a small dose of IR to make pix.
of the inside of bodyof the inside of body
 It is the oldest imagingIt is the oldest imaging
XR: x-ray, IR: ionizing radiation, RT: resp. tract, BV: blood vessels, SoB: short ofXR: x-ray, IR: ionizing radiation, RT: resp. tract, BV: blood vessels, SoB: short of
breathing, F: fever, Ca: cancer, HD: heart d.breathing, F: fever, Ca: cancer, HD: heart d.

6. How is a CXR done?How is a CXR done?
In standing, sitting, or lying. PA, AP, side/angleIn standing, sitting, or lying. PA, AP, side/angle
Time of exposure is oftenTime of exposure is often <0.5 second!<0.5 second!
Medical XRs are only 15% of annual IR exposure!Medical XRs are only 15% of annual IR exposure!
Even with multiple & repeated XR;Even with multiple & repeated XR; total dose is still small!total dose is still small!
The more solid a structure is, the whiter it appears.The more solid a structure is, the whiter it appears.
Bones appear very white:Bones appear very white: (opaque)(opaque)
Muscle, blood, skin, fat: darkerMuscle, blood, skin, fat: darker (lucent)(lucent)
Expected benefits of XR must always outweigh riskExpected benefits of XR must always outweigh risk

7. Patient PreparationPatient Preparation
CXR requires no special preparationCXR requires no special preparation
May need to remove some/all clothesMay need to remove some/all clothes
Remove jewelry, dentures, eye glasses & metal objectsRemove jewelry, dentures, eye glasses & metal objects
that might interfere with XRthat might interfere with XR
Women must inform ifWomen must inform if pregnantpregnant; many imaging are; many imaging are
not donenot done
If XR is necessary, precautions will be takenIf XR is necessary, precautions will be taken
toto minimize exposure to the babyminimize exposure to the baby

8. 1.1. PA or AP viewPA or AP view
2.2. Inspiration or expirationInspiration or expiration
3.3. XRXR penetrationpenetration: Under- or Over-: Under- or Over-
4.4. Lateral (L/R)Lateral (L/R)
5.5. Oblique (R/L; posterior/anterior):Oblique (R/L; posterior/anterior): helpful to localizehelpful to localize
lesionslesions
6.6. Lateral decubitus (L/R): effusion or thickeningLateral decubitus (L/R): effusion or thickening
7.7. Lordotic: apical lesionLordotic: apical lesion
PositionPosition

9. PA vs AP viewsPA vs AP views
PA: XR tube is 40in from the pt.PA: XR tube is 40in from the pt.
AP: the XR tube is 40in from the pt.AP: the XR tube is 40in from the pt.

10. PA vs APPA vs AP
Usually an upright PA is done. AP is less useful & doneUsually an upright PA is done. AP is less useful & done
only if pt. can’t standonly if pt. can’t stand
 Scapula is seen in peripheryScapula is seen in periphery
 Clavicles project over lungsClavicles project over lungs
 Posterior ribs are distinctPosterior ribs are distinct
 Scapulae are over lung fieldsScapulae are over lung fields
 Clavicles are above lung apexClavicles are above lung apex
 Anterior ribs are distinctAnterior ribs are distinct
 Broadened H & widening of M

11. Expiration:Expiration: can show a very abnormal chest. Loss of R heartcan show a very abnormal chest. Loss of R heart
border would lead to Dx of pn. On repeat exam. withborder would lead to Dx of pn. On repeat exam. with fullfull
inspiration,inspiration, the R heart border is normalthe R heart border is normal
Expiration vs InspirationExpiration vs Inspiration

12. InspirationInspiration
Full inspiration greatly helps to determineFull inspiration greatly helps to determine
lung abnormalities. Diaphragm should belung abnormalities. Diaphragm should be
found about the 8found about the 8thth
-10-10thth
posterior rib or 5posterior rib or 5thth
-6-6thth
anterior ribanterior rib

13. Correct exposure:Correct exposure: you should barely see IV discs through the heartyou should barely see IV discs through the heart
•If you see them very clearly, film is overpenetratedIf you see them very clearly, film is overpenetrated
•If you do not see them it is underpenetratedIf you do not see them it is underpenetrated
PenetrationPenetration

14. Good CXR: centered trachea, spine should be justGood CXR: centered trachea, spine should be just
transparent through H, full inspiration, anterior end of R 6transparent through H, full inspiration, anterior end of R 6thth
rib should pointrib should point
mid-way along the R hemidiaphragmmid-way along the R hemidiaphragm

15. RotationRotation

16. RotationRotation

17. Benefits vs. Risks of X-RaysBenefits vs. Risks of X-Rays
BenefitsBenefits
Non-invasive. Very fast & easy. PaNon-invasive. Very fast & easy. Particularly useful in ERrticularly useful in ER
No radiation remains in the body post XRNo radiation remains in the body post XR
Usually no SE in the diagnostic rangeUsually no SE in the diagnostic range
Equipment is cheap & widely availableEquipment is cheap & widely available
RisksRisks
Slight risk of CaSlight risk of Ca
Benefit of an accurate Dx far outweighs the riskBenefit of an accurate Dx far outweighs the risk
The effective radiation dose variesThe effective radiation dose varies
ER: emergency room. SE: side effectER: emergency room. SE: side effect

18. Radiation DoseRadiation Dose
CXR: very small (0.25 mRad)CXR: very small (0.25 mRad)
We all receive ~100 mRad/y from cosmic rays …We all receive ~100 mRad/y from cosmic rays …
But improperly used equipment can markedly increaseBut improperly used equipment can markedly increase
the radiation dosethe radiation dose
Minimizing IR DoseMinimizing IR Dose
Radiology protection councils update standardsRadiology protection councils update standards
Modern systems have tight control with significantModern systems have tight control with significant
filtration & dose controlfiltration & dose control
Parts of body not being imaged receive minimal doseParts of body not being imaged receive minimal dose

19. Accepted indications for CXRAccepted indications for CXR
Ac. resp./cardiac d.Ac. resp./cardiac d.
Major chest trauma, hemoptysisMajor chest trauma, hemoptysis
Chr. SoB, interstitial lung d.Chr. SoB, interstitial lung d.
P. embolism, Pn., pl. effusion, PTX, Positive MTP. embolism, Pn., pl. effusion, PTX, Positive MT
Febrile neutropenia, immunosuppressedFebrile neutropenia, immunosuppressed
Persistent symptoms 6w post CAPPersistent symptoms 6w post CAP
Post tube & line insertion (not PPM or tracheostomy)Post tube & line insertion (not PPM or tracheostomy)
Suspected mass, LAP or metastasisSuspected mass, LAP or metastasis
Suspected elevated diaphragm.Suspected elevated diaphragm. Resp. distress in NBResp. distress in NB
PTX: pneumothorax, MT: Mantaux test, CAP: comm. acquired pn., SS:PTX: pneumothorax, MT: Mantaux test, CAP: comm. acquired pn., SS:
symptoms & signs, LAP: lymphadenopathy, PPM: permanent pacemaker. NB:symptoms & signs, LAP: lymphadenopathy, PPM: permanent pacemaker. NB:
newbornnewborn

20. NOTNOT considered indications for CXRconsidered indications for CXR
Asymptomatic pre-admn., asymptomatic pre-operativeAsymptomatic pre-admn., asymptomatic pre-operative
Daily routine in ICU without clinical changeDaily routine in ICU without clinical change
Routine pre-employment, minor chest trauma, URTIRoutine pre-employment, minor chest trauma, URTI
Uncomplicated ac. exacerbation of BA/COPDUncomplicated ac. exacerbation of BA/COPD
Classical bronchiolitisClassical bronchiolitis
Ac./chr. chest painAc./chr. chest pain
Pre-discharge Pn., nor a follow up CXR if SS are betterPre-discharge Pn., nor a follow up CXR if SS are better
except if at high risk of lung Ca (>50y), has chr. lungexcept if at high risk of lung Ca (>50y), has chr. lung
d. or is a smokerd. or is a smoker
Thoracic aneurysm follow up (CT is of choice)Thoracic aneurysm follow up (CT is of choice)
Screening for lung cancer in asymptomaticScreening for lung cancer in asymptomatic

21. Limitations of Chest RadiographyLimitations of Chest Radiography
 As some d. of chest cannot be detected on a ordinaryAs some d. of chest cannot be detected on a ordinary
CXR, it cannot necessarily rule out all chest d.CXR, it cannot necessarily rule out all chest d.
 Small cancers may not show upSmall cancers may not show up
 P. embolism, cannot be seenP. embolism, cannot be seen
 More imaging may be needed to clarify results of a CXRMore imaging may be needed to clarify results of a CXR
or to look for abnormalities not visible on CXRor to look for abnormalities not visible on CXR

22. NORMALNORMALCXRCXR

24. Check ListCheck List
 Pt. data, position, technical quality & anatomyPt. data, position, technical quality & anatomy
 Review systematicallyReview systematically
o Bones:Bones: spine & ribs: alignment, disc space, lytic orspine & ribs: alignment, disc space, lytic or
blastic regions; soft tissues (breast, skin & SCT)blastic regions; soft tissues (breast, skin & SCT)
Clavicle placed at 2-3 interspaceClavicle placed at 2-3 interspace (if not, rotated)(if not, rotated)
o Mediastinum:Mediastinum:

margins:margins: SVC, ascending aorta, RA, L. subclavian a.,SVC, ascending aorta, RA, L. subclavian a.,
aortic arch, pulmonary trunk, LVaortic arch, pulmonary trunk, LV

lines & stripes:lines & stripes: paratracheal, paraspinal,paratracheal, paraspinal,
paraesophageal, paraaorticparaesophageal, paraaortic

retrosternal clear spaceretrosternal clear space

27. Check List …Check List …
 Lungs & pleura:Lungs & pleura:

hila: normal relationships, size, etc.hila: normal relationships, size, etc.

compare lung sizes, parenchymacompare lung sizes, parenchyma

BV pattern: compare upper to lower lobe, normalBV pattern: compare upper to lower lobe, normal
tapering to peripherytapering to periphery

pleura: fissures: major & minor - if seenpleura: fissures: major & minor - if seen

compare hemidiaphragmscompare hemidiaphragms

follow pleura around rib cagefollow pleura around rib cage
DiaphragmDiaphragm
 Contour. Sharp costophrenic & cardiophrenic anglesContour. Sharp costophrenic & cardiophrenic angles
 Right diaphragm is usually 1-2 cm higherRight diaphragm is usually 1-2 cm higher
Easy diagnosis:Easy diagnosis: Pn., Edema, TumorPn., Edema, Tumor

28. HeartHeart
 PositionPosition

More central in young childrenMore central in young children

More on the L side in older childrenMore on the L side in older children
 SizeSize

CARDIO-THORACIC RATIOCARDIO-THORACIC RATIO

Cardiac diameter:Cardiac diameter:
 normal <15.5 cm in males; <14.5 cm in femalesnormal <15.5 cm in males; <14.5 cm in females
 A change of >1.5 cm between 2 X-rays is significantA change of >1.5 cm between 2 X-rays is significant
Soft tissuesSoft tissues

Shadows: most commonly breast, nippleShadows: most commonly breast, nipple

abdo. for bowel gas, organ size, calcification, free airabdo. for bowel gas, organ size, calcification, free air

soft tissues & spine of necksoft tissues & spine of neck
Check List …Check List …

29. Cardio-thoracic ratioCardio-thoracic ratio
 PA viewPA view onlyonly
 >50% is abnormal in an adult:>50% is abnormal in an adult:
 cardiac failurecardiac failure
 pericardial effusionpericardial effusion
 L/R ventriculomegalyL/R ventriculomegaly
 >66% in a neonate>66% in a neonate

31. An area of more density within lung, must be result of:An area of more density within lung, must be result of:
1.1. Consolidation:Consolidation: filling of alveoli with fluid, pus, blood, cells (also tumor cells)filling of alveoli with fluid, pus, blood, cells (also tumor cells)
2.2. InterstitialInterstitial: fine or coarse reticular opacities or small nodules: fine or coarse reticular opacities or small nodules
3.3. Nodule or mass:Nodule or mass: any space occupying lesion either solitary or multipleany space occupying lesion either solitary or multiple
4.4. Atelectasis:Atelectasis: loss of air in the alveoli (volume loss & increased density)loss of air in the alveoli (volume loss & increased density)

33. LungsLungs
Start at the top.Start at the top.
Compare R & L.Compare R & L.
Trachea is centralTrachea is central
Lung parenchymaLung parenchyma
becomes lighter asbecomes lighter as
you go down lung.you go down lung.
If not, it may indicateIf not, it may indicate
pleural effusionpleural effusion

34. LobesLobes

35. Lobes …Lobes …

37. MEDIASTINUM …MEDIASTINUM …
 SUPERIORSUPERIOR MEDIASTINUMMEDIASTINUM

Begins -Begins - rootroot of the neck &of the neck &

Ends - line drawnEnds - line drawn T-4 vertebraeT-4 vertebrae ------ sternomanubrialsternomanubrial junctionjunction..
 this line skims the top of the aortic arch. Tthis line skims the top of the aortic arch. T
 (INFERIOR) MEDIASTINUM(INFERIOR) MEDIASTINUM

Below this line to diaphragm. Further divided intoBelow this line to diaphragm. Further divided into
 Anterior (Anterior (everything anterior to H)everything anterior to H)
 Middle (Middle (H & pericardium)H & pericardium)
 Posterior (Posterior (posterior to H to the spine)posterior to H to the spine)

38. The M can be divided into anterior,The M can be divided into anterior,
middle & posterior compartments.middle & posterior compartments.
But there isBut there is no tissue plane separatingno tissue plane separating
them.them.
On the lateral XR by 2 imaginaryOn the lateral XR by 2 imaginary lines:lines:
1.1.anterior to the trachea & posteriorly to the inferior VC.anterior to the trachea & posteriorly to the inferior VC.
2.2.passing 1 cm posteriorly to the anterior border of vertebraepassing 1 cm posteriorly to the anterior border of vertebrae
This helps to make a more narrow DDThis helps to make a more narrow DD

39. Pitfalls to CXR InterpretationPitfalls to CXR Interpretation
 Poor inspiration:Poor inspiration: high diaphragms & crowding of normalhigh diaphragms & crowding of normal
lung markingslung markings
 Over/under penetrationOver/under penetration of rays: obliterate/exaggerateof rays: obliterate/exaggerate
imp. findings. Properly-penetrated PA CXR: one canimp. findings. Properly-penetrated PA CXR: one can
just make out thoracic vertebrae overlying thejust make out thoracic vertebrae overlying the
image of the heartimage of the heart
 RotationRotation distorts normal structuresdistorts normal structures
 Forgetting the path of the x-ray beamForgetting the path of the x-ray beam

40. CONSOLIDATIONCONSOLIDATION
 Lobar/segmental DensityLobar/segmental Density
 Air BronchogramAir Bronchogram
 No Loss of Lung VolumeNo Loss of Lung Volume
 No shift of mediastinumNo shift of mediastinum
Here, loss of L heart silhouette,Here, loss of L heart silhouette,
diaphragmatic silhouette intact,diaphragmatic silhouette intact,
blunting of costophrenic angleblunting of costophrenic angle

41. Pneumococcal pn. Is thePneumococcal pn. Is the
commonest c/of lobarcommonest c/of lobar
consolidation.consolidation.
Architecture is intact.Architecture is intact.
Airway is patent.Airway is patent.
1. a density1. a density
corresponding to acorresponding to a
segment or lobesegment or lobe
2. air bronchogram2. air bronchogram
3. no loss of lung vol.3. no loss of lung vol.

42. (LOBAR) CONSOLIDATION …(LOBAR) CONSOLIDATION …
 RUL densityRUL density
 Loss of ascending aortaLoss of ascending aorta
silhouettesilhouette
 No shift of mediastinumNo shift of mediastinum
 Transverse fissure notTransverse fissure not
significantly shiftedsignificantly shifted
 Air bronchogramAir bronchogram
 No loss of lung volumeNo loss of lung volume

43. Extensive RUL consolidation, withExtensive RUL consolidation, with
bulging of minor fissurebulging of minor fissure

44. Staph. Pn.: RML consolidation withStaph. Pn.: RML consolidation with
cavitation & air bronchogram. There iscavitation & air bronchogram. There is
a small R p. effusion. The remaining thea small R p. effusion. The remaining the
lung fields are ok.lung fields are ok.

45. PLEURAL EFFUSIONPLEURAL EFFUSION
 Radiological criteriaRadiological criteria::
 homogenoushomogenous opacityopacity
 in dependent portionin dependent portion
 costophrenic &costophrenic &
cardiophrenic angles lostcardiophrenic angles lost
 loss of diaphragm silhouetteloss of diaphragm silhouette
A. shows fluid layering in the R pleural cavity. BA. shows fluid layering in the R pleural cavity. B
shows the normal width of the lungshows the normal width of the lung

46. Rt’Rt’ LateralLateral viewview
R. lateralR. lateral decubitusdecubitus viewview

47. Pleural Effusion …Pleural Effusion …
• CHFCHF
• MetsMets
• PancreatitisPancreatitis
• P. embolismP. embolism
• TraumaTrauma
• EmpyemaEmpyema
• Collagen vascular d.Collagen vascular d.
• Ovarian tumorOvarian tumor
(Meig’s Syn.)(Meig’s Syn.)
• ChylothoraxChylothorax
CCFCCF

48. Congestive Heart FailureCongestive Heart Failure
 Cardiothoracic ratioCardiothoracic ratio >0.5>0.5  Large hila withLarge hila with
indistinct markingsindistinct markings
 P. effusions, alveolarP. effusions, alveolar
edema (Bat’sedema (Bat’s wings)wings)
 Kerley B linesKerley B lines
(Interstitial edema)(Interstitial edema)
 Dilated prominent ULDilated prominent UL
vesselsvessels

49. ATELECTASIS/COLLLAPSEATELECTASIS/COLLLAPSE
Alveoli devoid of air:Alveoli devoid of air:
AA equallyequally increased densityincreased density
Signs of loss of lung volumeSigns of loss of lung volume

50. SIGNS OF ATELECTASISSIGNS OF ATELECTASIS (loss of volume)(loss of volume)
 Shift of M, elevation of diaphragmShift of M, elevation of diaphragm
 Drooping of shoulder, crowding of ribsDrooping of shoulder, crowding of ribs
 Movement of Fissures on lateral viewMovement of Fissures on lateral view
 Movement of Hilum:Movement of Hilum: R hilum is normally slightly lower
 Compensatory hyperinflation: more lucency & splayingCompensatory hyperinflation: more lucency & splaying
of BV seen in normal areasof BV seen in normal areas
 Alterations in proportion of Lt. & Rt.Alterations in proportion of Lt. & Rt. (55%)(55%) LungLung
 Hemithorax asymmetryHemithorax asymmetry
M: mediastinum. D: diaphragmM: mediastinum. D: diaphragm

51. Right upper lobe collapseRight upper lobe collapse
Movement of the Fissures, a
DIRECT sign of volume loss
Elevation of
diaphragm
Tracheal shift
Hilum displaced

52. Types of Atelectasis:Types of Atelectasis:
Resorptive:Resorptive: airways are obstructed; air gets absorbedairways are obstructed; air gets absorbed
Relaxation (passive):Relaxation (passive): lung is held to chest wall by -velung is held to chest wall by -ve
pressure; if it is lost (PTX & p. effusion) lung recoils.pressure; if it is lost (PTX & p. effusion) lung recoils.
Common misconception:Common misconception: a. is due to compressiona. is due to compression
Adhesive atelectasisAdhesive atelectasis:: surfactant loss: collapse (ARDS,surfactant loss: collapse (ARDS,
p. embolism)p. embolism)
Cicatricial (fibrotic) a.:Cicatricial (fibrotic) a.:
 Alveoli gets trapped in scar (in fibrotic d.)Alveoli gets trapped in scar (in fibrotic d.)
Round a.:Round a.:
 Lung gets trapped by pleural d. & is devoid of air.Lung gets trapped by pleural d. & is devoid of air.
Classically seen in asbestosisClassically seen in asbestosis
PTX: pneumothorax. BF: blood flow. D.: disease/disorder/defectPTX: pneumothorax. BF: blood flow. D.: disease/disorder/defect

53. RUL atelectasisRUL atelectasis
1.1. triangular densitytriangular density
2.2. elevated right hiluselevated right hilus
3.3. tenting R diaphragm (blue arrow)tenting R diaphragm (blue arrow)
4.4. obliteration of the retrosternal clear spaceobliteration of the retrosternal clear space (arrow)(arrow)

54. RML atelectasisRML atelectasis
1.1. Blurring of H border. 2. Triangular density on lateral view.Blurring of H border. 2. Triangular density on lateral view. Usually itUsually it
does not cause noticeable rise of D. Adoes not cause noticeable rise of D. A pectus excavatumpectus excavatum can mimick acan mimick a
RML a. on a frontal view, but the lateral view should solve this problemRML a. on a frontal view, but the lateral view should solve this problem

55. RLL atelectasisRLL atelectasis
Fall from stairs with severe pain on R flank. Look some loculatedFall from stairs with severe pain on R flank. Look some loculated
fluid posterolateral (hematothorax). Afluid posterolateral (hematothorax). Abnormal R border of H. Rightbnormal R border of H. Right
interlobar artery is not visible, as is surrounded by collapsed RLL,interlobar artery is not visible, as is surrounded by collapsed RLL,
which is adjacent to RAwhich is adjacent to RA
On aOn a FU filmFU film the a. has resolved (mucus plug). Note the R interlobarthe a. has resolved (mucus plug). Note the R interlobar
arteryartery (red arrow)(red arrow) & the normal R heart border& the normal R heart border (blue arrow)(blue arrow)

56. LUL atelectasisLUL atelectasis
• Minimal vol. loss with rise of D.Minimal vol. loss with rise of D. Large density with loss of H. borderLarge density with loss of H. border
• Band of increased density in the retrosternal spaceBand of increased density in the retrosternal space
• Abnormal L hilum, i.e. possible obstructing massAbnormal L hilum, i.e. possible obstructing mass
Apical region is dark (c/by overinflation), which causes the superiorApical region is dark (c/by overinflation), which causes the superior
segment to creep all the way up to the apical region; called thesegment to creep all the way up to the apical region; called the luftluft

57. Left LL atelectasisLeft LL atelectasis
Triangular density over H; must be located posterior to H. This is confirmed on LV.Triangular density over H; must be located posterior to H. This is confirmed on LV.
The contour of left D is lost when you go from anterior to posterior. We cannot seeThe contour of left D is lost when you go from anterior to posterior. We cannot see
the LL vessels, as they are surrounded by the atelectatic lobe. Normally when youthe LL vessels, as they are surrounded by the atelectatic lobe. Normally when you
follow the thoracic spine from top to bottom, the lower region becomes lessfollow the thoracic spine from top to bottom, the lower region becomes less
opaque. Here we have the opposite (blue arrow). Left hilum is pulled downopaque. Here we have the opposite (blue arrow). Left hilum is pulled down

58. Total atelectasisTotal atelectasis
RL: due to mucus plugging. Shifting of M. Re-aeration on FURL: due to mucus plugging. Shifting of M. Re-aeration on FU
CXR after suction. A common c/of total a. of a lung is aCXR after suction. A common c/of total a. of a lung is a
ventilation tube positioned too deep & thus obstructing oneventilation tube positioned too deep & thus obstructing one
of the main bronchiof the main bronchi

59. TOTAL ATELECTASIS …TOTAL ATELECTASIS …
 Homogenous density RHomogenous density R
hemithoraxhemithorax
 M shift to RM shift to R
 R hemithorax smallerR hemithorax smaller
 R heart & D silhouetteR heart & D silhouette
are not identifiableare not identifiable
R: right, D: diaphragm, M: mediastinumR: right, D: diaphragm, M: mediastinum

60. This pt. had widespread Br.Pn. & was on ventilation.This pt. had widespread Br.Pn. & was on ventilation.
During FU a white out on the left was seen. This was c/by aDuring FU a white out on the left was seen. This was c/by a
large mucus plug. After suction L lung was re-aeratedlarge mucus plug. After suction L lung was re-aerated
BrPn: bronchopneumonia. c/by: caused by. FU: follow upBrPn: bronchopneumonia. c/by: caused by. FU: follow up
TOTAL ATELECTASIS …TOTAL ATELECTASIS …

61. Cicacitration atelectasisCicacitration atelectasis
Can be the result of fibrosis of lung; seen after radiotherapy & in chr.Can be the result of fibrosis of lung; seen after radiotherapy & in chr.
inf, esp. TB. This pt. got radiotherapyinf, esp. TB. This pt. got radiotherapy

62. FIBROSISFIBROSIS
 Diffuse hazinessDiffuse haziness
 Apical cap thickeningApical cap thickening
 Blunting of costophrenic angleBlunting of costophrenic angle
 No shift of fluid in lateral decubitusNo shift of fluid in lateral decubitus
 Loss of lung volumeLoss of lung volume
 Lines not corresponding to fissuresLines not corresponding to fissures

64. MAS. Radiograph obtained shortly after birth shows ill-defined, predominantlyMAS. Radiograph obtained shortly after birth shows ill-defined, predominantly
perihilar opacities in the lungs; these are more severe on the right. The lungs areperihilar opacities in the lungs; these are more severe on the right. The lungs are
hyperexpanded. Heart size is normal.hyperexpanded. Heart size is normal.

65. PLEURAL FIBROSISPLEURAL FIBROSIS
 Smaller R hemithoraxSmaller R hemithorax
 Diffuse hazinessDiffuse haziness
 Tracheal shift to RTracheal shift to R
 Blunted costophrenicBlunted costophrenic
angleangle
 Lines not corresponding toLines not corresponding to
fissuresfissures

66. TUBERCULOSISTUBERCULOSIS
 LUL cavitiesLUL cavities
 RUL infiltrateRUL infiltrate
 Bilateral UL diseaseBilateral UL disease

69. MILIARY TBMILIARY TB
Interstitial nodulesInterstitial nodules
 Uniform sizeUniform size
 Sharper edgesSharper edges

71. PNEUMOTHORAXPNEUMOTHORAX
 Air (black) in R. pleural spaceAir (black) in R. pleural space
 No lung markingsNo lung markings
 No vascular markings ..No vascular markings ..
 Atelectatic (lung margin) ..Atelectatic (lung margin) ..
 Larger R hemithoraxLarger R hemithorax
 Opposite lung:Opposite lung: vascular marksvascular marks
prominentprominent
 No shift of MNo shift of M
 Deep sulcus signDeep sulcus sign
 More haziness on left: diversionMore haziness on left: diversion
of entire cardiac outputof entire cardiac output
 Small fluid level near CP angle:Small fluid level near CP angle:
hydro PTXhydro PTX

72. LeftLeft
PTXPTX.. Lucency atLucency at
left CP angleleft CP angle
(red arrow)(red arrow)
which projectswhich projects
well below thewell below the
CP angle on RCP angle on R
(white arrow)(white arrow)
is theis the "Deep"Deep
sulcus sign"sulcus sign"
indicating PTXindicating PTX
on a supineon a supine
CXRCXR

73. TENSION PNEUMOTHORAXTENSION PNEUMOTHORAX
 Atelectatic R lungAtelectatic R lung
No vascular markingsNo vascular markings
 Shift of MShift of M
 Deep sulcus signDeep sulcus sign
 Increased haziness onIncreased haziness on
L: diversion ofL: diversion of
entire cardiac OPentire cardiac OP

74. Tension PTX with M shift. Failure to place a R chest tube immediately couldTension PTX with M shift. Failure to place a R chest tube immediately could
diminishdiminish venous return & lead to deathvenous return & lead to death

76. HYDROPNEUMOTHORAXHYDROPNEUMOTHORAX
 Air in pleural cavityAir in pleural cavity
 Lung margin visibleLung margin visible
 Bilateral fluid level:Bilateral fluid level:
Any time; a horizontalAny time; a horizontal
fluid level means air &fluid level means air &
fluid in the spacefluid in the space

77. LUNG ABSCESSLUNG ABSCESS

78. PULMOARY EDEMAPULMOARY EDEMA
Ac. Diffuse AlveolarAc. Diffuse Alveolar
EdemaEdema
 BilateralBilateral
 DiffuseDiffuse
 Butterfly patternButterfly pattern
 Soft fluffy lesionsSoft fluffy lesions
 CoalescingCoalescing

79. EMPHYSEMAEMPHYSEMA
Alpha 1 Anti-TrypsinAlpha 1 Anti-Trypsin
DeficiencyDeficiency
 HyperinflationHyperinflation
 HyperlucencyHyperlucency
 Low flat diaphragmLow flat diaphragm
 Vertical tubular heartVertical tubular heart
 Pre & infra cardiacPre & infra cardiac lungslungs
 Barrel shape chestBarrel shape chest
 Avascular zonesAvascular zones
 Cephalization of upperCephalization of upper
lung is not evidentlung is not evident

80. MULTIPLE NODULES/MASS: >3CMMULTIPLE NODULES/MASS: >3CM
 Mets/Ca/LymphomaMets/Ca/Lymphoma
 TB/granulomaTB/granuloma
 WegenersWegeners
 Rheumatoid nodules/Round pneumoniaRheumatoid nodules/Round pneumonia
 FungalFungal
 SarcoidSarcoid
 Septic pulmonary emboliSeptic pulmonary emboli
 AVMsAVMs
 Septic emboliSeptic emboli

81. Micronodular Lung DiseaseMicronodular Lung Disease
 MetsMets
 SarcoidSarcoid
 PneumoconiosisPneumoconiosis
 Miliary TBMiliary TB
SarcoidSarcoid

82. CAVITYCAVITY
 CCa.: SCCa.: SCC
 AAbscess: fungal/bacterial/TBbscess: fungal/bacterial/TB
 VVascular: septic emboliascular: septic emboli
 IInflammatory: rheumatoid nodulenflammatory: rheumatoid nodule
 TTraumarauma
 YYoung: bronchogenic cystoung: bronchogenic cyst

84. Large Cavitary Lung LesionsLarge Cavitary Lung Lesions
 AbscessAbscess
 CarcinomaCarcinoma
 TBTB
Bronchogenic CaBronchogenic Ca

85. Cavitating PneumoniaCavitating Pneumonia
 StaphStaph
 StrepStrep
 TBTB
 G-veG-ve
(Klebsiella)(Klebsiella)
StaphStaph

86. LUNG MASSLUNG MASS
MassMass
 Round or ovalRound or oval
 Sharp marginSharp margin
 HomogenousHomogenous
 No respect forNo respect for
anatomyanatomy
Lung Ca.: large cellLung Ca.: large cell

87. Anterior Mediastinal MassesAnterior Mediastinal Masses
 ThymomaThymoma
 TeratomaTeratoma
 Substernal thyroidSubsternal thyroid
 LymphomaLymphoma

88. Posterior Mediastinal MassesPosterior Mediastinal Masses
Neurogenic tumorsNeurogenic tumors
LymphadenopathyLymphadenopathy
Extramedullary hematopoiesisExtramedullary hematopoiesis
SPINAL PATHOLOGYSPINAL PATHOLOGY
DIAPHRAGMATICDIAPHRAGMATIC
HERNIAHERNIA

90. Pulmonary Interstitial EdemaPulmonary Interstitial Edema
 CHFCHF
 Lymphangitic spreadLymphangitic spread
 Allergic reactionAllergic reaction
CHFCHF

91. Unilateral Pulmonary EdemaUnilateral Pulmonary Edema
AspirationAspiration
Disease in other lung,Disease in other lung,
e.g. COPDe.g. COPD
PosturalPostural
Rapid expansion ofRapid expansion of
PTXPTX

92. Hilar AdenopathyHilar Adenopathy
 SarcoidSarcoid
 TBTB
 LymphomaLymphoma
 Bronchogenic caBronchogenic ca
 Mets.Mets.
SarcoidSarcoid

93. Solitary Pulmonary NoduleSolitary Pulmonary Nodule
 Bronchogenic CaBronchogenic Ca
 HamartomaHamartoma
 HistoplasmomaHistoplasmoma
 TB granulomaTB granuloma
 Bronchial adenomaBronchial adenoma
 Solitary metSolitary met
 Round pneumoniaRound pneumonia
 Rounded atelectasisRounded atelectasis

94. HamartomaHamartoma

95. Metastatic Lung Cancer: multiple nodules seenMetastatic Lung Cancer: multiple nodules seen

98. 13. Does ET tube need to be advance or pulled back? Arrow
shows location of carina

99. 14. OK for NG feeding?

100. MCQMCQ
CXR is most commonly done XRCXR is most commonly done XR
Most CXR done are normalMost CXR done are normal
Deep sulcus sign is seen in PTX on supine CXRDeep sulcus sign is seen in PTX on supine CXR
onlyonly
Commonest c/of pl. effusion in BD is pneumoniaCommonest c/of pl. effusion in BD is pneumonia
PTB causes specific changes in CXRPTB causes specific changes in CXR