1. Look at the technical quality of the chest x-ray including whether it is centered, properly exposed, and taken in inspiration. 2. Examine the lungs for any opacities, consolidation, or atelectasis which can be localized using the zones and identifying fissure lines on lateral view. 3. Check the mediastinum, heart, and diaphragm for any shifts or distortions that may indicate underlying lung pathology such as atelectasis.

1. HOW READ CHEST XR -1
ANAS SAHLE ,MD

2. 1. Technical Quality
OUTLINE
2. look at the mediastinal
3. look at the lungs
4. diaphragm
5. Soft tissues and bones

3. Technical Quality

4. RPPI
Is the film centered? Rotation
Is it PA or AP film ? Positioning
Is it exposed properly ? Penetration
Is it a good inspiration film? Inspiration

5. observing the
clavicular heads
determining
whether they are
equal distance from
the spinous process
of the thoracic
vertebral bodies

6. Is this film
centered?

7. Is this film
centered?

8. Why do you have to know whether
the film is centered or not ?
Difficult to evaluatethe position of
Mediastinum if the film is not
centered

9. RPPI
Is the film centered? Rotation
Is it PA or AP film ? Positioning
Is it exposed properly ? Penetration
Is it a good inspiration film? Inspiration

10. If the scapulae no longer overlie the lung fields
then the film is PA
If the scapulae overlie the lung fields then the
film is AP

13. Why do you have to know whether
it is PA or AP film?

14. The PA (posterioranterior)
Positioning
Note that the x-ray
tube is 72 inches
“182.88 cm” away

15. The Supine AP (anteriorposterior) position
Note that the x-ray
tube is 40 inches
”111.76 cm” from
the patient

16. Heart appears larger

17. Mediastinum widens

18. Diaphragms are
higher

19. Pulmonary vessels
size is same in upper
and lower lung fields

20. RPPI
Is the film centered? Rotation
Is it PA or AP film ? Positioning
Is it exposed properly ? Penetration
Is it a good inspiration film? Inspiration

21. The thoracic spine
disc spaces
should be barely
visible through the
heart

22. Bony details of the
spine
are not usually seen

23. On the other hand
penetration is
sufficient that
bronchovascular
structures
can usually be seen
through the heart

24. Normal Penetrated An overpenetrated
PA film PA film

25. Normal Penetrated underpenetrated PA
PA film film

26. RPPI
Is the film centered? Rotation
Is it PA or AP film ? Positioning
Is it exposed properly ? Penetration
Is it a good inspiration film? Inspiration

27. The
diaphragm
should be
found at about
the level of
the 8th - 10th
posterior rib
or 5th - 6th
anterior rib on
good
inspiration

28. Why Do You Have To Know
Whether
It Is Good Inspiration
Or Poor Inspiration?

29. Mediastinum
appears
wider

30. Heart size
appears
larger

31. Lung bases
look
whiter
(mistaken for
interstitial
disease)

32. look at the lungs

33. Scan both
lungs
starting at the
apices and
working down
comparing left
with right at
the same level

34. The lungs
extend behind
the heart
so
look here too

35. Compare and
contrast
vascular
markings in
upper vs. lower
lung fields in PA
view

36. List conditions, where vascular markings are
prominent in upper lung fields
• Mitral stenosis
• Congestive heart failure
• Alpha one antitrypsin deficiency

37. Compare and
contrast
vascular
markings in
outer third vs.
inner two thirds
of lungs

38. increased markings in outer third of lung fields?
increased
pulmonary flow
• In:
1. Left to right shunts (ASD, VSD, PDA)

39. increased markings in outer third of lung fields?
• In :
2. Interstitial disease
3. Lymphangitic malignant spread
4. CHF with increased lymphatic flow

40. Fissures

41. The Minor
Fissure divides
the Right
Middle Lobe
from the Right
Upper Lobe
and is
sometimes not
well seen

42. Localizing lesions

43. The position of lesion
can be described in terms of
zones

44. To accurately localize a lesion on chest X ray
you need to look at both the PA and lateral
films

45. First look at the
PA film

46. The upper zone lies
above the anterior
border of the 2nd rib

47. The middle zone lies
between the right
anterior borders of
the 2nd and 4th ribs

48. The lower zone lies
between the right
anterior border of
the 4th rib and the
diaphragm

49. It does not give any
information about the
lobes of the lung

50. Look at the borders of the lesion
• If the lesion is next to a dense (white)
structure then the border between the
lesion and that structure will be lost

51. This is called
the silhouette
sign RML
lingula
LLL
RLL
LLL

52. Now look at the
lateral film

53. Identify the oblique fissure
• (pass obliquely downwards from the T4/T5
vertebrae through the hilum ending at the
anterior third of the diaphragm)

54. Identify the horizontal fissure
• (pass horizontally from the midpoint of the
hilum to the anterior chest wall)

55. If the lesion lies posterior to the oblique fissure it
must lie within the lower lobe

56. If the lesion lies anterior to the oblique fissure it
may be in the upper or middle lobe

57. If the lesion is below the horizontal fissure it is in
the middle lobe

58. If the lesion is above the horizontal fissure it is in
the upper lobe

59. There is no middle lobe on the left

60. The white lesion

61. Lung
The white lesion
pleura

62. parenchyma
Lung Airway
Pneumonectomy

63. Consolidation
is another term for
air space shadowing
Alveolar space
parenchyma
interstitial

64. Alveolar space
Consolidation
parenchyma
interstitial

65. Collapse
Alveolar space
air spaces filling

66. Loss of volume of part of the lung

67. On the PA film:
The right lung should be larger than the left
If it is not suspect an area of right sided
collapse

68. The major (Primary) sign
opacification of the
affected lobe due to
airlessness

69. The major (Primary) sign
displacement of the
interlobar fissure

70. The Secondary signs
displacement of the
mediastinal structures

71. The Secondary signs
The right diaphragm
should be higher than the
left (the difference should
be less than 3cm)
elevation of the
hemidiaphragm

72. The Secondary signs
decrease in the distance
of the intercostals spaces

73. The Secondary signs
displacement of the hila

74. The Secondary signs
compensatory
overinflation of the
remaining lung

75. The heart border should be distinct
If the lung adjacent to the heart is collapsed
then the heart border will appear blurred
Right heart border is Left heart border is
blurred blurred
RML collapse lingular collapse

76. Atelectasis Right Upper Lobe

77. Atelectasis Right Upper Lobe

79. Atelectasis Right Upper Lobe

80. Homogenous Atelectasis Right Upper Lobe
density right
upper lung
field.
Mediastinal
shift to right.
Loss of
silhouette of
ascending
aorta.
Movement of
oblique and
transverse
fissures.

81. RML Atelectasis

82. Vague density
in right lower
lung field
(almost a
normal film).
RML
Atelectasis

83. Dramatic RML
atelectasis in
lateral view,
Movement of
transverse
fissure.
Other findings
include:
Azygous lobe
RML Atelectasis

84. RML Lateral Segment
Atelectasis

85. RML Lateral Segment
Atelectasis

86. RLL Atelectasis

87. Right lower lobe atelectasis

89. Complete atelectasis of the right lung

90. Atelectasis Left Upper Lobe

91. Mediastinal shift
to left.
Density left
upper lung field.
Loss of aortic
knob and left
hilar silhouettes.
Atelectasis Left Upper Lobe

92. A:
Forward
movement
of oblique
fissure
C:
Atelectatic
LUL
B:
Herniated
right lung
Atelectasis Left Upper Lobe

93. Bowing
sign
•LUL atelectasis or
following resection
•The oblique fissure
bows forwards

94. Bowing sign

95. Left Lower Lobe Atelectasis

96. Inhomogeneous
cardiac density.
Triangular
retrocardiac
density.
Left hilum pulled
down.
Atelectasis
Left Lower Lobe

97. Left Lower Lobe Atelectasis

98. •Lateral
left
diaphragm
not visible
•Increased
density
over lower
spine
Left Lower Lobe Atelectasis

99. Atelectasis Left Lung