cxr read practical approche

1. HOW READ CHEST XR -2
ANAS SAHLE ,MD

2. Technical Quality

3. 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

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

5. 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

6. 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

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. Normal Penetrated An overpenetrated
PA film PA film

11. Normal Penetrated underpenetrated PA
PA film film

12. 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

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

14. look at the lungs

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

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

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

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

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

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

21. Fissures

22. Localizing lesions

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

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

25. First look at the
PA film

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

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

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

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

30. 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
This is called
the silhouette sign

31. Now look at the
lateral film

32. Lateral Positioning

33. A brief look at
the lateral CXR
Key points
• There should be a
decrease in density
from superior to
inferior in the
posterior mediastinum.
• The retrosternal
airspace should be
of the same density
as the retrocardiac
airspace.

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

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

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

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

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

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

40. There is no middle lobe on the left

41. POSITION
PA AP
QUALITY
ROTATION PENETRATION INSPIRATION
LESION
Homo Heterogenous
Densityinfiltration
necrotic
Zone Centralperipheral Silhouet sign
MEDIASTINAL
Central deviasionwided
COSTO-PHRENIC ANGEL
Freeoblitern
OTHER
Bone soft tissuediaphragm

42. CASE-1
This elderly
male had
recent onset
of streaky
hemoptysis.?

43. POSITION •AP CXR
QUALITY •Poor Technical Quality
•homogeneous density in the right upper zone
LESION , elevation of the transverse fissure
•Central trachea and mediasteinal
MEDIASTINAL
•Free costo-phrenic angels
ANGELS
•NO
OTHER

44. S sign
• homogeneous density in the right upper zone
• elevation of the transverse fissure
( Instead of the transverse fissure being straight)
• there is a bulge at the medial end giving it an
inverted S shape.
• Golden described this sign and
the explanation for it is that the upper lobe
collapse is due to a right hilar mass
which accounts for the medial bulge

46. 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.

47. Case-2
This middle-aged
female complained of:
•Hemoptysis
•loss of
weight
two months’ duration.

48. POSITION •PA CXR
QUALITY •Poor Technical Quality
•(poor penetration).
•hazy, veil-like opacification
LESION •in the left upper zone,obscured
aortic arc,from hilar to peripheral
•Central trachea and mediasteinal
MEDIASTINAL
•Obscured left costo-phrenic angels
ANGELS •Elevate left hemidiaphragm
•NO
OTHER

49. Illustration
• The CXR shows evidence of left upper lobe collapse.
• There is a hazy, veil-like opacification
in the left upper lobe, which does not have a sharp
inferior margin unlike right upper lobe collapse.
• This is because there is usually no left transverse
fissure and the lobe collapses anteriorly..
• There is also volume loss in the left hemithorax as
evidenced by an elevated left hemidiaphragm and
crowding of the left upper ribs.
• Sometimes the trachea may also be deviated to the
same side and the aortic knuckle may be obscured by
the collapse

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

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

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

53. Bowing sign

54. CASE-3
• 50-year-old
female with a
past history of
tuberculosis
had
• chronic cough
over the past
year.

55. POSITION •PA CXR
QUALITY •GOOD Technical Quality
•No
LESION •Left lung smaller than right
•Left deviation trachea and
MEDIASTINAL mediasteinal
•Obscured left costo-phrenic angels
ANGELS •Elevate left hemidiaphragm
•NO
OTHER

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

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