1. The document provides guidance on how to systematically read chest x-rays, including reviewing anatomy, exposure factors, common findings, and pathological changes. 2. It describes the lobar anatomy of the lungs and how to identify abnormalities using knowledge of typical appearances of conditions like pneumonia, cancer, and heart failure. 3. Examples of chest x-ray cases are presented and findings are described, such as cavitation in a cancer case and fluid in the fissure resembling a tumor in another case. 4. Key areas to review on chest x-rays are listed as well as potential pitfalls to avoid like poor inspiration and over/under exposure.

1. HOW TO READ CXRHOW TO READ CXR
DR R KR PRADHAN, MD
LOWER ASSAM HOSPITAL

2. IntroductionIntroduction
CXR Routinely obtained, most common
Inherent physical exam limitations
Chest x-ray limitations
CXR finding not always diagnostic
Physical exam and chest x-ray provide
compliment

3. Essentials Before GettingEssentials Before Getting
StartedStarted
 Exposure
– Overexposure
– Underexposure
 Sex of Patient
– Male
– Female

4. EXPOSURE
Over ExposureOver Exposure Proper ExposureProper Exposure

5. Essentials Before Getting StartedEssentials Before Getting Started
 Path of x-ray beam
– PA
– AP
– LAT
 Patient Position
– Upright
– Supine

6. Essentials Before GettingEssentials Before Getting
StartedStarted
Breath
– Inspiration
– Expiration

7. Systematic ApproachSystematic Approach
• Name/marker/rotation/
penetration
• Airway
• Heart
• Mediastinum
• Lungs
• Zones
(upper/middle/lower)
• Bones
• Diaphragm
• Soft Tissues

8. Systematic ApproachSystematic Approach
 Bony Fragments
– Ribs
– Sternum
– Spine
– Shoulder girdle
– Clavicles

9. Systematic ApproachSystematic Approach
 Soft Tissues
– Breast shadows
– Supraclavicular areas
– Axillae
– Tissues along side of
breasts

10. Systematic ApproachSystematic Approach
 Lung Fields and Hila
– Hilum
 Pulmonary arteries
 Pulmonary veins
– Lungs
 Linear and fine nodular
shadows of pulmonary
vessels
– Blood vessels
– 40% obscured by other
tissue

11. Systematic ApproachSystematic Approach
 Diaphragm and
Pleural Surfaces
– Diaphragm
 Dome-shaped
 Costophrenic angles
– Normal pleural is not
visible
– Interlobar fissures

12. Systematic ApproachSystematic Approach
 Mediastinum and
Heart
– Heart size on PA
– Right side
 Inferior vena cava
 Right atrium
 Ascending aorta
 Superior vena cava

13. Systematic ApproachSystematic Approach
 Mediastinum and
Heart
– Left side
 Left ventricle
 Left atrium
 Pulmonary artery
 Aortic arch
 Subclavian artery and
vein

14. Systematic ApproachSystematic Approach
 Abdomen and Neck
– Abdomen
 Gastric bubble
 Air under diaphragm
– Neck
 Soft tissue mass
 Air bronchogram

15. Summary of DensitySummary of Density
 Air
 Fat (Grey)
 Water
 Tissue
 Bone
Tissue

16. Lung AnatomyLung Anatomy
 Trachea
 Carina
 Right and Left Pulmonary
Bronchi
 Secondary Bronchi
 Tertiary Bronchi
 Bronchioles
 Alveolar Duct
 Alveoli

17. Lung AnatomyLung Anatomy
 Right Lung
– Superior lobe
– Middle lobe
– Inferior lobe
 Left Lung
– Superior lobe
– Inferior lobe

18. Lung Anatomy on Chest X-rayLung Anatomy on Chest X-ray
 PA View:
– Extensive overlap
– Lower lobes extend
high
 Lateral View:
– Extent of lower lobes

20. Lung Anatomy on Chest X-rayLung Anatomy on Chest X-ray
 The right upper lobe
(RUL) occupies the upper
1/3 of the right lung.
 Posteriorly, the RUL is
adjacent to the first 3 to 5
ribs.
 Anteriorly, the RUL
extends inferiorly as far as
the 4th right anterior rib

21. Lung Anatomy onLung Anatomy on
CXRCXR
 The right middle lobe
is typically the
smallest of the three,
and appears triangular
in shape, being
narrowest near the
hilum

22. Lung Anatomy onLung Anatomy on
CXRCXR
 The right lower lobe is the
largest of all three lobes,
separated from the others by
the major fissure.
 Posteriorly, the RLL extend
as far superiorly as the 6th
thoracic vertebral body, and
extends inferiorly to the
diaphragm.
 Review of the lateral plain
film surprisingly shows the
superior extent of the RLL.

23. Lung Anatomy on Chest X-rayLung Anatomy on Chest X-ray
 These lobes can be separated
from one another by two
fissures.
 The minor fissure separates
the RUL from the RML, and
thus represents the visceral
pleural surfaces of both of
these lobes.
 Oriented obliquely, the
major fissure extends
posteriorly and superiorly
approximately to the level of
the T4 vertebral body.

24. LEFT Lung AnatomyLEFT Lung Anatomy
on CXRon CXR
 The lobar architecture
of the left lung is
slightly different than
the right.
 Because there is no
defined left minor
fissure, there are only
two lobes on the left;
the left upper &
lower lobes

25. Lung Anatomy on Chest X-rayLung Anatomy on Chest X-ray
Left lower
lobes

26. LLL-LAT

27. LAT VIEW-CXRLAT VIEW-CXR
 These two lobes are
separated by a major
fissure, identical to that
seen on the right side,
although often slightly
more inferior in location.
 The portion of the left
lung that corresponds
anatomically to the right
middle lobe is
incorporated into the left
upper lobe.

28. THE CXRTHE CXR
 PA View:
1. Aortic arch
2. Pulmonary trunk
3. Left atrial appendage
4. Left ventricle
5. Right atrium
6. Superior vena cava
7. Right hemidiaphragm
8. Left hemidiaphragm
9. Horizontal fissure

29. Normal CXR-LATNormal CXR-LAT
 Lateral View:
1. Oblique fissure
2. Horizontal fissure
3. Thoracic spine and
retrocardiac space
4. Retrosternal space
5. Retratracheal space

30. The Silhouette SignThe Silhouette Sign
 An intra-thoracic radio-
opacity, if in anatomic
contact with a border of
heart or aorta, will obscure
that border. An intra-
thoracic lesion not
anatomically contiguous
with a border or a normal
structure will not
obliterate that border.

31. Putting It All TogetherPutting It All Together

32. Understanding PathologicalUnderstanding Pathological
ChangesChanges
Most disease states replace air with a
pathological process- Fluid, cells
Each tissue reacts to injury in a predictable
fashion
Lung injury or pathological states can be
either a generalized or localized process

33. Liquid DensityLiquid Density
Liquid density Increased air density
Generalized Localized
Diffuse alveolar
Diffuse interstitial
Mixed
Vascular
Infiltrate
Consolidation
Cavitation
Mass
Congestion
Atelectasis
Localized airway obstruction
Diffuse airway obstruction
Emphysema
Bulla

34. ConsolidationConsolidation
 Lobar consolidation:
– Alveolar space filled with
inflammatory exudate
– Interstitium and architecture
remain intact
– The airway is patent
– Radiologically:
 A density corresponding to a
segment or lobe
 Airbronchogram, and
 No significant loss of lung
volume

35. AtelectasisAtelectasis
 Loss of air
 Obstructive atelectasis:
– No ventilation to the lobe beyond
obstruction
– Radiologically:
 Density corresponding to
a segment or lobe
 Significant loss of volume
 Compensatory
hyperinflation of normal
lungs

36. Stages of Evaluating anStages of Evaluating an
AbnormalityAbnormality
1. Identification of abnormal shadows
2. Localization of lesion
3. Identification of pathological process
4. Identification of etiology
5. Confirmation of clinical suspicion

37. Putting It Into PracticePutting It Into Practice

38. Case 1Case 1

40. A single, 3cm relatively thick-walled cavity is noted in the left
midlung. This finding is most typical of squamous cell
carcinoma (SCC). One-third of SCC masses show cavitation

41. Case 2Case 2

43. LUL Atelectasis: Loss of heart borders/silhouetting. Notice
over inflation on unaffected lung

44. Case 3Case 3

45. Right Middle and Left Upper Lobe Pneumonia

46. Case 4Case 4

48. Cavitation:cystic changes in the area of consolidation due to the
bacterial destruction of lung tissue. Notice air fluid level.

49. Cavitation

50. Case 5Case 5

51. Tuberculosis

52. Case 6Case 6

54. COPD: Decrease in heart diameter, flattening of the diaphragm,
and increase in the size of the retrosternal air space. In addition the
upper lobes will become hyperlucent due to destruction of the lung
tissue.

55. Case 7Case 7

57. Pseudotumor: fluid has filled the fissure creating a density that
resembles a tumor (arrow). Fluid and soft tissue are indistinguishable
on plain film. Further analysis, however, reveals a classic pleural
effusion in the right pleura. Note the right lateral gutter is blunted and
the right lateral diaphragm is obscured.

58. Case 8Case 8

60. Pneumonia: a large pneumoniac consolidation in the right
lower lobe. Knowledge of lobar and segmental anatomy is
important in identifying the location of the infection

61. Case 9Case 9

63. CHF: accentuated interstitial markings, Kerley B lines,
and an enlarged heart. Normally indistinct upper lobe
vessels are prominent but are also masked by
interstitial edema.

64. 24 hours after diuretic therapy

65. Case 10Case 10

66. RT HILAR NODE

67. AORTO-PA WINDOW NODE

68. Chest wall lesion: arising off the chest wall and not the lung

69. Case 11Case 11

70. Pleural effusion: Note loss of left hemidiaphragm. Meniscus
sign

71. Case 12Case 12

72. Lung Mass

73. Case 13Case 13

75. Small Pneumothorax: LUL

76. Case 15Case 15

77. Right Pneumothorax: complete lower /middle lobar collapse

78. Post chest tube insertion and re-expansion

79. Case 16Case 16

80. Metastatic Lung Cancer: multiple nodules seen

81. Case 17Case 17

83. Right upper lower lobe pulmonary nodule

84. Case 18Case 18

86. Tuberculosis

87. Case 19Case 19

89. Perihilar mass: Hodgkin’s disease

90. Case 20Case 20

92. Widened Mediastinum: Aortic Dissection

93. Case 21Case 21

94. REVIEW AREAS
THE APICES
THORACIC INLET
LUNG OVERLYING SCAPULA
COSTOPHRENIC ANGLES
SUBPHRENIC REGIONS
RETROCARDIAC REGION
CARDIOPHRENIC ANGLES

95. APEX

96. RETROCARDIAC OPACITY

97. LUNG OVERLYING SCAPULA

98. PITFALLSPITFALLS
Poor inspiration
Over or under penetration
Rotation
Pseudopneumothorax
Nipple shadows
Buttons
Hair braids

99. THANK U FOR YOUR KINDTHANK U FOR YOUR KIND
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