3. NAME THE DIRECTION OF THE CXR
LATERAL FILM; NOTE RECEPTOR IS AGAINST
LEFT CHEST
4. WHICH RIBS ARE LARGER ON LATERAL CXR?
RIGHT RIBS: USUALLY PROJECTED POSTERIOR TO LEFT
RIBS IF PATIENT WAS EXAMINED IN TRUE LATERAL
POSITION.
RED ARROWS: RIGHT RIBS; BLUE ARROWS: LEFT RIBS
5. WHICH SIDE OF THE DIAPHRAGM IS HIGHER?
RIGHT IS USUALLY HIGHER. HEART LIES PREDOMINANTLY ON LEFT SIDE.
R DIAPHRAGM CONTINUES ANTERIORLY, LEFT DISAPPEARS BECAUSE
SILOUHETTING OF HEART. R DIAPHRAGM AT BLUE ARROWS CONTINUES PAST
THE SMALLER L RIBS AND ENDS AT LARGER AND MORE POSTERIOR R RIBS
6. IDENTIFY THE AIRWAYS
TRACHEA
CARINA
RIGHT MAIN BRONCHUS
BRONCHUS INTERMEDIUS
LEFT MAIN BRONCHUS
7. IDENTIFY THE AIRWAYS
TRACHEA
RIGHT MAIN BRONCHUS
BRONCHUS INTERMEDIUS
LEFT MAIN BRONCHUS
10. PA CXR: FISSURES
A: Minor (horizontal) fissure: separating upper R lobe
from middle R lobe
B: Major (oblique) fissure: suparates inferior lobe of
either lung from the remainder of the lung.
Inferior border (first image): borders of major fissure.
Lateral CXR are better for observing major fissure.
Superior border (second image)
11. LATERAL CXR: FISSURES
• Left lung will only have major fissure (B): dividing
upper and lower left lung.
• Right lung will have major (B) and minor (A) fissures
• Major fissure separates inferior lobe from middle lobe
• Minor (horizontal) fissure separates superior from middle lobe
12.
13. MASS LOCATION RELATIVE TO HEART?
(ANTERIOR/ POSTERIOR OR IN CONTACT WITH?)
NO LOSS OF SILHOUETTE, SO MEDIASTINAL MASS
MUST LIE ANTERIOR OR POSTERIOR TO HEART
14. MASS LOCATION RELATIVE TO HEART?
(ANTERIOR/ POSTERIOR OR IN CONTACT WITH?)
LOSS OF SILHOUETTE FLUID IN RIGHT MIDDLE
LOBE OF LUNG IS IN CONTACT WITH HEART
15. CXR OPACITIES
Too white, increased opacity
• Consolidation, pneumonia
• Atelectasis
• Nodule/ mass
• Interstitial disease
• Pleural effusion
Too dark, decreased opacity
• Emphysema (COPD)
• Large pneumothorax
• Large pulmonary embolus (massive)
16. WHAT ARE SIGNS OF ATELECTASIS?
Increase in density of the affected lung
(Atelectasis is volume loss/ collapse= decreased air in lung)
Displacement of the fissures or the mediastinum towards the
atelectasis
Elevation of the diaphragm
17. WHAT ARE CAUSES OF ATELECTASIS?
ETIOLOGY: PROXIMAL OCCLUSION OF A BRONCHUS
INFANT: FOREIGN BODY (EX: PEANUT)
CHILD/ YOUNG ADULT: MUCOUS PLUG/ ASTHMA
MIDDLE AGED/ ELDERLY: CENTRAL LESIONS (EX:
CARCINOMA)
HOSPITALIZED: MUCOUS PLUG
POST OP!!!
18. NAME THE PATHOLOGY
RIGHT UPPER LUNG ATELECTASIA: IPSILATERAL MEDIASTINAL SHIFT
(SHIFT TO SAME DIRECTION AS ATELECTASIA)
19. WHAT ARE SIGNS OF PLEURAL EFFUSION?
• An effusion will appear as a graded haze that is denser at the base
(increased opacity; lighter)
• Outside of the lung: fluid buildup within potential space of pleural
cavity (between visceral and parietal pleura)
• The most common radiographic sign is a pleural meniscus
20. NAME THE PATHOLOGY
PULMONARY EFFUSION: MOST CXRS IN PE WILL BE NORMAL. THIS CXR
HAS HAMPTON’S HUMP: WEDGE SHAPED OPACITY.
OTHER SIGNS: INCREASED HILUM SIZE (CAUSED BY THROMBUS
IMPACTION; ATELECTASIS; PLEURAL EFFUSION; CONSOLIDATION
21. WHAT ARE SIGNS OF PNEUMOTHORAX?
Visceral pleura (very thin white line) is displaced from right lateral chest wall
Increased lucency (darker) on lateral side represents air in pleural space
Air appears black on CXR
Lucency on the medial side is normal as it represents air in the lung
There will also be an absence of pulmonary vessels lateral to the pleural line (see no
white streaks)
Is this Westermark’s Sign?
NO! You don’t see any of the white streaks (vasculature) because it’s
just air in the pleural cavity. Westermark’s sign is due to decreased
vasculature but it’s still lung (seen in pulmonary embolus).
22. WHAT ARE SIGNS OF EMPHYSEMA?
Hyperinflated lungs:
• enlarged intercostal spaces
• low set diaphragm
Reduced pulmonary vasculature resulting in hyperlucent lungs
(darker)
• Due to more air left in lungs, and because white stuff in a normal
CXR are usually vessels, so if they’re not around, lung = more black
Presence of bullae (arrows)
• lucent, air-containing sacs
23. ATELECTASIS OR PNEUMONIA?
RUL
Collapse
• ATELECTASIS (NOTE THE STRAIGHT UPWARDS LINE):
THIS IS THE HORIZONTAL FISSURE; IT HAS BEEN DISPLACED
RUL COLLAPSES UPWARD, MEDIALLY, ANTERIORLY;
SHIFT OF MINOR FISSURE, INCREASED DENSITY AGAINST MEDIASTINUM, TRACHIAL
SHIFT, HILAR SHIFT
26. WHICH SHOWS COLLAPSE?
WHICH SHOWS VOLUME EFFUSION?
RIGHT CXR: HEART IS BARELY VISIBLE (IT HAS SHIFTED LEFT)
27. WHICH CXR SHOWS VOLUME LOSS?
RIGHT CXR: COLLAPSE
LEFT CXR: EFFUSION
28. NAME THE SIGN
CONSOLIDATION: “FLUFFY”. REGION OF NORMALLY COMPRESSIBLE LUNG
TISSUE THAT HAS FILLED W/FLUID.
-SIGN CAN INDICATE PATHOLOGY LIKE PNEUMONIA, PULMONARY EDEMA ETC.
-THEY MAY HAVE POOR MARGINS, MAY HAVE AIR BRONCHOGRAMS (SEEN ON
LATERAL CXR)
29. NAME THE SIGN
MASS: ANOTHER MEDICAL SIGN THAT CAN BE INDICATIVE
OF CANCER, FUNGAL OR PNEUMONIA
30. NAME THE SIGN
MASS: DISCRETE, WITH BORDERS
THINK CANCER, METASTATIC DZ// DISSEMINATED INFECTION
31. NAME THE SIGN
PULMONARY NODULES: DISCRETE OPACITY WITHIN THE
LUNG
< 3 CM DEFINED AS A NODULE
> 3 CM DEFINED AS A MASS
33. NAME THE PATHOLOGY
NORMAL Hilar
points
HYLAR LYMPHADENOPATHY: HILA (LUNG ROOTS) CONTAIN MAJOR
BRONCHI, PULMONARY VEINS + ARTERIES, +LYMPH NODES (LN)
-HILAR LN ARE NOT VISIBLE ON A NORMAL CXR
-HILAR ENLARGEMENT IS OFTEN DUE TO LN ENLARGEMENT
-BILATERAL, BUT ASYMMETRICAL
34. NAME THE PATHOLOGY
MEDIASTINAL LYMPHADENOPATHY: ENLARGEMENT OF
MEDIASTINAL LYMPH NODES (ARROWS)
35. NAME THE SIGN/ PATHOLOGY
PLEURAL MENISCUS (PLEURAL EFFUSION), WITH IPSILATERAL
MEDIASTINAL SHIFT (SHIFT TO SAME DIRECTION AS ATELECTASIA)
37. NAME THE PATHOLOGY
LOBAR PNEUMONIA: INFLAMMATORY CONDITION OF THE
LUNG, MOST COMMONLY CAUSED BY VIRUS, BACTERIA,
OR FUNGI.
38. NAME THE PATHOLOGY
DIFFUSE ALVEOLAR PNEUMONIA: INFLAMMATORY
CONDITION OF THE LUNG, MOST COMMONLY CAUSED BY
VIRUS, BACTERIA, OR FUNGI.
39. NAME THE PATHOLOGY
PLEURAL EFFUSION: FLUID BUILDUP IN PLEURAL SPACE (B/W VISCERAL &
PARIETAL PLEURA);
-MOST COMMON RADIOGRAPHIC FINDING IN PLEURAL EFFUSION IS PLEURAL
MENISCUS (FLUID IN THE COSTOPHRENIC ANGLE; SEE ARROWS)
HORIZONTAL FLUID LEVEL IS DIAGNOSTIC OF AIR AND FLUID IN THE PLEURAL
SPACE (HYDROPNEUMOTHORAX)
40. NAME THE PATHOLOGY
PULMONARY EFFUSION: MOST CXRS IN PE WILL BE NORMAL. THIS CXR HAS
WESTERMARK’S SIGN: DECREASE OF VASCULARIZATION AT THE PERIPHERY
OF THE LUNGS.
OTHER SIGNS: INCREASED HILUM SIZE (CAUSED BY THROMBUS IMPACTION;
ATELECTASIS; PLEURAL EFFUSION; CONSOLIDATION
41. NAME THE PATHOLOGY
PLEURAL EFFUSION: FLUID BUILDUP IN PLEURAL SPACE (B/W
VISCERAL & PARIETAL PLEURA); THIS IS AN UPRIGHT CXR; FLUID
IS NOT FALLING TO BOTTOM, NOT LAYERING. PT HAD EMPYEMA
42. NAME THE PATHOLOGY
PULMONARY EDEMA: ABNORMAL FLUID IN PULMONARY
INTERSTITIUM AND ALVEOLI
43. NAME THE PATHOLOGY
PULMONARY EDEMA: ABNORMAL FLUID IN PULMONARY INTERSTITIUM AND ALVEOLI
ARROW: KERLEY A LINES; ARROWHEAD: KERLEY B LINES; ENLARGED CARDIAC
SILHOUETTE
44. WHAT THE HECK ARE THESE ARROWS POINTING AT?
NOTHING?
45. WHAT THE HECK ARE THESE ARROWS POINTING AT?
JK! PERIBRONCHIAL CUFFING: VISUALIZATION OF SMALL
DOUGHNUT-SHAPED RINGS REPRESENTING FLUID IN
THICKENED BRONCHIAL WALLS. SIGN OF PULMONARY EDEMA
46. NAME THE PATHOLOGY
PULMONARY EDEMA: ABNORMAL FLUID IN PULMONARY
INTERSTITIUM AND ALVEOLI
48. NAME THE PATHOLOGY
Normal
INTERSTITIAL DISEASE:
“SCRATCHY”: THESE ARE CALLED LUNG MARKINGS; LINEAR OPACITIES
NON-BACTERIAL INFECTIONS (MYCOPLASMA, VIRAL); DIFFUSE LUNG DISEASE (PULMONARY FIBROSIS),
INTERSTITIAL EDEMA
CAN’T FOLLOW VESSELS LIKE WE NORMALLY WOULD. (ORANGE LINES FOR COMPARISON, ON NORMAL)
49. NAME THE PATHOLOGY
INTERSTITIAL DISEASE: VARIETY OF CONDITIONS CAN LEAD TO DIFFUSE
PARENCHYMAL LUNG DISEASE (E.G. TB, SARCOIDOSIS, AMIODARONE
INDUCED PULMONARY FIBROSIS ETC.)
“SCRATCHY”: THESE ARE CALLED LUNG MARKINGS.
50. NAME THE PATHOLOGY
TENSION PNEUMOTHORAX: COLLAPSED R LUNG, R SIDED
LUCENCY AND LEFTWARD MEDIASTINAL SHIFT.
52. CONSIDER THE FOLLOWING:
TENSION PNEUMOTHORAX CAUSES SHIFT OF MEDIASTINAL
STRUCTURES AWAY FROM THE PNEUMOTHORAX, WHEREAS
ATELECTASIS MAY CAUSE DISPLACEMENT TOWARDS
ATELECTASIS.
