4. • First look at the mediastinal contours—run your eye down the left side of the patient and
then up the right.
• The trachea should be central.
• The aortic arch is the first structure on the left, followed by the left pulmonary artery; notice
how you can trace the pulmonary artery branches fanning out through the lung
• Two thirds of the heart lies on the left side of the chest, with one third on the right. The heart
should take up no more than half of the thoracic cavity.
• The left border of the heart is made up by the left atrium and left ventricle.
• The right border is made up by the right atrium alone. Above the right heart border lies the
edge of the superior vena cava.
• The pulmonary arteries and main bronchi arise at the left and right hila. Enlarged lymph
nodes can also occur here, as can primary tumours. These make the hilum seem bulky.
• Now look at the lungs.
• Apart from the pulmonary vessels (arteries and veins),they should be black (because they are
full of air).
• Scan both lungs, starting at the apices and working down, comparing left with right at the
same level. The lungs extend behind the heart, so look here too. Force your eye to look at
the periphery of the lungs—you should not see many lung markings here; if you do then
there may be disease of the air spaces or interstitium.
• Don’t forget to look for a pneumothorax.
• Make sure you can see the surface of the hemidiaphragms curving downwards, and that the
costophrenic and cardiophrenic angles are not blunted—suggesting an effusion.
• Check there is no free air under the hemidiaphragm
5. The Normal Cardiac Borders in the PA View:
A) The left cardiac border is formed from above down by:
1. The aortic arch (= knob, knuckle).
2. The main pulmonary artery.
3. The left atrial appendage.
4. The left ventricle.
B) The right border of the heart is formed by:
1. In the lower two thirds by the right atrium.
2. In the upper third by the superior vena cava.
6.
7.
8. How to read
• This is a chest radiograph of a young male patient
PA view.
• The patient has taken a good inspiration and is
not rotated; the film is well penetrated.
• The trachea is central, the mediastinum is not
displaced.
• The mediastinal contours and hila seem normal.
• The lungs seem clear, with no pneumothorax.
• There is no free air under the diaphragm.
• The bones and soft tissues seem normal
15. Features to look for Present features
1. Opacification Dense opacification of the right upper
zone, V shaped
2. Horizontal fissure Has been displaced upwards from its
original position
3. Hilum enlarged or elevated Right hilum is elevated than left hilum
4.Smaller lung, smaller hemithorax Not present
5. Compensatory hyperinflation and Present
hyperlucency in other lobes
6. Tracheal deviation Absent
7. Elevated ipsilateral hemidiaphragm Present
25. Pneumothorax
Increased volume of the right hemithorax
with tracheal shift to the OPPOSITE side-
”PUSH” effect
Hyperlucency on the right side
Absence of lung markings
Presence of margin of collapsed lung at the
hilum
D/D:Unilateral emphysema
27. Hydropneumothorax
Horizontal fluid level with hyperlucent area
above it
Hyperlucent area with no lung markings
Presence of air+fluid = Hydropneumothorax
Trachea shifted to the SAME side-”PULL “
effect
D/D:lung abscess
29. Lung abscess
Loculated cavity with thin wall(maybe post
infective cyst, wall made up of a fibrous
tissue)
Presence of air fluid level
Mild trachea shift to the left(probably due
to rotation)
Fundic air bubbles separately seen
30. Lung abscess VS
Hydropneumothorax
Feature Lung Abscess Hydropneumothorax
Definition Intrapulmonary air- Intrapleural air-
fluid collection fluid collection
Shape of fluid Round, take up the Take up shape of the
shape of cavity wall thoracic cavity &
margin of collapsed
lung
Cavity Wall Clearly seen Not seen
Margin of collapsed Not seen May be seen
lung
Length of air-fluid Equal regardless of Length varies with
level radiographic radiographic
projection projection
32. Pleural effusion
Homogenous opacity of right middle &
lower zone = almost totally WHITE OUT
LUNG
Minimal tracheal shift to the left
Cardiac shift to the opposite side with
reduced left hemithorax size.
Obliteration of right costophrenic &
cardiophrenic angles
D/D:consolidation, pleural
thickening(heterogenous opacity), collapse.
39. • Double aortic
knuckle.
• 3 sign at left margin
of the aorta at the
level of coarctation.
Coarctation of Aorta.
40. Coarctation of Aorta.
• Rib notching:
– Due to pressure from tortuous intercostal arteries
acting as collaterals.
– Becomes evident after the age of 8 years.
• Cardiomegaly.
43. • A:
– Straightening of left
cardiac border.
– Notching at left
cardiac border.
• B:
– Double atrial
shadow.
– LA shadow seen
through the heart
inside its right
border.
46. Pulmonary Edema
Bat
wings/butterfly
distribution
Pleural effusion
47. Pulmonary Edema
• Produces air space opacities with variable
distribution.
• Sparing of the apices and extreme lung bases.
• “Butterfly” or “Bat wings” distribution – central
lungs affected more.
• With progression – opacities coalesce to form a
“white-out” on chest radiograph.
• Blurring of blood vessels occurs.
• Air bronchogram – indicating intra alveolar
edema.
48. Sequence of events on CXR in acute
pulmonary edema.
Early changes. Late changes.
1. Prominent pulmonary artery. 7. Fluffy shadows.
2. Prominent pulmonary lobe 8. Air bronchogram.
veins.
3. Interlobar fissure. 9. Bat’s wing appearance.
4. Perivascular cuffing. 10. Cardiomegaly .
5. Peribronchial cuffing. 11. Pleural effusion.
6. Kerley B lines.
49.
50. Differences..
Criteria. Cardiogenic (LVH) Non cardiogenic(ARDS)
1. Cardiomegaly . Comman +++ Uncomman+
2. Alveolar edema. +++ +++
3. Appearance of Bat’s wing /butterfly More patchy
shadow . appearance
4. Perivascular and More often seen Less likely
peribronchial cuffing.
5. Tendency for Yes No
gravitational
distribution.
6. Pleural effusion. May be present Unlikely
51. Silhouette Sign
• On the radiograph, loss of normal border of
the heart, aorta, or diaphragm by
intrathoracic lesions known as silhouette
sign.
Silhouete signs seen as Intrathoracic lesions
Upper right heart
Anterior segment of RUL
border/ascending aorta
Right heart border RML (medial)
Upper left heart border Anterior segment of LUL
Left heart border Lingula (anterior)
Apical portion of LUL
Aortic knob
(posterior)
Anterior hemidiaphragms Lower lobes (anterior)
54. Hiatal Hernia.
67 years old
patient
complained of
chronic cough and
mild heartburn
with no other
symptoms.
Editor's Notes
most common symptoms being dyspnoea and / or a non-productive cough. In patients who are profoundly immunocompromised, onset may be more dramatic and resemble other pulmonary infectionsbilateral, diffuse, often perihilar, fine, reticular interstitial opacification, which may appear somewhat granularBat's wing or butterfly pulmonary opacities
Nodules are either sharply or poorly defined 1–4-mm in size Diffuse, random distributionImaging Findings Discrete Distinctive Pin-point opacities Nodule size 1 – 2 mm in diameter - SPHERICAL LESION IN Miliary ( millet seed ) Pattern INTERSTITIUM B/L even distribution - WELL CIRCUMSCRIBED Basal Predominance HOMOGENOUS PATTERN Rare or non-existent calcifications Upto 30 % no radiological signs Thickening of intralobar fissure / interlobular septa Nodular irregularity of vessels HRCT – more sensitiveAlveolar microlithiasisPNEUMOCONIOSIS - Coal Workers Pneumoconiosis - Silicosis - Siderosis - StannosisSARCOIDOSIS METASTATIC LUNG DISEASES NON TB INFECTIONS – Histoplasmosis - Blastomycosis - Cryptococcosis - Nocardiosis – Coccidiodomycosis BRONCHIOLITIS OBLITERANS
Many thoracic aneurysms are visible on chest x ray and are characterised by widening of the mediastinal silhouette, enlargement of the aortic knob or displacement of the trachea of the midline.
Tracheal shift to the left-PUSH effect, increased volume of the right hemithoraxHyperlucency of right hemithorax + absence of lung markings + margin of collapsed lung(compression collapsed) = pneumothoraxTotal collapse=collapse like a cricket ball towards the hilum
Loculated cavity with thin wall(myb post infective cyst, wall made upof a fibrous tissue)Presence of air fluid levelMild trachea shift to the left(probably due to rotation)Fundic air bubbles separately seend/d:lung abscess(unresolved pneumonia), primary tumor (?blood clot)
Trachea remains central-why?Cardiac shift to the opposite side ,lefthemithorax size reducedHomogenous opacity starts from right middle zone downwards +obliteration of right costophrenic & cardiophrenic angles = almost totally WHITE OUT LUNGNot WHITE OUT LUNG because,not involve entire lungd/d:consolidation, pleural effusion/thickening(heterogenous opacity), collapse, upward enlargement of the liver(r/o)Notes:left 4th rib…cavities???
Not WHITE OUT LUNG because,not involve entire lungWhy notConsolidation-no air bronchogramPleural thickening-heterogenous opacityCollapse-presence of lung markings
Changes of 1-6 indicates interstitial edema.7-9 indicates alveolar edema.10-11 likely present in the cardiogenic causes of pulmonary edema (LVH)
left border of heart obliterated:lesion in lingulaRight hemidiaphragmobliterated:lower lobe lesionParatracheal stripes obliteration :paratrachealdzIt can be either consolidation or superimposed mass lesion.p/s :tram track appearance near arrow 2?? : thickened bronchial wall..(d/d:bronchiectasis ,cystic fibrosis,allergicaspergillosis,recurrent asthma/bronchitis in child)Air under left diaphragm : colonic gas shadow overlapping fundic gas bubble…..you can see the haustration!! Volvulus??
Air under diaphragm:In normal x-ray :there will be a fundic bubble gas on right side.Presence of air under diaphragm here may be due to perforation of hollow viscus (stomach @ intestine) following procedures.examples following laparatomy.Laparoscopy??
As u can see a curved white line lying behind the heart.
