In the United States, chest x-rays are routinely obtained for

hospitalized adults. Pulmonary specialists will almost never provide a

consultation without having seen a chest x-ray. In under developed countries
chest x-rays are obtained very selectively and physicians rely mostly on
physical exam and history for diagnosis. Physical examination of the chest
has inherent limitations. Lesions located in the mediastinum, interstitium,
and in the center of the lung are rarely picked up by physical exam. Ease of
availability of chest x-ray has made many physicians avoid time consuming
physical exam which in most cases fails to reveal all of the problems. As a
result, physicians have lost the skill of physical exam. Just as physical
examination has limitations, chest x-ray also has limitations, and it should be
recognized that a normal chest x-ray does not rule out pulmonary problems.
Interstitial, airway and pulmonary vascular disease in certain cases cannot
be recognized by chest x-ray while it is easily evident on physical exam, e.g.
asthmatics can have normal chest x-rays. Physical exam and chest x-ray
provide a compliment of any information and they are not mutually
exclusive. Physical exam in general is good for acute illness, while chest xray is better for chronic illness.
--------------------------------------------------------------------------------------------------Overexposure causes a film to be too dark. Under these circumstances,
the thoracic spine, mediastinal structures, and retrocardiac areas are well
seen, but small nodules and the fine structures in the lung cannot be seen
Underexposure causes the film to be quite white. This is a major
problem for adequate interpretation. It will make small pulmonary blood
vessels appear prominent and may lead you to think that there are
generalized infiltrates when none is really present.
The major difference between male and female chest x-rays is caused
by differences in the amount of breast tissue. Breast tissue absorbs some of
the x-ray beam, essentially causing underexposure of the tissues in the path.
This is not a problem if the inferior aspect of the breasts is above the
hemidiaphragms.
Chest x-rays on ambulatory patients are usually done with the
patients chest up against the film holder. The x-ray tube is behind the
patient, and the beam passes from the back and exits in front of the chest.
This is referred to as a PA (posterior to anterior) projection. If the patient is
lying down, it is standard practice to take an AP (anterior to posterior) chest
x-ray.

-----------------------------------------------------------------For interpretive purposes, the main difference is that the heart will be
magnified on an AP projection. This is because in the AP projection the heart
is farther from the film and the x-ray beam diverges as it goes farther from
the tube.
The amount of inspiration is greater in an upright film, which allows for
spreading of the pulmonary vessels and allowing clearer visualization.
Another reason for preferring upright films is that small pleural effusions tend
to run down into the normally deep costophrenic angles.
The degree of inspiration is important not only for assessing the quality
and limitations of the examination but also for diagnosing different diseases.
When standing, most adults can easily take an inspiration that brings
the domes of the hemidiaphragms down to the kevel of the tenth posterior
ribs.
When sitting down, often the level is between the eighth and tenth
ribs.
If the radiograph has the domes of the diaphragms at the seventh
posterior ribs, the chest should be considered hypoinflated, and you need to
be very careful before diagnosing basilar pneumonia or cardiomegaly.
First, inspect the BONY FRAMEWORK of the chest
You should be able to count and number the ribs, inspect the scapulae,
humeri and shoulders, and clavicles, and seethe diaphragms overlying the
posterior aspects of the 10th or 11th ribs (in a normal adult)> The spine and
sternum are generally difficult to visualize in detail on standard PA films due
to overlying shadows.
Next, inspect the soft the SOFT TISSUES that overlie the
thoracic
cage
Note the breast shadows,supraclavicular areas, axillae, and tissues along the
sides of the chest.
Examine
the
LUNG
FIELDS
and
HILA
The hilum ("lung root") is the shadow of pulmonary artery and vein adjacent
the
heart
shadow.
Normal lung markings are the linear and fine nodular shadows of pulmonary
vessels.

Abnormalities in the lung fields are marked by excessive radiolucency,

excessive radiopacity, or opacified areas.
Next, examine the DIAPHRAGM and PLEURAL SURFACES
Diaphragmatic images in the lung bases are dense, radiopaque shadows
made principally by the liver on the left and the spleen on the right.
The normal pleura is not visible on the chest x-ray, except where two layers
come together to form the interlobar fissures.
Finally, examine the MEDIASTINUM and and HEART
Displacement of the mediastinum is an important clue to disease in on or the
other
hemithorax.
On the PA chest film, the normal right heart and mediastinal border is made
up (from bottom to top) of the 1) inferior vena cava; 2) the right atrium;
3)ascending aorta; and 4) superior vena cava. The normal left heart and
mediastinal border consists (from bottom to top) of the 1) left ventricle; 2)
left atrium; 3)pulmonary artery; 4) aortic arch; and 5) subclavian artery and
vein

A patient lying down is unable to take a full inspiration; the liver and
abdominal contents are pushing up on the lungs and heart, and the result is
that the pulmonary vessels are crowded. On a supine film, the standard AP
projection combined with the cephalic push of the abdominal contents will
make a normal heart appear large.
1. Poor inspiration results in high diaphragms and crowding of normal
lung markings.
2. Over- or under-penetration of the x-ray beam can obliterat or
exaggerate important findings. On a properly-penetrated PA chest
rafiograph, one can just make out the thoracic vertebrae overlying the
image of the heart.
3. Rotation from the true perpendicular on the PA chest film distorts
normal structures. Check proper orientation by noting equal distances
from the vertebral spines to the medial ends of the clavicles.

The right upper lobe (RUL) occupies the upper 1/3 of the right lung.
Posteriorly, the RUL is adjacent to the first three to five ribs. Anteriorly,
the RUL extends inferiorly as far as the 4th right anterior rib
The right middle lobe is typically the smallest of the three, and appears
triangular in shape, being narrowest near the hilum.
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; there is
considerable overlap between the more anterosuperiorly located RUL and
the RLL.
Similarly, the deep posterior gutters extend considerably
inferiorly; with full inspiration, the lower lobe can extend may as low as
L2, becoming superimposed over the upper poles of the kidneys.
Grossly, these lobes can be separated from one another by two fissures
which anatomically correspond to the visceral pleural surfaces of those
lobes from which they are formed. The minor fissure separates the RUL
from the RML, and thus represents the visceral pleural surfaces of both of
these lobes.
The minor fissure is oriented horizontally, extending
ventrally from the chest wall, and extending posteriorly to meet the major
fissure. Generally, the location of the minor fissure is approximately at the
level of the fourth vertebral body and crosses the right sixth rib in the
midaxillary line. The right major fissure is more expansive in size than the
minor fissure, separating the right upper and middle lobes from the larger
right lower lobe. Oriented obliquely, the major fissure extends posteriorly
and superiorly approximately to the level of the fourth vertebral body. The
major fissure extends anteroinferiorly, intersecting the diaphragm at the
anterior cardiophrenic angle
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; left upper and left lower lobes

. 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.

It is important to understand that in most individuals, interlobar fissures

are usually not completely formed; in some individuals there may be
complete absence of a fissure thus losing the demarcation between lobes
on gross examination.
In general, fissures are not readily identifiable on plain films, with only
small portions typically visualized at best. This is because fissures which
are composed of only two layers of visceral pleura, may not present a
significant radiographic interface and will not produce a shadow. However,
if there is fluid within the pleural space or if the visceral pleura is
thickened, fissures may be seen in their entirety.
Each tissue reacts to injury in a predictable fashion. Multiple etiology can
evoke a similar pathological reaction. Let us just exam the pathological
process that can occur in the lung. Lung injury or pathological states can
be either a generalized or localized process.
Consolidation: In the lobar consolidation, a lobe is involved. The alveolar
space is filled with inflammatory exudate made up of WBC, bacteria,
plasma, and debris. In Pneumococcal pneumonia, the most common
cause for lobar consolidation, the lobe goes through red hepatization and
gray hepatization stage. In the stage of resolution, some secretions can
be in the airway. The interstitium and architecture of the lung remain
intact and complete recovery occurs. The lobe swells up initially and may
shrink slightly later if there is significant secretions in the airway causing
some obstruction. The airway is patent.
Radiologically this transcribes to:
1. a density corresponding to a segment or lobe
2. airbronchogram, and
3. no significant loss of lung volume.
Atelectasis: Atelectasis means loss of air. In absorptive Atelectasis there is
an obstructive lesion on the bronchus. There is no ventilation to the lobe
beyond the obstruction. Gradually the air gets absorbed by pulmonary
circulation. The involved lobe eventually is devoid of air and becomes
atelectatic.
Radiologic criteria for absorptive Atelectasis is

1. a density corresponding to a segment or lobe,

2. significant signs of loss of volume, and
3. compensatory hyperinflation of normal lungs.
STAGES OF EVALUATING AN ABNORMALITY:
In reading chest x-rays, I recommend that you do it in 4 steps:
Step:

1. Identify the abnormal shadows

2. Anatomically localize the lesion

3. Identify pathological process
4. Identify the etiology
Step 1: Identification of abnormal shadows
You have to know what is normal before you recognize abnormalities. Let
us identify the normal structures in the thorax (heart, aorta, pulmonary
artery, lung fields, costophrenic angles, diaphragm, trachea, etc.).
Which lung is larger?
Which diaphragm is higher and why?
What is the normal size of the heart?
What is the normal size and shape of the aorta?
You need to know normal and variations before you can detect and
recognize abnormal shadows on chest x-ray.