RespPath-Lecture 3b-Basic Chest X-Ray Interpretation

Lecture 3
Prepared and presented by

Marc Imhotep Cray, M.D.
Photo: Colorized scanning electron micrograph of the lung, showing alveoli. Seeley’s Anatomy & Physiology. 10th ed. New York, NY; McGraw-Hill 2010
Respiratory Patholog
Introduction
Lecture 3 CXR Interp
REVIEW OF NORMAL CHEST

 ADMINISTRATIVE
 INITIAL SURVEY
USUHS - Chest X-Ray Review
Marc Imhotep Cray, M.D. 2

REVIEW OF NORMAL CHEST Lecture 3 CXR Interp
A systematic approach to film review follows and is

designed to stress that major areas of chest should be
viewed in sequential order

REVIEW OF NORMAL CHEST (2) Lecture 3 CXR Interp
Sequenced Checklist
1. Check patient name, position, technical quality.
2. Soft tissue including breast, chest wall, companion shadow.
3. Review soft tissues and skeletal structures of shoulder
girdles and chest wall.
4. Review abdomen for bowel gas, organ size, abnormal
calcifications, free air, etc.
5. Review soft tissues and spine of neck.
6. Review spine and rib cage: check alignment, disc space
narrowing, lytic or blastic regions, etc.

Sequenced Checklist
7. Review mediastinum:
A.overall size and shape
B.trachea: position
C.margins: SVC, ascending aorta, right atrium, left subclavian
artery, aortic arch, main pulmonary artery, left ventricle
D.lines and stripes: paratracheal, paraspinal, paraesophageal
(azygoesophageal), paraaortic
E.retrosternal clear space

Sequenced Checklist cont.

8. Review hila:
A.normal relationships
B.size
9. Review lungs and pleura:
A.compare lung sizes
B.evaluate pulmonary vascular pattern: compare upper to
lower lobe, right to left, normal tapering to periphery
C.pulmonary parenchyma
D.pleural surfaces
a.fissures - major and minor - if seen
b.compare hemidiaphragms
c.follow pleura around rib cage
ADMINISTRATIVE
 Get in habit of always
checking following items
before anything else
 It takes a few seconds and is an
important legal safe guard
1.Patient's name
2.Date exam done (very
important if comparing prior
exams)
3. Check for position
markers - right vs. left,
upright

ADMINISTRATIVE (2) Lecture 3 CXR Interp
Other items to check before commencing with clinical review of film include:
1.Type of film
2.Patients position - supine, upright, lateral, decubitus.
3.Technical quality of exam

ADMINISTRATIVE (3)
 A basic principle to adopt is going from general observations to specific
details.
 After completing your administrative housekeeping, get a general

overview of film before zooming in on tiny detail.
 Notice the following because it may change baseline normals you use
as reference points, and you may be sensitized to look for specific
findings.
1.General Body Size, Shape, and Symmetry
2.Male vs. Female
3.Is this an infant, child, young adult, elderly person?
4.Survey for foreign objects - tubes, IV lines, EKG leads, surgical drains, prosthesis, etc.,
as well as non-medical objects, bullets, shrapnel, glass, etc.

The Chest X-Ray Lecture 3 CXR Interp
The following radiographic plates are scan ins from:

Felson, B., et al.: Principles of Chest Roentgenology. Philadelphia, W.B. Saunders Co., 1973.
Fraser, R., et al.: Diagnosis of Diseases of the Chest, 3rd edition. Philadelphia, W.B. Saunders Co., 1988.

Outline
•Densities
•Techniques
•Anatomy
•CXR Interpretation
•Common Pathologies

Densities
The big two densities are:
(1) WHITE - Bone
(2) BLACK - Air
others are:
(3) DARK GREY- Fat
(4) GREY- Soft tissue/water
And if anything man-made is on
the film, it is:
(5) BRIGHT WHITE – man made

Techniques - Projection Lecture 3 CXR Interp
PA (relation of x-ray beam to patient)

Techniques - Projection (continued)

Lateral

Techniques - Projection (continued)

Lateral Decubitus

Rotation

Rotation (continued)

Penetration

Inspiration/Expiration

Anatomy

Anatomy

Anatomy

Lobes Right upper lobe:

Lobes (continued) Right middle lobe:

Lobes (continued)
Right lower lobe:

Lobes (continued)
Left lower lobe:

Lobes (continued)
Left upper lobe with Lingula:

Lobes (continued) Lingula:

Lobes (continued) Left upper lobe - upper division:

Heart (continued)
Right border: Edge of (r) Atrium
2. Left border: (l) Ventricle + Atrium
3. Posterior border: Left Ventricle
4. Anterior border: Right Ventricle

Heart (continued)

Heart (continued)
Valves

Mediastinum

Hilum
Made of:
1. Pulmonary Art.+ Veins
2. The Bronchi
Left Hilus higher (max 1-2.5

cm)
Identical: size, shape, density

Ribs

Lateral CXR anatomy

Lateral CXR (continued)


Tracheoesophageal Stripe


CXR Interpretation
Chest radiographs reveal normal posterior- anterior (PA) (left) and lateral (right)
Darker air density represents the aerated lung parenchyma, with soft tissue and
bone of chest wall and hilum brighter
Normal PA heart shadow is about width of left lung
Technical Details
•Type
•Orientation
•Rotation
•Inspiration/expiration
•Penetration

Lungs:
•Lungs
• Density
• Symmetry
• Lesions

Heart Size:

Heart
• Size of heart
• Size of individual chambers
of heart
• Size of pulmonary vessels
• Evidence of stents, clips,
wires and valves
• Outline of aorta and IVC
and SVC

Mediastinum:
• Width
• Contour
• AP window
• Size
• Location

Review areas:
• Apices
• Behind the heart
• CP angles
• Below the diaphragm
• Soft tissues ( breast, surgical emphysema)
• Ribs & clavicle
• Vertebrae

Identify the lesion → localize the lesion →

describe the lesion → give DDx
Never stop looking, carry on with your

systematic approach!!

Pathology
The following radiographic plates are scan ins from:
Felson, B., et al.: Principles of Chest Roentgenology. Philadelphia, W.B. Saunders Co., 1973.
Fraser, R., et al.: Diagnosis of Diseases of the Chest, 3rd edition. Philadelphia, W.B. Saunders Co., 1988.

RUL pneumonia

RML pneumonia

RLL pneumonia

LUL pneumonia

LLL pneumonia

• Consolidation on CT

Hilar mass
Enlarged Hilum
Causes:
1. Neoplasia
2. Infection
3. Primary Tumor
4. Vascular
5. Sarcoidosis

• Multiple Masses

Hilar Lymphadenopathy - BL

Hilar Lymphadenopathy - BL
Pleural Effusion
Pulmonary Fibrosis
Heart failure
Pneumothorax

RUL collapse
LLL collapse

Air under the diaphragm

Emphysema
Cavitating lesion

Hiatus hernia
Miliary shadowing

Chest Tube, NG Tube, Pulm. artery cath


Companion Online Folder:

Basic Chest X-Ray Interpretation (Video Mini-Tutorials)
Further study:
Radiology Online Study Resources:
 Albert Einstein Medical Center – Learning Radiology eMedicine - Radiology
 GE - Medcyclopaedia
 McGill University - Basic Radiology Primer: An Introduction to Problem-Oriented
Imaging Algorithms
 Medical College of Wisconsin - Chorus RadiologyEducation.com
 SearchingRadiology.com
 StudentBMJ - Introduction to Imaging
 USUHS - Chest X-Ray Review

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Lecture 3

Prepared and presented by

REVIEW OF NORMAL CHEST

Marc Imhotep Cray, M.D. 2

REVIEW OF NORMAL CHEST Lecture 3 CXR Interp

A systematic approach to film review follows and is

Marc Imhotep Cray, M.D. 3

REVIEW OF NORMAL CHEST (2) Lecture 3 CXR Interp

Marc Imhotep Cray, M.D. 4

REVIEW OF NORMAL CHEST (3) Lecture 3 CXR Interp

Marc Imhotep Cray, M.D. 5

Sequenced Checklist cont.

Marc Imhotep Cray, M.D. 7

ADMINISTRATIVE (2) Lecture 3 CXR Interp

Marc Imhotep Cray, M.D. 8

 After completing your administrative housekeeping, get a general

Marc Imhotep Cray, M.D. 9

The Chest X-Ray Lecture 3 CXR Interp

The following radiographic plates are scan ins from:

Marc Imhotep Cray, M.D. 10

Marc Imhotep Cray, M.D. 11

Marc Imhotep Cray, M.D. 12

Techniques - Projection Lecture 3 CXR Interp

PA (relation of x-ray beam to patient)

Marc Imhotep Cray, M.D. 13

Techniques - Projection (continued)

Marc Imhotep Cray, M.D. 14

Techniques - Projection (continued)

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Lobes Right upper lobe:

Marc Imhotep Cray, M.D. 23

Lobes (continued) Right middle lobe:

Marc Imhotep Cray, M.D. 24

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Lobes (continued) Lingula:

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Lobes (continued) Left upper lobe - upper division:

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2. Left border: (l) Ventricle + Atrium

3. Posterior border: Left Ventricle

4. Anterior border: Right Ventricle

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Left Hilus higher (max 1-2.5

Identical: size, shape, density

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Lateral CXR anatomy

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Lateral CXR (continued)

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Lateral CXR (continued)

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