INTERPRETASI FOTO THORAX

Lenny Violetta
Departemen Radiologi RSUD Dr Soetomo
Fakultas Kedokteran Universitas Airlangga
2018
 FAKTOR YANG MEMPENGARUHI KUALITAS
FOTO THORAX

• FAKTOR TEKNIK
• ROTASI
• INSPIRASI
• PENETRASI
• PROYEKSI
• PA/AP
• POSISI
• BERDIRI/DUDUK/SUPINE
 ROTASI

Simetris Rotasi
ROTASI

Jarak antara medial clavikula kanan-kiri

dengan prosesus spinosus sama --> simetris
,tidak ada rotasi
 Jika prosesus spinosus lebih dekat dengan clavikula kanan , maka tubuh
pasien mengalami rotasi ke sisi kiri

Jika prosesus spinosus lebih dekat dengan clavikula kiri , maka tubuh pasien
mengalami rotasi ke sisi kanan
 INSPIRASI

Inspirasi adequat
Tampak costae 10 posterior
Costa 6 kanan anterior memotong
pertengahan diafragma
Costa posterior 10 akan
tampak pada kondisi
inspirasi optimal
Costa anterior 6 kanan
berpotongan pada
hemidiafragma kanan

10
 Pitfall Due to Poor Inspiration

Inspirasi yang kurang

membuat lung marking
lebih prominent ,
tampak pasien seperti
memiliki kelainan /
penyakit yang mengenai 8

airspace

Costa 8 posterior yang terlihat

Pada Pasien yang sama

8 9

Costa 8 yang terlihat Costa 9-10 yang terlihat

Pada inspirasi yang optimal,kelainan di basal paru akan

lebih jelas terlihat
Ekspirasi Inspirasi
Inspirasi kurang Inspirasi Optimal
 PENETRASI

• Penetrasi baik : Terlihat disc spaces+vertebral Th8

• UNDEREXPOSE
• OVEREXPOSE
 UNDEREXPOSE

• JANTUNG TERLIHAT
LEBIH OPAQUE
• TIDAK TERLIHAT VTH
• PARU TERLIHAT LEBIH
PUTIH KADANG
TERLHAT SEPERTI
INFILTRAT
Overexposure
• Jantung
tampak
radiolusent
• Paru tampak
lebih hitam 
parenchym
paru jadi
gelap 
emphyesema
PROYEKSI - POSISI
• PROYEKSI
• Posterior-anterior (PA)
• Anterior-posterior (AP)
• POSISI
• Berdiri,duduk atau supine
 POSTERIOR ANTERIOR (PA)

• Standard
• PA : minimal magnifikasi jantung
• Posisi berdiri
• Full inspirasi
Anteriorposterior (AP) Position
• Immobilisasi, tidak kooperatif
• Posisi : Duduk/ supine
• Jantung tampak lebih besar
• Scapulae tampak di dalam paru
Effect of projection on apparent heart size

PA X-ray tube

AP
Effect of projection on apparent heart size

PA X-ray tube

AP
 AP versus PA
Efek dari Magnifikasi

Film AP membuat gambaran Pasien PA  gambaran

jantung lebih besar dari ukuran jantung tidak mengalami
seungguhnya magnifikasi
 Anterior vs. Posterior Ribs
Costa Costa anterior
posterior akan tampak
lebih jelas lebih kabur
tampak Akan tampak
pada foto lebih
thoraks. melengkung
Akan kebawah
tampak sekitar 45
lebih derajat
horizontal
Bagaimana perbedaan antara costa
anterior dan posterior
Closed Scapula Opened Scapula
PROYEKSI FOTO THORAX
• PA
AP
LATERAL
 LATERAL VIEW
• Tujuan
– Menunjukan lokasi lesi yang Tampak pada PA
– Mengidentifikasi lesi di belakang jantung
– Tidak rutin di lakukan
LATERAL DECUBITUS
 LATERAL DECUBITUS
– Mengkonfirmasi kecurigaan adanya cairan
pada posisi PA

Subpulmonic effusion on decubitus film

• The PA film shows an apparently elevated right diaphragm
• On the decubitus view, the effusion flows up along the side of the lung
 Densities Displayed on CXR
• Air Black
• Fat
• Water/soft tissue
• Calcium
• Bone
• Metal
White
ANATOMI NORMAL THORAX
Normal PA CXR
Anatomi Thorax, PA
Gambaran Thorax Normal
Posisi Posteroanterior & Lateral
• Pada Foto thorax
normal, hal-hal yang
perlu diperhatikan
adalah :
1.Posisi
2.Simetrisasi
3.Inspirasi
4.Kondisi
Trachea
Left main bronchus
Right main bronchus
Carinal Angle (40-75 degrees)
Right pulmonary artery
Left pulmonary artery
Aortic Arch
Descending Aorta
Aortopulmonary Window
Right Heart Border = Right atrium
Left Heart Border = Left Ventricle
Left Atrium
Cardiothoracic Ratio (<50%)
 1
2

Anterior Ribs - full inspiration

Gastric air bubble
Normal lateral CXR
Trachea
Scapulae
2 hemidiaphragms
Gastric air bubble
Aortic Arch
Left pulmonary artery
Left upper lobe bronchus
Right pulmonary artery
Left atrium
Left ventricle
IVC
Oblique Fissures
 Horizontal

Fissures
Thoracic Vertebrae getting darker inferiorly
(if the lower vertebrae appear denser, it suggests pathology in a lower
lobe e.g. consolidation)
Anatomy
 Lobes
• Right upper lobe:
• Right middle lobe:
• Right lower lobe:
• Left lower lobe:
• Left upper lobe with Lingula:
• Lingula:
• Left upper lobe - upper division:
Interpretasi Foto Thorax
Don’t panic!
1. Cek label pasien – nama, DOB, gender,RM
2. Cek Posisi , Marker
– Marker R atau L (?dextrocardia)
– PA atau AP (tidak ada label : PA)
3. Faktor teknik
– Rotasi
– Inspirasi
– Penetrasi
4. Tanya kalau ada foto sebelumnya
 Rotated ED film

One lung field appears whiter,

Difficult to assess cardiac silhouette

Traumatic diaphragmatic hernia

Same patient,
better centred CXR
Don’t get caught out by markers!
Same image shown the correct way around –
Patient had Kartagener’s Syndrome with situs
inversus
Interpretasi Foto Thorax

ABCDEFGHI
 YANG DI EVALUASI
A - AIRWAY
B - BONES AND SOFT TISSUE
C - CARDIAC AND MEDIASTINUM
D - DIAFRAGMA
E - EFFUSION
F - FIELD OF LUNG
G - GAS BUBLE
H - HILA
I - INSTRUMENT
X ray chest reading technique
X ray chest reading technique
 Airway

• Trachea, carina dan main bronchus

 Airway
• Trachea
– Normal : central /sedikit ke kanan
– Deviasi  Rotasi /Kelainan
• Tertarik
– lobar collapse
– fibrosis (e.g. old TB)
– lobectomy
• Terdorong
– mediastinal mass
– tension pneumothorax – large pleural effusion
 Airway
• Trachea
– Menyempit?
• Retrosternal goitre, mediastinal masses
• Carina
– Splayed?
• Normal carinal angle : ~60 degrees (range 40-75)
• Angle meningkat ok subcarinal lymphadenopathy,
left atrial enlargement
 Airway
• Bronchi
– Menyempit?
– Elevasi atau depressi?
• Lobar collapse, lobectomy, fibrosis
 Goitre
Trachea

Retrosternal goitre

Goitre on CT
Splaying carina akibat
lpembesaran atrium kiri
(cardiomyopathy)
 Bones & soft tissue
• Destruksi tulang – metastases
Osteolityc
Osteoblastyc
• Erosion oleh tumour di dekatnya c/ Pancoast
• Fraktur costae
– Sensitivitas CXR < 20%
– Bila ada Fraktur ,cari apakah ada pneumothorax,
hematothorax,lung contusio
• Dislokasi Shoulder
Right mastectomy - rib met and pathological fracture left humerus
Rib met
Forequarter amputation – left clavicle and scapula missing
 Soft Tissues
• Surgical emphysema – leher and thorax
– Trauma
– Surgery
– Chest drain
– Asthma
• Ketika tampak surgical emphysema, lihat apakah
ada pneumothorax /pneumomediastinum
•Breast : Mastectomy?
– Paru terlihat relatif lebih gelap
– Cek apakah ada
• Lung mets
• Pleural effusion
• Interstitial disease (lymphangiitis)
• Lymphadenopathy
• Bone mets
Right mastectomy – arrow pointing at left breast
shadow Note how relatively lucent the right lung
appears.
Left mastectomy
Beware of remaining nipple mimicking a nodule!
 C-Cardiac - MEDIASTINUM

• 2/3 jantung berada di sisi kiri,1/3 di sisi kanan

• Normal CTR < 50 %
• Batas jantung kiri di bentuk oleh : Atrium dan ventrikel kiri Batas jantung
kanan adalah atrium kanan
• Cek
• Size  CTR
• Shape
• Silhouette margins
• Kalsifikasi abnormal
• Valves,a.coronary, old infark,atrial myxoma pericarditis ec old TB
• Aorta thoracalis aneurisma ?
• Aorta pulmonary window – Nodes?
Left atrium enlargment
Membesar atau tidak

Ya
Membesar atau tidak ?

Ya
Membesar atau Tidak

Tidak
Left atrial enlargement in mitral stenosis -
double right heart border, splayed carina
Sternotomy wires and aortic valve replacement
Ascending thoracic aortic aneurysm
Kerley B lines

Left atrial enlargement

Upper lobe venous diversion

- patient with mitral stenosis
Magnified Kerley B lines in same patient
Large hiatus hernia
MEDIASTINUM
 Diaphragma

• Normal
– Berbentuk kubah
– Dibawah diafragma terlihat lung marking
– Kanan lebih tinggi dari kiri
Bila perbedaan tinggi :
– Phrenic nerve palsy e.g. tumour, surgery
– Atelektasis
– Hernia Diaphragmatic hernia
– Subpulmonic effusion
Cek
– Depressi, flattening diaphragma
– Hyperinflation (asthma, COPD, cystic fibrosis)
– Gas di bawahdiafragma(erect film
Pneumoperitoneum
E- Effusion

• Effusi
• Lihat sinus phrenicocostalis ,Tajam/tumpul
• Cek
• Penebalan pleura
• loculated cairan
• Kalsifikasi
• Pneumothorax
FIELD OF LUNG

upper

middle

lower
• Lung marking : Normal sampai 2/3 paru
FIELD OF LUNG
• Apakah densitas paru sama?
• Satu terlalu hitam bisa ok:
– Rotation
– Mastectomy
– Pneumothorax
– Large bull
• Satuterlaluputih
– Pleural effusion
– Pleural mass (mesothelioma, mets)
– Lobar collapse
– Consolidation
– Pulmonary mass
Left lung slightly dark-
small pneumothorax
Large effusion with mediastinal shift
Effusion with absent meniscus -
hydropneumothorax
• Apakah densitas kedua paru sama
• Kedua paru terlalu hitam
– Overexposed
– COPD
– Hitung costae (> 8 anterior)
• Kedua paru terlalu putih
– Underexposed film
– Pulmonary oedema
– Pulmonary fibrosis (what zones??)
– Miliary shadowing – TB, mets
 1

Emphysema
Flattened diaphragms
• Too many ribs
Pulmonary oedema - cardiomegaly
• Apakah volume hemtihorax sama?
– Volume meningkat
• Tension pneumothorax
• Large effusion
– volume berkurang
• Lobar collapse
• Lobectomy, pneumonectomy
• Fibrothorax (restrictive, thickened pleura
secondary old TB / empyema)
• Diaphragmatic paralysis or rupture
Tension pneumothorax
Surgical emphysema – pneumothorax (arrow)
G – Gastric Air Bubble

• NORMAL:
• Bentuk kubah
• Kanan lebih tinggi dari kiri
• Cek
• Lihat udara bebas/pneumoperitoneum
• Bowel antara diafragma dan liver
H.HILUM

• Struktur yang complex terdiri dari a-v pulmonum , main

bronchus dan lymph node ( Normal tidak terlihat)
• Normal: Hilus kiri lebih tinggi dari kanan
• Check
• Posisi ,size dan densitas
• Enlarged lymph nodes
• Calcified nodules
• Mass lesions
• A. Pulmonary > , 1.5cm pikirkan kemungkinan dilatasi
Instrument

• Tubes ,IV lines, EKG leads, surgical drains,

pacemaker,posisi dimana.
 CXR Patterns

• Having identified that the lungs are abnormal,

you now need to decide what the problem is
• Which of the following patterns does the
abnormality fit into?
– Alveolar consolidation
– Interstitial lung disease
– Atelectasis (collapse)
– Nodules and masses
– Cavities and cysts
– Calcification/ossification
Kelainan pada paru
• Densitas meningkat
• Consolidation
• Atelectasis
• Nodule or mass - solitary or multiple
• Interstitial
• Densitas menunrun
• Emphysema or lung cysts.
 Alveolar Consolidation
• Sign
– Localized or diffuse
– Homogeneous, amorphous increased density
– Ill-defined margins
– Air bronchograms
– No volume loss
Air bronchograms in left lower lobe and lingular pneumonia
 Alveolar Consolidation
• Causes
– Air ( oedema)
– Pus (pneumonia)
– Blood (contusion, vasculitis, Goodpasture’s,
anticoagulation)
– Chronic infiltrative lung disease (BOOP, alveolar
proteinosis, eosinophilic pneumonias)
– Neoplasm (adenocarcinoma)
– Aspiration (gastric contents, near-drowning)
 Alveolar Consolidation
• Which lobe is involved?
• Look for absent silhouette:
– Right hemidiaphragm = RLL
– Right heart border = RML
– Left hemidiaphragm = LLL
– Left heart border = lingula (of LUL)
– None – could be upper lobes or apical
segments of lower lobes
 Horizontal fissure

RUL (above horizontal fissure) and

lingular (obscuring left heart border)
pneumonia
 Small effusion
(meniscus sign)

RLL pneumonia LLL pneumonia (apical segment)

LLL pneumonia obscuring left hemidiaphragm
 Interstitial Lung Disease
• Signs
– Opacities
• Linear (reticular – fine or coarse)
• Nodular
• Mixed (reticulonodular)
– Septal lines e.g. Kerley B
– Honeycombing
 Interstitial Lung Disease
• Examples
– Reticular pattern
• Fibrotic lung diseases
– UIP/CFA/IPF
– Collagen vascular disease
– Asbestosis
 Interstitial Lung Disease
• Examples
– Nodular pattern
• Silicosis
• Coal workers’ pneumoconiosis
• Sarcoidosis
• Miliary TB
Fine reticular pattern -
Idiopathic pulmonary fibrosis
Nodular pattern - miliary TB
 Atelectasis
• Signs
– Opacification of a lobe
– Volume loss
• Displacement of fissures
• Elevated hemidiaphragm
• Mediastinal displacement
• Tracheal displacement
• Compensatory hyperinflation of opposite lung
 Atelectasis
• Right upper lobe atelectasis
– Collapses superiorly and medially
– Wedge shaped opacity in right upper zone
– Horizontal fissure displaced upwards
– Oblique fissure displaced anteriorly on lateral CXR
 Atelectasis
• Left upper lobe atelectasis
– ‘veil’-like opacity in left hemithorax
– Often obliterates left heart border silhouette
(as lingula is in LUL)
– Elevated left hilum
– Oblique fissure displaced anteriorly
LUL collapse -
trachea displaced to left
left hilum elevated
left hemidiaphragm elevated
 Atelectasis
• Right middle lobe atelectasis
– Collapses medially obliterating right heart border
– On lateral, see wedge-shaped opacity anteriorly
– Pulls horizontal fissure downwards
RML collapse
 Atelectasis
• Lower lobe atelectasis
– Similar appearance on both sides
– Obliterates normal silhouette of hemidiaphragm
– On lateral CXR, see triangular density posteriorly
with increasing opacity of lower thoracic
vertebrae
LLL collapse – ‘sail’ sign
LLL collapse – lateral
 Nodules and Masses
• Nodule <3cm, massa >/= 3cm
• Solitary or multiple?
• Solitary – DD/
– Bronchogenic ca, granuloma, hamartoma, met
• Multiple – DD/
– Mets, granulomas, rheumatoid nodules,
sarcoidosis
Bronchogenic carcinoma -
background COPD and thoracic aortic aneurysm
Cannonball metastases
 Cavits dan Cysts
• Cyst = thin wall (< 3mm)
– Fluid atau air-filled,atau keduanya (air/fluid
level)
• Cavity = thicker wall (> 3mm)
– Always contain air +/- air/fluid level
– Usually in an area of consolidation, a mass or a
nodule
 Cavities or Cysts
• Types
– Congenital
• Bronchogenic cyst
• Cystic adenomatoid malformation
– Acquired
• Infection – abscess, TB, fungal, septic infarct
• Rheumatoid nodules
• Wegener’s
• Neoplasms - primary (SCC), mets
• Bullae
• Bronchiectasis
Cavitating pneumonia
 Calcification and Ossification
• Nodules
– TB, histoplasmosis, mets from osteosarcoma
• Diffuse
– Alveolar microlithiasis
– Silicosis
– End-stage mitral stenosis
– Healed infections – miliary TB, chickenpox
Multiple very dense lung masses –
Metastatic osteosarcoma