CHEST X RAY

KABERA René MD, M.Med Candidate

Resident PGY II, Family and Community Medicine
Faculty of Medicine
National University of Rwanda
Objectives

• Differences between radiodence and radiolucent

objects on an x-ray film.
• Four most common x-ray view.
• Steps of reading a chest x-ray.
• Identify major landmarks on chest x-ray.
• Major syndromes on a CXR.
• References .
Radiodence and radiolucent image

• The greater the density, the less penetration

of x-ray through the object.
The film remains under exposed.
Color: white.

• The less dense object allows x-ray to

penetrate it
The film is more exposed.
Color: black.
Radiodence and radiolucent image

• AIR

• FAT

• BLOOD

• MUSCLE

• BONE
FOUR X-RAY VIEW

• POSTEROANTERIAL [PA]
• ANTEROPOSTERIAL [AP]
• LATERAL [L]
• OBLIQUE [ 3/4 ]
FOUR X-RAY VIEW

• Typical CXR is a PA
• More views are better than one bcs
the body is 3 dimensional.
Read a CXR

• Check the name on the film

• Check the date of the film
• Chest anatomy
Quick look : BSO
Bones : Deformation or wrong place.
Soft tissue: is there air where it shouldn’t
be?
Organs: are they all there ?
Symetrical ?
Read a CXR

• Chest anatomy

• Trachea
• Clavicle
• Spatula

• Lung field
• Mammal gland
• Heart
• Ribs
• Vertebrae
• Costo-diaphragmatic angle

• Gastric Air bubble

Read a CXR

• PA view
• Clavicles are straight ?
• How many ribs ?

Count ante ribs.

Count post ribs.
Count spaces between post ribs.

7-8 inspiration

5-6 expiration
Read a CXR

• Ante ribs

• Spaces :ante / post

• Post ribs
Read a CXR

• Inspiration • Expiration
Read a CXR

• Standing • Lying

X
 Read a CXR

• How big is the heart [ PA view only ]

• ID = Internal diameter of chest at level

of right hemidiaphragm
MRD = greatest perpendicular diameter
from midline to right heart border
MLD = greatest perpendicular diameter
from midline to left heart border
• CT index = (MRD + MLD)/ID
• 0-3 wks: CT 0.55
• 4-7 wks: CT 0.58
• 2-11months: CT 0.57-0.54
• 1yr -6yrs: CT 0.53-.045
• >7 yrs :<0.50
Read a CXR

• Look at the lungs

Are the diaphragmatic
borders clear and
sharp?

Are the cardiac borders
clear and sharp?
Read a CXR

• THYMUS

-Thymus: visible till 2 years

old.
-Anatomical confusions
with pathological image.
Read a CXR
• Lung field
Right :
• upper and middle
lobes are div. by
major fissure .
[PA, L]
• Middle and lower
lobes are div. by minor
fissure .
Left :
• upper and lower
lobes div. major fissure
Read a CXR

• Fissures seen on film x-

ray that may indicate a
pathology.
Read a CXR

• “Silhouette ”Sign

Same plan

Different plan
Read a CXR

• NORMAL CXR
 Major landmarks on CXR
• Alveolar syndrome
• Interstitial syndrome
• Bronchial syndrome
• Pleural syndrome
• Cavity syndrome
• Vascular syndrome
• Parietal syndrome
• Mediastinum syndrome
Major landmarks on CXR

• Alveolar syndrome:
-Opacities with out of focus borders, confluence
-Rapid onset.
-Aeric bronchogramm.
-Alveolar nodules.

D’se involved:
Localised : pneumonia ,tbc, pulmonary oedema,
broncho-alveolar cancer …
Diffuse : Viral dss, Inhalation, HMD …
 Major landmarks on CXR
• ALVEOLAR SD
1. PNEUMONIA
RUL RML
Major landmarks on CXR

• ALVEOLAR SD
1.PNEUMONIA
[LUL]
Major landmarks on CXR

• ALVEOLAR SD
2.BRONCHOPNEUMONIA
Major landmarks on CXR

• INTERSTITIAL SD

Well limited opacities.

Micronodular opacities.

Not organised. No confluence.

No air bronchogram.

Slow evolution.

Kerley ligns.

D’se involved: TBC, bronchiolitis, inhalation
pneumonia, PCP, mucoviscidosis…
Major landmarks on CXR

• INTERSTITIAL SD

KERLEY LINES
Major landmarks on CXR

• INTERSTITIAL SD
1.TBC [MILIAIRE]
Major landmarks on CXR

• INTERSTITIAL SD
1.PULMONARY TBC
Major landmarks on CXR

• INTERSTITIAL SD
2.PCP
Major landmarks on CXR

• INTERSTITIAL SD
3.PULMONARY
FIBROSIS
Major landmarks on CXR

• INTERSTITIAL SD
4.INHALATION
PNEUMONIA
Major landmarks on CXR

• INTERSTITIAL SD

5.MUCOVISCIDOSE
Major landmarks on CXR

• BRONCHIAL SD

Thickening of the bronchial wall .

Dilatation of the bronchial lumen.

Hypersecretion ,bronchial obstruction, …

Obstruction of the bronchial lumen.

Dse’s involved: chronic bronchitis.
atelectasis
 Major landmarks on CXR

• BRONCHIAL SD

Atelectasis right lung

Major landmarks on CXR

• BRONCHIAL SD

Chronic bronchitis

Dilatation of bronchial
lumen
Major landmarks on CXR

• PLEURAL
SYNDROM
1.Pleural effusion
Damoiseau curve
Major landmarks on CXR

• PLEURAL SD
1.Pleural effusion
[ Lying position ]
Major landmarks on CXR

• PLEURAL SD
2.Pneumothorax
Major landmarks on CXR

• MEDIASTINUM SD
Air , liquid, lymphadenopathies, tumors in
mediastinum…
Major landmarks on CXR

• MEDIASTINUM SD
1.Pneumopericardium
Major landmarks on CXR

• MEDIASTINUM SD

2. LYMPHADENOPATHIES
Major landmarks on CXR

• CAVITY SD
1.PULMONARY ABCESS
Major landmarks on CXR

• CAVITY SD
2.KYSTE HYDATIQUE
 Major landmarks on CXR
• CAVITY SD
3.METASTASIS
Major landmarks on CXR

Cavitating Metastasis
Multiple Thin Walled Cavities
Major landmarks on CXR
CAVITY SD
Major landmarks on CXR

• VASCULAR SD
Major landmarks on CXR

• PARIETAL OR
EXTRAPLEURAL
SYNDROME

concerning soft tissue and

bones .[deformation,
tumors…]

Horizontal ribs
Major landmarks on CXR

• PARIETAL OR
EXTRAPLEURAL
SYNDROME

Breast cancer
Major landmarks on CXR

 PARIETAL OR
EXTRAPLEURAL
SYNDROME

Old fractured ribs

References

• www.uab.edu/pedradpath
• www.pediatricradiology.com

• www.spiral.univ-lyon1.fr/polycops/semeilogie-radiologique
• www.virtualpediatrichospital.org/providers
• Notes de cours “Imagerie médicale”.Doc III Prof SPEHL
Marianne.NUR/FACMED
• Chest x-ray Atlas ,
http://www.meddean.luc.edu/lumen/MedEd/medicine/pulmonar/
cxr/atlas/cxratlas_f.htm
THANK YOU
Murakoze