Dr.

Sreedhar Rao
Associate Professor, Department of Rog Nidan
 MODULE 1: Outline
What is a Chest X-ray (Chest Radiography)?
What are some common uses of the procedure?
How should the patient be prepared?
What does the equipment look like?
How does the procedure work?
How is the procedure performed?
What will patient experience during and after the
procedure?
Who interprets the results?
What are the benefits vs. risks?
What are the limitations of Chest Radiography?
What is a Chest X-ray (Chest Radiography)?

The chest x-ray is the most commonly performed

diagnostic x-ray examination.
A chest x-ray makes images of the heart, lungs,
airways, blood vessels and the bones of the spine and
chest.
An x-ray (radiograph) is a noninvasive medical test that
helps physicians diagnose and treat medical conditions.
Imaging with x-rays involves exposing a part of the
body to a small dose of ionizing radiation to produce
pictures of the inside of the body.
X-rays are the oldest and most frequently used form of
medical imaging.
What are some common uses of the procedure?

The chest x-ray is performed to evaluate the

lungs, heart and chest wall.

A chest x-ray is typically the first imaging test

used to help diagnose symptoms such as:
shortness of breath.
a bad or persistent cough.
chest pain or injury.
fever.
 Physicians use the examination to
help diagnose or monitor treatment
for conditions such as:
pneumonia.
heart failure and other heart problems.
emphysema.
lung cancer.
line and tube placement.
other medical conditions.
How should the patient be prepared?
A chest x-ray requires no special preparation.
Patient may be asked to remove some or all of his
clothes and to wear a gown during the exam.
They may also be asked to remove jewelry, removable
dental appliances, eye glasses and any metal objects or
clothing that might interfere with the x-ray images.
Women should always inform their physician and x-ray
technologist if there is any possibility that they are
pregnant.
Many imaging tests are not performed during
pregnancy so as not to expose the fetus to radiation.
If an x-ray is necessary, precautions will be taken to
minimize radiation exposure to the baby.
 What does the equipment look like?
The equipment consists of a wall-mounted,
box-like apparatus containing the x-ray film or
a special plate that records the image digitally
and an x-ray producing tube, that is usually
positioned about six feet away.
The equipment may also be arranged with the
x-ray tube suspended over a table on which
the patient lies.
A drawer under the table holds the x-ray film
or digital recording plate.
Equipment
 How does the procedure work?

X-rays are a form of radiation like light or radio

waves.
X-rays pass through most objects, including
the body.
Once it is carefully aimed at the part of the
body being examined, an x-ray machine
produces a small burst of radiation that passes
through the body, recording an image on
photographic film or a special digital image
recording plate.
 Different parts of the body absorb the x-rays
in varying degrees.
Dense bone absorbs much of the radiation
while soft tissue, such as muscle, fat and
organs, allow more of the x-rays to pass
through them.
As a result, bones appear white on the x-ray,
soft tissue shows up in shades of gray and air
appears black.
On a chest x-ray, the ribs and spine will absorb
much of the radiation and appear white or
light gray on the image.
Lung tissue absorbs little radiation and will
appear dark on the image.
 Until recently, x-ray images were maintained
as hard film copy (much like a photographic
negative).

Today, most images are digital files that are

stored electronically.

These stored images are easily accessible and

are frequently compared to current x-ray
images for diagnosis and disease
management.
 How is the procedure performed?
Typically, two views of the chest are taken, one
from the back and the other from the side of the
body as the patient stands against the image
recording plate.
The technologist, an individual specially trained
to perform radiology examinations, will position
the patient with hands on hips and chest
pressed against the image plate.
For the second view, the patient's side is against
the image plate with arms elevated.
PA (Postero-anterior)
FILM
 Projection

Posterio-
anterior
view
Lateral
view
Exposed in full inspiration and the
patient in upright position.
 PA view
Film is placed
anteriorly, X-ray
beam passes from
posterior aspect to
anterior side.
 Lateral view
X-ray beam passes from one
lateral to other lateral, and
the film is placed at the
latter lateral.
 Patients who cannot stand may be positioned lying
down on a table for chest x-rays.
Patient must hold very still and may be asked to
keep from breathing for a few seconds while the x-
ray picture is taken to reduce the possibility of a
blurred image.
The technologist will walk behind a wall or into the
next room to activate the x-ray machine.
When the examination is complete, patient will be
asked to wait until the radiologist determines that all
the necessary images have been obtained.
The chest x-ray examination is usually completed
within 15 minutes.
 Who interprets the results and how
do I get them?
A radiologist, a physician specifically trained to
supervise and interpret radiology
examinations, will analyze the images and
send a signed report to primary care or
referring physician, who will discuss the
results.

The results of a chest x-ray can be available

almost immediately for review by physician.
 What are the benefits vs. risks?
Benefits
No radiation remains in a patient's body after an
x-ray examination.
X-rays usually have no side effects in the
diagnostic range.
X-ray equipment is relatively inexpensive and
widely available in emergency rooms, physician
offices, ambulatory care centers, nursing homes
and other locations, making it convenient for
both patients and physicians.
Because x-ray imaging is fast and easy, it is
particularly useful in emergency diagnosis and
treatment.
 Risks
There is always a slight chance of cancer from
excessive exposure to radiation.
However, the benefit of an accurate diagnosis
far outweighs the risk.
The effective radiation dose for this procedure
varies.
Women should always inform their physician
or x-ray technologist if there is any possibility
that they are pregnant.
 Radiation Dose
The dose of radiation from a chest x-ray is very
small (0.25 mRad).

Although this unit of measurement is probably

unfamiliar, we all receive approximately 100
mRad (400 times that of a chest x-ray) yearly
from cosmic rays and the trace radioactive
minerals in rocks and building foundations.

However, improperly used equipment can

markedly increase the radiation dose.
 A Word About Minimizing Radiation
Exposure
Special care is taken during x-ray examinations to use the
lowest radiation dose possible while producing the best
images for evaluation.
National and international radiology protection councils
continually review and update the technique standards
used by radiology professionals.
State-of-the-art x-ray systems have tightly controlled x-ray
beams with significant filtration and dose control methods
to minimize stray or scatter radiation.
This ensures that those parts of a patient's body not being
imaged receive minimal radiation exposure.
 What are the limitations of Chest
Radiography?
Because some conditions of the chest cannot be
detected on a conventional chest x-ray image, this
examination cannot necessarily rule out all
problems in the chest.
For example, small cancers may not show up on a
chest x-ray.
A blood clot in the lungs, a condition called a
pulmonary embolism, cannot be seen on chest x-
rays.
Further imaging studies may be necessary to clarify
the results of a chest x-ray or to look for
abnormalities not visible on the chest x-ray.
 MODULE 2: Technique
Learn the difference between PA vs. AP CXR

Learn the utility of a lateral decubitus CXR

Understand the terms inspiration,

penetration, and rotation as they apply to
determining a technically adequate film
 Positioning - Posterioranterior

On the left is a simulated patient in position for a standard PA

(posterioranterior) chest x-ray. On the right is a normal PA film.
 Positioning - Lateral

On the left is a simulated patient in position for a lateral chest x-ray and on the right is a
normal lateral film.
When reading a patient's chest films you should look at both the PA and the lateral films and
hang them in this manner (PA on left and lateral on right).
 When using comparison films one should hang old PA then new PA
then new lateral followed by old lateral
View the PA and lateral,
then compare the new PA to old PA,
and finally the new lateral to the old lateral.
 Lateral Positioning
The lateral view is obtained with the left
chest against the cassette.
This diminishes the effect of magnification on
the heart.
Looking carefully at the posterior aspect of
the chest on the lateral view, which ribs are
left and right? Which is the right/left
hemidiaphragm?
Lateral Positioning
 The right ribs (red arrows below) are larger due to magnification and usually
projected posterior to the left ribs if the patient was examined in a true
lateral position. This can be very helpful if there is a unilateral pleural
effusion seen only on the lateral view.

By zooming in on the image you can clearly notice the increased width
and posterior location of the right ribs (red arrows) as compared to the
left ribs (blue arrows) on CXR.
 The left hemidiaphragm is usually lower than the right. Also, since the heart lies
predominantly on the left hemidiaphragm the result on a lateral film is silouhetting
out of the anterior portion of the hemidiaphragm, whereas the anterior right
hemidiaphragm remains visible.

Notice how the right diaphragm (red arrows) continues anteriorly, while the left
diaphragm disappears (black arrow) because of the silouhetting caused by the
heart. Also notice how the right diaphragm at the blue arrows continues past the
smaller left ribs and ends at the larger and more posterior right ribs.
 Posterioranterior and Lateral
The standard chest examination consists of a PA
(posterioranterior) and lateral chest x-ray.

The films are read together.

The PA exam is viewed as if the patient is standing in

front of you with their right side on your left.

The patient is facing towards the left on the lateral view.

Comparison films can be invaluable - Old Gold! If you

have comparison films, the old PA film is displayed
adjacent to the new PA film and the old lateral is
displayed adjacent to the new lateral.
 PA vs AP

Patient in PA (posterioranterior)
position.
Note that the x-ray tube is 72
inches away.

Supine AP (anteriorposterior)
position, the x-ray tube is 40
inches from the patient.
 PA film on the left compared with a AP supine film on the right.

The AP shows magnification of the heart and widening of the

mediastinum. Whenever possible the patient should be imaged
in an upright PA position.

AP views are less useful and should be reserved for very ill
patients who cannot stand erect.
 Lateral decubitus position
The patient can also be examined in a lateral
decubitus position.
This could be helpful to assess the volume of
pleural effusion and demonstrate whether a
pleural effusion is mobile or loculated.
You could also look at the nondependent
hemithorax to confirm a pneumothorax in a patient
who could not be examined erect.
Additionally, the dependant lung should increase in
density due to atelectasis from the weight of the
mediastinum putting pressure on it.
Failure to do so indicates air trapping.
 Left shows a patient in position for a right
lateral decubitis position.

The right is an example of a decubitus film in

this case showing a mobile pleural effusion
(arrows).
 Inspiration
The patient should be
examined in full inspiration.
This greatly helps the
radiologist to determine if
there are intrapulmonary
abnormalities.
The diaphragm should be
found at about the level of
the 8th - 10th posterior rib or
5th - 6th anterior rib on good
inspiration.
A patient can appear to have a very abnormal chest if the film
is taken during expiration.
- On the first film, the loss of the right heart border silhouette
would lead you to the diagnosis of a possible pneumonia.
However, the patient had taken a poor inspiration.
- On repeat exam with improved inspiration, the right heart
border is normal.
Penetration
Adequate penetration of the
patient by radiation is also
required for a good film.

On a good PA film, the thoracic

spine disc spaces should be
barely visible through the heart
but bony details of the spine are
not usually seen.

On the other hand penetration is

sufficient that bronchovascular
structures can usually be seen
through the heart.
 On the lateral view, you can
look for proper penetration
and inspiration by observing
that the spine appears to be
darken as you move
caudally.

This is due to more air in

lung in the lower lobes and
less chest wall.

The sternum should be seen

edge on and posteriorly you
should see two sets of ribs.

an example of a normal PA film an overpenetrated PA film.

that is underpenetrated.
 Rotation
The technologists are usually very careful to x-
ray the patient flat against the cassette.

If there is rotation of the patient, the

mediastinum may look very unusual.

One can access patient rotation by observing the

clavicular heads and determining whether they
are equal distance from the spinous process of
the thoracic vertebral bodies.
Normal PA film without any rotation.
 Magnification of clavicular head and spinous
process alignment demonstrating a straight film.

In this rotated film skin folds can be mistaken for a tension

pneumothorax (blue arrows).
Notice the skewed positioning of the heads of the clavicles (red
arrows) and the spinous processes.
 Opacity
Mass vs. Infiltrate
The basic diagnostic instance is to detect an abnormality. In both of the cases above,
there is an abnormal opacity. It is most useful to state the diagnostic findings as
specifically as possible, then try to put these together and construct a useful
differential diagnosis using the clinical information to order it.

In each of the cases above, there is an abnormal opacity in the left upper
lobe. In the case on the left, the opacity would best be described as a
mass because it is well-defined. The case on the right has an opacity that
is poorly defined. This is airspace disease such as pneumonia.
 MODULE 3: Anatomy
Learn the basic anatomy of the fissures of the
lungs, heart borders, bronchi, and
vasculature that can be seen on a chest x-ray
 Lobes and Fissures
On the PA chest x-ray, the minor fissure divides the right middle lobe from
the right upper lobe and is sometimes not well seen. There is no minor
fissure on the left. The major fissures are usually not well seen on the PA
view because you are looking through them obliquely. If there is fluid in the
fissure, it is occasionally manifested as a density at the lower lateral margin.

The left image shows the right minor fissure (A) and the inferior
borders (B) of the major fissures bilaterally. The right image shows the
superior border of the major fissures (B) bilaterally.
 On the lateral view, both lungs are superimposed.
Think about them separately, the left lung has only a major fissure as shown.
The right lung will have both the major and minor fissure.
The patient above has a pleural effusion extending into the fissure.
Which fissure is which?
 Mediastinum and Lungs
The radiologist needs to know both the structures within the mediastinum
forming the mediastinal margins and the lobes of the lungs forming the
margins of the lungs along the mediastinum and chest wall.

If a mass or pneumonia "silhouettes" (obscures) a part of the

lung/mediastinal margin, the radiologist should be able to identify what
part of the lung and what organ within the mediastinum are involved.

The margins of the mediastinum are made up of the structures shown

below. Trace the margin of the mediastinum with your eye all the way
around the margin.

Think of the mediastinal structures that comprise this interface.

If the margin were abnormal you could diagnose the cause.

Specific anatomy of the PA chest x-ray.
The locations of each lung margin on chest x-ray.
 Trace the margin of the lung with your eye in the image below
thinking about what mediastinal structure and what lobe of the
lung is present at this margin.
 A = Right Main Stem Bronchus
B = Right Upper Lobe Bronchus
B1 = Apical Segmental Bronchus
Bronchi B2 = Anterior Segmental Bronchus
B3 = Posterior Segmental Bronchus
C = Bronchus Intermedius
D = Right Middle Lobe Bronchus
D4 = Lateral Segmental Bronchus
D5 = Medial Segmental Bronchus
E = Right Lower Lobe Bronchus
E6 = Superior Segmental Bronchus
E7 = Medial Basal Segmental Bronchus
E8 = Anterior Basal Segmental Bronchus
E9 = Lateral Basal Segmental Bronchus
E10 = Posterior Basal Segmental Bronchus
F = Left Main Stem Bronchus
G = Left Upper Lobe Bronchus
G1, G2 = Apicoposterior Segmental Bronchus
G3 = Anterior Segmental Bronchus
H = Lingular Bronchus
H4 = Superior Lingular Segmental Bronchus
H5 = Inferior Lingular Segmental Bronchus
I = Left Lower Lobe Bronchus
I6 = Superior Segmental Bronchus
I7 = Medial Basal Segmental Bronchus
I8 = Anterior Basal Segmental Bronchus
I9 = Lateral Basal Segmental Bronchus
I10 = Posterior Basal Segmental Bronchus

SMALP = "Suppose My Aunt Loves Peaches" is a helpful

way to remember the segmental lower lobe bronchi.
 Pulmonary Vasculature
The following drawings show the major pulmonary vessels
within the mediastinum. The bronchi that you have
already learned are the same as on the prior
drawing. These structures are obviously present on every
chest x-ray but are usually unrecognized.
 MODULE 4:
How to Read a Chest X-Ray
 MODULE 4: How to Read a Chest X-Ray
Turn off stray lights, optimize room lighting, view images
in order
Patient Data (name history #, age, sex, old films)
Routine Technique: AP/PA, exposure, rotation, supine or
erect
Trachea: midline or deviated, caliber, mass
Lungs: abnormal shadowing or lucency
Pulmonary vessels: artery or vein enlargement
Hila: masses, lymphadenopathy
Heart: thorax: heart width > 2:1 ? Cardiac configuration?
Mediastinal contour: width? mass?
Pleura: effusion, thickening, calcification
Bones: lesions or fractures
Soft tissues: dont miss a mastectomy
 Looking for abnormalities
It is best to do a directed search of the chest film rather than
simply gazing at the film.
An abnormality will not likely hit you over the head.
Remember that detail vision is only permitted at the fovea
centralis of your retina.
This area contains only cones and is the part that you use to
read.
The remainder of the retina helps you to put this detailed
portion in context and helps to determine whether this is a
saber tooth tiger sneaking up on you.
Therefore, it is best to look for abnormalities and to have a
planned search in mind.
Your eye gaze should scan all portions of the film, follow
lung/mediastinal interfaces and look again carefully in areas
where you know that mistakes are easily made, such as over
the spine on the lateral view and in the apex on the PA view.
 The diagrams depict the human eye
and light waves hitting the fovea, the
area of detailed vision.
 Stare at the 'X' in the center of the image above. Note how you cannot read the
letters in the corner unless you are looking directly at them (ie unless the letter you
are trying to read is hitting your retina at the fovea).
PA technique for looking at films. Encompassing the entire lung boundaries
(left), scanning with fovea over each part of lung (right).
Lateral scanning technique
Signs
 Silhouette sign
One of the most useful signs in chest radiology is
the silhouette sign.
This was described by Dr. Ben Felson.
The silhouette sign is in essence elimination of
the silhouette or loss of lung/soft tissue interface
caused by a mass or fluid in the normally air filled
lung.
In other words, if an intrathoracic opacity is in
anatomic contact with, for example, the heart
border, then the opacity will obscure that border.
The sign is commonly applied to the heart, aorta,
chest wall, and diaphragm.
The location of this abnormality can help to
determine the location anatomically.
 For the heart, the silhouette sign can be caused by
an opacity in the RML, lingula, anterior segment of
the upper lobe, lower aspect of the oblique fissure,
anterior mediastinum, and anterior portion of the
pleural cavity.

This contrasts with an opacity in the posterior

pleural cavity, posterior mediastinum, of lower
lobes which cause an overlap and not an
obliteration of the heart border.

Therefore both the presence and absence of this

sign is useful in the localization of pathology.
 The right heart border is silhouetted out.
This is caused by a pneumonia, can you determine which lobe the pneumonia affects?
 Air Bronchogram
An air bronchogram is a tubular outline of an
airway made visible by filling of the surrounding
alveoli by fluid or inflammatory exudates.
Six causes of air bronchograms are;
1. lung consolidation,
2. pulmonary edema,
3. nonobstructive pulmonary atelectasis
4. severe interstitial disease,
5. neoplasm, and
6. normal expiration.
 This patient has bilateral lower lobe pulmonary edema. The alveoli
are filled with fluid making the bronchi visible as an air
bronchogram. The upper right is a closeup of the right side of the film
with arrows outlining a prominent air bronchogram. The lower right is
a CT scan demonstrating an air bronchogram clearly.
 Solitary Pulmonary Nodule
A solitary nodule in the lung can be potentially a
fatal lung cancer.
After detection the initial step in analyis is to
compare the film with prior films if available.
A nodule that is unchanged for two years is
almost certainly benign.
If the nodule is completely calcified or has
central or stippled calcium it is benign.
Nodules with irregular calcifications or those
that are off center should be considered
suspicious, and need to be worked up further
with a biopsy.
 PA and Lateral of a subtle right lower lobe cancer.

Can you find it in the frontal projection?

 Atelectasis
Atelectasis is collapse or incomplete expansion of
the lung or part of the lung.

This is one of the most common findings on a chest

x-ray.
It is most often caused by an endobronchial lesion,
such as mucus plug or tumor.
It can also be caused by extrinsic compression
centrally by a mass such as lymph nodes or
peripheral compression by pleural effusion.
An unusual type of atelectasis is cicatricial and is
secondary to scarring, TB, or status post radiation.
 Atelectasis
Atelectasis is almost always associated with a linear
increased density on chest x-ray.
The apex tends to be at the hilum.
The density is associated with volume loss.
Some indirect signs of volume loss include vascular
crowding or fissural, tracheal, or mediastinal shift,
towards the collapse.
There may be compensatory hyperinflation of adjacent
lobes, or hilar elevation (upper lobe collapse) or
depression (lower lobe collapse).
Segmental and subsegmental collapse may show linear,
curvilinear, wedge shaped opacities.
This is most often associated with post-op patients and
those with massive hepatosplenomegaly or ascites .
Note the loss of the right heart border silhouette due to partial
atelectasis of the RML. Atelectasis is usually, but not always, a
benign finding as in this example which was caused by an
endobronchial mass in the RML.
 This is a PA and lateral film showing round
atelectasis, where the lung becomes attached to the
chest wall by an area of previous inflammation. The
lung then rolls up, causing this opacity.
 Left Lung Atelectasis
Left Upper Lobe
The left lung lacks a middle lobe and therefore a minor
fissure, so left upper lobe atelectasis presents a different
picture from that of the right upper lobe collapse.
The result is predominantly anterior shift of the upper
lobe in left upper lobe collapse, with loss of the left
upper cardiac border.
The expanded lower lobe will migrate to a location both
superior and posterior to the upper lobe in order to
occupy the vacated space.
As the lower lobe expands, the lower lobe artery shifts
superiorly.
The left mainstem bronchus also rotates to a nearly
horizontal position.
 This patient suffered from left upper lobe
atelectasis following right upper lobectomy.
 Left Lower Lobe
Atelectasis of either the right or left lower lobe
presents a similar appearance.
Silhouetting of the corresponding hemidiaphragm,
crowding of vessels, and air bronchograms are
sometimes seen, and silhouetting of descending
aorta is seen on the left.
It is important to remember that these findings are
all nonspecific, often occuring in cases of
consolidation, as well.
A substantially collapsed lower lobe will usually
show as a triangular opacity situated
posteromedially against the mediastinum.
These radiographs demonstrate left lower lobe
atelectasis followed by partial resolution,
respectively.
 Right Lung Atelectasis
Right Upper Lobe
Right upper lobe atelectasis is easily detected as
the lobe migrates superomedially toward the
apex and mediastinum.
The minor fissure elevates and the inferior
border of the collapsed lobe is a well
demarcated curvilinear border arcing from the
hilum towards the apex with inferior concavity.
Due to reactive hyperaeration of the lower lobe,
the lower lobe artery will often be displaced
superiorly on a frontal view.
Note the elevation of the horizontal fissure
(arrows) caused by RUL atelectasis.
 Right Middle Lobe
Right middle lobe atelectasis may cause minimal
changes on the frontal chest film.
A loss of definition of the right heart border is the
key finding.
Right middle lobe collapse is usually more easily
seen in the lateral view.
The horizontal and lower portion of the major
fissures start to approximate with increasing
opacity leading to a wedge of opacity pointing to
the hilum.
Like other cases of atelectasis, this collapse may by
confused with right middle lobe pneumonia.
- Right middle lobe atelectasis can be difficult to detect in
the AP film.
- The right heart border is indistinct on the AP film.
- The lateral, though, shows a marked decrease in the
distance between the horizontal and oblique fissures.
 Right Lower Lobe

Silhouetting of the right hemidiaphragm and

a triangular density posteromedially are
common signs of right lower lobe atelectasis.

Right lower lobe atelectasis can be

distinguished from right middle lobe
atelectasis by the persistance of the right
heart border.
 Notice the stretched vessels in the hyperexpanded right
upper lobe in right lower lobe atelectasis. The right hilum is
also displaced inferiorly. This is a tough one.
 Pulmonary Edema
There are two basic types of pulmonary edema.
One is cardogenic edema caused by increased
hydrostatic pulmonary capillary pressure.
The other is termed noncardogenic pulmonary edema,
and is caused by either altered capillary membrane
permeability or decreased plasma oncotic pressure.
A helpful mnemonic for noncardiogenic pulmonary
edema is NOT CARDIAC (near-drowning, oxygen
therapy, transfusion or trauma, CNS disorder, ARDS,
aspiration, or altitude sickness, renal disorder or
resuscitation, drugs, inhaled toxins, allergic alveolitis,
contrast or contusion.
 X-ray findings
On a CXR, cardiogenic pulmonary edema can
show; cephalization of the pulmonary vessels,
peribronchial cuffing, "bat wing" pattern, patchy
shadowing with air bronchograms, and increased
cardiac size.
Unilateral, miliary and lobar or lower zone edema
are considered atypical patterns of cardiac
pulmonary edema.
A unilateral pattern may be caused by lying
preferentially on one side.
Unusual patterns of edema may be found in
patients with COPD who have predominant upper
lobe emphysema.
PA film of a patient with pulmonary edema showing
cephalization of pulmonary veins and indistinctness
of the vascular margins. The heart is enlarged.
Would you favor pneumonia or CHF in this
patient? Why? What pattern is shown?
 Congestive Heart Failure
Congestive heart failure (CHF) is one of the most
common abnormalities evaluated by CXR.

CHF occurs when the heart fails to maintain

adequate forward flow.

CHF may progress to pulmonary venous

hypertension and pulmonary edema with leakage
of fluid into the interstitium, alveoli and pleural
space.
 X-ray Findings
The earliest CXR finding of CHF is cardiomegaly,
detected as an increased cardiothoracic ratio
(>50%).
In the pulmonary vasculature of the normal chest,
the lower zone pulmonary veins are larger than the
upper zone veins due to gravity.
In a patient with CHF, the pulmonary capillary
wedge pressure rises to the 12-18 mmHg range and
the upper zone veins dilate and are equal in size or
larger, termed cephalization.
Often in a classic perihilar bat wing pattern of
density.
Pleural effusions also often occur.
 This is a typical chest x-ray of a patient in severe CHF.
Note the cardiomegaly, alveolar edema, and haziness of
vascular margins.
 Kerley B lines
These are horizontal lines less than 2cm long,
commonly found in the lower zone periphery.
These lines are the thickened, edematous
interlobular septa.
Causes of Kerley B lines include; pulmonary
edema, lymphangitis carcinomatosa and
malignant lymphoma, viral and mycoplasmal
pneumonia, interstital pulmonary fibrosis,
pneumoconiosis, sarcoidosis.
They can be an evanescent sign on the CXR of a
patient in and out of heart failure.
The patient above is suffering from congestive heart
failure resulting in interstitial edema.
Notice the Kerley's B lines in right periphery
(arrows).
 Pneumonia
Pneumonia is airspace disease and consolidation.
The air spaces are filled with bacteria or other
microorganisms and pus.
Other causes of airspace filling not distinguishable
radiographically would be fluid (inflammatory),
cells (cancer), protein (alveolar proteinosis) and
blood (pulmonary hemorrhage), Pneumonia is
NOT associated with volume loss.
Pneumonia is caused by bacteria, viruses,
mycoplasmae and fungi.
 X-ray findings
Airspace opacity, lobar consolidation, or
interstitial opacities.
There is usually considerable overlap.
Again, pneumonias is a space occupying
lesion without volume loss.
What differentiates it from a mass? Masses
are generally more well-defined.
Pneumonia may have an associated
parapneumonic effusion.
Major differentiating factors between
atelectasis and pneumonia
Atelectasis Pneumonia

Volume Loss Normal or Increased

Volume
Associated Ipsilateral No Shift, or if Present
Shift Then Contralateral

Linear, Wedge-Shaped Consolidation, Air Space

Process
Apex at Hilum
Not Centered at Hilum
Air bronchograms can occur in both.
These are PA and lateral films of RML pneumonia (arrows).
Note the indistinct borders, air bronchograms, and
silhouetting of the right heart border.
 Tuberculosis
Primary tuberculosis (TB) is the initial infection
with Mycobacterium tuberculosis.
Post-primary TB is reactivation of a primary
focus, or continuation of the initial infection.
Radiographically, TB is represented by
consolidation, adenopathy, and pleural effusion.
A Ghon focus is an area of consolidation that
most commonly occurs in the mid and lower
lung zones.
A Ghon complex is the addition of hilar
adenopathy to a Ghon focus.
 Radiographic features
Focal patchy airspace disease "cotton wool"
shadows, cavitation, fibrosis, nodal calcification,
and flecks of caseous material.
These occur most commonly in the posterior
segments of the upper lobes, and superior
segments of the lower lobes.
Endobronchial TB involves the wall of a major
bronchus.
Complications of endobronchial TB are cicatrical
stenosis and obstruction.
 This is a PA film of a patient who has had tuberculosis for years.
This shows fibrosis, cavitation, and calcification, particularly in the
left upper lobe.
 Pulmonary Hemorrhage
Pulmonary hemorrhage has an appearance like
that of other airspace filling processes
(pneumonia, edema) which have opacity often
with air bronchograms.
It is caused by trauma, Goodpastrue's
syndrome, bleeding disorders, high altitude, and
mitral stenosis.
Blood fills the bronchi and eventually the
alveoli.
Pulmonary hemorrhage is notable in that it may
clear more quickly than other alveolar densities
such as pneumonia.
 PA and Lateral films of a patient with right upper
lobe hemorrhage. Notice the large pleural effusion
in the left hemithorax.
 Pleural Effusion
Common causes for a pleural effusion are CHF, infection
(parapneumonic), trauma, PE, tumor, autoimmune disease,
and renal failure.

On an upright film, an effusion will cause blunting on the

lateral and if large enough, the posterior costophrenic sulci.
Sometimes a depression of the involved diaphragm will
occur.
A large effusion can lead to a mediastinal shift away from
the effusion and opacify the hemothorax.
Approximately 200 ml of fluid are needed to detect an
effusion in the frontal film vs. approximately 75ml for the
lateral.
Larger effusions, especially if unilateral, are more likely to
be caused by malignancy than smaller ones.
 In the supine film, an effusion will appear as
a graded haze that is denser at the base.

The vascular shadows can usually be seen

through the effusion.

An effusion in the supine view can veil the

lung tissue, thicken fissure lines, and if large,
cause a fluid cap over the apex.

There may be no apparent blunting of the

lateral costophrenic sulci.
 A lateral decubitis film is helpful in confirming an
effusion in a bedridden patient as the fluid will
layer out on the affected side (unless the fluid is
loculated).

Today, ultrasound is also a key component in the

diagnosis.

Ultrasound is also used to guide diagnostic

aspiration of small effusions.
PA and lateral film of a patient with bilateral pleural
effusions.
Note the concave menisci blunting both posterior
costophrenic angles.
 Pneumothorax
A pneumothorax is defined as air inside the thoracic cavity but outside the
lung.
A spontaneous pneumothorax (PTX) is one that occurs without an obvious
inciting incident.
Some causes of spontaneous PTX are; idiopathic, asthma, COPD, pulmonary
infection, neoplasm, Marfan's syndrome, and smoking cocaine.
However, most pneumothoraces are iatrogenic and caused by a physician
during surgery or central line placement.
Trauma, such as a motor vehicle accident is another important cause.
A tension PTX is a type of PTX in which air enters the pleural cavity and is
trapped during expiration usually by some type of ball valve-like mechanism.
This leads to a buildup of air increasing intrathoracic pressure.
Eventually the pressure buildup is large enough to collapse the lung and shift
the mediastinum away from the tension PTX.
If it continues, it can compromise venous filling of the heart and even death.
 X-ray findings
On CXR, a PTX appears as air without lung markings in the
least dependant part of the chest.
Generally, the air is found peripheral to the white line of the
pleura.
In an upright film this is most likely seen in the apices.
A PTX is best demonstrated by an expiration film.
It can be difficult to see when the patient is in a supine
position.
In this position, air rises to the medial aspect of the lung and
may be seen as a lucency along the mediastinum.
It may also collect in the inferior sulci causing a deep sulcus
sign.
A hydropneumothorax is both air and fluid in the pleural
space.
It is characterized by an air-fluid level on an upright or
decubitus film in a patient with a pneumothorax. Some causes
of a hydropneumothorax are trauma, thoracentesis, surgery,
ruptured esophagus, and empyema.
The above film shows a right sided tension pneumothorax with right
sided lucency and leftward mediastinal shift. This is a medical
emergency. Failure to place a right chest tube immediately could
allow venous return to diminish and lead to possible death.
 Left is a supine view of a PTX, note the medial position of the air.
Right is an image demonstrating the deep sulcus sign (letter D in the
image) in supine views of a PTX.
The above three images show a hydropneumothorax in three different
views.
The PA, lateral, and right decube reveal a layering out of the air and
fluid.
The right decube film demonstrates a right hydropneumothorax.
Note the pleural air/fluid level demonstrated by the horizontal
air/fluid interface (arrows).
 Emphysema
Emphysema is loss of elastic recoil of the lung
with destruction of pulmonary capillary bed
and alveolar septa.

It is caused most often by cigarette smoking

Functional hallmarks are decreased airflow

and diffusing capacity.
 X-ray findings
Emphysema is commonly seen on CXR as diffuse
hyperinflation with flattening of diaphragms,
increased retrosternal space.

Hyperinflation and bullae are the best

radiographic predictors of emphysema.

However, the radiographic findings correlate

poorly with the patients pulmonary function
tests.
Note bilateral flattening of the diaphragms and
significant hyperinflation as demonstrated by
visualization of 11 posterior ribs.
 Pericardial Effusion
Pericardial effusion causes an enlarged heart shadow that is
often globular shaped (transverse diameter is
disproportionately increased).
A "fat pad" sign, a soft tissue stripe wider than 2mm between
the epicardial fat and the anterior mediastinal fat can be seen
anterior to the heart on a lateral view.
Serial films can be helpful in the diagnosis especially if rapid
changes in the size of the heart shadow are observed.
Approximately 400-500 ml of fluid must be in the pericardium
to lead to a detectable change in the size of the heart shadow
on PA CXR.
Pericardial effusion can be definitively diagnosed with either
echocardiography or CT.
It can be critical to diagnose pericardial effusion because if it
is acute it may lead to cardiac tamponade, and poor cardiac
filling.
PA of a patient with a pericardial effusion.
A lateral film and closeup of a pericardial effusion showing
the anterior mediastinal fat (blue arrows)
and epicardial fat (red arrows) separated by a soft tissue
stripe reflecting the pericardial effusion seen edge-on.
Thanks for your attention!