Chest x-ray reading

Check List(1)
1. 2.
o o o

Check patient data, position, technical quality and normal anatomy. Review systematically
Initial survey Review skeletal structures of shoulder girdles and chest wall Review mediastinum:
overall size and shape trachea: position margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch, main pulmonary artery, left ventricle lines and stripes: paratracheal, paraspinal, paraesophageal (azygoesophageal), paraaortic retrosternal clear space

Review hila:
normal relationships size

Check List(2)
o

Review lungs and pleura:

compare lung sizes evaluate pulmonary vascular pattern: compare upper to lower lobe, right to left, normal tapering to periphery pulmonary parenchyma pleural surfaces fissures - major and minor - if seen compare hemidiaphragms follow pleura around rib cage

Soft tissue including breast, companion shadow .

Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc. Review soft tissues and spine of neck. Review spine and rib cage: check alignment, disc space narrowing, lytic or blastic regions, etc.

Check List
1. Check patient data, position, technical quality and normal anatomy. Review systematically
o o o o o o Initial survey Review skeletal structures of shoulder girdles and chest wall Review mediastinum Review hila Review lungs and pleura Soft tissue including breast, companion shadow

2.

1. Data base
1. Name 2. Date - important for comparing prior exams
- Serial image

3. Position markers - right(R) vs. left(L) 4. Type of film 5. Patients position

supine, upright, lateral, etc.

6. Technical quality

1
3

(erect)

Introduction
Serial image: Doubling time
Point of disease(location/size) Make diagnosis easily
Pneumonia Edema Tumor

Position
Chest x-ray
P-A view A-P A-P supine Lateral (Lt/Rt) Lateral decubitus (Lt/Rt) Lordotic Oblique(Rt/Lt; post/anterior)

Position
Speical position for special purpose
A-P supine: Ambulatory limit A-P Lateral (Lt/Rt): Anatomy reading Lateral decubitus: Effusion or thickening Lordotic: Apical lesion Oblique: Eliminate superimposed lesion

Affect read result - eg. redistritubion Phenomenon (slide 183)

P-A view

Rt Lateral view

Rt Lateral decubitus view

Technical quality
Ideal KV exposure
Key points
Apex Retrocardiac lung marking Trachea position Spine Scapula

You can't find a subtle pneumothorax if there is patient motion or the film is overexposed.

4 basic radiographic densities

Technical quality
Ideal KV exposure 4 basic radiographic densities
Air Fat Water(soft tissue) Bone(metal)

Normal Anatomy
Anatomy & projection
General anatomy Lobar anatomy Segmental anatomy

The sihouette sign

Normal Anatomy
Anatomy & projection
General anatomy
Posterior process Rib(Ant/Post) Left 2/Right 4 Costothoracic ratio Central trachea Hilar: Lt>Rt Lung field: Central> Peripheral/ Peripheral clear zone Pleura: Linear Diaphragm: Right >left/ Angle/Gastric pattern Subcutaneous tissue

Lobar anatomy Segmental anatomy

Anatomy & projection

Normal Anatomy

General anatomy of lateral view

1. Right diaphragm 2. Left diaphragm 3. Spine 4. Scapula 5. Axiallary fold 6. Sternum 7. Subcutaneous tissue 8. Trachea 9. Aortic arch 10. Main bronchus 11. Pulmonary artery 12. Heart 13. Retrosternal clear space 14. Retrocardiac clear space 15. Costophrenic angle 16. Costocardiac angle

5 8 4 9 11 10

13
6

12 7 16 14 1 2 16 15

Normal Anatomy
Anatomy & projection
General anatomy Lobar anatomy
Fissures
Def: Pleura surround by air 3 main(1 minor; 2 major) 3 accessory(Azygos; inferior & superior accessory) If fissure do not appear a thin line? - Ans: ?

Segmental anatomy

The sihouette sign

Normal Anatomy
Anatomy & projection
General anatomy Lobar anatomy
Fissures
Def: Pleura surround by air 3 main(1 minor; 2 major) 3 accessory(Azygos; inferior & superior accessory) If fissure do not appear a thin line - Pneumonia(Bulging) - Atelectasis (Deviation) - Pleural effusion (Pseudotumor)

Segmental anatomy

The sihouette sign

Lobar anatomy

5 3-4-5 3-4-6 6

3-4

Normal Anatomy
Anatomy & projection The sihouette sign
Define
Interface is invisible when two areas of similar radiodensity touch.

Position

Normal Anatomy
Anatomy & projection The sihouette sign
Define Location
Heart/Asending aorta Desending aorta/Diaphragm Airbronchogram Incomplete border

Normal Anatomy
Anatomy & projection
General anatomy Lobar anatomy Segmental anatomy
Rt: 1-10 Lt 1-10 (1+2, 7+8)

1 2 3 1 3 2

4 5

4 5

8 8 10

10

1+2
1+2 3 3

4
5

7 9 + 8 10

Check List
1. Check patient data, position, technical quality and normal anatomy. Review systematically
o o o o o o Initial survey Review skeletal structures of shoulder girdles and chest wall Review mediastinum Review hila Review lungs and pleura Soft tissue including breast, companion shadow

2.

Systematic review
A-B-C-D-E-F-G-H or Try interpret and understand what you see:
D.D. normal v.s. abnormal?

Systematic review
A-B-C-D-E-F-G-H
o o o o o o o o A: Airway B: Bone C: CV D: Diaphragm E: Extra-pulmonary F: Lung field G: Gastric bubble H: Hilum/Hernia

Systematic review

o o o o o o Initial survey Review skeletal structures of shoulder girdles and chest wall Review mediastinum Review hila Review lungs and pleura: Soft tissue including breast, companion shadow. .

Check List
1. Check patient data, position, technical quality and normal anatomy. Review systematically
o o o o o o Initial survey Review skeletal structures of shoulder girdles and chest wall Review mediastinum Review hila Review lungs and pleura Soft tissue including breast, companion shadow

2.

Initial survey
1. General Body Size, Shape, and Symmetry 2. Sex 3. Age(cartilage/aortic arch /asending aorta/Pulmonary trunk)
Infant/ child/ young adult/ elderly person

4. Foreign objects
tubes, IV lines, EKG leads, surgical drains, prosthesis non-medical objects, bullets, shrapnel, glass, etc

Check List
1. Check patient data, position, technical quality and normal anatomy. Review systematically
o o o o o o Initial survey Review skeletal structures of shoulder girdles and chest wall Review mediastinum Review hila Review lungs and pleura Soft tissue including breast, companion shadow

2.

Skeletal structures
Overall size, shape, contour of each bone.
Density( mineralization) Compare cortical thickness to medullary cavity, trabecular pattern, Erosions, fractures, any lytic or blastic regions. Articular relationships Joint spaces narrowed, widened Calcification in the cartilages Air in the joint space, abnormal fat pads

Joints

Refresh gross anatomy radiology

Neck and Cervical spines

Overall(soft tissue)
amounts calcifications, subcutaneous emphysema

Trachea
position size

Cervical spine,
alignment note any major congenital abnormalities.

Specific parts of the vertebra and disc spaces Checking

erosions lytic or blastic lesions disc and synovial joint narrowing Other abnormalities.

Thoracic spine and Rib cage

Overall alignment- spine Symmetry - rib cage Double check bone density Two reminders at this point:
Principle of general
More detailed review in each section.

concentrate on the skeletal detail

Look through" the mediastinum and lungs.

Thoracic spine
Specific parts(Each)
Vertebra Disc spaces
height integrity of cortical margins/pedicles/lamina presence of any lytic or sclerotic areas synovial joints(normal /narrowing /sclerosis spacing )

Compare frontal & lateral projections

Thoracic spine

Ribs
1. Posterior Rib 2. Anterior Rib

Ribs
1. Posterior rib, 2.Ant rib

Compare
Side to side, Cortical margins, Trabecular patterns.

Note calcified anterior cartilages

may obscure or mimic underlying lung lesions.

Lt/Rt SHOULDER GIRDLE

7 1 6 4

Check List
1. Check patient data, position, technical quality and normal anatomy. Review systematically
o o o o o o Initial survey Review skeletal structures of shoulder girdles and chest wall Review mediastinum Review hila Review lungs and pleura Soft tissue including breast, companion shadow

2.

Mediastinum
Define
Area between the lung Water density
Surrounded two air filled lungs and Intersected by the air filled trachea and major bronchi.

Key is knowledge of anatomical relationships and how structures project on a radiograph. CT and MRI is helpful. Interfaces of air-soft tissue margins may be distorted by pathological lesion
Masses otherwise

Mediastinum
Define
Area between the lung Water density
Surrounded two air filled lungs and Intersected by the air filled trachea and major bronchi.

Key is knowledge of anatomical relationships and how structures project on a radiograph. CT and MRI is helpful. Interfaces of air-soft tissue margins may be distorted by pathological lesion
Masses otherwise

MEDIASTINUM

Mediastinum
Define
Area between the lung Water density
Surrounded two air filled lungs and Intersected by the air filled trachea and major bronchi.

Key is knowledge of anatomical relationships and how structures project on a radiograph. CT and MRI is helpful. Interfaces of air-soft tissue margins may be distorted by pathological lesion
Masses otherwise

Anatomy

Project

Anatomy & project

1. Carina 2. Left Main Stem Bronchus 3. Descending Aorta 4. Main Pulmonary Artery 5. Aorticopulmonary Window 6. Arch of Aorta

MEDIASTINUM
Anatomy dividing region
SUPERIOR MEDIASTINUM
Begins - root of the neck and Ends - line drawn T-4 vertebrae --- sternomandible junction.
line skims the top of the aortic arch. T

Mediastinum
Begins - this line End- diaphragm Further divided into three regions
Anterior Middle Posterior.

4
1cm

Mediastinum
Overall size and shape Trachea: position Margins Lines and stripes Retrosternal clear space

Mediastinum

Overall size and shape Trachea- position Margins

SVC- Ascending aorta Right atrium Left subclavian artery- Aortic arch Main pulmonary artery Left antrium Left ventricle

Lines and stripes Retrosternal clear space

Margins

I II III

II

IV

Venography
1. Right Brachiocephalic Vein 2. Superior Vena Cava 3. Left Brachiocephalic Vein

Axial plan of computer tomography

1. Right Brachiocepahlic Artery 2. Superior Vena Cava 3. Right Paratracheal Stripe 4. Esophagus 5. Left Subclavian Artery 6. Left Common Carotid Artery 7. Left Brachiocephalic Vein

4
1cm

Mediastinum

Overall size and shape Trachea: position Margins Lines and stripes
Paratracheal Paraspinal Paraesophageal (azygoesophageal) Paraaortic

Retrosternal clear space

Edge of Superior vena cave (SVC) Seen PA(AP) view only Often only a portion Never bulge into the lung with a convex border.

Right Pratracheal stripe

Right Pratracheal stripe

Normal- < 5 mm, usually 2-3 mm.
Important marker for subtle adenopathy.

Distal end - formed by azygous vein

Distended vein, stripe > 1 cm.

Medial margin -soft tissue interface /right mucosal surface of trachea. Outer margin -begins medial end of clavicle/formed by plural surface of right upper lobe (RUL). Normal structures in soft tissue density between air trachea and the RUL
Right wall of the trachea Nerves Fat Lymph nodes Pleura of the RUL.

Azygous vein - anteriorly to empty into the posterior surface of the SVC.

Right paratracheal stripe(TOMOGRAM )

CT of Paratracheal stripe
1. Asending aorta 2. Azygous vein 3. Esophagus 4. Desending aorta 5. Pulmonary trunk

Left Subclavian stripe

Width- normal 1.0-1.5 cm. Inner marginAir mucosal interface mucosal surface of the trachea, Outer margin interface Medial aspect of left upper lobe Upper- outer edge Level of the clavicle and will be able to follow it EndBulge of the aortic arch.

Paraspinal stripe

 Sometimes(+) on the frontal view Plural edge parallel to the lateral margins of the vertebral bodies. Edge > millimeters beyond the vertebral bodies
Should not be lumpy or bulging.

Pleural mediastinal interface

1. Superior Vena Cava 2. Right Paratracheal Stripe 3. Left Subclavian Stripe

Azygoesophageal line or Paraesophageal line

 On the forntal view only Formed by the right lower lobe & Mediastinum, containing
Esophagus Azygous vein.

Overlies the thoracic spine

Near the midline Fairly straight, vertically.

Bulges convex to lung

S/p mediastinal mass, eg.
subcarinal lymph nodes Enlarged left atrium.

CT of the Azygoesophageal line

1. Esophagus 2. Azygous Vein 3. Descending Aorta

Lateral view of tracheal wall

Posterior tracheal < 4mm

MEDIASTINUM
Overall size/ shape on PA & lateral views
Decide if it is normal & age.

Look for
Obvious masses Calcifications Double check for foreign projects
Tubes Electrical leads Pacemaker Artificial valves

MEDIASTINUM
Evidence of
Mediastinal shift
Entire or Section of it.

Look trachea/major bronchus

Size Position Intraluminal masses

SUPERIOR MEDIASTINUM PA Overall width for normal size,

Look for
Masses Calcifications Free air.

Detailed search for subtle distortion of

several major pleural mediastinal interfaces.

Not all of the following structures are seen on every film

Try to find them

Mediastinum
Define
Area between the lung Water density
Surrounded two air filled lungs and Intersected by the air filled trachea and major bronchi.

Key is knowledge of anatomical relationships and how structures project on a radiograph. CT and MRI is helpful. Interfaces of air-soft tissue margins may be distorted by pathological lesion
Masses otherwise

HEART
1 Edge of superior vena cava 2. Right atrium 3. Aortic arch 4. Edge of main pulmonary artery 5. Left atrial appendage 6. Left ventricle

Superimposed on the frontal view. The major structure is the heart. Pericardium and heart is inseparable on plain film views. Review the heart for overall size and shape. Rough yardstick - cardiac-thoracic ratio
Widest diameter of the heart /widest width of the thoracic cage( inner aspect of rib to rib). > 50%

Check
Calcifications Pneumopericardium Pneumomediastinum Sutures Prosthetic valves etc.,

You may have overlooked on the general survey of the entire mediastinum.

Lateral view of heart

1. Trachea 2. Right Ventricle 3. Left Ventricle 4. Left Atrium 5. Right Pulmonary Artery

Aorta

 Try tracking
Root Distal descending aorta.

Young adult - hidden in the mediastinum Older - swing to the right to cast a soft tissue bulge. Arch- always be seen
make sure left to distal trachea Pushes trachea slightly to the right actually .

Check aortic calcifications and size. Left lateral border of descending aorta
abuts the left lung (column of dots on the pt's. left, on the annotated image).

Lateral view- aorta is usually not seen.

Pulmonary artery
1. Carina 2. Left Main Stem Bronchus 3. Descending Aorta 4. Main Pulmonary Artery 5. Aorticopulmonary Window 6. Arch of Aorta

 Main pulmonary artery

Straight or Convex (most commonly in young females).

"middle mogul" - when convex

Upper "mogul" - aortic knob Lower mogul - left ventricle.

Left pulmonary artery- branching of main pulmonary artery Right pulmonary artery Proximal- not seen, ( buried in the mediastinum) Branches can see ( as the right hilum)

Blood vesseles in the lung

Pulmonary arteries, Lateral view

1. Trachea 2. Right Ventricle 3. Left Ventricle 4. Region of left Atrium 5. Right Pulmonary Artery 6. Left Pulmonary Artery

Pulmonary artery
Right pulmonary artery
Ovoid branching structure- easily seen, Just anterior to the air column of the trachea and main bronchi.

Left pulmonary artery

Never seen as clearly as the right Unless markedly enlarged. Curved shadow, similar to the aorta just behind the air column

Aorticopulmonary window (AP WINDOW)

 Double check area - for subtle mediastinal masses. Between

Aortic arch Left pulmonary artery Residual portion
Ligamentum arteriosum left recurrent laryngeal nerve

Should concave or straight border.

Mediastinal mass(+)
Lung pushed laterally border becomes convex.

MISCELLANEOUS
Lateral view
Adult
anterior mediastinum cephalad to the heart Lung-air density, not soft tissue density.

Infants and young children

Thymus fills this area.

Check posterior sternal margin

Small masses: internal thoracic lymph node enlargement.

Check List
8. Review hila:
normal relationships size compare lung sizes evaluate pulmonary vascular pattern: compare upper to lower lobe, right to left, normal tapering to periphery pulmonary parenchyma pleural surfaces
fissures - major and minor - if seen compare hemidiaphragms follow pleura around rib cage

9. Review lungs and pleura:

Frontal view of the hila

Frontal view of the hila

Frontal view, hilar shadows most
left pulmonary arteries. right pulmonary arteries.

Bronchi(with the arteries)

Radiolucent.

Pulmonary veins
Not clearly seen
they are behind the widest parts of the heart, inferior to the hila, where they converge into the left atrium.

Left pulmonary artery always more superior > right, left hilum higher. Calcified lymph nodes may be visible within the hilar shadows.

Lateral view of the hila

1. Trachea 2. Lower lobe bronchi (left and right superimposed) 3. Right Pulmonary Artery

Check List
8. Review hila:
normal relationships size compare lung sizes evaluate pulmonary vascular pattern
compare upper to lower lobe, right to left, normal tapering to periphery

9. Review lungs and pleura:

pulmonary parenchyma pleural surfaces

fissures - major and minor - if seen compare hemidiaphragms follow pleura around rib cage

Lung size

Lung
Compare overall size of one lung bilateral, Also a double check on your earlier look at the rib cage size. Look for major areas of abnormal lucency/or density Train your eyes to look through the heart and upper abdomen to lung posterior to these areas.

Blood vesseles in the lung

Blood vesseles in the lung

Distribution- side to side
Compare right/left upper lobes and lower lobes for roughly equal.

Distribution- upper to a lower

Vessel in the same middle zone of the lung.

Upright person- pressure differential

lower lobe vessel wider (i.e., larger) If same size or reversed in size,
Redistribution of flow has occurred.

Phenomenon does not apply, if the person is semi-recumbent or supine.

Blood vesseles of lung

PARENCHYMA

PARENCHYMA
Large abnormalities/small lesion
Masses Infiltrates calcifications

Compare- side to side at a time. Now ignore the bone but lung. 3 areas easily overlooked:
Behind the calcified anterior first rib cartilage, Behind the heart Behind the diaphragm

LATERAL VIEW OF THE LUNG

Lateral view
Help to look
Posterior costophrenic recess Anterior mediastinum.

Pleura
PA view
Minor fissue thickness and location

Lateral view
minor fissures major fissures
(even if you do not see them in their entirety which you rarely will).

AP VIEW OF THE PLEURA

Follow the pleural surface around the lung periphery making the following observations. On the frontal view, the apex of the hemidiaphragms should be in the mid third of each hemithorax with the right hemidiaphragm usually 2-2.5 cm higher than the left. The costophrenic angles laterally should be sharp. The lung should abut right up against the inner margins of the rib cage. If the pleural space is widened by fluid or mass, the lung will be pushed away by soft tissue density. Also check for pleural calcifications, and presence of pneumothorax.

LATERAL VIEW OF THE PLEURA

Lateral view
,follow the pleura into the posterior costophrenic recess along the inner aspect of the posterior ribs, if
possible.

Recheck Posterior sternal margin.

Soft tissues
1. Overall 2. Following
Calcifications Bony defect Soft tissue companion shadow for the clavicle
Supraclavicular LAP

Lt/Rt CHEST WALL

Overall thickness, subcutaneous emphysema, calcification. Muscle-fat planes (sharp, distinct; dots).

BREAST TISSUE
Symmetry (Normal variation
Standing(PA view) + unequal pressure against the film holder)

Notice lung density changes

(lung area +/- soft tissue of the breast )

ABDOMEN
Highly variable look for following
Gastric and bowel gas
Amount/ location( normal? )

Organ size
liver, spleen, kidneys

Free peritoneal air

Position will change location of free air.

Calcifications and masses

can they be localized to a specific structure.

Final Notes

 This completes an introduction into the beginnings of chest review. Be aware there are many more detailed observations to learn in the future. Go through the sections until you understand the anatomy, and then start practicing a continuous review looking at a full frontal and lateral view. When you have developed a review system that works for you (remember the order here is only a guide) go to the next section that has the check off list type of review. Many people find it helpful to talk their way through the film, the eye-brain-mouth loop does work. Finally look at films on a variety of normal people of all ages, sizes, and both sexes to develop a data base of normal references. Practice the review sequence that works best for you until it is automatic, and then you can concentrate on the diagnostic findings.

Check List (1)

1. 2. 3.

Check patient name, position, technical quality. Initial survey Soft tissue including breast, chest wall, companion shadow.
Review soft tissues and skeletal structures of shoulder girdles and chest wall. Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc. Review soft tissues and spine of neck. Review spine and rib cage: check alignment, disc space narrowing, lytic or blastic regions, etc.

4.

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

Check List (2)

8. Review hila:
normal relationships size compare lung sizes evaluate pulmonary vascular pattern: compare upper to lower lobe, right to left, normal tapering to periphery pulmonary parenchyma pleural surfaces
fissures - major and minor - if seen compare hemidiaphragms follow pleura around rib cage

9. Review lungs and pleura: