Chest

Radiography
Interpretation

M Chadi Alraies, MD
Chief Medical Resident
Case Western Reserve University
SVCH

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 Reading CXR’s
 Have a structured method!
 Be consistent with that method
 Don’t take short cuts
 LOOK AT ALL YOUR PATIENTS XRAYS
YOURSELF (and with your resident of
course!)
 PRACTICE…PRACTICE… PRACTICE

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What is a Chest Radiograph?

SHADOW
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 Start at the beginning

Identification
! Correct patient
 Correct date and time
 Correct examination

 Areold films available?

 DO THIS EVERYTIME – It buys you time and is
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 Approach to the CXR: Technical Aspects

 Projection – PA or AP
 Position – Upright or Supine (Supine folks are
sick)
 Inspiratory effort
 9-10 posterior ribs
 Penetration
 thoracic intervertebral disc space just visible
 Positioning/rotation
 medial clavicle heads equidistant to spinous process
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Projection
Portable (AP or Antero-
posterior)
FILM

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PA (Postero-anterior)
FILM

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 Projection

PA AP
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Low Lung Volumes

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Over Exposure Proper Exposure

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Mental Break

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 Anatomy

RUL

RML

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RUL (Right Upper Lung)

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RML (Right Middle Lung)

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RLL (Right Lower Lung)

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Right Sided Fissures

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LUL (Left Upper Lung)

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LLL (Left Lower Lung)

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Left Side Fissure

LUL

LLL

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 What to Evaluate

 Lungs
 Pleuralsurfaces
 Cardiomediastinal contours
 Bones and soft tissues
 Abdomen

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 Where to Look

 Apices
 Retrocardiacareas (left and right)
 Below diaphragm

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Apical TB

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Left Retrocardiac Opacity

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Normal Anatomy: Frontal CXR

 Heart
 Aorta
 Pulmonary arteries
 Airways
 Diaphragm/costophrenic sulci

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 Normal Anatomy: Lateral

 Heart
 Aorta
 Pulmonary arteries
 Airways
 Spine

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 Maximum x-ray Blackest
Transmission
air
(least dense tissue)
fat
soft tissue
calcium
bone
x-ray contrast
Maximum x–ray metal
Absorption
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 Chest Radiography: Basic Principles

A structure is rendered visible on a

radiograph by the juxtaposition of two
different densities

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 Silhouette Sign

 Loss of the expected interface normally

created by juxtaposition of two structures
of different density
 No boundary can be seen between two
structures of similar density

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Right Lower Lobe Pneumonia

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 Differential X-Ray Absorption

 The absence of a normal interface may

indicate disease;
 The presence of an unexpected
interface may also indicate disease
 The presence of interfaces can be used
to localize abnormalities
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 Chest Radiographic
Patterns of Disease
 Air space opacity
 Interstitial opacity
 Nodules and masses
 Lymphadenopathy
 Cysts and cavities
 Lung volumes
 Pleural diseases
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LUL Pneumonia

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 Air Space Opacity

 Components:
 airbronchogram: air-filled bronchus
surrounded by airless lung
 confluent opacity extending to pleural
surfaces
 segmental distribution

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 Air Space Opacity: DDX

 Blood (hemorrhage)
 Pus (pneumonia)
 Water (edema)
 hydrostatic or non-cardiogenic
 Cells (tumor)
 Protein/fat: alveolar proteinosis and
lipoid pneumonia
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Interstitial Opacity: Small Nodules

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Interstitial Opacity:
Lines

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Interstitial Opacity: Lines & Reticulation

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 Interstitial Opacity

 Hallmarks:
 small, well-defined nodules
 lines
 interlobular septal thickening
 fibrosis

 reticulation

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 Interstitial Opacity: DDX
 Idiopathic interstitial pneumonias
 Infections (TB, viruses)
 Edema
 Hemorrhage
 Non–infectious inflammatory lesions
 sarcoidosis

 Tumor
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Well-Defined

Calcification

Mass
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Ill-Defined
 Nodules and Masses

 Nodule: any pulmonary lesion represented in

a radiograph by a sharply defined, discrete,
nearly circular opacity 2-30 mm in diameter
 Mass: larger than 3 cm

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 Nodules and Masses

 Qualifiers:
 single or multiple
 size
 border definition
 presence or absence of calcification
 location

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 Right Paratracheal
Lymphadenopathy

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Right Hilar LAN

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Right Hilar LAN

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Left Hilar LAN

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 Subcarinal LAN

*
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AP Window LAN

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 Lymphadenopathy

 Non-specific presentations:
 mediastinal widening
 hilar prominence

 Specific patterns:
 particular station enlargement

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 Cysts & Cavities

 Cyst: abnormal pulmonary parenchymal

space, not containing lung but filled with air
and/or fluid, congenital or acquired, with a
wall thickness greater than 1 mm
 epithelial lining often present

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 Cysts & Cavities
 Cavity:abnormal pulmonary parenchymal
space, not containing lung but filled with air
and/or fluid, caused by tissue necrosis, with
a definitive wall greater than 1 mm in
thickness and comprised of inflammatory
and/or neoplastic elements

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Benign Lung Cyst : PCP Pneumatocele
• Uniform wall thickness
• 1 mm
• Smooth inner lining

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 Benign Cavities :
Cryptococcus

• max wall thickness ≤ 4 mm

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• minimally irregular inner lining

 Indeterminate Cavities

• max wall thickness 5-15 mm

• mildly irregular inner lining
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Malignant Cavities: Squamous Cell Ca
• max wall thickness ≥ 16 mm
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• Irregular inner lining

 Cysts & Cavities

 Characterize:
 wallthickness at thickest portion
 inner lining
 presence/absence of air/fluid level
 number and location

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Pleural Effusion

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Pleural Effusion

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Pleural Calcification

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Pleural Disease: Basic Patterns
 Effusion
 angle blunting to massive
 mobility
 Thickening
 distortion, no mobility
 Mass
 Air
 Calcification
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Thoracic Aorta Aneurysm

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Chest breast implants

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 ◆ Rib fx’s
◆ Mediast. OK
◆Pulmonary
contusion
◆ Subcu air
◆ Chest tube
◆ NG tube

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MVC victim
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Tip of ET tube Carina

Deep Right Mainstem Intubation

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 Tip of ET

Pneumomediastinum
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 Potential X ray
findings

 wide
mediastinum
 obliteration of
aortic knob
 Rt mainstem
shift up and
right
 NG deviate
to right
 pleural cap
Major Vessel Injury
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Pneumothoraces

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 Expiration reduces lung volume,
making a small pneumo easier to see
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Irregular linear opacities are present in both lungs, especially in the periphery
and the bases of the lungs. The heart is slightly enlarged, but this is not related
to the pulmonary abnormalities in this case.
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Hodgkin’s Disease
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 Ao

SVC

Mediastinal Hematoma
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 ET tube
Obliterated aortic knob First rib fx

Tracheal deviation to Rt.

Chest tube

NG shift to Rt.

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 Lt. Internal Carotid
Rt. Subclavian Art. Artery

ET
Lt. Subclavian
Artery
NG
Aortic
Rupture

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Tension Pneumothorax on CT

Tension Pneumo
Mediastinum
Rt. Lt.

Ao

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Hemothoraces

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 Hemothorax

Supine Upright
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Hemopneumothorax
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 Indistinct diaphragm

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 Elevated, irregular
hemidiaphragm

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 Clavicle fx
Suspicious

Rib fxs
Close-up
Indistinct, elevated diaphragm

Chest tube

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Crushed right chest
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After ventilated with PEEP
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www.chadialraies.blogspot.com

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