Brandy McKelvy, MD, FCCP

Assistant Professor
Division of Pulmonary, Critical Care and Sleep Medicine
Air Fat Soft tissue Bone Metal

least opaque to most opaque

most lucent to least lucent
Black to White
Anatomic Example
Air Air
Fat Mineral oil
Water Water
Bone Tums tablets
Metal Lead-bottom glass
 PA & Lateral
 AP
 Apical lordotic
 Lateral decubitus
 Free flowing pleural effusions
 Up-right (erect) semi-erect & supine
 Supine increases medistinal size due to gravity
 Distribution of pleural fluid
 KUB vs abdominal series (3 views)
 Know what you are ordering!
 Inspiratory/expiratory films
 Number of ribs visible?
▪ Ideally 8-10 posterior ribs
 Posterior-Anterior (PA)
 Standard view & most reliable technique
 Erect films detect air under the diaphragm
 Lateral view
 Done at the same time as the PA film
 Helps localize infiltrates, identify caridomegaly, effusions &
lymphadenopathy
 Posterior mediastinum and cost-phrenic recesses visible
 Anterior-posterior (AP)
 Portable- patient is too ill to go to radiology, usually patient is
sitting upright in bed
 Poorer quality
 AP films may cause the mediastinum & heart to appear larger ( up
to 15% increase in mediastinal structures)
 Enlargement of the radiographic image of
an object relative to its actual size
 Increased film-subject distance
 Super-imposition of structures in different planes
 Resultant image = summation of opacities
 Two structures of the same radiopacity in contact –
their margins cannot be identified
 Pick one order of operations that you prefer
 You will not be a professional radiographer but
you should always look at your own films
 Start with:
 Reading the label on the chest film (what type of film)
 Reading the label of the film (correct patient)
 Assessing the quality of the film
 Identifying the radiographic technique
▪ AP/PA film, exposure, rotation, position (supine, sitting or
erect)
 Poor inspiration
 High diaphragms, crowded
lung markings
 “Penetration”
 Disappearing thoracic
vertebral details through the
heart
 Rotation
 Note equal distances from
the vertebral spines to the
medial ends of the clavicles
 Under penetrated: you will  Over penetration:
not be able to see the  Lungs are “too black”
thoracic vertebrae  Unable to see lung markings
 Check for rotation
 Does the thoracic spine
align in the center of the
sternum and between the
clavicles?
 Are the clavicles level?
 Equal distant from sternum?
 Was film taken under full inspiration?
 A good film will show:
 10 posterior ribs
 6 anterior ribs to qualify
 When x-ray beams pass through the anterior
chest on to the film under the patient, the
ribs closer to the film (posterior) are most
apparent
 Gastric bubble should be on the left
 Aortic knob typically should be on the left
 Soft tissues- thickness, contours, presence of gas, masses
 Bones- density, lesions, fractures
 Lungs- look for abnormal densities, (opacity or luncency) or
pneumothorax
 Pleura- thickening, calcification, effusion, or pneumothorax
 Trachea- midline, or deviated, wall, lumen diameter
 Mediastinum- width and contour, discreet masses
 Heart- size and shape
 Pulmonary vessels- artery or vein enlargement
 Hila- position, masses, lymphadenopathy
 Identify and check positioning of lines, tubes, and other invasive
devices
 Foreign bodies- anything that should not normally be in the chest
 Boundaries of the film
A. Costophrenic angle
B. Diaphragm
C. Heart
D. Aortic arch
E. Trachea
F. Hilum
G. Main carina
H. Stomach bubble
J. Ascending aorta
A. Costophrenic angle
B. Diaphragm
C. Heart
D. Aortic arch
E. Trachea
F. Hilum
G. Main carina
H. Stomach bubble
J. Ascending aorta
1. Right Atrium
2. R Ventricle
3. Apex of L
Ventricle
4. Superior Vena
Cava
5. Inferior Vena
Cava
6. Tricuspid Valve
7. Pulmonary
Valve
8. Pulmonary
Trunk
9. Right PA
10. Left PA
Cardio/thoracic ratio
should be < 50%
 The hila – the large blood
vessels going to and from
the lung at the root of
each lung where it meets
the heart
 Check for elevation,
location, symmetry,
lymph nodes, enlarged
vessels, masses
 Increased
 Pulmonary arterial HTN
▪ Pruning
 Pulmonary venous HTN
▪ Pulmonary edema
▪ No pruning
 Decreased
 Pulmonary embolism
 Hypovolemia
Right side Left side
1. SVC 4. LSCA
2. Ascending 5. Aortic knob
aorta 6. Left PA
3. Right 7. Left atrium
Atrium (RA) 8. Left ventricle
5. Aortic arch
2. Ascending 7. Left
aorta atrium
9.Right
Ventricle 8. Left
6.Pulmonary Ventricle
trunk
Superior
Anterior
Middle
Posterior
 Anterior mediastinal masses
 Thymoma
 Thyroid
 Teratomas
 “Terrible lymph-nodes”(lymphoma)
 Middle mediastinum
 Lymph nodes
 Esophagus
 Aorta
 Duplication cysts, bronchogenic cysts
 Hiatal hernia
 Posterior mediastinum
 Neurogenic tumors
 Spinal mass
 Chest wall masses
lymphoma
thymoma
thryroid
Right upper lobe Right middle lobe Right lower lobe

Left upper lobe Lingula Left lower lobe

 Loss of lung volume
 Anatomy shifts towards atelectasis
 Linear, smooth, wedge-shaped
 Apex of opacity starts at hilum
 Air bronchograms or lack of air
 Sharp edges
 Volume loss
 Normal lung volume
 No anatomical shift
 Consolidation/infiltrates
 Irregular margins
 Coalesce of infiltrates
 Air bronchograms
 Blood, pus, water, protein, tumor all look the
same on chest-x-ray
 Focal vs Diffuse
 Infiltrates will occupy 1 of 3 spaces:
 Alveoli
▪ “Fluffy”, irregular
▪ Confluence
▪ Air-bronchograms
▪ Silhouette sign
▪ Acinar nodules
 Supporting structures
▪ The interstitium or the lymphatics
▪ Reticular i.e. “lacy” infiltrates
▪ Nodules
▪ Lymphatics spread of tumor
▪ Interstitial fibrosis
 The blood vessels
Alveolar-filling, or “airspace” disease:
“Pointillist” patterns
Air bronchograms
RML consolidation
Right Upper Lobe Infiltrate
Multi-lobar opacities
 “Always” diffuse
 Linear
 Reticular
 Nodular/miliary
 Honey -combing
 Curly B lines – fluid in the intra-lobular septae
A. Generalized interstitial thickening = linear (“reticular”)
B. Discrete interstitial thickening = nodules
C. Interstitial & alveolar filling = silhouette
Curly B lines
Curly B lines
Cardiogenic vs non-cardiogenic pulmonary edema?
Bat-wing
ARDS
 Nodules
 Solitary or multiple
 Solitary pulmonary nodule
 Size
▪ 1-2 mm, micronodular (miliary)
▪ 2 mm- 3.0 cm
 Calcified or non-calcified
 Margins? Cavitation?
 Doubling time? How long has it been present?
 Masses > 3 cm
 Renal Cell Carcinoma

Testicular cancer
TB/HIV
 No walls
 Emphysema
 Bullea >1 cm
 Thin walled
 Pneumatocels
 Aircysts (LAM, EG, PLCH)
 Thick walled
 Honey combing
 With Air-fluid levels
▪ Lung abscess, septic emboli, TB, tumors
 Bronchiectasis
Aspergillus cavity
 Pleural effusions
 Free flowing
 Loculated
 Pleural calcifications
 Pleural line
 Pneumothorax?
 Right hemi-diaphragm always slightly higher than the left
 Bilateral elevated hemi-diaphragms:
 Increased intra-abdominal pressure, increased airway pressures
 Bilateral phrenic nerve palsy
 Unilateral elevated hemi-diaphragm
 Unilateral phrenic nerve palsy
 Volume loss
▪ Atelectasis
▪ Lobectomy
 Intra-abdominal mass
 Sub-pulmonic effusion
 Herniation thru the diaphragm
 Look under the diaphragm
Chest tube port outside chest wall