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Interpreting the Chest Radiograph (printer-friendly)

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Interpreting the Chest Radiograph

A Systematic Approach Will Ensure You Don't Miss Major Pathology Jen Jou Wong; John Curtis Posted: 04/24/2012; Stud BMJ 2012 BMJ Publishing Group

Introduction Chest radiographs are common investigations that require careful and confident interpretation. Junior doctors might not always be able to rely on a senior opinion during on-call shifts. It is therefore important that you can confidently assess a chest radiograph and detect abnormalities, especially those that are life threatening. Using a systematic approach you should be able to detect major chest abnormalities, reach a diagnosis, and take appropriate and timely action. Normal Anatomy Being familiar with normal anatomy in chest radiographs increases your chances of detecting an abnormality when one is present, even if you cant diagnose the condition definitively. Regularly reviewing and presenting radiographs to senior colleagues while on the ward will help. Figure 1 is a normal chest radiographcan you identify the labelled structures?

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Figure 1. Normal anatomy. A=trachea, B=carina, C=right atrium, D=aortic knuckle, E=cardiophrenic angle, F=left ventricle, G=clavicle, H=hemidiaphragm, I=gastric air bubble, J=hilar points, K=rib, L=lung, M=costophrenic angle, N=breast shadow, O=thoracic spine It is important to know how the lung lobes are divided because being aware of how the fissures move in different pathologies will aid diagnosis (Figure 2). On a posterior-anterior (PA) film (see Box 1 for explanation), the fissure you are most likely to see is the horizontal fissure of the right lung, which divides the upper and middle lobes.
Box 1. Technical aspects of a plain film

Name and agemake sure you have the correct patient. The age of a patient will help you determine how likely you are to find a particular pathologyfor example, cancer is not the most likely diagnosis in a young patient. SexDoes the image belong to a man or woman? The presence or absence of breast shadows can help determine this. OrientationIs the radiograph anterior-posterior (AP), where the x ray plate is behind the patient and the x rays shot from the front, or posterior-anterior (PA), where the x rays are shot from behind the patient and the x ray plate is at the front? PA films more accurately depict heart size than AP films but require the patient to stand. An ill patient who is bed bound would be more likely to have an AP film. Know your right from your left and which way round the image is. RotationIn a well centred image the medial ends of the clavicles are equidistant from the spinous processes of the thoracic spine. Rotation can obscure structures and accentuate differences in attenuation between the lung fields. PenetrationOver or under exposure of the film results in too little or too much contrast, potentially at the expense of omitted detail or exaggeration of normal features respectively. InspirationPoor inspiration results in less air filling the lungs and can imitate pathology, such as collapse or atelectasis in the lower lobes.

Figure 2. Lung lobes and fissures. (A) Anterior view of the lungs and the horizontal fissure. (B) Right lung (in lateral view) has three lobes: the upper and middle lobes divide by the horizontal fissure, with the lower lobe sitting posterior to these two and separated by the oblique fissure. (C) Left lung (in lateral view) has only two lobes, upper and lower, which are divided by an oblique fissure An Aide Memoire An aide memoire can help ensure a thorough, systematic approach in examining all parts of a radiograph. Remember that when you find something abnormal, dont stop looking. It is easy to become complacent once an abnormality is found, but there could be other, more serious findings on the radiograph.

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Begin the analysis of the chest radiograph by commenting on the technical aspects of the film. Not only does this ensure that you are looking at a film belonging to the correct patient, but it also gives you an overall view of the quality of the radiograph and its potential to convey anatomy and any potential pathology accurately. Formulating an Approach One approach that is particularly favoured was developed by the chest radiologist Benjamin Felson. It is designed to target the least interesting areas of the radiograph first, before proceeding to analyse the more important areasthe lungs and heart. This is to lessen the chance of boring areas being reviewed improperly. No gold standard system for reviewing a chest radiograph exists, however. Doctors use different methodsthe approach that suits you most is acceptable as long as all areas of the radiograph are reviewed and commented on ( Box 2 ).
Box 2. Felsons system1

Abdomen Thorax Mediastinum Lungs (one side at a time) Lungs (compare one against the other) Aide memoire: Are There Many Lung Lesions?

Review the Upper Abdominal Structures

Even if you dont suspect any abdominal pathology, you should look at the abdominal cavity. Gas should be visible in the stomach and sometimes in the hepatic and splenic flexures of the colon. Any other airspaces forming below the diaphragm could indicate a pneumoperitoneum, leading to concerns of a perforated viscus. A large bubble of gas with a fluid level in the middle of the chest can indicate a hiatus hernia. Chest and upper abdominal pathology can mimic each other clinically, making assessment of the abdomen on the chest radiograph an important part of the routine. The converse is trueabdominal pain may be caused by lower lobe lung pathology, such as consolidation, and can be detected on the chest radiograph.
Examine the Bones and Soft Tissues

This is primarily to look for fractures, lytic lesions, or sclerosis suggesting metastases. While you are looking at the ribs, the costophrenic anglesformed at the intersection of the lateral ends of the hemidiaphragms with the rib cageshould be assessed. Blunting of these might be caused by small pleural effusions.
Assess the Mediastinum and Trachea

Do this to see whether they seem central and not overly bulky (suggesting abnormal, possibly cancerous growth). The trachea can be displaced in certain conditions (this is described in more detail later). It is also important to note the position of the hilar points, formed by descending upper lobe veins crossing behind lower lobe arteries. The right hilar point typically sits just below the level of the left hilar point, primarily because of the more horizontally oriented left main bronchus. The hilar points can change position, typically in lobar collapse.
Look at the Heart

Assess the greyness of heart muscle either side of the vertebral bodies. By adjusting the contrast or brightness of the film you might be able to spot a difference in the density of the two areas projected over the heart muscle lateral to the vertebral body, indicating a hidden patch of consolidation. The heart on a PA film should be less than half the total chest diameter at its largest pointif it is bigger than this cardiomegaly secondary to heart failure might be indicated. The cardiophrenic angles (formed by the intersection of the heart borders with the medial end of the hemidiaphragms) should be clear and could be deformed by cysts or solid masses. Areas of hazy opacity abutting the cardiophrenic angles are occasionally present. This can correspond to cardiac fat pads, especially in a population where obesity is increasing.
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Interpreting the Chest Radiograph (printer-friendly)

Comment on the Lung Fields Lastly, review the lungs and be sure to comment on their size. This might indicate how well a patient can expand their chest, which in turn can be affected by the severity of the illness or how expansile the lung tissues are. A good inspiratory effort should allow at least six anterior ribs (or nine posterior ribs if the anterior ribs are difficult to see) to be evident crossing the mid-clavicular line and the diaphragm. Poor inspiration can result in increased opacification and can be mistaken for consolidation or collapse. Follow the borders of the pleura and the extent to which lung markings are evident towards the peripheries. Ordinarily, lung markings stop just short of the edge of the chest wall by about 1 cm. Lung markings that go all the way to the edge can suggest interstitial disease, and markings that stop abruptly with a definite margin separate to that of the rib cage could suggest a pneumothorax, especially if a pleural edge is evident. Signs and Patterns On a radiograph, air appears black, bone appears white, fluid a slightly less opaque white, and other structures such as fat and muscle appear grey. These appearances depend on the ability of tissues to absorb x rays. When there is a sharp transition between two tissues of differing densities (for example, bone, which is dense and white, and lung, which is air filled and black) there is also a sudden change in the absorption of x ray beams, leading to the appearance of one border being silhouetted against another. This can happen only if the x ray beam is tangential to the interface of the adjacent structures. The loss of usually clear margins between anatomical structures due to the presence of additional material, whose density obscures this silhouette, is called the silhouette sign.[2] This can help localise the area of pathology. Disruption of the border between the lungs and diaphragm suggests lower lobe pathology. An unclear right heart border would correspond to right middle lobe pathology. Right upper lobe consolidation disrupts the silhouette between the upper lobe and the upper mediastinum and ascending aorta. Left upper lobe consolidation results in unclear borders with the left atrium and mediastinum. Another sign that is useful in determining the presence of pathology is the air bronchogram sign.[3] This occurs when there is consolidation surrounding the small airways. The alveoli become filled with pus, blood, or fluid, resulting in the air filled bronchi standing out against a background of consolidated alveolar air spaces. It is a classic indication of a pulmonary process, rather than a mediastinal or pleural process. Thus the sign can be present in pneumonia, pulmonary oedema, or pulmonary infarction. In some pathologies, structures within the chest may be displaced from their normal positions, and there is a pattern to the movement depending on the condition. This is summarised in the table. Movement of intrathoracic structures in lung pathologies Hemidiaphragm movement Depressed on affected side Depressed on affected side Raised on affected side Raised on

Mediastinal shift

Lung volume

Other signs Visible pleural edge, deep sulcus sign, increased rib spacing Blunting of costophrenic angles, air-fluid level with meniscus sign See figures for lobe collapse Exaggerated lung markings, continues right up to pleural
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Reduced lung filling on Tension Pushed towards affected side, and pneumothorax contralateral side hyperinflated hemithorax Pleural Effusion Pushed away from affected hemithorax Reduced on affected side

Pulled towards Lobe collapse affected hemithorax Fibrotic Pulled towards affected

Reduced on affected side

Reduced on affected side

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Interpreting the Chest Radiograph (printer-friendly)

disease

hemithorax

affected side

edge

Lobar Collapse Lobar collapse presents with predictable patterns, which are best described pictorially (see Figure 3). Collapsed lobes are the result of an obstruction of a proximal airway, the reasons for which vary depending on the patients historyfor example, possibly a mucus plug in a patient with severe pneumonia or an inhaled foreign body in a child. In an older patient with lobar collapse on a chest radiograph with no obvious cause, bronchial cancer must always be suspected, especially where there is a history of smoking. The patient would require follow-up by chest doctors, usually with bronchoscopy.

Figure 3. Lobar collapse. Top row: shows the movement of the lobes of the right lung when they collapse. The upper lobe (A) collapses towards the apex, pulling the horizontal fissure upwards. The middle lobe (B) collapses to form a poorly defined opacity, often obscuring the right heart border. Finally, in lower lobe (C) collapse the oblique fissure is pulled more horizontally and the border of the diaphragm is obscured while the right heart border is generally preserved. Only a few important aspects of chest radiograph interpretation have been mentioned here, but these points should give you a foundation on which to develop and read about radiograph interpretation. Below are a few images with some abnormalities. Using the principles outlined in the article, can you reach a diagnosis for each radiograph? Quiz Yourself

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Figure 4

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Figure 5

Figure 6

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Figure 7 Chest Radiograph Quiz Answers

Lingular Pneumonia (Figure 4)

Although this image does not show the classic veil sign, a silhouette sign disrupts the left border of the heart, but the left hemidiaphragm border is preserved. This specifically corresponds to the lingular segment of the left upper lobe. The cardiac notch of the left lung creates a small projection of lung tissue arising from the most inferior aspect of the upper lobe to form the lingular lobe. As the lingula does not have a large volume there is little volume loss in lingular collapse, and differentiating collapse from consolidation can be difficult on the frontal film alone.
Pneumoperitoneum (Figure 5)

The typical areas of focus on the chest radiographthe heart and lungsappear clear. On closer inspection, however, free air is seen under both hemidiaphragms which should not be present. It does not correspond to normal air patterns found in the bowel.
Pulmonary Oedema (Figure 6)

The bilateral fluffy or cotton wool consolidation takes on a bats wing configuration, and also shows the presence of the air bronchogram sign. Electrocardiogram leads and oxygen tubing can also be seen, giving clues about how ill the patient is.
Right Tension Pneumothorax (Figure 7)

A mediastinal shift to the left is seen, as is a complete absence of lung markings on the right, and what seems to be a mass running along the right mediastinum with a distinct border. This mass represents a completely compressed right lung caused by a build-up of air that is unable to escape from the thoracic cavity. More
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advanced cases of tension pneumothorax lead to depression of the diaphragm. Tension pneumothorax is a clinical condition that should be recognised and treated appropriatelythat is, with the insertion of a large bore cannula into the second intercostal space, mid-clavicular linebefore the need for a chest radiograph.
References

1. Goodman LR. Felson's principles of chest roentgenology. 3rd ed. Saunders, 2006. 2. Felson B, Felson H. Localization of intrathoracic lesions by means of the postero-anterior roentgenogram; the silhouette sign. Radiology 1950;55:363-74. 3. Hansell DM, Bankier AA, MacMahon H, McLoud TC, Mller NL, Remy J. Fleischner society: glossary of terms for thoracic imaging. Radiology 2008;246:697-722.

Acknowledgments: Thanks to Azadeh Taheri for her guidance and in editing the article. Competing interests: None declared. Provenance and peer review: Not commissioned; externally peer reviewed. Stud BMJ 2012 BMJ Publishing Group

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