NORMAL CHEST

RADIOGRAPH
VENU MADHAV
Male or female?
 Look for the
presence of
breast shadows
(this will help
you to notice a
mastectomy
too).
 Old or young?

 Try to use the patient's age to

your advantage by making
sensible suggestions. A 20 year
old is much less likely to have
malignancy than someone who is
70.
Child or Neonate?
 Apparent superior
mediastinal
widening in a
child due to
normal THYMUS
should not be
mistaken for a
pathology.
 VIEWS
 PA
 AP
 LATERAL (LEFT AND RIGHT)
 SUPINE
 LATERAL DECUBITUS (LEFT AND RIGHT)
 OBLIQUE
 APICAL/LORDOTIC
 PAIRED INSPIRATORY AND EXPIRATORY
 The PA view
 Patient faces the film chin up with the
shoulders rotated forward to displace
the scapulae from the lungs.
 Exposure should me made on full
inspiration (centering at T5)and
breasts should be compressed against
the film for optimal visualisation of
lung bases.
 Low kVp: (60-80 kV)
High contrast film.
Miliary shadowing and calcification
more clearly seen.

• High kVp: (120-170 kV)

Low contrast film.
Hidden areas of lung could be better
visualized.
A FFD of 1.85m (6 feet) reduces
magnification and produces a
sharper image.

A Grid or Air Gap is necessary to

reduce scatter and improve
contrast.
 AP
 Done in patients who are unable to
stand or portable radiographs.

 The ribs are projected over

different areas of the lung from the
PA view and posterior chest is well
shown.
PA or AP?
 PA
 Ina PA film, the heart is closer to
the film and thus less magnified.

 The standard chest x-ray is a PA

film.
 AP
• In an AP film, the heart is farther
from the film and is more magnified.
 On the AP supine film there is more
equalization of the pulmonary
vasculature when the size of the
lower lobe vessels are compared to
the upper.
 AP
 Scapulae overlie the upper lungs.
 Clavicles are projected more
cranially over the apices.
 The disc spaces of the lower
cervical spine are more clearly
seen.
 The Lateral View
 With shoulders parallel to the film the
arms are elevated, or displaced back
if the anterior mediastinum is of
interest.

 For
sharpness the side of interest is
nearest the film.
 SUPINE and DECUBITUS
 Todistinguish a SUBPULMONARY
EFFUSION from an elevated
diaphragm or consolidation.

 Inthe supine and decubitus

positions, the free fluid becomes
displaced.
 DECUBITUS FILM
 Patient is placed lying on the cassette
with either the left or right side
dependent.
 It is most frequently used for evaluating
the presence of free-moving pleural
fluid.
 The usual technique is to have the
patient lie on the side with the fluid and
look for a radiodense fluid line along the
dependent side.
 With small amounts of pleural
fluid, it is helpful to have the
patient lie with the normal side
dependent and see if the
diaphragmatic angle on the
involved side becomes sharp,
thus indicating the presence of a
small, free-moving effusion.
 OBLIQUE
 Retrocardiacarea, the
posterior costophrenic angles
and the chest wall with
pleural plaques are clearly
demonstrated.
 APICAL VIEW
 The x-ray beam is angled in a slightly
upward projection, causing anterior
thoracic structures to be projected above
the posterior thoracic structures.
 The clavicle and first several sets of ribs
are projected above the apices of the
lung, allowing a good view of this area.
 It is particularly useful in evaluating the
upper lobes for evidence of tuberculous
disease.
 LORDOTIC VIEW
 With the patient in lordotic PA
position, the tube is angled
downwards.

 Bestto visualize a middle lobe

collapse, seen as a well-defined
triangular shadow.
 PAIRED INSP AND EXP FILMS

 Demonstrate
air trapping and
diaphragm movement.

 Usefulin children with a

possible diagnosis of an
INHALED FOREIGN BODY.
 What is a technically
adequate Chest X Ray?

Adequate

 Penetration
 Inspiration
 Rotation
 Angulation
Good inspiration?
The
diaphragms
should lie at
the level of
the sixth ribs
anteriorly.
 About 10
posterior ribs
visible is an
excellent
inspiration.

 In many
hospitalized
patients 9
posterior ribs
is an adequate
inspiration.
• On expiration
heart shadow
appears larger.
• Poor inspiration
will crowd lung
markings and
make it appear
as
though the
patient has
airspace disease.
Good penetration?
 You should
just be able to
see the lower
thoracic
vertebral
bodies through
the heart.
 If the film is
under penetrated,
the left hemi
diaphragm (and
left
lung base) will
not be visible and
the pulmonary
markings will
appear more
prominent than
they actually are.
 Over
penetration
results in loss
of visibility of
low-density
lesions such
as early
consolidation.
Is the patient rotated?
 Thespinous
processes of the
thoracic
vertebrae
should be
midway
between the
medial ends of
the clavicles.
LEFT ROTATION
 If spinous process
appears closer to
the right clavicle,
the patient is
rotated toward
their own left side.
 If the medial end of
the clavicle is
farther on the left
side, then the
patient is rotated
left.
RIGHT ROTATION
 If spinous process
appears closer to
the left clavicle, the
patient is rotated
toward their own
right side.
 If the medial end of
the clavicle is
farther on the right
side, then the
patient is rotated
right.
 Smalldegrees of rotation distort
the mediastinal borders, and the
lung nearer the film appears less
translucent.

 Severe rotation may make the

pulmonary arteries
appear larger on the side nearer
the film.

 Thoracic deformities like

Scoliosis, negate the value of
conventional centering.
 ANGULATION
 Ifthe x-ray beam is angled toward
the head (mostly because the
patient is semi-recumbent), the
film so obtained is called an “apical
lordotic” view.
 Anterior structures (like the
clavicles) will be projected higher
on the film than
posterior structures.
 The factors to evaluate the
quality of a chest x-ray are:

 Penetration – see spine through the

heart

 Inspiration – at least 8-9 posterior ribs

 Rotation – spinous process between

clavicles.

 Angulation – clavicle over 3rd rib

Viewing a PA film
 TRACHEA
 Midline in its upper part, then
deviates slightly to the right
around the aortic knuckle.
 On expiration, deviation to the
right becomes more marked.
 In addition, there is shortening
in expiration.
 Normal maximum coronal
diameter is 25mm for males
and 21mm for females.
 Its calibre should be even, with
translucency of the tracheal
column decreasing caudally.
 The trachea should be
examined for narrowing,
displacement and intraluminal
lesions.
 Right Paratracheal Stripe
 Right tracheal margin, where the
trachea is in contact with the lung.
 Seen in 60% of patients, normally
measuring <5mm.
 Widening of this stripe occurs in
cases of mediastinal
lymphadenopathy, tracheal and
mediastinal malignancies,
mediastinitis and pleural effusion.
 Leftparatracheal stripe is not
visualised because the left
tracheal border is adjacent to
the great vessels and not the
lung.
 CARINA
 The normal angle is 60-75
degrees.
 Widening of the carina occurs
in inspiration.
 Pathological causes of
widening:
 Enlarged left atrium.
 Enlarged carinal nodes.
 AZYGOS VEIN
 Lies in the angle between the
right main bronchus and
trachea.
 On the erect film, it should be
less than 10mm in diameter.
 Its size decreases in
 Inspiration
 Valsalva manoeuvre.
 Size of Azygos vein increases
in:
 Supine position.
 Pregnancy.
 Enlarged subcarinal nodes.
 Portal hypertension.
 IVC and SVC obstruction.
 Right Heart Failure.
 Constrictive Pericarditis.
 MEDIASTINUM
 Look at the overall size and shape of
the entire mediastinum on the frontal
and lateral views
 Look for obvious masses and
calcifications, check for tubes,
electrical leads, a pacemaker,or
artificial valves.
 Check for evidence of mediastinal
shift and if present, is the entire
mediastinum shifted, or just a section
of it?
 SUPERIOR MEDIASTINUM
 The superior mediastinum begins
at the root of the neck and ends
caudally at a line drawn between
T-4 vertebra and the
sternomanubrial junction.
 The area between this line and
the diaphragm is further divided
into three regions, anterior,
middle, and posterior.
 Basically,the heart and
pericardium form the middle
section, everything anterior to
the heart is the ANTERIOR
MEDIASTINUM, and everything
posterior to the heart back to the
spine is the POSTERIOR
MEDIASTINUM. 
 Theright superior medastinal
shadow is formed by SVC and
Innominate vessels. A dilated
Aorta may contribute to this
border.

 Leftmediastinal border is less

sharp. It is formed by
subclavian artery and above
the aortic knuckle.
 Anterior Middle and Posterior
Mediastinum
 These regions are superimposed on the
frontal view.
 The major structure is the heart. For all
practical purposes the pericardium will
be inseparable from the heart on plain
film views.
 Review the heart for overall size and
shape. Look carefully for calcifications,
pneumopericardium,
pneumomediastinum, sutures,
prosthetic valves etc.
 CARDIAC SHADOW
 With good centering, 2/3rds of
the cardiac shadow lies to the
left of midline and 1/3rd to the
right.

 TRANSVERSE CARDIAC
DIAMETER:
 Normal for females <14.5cm and
for males <15.5cm.
 CARDIO THORACIC RATIO:
The ratio of the widest diameter of
the heart to the widest width of the
thoracic cage as measured from inner
aspect of rib to rib. This cardiac-
thoracic ratio should be less than
50%. 
• An increase in excess of 1.5cm in the
transverse diameter on comparable
serial films is significant.
 False enlargement of heart:

 Short FFD.
 Expiration.
 AP projection.
 When diaphragms are
elevated.
 AORTA
 Try tracking it from the root to distal
descending aorta.
 In the young adult the ascending aorta
usually is hidden in the mediastinum, in
older people it may swing to the right
enough to cast a soft tissue bulge.
 The arch should always be seen, make
sure it is to the left of the distal trachea
and actually pushes the distal trachea
slightly to the right.
 Check for aortic calcifications and size.
The left lateral border of the descending
aorta abuts the left lung
 PULMONARY ARTERY
 On the frontal view, the only part of
the main pulmonary artery seen is
the left lateral border where it meets
the left lung.
 It can be relatively straight or
convex (most commonly in young
females).
 The left pulmonary artery is directly
behind the main pulmonary artery,
and is visible on frontal films as a
branching structure.
AORTICOPULMONARY WINDOW
• It is formed by a portion of the
upper lobe sitting in the space
immediately lateral to the area
between the aortic arch and left
pulmonary artery.
 The AP window should have a
concave or straight border.
 If there is a mediastinal mass in the
AP window region, the lung will be
pushed laterally and the border
becomes convex.
 THYMUS
 Seen in children.
 Normal thymus is a triangular or sail-
shaped structure with well defined
borders projecting from one or both
sides of the mediastinum.
 Both borders may be wavy in outline, the
“wave sign of MUVLEY” as a
consequence of indentation by costal
cartilages.
 Thymus is absent in DI GEORGE
SYNDROME.
 Large thymus may be seen commonly
in boys and also following recovery
from an illness.
 Thymic size decreases on inspiration
and in response to stress and illness.
 PARASPINAL LINES
 These lines run adjacent to the
vertebral bodies.
 On left this is normally <10mm
wide.
 On the right, <3mm.
 The left paraspinal line is wider due
to the Descending thoracic aorta.
 Causes of enlargement of
Paraspinal lines:
 Osteophytes.
 Tortuous Aorta.
 Vertebral and adjacent soft-tissue
masses.
 Paravertebral hematomas.
 Dilated Azygos system.
 JUNCTION LINES
 Formed by pleura being outlined by
the adjacent air-filled lung.
 They are:
 Anterior junction line.
 Posterior junction line.
 Azygo oesophageal interface.
 Pleuro-oesophageal stripe.
 ANTERIOR JUNCTION LINE

 It is formed by the lungs meeting

anterior to the ascending aorta.
 It is 1mm thick.
 Overlying the tracheal translucency, it
runs downward from below the
suprasternal notch, slightly curving
from left to right.
 POSTERIOR JUNCTION LINE

 Formed where the lungs meet

posteriorly behind the oesophagus.
 It is 2mm wide.
 Straight or curved line convex to the
left.
 Extends from the lung apices to the
aortic knuckle or below.
 AZYGO-OESOPHAGEAL
INTERFACE
 Has the shape of an “inverted
hockey stick”
 It runs from the diaphragm on the
left of midline up and to the right
extending to the tracheo-bronchial
angle where the Azygos vein drains
into the IVC.
PLEURO-OESOPHAGEAL STRIPE

 Itis formed by the lung and right

wall of the oesophagus.
 Extends from the lung apex to the
Azygos.
 Visualised only if the oesophagus
contains air.
 THE DIAPHRAGM
 In most patients, right hemi diaphragm
is higher than the left.
 This is due to the heart depressing the
left side and not due to the liver
pushing the right hemi diaphragm.
 The hemidiaphragms may lie at the
same level normally, or if the stomach
or splenic flexure is distended with gas.
 In 3% subjects, the left hemi
diaphragm is higher.
A difference >3cm in height is
considered significant.
 On inspiration, the domes are at the
level of 6th rib anteriorly and at or
below the 10th rib posteriorly.
 Loss of outline indicates that the
adjacent tissue does not contain air,
for example in consolidation or
pleural disease.
 THE FISSURES
 These fissures separate the lobes of
the lung but are usually incomplete
allowing collateral air drift to occur
between adjacent lobes.
 Main fissures:
 Horizontal
 Oblique (Left and Right)
 Horizontal (or lesser) fissure:

 Seen, often incompletely on the

PA film running from the hilum
to the region of the 6th rib in the
axillary line.
 On the lateral film, it runs
anteriorly and often slightly
downward.
Oblique fissures:
 Both oblique fissures commence
posteriorly at the level of T4 or
T5, passing through the hilum.
 The left is steeper and finishes
5cm behind the anterior
costophrenic angle, whereas the
right ends just behind the angle.
 ACCESSORY FISSURES

 Azygos fissure.
 Superior accessory fissure.
 Inferior accessory fissure.
 Left sided horizontal fissure.
 AZYGOS FISSURE
 Comma shaped with a triangular base
peripherally.
 Nearly always right-sided.
 It forms in the apex of the lung.
 Consists of paired folds of parietal
and visceral pleura plus the Azygos
vein which has failed to migrate
normally.
SUPERIOR ACCESSORY FISSURE
 Separates the apical from the basal
segments of the lower lobes.
 Commoner on the right side.
 On the PA film, it resembles the
horizontal fissure.
 But on lateral film, it can be
differentiated as it runs posteriorly
from the hilum.
INFERIOR ACCESSORY FISSURE

 Appears as an oblique line running

from the cardiophrenic angle
toward the hilum and separating
the medial basal from the other
basal segments.
 Commoner on the right side.
 Incidence: 5-8%
 LEFT SIDED HORIZONTAL
FISSURE
 Separatesthe lingula from the
other upper lobe segments.
 Rare
 COSTOPHRENIC ANGLES

 Sharply defined acute angle which

is formed by the lateral attachment
of the diaphragm to the ribs.
 They become obliterated when the
diaphragms are flat or when there
is pleural effusion or effusion
associated with consolidation.
 CARDIOPHRENIC ANGLES
 Medially, the diaphragm meets the
heart at the Cardiophrenic angle.
 This is higher than Costophrenic angle.
 Ill-defined owing to the presence of fat.
 Prominent fat pads at the cardiophrenic
angles are an occasional cause of over
estimation of the transverse cardiac
diameter, esp if the film is
underexposed.
 THE LUNGS
 Compare overall size of one lung
to the other.
 Look for major areas of abnormal
lucency or density.
 Look through the heart and
upper abdomen to lung posterior
to these areas.
 THE HILA
 Pulmonary arteries and Upper lobe
veins contribute significantly to the
hilar shadows on the plain
radiograph.
 The left pulmonary artery is always
more superior than the right, thus
making the left hilum appear higher.
 Normal lymph nodes are not seen.
 The hila should be of equal
density and similar size with
clearly defined concave lateral
borders where the superior
pulmonary vein meets the basal
pulmonary artery.
 Air can be identified within the
proximal bronchi but normal
bronchial walls are only seen
end-on.
 PULMONARY VESSELS
 The left pulmonary artery lies above the
left main bronchus before passing
posteriorly.
 The right pulmonary artery is anterior to
the bronchus resulting in the right hilum
being the lower.
 The max diameter of the descending
branch of pulmonary artery is 16mm for
males and 15mm for females(measured
1cm medial and lateral to hilar point)
 PULMONARY VESSELS
 At the 1st intercostal space the normal
vessels should not exceed 3mm in
diameter.
 The lower lobe vessels are larger
than those of the upper lobes in erect
position, perfusion and aeration of
the upper zones being reduced.
 In supine position, the vessels
equalise.
 PULMONARY VESSELS
 The peripheral lung markings are mainly
vascular, veins and arteries having no
distinguishing characteristics.
 The arteries accompany the bronchi,
lying posterosuperior, whereas veins do
not follow the bronchi.
 Pulmonary veins have fewer branches
than arteries and are straighter, larger
and less well defined.
 THE BRONCHIAL VESSELS
 These are normally not visualised on
a plain film.
 They arise from the ventral surface of
the descending aorta at T5/6 level.
 2 branches: left and right.
 On entering the hila, they accompany
the bronchi.
 Enlarged bronchial arteries
 They appear as multiple small nodules
around the hilum and as short lines in
the proximal lung fields.
 CAUSES:
 General: Cyanotic congenital heart
disease
 Local: Bronchiectasis, Bronchial
carcinoma
 PULMONARY SEGMENTS AND
BRONCHI
 The pulmonary segments are
served by segmental bronchi and
arteries but unlike the lobes are not
separated by pleura.
 Normal bronchi are not visualised in
the peripheral one thirds of lung
fields.
 THE LYMPHATIC SYSTEM
 They run in the interlobular septa,
connecting with subpleural lymphatics
and draining via the deep lymphatics
to the hilum.
 Normal lymphatics are not seen but
thickening of the lymphatics and
sorrounding connective tissue
produces KERLEY LINES.
 KERLEY LINES
 Kerley A: Unbranching lines coursing
diagonally from the periphery toward the
hila in the inner half of the lungs.
 Kerley B: Short parallel lines at the lung
periphery. These lines represent
interlobular septa, which are usually less
than 1 cm in length and parallel to one
another at right angles to the pleura.
 Kerley C: They are short, fine lines
throughout the lungs, with a reticular
appearance.
 BRONCHOPULMONARY
SEGMENTS

 UPPER LOBE:

1. Apical bronchus.
2. Posterior bronchus.
3. Anterior bronchus.
RIGHT-MIDDLE LOBE:
4. Lateral bronchus.
5. Medial bronchus.

LEFT-LINGULA:
4. Superior bronchus.
5. Inferior bronchus.
 LOWER LOBE
6. Apical 6. Apical
bronchus. bronchus.
7. Medial basal 8. Anterior basal.
(Cardiac) 9. Lateral basal.
8. Anterior basal.
10.Posterior basal.
9. Lateral basal.
10.Posterior basal
 LYMPH NODES
 Anterior Mediastinal: Lie in the
region of aortic arch and drain the
thymus and right heart.
 Intrapulmonary nodes: Lie along the
main bronchi.
 Middle Mediastinal nodes: Drain the
lungs, bronchi, left heart and visceral
pleura.
4 groups
 Bronchopulmonary (hilar)nodes.
 Carinalnodes.
 Tracheobronchial nodes.
 Paratracheal nodes.

• Posterior Mediastinal nodes:

Drain posterior diaphragm and lower
oesophagus.
• Parietal nodes: drain soft tissues
and parietal pleura.
 BELOW THE DIAPHRAGM
 Look for other abnormal gas shadows
such as dilated bowel, abscesses,
displaced gastric bubble, intramural
gas as well as calcified lesions.
 Interposition of colon between liver
and diaphragm, CHILADITI’S
SYNDROME is a common and
transient finding usually seen in
elderly.
SOFT TISSUES
 Shoulder girdle:
Look for calcifications,
obvious mass effect,
abnormal air
collections
(subcutaneous
emphysema), and soft
tissue companion
shadow for the
clavicle.
CHEST WALL
 Look for overall
thickness,
subcutaneous
emphysema,
calcification.
 Look for sharp,
distinct muscle
fat planes
BREAST TISSUE
 Confirm presence
or absence of
breast shadows.
 Breasts may
partially obscure
lung bases.
 Nipple shadows
are often well-
defined laterally
and may have a
lucent halo.
ABDOMEN
 Gastric and bowel
gas.
 Check for organ
size of liver, spleen,
and kidneys if
visible.
 Check for free
peritoneal air
 Look for
calcifications and
masses.
NECK AND SPINE
 Check, position and
size of trachea.
 For the cervical spine,
check alignment and
note any major
congenital
abnormalities.
 Look at specific parts
of the vertebra and
disc spaces, checking
for erosions, lytic or
blastic lesions, disc
and synovial joint
narrowing or other
abnormalities.
 THORACIC SPINE
 Look for height of vertebral
bodies and disc spaces, integrity
of cortical margins around the
bodies, pedicles, and lamina.
 And also for presence of any lytic
or sclerotic areas, normal
spacing of synovial joints.
 RIBS
 Compare individual ribs side to
side, check specific parts, cortical
margins, trabecular patterns.

 See if the anterior cartilages are

calcified, frequently the first one
does so irregularly and may
obscure or mimic underlying lung
lesions.
 VIEWING THE LATERAL
FILM
 Routinely the left side is adjacent to
the film because more of the left
lung than the right is obscured on
the PA view.
 But, if there is a specific lesion the
side of interest is positioned
adjacent to the film.
 THE CLEAR SPACES
 Retrosternal space.
 Retrocardiac space.

 Loss of translucency of these areas

indicates local pathology.
 Widening occurs in Emphysema.
 VERTEBRAL TRANSLUCENCY

 The vertebral bodies become

progressively more translucent
caudally.
 Loss of this translucency may be
the only sign of posterior basal
consolidation.
 DIAPHRAGM OUTLINE
 Both diaphragms are visible
through out their length, except the
left anteriorly where it merges with
the heart.
 The posterior cardiophrenic angles
are acute and small amounts of
pleural fluid may be detected by
blunting of these angles.
 TRACHEA
 Passes down in a slightly posterior
direction to T6/7 level of the spine.
 The normal posterior wall measures
5mm, this measurement includes
tracheal and oesophageal walls plus
the pleura.
 Widening may occur with disease of all
the above structures.
 CHECK LIST
 Check patient name, position,
technical quality.
 Soft tissue including breast,
chest wall, companion shadow.
 Review soft tissues and
skeletal structures of shoulder
girdles and chest wall.
 CHECK LIST
 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
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
Review hila:
 Normal relationships
 Size
Review lungs and pleura:
 Compare lung sizes
 Evaluate pulmonary vascular pattern:
pulmonary parenchyma
 Pleural surfaces
 fissures - major and minor - if seen
 compare hemidiaphragms
 follow pleura around rib cage