Basic

Interpretation of
Chest
Radiography
By Dr. Chia Kok King
 Five Radiographic Opacities

Air Fat Soft tissue Bone Metal

least opaque to most opaque

most lucent to least lucent
Black to White
Radiographic Opacities & Contrasts

Air Air
Fat Mineral oil
Water Water
Bone Tums
Metal ???
 Film Quality
1. PA or AP view.
2. Upright/Erect or Supine
3. Breath : Inspiration or Expiration
4. X-ray penetration : Under- or Over-
5. Rotation
 PA vs AP views
PA view AP view
Scapula is seen in Scapulae are over
periphery of thorax lung fields
Clavicles project over Clavicles are above
lung fields the apex of lung
fields
Posterior ribs are Position of markers
distinct
Anterior ribs are
Position of markers distinct
Inspiration vs Expiration
 Penetration
With correct exposure you should barely see
the intervertebral disc through the heart

If you see them very clearly

the film is overpenetrated

If you do not see them it is

underpenetrated
Penetration
Rotation
 Pitfalls to Chest X-ray Interpretation

Poor inspiration
Over or under penetration
Rotation
Forgetting the path of the x-ray beam
 Normal Chest X-ray
Cardiac Structures
Position
More central in younger infants and children
More on the L side in older infants and teens
Size
CARDIO-THORACIC RATIO!
Cardiac diameter :
normal individuals < 15.5 cm in males; <14.5 cm in females.
A change in diameter of greater than 1.5 cm between two
X-rays is significant.
 Cardio-thoracic ratio
seen on postero-anterior
(PA) view only
>50% is considered abnormal
in an adult; more than 66% in
a neonate.
Possible causes of a ratio
greater than 50% include:
cardiac failure
pericardial effusion
left or right ventricular
hypertrophy
*AP views make heart appear larger than it actually is.*
 Normal Chest X-ray
1. Soft tissue structures
Shadows, most commonly, breast
2. Bony structures
Count the ribs
8 10 ribs should be visible on inspiration
Clavicle placement at 2-3 intercostal space (if not,
may be rotated)
 Normal Chest X-ray
3. Diaphragm
Contour
Rounded with sharp pointed costophrenic and
costocardiac angles
Right diaphragm is usually 1-2 cm higher
 Normal Chest X-ray
4. Lungs
Start at the top and compare the R and L
Trachea should be midline over the thoracic
vertebrae and air filled
Lung parenchyma becomes lighter as you go down
the lung. If not, it may indicate a lower lobe or
pleural effusion
Anatomy
Anatomy
 Lobes
Right upper lobe:
 Right middle lobe:
 Right lower lobe:
 Left lower lobe:
 Left upper lobe with Lingula:
 Lingula:
 Left upper lobe - upper division:
 Abnormal Chest X-ray
Radiopacity (whiteness) = increased density
Radiotranslucency (blackness) = decreased density
 Radiopacity
Alveolar Pattern Interstitial Pattern Vascular pattern
Fluffy, soft, poorly Consolidation of If there is an
demarcated interstitial tissue increase in size
opacifications < 1cm of the pulmonary
in diameter Looks like branching arteries as they
lines radiating extend out into lung
Possible causes: toward the pulmonary
1. Pulmonary periphery of the hypertension
edema lung
2. Viral pneumonia If there is a
3. Pneumocystis Possible causes: decrease in size,
4. Alveolar cell 1. Interstitial truncation, or
carcinoma pneumonitis obliteration of a
2. Pulmonary pulmonary artery
fibrosis embolus

Lack of vascular
marking in the
periphery
pneumothorax
Consolidation
Lobar consolidation:
Alveolar space filled with
inflammatory exudate
Interstitium and
architecture remain
intact
The airway is patent
Radiologically:
A density corresponding to
a segment or lobe
Air bronchogram, and
No significant loss of lung
volume
Consolidation
 Atelectasis
Loss of air
Obstructive atelectasis:
No ventilation to the lobe
beyond obstruction
Radiologically:
Density corresponding to a
segment or lobe
Significant loss of volume
Compensatory
hyperinflation of normal
lungs
Atelectasis
No ventilation to lobe beyond
the obstruction
Trapped air absorbed by
pulmonary circulation
Segmental/lobar density
Compensatory hyper-inflation
of normal lungs.
 Congestive Heart Failure
Increased heart size:
cardiothoracic ratio >0.5
Large hila with
indistinct markings
Fluid in interlobar
fissures
Pleural effusions,
alveolar edema
Congestive Heart Failure
Alveolar edema
(Bats wings)
Kerley B lines
(Interstitial edema)
Cardiomegaly
Dilated prominent
upper lobe vessels
Pleural effusion
ARDS

Congestion
Interstitial and
alveolar edema
Collapsed or
distended alveoli
Bilateral
Pneumothorax
 Right side
tension
pneumothorax
Left Sided Pneumothorax
Pleural effusion
Right Side
Pleural
Effusion
 RLL
Pneumonia
????????????
Fracture of posterior rib #7
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A single, 3cm relatively thin-walled cavity is noted in the left
midlung. This finding is most typical of squamous cell carcinoma
(SCC). One-third of SCC masses show cavitation
 Right
Squamous
Cell
Carcinoma
???????????????
Right Middle and Left Upper Lobe Pneumonia
????????????
Cavitation : cystic changes in the area of consolidation due to the
bacterial destruction of lung tissue. Notice air fluid level.
Cavitation
????????????
Tuberculosis
??????????
COPD: increase in heart diameter, flattening of the diaphragm,
and increase in the size of the retrosternal air space. In addition
the upper lobes will become hyperlucent due to destruction of
the lung tissue.
Chronic emphysema effect on the lungs
????????
CHF:a great deal of accentuated interstitial markings,
Curly lines, and an enlarged heart. Normally indistinct
upper lobe vessels are prominent but are also masked
by interstitial edema.
24 hours after diuretic therapy
Chest wall lesion: arising off the chest wall and not the lung
Pleural effusion: Note loss of left hemidiaphragm. Fluid drained
via thoracentesis
Lung Mass
 The Enlarged Hila

Causes:

1. Adenopathies (neoplasia, infection)

2. Primary Tumor

3. Vascular

4. Sarcoidosis
Small Pneumothorax : LUL
Right Middle Lobe Pneumothorax: complete lobar collapse
Post chest tube insertion and re-expansion
Metastatic Lung Cancer: multiple nodules seen
Tuberculosis
Pleural Effusion
Pulmonary Fibrosis
Cavitating lesion
Miliary shadowing
5. 65 yo male admitted for sepsis. CHF or ARDS?
12. Is the central line correctly positioned?
13. Does ET tube need to be advance or pulled back? Arrow
shows location of carina
14. OK for R/T feeding?