Basics of Chest X-Ray

1. Dr. M.Ikram Nasir
PGR Pulmonology LRH
BASIC INTERPRETATION OF CHESTX.RAYS
AND COMMON DISEASES

3. It’s a chest x-ray,
not a lung x-ray.

6. How do you look at a
chest x-ray?
Avoid tunnel vision!
or

10. 5 DIFFERENT DENSITIES

12. FiveRadiographicOpacities
Air Fat Soft tissue Bone Metal
least opaque to most opaque
most lucent to least lucent
Black to White

13. Have a system

14. Chest wall, bones and abdomen

15. Mediastinum, heart and hila

16. Lungs

17.  Right lung: 3 lobes:
Right upper lobe
Right middle lobe
Right lower lobe

19.  Left lung: has two lobes:
Left upper lobe (includes lingula which
anatomically corresponds to the middle lobe
on the right lung)
Left lower lobe

21.  Lobes are separated by fissures:
 Right major fissure separates the right upper lobe,
and right middle lobe from the right lower lobe.
 Right minor (horizontal) fissure separates the right
upper lobe from the right middle lobe.
 Left major fissure separates the left upper lobe
from the left lower lobe
 Also note that the lower lobes extend behind the
outline of the diaphragm on a PA view.

22. Lobes
• Right upper lobe:

29.  Hilar anatomy: need not be confusing
 The "hilum" is composed of the pulmonary artery
and its branches, and adjacent airway and
pulmonary veins. Since airways do not produce a
significant shadow on plain film radiography, the
majority of the detectable "hilar" structures are
vascular

30.  On the left side, the left pulmonary artery is
directed posterolaterally, toward the left
scapula.This artery goes over the left main stem
bronchus.Therefore, the left pulmonary artery is
located higher than the right pulmonary artery.
 On the lateral projection, the left pulmonary
artery is posterior to a line drawn down the
trachea air column

31. LEFT HILUM

32.  Right Hilum:
 As opposed to the left pulmonary artery, the right pulmonary artery
(RPA) courses underneath the left main stem bronchus. As a result,
the right hilar shadow is inferior to the left on the PA projection.This
is true in 70% of the population. In the remaining 30%, the hilar
shadows are equal in height.The right hilum is never superior to the
left hilum.
 On the lateral projection, the right hilum is anterior to a line drawn
through the tracheal air column.The right pulmonary artery is
approximately 3 times larger than the LPA.This is a result of the
more horizontal course of the RPA.

34.  Tracheobronchial Anatomy
 Overview
 The trachea appears as an air-shadow coursing down the
midline of the chest and terminating at the carina.The
left and right mainstem bronchus may be evident as well
as the lobar bronchi.
 Left main stem bronchus.
 Right main stem bronchus.
 Right upper lobe bronchus
 Left upper lobe bronchus
 Right bronchus intermedius

36. Enlarged goiter displacing
trachea

37.  PulmonaryVenous Anatomy
 Pulmonary veins course more horizontally
than pulmonary arteries.
 They are ultimately directed toward the left
atrium and they are best seen on a lateral
projection.
 Pulmonary venous anatomy should not to be
confused with a retrocardiac infiltrate

39.  Mediastinal Compartments
 Overview

41.  Anterior mediastinal compartment:
 Borders include the sternum anteriorly, and the
ventral cardiac surface posteriorly.
 Includes fat, ascending aorta, lymph nodes, internal
mammary artery and vein, adjacent osseous
structures (ribs and sternum), thymus.Therefore will
most likely see masses typical to these structures, ie a
lymphoma in lymph nodes. Knowledge of the
mediastinal contents can aid in your differential
diagnosis

43. Anterior mediastinal mass
thymoma

44.  Middle mediastinal compartment:
 Borders composed of the anterior mediastinal
compartment ventrally, and the anterior surface
of the spine, posteriorly.
 Structures include the esophagus (which will not
be visible unless there is a problem), vagus nerve,
recurrent laryngeal nerve, heart, proximal
pulmonary arteries and veins (hilar), trachea and
root of the bronchial tree, and superior and
inferior vena cava

46.  Posterior mediastinal compartment:
 Borders:Anterior surface of the spine
posteriorly to the ribs.
 Structures include the descending aorta,
adjacent osseous structures (the spine and
ribs) and nerves, roots, spinal cord, and the
azygous and hemiazygous

48.  Superior mediastinal compartment:
 It is located above a horizontal line drawn from
the angle of Louis posteriorly to the spine.
 Structures include the thyroid gland, aortic arch
and great vessels, proximal portions of the vagus
and recurrent laryngeal nerves, esophagus and
trachea

50.  Aortopulmonary window
 A "space" located underneath the aortic arch
and above the left pulmonary artery.
 It contains fat.
 On the PA projection, it appears as a concave
shadow. If, however, there is adenopathy, it
manifests as a convex shadow.

52.  Diaphragm
 The left and right diaphragm appear as
sharply marginated domes.
 The peripheral margins of the diaphragm
define the costophrenic sulci.
 The right diaphragm is higher than left due to
the position of the liver.

54.  Osseous structures
 Ribs
 Anterior and posterior ribs.
 Spine
 Pedicles
 Transverse processes
 Spinous Processes
 Sternum

56. MISSED OR HIGH RISK AREAS

66. Portable (AP or Antero-posterior)
FILM

68. PA (Postero-anterior)
FILM

70. PA vs AP views
PA view
 Scapula is seen in
periphery of thorax
 Clavicles project
over lung fields
 Posterior ribs are
distinct
AP view
 Scapulae are over
lung fields
 Clavicles are above
the apex of lung
fields
 Anterior ribs are
distinct

76. Rotation

88. FOREIGN BODIES

164. A 70 years old man with a history of chronic
obstructive pulmonary disease is admitted with
increasing sputum production,fever,chills,and
decreased O2 saturation.His chest x.ray shows a left
lower lobe homogeneous opacities,He is treated with
IV antibiotics and improves.
On the fourth day ,prior to discharge ,CXR is repeated
and there is no change as compared to the admission
X.rays

189. A 26 years known epileptic woman admitted in
medical icu with status epilepticus ,due to
contineu seizures she was in respiratory distress
,she was intubated and placed on ventilator,she
remained stable over night but she was
excessive mucopuluent secretion throughout the
night,the next morning x.rays is shown

197. A30 years old man is admitted with increasing
cough,fever,sputum production,He gives
history of repetated pneumonia since
childhood.
ON EXAMINATION
diffuse bilateral crackles,more on left side

201. CASE 1
 A 45 years old man with a history of IVDA from
peshawar presented with a history of low grade
fever ,night sweats,wieght loss.
 ON EXAMINATION
 Ill looking,having palpable cevical
lymphadenopathy
 Temp:100F,pulse 108,Respiration
23/min,B.p;120/70
 PPD test negative

203. Tuberculosis