1. CHEST X-RAY
DR. NIKHIL MURKEY

3. STRUCTURES TO BE IDENTIFIED

4. • 1 SVC
• 2 IVC
• 3 RA
• 4 RV
• 5 LV

7. SCHEME
• Patient demography
• Technical aspect
• Trachea
• Heart and
mediastinum
• Diaphragms
• Pleura
• CP angles
• Hilum
• Lung field
• Hidden areas
• Below diaphragm
• Soft tissue
• Bones

8. TECHNICAL ASPECT
• Centering
• Penetration
• Inspiration
• Angulation

9. • Rotation
• Medial ends of
bilateral clavicles are
equidistant from the
midline or vertebral
bodies

10. If spinous process appears closer to the right clavicle (red
arrow), the patient is rotated toward their own left side
If spinous process appears closer to the left clavicle (red arrow),
the patient is rotated toward their own right side

11. • Penetration
• Should see ribs
through the heart
• Barely see the spine
through the heart
• Should see
pulmonary vessels
nearly to the edges
of the lungs

12. Overpenetrated Film
• Lung fields darker than
normal—may obscure
subtle pathologies
• See spine well beyond the
diaphragms
• Inadequate lung detail

13. Underpenetrated Film
•Hemidiaphragms are obscured
•Pulmonary markings more prominent than they actually are

14. • Inspiration 1
2
• Should be able to 3
count 9-10 posterior 4
ribs 5
6
• Heart shadow should 7
not be hidden by the
diaphragm 8
9
10

15. • Angulation
1
2
• Clavicle should lay over
3
3rd rib

16. Apical lordotic Same patient, not lordotic
A film which is apical lordotic (beam is angled up toward
head) will have an unusually shaped heart and the usually
sharp border of the left hemidiaphragm will be absent

17. TRACHEA
• 25 mm in males 21
mm in females.
• Right paratracheal
stripe
• Widening occurs in
Lymphadenopathy, tr
acheal
malignancy, mediasti
nal
tumours, mediastinitis,
pleural effusion
• Normal carinal angle
60-75 degees.

18. HEART & MEDIASTINUM
• Cardio-thoracic ratio
• Transverse cardiac
diameter
• Increase in transverse
cardiac diameter by 1.5
cm in significant.
• Normal in neonates and
AP projection is 60
percent
• Cardiac shadow
measuring more than 5.5
cm to the right signifies
right atrial enlargement

19. DIAPHRAGM
• Position, sharpness
of border
• Difference should
be less than 3 cm
between both sides.
• Subdiaphragmatic
air

20. PLEURA
• Pleural thickening
• Calcification
• Plaques
• Pneumothorax
• Effusion.

21. COSTOPHRENIC ANGLES
• Acute
• Well defined

22. LUNG FIELDS
• Infiltrates
• Increased interstitial
markings
• Masses
• Absence of normal
margins
• Air bronchograms
• Increased
vascularity

23. LUNG FIELDS: USING STRUCTURES
/ SILHOUETTES
Silhouette / Structure Contact with Lung
Upper right heart
Anterior segment of RUL
border/ascending aorta
Right heart border RML (medial)
Upper left heart border Anterior segment of LUL
Left heart border Lingula (anterior)
Apical portion of LUL
Aortic knob
(posterior)
Anterior hemidiaphragms Lower lobes (anterior)

24. LUNG FIELDS: USING STRUCTURES
/ SILHOUETTES
Upper right
heart border / Aortic knob
ascending aorta (Apical
(anterior RUL) portion of
LUL )
Upper left
Right heart border heart
(medial RML) border
(anterior
LUL)
Left heart
border
Anterior (lingula;
hemidiaphrag anterior)
ms
(anterior
lower lobes)

25. LUNG FIELDS: FISSURES
• The fissures can also help you to determine the
boundaries of pathology
Major Oblique Fissure Separates the LUL from the LLL
Separates the RUL/RML from
Right Major Fissure
the RLL
Separates the RUL from the
Right Minor Fissure
RML

27. LUNG FIELDS: HIDDEN AREAS
• Apices
• Mediastinum
and hila
• Behind the
diaphragm

28. HILA
• Position (left 2.5 cm
higher than right)
• Equal density
• Clearly defined lateral
borders
• Lower lobe pulmonary
arteries and upper lobe
pulmonary veins
• Diameter of pulmonary
arteries should measure
10-16 mm in males and 9
– 15 mm in females.
• Upper lobe veins lie
lateral to the arteries and
lower lobe veins lie
medial to the arteries.

29. BRONCHIAL ARTERIES
• Usually not visualized
• Branches of descending thoracic aorta at T5/6 level
• 2 on left; 1 on right
• When enlarged appear as multiple small nodules
around hila
• Enlarged in cyanotic heart disease like
TOF, Pulmonary atresia
• Other causes include bronchiectasis or bronchial
carcinoma

30. SUBDIAPHRAGMATIC REGION
• Free air
• Bowel (Chilaiditi
syndrome)
• Dilated bowel loops

31. SOFT TISSUE
• Breast
• Nipple
• Skin folds especially in oblique and ill centered X-rays
• Companion shadow – upper border of clavicle

32. BONES
• Vertebrae
• Clavicle
• Ribs
• Scapulae
• Sternum*

33. THANK YOU!!!