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1. INTERPRETING A CHEST X-RAY
FILM

2. RESOURCES
• Radiopaedia
• Learning Radiology - Medical Students

3. A TECHNICALLY ACCURATE X-RAY
• The factors to evaluate the quality of a chest x-ray are:
PAIR
• Penetration – see spine through the heart
• Inspiration – at least 8-9 posterior ribs
• Rotation – spinous process between clavicles
• Angulation – clavicle over 3rd rib

4. WHICH ONE IS P/A?

5. POOR VS ADEQUATE INSPIRATION

6. POOR FILMS DUE TO ROTATION

7. THE POSTERIOR -ANTERIOR (PA) FILM. (1) HORIZONTAL FISSURE; (2,3)
LEFT AND RIGHT HILUM; (4) TRACHEA; (5,6) RIGHT AND LEFT DIAPHRAGM; (7)
COSTOPHRENIC ANGLES; (8) TRACHEA; (9) AORTIC KNUCKLE.

8. BASIC INTERPRETATION OF THE CHEST X-RAY IS
EASY. IT IS SIMPLY A BLACK AND WHITE FILM AND
ANY ABNORMALITIES CAN BE CLASSIFIED INTO:
(A) TOO WHITE.
(B) TOO BLACK.
(C) TOO LARGE.
(D) IN THE WRONG PLACE.

9. CHEST X-RAY REVIEW: ABCDE
Using A, B, C, D, E is a helpful and systematic method for chest x-ray
review:
A: airways
B: breathing (the lungs and pleural spaces)
C: circulation (cardiomediastinal contour)
D: disability (bones - especially fractures)
E: everything else, e.g. pneumoperitoneum

10. AIRWAYS
• Start at the top in the midline and review
the airways.
• trace down the trachea to the carina
• is it straight and midline?
• is there any narrowing?
• trace down both main bronchi
• is the carina wide (more than 100 degrees)?
• is there bronchial narrowing or cut-off?
• is there any inhaled foreign body?

11. AIRWAYS

12. BREATHING
• Look for lung and pleural pathology.
• both lungs should be well expanded and similar
in volume
• can you count 10 posterior ribs bilaterally?
• is one lung larger than the other?
• compare the apical, upper, middle and lower
zones in turn
• are they symmetrical?
• are there areas of increased density?

13. BREATHING
• trace the lung vessels
• do they branch out progressively and
uniformly?
• can you see the retrocardiac and
retrodiaphragmatic lung vessels?
• are there extra lines in the periphery that
aren't vessels?
• trace the lateral margins of the lung to
the costophrenic angles
• are the costophrenic angles crisp?

14. BREATHING
• trace the hemidiaphragms in to the
vertebra
• can you see the whole of the
hemidiaphragm?
• trace the cardiac borders
• can you clearly see the left and right
heart border?
• can you see the descending aorta?

15. BREATHING
• procedure
• check for symmetry (allowing for mediastinum)
• check each zone in turn and compare with the other side
• apices, upper, middle and lower zones
• check volume and density
• look for any focal areas of increased density
• check around the lungs comparing each step on both sides
• start at the apex and trace down the edges of the lungs
• check the costophrenic angles are sharp
• trace the hemidiaphragms to the spine
• check the cardiac borders are crisp and clear
• check the hilar structures can be seen clearly

16. BREATHING
• checklist
• both lungs are expanded and similar in
volume
• apices, upper, middle and lower zones are
symmetrical
• normal lateral margins
• normal CPAs
• normal hemidiaphragms
• normal cardiac borders
• normal lung behind the heart

17. BREATHING

18. BREATHING

19. BREATHING

20. HYPERINFLATION

21. 1. Look at the shape of the diaphragm. In COPD the diaphragms are flat or even scallop
shaped instead of concave upwards. This is a more reliable sign of hyperexpansion than
rib counting.
2. Count the number of ribs you see anteriorly. If the lungs are enlarged you should be
able to count more than seven. Be careful, however, because you can sometimes count
more than seven ribs in normal patients if they are tall and slim.
3. Look at the shape of the heart. The enlarged thorax of COPD appears on the x-ray to
elongate and narrow the heart, elevating the lower border. The heart, instead of sitting
on the diaphragm, often appears to ‘swing in the wind’. It will also appear small unless
there is also an element of cardiac failure, in which case it will be normal in size or large.
4. Look for bullae. These are densely black areas of lung, usually round, surrounded by
fine curvilinear shadows. Bullae distort the surrounding vasculature so to help find them
look out for areas of distortion of vascular markings.
5. Look at the distribution of lung markings. The black lungs of COPD are due to reduced
size of blood vessels. The lung markings are reduced bilaterally and fan out in straight
lines from the hilum, starting off chunky but stopping two-thirds of the way out –
peripheral pruning.

23. AIRSPACE DISEASES
Airspace Disease
• Soft-tissue opacities
• With hazy and indistinct margins
• Tend to respect segmental or lobar boundaries
• May contain air bronchograms
Common Airspace Diseases
• Pneumonia – inflammatory exudate
• Pulmonary edema – edema fluid
• Pulmonary hemorrhage – blood
• Aspiration – gastric juices

24. RT UPPER LOBAR CONSOLIDATION

25. AIR BRONCHOGRAM

26. SILHOUETTE SIGN

27. LEFT UPPER LOBAR COLLAPSE

28. ARDS

29. INTERSTITIAL DISEASES
• Now referred to as infiltrative lung diseas
e
• Discrete particles of disease
• Inhomogeneous
• Doesn’t respect lobar boundaries
• Usually no air bronchograms
• Made up of lines (reticular) or dots(nodul
ar) or both (reticulonodular)

30. BRONCHIECTASIS

31. FIBROSIS

32. TB

33. MILIARY
SHADOWING

34. MALIGNANICES

35. LEFT SIDED TENSION PNEUMOTHORAX

36. LEFT SIDED PLEURAL EFFUSION

37. • Blunting of the CP Angle
• Normally there are 2-10cc of fluid in the pleural
space
• When >75cc accumulate, the posterior costophrenic
(CP) sulci, seen on the lateral film, become blunted
• When 200-300cc accumulate, the CP sulci on the
frontal film become blunted

38. HYDROPNEUMOTHORAX

39. LEFT SIDED PNEUMONECTOMY

40. CIRCULATION
• procedure
• assess the position of the heart
• is it on the left and is the apex pointing to the left
• assess the heart size
• PA projection: should be <50% of the chest diameter
• AP projection: will be artifactually enlarged
• aortic knuckle
• should be on the left
• upper mediastinal contour
• pulmonary vessels
• hilar structures and the hilar point
• left hilum usually higher than the right

41. CIRCULATION
• checklist
• cardiac position
• cardiac size
• aortic arch and upper mediastinum
• hilar vessels

42. CIRCULATION

43. CIRCULATION

44. (1) RIGHT ATRIUM; (2) SUPERIOR VENA CAVA; (3) LEFT VENTRICLE; (4) LEFT ATRIAL
APPENDAGE; (5) PULMONARY ARTERY; (6), AORTIC KNUCKLE.

45. DEXTROCARDIA

46. ALVF WITH PULMONARY EDEMA

47. • Features useful for broadly assessing pulmonary edema on a plain chest radiograph
include:
• upper lobe pulmonary venous diversion (stag's antler sign)
• increased cardiothoracic ratio/cardiac silhouette size: useful for assessing for an
underlying cardiogenic cause or association
• features of pulmonary interstitial edema:
• peribronchial cuffing and perihilar haze
• septal (Kerley) lines
• thickening of interlobar fissures
• features of pulmonary alveolar edema:
• air space opacification classically in a batwing distribution
• may have air bronchograms
• pleural effusions and fluid in interlobar fissures (including 'vanishing' pulmonary
pseudotumor

48. UPPER LOBE PULMONARY VENOUS DIVERSION AND
BORDERLINE CARDIOMEGALY

49. MITRAL STENOSIS

50. BHL

51. DISABILITY
• Check for any bony pathology (fracture or metastasis).
• trace along each posterior (horizontal) rib on one side of the
chest
• is there a fracture or abnormal area?
• repeat with the other side of the chest
• now trace lateral and anterior ribs on the first side
• repeat on the other side
• now, check the clavicles and shoulders
• can you trace around the cortex of the bones?
• finally the check the vertebral bodies
• are they all rectangular and of a similar height?
• can you see 2 pedicles per vertebral body?
• are there disc spaces?

52. DISABILITY
• procedure
• trace each of the ribs from posterior to anterior
• check the clavicles
• check the proximal humeri
• check the scapula
• look at each vertebral body
• checklist
• ribs for any evidence of fracture
• ribs for a lucent or destructive lesion
• shoulders (acromioclavicular and glenohumeral joints)
• clavicles
• vertebral bodies (loss of height)

53. RIB FRACTURE

54. CLAVICLE FRACTURE

55. EVERYTHING ELSE
• Review the upper abdomen, soft tissues and take a look at some
final check areas.
• is there free gas under the diaphragms?
• is there subcutaneous emphysema?
• is the gastric bubble in the correct place?
• is there a hiatus hernia?
• is there an absent breast shadow?
• are there any surgical clips?
• check again...
• are the lung apices clear?
• is there any retrocardiac or retrodiaphragmatic pathology?

56. EVERYTHING ELSE
• Procedure
• apices
• many people forget to look above the clavicles
• look again at the lung above the clavicles
• behind the heart
• altered density in the retrocardiac region can be difficult
• check for basal consolidation or a mass in this region
• fluid-level of hiatus hernia
• below the diaphragm
• diaphragmatic contour is the dome of the diaphragm
• the lungs extend posteriorly below the diaphragm
• look out for mass lesions below the diaphragm
• soft-tissue abnormalities
• gas in the soft-tissues (surgical emphysema)
• look for both breast shadows in female patient

57. EVERYTHING ELSE
• checklist
• apical lung tumor
• left lower lobe collapse
• hiatus hernia
• breast shadows

58. PNEUMOPERITONEUM

59. 3 major findings for free air:
• Air beneath the diaphragm
• Falciform Ligament sign
• Air on both sides of bowel wall
• Most common cause of free air is a
perforated ulcer
• For plain films, free air is best seen on
an erect or left lateral decubitus (left-
side down) film

60. LEFT MASTECTOMY

61. PECTUS EXCAVATUM

62. HIATUS HERNIA

63. 1,894 coins
weighing just
over 8kg!!!

64. THAT’S ALL!