HOW READ CHEST XR -1

ANAS SAHLE ,MD

1. Technical Quality

2. look at the mediastinal

3. look at the lungs

4. diaphragm

5. Soft tissues and bones

OUTLINE

Technical Quality

Is the film centered? Rotation

Is it PA or AP film ? Positioning

Is it exposed properly ? Penetration

Is it a good inspiration film? Inspiration

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RPPI

observing the clavicular headsdetermining whether they are equal distance from the spinous process of the thoracic vertebral bodies

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Is this film centered?

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Is this film centered?

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Why do you have to know whether the film is centered or not ?

Difficult to evaluatethe position of Mediastinum if the film is not centered

Is the film centered? Rotation

Is it PA or AP film ? Positioning

Is it exposed properly ? Penetration

Is it a good inspiration film? Inspiration

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RPPI

If the scapulae no longer overlie the lung fields then the film is PA

If the scapulae overlie the lung fields then the film is AP

Why do you have to know whether it is PA or AP film?

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The PA (posterioranterior)Positioning

Note that the x-ray tube is 72 inches “182.88 cm” away

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The Supine AP (anteriorposterior) position

Note that the x-ray tube is 40 inches ”111.76 cm” from the patient

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Heart appears larger

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Mediastinum widens

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Diaphragms are higher

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Pulmonary vessels size is same in upper and lower lung fields

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Is the film centered? Rotation

Is it PA or AP film ? Positioning

Is it exposed properly ? Penetration

Is it a good inspiration film? Inspiration

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RPPI

The thoracic spine disc spacesshould be barely visible through the heart

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Bony details of the spineare not usually seen

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On the other hand penetration is sufficient that bronchovascular structurescan usually be seen through the heart

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Normal Penetrated PA film

An overpenetrated PA film

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Normal Penetrated PA film underpenetrated PA film

Is the film centered? Rotation

Is it PA or AP film ? Positioning

Is it exposed properly ? Penetration

Is it a good inspiration film? Inspiration

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RPPI

The diaphragm should be found at about the level of the 8th - 10th posterior rib or 5th - 6th anterior rib on good inspiration

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Why Do You Have To Know Whether

It Is Good InspirationOr Poor Inspiration?

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Mediastinum appears wider

Heart size appears larger

Lung bases look

whiter (mistaken for

interstitial disease)

look at the lungs

Scan both lungs

starting at the apices and working down

comparing left with right at the same level

The lungs extend behind the heartsolook here too

Compare and contrast vascular markings in upper vs. lower lung fields in PA view

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List conditions, where vascular markings are prominent in upper lung fields

• Mitral stenosis • Congestive heart failure • Alpha one antitrypsin deficiency

Compare and contrast vascular markings in outer third vs. inner two thirds of lungs

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increased markings in outer third of lung fields?

• In:1. Left to right shunts (ASD, VSD, PDA)

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increased pulmonary flow

increased markings in outer third of lung fields?

• In :2. Interstitial disease3. Lymphangitic malignant spread4. CHF with increased lymphatic flow

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Fissures

The Minor Fissure divides the Right Middle Lobe from the Right Upper Lobe and is sometimes not well seen

Localizing lesions

The position of lesioncan be described in terms ofzones

To accurately localize a lesion on chest X ray you need to look at both the PA and lateral films

First look at thePA film

The upper zone lies above the anterior border of the 2nd rib

The middle zone lies between the right anterior borders of the 2nd and 4th ribs

The lower zone lies between the right anterior border of the 4th rib and the diaphragm

It does not give any information about the

lobes of the lung

Look at the borders of the lesion

• If the lesion is next to a dense (white) structure then the border between the lesion and that structure will be lost

This is calledthe silhouette sign

RLL

RML lingula

LLL

LLL

Now look at thelateral film

Identify the oblique fissure

• (pass obliquely downwards from the T4/T5 vertebrae through the hilum ending at the anterior third of the diaphragm)

Identify the horizontal fissure

• (pass horizontally from the midpoint of the hilum to the anterior chest wall)

If the lesion lies posterior to the oblique fissure it must lie within the lower lobe

If the lesion lies anterior to the oblique fissure it may be in the upper or middle lobe

If the lesion is below the horizontal fissure it is in the middle lobe

If the lesion is above the horizontal fissure it is in the upper lobe

There is no middle lobe on the left

The white lesion

The white lesion

Lung

pleura

Lung

parenchyma

Airway

Pneumonectomy

parenchyma

Alveolar space

interstitial

Consolidationis another term for

air space shadowing

parenchyma

Alveolar spaceConsolidation

interstitial

Alveolar space

Collapse

air spaces filling

Loss of volume of part of the lung

On the PA film:

The right lung should be larger than the left

If it is not suspect an area of right sided collapse

The major (Primary) sign

opacification of the affected lobe due to airlessness

The major (Primary) sign

displacement of the interlobar fissure

The Secondary signs

displacement of the mediastinal structures

The Secondary signs

elevation of the hemidiaphragm

The right diaphragm should be higher than the left (the difference should

be less than 3cm)

The Secondary signs

decrease in the distance of the intercostals spaces

The Secondary signs

displacement of the hila

The Secondary signs

compensatory overinflation of the remaining lung

The heart border should be distinctIf the lung adjacent to the heart is collapsed then the heart border will appear blurred

Right heart border is blurred

RML collapse

Left heart border is blurred

lingular collapse

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Atelectasis Right Upper Lobe

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Atelectasis Right Upper Lobe

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87Atelectasis Right Upper Lobe

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Atelectasis Right Upper LobeHomogenous density right upper lung field.

Mediastinal shift to right.

Loss of silhouette of ascending aorta.

Movement of oblique and transverse fissures.

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RML Atelectasis

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Vague density in right lower lung field (almost a normal film).

RML Atelectasis

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Dramatic RML atelectasis in lateral view,

Movement of transverse fissure.

Other findings include:

Azygous lobe

RML Atelectasis

92RML Lateral Segment

Atelectasis

93RML Lateral Segment

Atelectasis

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RLL Atelectasis

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Right lower lobe atelectasis

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Complete atelectasis of the right lung

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Atelectasis Left Upper Lobe

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Mediastinal shift to left.

Density left upper lung field.

Loss of aortic knob and left hilar silhouettes.

Atelectasis Left Upper Lobe

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A: Forward movement of oblique fissureC: Atelectatic LULB: Herniated right lung

Atelectasis Left Upper Lobe

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Bowing sign

•LUL atelectasis or following resection

•The oblique fissure bows forwards

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Bowing sign

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Left Lower Lobe Atelectasis

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Inhomogeneous cardiac density.

Triangular retrocardiac density.

Left hilum pulled down.

AtelectasisLeft Lower Lobe

105Left Lower Lobe Atelectasis

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•Lateral left diaphragm not visible•Increased density over lower spine

Left Lower Lobe Atelectasis

107Atelectasis Left Lung