MEDICINE III

DR. SAMUEL MARTINEZ

TOPIC: CHEST X-RAY
DATE: 9 SEPTEMBER 2022

Outline Page
Anatomy - Bones
Systematic Approach and Anatomy 1
ABCDEF System 1
Airways 2
Bone Abnormalities 3
Cardiac Silhouette 5
Mediastinum and Hila 6
Diaphragm 7
Pleural Effusions 7
Hyperinflation 10
Alveolar (a.k.a. airspace) opacities 10
Interstitial opacities 11
Cardiogenic Pulmonary Edema 12

The Systematic Approach and Anatomy

Learning Objectives:
• To be familiar with a systematic approach to interpreting chest
X-rays
• To know the correlation between anatomy and normal shadows
on the chest X-ray

Principles of the Systematic Approach

• Most important for the clinicians least experience with reading
chest X-rays, since it reduces the chance that important findings
will be missed
• All aspects of X-ray interpretations should be included
• The individual elements of the approach should be examined in
a sequence that’s either logical and/or easy to remember

The ABCDEF System

(Assess the technical quality)
• A – Airways
• B – Bones (and soft tissue)
• C – Cardiac silhouette (and mediastinum)
• D – Diaphragm (and gastric bubble)
• E – Effusions (i.e. Pleura)
• F – “Fields” (i.e. Lung Fields)

(Lines, Tubes, Devices, Surgeries)

Anatomy - Airways

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Airways, Bones and Soft Tissues
• To be able to assess the airways, bones and soft tissues
• To know the common etiologies of abnormalities seen in the
airways, bones, and soft tissue

AIRWAYS
Abnormalities deviating Abnormalities deviating
• Abnormalities of the Airways
trachea away from affected trachea towards the affected
o On chest X-ray, airways can either be:
▪ Narrowed side side
▪ Deviated Pneumothorax Marked atelectasis/ collapsed
▪ Contain foreign objects lung
Pleural effusion Lobectomy/ Pneumonotomy
Airway Narrowing Large Mass Pleural fibrosis
• Subglottic airway narrowing is an important radiographic finding Pulmonary fibrosis (rarely
in croup and tracheal stenosis unilateral)
• However, narrowing of trachea is easy to over-call in
asymptomatic adults due to overlying shadows from mediastinal Pleural Effusion
structures

Airway Deviation

Airways can also be deviated due to local displacement

• Lateral deviation due to mediastinal/hilar lymphadenopathy in
lymphoma or other malignancies
• Splaying of the right and left bronchi by extreme left atrial
enlargement

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Airway deviation • Old rib fracture is suggested by focal thickening of the rib
consistent with callous formation

Other Fractures

Cardiomegaly with splaying

Scoliosis vs Kyphosis
• Scoliosis– spine curves from side to side

Foreign body aspiration

• Kyphosis—exaggerated front to back curvature of upper spine

BONE ABNORMALITIES
On chest X- ray, bones can be:
• Fractured (recent vs old)
• Deformed (Kyphosis, scoliosis)
• Sclerosed (solitary vs multiple vs diffuse) Barrel Chest
• Lytic (solitary vs Multiple) • Refers to specific thoracic deformity that occurs in advanced
• Osteopenic COPD:
• Notched (ribs) o Kyphosis
o Increased AP diameter
Rib fracture

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Sclerosis Cervical Ribs
• Sclerosis- high density of bone • Anatomic variant
• Can be focal or diffuse • Prevalence ~ 0.5—1%
• Etiologies include: • Can be unilateral or bilateral
o Osteoblastic metastasis • Usually, an incidental finding
o Primary bone tumor • Can cause thoracic outlet syndrome
o Various benign tumor-like bone lesions
o Paget’s disease
o Chronic osteomyelitis

SOFT TISSUES

Lytic Lesions
• Lytic lesions– low density of bone
• Can be solitary or multiple
• Etiologies include:
o Osteolytic metastasis
o Multiple myeloma
o Various benign cyst-like bone lesions
o Paget’s disease
o Acute osteomyelitis Subcutaneous Emphysema
Air within the subcutaneous tissue can occur due to:
• Air introduced internally
o Pneumothorax
o Pneumomediastinum
o Pulmonary interstitial emphysema
• Air introduced externally
o Penetrating chest wall trauma
o Post-surgical
o Complications from chest tube
• Air produced locally
o Necrotizing infection with gas producing organism
Rib Notching otherwise known as gas gangrene
• Rib notching is focal deformation of one or more ribs
• Etiologies depend upon whether the superior or inferior surface Shrapnel Injuries
is affected:
Superior surface Inferior surface
Osteogenesis imperfecta Coarctation of the aorta
Connective tissue diseases Subclavian or SVC
obstruction
Local pressure s/p Blalock Taussig shunt
(only 2 upper ribs)
Hyperparathyroidism

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CARDIAC SILHOUETTE AND MEDIASTINUM o Mitral valve disease

RIGHT VENTRICLE ENLARGEMENT

PA vs. AP films
Chest X-ray quality – Projection
AP projection:
• AP projection image is of lower quality than PA image • Findings include
• The scapulae are not retracted laterally, and they remain o Filling of retrosternal space (on lateral view)
projected over each lung. • Right ventricular enlargement
• Heart size is exaggerated o Pulmonary hypertension (any cause)
o Pulmonary valve disease (e.g., pulmonic stenosis,
Abnormalities of the Cardiac Silhouette pulmonary regurgitation)
• Cardiomegaly
Cardiothoracic Ratio = Maximum horizontal cardiac width
Maximum horizontal thoracic width
(inner surface of rib cage)
*Cardiomegaly is considered to be present if the cardiothoracic ratio
is > 50% on PA film

PERICARDIAL EFFUSION
• not all clinically relevant pericardial effusions are visible on X-
ray, particularly if they developed acutely.
• Primary finding is an enlarged cardiac silhouette
• Other findings include:
o Water bottle morphology of silhouette
Etiologies of Cardiomegaly o Oreo cookie sign
• any cause of left or right sided heart failure
• pericardial effusion can be mistaken for cardiomegaly

LEFT ATRIAL ENLARGEMENT

• Findings include:
o Splaying of the carinal angle >90 degrees
o Double density sign
• Left atrial enlargement
o Left sided heart failure (any cause)

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 • Posterior Chocolate Layer = Pericardial Fat
• Middle Cream Layer = Pericardial Effusion
• Anterior Chocolate Layer = Epicardial Fat Mediastinal Masses

PERICARDIAL EFFUSION ETIOLOGIES

Acute
• Trauma
• Viral pericarditis
• Complication of MI (e.g. Free will rupture, Dressier syndrome)
• Iatrogenic (e.g. RV biopsy, EP procedures)

Sub-acute to Chronic
• Malignancy (e.g. lymphoma, breast, lung)
• Renal failure
• Collagen Vascular Disease
• Hypothyroidism
• Tuberculosis Hilar Enlargement
Malignancy Infection Other
DEXTROCARDIA - Primary lung - Tuberculosis - Sarcoidosis
• Congenital anomaly cancer - Viruses (e.g. EBV) - Silicosis
• Incidence= 1/12,000 pregnancies - lymphoma - Histoplasmosis - Pulmonary
- Metastatic - Coccidioidomycosis Hypertension
• May be isolated and discovered incidentally, or associated with
disease (e.g. - Tularemia - Pulmonary artery
life-threatening additional congenital malformations
Lung, breast, aneurysm
head/neck, - Bronchogenic
melanoma) cyst

ABNOMRALITIES OF THE MEDIASTINUM AND HILA

Widened Mediastinum
Hilum Overlay Sign
• Generally defined as > 8 cm
• Most cases of “widened mediastinum” are due to suboptimal
technical quality
o Rotation
o Poor inspiratory effect
o AP view

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DIAPHRAGM AND PLEURA • Visceral pleural line -
necessary to make a definitive
diagnosis
• Visceral pleural line parallels
the curvature of the chest wall
(ie. Convex outwards)
o Pneumothorax mimic
conditions do not
maintain this spatial
relationship Eg. bullae,
artifacts.
• Usually there is absence of
lung markings peripheral to
ABNORMALITIES OF THE DIAPHRAGM AND PLEURA pleural line.
Learning objectives o Pleural adhesions - lung
• To be able to identify and list the common etiologies of common markings may be visible beyond the pleural line
radiographic abnormalities of the pleura and diaphragm
(including abnormal air under the diaphragm)

PNEUMOTHORAX
• Size of a pneumothorax is based on the thickness of the rim of
air around the lung at the level of the hilum on a PA film
• <2cm -”small” pneumothorax
• >2cm -”Large” pneumothorax
• Radiologic findings:
o Contralateral mediastinal shift
o Depression of ipsilateral hemi-diaphragm
o Compressive atelectasis of adjacent normal lung
• Presence of significant increased intrathoracic pressure
• Role of imaging in patients with pneumothorax:
1. Confirm the clinical diagnosis PNEUMOTHORAX
2. Assess extent of pneumothorax Primary pneumothorax
3. Detect signs of tension ● A.k.a spontaneous pneumothorax
4. Follow-up examination to monitor resolution of
pneumothorax after drainage Secondary pneumothorax
● Iatrogenic
● (e.g., Thoracentesis, lung biopsy, central line placement)
● COPD
● Cystic fibrosis

PLEURAL EFFUSIONS
Characteristics of effusions visible on chest X-ray:
● Unilateral vs. Bilateral
● Size
● Free flowing vs. Loculated
● Associated findings that may suggested the etiology of the
Bilateral tension pneumothorax due to barotrauma from positive
effusion
pressure ventilation. Note the flattening of the diaphragm. The
presence of bilateral abnormality results in no mediastinal shift. Note
the collapsed lungs (arrows) and bilateral hyperlucency.

Standard PA erect CXR - Radiological features

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LOCATED PLEURAL EFFUSION Etiologies of Pleural Effusions
● Homogeneous density Transudative Exudative
● Loculated (Secondary to imbalance (Secondary to pleural
● Loss of cardiophrenic angle between hydrostatic and inflammation or lymphatic
● Loss of lateral portion of diaphragmatic silhouette oncotic pressures within obstruction)
pleural space)
Heart failure Pneumonia/ Empyema
Hepatic hydrothorax Malignancy
(pleural effusions due to
cirrhosis/ascites)
Hypoalbuminemia Pleural Tuberculosis
Nephrotic Syndrome Pancreatitis
Sarcoidosis
Various rheumatological
Free flowing vs Loculated (lateral decubitus view)
diseases
(e.g. Lupus, rheumatoid
arthritis, etc.)

Miscellaneous Pleural Disease

• Pleural Plaques
• Pleural Thickening
• Pleural-based malignancy

SUBPULMONIC EFFUSIONS Pleural Plaques

● Fluid accumulation between the lung base and the diaphragm Prior to Asbestos Exposure
which does nor track up the pleura, and therefore, does not
blunt the costophrenic angle.
● Primarily suggested by:
o “diaphragm” appears to peak more lateral than normal
o “diaphragm” appears more than horizontal than normal
o On left: abnormally large distance between gastric bubble
and lung base
o On right: abnormally high horizontal fissure

Diffuse Pleural Thickening

Prior infection
Prior hemothorax
Occupational exposure (e.g. Asbestos, silica dust)
Radiation
Malignancy

Pseudotumor
● Term most commonly used to refer to a fluid collection trapped
within a fissure, which can give the appearance of a lung mass.
● Suspicion for trapped fluid based on:
○ Location at a fissure (most occur in the horizontal fissure)
○ Smooth lenticular contour

Pleural-based malignancy
Pleural Malignancies
Metastatic disease
(can be from hematogenous dissemination or direct invasion)
Mesothelioma
(strongly associated with asbestos exposure)

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 Pneumomediastinum
Trauma
Esophageal rupture
Vomiting
Asthma
Post-neck or chest surgery
Barotrauma (e.g. Diving, positive pressure ventilation)

Elevated Hemidiaphragm
Elevated Hemidiaphragm
Diminished lung volume (e.g. Atelectasis)
Phrenic nerve paralysis
Eventration of the diaphragm
Subphrenic abcess
Hepatomegaly or splenomegaly

PNEUMOPERICARDIUM
• Trauma
• Bacterial pericarditis secondary to gas-producing organism
• Post-cardiac surgery or pericardial drain
• Fistula between pericardium and either lung, stomach, or
esophagus

Pathologic Locations of Air

Pneumoperitoneum
Perforated viscus (e.g. PUD, appendicitis, diverticulitis,
malignancy bowel obstruction, complication endoscopy)
Post-operative
Trauma
Peritoneal dialysis
CHILAIDITI’S SIGN AND SYNDROME
• Chilaiditi’s sign:
o Gas seen between liver and diaphragm
o Presence of haustral folds suggesting gas is intracolonic
and not pneumoperitoneum
• Can be mistaken for pneumoperitoneum
• Chilaiditi’s syndrome refers to conditions of abdominal pain or
other symptoms cause by the interposed colon.

DIFFUSE LUNG DISEASE

Diaphragmatic Hernias

LEARNING OBJECTIVES
• To be able to identify and know the differential diagnosis of how
lung volumes, and hyperinflation

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• To be able to identify pulmonary edema, as well as specific DIFFERENTIATING CARDIOGENIC FROM NON-CARDIOGENIC
features that can help distinguish cardiogenic from non- EDEMA
cardiogenic etiologies • Air Bronchograms
• To be able to classify interstitial processes based on their • Peribronchial Cuffing
radiographic features • Kerley Lines
• To be able to compare typical findings in alveolar and interstitial • Cephalization
processes • Bat’s Wing Pattern
HYPERINFLATION AIR BRONCHOGRAMS
• Subjective impression that the total lung capacity is likely • Bronchi are usually not visible on X-ray
increased, based upon: • Opacification of alveoli adjacent to bronchi results in the dark,
o Number of ribs seen air-filled bronchi becoming identifiable
o Flattening of the diaphragm
o Diffusely increased lucency of the lungs
• Hyperinflation
o COPD
o Asthma (during an exacerbation only)

Peribronchial Cuffing
• Bronchi are usually not visible on X-ray
• Interstitial edema can accumulate around bronchi, making the
bronchi walls thick
• Appears like a ring when seen in cross section, and like tram
RADIOGRAPHIC CATEGORIES OF DIFFUSE LUNG OPACITIES tracks when seen longitudinally
• Alveolar (a.k.a. airspace) opacities
• Interstitial opacities

ALVEOLAR (A.K.A. AIRSPACE) OPACITIES

• Due to fluid accumulation within the alveoli and terminal
bronchioles, fluid may be edema, pus, or blood.
• Opacities are hazy with poorly defined margins, but can respect
lobar boundaries (unless diffuse)

KERLEY A AND B LINES

• Kerley A Lines
o Diagonal, unbranching lines, 2-6 cm long, extending from
the hilum. Represent channels between peripheral and
central lymphatics

Cardiogenic Pulmonary Non-Cardiogenic Pulmonary

Edema (elevated PCWP) Edema (normal PCWP)
Any cause of congestive heart Acute Lung Injure (ALI) =Acute
failure Respiratory Distress Syndrome
(.eg. Exacerbation of long- (ARDS)
standing cardiomyopathy, (e.g. Severe sepsis,
acute MI, arrhythmia pneumonia, aspiration
myocarditis, acute AR/MR pneumonitis, pancreatitis, • Kerley B Lines
secondary to endocarditis) severe burns, post-transfusion, o Faint, thin horizontal lines, 1-2 cm long, at the lung
near drowning, extreme periphery, usually at the bases. Represent interlobular
elevation, CNS catastrophe, septa
inhalational injury)

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 Diffuse Alveolar Opacities Not due to Pulmonary Edema
Alveolar Opacities without Edema
Multilobar Pneumonia
Diffuse Alveolar Hemorrhage

INTERSTITIAL OPACITIES
- Subtypes Interstitial Opacities
o The appearance of interstitial opacities can be further
described based on pattern:
▪ Reticular (too many lines)
Cephalization ▪ Nodular (too many dots)
• Increased visibility of pulmonary vessels at the lung apices as ▪ Reticulonodular (too many line and dots)
compared to the bases
• Suggestive of increased left atrial pressure

Bat’s Wing Pattern Differential Diagnosis of Interstitial Opacities

- Bilateral, perihilar concentration of opacification Predominantly Reticular
Bat’s Wing Pattern Idiopathic Pulmonary Fibrosis
Cardiogenic Pulmonary Edema Connective Tissue Diseases (eg scleroderma, rheumatoid arthritis)
Pneumonia: Viral, PCP, Aspiration Atypical pneumonia
Inhalational injury Idiopathic Interstitial Pneumonias
Pulmonary Alveolar Proteinosis Asbestosis
Chronic Aspiration
Pulmonary Drug Toxicity (eg. Nitrofurantoin, cyclophosphamide)
Sarcoidosis
Chronic Hypersensitivity Pneumonitis
Langerhans Cells Histiocytosis
Lymphangitis Carcinomatosis

Differential Diagnosis of Diffuse Opacities

Predominantly Nodular Pattern
Nodules <2mm Nodules <2mm
Military Tuberculosis Metastatic cancer
Fungal infection (eg. Subacute hypersensitivity
Histoplasmosis, pneumonitis
Cardiogenic vs. Non- cardiogenic Pulmonary Edema coccidioidomycosis,
Cardiogenic Non- Cardiogenic (eg ARDS) blastomycosis)
Cardiac size typically enlarged Cardiac size typically normal Silicosis Lymphoma
Regional distribution of Regional distribution of Coal worker’s pneumoconiosis Sarcoidosis
opacities relatively opacities relatively patchy Sarcoidosis Granulomatosis with
homogenous polyangiitis
Air bronchograms uncommon Air bronchograms common Rheumatoid nodules
Peribronchial cuffing common Peribronchial cuffing
uncommon Alveolar vs. Interstitial Opacities –A SUMMARY
Concurrent pleural effusion(s) Concurrent pleural effusion(s) Alveolar Opacities Interstitial Opacities
and Kerley B lines more and Kerley B lines less common Lobar or segmental distribution, Does not respect lobar or
common unless diffuse or the bat’s wing segmental boundaries
pattern
Relatively hazy margin Relatively sharp margin

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 May contain air bronchograms Usually devoid air
(if Edema is non-cardiogenic) bronchograms
Rapidly changing over time Changes more slowly over time
Described in highly subjective Described in semi-objective
terms: “fluffy”, “cotton wool-like”, terms: reticular, nodular,
“cloud-like” reticulonodular

CARDIOGENIC PULMONARY EDEMA

Stage I CHF - Redistribution
• Redistribution of the pulmonary veins. This is known as
cephalization (blue arrow) because the pulmonary veins of the
superior zone dilate due to increased pressure.
• An increase in width of the vascular pedicle (red arrows)

Stage II CHF - Interstitial edema

• Characterized by: Kerley's A lines: extend radially from the
hilum to the upper lobes; represent thickening of the interlobular
septa that contain lymphatic connections.

Stage III CHF - Alveolar edema

• Characterized by: Alveolar edema with perihilar
consolidations and air bronchograms (Bat's wing or butterfly
pulmonary opacities) (yellow arrows)
• pleural fluid (blue arrow)
• prominent azygos vein and increased width of the vascular
pedicle (red arrow)
• an enlarged cardiac silhouette (arrow heads).

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