Ahmed Mohammed

Lecturer –MRT Department, AAU

12/13/2021 Prepared By Ahmed. M 1

 Why order a CXR?

SYMPTOMS:

• Bad or persistent cough

• Chest pain

• Chest injury

• Coughing up blood

• Fever

• Shortness of breath
 Why order a CXR?

• Pleural effusion • Lung cancer

• Pneumothorax • Chest pain (MI?)
• Hemothorax • Hypertension
• Pulmonary embolus • Screening
• Trauma • Pneumonia
• Monitoring chest • COPD
drainage • Asthma
• TB
 Check
• patient name, position, technical quality.

• Soft tissue including breast, skeletal structures of shoulder

girdles and chest wall.

• Review abdomen for bowel gas, organ size, abnormal

calcifications, free air, etc.

• Review spine of neck and rib cage.

▪ Review mediastinum:
– overall size and shape
– trachea: position
– margins: SVC, ascending aorta, right atrium, left
subclavian artery, aortic arch, main pulmonary artery, left
ventricle
– lines and stripes: paratracheal, paraspinal, paraesophageal
(azygoesophageal), paraaortic
 Technical Adequacy

• Factors to be considered on all chest x-rays

– Inspiration

– Penetration

– Rotation

– Angulation

– Orientation
Inspiration

• The degree of inspiration is important for diagnosing different

diseases.

• If the domes of the diaphragms is at the seventh posterior

ribs, the chest should be considered hypoinflated

◼ Diaphragms elevated causing heart & mediastinum to appear

enlarged
 Penetration:
• Refers to adequate photons traversing the patient to expose the
radiograph.
• The lack of penetration renders the area “whiter” than with an
adequate film and can simulate pneumonia or effusion.
• In an ideal radiograph the thoracic spine should be barely
perceptual viewing through the cardiac silhouette.
• The soft tissues at the shoulder can also give an estimate of the
relative degree of penetration of the film.
▪ Over-penetrated dark films can obscure subtle pathologies

▪ Under-penetrated white films may given impression of diffuse

increased density
Is the exposure appropriate?
 Rotation

▪ Rotation of the patient distorts mediastinal anatomy

▪ Determined by distance between spinous process & medial clavicle

▪ Ideally the clavicle heads should be equidistant from the spinous

process.

▪ Affects heart size & shape, aortic tortuosity, mediastinal widening,

density of lung fields

The abnormal chest X-ray
 Abnormal Chest X-ray
• Radiopacity (whiteness) means increased density
• Radiotranslucency (blackness) means decreased density
• Radiopacity can be of 3 causes
• Alveolar pattern – fluffy, soft, poorly demarcated
opacifications < 1 cm in diameter
– Possible causes:
• Pulmonary edema
• Viral pneumonia
• Pneumocystis
• Alveolar cell carcinoma
Pneumonia
 Abnormal Chest X-ray
• Interstitial pattern
– Consolidation of interstitial tissue (alveolar walls,
intralobular vessels, interlobar septa and connective
tissue)
– Looks like branching lines radiating toward the periphery
of the lung
– Possible causes:
• Interstitial pneumonitis
• Pulmonary fibrosis
Pulmonary
Fibrosis
 Abnormal Chest X-ray
• Vascular pattern – assessment of the pulmonary arteries and
capillaries

– If there is an increase in the size of the pulmonary arteries

as they extend out into the lung – pulmonary hypertension

– If there is a decrease in size, truncation, or obliteration of a

pulmonary artery – embolus

– Lack of vascular making in the periphery - pneumothorax

Pulmonary Hypertension
Pulmonary
Embolism
 Lung pathologies

White Lung field Black lung Field

Well defined Ill defined

✓ Collapse ✓ Consolidation
✓ Pleural Effusion ✓ Fifrosis
✓ Pulmonary Edema
✓ Infiltration
 Summary

▪ Alteration in the normal anatomy

▪ Abnormal opacity(increased radiographic density)

▪ Increased lucency(decreased radiographic density)

 Lung diseases that increase Radiographic density

▪ Lung diseases classified in to three general groups depending

on w/h predominantly affected.air space disease

▪ Consolidation

▪ Atelectasis / Collapse

▪ Interstitial disease

▪ Combined air space and interstitial disease

 Consolidation
• Lobar or Segmental Density

• No Loss of Lung Volume

▪ Absence of atelectasis /no volume reduction

• Radiological features

➢ Airbronchogram

➢ Silhouette sign
Consolidation Without Volume Loss
Air bronchogram.
 Cont’d
Time factor
▪ Consolidation that clears in hours or days suggest pulmonary
edema or Hemorrhage

▪ that persists for weeks or months

✓ Lymphoma

✓ Broncho alveolar CA
ddx for consolidation

▪ Acute inflammatory exudate Eg pneumonia

▪ Pulmonary edema

▪ Hemmhorage

▪ Aspiration

▪ Mass/neoplasm.
 ATELECTASIS
▪ is diminished volume of air in the lung with associated reduction of
lung volume
▪ in consolidation there is diminished volume of air in the lung
associated with normal lung volume
• Pulmonary atelectasis can be divided into six types, based on
mechanism:
• Types of Atelectasis:
– Resorptive Atelectasis
– Relaxation Atelectasis/passive
– Adhesive Atelectasis
– Cicatricial Atelectasis
– Round Atelectasis
Consolidation With Volume Loss
Resorption atelectasis / obstructive

▪ Commonest form : acute bronchial obstruction

▪ Caused by Resorbtion of gas from alveoli.

• Acute bronchial obstruction .
• Gases in the alveoli are taken up by the blood.
• Modified by collateral air drift and infection.
• Chronic → Collapse
 Cnot……
Passive atelectasis/ relaxation
• Lung retracts towards the hilum.
• Air or increased fluid in the pleural cavity
▪ Occur in the presence of
– Pneumothorax
– Pleural effusion
– Adjacent to space occupying lesion
Cicatrisation atelectasis
▪ Classically occurs in pulmonary fibrosis
• Lung is abnormally stiff
• Reduction in lung compliance
• Resulting in collapse
• Pulmonary Fibrosis.
 Adhesive atelectasis
• Surfactant reduces the surface tension
• Disturbance of this mechanism
• Collapse of the alveoli
• Respiratory Distress Syndrome.
▪ also referred micro atelectasis or non obstructive atelectasis
▪ W/n action of surfactant is deficient or absent there’ll be wide Spread
collapse of the alveoli
E.g.: - HMD
- Viral pneumonia
- Post op atelectasis
Direct sign Indirect sign
• Displacement of fissures – Elevated diaphragm
• loss of aeration – Tracheal shift
• crowding vessels & bronchi – Mediastinal shift
– Elevated or lowered
mainstem bronchus
– Movement of hilum
– Fewer vessels in aerated lung
– compensatory hyperinflat
• Patterns of lung collapse
– Complete collapse of a lung
– Lobar collapse
 COMPLETE COLLAPSE

• Causes opaque hemithorax with displacement of

mediastinum to the affected side with compensatory
hyperinflation of opposite lung often with herniation across
midline.

• Herniation mostly occurs in retrosternal space but may occur

posterior to heart or under aortic arch
ATELECTASIS RIGHT LUNG

• Homogenous density right

hemithorax
• Mediastinal shift to right
• Right hemithorax smaller
• Right heart and
diaphragmatic silhouette
are not identifiable
Complete collapse
Tracheal shift
Bronchus amputated

Diaphragm
 Pulmonary Edema

Interstitial and Airspace Edema

Pulmonary Edema

• Cardiogenic edema - increased hydrostatic pulmonary capillary

pressure
▪ cephalization of the pulmonary vessels
▪ Kerley B lines or septal lines
▪ peribronchial cuffing
▪ "bat wing" pattern
▪ air bronchograms
▪ increased cardiac size
Interstitial Pulmonary Edema
Pulmonary Edema
 Interstitial Pulmonary Edema
• Kerley “B” Lines
• Peribronchial cuffing
• Hila look larger
• Vessels are ill-defined
• Upper lobe vessels are
larger
• Fluid in fissures
• Small pleural effusions
Interstitial Pulmonary Edema

NORMAL INTERSTITIAL EDEMA

 Interstitial Edema

PA View Lateral
Airspace Edema
 Congestive Heart Failure

▪ heart fails to maintain adequate forward flow

✓ earliest CXR finding of CHF is cardiomegaly

✓ upper zone veins dilate

✓ interstitial edema occurs with the appearance of Kerley

lines

✓ alveolar edema
 CHF

cardiomegaly, alveolar edema,

and haziness of vascular margins
Causes of Kerley B lines

• pulmonary edema

• lymphangitis carcinomatosa

• lymphoma

• viral and mycoplasmal pneumonia

• interstitial pulmonary fibrosis

• pneumoconiosis
 Predominantly Interstitial disease

▪ any interstitial disease may also affect the adjacent air space
▪ there are different patterns of interstitial disease
▪ Reticular
▪ reticulonodular
▪ Nodular
▪ linear
▪ Honey comb pattern
Cavity
LUNG DISEASES THAT DECREASERADIOGRAPHIC DENSITY

• Density may be decreased by the change in the relative

amount of air, blood, & interstitial tissue

• Grossly Classified

▪ Generalized (bilateral) e.g.- Asthma

▪ Localized disease , e.g.- lobar emphysema or Large bulla

 Chronic Obstructive Pulmonary Disease

• A group of disorders that cause chronic airway obstruction

• Bronchitis

• Asthma

• Emphysema

• Bronchectasis
 RADIOLOGIC SIGNS OF PLEURAL DISEASE

▪ Pleura involved by many intra thoracic

diseases

▪ Radiographic manifestation Consists of

- Pleural effusion

- Pl. fibrosis /thickening

- Pneumothorax

- Neoplastic infltration
 Pleural Effusion
• Results from excess fluid collecting in the pleural cavity
• Usually results from pulmonary or cardiac disease
• It is not a disease entity itself, but the result of another serious
disorder
▪ The amount of fluid required to be demonstrated on PA CXR (Erect)
range 250-600 ml.
▪ Lateral decuitus detect as small as 5 ml.
▪ Typical distribution of free PL. fluid depend on gravity
1st fluid spill out to posterior CPA, Lateral & eventually anterior
then with further accumulation, it spread up wards
Pleural Effusion
 Cont…….
• The costophrenic angles will be blunted

• This disorder is best demonstrated by erect and lateral

decubitus chest films

• Excess fluid is usually removed by thoracentesis, sometimes

developing in a pneumothorax
Pleural Effusion
 Pneumothorax
• Occurs when free air is trapped in the pleural space and
compresses the lung tissue
• Air can enter from perforation from trauma, or by generation
of gas forming bacteria
• A pathologic process can result in a spontaneous
pneumothorax
• A radiograph will reveal a strip of radiolucency devoid of any
lung markings
• It is best demonstrated by an expiration CXR
• A tension pneumothorax occurs when air enters the pleural
space but cannot leave it
http://www.blebinfo.co.uk/phpBB2/viewtopic.php?t=60

http://www.ispub.com/journal/the_internet_journal_of_thoracic_and_cardiovascular_surgery/vo
lume_13_number_1_2/article_printable/spontaneous_esophageal_perforation_presenting_as_pn
eumothorax_a_case_report.html
Pneumothorax
 hydropneumothorax

• Presence of both gas & fluid in pleural space

- On erect CXR –air fluid level

- Loculated form - appear as single or multiple collection

With air fluid level

Hydropneumothorax
 Opaque hemi Thorax
• shift of mediastinum
towards - collapse,
- pneumonectomy,
- pulmonary agenesis or
- hypoplasia
away – pleural effusion
- diaphragmatic hernia
no shift
– consolidation,
- mesothelioma