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By Dr. Chia Kok King

This document provides an overview of basic chest radiograph interpretation. It discusses the radiographic appearance and contrast of common structures seen on chest x-rays such as air, fat, soft tissue, bone, and metal. It also covers important factors that affect image quality like positioning, inspiration level, and penetration. Common normal findings and measurements are outlined as well as abnormal findings including opacities, consolidations, atelectasis, heart failure, and pneumothorax. Specific diseases like tuberculosis, COPD, and lung cancer are also reviewed.

Uploaded by

Lokanath Seepana
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© © All Rights Reserved
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
43 views

By Dr. Chia Kok King

This document provides an overview of basic chest radiograph interpretation. It discusses the radiographic appearance and contrast of common structures seen on chest x-rays such as air, fat, soft tissue, bone, and metal. It also covers important factors that affect image quality like positioning, inspiration level, and penetration. Common normal findings and measurements are outlined as well as abnormal findings including opacities, consolidations, atelectasis, heart failure, and pneumothorax. Specific diseases like tuberculosis, COPD, and lung cancer are also reviewed.

Uploaded by

Lokanath Seepana
Copyright
© © All Rights Reserved
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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Basic

Interpretation
of
Chest
Radiography
By Dr. Chia Kok Kin

Five Radiographic Opacities


Air

Fat

Soft tissue Bone

least opaque
most lucent
Black

to
to
to

Metal

most opaque
least lucent
White

Radiographic Opacities & Contrasts

Air
Air
Fat
Mineral oil
Water Water
Bone
Tums
Metal
???

Film Quality
1.
2.
3.
4.

PA or AP view.
Upright/Erect or Supine
Breath : Inspiration or Expiration
X-ray penetration : Under- or
Over5. Rotation

PA vs AP views
PA view
Scapula is seen in
periphery of thorax
Clavicles project
over lung fields
Posterior ribs are
distinct
Position of markers

AP view

Scapulae are over lung fields


Clavicles are above the apex of lung fields
Position of markers
Anterior ribs are distinct

Inspiration vs Expiration

Penetration
With correct exposure you should
barely see the intervertebral disc
through the heart

If you see them very clearly the film is overpenetrated

If you do not see them it is underpenetrated

Penetration

Rotation

Pitfalls to Chest X-ray Interpretation

Poor inspiration
Over or under penetration
Rotation
Forgetting the path of the x-ray
beam

Normal Chest X-ray


Cardiac Structures
Position
More central in younger infants and children
More on the L side in older infants and teens

Size
CARDIO-THORACIC RATIO!
Cardiac diameter :
normal individuals < 15.5 cm in males; <14.5 cm in
females.
A change in diameter of greater than 1.5 cm
between two
X-rays is significant.

Cardio-thoracic ratio
seen on postero-anterior
(PA) view only
>50% is considered
abnormal in an adult; more
than 66% in a neonate.
Possible causes of a ratio
greater than 50% include:
cardiac failure
pericardial effusion
left or right ventricular
hypertrophy
*AP views make heart appear larger than it
actually is.*

Normal Chest X-ray


1. Soft tissue structures
Shadows, most commonly, breast

2. Bony structures
Count the ribs
8 10 ribs should be visible on
inspiration
Clavicle placement at 2-3 intercostal
space (if not, may be rotated)

Normal Chest X-ray


3. Diaphragm
Contour
Rounded with sharp pointed
costophrenic and costocardiac angles
Right diaphragm is usually 1-2 cm
higher

Normal Chest X-ray


4. Lungs
Start at the top and compare the R and
L
Trachea should be midline over the
thoracic vertebrae and air filled
Lung parenchyma becomes lighter as
you go down the lung. If not, it may
indicate a lower lobe or pleural effusion

Anatomy

Anatomy

Lobes

Right upper lobe:

Right middle lobe:

Right lower lobe:

Left lower lobe:

Left upper lobe with Lingula:

Lingula:

Left upper lobe - upper division:

Abnormal Chest X-ray


Radiopacity (whiteness) = increased
density
Radiotranslucency (blackness) =
decreased density

Radiopacity
Alveolar Pattern
Fluffy, soft,
poorly
demarcated
opacifications <
1cm
in diameter
Possible causes:
1. Pulmonary
edema
2. Viral
pneumonia
3. Pneumocystis
4. Alveolar cell
carcinoma

Interstitial Pattern

Vascular pattern

Consolidation of
interstitial
tissue

If there is an
increase in size
of the
pulmonary
arteries as they
extend out into
lung
pulmonary
hypertension

Looks like
branching
lines radiating
toward the
periphery of the
lung
Possible causes:
1. Interstitial
pneumonitis
2. Pulmonary
fibrosis

If there is a
decrease in
size,
truncation, or
obliteration of a
pulmonary
artery
embolus
Lack of vascular

Consolidation
Lobar consolidation:
Alveolar space filled
with inflammatory
exudate
Interstitium and
architecture remain
intact
The airway is patent
Radiologically:
A density corresponding
to a segment or lobe
Air bronchogram, and
No significant loss of
lung volume

Consolidation

Atelectasis
Loss of air
Obstructive
atelectasis:
No ventilation to the
lobe beyond
obstruction
Radiologically:
Density
corresponding to a
segment or lobe
Significant loss of
volume
Compensatory
hyperinflation of

Atelectasis
No ventilation to lobe
beyond the obstruction
Trapped air absorbed by
pulmonary circulation
Segmental/lobar density
Compensatory hyperinflation of normal lungs.

Congestive Heart Failure

Increased heart size: cardiothoracic ratio >0.5

Large hila with


indistinct
markings
Fluid in
interlobar
fissures
Pleural
effusions,

Congestive Heart Failure

Alveolar edema
(Bats wings)
Kerley B lines
(Interstitial
edema)
Cardiomegaly
Dilated
prominent
upper lobe
vessels

ARDS
Congestion
Interstitial and
alveolar
edema
Collapsed or
distended
alveoli
Bilateral

Pneumothorax

Right side
tension
pneumothor
ax

Left Sided
Pneumothorax

Pleural effusion

Right
Side
Pleural
Effusio
n

RLL
Pneumon
ia

????????????

Fracture of posterior rib #7

?????????????????????

A single, 3cm relatively thin-walled cavity is noted in


the left midlung. This finding is most typical of
squamous cell carcinoma (SCC). One-third of SCC
masses show cavitation

Right
Squamou
s Cell
Carcinom
a

???????????????

Right Middle and Left Upper Lobe Pneumonia

????????????

Cavitation : cystic changes in the area of consolidation


due to the bacterial destruction of lung tissue. Notice

Cavitation

????????????

Tuberculosis

??????????

COPD: increase in heart diameter, flattening of the


diaphragm, and increase in the size of the
retrosternal air space. In addition the upper lobes will
become hyperlucent due to destruction of the lung

Chronic emphysema effect on the lungs

????????

CHF:a great deal of accentuated interstitial


markings, Curly lines, and an enlarged
heart. Normally indistinct upper lobe
vessels are prominent but are also masked
by interstitial edema.

24 hours after diuretic therapy

Chest wall lesion: arising off the chest wall and not the lung

Pleural effusion: Note loss of left hemidiaphragm.


Fluid drained via thoracentesis

Lung Mass

The Enlarged Hila


Causes:
1. Adenopathies (neoplasia, infection)
2. Primary Tumor
3. Vascular
4. Sarcoidosis

Small Pneumothorax : LUL

Right Middle Lobe Pneumothorax: complete lobar collapse

Post chest tube insertion and re-expansion

Metastatic Lung Cancer: multiple nodules seen

Tuberculosis

Pleural Effusion

Pulmonary Fibrosis

Cavitating lesion

Miliary shadowing

5. 65 yo male admitted for sepsis. CHF or ARDS?

12. Is the central line correctly positioned?

13. Does ET tube need to be advance or pulled


back? Arrow shows location of carina

14. OK for R/T feeding?

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