Chest Radiography

Interpretation

Dr Jam Muzafar
03009670504 Diagnostic Radiology
 Sequence For Radiography Reading
1. Correct name of investigation:
Example: Simple radiography of chest
(frontal or lateral view)
2. Radiological features (signs) by symptoms and syndroms:
– Lungs
– Pulmonary pattern
– Hillum
– Pleura
– Mediastinum-aorta, trachea
– Heart
– Bone and Soft Tissue including abdomen
3. Conclusion (what pathology)
 IMAGING MODALITIES
1. Plain chest Radiograph
2. Fluoroscopy
3. CT
4. Radionuclide lung scan
5. MRI
6. Ultrasound
7. Pulmonary angiography
 Chest Radiographs
 Path of x-ray beam
– PA
– AP
 Patient Position
– Upright
– Supine
 Essentials Before Getting
Started
 Exposure
– Overexposure
– Underexposure
 Sex of Patient
– Male
– Female
 Pitfalls to Chest X-ray
Interpretation
 Poor inspiration
 Over or under penetration
 Rotation
 Forgetting the path of the x-ray beam
 1

1: Adequate penetration of
4
a the mediastinum-is the
a thoracic spine seen?

2: Has the patient taken a good

inspiratory effort? About 8-10
7 posterior thoracic ribs should be
seen through the lungs. Breath:
• Inspiration
• Expiration
3: Is there any rotation of the
10 chest? Assessed by checking
the upper thoracic spinous
process (oval) in relation to the
medial ends of the clavicles
(lines ‘a’) - this CXR is rotated to
left
 Systematic Approach
 Lung Fields, pulmonary pattern
and hilum
Lung Fields without any
pathology, radiologicaly =
transparent
Pulmonary pattern and hilum can be:

1. Structured if dimensions are1.5x3cm

2. Enhaced
3. Decreased (rare)
4. Deformed
 Systematic Approach
 Diaphragm and
Pleural Surfaces
– Diaphragm
 border
 Costophrenic angles
– Pleural is not visible in
case of no pathology
– Interlobar fissures
 Systematic Approach
 Mediastinum and
Heart
– Heart size on PA
– Measure CTR=cardio
thoracic ratio
 Systematic Approach
 Soft Tissues
– Breast shadows
– Supraclavicular areas
– Axillae
– Tissues along side of
breasts
 Systematic Approach
 Bony Fragments
– Ribs
– Sternum
– Spine
– Shoulder
– Clavicles
 Systematic Approach
 Abdomen
– Abdomen
 Gastric bubble
 Air under diaphragm
 Lung Anatomy
 Right Lung
– Superior lobe
– Middle lobe
– Inferior lobe
 Left Lung
– Superior lobe
– Inferior lobe
Lung Anatomy on Chest X-ray
 The right upper lobe
(RUL) occupies the upper
1/3 of the right lung.
 Posteriorly, the RUL is
adjacent to the first three
to five ribs.
 Anteriorly, the RUL
extends inferiorly as far as
the 4th right anterior rib
Lung Anatomy on Chest X-ray
 The right middle lobe
is typically the
smallest of the three,
and appears triangular
in shape, being
narrowest near the
hilum
 Lung Anatomy on Chest X-ray
 The right lower lobe is the
largest of all three lobes,
separated from the others by
the major fissure.
 Posteriorly, the RLL extend
as far superiorly as the 6th
thoracic vertebral body, and
extends inferiorly to the
diaphragm.
 Review of the lateral plain
film surprisingly shows the
superior extent of the RLL.
 Lung Anatomy on Chest X-ray
 These lobes can be separated
from one another by two
fissures.
 The minor fissure separates
the RUL from the RML, and
thus represents the visceral
pleural surfaces of both of
these lobes.
 Oriented obliquely, the
major fissure extends
posteriorly and superiorly
approximately to the level of
the fourth vertebral body.
Lung Anatomy on Chest X-ray
 The lobar architecture
of the left lung is
slightly different than
the right.
 Because there is no
defined left minor
fissure, there are only
two lobes on the left;
the left upper
Lung Anatomy on Chest X-ray
 Left lower lobes
Lung Anatomy on Chest X-ray
 These two lobes are
separated by a major
fissure, identical to that
seen on the right side,
although often slightly
more inferior in location.
 The portion of the left
lung that corresponds
anatomically to the right
middle lobe is
incorporated into the left
upper lobe.
 Chest Imaging
Radiological anatomy
 Right Lung
– Superior lobe:
 1 - apical; 2 - posterior; 3 - anterior

– Middle lobe:
 4 - lateral; 5 - medial

– Inferior lobe:
 6 - superior (apical); 7 - medial basal;

8 - anterior basal; 9 - lateral basal;

10 - posterior basal
 Chest Imaging
Radiological anatomy
 Left Lung
– Superior lobe:
 1 - apical; 2 - posterior; 3 – anterior; 4, superior

lingular; 5, inferior lingular

– Inferior lobe:
 6 - superior (apical); 8 - anterior basal;

9 - lateral basal; 10 - posterior basal

 Radiological semiology of
pulmonary pathology

 Pulmonary opacity
 Pulmonary hyperlucency
 Changes of pulmonary picture
 Changes of hilum
Pulmonary opacification represents the result of a decrease in the ratio of
gas to soft tissue (blood, lung parenchyma and stroma) in the lung. When
reviewing an area of increased attenuation (opacification) on a chest
radiograph or CT it is vital to determine where the opacification is. The
patterns can broadly be divided into airspace opacification, lines and dots.
Classification of pulmonary opacification
1. airspace opacification
consolidation
atelectasis
ground-glass opacification
airspace nodules
branching, e.g. mucoid impaction
2. linear opacification
reticular interstitial pattern, e.g. usual interstitial pneumonia
reticulonodular interstitial pattern, e.g. sarcoidosis
linear interstitial pattern, e.g. pulmonary oedema
3. nodular opacification
miliary (<2 mm), e.g. miliary tuberculosis
micronodular (2-7 mm), e.g. acute hypersensitivity pneumonitis
nodule (7-30 mm), e.g. lung metastasis, lung granuloma
mass (>30 mm), e.g. bronchogenic carcinoma
4. pulmonary mucoid impaction,
 Radiological semiology of pulmonary pathology
Pulmonary opacity
 Number (single / multiple, disseminated or not)
 Dimensions (nodular / large)
 Location (unilateral or bilateral / regions / lobes / segments)
 Shape (rounded / ring-shape / linear / triangle / irregular)
 Borders (well-defined, regular or irregular / ill-defined )
 Structure (homogeneous / heterogeneous)
 Intensity (subcostal / costal / supracostal)
 Relation to the mediastinum (without displacement / pushing /
pulling)
 Pulmonary hyperlucency

Def: Decreased lung density on images can be described

as pulmonary hyperlucency on conventional chest
radiographs and hypoattenuation on CT scans.

Hyperlucency on images can result from an excess of air

in the pulmonary parenchyma or a decrease in mass of the
pulmonary parenchyma caused by a reduction in
vasculature or blood flow, reduction or obliteration of
airways, or a combination of these potential causes.
 Radiological semiology of
pulmonary pathology

Pulmonary hyperlucency
Classification

 Outside or Inside the lungs

 unilateral or bilateral,
 focal or diffuse.
 Radiological semiology of
pulmonary pathology

Changes of pulmonary picture

 Deformation
 Enhanced
 Reduced
Changes of hilum

NORMAL
Unilateral Hilar Enlargement
 Causes of hilar lymphadenopothy
– Neoplastic, e.g. spread from bronchial
carcinoma, primary lymphoma
– Infective, e.g. tuberculosis
– Sarcoidosis (rarely unilateral)
 Causes of hilar vascular enlargement
– Pulmonary artery aneurysm
– Poststenotic dilatation of the pulmonary artery
 Bilateral Hilar Enlargement
 Causes of bilateral hilar lymphadenopathy
– Sarcoid
– Tumors, e.g. lymphoma, bronchial carcinoma, metastatic tumors
– Infection, e.g. tuberculosis, recurrent chest infections, AIDS
– Berylliosis

 Causes of pulmonary hypertension

– Obstructive lung disease, e.g. asthma, COPD
– Left heart disease, e.g. mitral stenosis, left ventricular failure
– Left to right shunts, e.g. ASD, VSD
– Recurrent pulmonary emboli
– Primary pulmonary hypertension
 R R

1. Radiography of chest PA and lateral right view

2. The position of patient is correct. The image is with good and correct exposure. In the right lung,
inferior lobe, S 10 is determined an opacity. It is single, limited, irregular shape and unclear borders,
without displacement of mediastinum The structure of it is heterogeneous. The pulmonary pattern is
enhanced. The pulmonary hilum are unstructured bilateral. The costophrenic angles are free bilateral.
The diaphragm is unclear on right because of opacity, on left the contour is clear. The bones are
structured and soft tissues are clear. The heart is not enlarged.

3. Conclusion: right side Pneumonia

 R

1. Radiography of chest PA view

2. The position of patient is correct. The image is with good and correct exposure. Bilateral, in medium
and inferior zone in right lung and medium zone in left lung is seen multiple diffuse nodular opacities
with irregular shape and unclear borders, without displacement of mediastinum The structure of it is
heterogeneous. The pulmonary pattern is enhanced. The pulmonary hilum are unstructured bilateral.
The costophrenic angles are free bilateral. The diaphragm is with clear borders. The bones are
structured and soft tissues are clear. The heart is not enlarged.

3. Conclusion: Bilateral Pneumonia

 R

1. Radiography of chest PA view

2. The position of patient is correct. The image is with good and correct exposure. In the left
lung, medium zone, perihilar is determined a single ring shape opacity with clear and thick
borders, without displacement of mediastinum The structure of it is heterogeneous. The
pulmonary pattern is enhanced. The pulmonary hilum are unstructured bilateral. The
costophrenic angles are free bilateral. The diaphragm is with clear borders. The bones are
structured and soft tissues are clear. The heart is not enlarged.

3. Conclusion: left lung central cancer

 R

1. Radiography of chest PA view

2. The position of patient is correct. The image is with good and correct exposure. Bilateral perihilar and
inferior zone in right side is seen diffuse limited opacitiy with irregular shape and unclear borders,
without displacement of mediastinum The structure of it is heterogeneous. The pulmonary pattern is
enhanced. The pulmonary hilum are dilated bilateral. The costophrenic angles are opacified. The
diaphragm is not clear because of opacity. The bones are structured and soft tissues are clear. The heart
is encrased, cardio-thoracic ratio (CTR)=0.6

3. Conclusion: pulmonary edema. Cardiomegaly

24 hours after diuretic therapy
 R

1. Radiography of chest frontal view

2. The position of patient is correct, the clavicles are simetric. The image is with good and correct exposure.
On the radiography we determine radiological symptom of opacity. It is single, limited, localized in the
left lung, inferior zone. The structure of opacity is homogeneous with displaced mediastinum organs,
such us trachea and heart away from opacity. The pulmonary pattern is deformed. The pulmonary hilum
unstructured. The costophrenic angles : on right is clear; on left is opacified. The diaphragm : on right is
well defined; on left can’t be seen because of opacity . The bones are structured. Soft tissues are clear.
The heart is not enlarged.

3. Conclusion: left side pleural effusion

 Mass effect with large effusion

1. Radiography of chest frontal view

2. The position of patient is correct, the clavicles are simetric. The image is with good and correct exposure.
The left lung is transparent. In the right side is seen single total opacity with homogeneous structure and
with displaced mediastinum organs, such us trachea and heart away from opacity. In left side the
pulmonary pattern is deformed and the pulmonary hilum structured. The costophrenic angles : on left is
clear; on right is opacified. The diaphragm : on left is well defined; on right can’t be seen because of
opacity . The bones are structured. Soft tissues are clear. The heart is not enlarged.

3. Conclusion: right side pleural effusion

 Volume loss with atelectasis

1. Radiography of chest frontal view

2. The position of patient is correct, the clavicles are simetric. The image is with good and correct exposure.
The right lung is transparent. In the left side is seen single total opacity with heterogeneous structure and
with displaced mediastinum organs toward to opacity. In right side the pulmonary pattern is deformed
and the pulmonary hilum structured. The costophrenic angles: on right is clear; on left is opacified. The
diaphragm : on right is well defined; on left can’t be seen because of opacity . The bones are structured.
Soft tissues are clear.

3. Conclusion: left lung atelectasis

 R

1. Radiography of chest PA and left lateral view

2. The position of patient is correct. The image is with good and correct exposure. In the left
lung, superior lobe, S3, perihilar is determined a single round shape opacity with clear and
thin borders, without displacement of mediastinum The structure of it is homogeneous. The
pulmonary pattern is enhanced. The pulmonary hilum are unstructured bilateral. The
costophrenic angles are free bilateral. The diaphragm is with clear borders. The bones are
structured and soft tissues are clear. The heart is not enlarged.

3. Conclusion: left lung benign mass (cyst)

 R

1. Radiography of chest PA view

2. The position of patient is correct. The image is with good and correct exposure. Bilateral, in medium
and inferior zone is seen multiple nodular opacities with regular, clear borders, without displacement of
mediastinum The structure of it is homogeneous. The pulmonary pattern is enhanced. The pulmonary
hilum are unstructured bilateral. The costophrenic angles are free bilateral. The diaphragm is with clear
borders. The bones are structured and soft tissues are clear. The heart is not enlarged.

3. Conclusion: Bilateral lung metastasis

 R

1. Radiography of chest PA view

2. The position of patient is correct. The image is with good and correct exposure. In left lung, in superior
and medium zone is seen diffuse nodular opacities with irregular shape and unclear borders, afecting
the left hilum, without displacement of mediastinum The structure of it is heterogeneous. The
pulmonary pattern is enhanced. The pulmonary hilum are unstructured bilateral. The costophrenic
angles are free bilateral. The diaphragm is with clear borders. The bones are structured and soft tissues
are clear. The heart is not enlarged.

3. Conclusion: infiltrative tuberculosis

 R

1. Radiography of chest PA view

2. The position of patient is correct. The image is with good and correct exposure. In the left
lung, infrahilar is determined a single round shape opacity with clear and thin borders,
without displacement of mediastinum The structure of it is homogeneous. The pulmonary
pattern is enhanced. On right side the pulmonary hilum is structured. The costophrenic
angles are free bilateral. The diaphragm is with clear borders. The bones are structured and
soft tissues are clear. The heart is not enlarged.

3. Conclusion: unilateral left hilar lymphadenopathy

Bilateral Hilar lymphadenopathy
 Tracheal Deviation

Collapsed Right Lung

What would you do with this patient?

Tension Pneumothorax: Requires chest tube

 Causes of a pneumothorax
 Spontaneous
 Iatrogenic/trauma,
 Obstructive lung disease, e.g. asthma
 Infection, e.g. pneumonia, tuberculosis, Cystic
fibrosis
 R
1. Radiography of chest frontal view

2. The position of patient is correct. The

image is with good and correct exposure.
The right side is increased in size due to
total hyperlucency, with absent of
pulmonary pattern in that region and
collapsed right lung. On left side the
pulmonary pattern is enhanced and the
pulmonary hilum is structured. The
costophrenic angles are free bilateral. The
diaphragm is well defined. The bones are
structured. Soft tissues are clear. The
heart is not enlarged.

3. Conclusion: right side pneumothorax.

R

Left side Limited Pneumothorax

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