PA Projection AP Projection

X-ray beam from behind, plate in front X-ray beam from the front, plate
of the patient behind the patient
Patient lying down (gastric bubble at
Patient usually in standing position
the sides) since AP is usually done at
(gastric bubble near hemidiaphragm)
bedside for non-ambulatory patients
Scapula winged out, ribs more Scapula not winged out and obscures
angulated view, ribs more horizontal
Clavicles in a BMX handle position Clavicles in a mountain bike handle
(angulated), arms at an angle with the position (horizontal), arms usually
body with hands at waist parallel to body
Mongolian hat sign appreciated
(formed by the C7 and T1 spine and Mongolian hat sign not appreciated
transverse process)
Heart not magnified (nearer the plate) Heart and other structures magnified
Marker in landscape orientation Marker in portrait orientation
• In the succeeding slides, take note of the following legends:
Ao: Aorta PA: Pulmonary artery and trunk
SVC: Superior Vena Cava IVC: Inferior Vena Cava
RA: Right atrium RV: Right ventricle
LA: Left atrium LV: Left ventricle
Cardiac Series (Frontal Projection)

Ao

PA PA
SVC LA

RV
LV
Inspiratory Effort
• 8-10 posterior ribs and 5-6 anterior ribs above the
right hemidiaphragm (through the R midclavicular
line) (PA)
Signs of Obliquity
• Discrepancy in the length of the clavicles
• Spinous processes equidistant form medial ends of
each clavicle
• Alignment of the cervical spine with the sternum
Penetration
• Thoracic spines must be visible through the heart
• Underpenetrated- thoracic spines (T1-T4) not visible
 Cardiac Series (Lateral Projection)

TheRemember
The Lateral
outline ofView
that
the
also
the gives
arch of
LA follows us the
the 2nda
chance
aorta tomakes
indentationassess the
the
over Arch of aorta
pericardiac
first anatomic
the esophagus spaces:
theindentation
retrosternumover
and Esophagus
thethe esophagus
retrocardiac
space. (not greatly Left Atrium
Right Ventricle
appreciated here )
Left Ventricle
Aortic Knob
• From the lateral border of the trachea, the aortic knob should
measure less than 35 mm.
• Main differential for widened aortic knob
• Aortic dissection/aneurysm
Lung Parenchyma
• Should be clear
• Always compare right side from left side
• Lower fields and inner zones with visible vascular markings
due to gravity (upper fields and outer zones devoid of vascular
markings; if present, consider congestion)
Lung Anatomy on Chest X-ray
• PA View:
• Extensive overlap
• Lower lobes extend high
• Lateral View:
• Extent of lower lobes
Lung Anatomy on Chest X-ray
• The right upper lobe
(RUL) occupies the upper
1/3 of the right lung on PA
projection.
• 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.
Trachea
• Represents the mediastinum
• Check for deviations due to traction (or pull, as in atelectasis or
consolidation) or pressure (or push, as in masses)
Hemidiaphragms and Costophrenic
Sulci
• Right diaphragm higher than left because of the liver (or, left
diaphragm is lower because of the heart) by 1.5 ICS
• Check for elevation (as in hepatomegaly) or flattening (as in
hyperaeration) of the hemidiaphragm, tenting deformities (in
inflammation), subpulmonic effusion (diaphragm concavity
appears thickened > 1 cm)
• Check for blunting of the costophrenic angles (if present,
consider pleural effusion, request for lateral decubitus)
Right Descending Pulmonary Artery
• If the patient is on an upright position
• < 17 mm
Pulmonary Artery
• By drawing a line connecting the cardiac apex to the aortic
knob, the pulmonary artery must lie 0-15 mm away from that
line.
• If < 0 mm (meaning the pulmonary artery goes beyond the tangent line)
• Increased pressure or flow to the pulmonary circuit
• If > 15 mm
• Enlargement of the LV or the aortic knob
• Hypoplasia of the pulmonary artery
Since the PA artery crossed the line
(i.e. < 0 mm, this patient has a prominent
PA.
Pulmonary Vasculature
• Normal Findings
• right descending pulmonary artery is less than 17mm
• lower lobe vessels are larger than the upper lobe vessels
• gradual tapering of the blood vessels from central to
peripheral
Cardiomegaly
• CTR > 0.5
• Causes of False Cardiomegaly
• Pregnancy
• Ascites
• Obesity
• Pectus Excavatum
• Straight-Back Syndrome
Left Atrial Enlargement
Radiologic Findings
• Enlargement first occurs posteriorly and then to the right and to
the left
• Signs of LA enlargement on CXR include:
• “Double density” over the area of the R atrium
• Widening of the carinal angle (> 90°, NV 65°-75°)
• Localized convexity or straightening just below the pulmonary segment
on the L cardiac border due to the projection of the L auricular
appendage beyond the left ventricle
Left Atrial Enlargement

Widened carinal angle

Elevated LMB
Elevated LMB

Double density
Left Atrial Enlargement

Convexity
Right Atrial Enlargement
• cardiomegaly
• RA > 1/3 of the R thoracic space
Left Ventricular Cardiomegaly
Radiographic Findings
• Inferior and downward displacement of cardiac apex.
• On chest lateral view, retrocardiac space is obliterated.
Left Ventricular Cardiomegaly
• Hoffman-Rigler's rule
• It is done by drawing a 2.0-cm vertical line upward along the
junction of the posterior aspect of the inferior vena cava and
the diaphragm.
• From this point, a second line is drawn parallel to the
vertebral bodies. If the distance between the left ventricular
border and the vertical line exceeds 1.8 cm, left ventricular
enlargement is suggested.
LV Cardiomegaly

Inferolateral displacement of the

cardiac apex
Red- border of the left ventricle

Blue Arrow- posterior border of the

IVC in contact with the diaphragm

Broken Yellow Lines- vertical line

from the posterior border of the IVC
in contact with the diaphragm
from this line, you draw another
line parallel to the vertebral bodies
The distance of the LV border from
the line must not exceed 1.8 cm
Right Ventricular Hypertrophy

• Often with associated enlargement of the

pulmonary artery – prominence and convexity of
the pulmonary artery segment in frontal
projection  straightening or convexity of the
left-upper cardiac contour below the aortic knob

• When the inflow tract (tricuspid valve to the apex

includes the lower half of the interventricular
septum inferiorly and the lower part of its outer
wall anteriorly) enlarges, the diaphragmatic
portion is increased in length, resulting in an
anterior rounding or buldge in the RV area. This
enlargement may displace the LV posteriorly and
elevate the cardiac apex.
Right Ventricular Hypertrophy
• Lateral projection:
anterolateral bulge in the
region of the outflow tract of
the RV reduces the size of
the retrosternal space
between the upper cardiac
border and the sternum
• Pulmonary artery also
contributes to the narrowing
Pericardial Effusion
Typical finding: Water bottle sign—
cardiac shadow enlarged without
following the contour of heart

Pericardial effusion vs. Cardiomegaly

• Enlargement does not follow contour
of heart
• No congestion of pulmonary
vasculature (not appreciated)
• Differential density sign (not
appreciated)- fluid appears more lucent
than the blood-filled chambers
Definitive diagnosis: 2D Echo!
Pneumopericardium
• Collection of air/gas in the pericardial cavity
Pneumopericardium

Radiographic findings:
• Thick, shaggy soft tissue density of fibrous pericardium separated by air
from the cardiac density
• Air limited to distribution of pericardial reflection (up to hilum only)
• Halo sign – air partially or completely surrounds the heart
Pulmonary Arterial Hypertension
• Widened PA
• Lower lobe vessels are greater than the upper lobe
vessels
• Rapid decrease in the size of the peripheral vessels
relative to the central vessels
Pulmonary Arterial Hypertension
• A posterior-anterior (PA)
chest radiograph
demonstrates enlargement of
the main pulmonary artery (
long black arrow) and right
pulmonary artery (
short black arrow). The
peripheral pulmonary
arteries are reduced in
caliber (white arrow).
Congestive Heart Failure

CXR Finding LA Pressure

Normal 5-10 mm Hg
Cephalization 10-15 mm Hg
Kerley B Lines 15-20 mm Hg
Pulmonary Interstitial Edema (±Pleural 20-25 mm Hg
Effusion)
Pulmonary Alveolar Edema > 25 mm Hg
Pulmonary Venous Hypertension
• Widened PA
• Upper lobe vessels are equal to or greater than the size
of the lower lobe vessels (if patient is on upright
position)
• Gradual tapering
• Kerley A Lines (yellow)
•  longer (at least 2cm and up to
6cm) unbranching lines
coursing diagonally from the
hila out to the periphery of the
lungs

• Kerley B Lines (red)

• short parallel lines at the lung
periphery in contact with the
pleura

• Kerley C Lines
• short, fine lines throughout the
lungs, with a reticular
appearance
• Kerley A (white
arrows)
• Kerley B (white
arrowheads)
• Kerley C (black
arrowheads)
Pulmonary Interstitial Edema
• Cephalization
• Kerley B Lines
• Hilar fullness with
haziness
Pulmonary Alveolar Edema
• Once alveolar phase starts
• Basal congestion becomes
more prominent
• There may be bilateral diffuse
alveolar findings with butterfly
distribution, self-coalescing
densities.
Aortic Aneurysm
• Common radiographic findings
• ~12% of thoracic aortic aneurysms are normal on chest Xray
• 80-90% are abnormal but often nonspecific
• Mediastinal widening
• Tortuous aorta due to longstanding hypertension (may be hard to distinguish from
an aneurysm)
• Obviously, focal increase in caliber of >50%
• 3cm is a generally accepted normal aortic diameter
• Calcium sign
• Rare sign where intimal calcium deposits are seen along the wall of the aorta,
dissection is indicated when this is more than 0.5cm from the outer most portion
of the aorta
• Tracheal displacement
• Disparity between ascending and descending aortic caliber
• Obliteration of aortic knob
Aortic Aneurysm
Atherosclerotic Aorta
• Accumulation of intimal, smooth muscle cells loaded
with lipid, chiefly cholesterol
• As a result of loss of elasticity, the vessel affected
becomes elongated and dilated.
Atherosclerotic Aorta

• Aortic knob more prominent as

there are calcific deposits with
diffuse opacities all over
• Convexity of the R upper cardiac
margin
• Course: curves to the left initially
then sharply curves medially
before reaching the diaphragm
Atherosclerotic Aorta

• In lateral view, arch of the aorta

swings in a wider arc so that it often
angles forward and upward and,
finally, backward
• Descending aorta may curve far
backward to overlie the thoracic spine
in the lateral view.
 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
• Airbronchogram, and
• No significant loss of lung
volume
 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 normal lungs
Bulla
• Thin-walled
• < 1 mm
• Bleb
• A bulla adjacent to/near the
pleura
• Pneumatocele
• A bulla developing in
association with acute
pneumonia
Cavity
• Thick-walled
• > 1 mm
Pneumonia
• Lobar Pneumonia
• Homogenous opacity
• Air bronchogram
• Bronchopneumonia
• Homogenous opacity
Lobar Pneumonia
Bronchopneumonia
Bronchiectasis
Pleural Effusion

If the height of the pleural fluid from the

chest wall is > 10 mm, a therapeutic
thoracentesis should be performed.
Lung Abscess

bulla

cavity with
air-fluid level
Pneumothorax
Pulmonary Tuberculosis
Pulmonary Nodule
• Nodule
• < 3 cm
• Mass
• ≥ 3 cm