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Chest x rays made easy

In the third of a five part series, Elizabeth Dick looks at abnormalities of the lung fields

The basics of looking at a chest x ray (recap):

First look at the mediastinal contours—run your eye down the left side of the patient and then up the right.

The trachea should be central. The aortic arch is the first structure on the left, followed by the left pulmonary artery; notice how you can trace the pulmonary artery branches fanning out through the lung (see figure 1).

Two thirds of the heart lies on the left side of the chest, with one third on the right. The heart should take up no more than half of the thoracic cavity. The left border of the heart is made up by the left atrium and left ventricle.

The right border is made up by the right atrium alone. Above the right heart border lies the edge of the superior vena cava.

The pulmonary arteries and main bronchi arise at the left and right hila. Enlarged lymph nodes can also occur here, as can primary tumours. These make the hilum seem bulky—note the normal size of the hila on this film.

Now look at the lungs. Apart from the pulmonary vessels (arteries and veins), they should be black (because they are full of air). Scan both lungs, starting at the apices and working down, comparing left with right at the same level, just as you would when listening to the chest with your stethoscope. The lungs extend behind the heart, so look here too. Force your eye to look at the periphery of the lungs—you should not see many lung markings here; if you do then there may be disease of the air spaces or interstitium. Don’t forget to look for a pneumothorax.

Make sure you can see the surface of the hemidiaphragms curving downwards, and that the costophrenic and cardiophrenic angles are not blunted—suggesting an effusion. Check there is no free air under the hemidiaphragm.

Finally, look at the soft tissues and bones. Are both breast shadows present? Is there a rib fracture? This would make you look even harder for a pneumothorax. Are the bones destroyed or sclerotic?

Pneumothorax

It is important to view around the periph- ery of the lungs to look for a pneumotho- rax (air in the pleural space with associated collapsed lung). It is very easy to miss a pneumothorax. Watch out for the following signs:

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Fig 1 Right pneumothorax. The right side of the lung is blacker, and the lung edge is seen (arrow). There is no mediastinal shift and therefore no tension

One half of the lung may seem blacker—that is, more radiolucent— than the other, which will be more radio-opaque or whiter. In particular, the area beyond the collapsed lung will be very radiolucent because there are no pulmonary vessel markings.

You should be able to identify the edge of the collapsed lung (see fig 1).

Having identified a pneumothorax you need to look for several more associated abnormalities:

Most importantly—this is a pass or fail observation—is there evidence of a tension pneumothorax? This occurs

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when air can enter the pleural space (via a hole in the lung surface or the chest wall) but, because of a ball-valve effect, air cannot leave by the same route. So more and more air accumulates in the pleural space. This pushes the mediastinum over to the opposite (normal) side and eventually compresses the normal lung so that less inspiration occurs on the normal side, with compression on the heart and decreased venous return until finally the patient arrests (see fig 2). Always look for this and say: “There is no shift of the mediastinum and therefore no tension pneumothorax” or “There is

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shift of the mediastinum away from the side of the pneumothorax indicating a (right/left) tension pneumothorax. This is a medical emergency which I would treat immediately by inserting a large bore cannula into the (right/left) pleural space.” The cause of the pneumothorax may be apparent—for example, fracture of the ribs. There may be associated surgical emphysema—that is, air in the soft tissues—and air in the mediastinum (see fig 3).

There is extra shadowing in the lungs

It may be difficult to work out what is caus- ing extra shadowing in the lungs, especial- ly near the mediastinum where normal structures may overlay the extra shadow- ing. It is useful to look at the periphery of the lungs because normally the outermost edge of the lungs should be fairly black with a few tapering blood vessels. If you do see more shadowing in the periphery then there may be either interstitial or air space disease. As examiners often show films with one of these two types of shadowing, understanding the difference between these two is worth while because it will help you to interpret what you see and lead you to the correct differential diagnosis. The lung is made up of bronchi, which branch, at the end of which are alveoli. The interstitial space (or potential space) sur- rounds the alveoli. The whole of the lung

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Fig 2 Left tension pneumothorax with shift of the mediastinum to the right. The lung edge is arrowed

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Fig 3 Surgical emphysema (arrow) and pneumomediastinum (arrowhead)

from bronchi to alveoli is the air space—

that is, it normally contains air. But the air spaces can fill up—with fluid (such as in severe pulmonary oedema), with pus (as in infection), with blood (as in rare diseases such as Goodpasture’s syndrome, associ- ated with renal failure), or with tumour cells (alveolar carcinoma). Fluid and pus are more common than the second two. When the air spaces fill up, the alveoli fill first, with the bronchi being relatively spared. Therefore the bronchi, which are still air filled, stand out against the alveoli, which are filled with pus or fluid. This is called an air bronchogram and is simply a sign that there is air space disease. Consolidation is another term for air space shadowing (see figs 4 and 5). If there is air space disease then you need to work out which part of the lungs it is affect- ing. A quick way is to use the word “zone” to describe which part of the lung is affect- ed. Say something like “There is shadow- ing in the air spaces of the right mid and lower zone.” You can then take your time to work out which lobe is affected. You can

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Fig 4 Left and right lower lobe air space shadowing in an ITU patient

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Fig 6 Recticular-nodular shadowing caused by lung fibrosis (circled). Note how the heart has lost its normal smooth outline and seems “shaggy”

Features of air space and interstitial lung disease

Air space disease

Interstitial lung disease

Zones

Any

Any

Appearances

Confluent shadowing

Linear/reticular/nodular

Air bronchograms

shadowing

Causes

Fluid (pulmonary oedema,

Fluid (pulmonary oedema/

(differential

adult respiratory distress

lymphangitis

diagnoses)

syndrome)

carcinomatosa)

Pus (infection/consolidation)

Inflammation leading to

Blood (Goodpasture’s syndrome)

fibrosis (industrial lung disease, inflammatory arthritides, inflammation of unknown cause, sarcoid)

Tumour cells (alveolar cell carcinoma)

find out more about lobar anatomy in the

later section on collapse and consolidation. Let’s turn to the interstitial space. This surrounds bronchi, vessels, and groups of alveoli. When there is disease in the interstitium it manifests itself by reticulo- nodular shadowing (criss cross lines or tiny nodules or both). The main two processes affecting the interstitium are accumulation of fluid (occurring in pul- monary oedema or in lymphangitis carci- nomatosa) and inflammation leading to fibrosis (occurring in industrial lung dis- ease, inflammatory arthritides such as rheumatoid arthritis, inflammation of unknown cause such as cryptogenic fibros- ing alveolitis and sarcoidosis). If you see criss cross lines or tiny nodules or both say:

“There is reticulo-nodular shadowing with- in the lower zones.” (See figure 6.) Use the table to work out whether the extra shadowing you can see is air space or interstitial. Next month: we will look at collapse, consolidation, and pleural effusions. I would like to thank Dr Anju Sahdev, Dr Brian Holloway, and Dr Robert Dick for contributing some of the films which are illustrated.

Elizabeth Dick, specialist registrar in radiology, North Thames Deanery

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Fig 5 Right middle and lower zone consolidation/air space shadowing. Note air bronchogram (arrow). There is no loss of volume, which is a key feature of consolidation

no loss of volume, which is a key feature of consolidation Erratum: see p407. See Web

Erratum: see p407.

See Web Extra at studentbmj.com for our web-based x ray quiz

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