Chest X Ray Interpretation: August 2015

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Chest X ray interpretation
Chapter · August 2015
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Subin Solomen
Governmental Medical College, Kottayam
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Basic CHEST X ray
interpretation
By
Subin solomen MPT(manipal)
Professor
Subin Solomen MPT Manipal

CHEST RADIOGRAPH
 Most common modality of imaging
 Simple and inexpensive
 If properly interpreted
- can provide valuable clues.
- can avoid further unnecessary investigations.

STANDARD VIEWS
 POSTEROANTERIOR VIEW ( PA)
 ANTEROPOSTERIOR VIEW ( AP )
 LATERAL VIEW

Patient Identification
 Name, Age, Sex
 Date of examination
 Clinical information
 SIDE MARKER

TECHNICAL ASPECTS
 PA / AP view
 CENTERING
 PENETRATION
 DEGREE OF INSPIRATION

POSTEROANTERIOR (PA) VIEW
 The standard frontal view of the chest

 Refers to direction of x-ray beam
 Positioning of the patient
 Taken at a distance of SIX FEET
 In deep inspiration at suspension
 Breasts to be compressed against film

PA VIEW
PA VIEW
ANTEROPOSTERIOR (AP) VIEW
 Patient in supine position

 Used in very sick patients,infants,one who
is unable to sit or stand
 Direction of x-ray beam
 At a distance of 100 cm {4 feet}
 Greater magnification
 Less sharpness of images

AP VIEW
AP VIEW
PA vs AP VIEW
PA AP
1. Scapulae not 1. Scapulae overlapping
overlapping lung fields lung fields
2. Clavicle is oblique 2. Clavicle is horizontal
3. Heart border clear 3. Heart border not clear
4. Cardiac magnification 4. Cardiac magnification
not seen
5. Fundic air bubble seen 5. Fundic air bubble not
seen
1) Scapular border
PA VS AP

3) Heart border
PA VS AP

4) Heart size
PA VS AP

5) Fundic shadow
PA VS AP

6) Companion shadow
PA VS AP

7) Counting of ribs
Rt PA 6th VS AP 5th

8) Inverted V shadows
In PA View

PA vs AP VIEW
PA AP
9)Tear drop not present 9) Tear drop sign

10) Overriding of clavicle  Absent or prominent
and first rib
11)Vertbral bodies
square shaped

CENTERING

CENTERING

PENETRATION

NORMAL UNDER PENETRATED
NORMAL OVERPENETRATED

EXPIRATORY INSPIRATORY
VIEWING PA VIEW
 Soft tissues
 Bony cage
 Lung fields
 Heart and mediastinum
 Hilum
 Trachea
 Diaphragm
 Costophrenic angles
 Cardiophrenic angles
 Infradiaphragmatic areas
THE LUNG FIELDS
 DIVIDED into 3 Zones: UPPER
MID
LOWER
 COMPARE both the lung fields
 DISTRIBUTION of lung markings

TYPES OF DENSITIES
 GAS – BLACK
 WATER (soft tissue & fat)- GREY
 MINERAL(CALCIFIC)- WHITE

PA VIEW
HEART AND MEDIASTINUM
 RIGHT MEDIASTINAL BORDER

 LEFT MEDIASTINAL BORDER
 AORTIC KNUCKLE
 SIZE OF HEART: CARDIOTHORACIC
RATIO

CR
CL
CT RATIO = CR + CL / T
CR + CL = TRANSVERSE CARDIAC DIAMETER

T = TRANSVERSE THORACIC DIAMETER
HILUM
 Components of Hilar shadows

 Left hilum higher than the right in 97% of
subjects
 At the same level in 3% of subjects
 Should be of equal density and similar size
on either sides

RIGHT LEFT HILUM
HILUM

TRACHEA
DIAPHRAGM
 LOCATION
 RELATIVE LEVELS of the right and left

hemidiaphragms
 SHAPE

Diaphragm tenting
Collapse
Hepatomegaly
Sub dia abscess
Diaphragm flattened
COPD
A
Diaphragm tenting
DIAPHRAGM
COSTOPHRENIC ANGLES
 Look for VISIBILITY and SHARPNESS

 BLUNT angles Subin Solomen MPT Manipal
Cardio phrenic angles
LV
hypertrophy
PA view – there is an increase in the diameter of the heart, and

elongation and increased convexity of the left heart border. The apex
extends downwards and out into the diaphragm.
Cardio phrenic angles
RV
Hypertrophy
PA view – enlargement of the RV produces elevation of the apex; if

there is gross dilatation there is forward bulging of the RV outflow
tract with increased convexity.
THE HIDDEN AREAS
 THE APICES
 RETROCARDIAC AREA
 RETRODIAPHRAGMATIC AREAS
 PARTS OBSCURED BY BONES

VIEWING THE LATERAL FILM
 THE CLEAR SPACES

 VERTEBRAL TRANSLUCENCY
 DIAPHRAGM OUTLINE
 THE FISSURES
 THE TRACHEA
 THE STERNUM

PULMONARY VASCULAR PATTERNS
 GOOD ERECT PA CHEST FILM.
 SIZE AND DISTRIBUTION of vessels is of

major importance.

BRONCHOVASCULAR
MARKINGS

NORMAL VASCULAR PATTERNS

PULMONARY ARTERIAL HTN
HALLMARK:
 Enlargement of main and central pulmonary

arteries.
 Pruning of peripheral pulmonary arteries
 Normal sized heart/right heart enlargement.

SUPPORT DEVICES
 Endotracheal tube / Tracheostomy tube
 Nasogastric tube
 Central venous catheter
 Pulmonary artery catheter
 Cardiac pacemaker
 Pleural drainage tubes
ENDOTRACHEAL TUBE

MISPLACED ETT
RYLE’S TUBE

RYLES TUBE

Naso-gastric Tube in Right Main Bronchus.
CVP

SWAN GANZ CATHETER
PACEMAKER
PACEMAKER TIP IN APEX OF RV.

ICD TUBE

Collapse ( Atelectasis)
 Lobar signs
 Shift of fissures
 Crowding of vessels and airways
 Increased opacity -Silhouette sign
 Extralobar signs
 Elevation of hemidiaphragm
 Mediastinal shift
 Hilar shift and distortion
 Compensatory hyperinflation
 Ribs are close together
 Tracheal shift
Silhouttes sign
RML Lingula
Rt border Lt heart
Asc aorta

Apico posterior LUL
Aortic knuckle

Anterior segment
RUL

Atelectasis Following ET
Intubation

Atelectasis – LLL- PA

Atelectasis – LLL- Lat.

Atelectasis – RML- PA

Aspiration Pneumonitis
 Radiographic appearance
appears within few hrs of
aspiration , progresses for 24-48
hrs and regresses by 72 hrs
.Complete clearing is within a
week or two.
 May be patchy or diffuse , usually

bilateral, mainly right sided, most
often lung bases or superior
segment of lower lobe.

Pulmonary edema-
perihilar.

Kerley B lines

Pulmonary embolism
WESTERMARK’S SIGN
ARDS

PNEUMOTHORAX
Chest Radiograph:
 Supine signs
 Hyperlucency Of
Hemithorax
 Deep sulcus sign


DEEP SULCUS SIGN

PNEUMOTHORAX

Tension Pneumo thorax
Lt Rt

HYDROPNEUMOTHORAX

Lung abscess

COPD
HypeSubin
inflated
Solomen MPT Manipal
Giant Bullae

Large Bullae

PNEUMOMEDIASTINUM
Causes
 Bronchial perforation
 Esophageal perforation
 Pharyngeal perforation
MACKLIN EFFECT.
 Chest radiograph : lucent
streaks outlining
mediastinal structures,
elevate the pleura and
extends in to the neck or
chest wall.
 Continuous diaphragm
sign
Subcutaneous emphysema
PLEURAL EFFUSION
Erect radiograph
• Blunting of
costophrenic
angles
• Homogenous
increase in
density over the
lower lung fields

PLEURAL EFFUSION

 Detection of small pneumothorax is important
as it may increase in size as patient receives
positive pressure ventilation.
 TENSION PNEUMOTHORAX:
CHEST RADIOGRAPH:
 Absent lung markings
 Mediastinal displacement
 Eversion of diaphragm

PSEUDOANEURYSM
PNEUMOPERICARDIUM
Upper Airway Obstruction
Foreing Body Aspiration

MV Replacement

Dextrocardia- situs inverses

Bronchogenic carcinoma

THANK YOU
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Chest X Ray Interpretation: August 2015

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See discussions, stats, and author profiles for this publication at: https://www.researchgate.

Chest X ray interpretation

Chapter · August 2015

Exercise physiology, Health promotion & Fitness testing View project

electrophysiology View project

The user has requested enhancement of the downloaded file.

Subin Solomen MPT Manipal

Subin Solomen MPT Manipal

Subin Solomen MPT Manipal

Subin Solomen MPT Manipal

Subin Solomen MPT Manipal

 The standard frontal view of the chest

Subin Solomen MPT Manipal

 Patient in supine position

Subin Solomen MPT Manipal

Subin Solomen MPT Manipal

Subin Solomen MPT Manipal

Subin Solomen MPT Manipal

Subin Solomen MPT Manipal

Subin Solomen MPT Manipal

Subin Solomen MPT Manipal

Subin Solomen MPT Manipal

9)Tear drop not present 9) Tear drop sign

Subin Solomen MPT Manipal

Subin Solomen MPT Manipal

Subin Solomen MPT Manipal

Subin Solomen MPT Manipal

Subin Solomen MPT Manipal

 COMPARE both the lung fields

 DISTRIBUTION of lung markings

Subin Solomen MPT Manipal

 RIGHT MEDIASTINAL BORDER

Subin Solomen MPT Manipal

CR + CL = TRANSVERSE CARDIAC DIAMETER

 Components of Hilar shadows

Subin Solomen MPT Manipal

Subin Solomen MPT Manipal

 RELATIVE LEVELS of the right and left

Subin Solomen MPT Manipal

Subin Solomen MPT Manipal

 Look for VISIBILITY and SHARPNESS

PA view – there is an increase in the diameter of the heart, and

PA view – enlargement of the RV produces elevation of the apex; if

 PARTS OBSCURED BY BONES

Subin Solomen MPT Manipal

 THE CLEAR SPACES

Subin Solomen MPT Manipal

 GOOD ERECT PA CHEST FILM.

 SIZE AND DISTRIBUTION of vessels is of

Subin Solomen MPT Manipal

Subin Solomen MPT Manipal

Subin Solomen MPT Manipal

 Enlargement of main and central pulmonary

 Pruning of peripheral pulmonary arteries

 Normal sized heart/right heart enlargement.

Subin Solomen MPT Manipal

Subin Solomen MPT Manipal

Subin Solomen MPT Manipal

Subin Solomen MPT Manipal

Subin Solomen MPT Manipal

PACEMAKER TIP IN APEX OF RV.

Subin Solomen MPT Manipal

Subin Solomen MPT Manipal