© 2005 Adam Guttentag, MD

Basic Chest X-Ray

Interpretation

Adam Guttentag, M.D.

All photos retain the copyrights of their original authors

How do you look at a
chest x-ray?

or

Avoid tunnel vision!

Have a system
Chest wall, bones and abdomen
Mediastinum, heart and hila
Lungs
 The Lateral Chest Film
Our best friend!

• Find abnormalities
hidden on the frontal
film
• Confirm
abnormalities
suspected from
frontal film
• Don’t be afraid to
look at it!
Looking at the lateral CXR
Hilar structures on the lateral film
“Ring around the bronchus”
 Technical Factors
(How we’ll try to fool you)

• Positioning
 straight vs
oblique
Effect of obliquity on heart size
 Technical Factors

• Positioning
 straight
vs oblique
 PA vs AP
 Technical Factors
erect supine

• Positioning
 straight vs
oblique
 PA vs AP
 erect vs
supine
 Technical Factors

• Positioning
 straight vs
oblique
 PA vs AP lordotic
 erect vs supine
 lordotic vs
kyphotic

kyphotic
 Technical Factors

• Positioning
 straight vs
oblique
 PA vs AP
 erect vs
supine
 lordotic vs
kyphotic

Effect on mediastinal contour

 Technical Factors

• Depth of inspiration
• Visualization of
pathology depends on
contrast provided by air
in the lungs
10
• Count ribs!
 Short of breath

8
8

One minute later

 Technical Factors

Body habitus

Radiographic technique:
Is it really different?
Changing technique can make
disease look better or worse.
Same patient, 4 films within one month

Is the heart large? Is the

mediastinum wide?
 Recognizing air space disease

• Alveolar spaces filled with…something.

• Radiologist's report:
 “consolidation”
 “air space opacity”
 “fluffy density”
 “infiltrate”
• Nonspecific:
 Atelectasis, pneumonia, bleeding, edema, tumor
 The Silhouette Sign

• Indicates air space disease.

• Obscuration of a normally seen
border, e.g. diaphragm or heart.
• Opacity with sharp edge along a
fissure.
Localizing disease from the
silhouette sign

RML
Lingula
LLL
RLL
LLL
Localizing disease from the
silhouette sign

UL

RUL
LL
RML

RML or
lingula
What happened here?

16 hours later
 Lobar Atelectasis

• Best sign – shift of a fissure

• Rapid development and clearance
• Air bronchograms if non-obstructive
• Secondary signs:
 Mediastinal shift
 Elevated diaphragm
 Ribs closer together
 Vague increased density
LLL Atx

Next day
RUL Atx
RML Atx
LUL Atx
 Pneumonia
• Signs:
 Air bronchogram
 Silhouette - “positive” or “negative”
 Dense hilum
 “Spine” sign
• All are signs of any air space process
• Dx of pneumonia depends on appropriate
clinical scenario.
 Air bronchogram sign

Pseudomonas Lung cancer

pneumonia
Air bronchograms — CT

Pneumonia Lung cancer

Right middle lobe
Right upper lobe
Right lower lobe

Posterior diaphragm silhouetted

Dense hilum, spine sign
Dense hilum, spine sign again
Four days later
Final Exam
21 y.o. with fever and cough
 Hyperlucent
hemithorax: why?
Did you notice the mass?
Lymphoma
Take home message #1

It’s a chest x-ray,

not a lung x-ray.
6 cm lung mass missed. How?

2 years ago
Take home message #2

Old films are your friend!

Elderly man with hypotension
Suddenly septic
Pneumatosis of small bowel
Take home message #3

The patient pays for

the whole film!
Review Questions
 All are kinds of air space
disease except:
• Hemorrhage
• Pneumonia
• Tumor
• Sarcoidosis
• Atelectasis
 The most specific sign of
atelectasis is:
• Obscuration of a diaphragm
• Shift of a fissure
• Air bronchograms
• Density over the spine
• Mediastinal shift
This can make the heart look
larger than it is:
• Lordotic positioning
• AP positioning
• Expiratory film
• Supine positioning
• All of the above
Additional Reading
• Chest Roentgenology Felson, B W.B. Saunders
Co, Philadelphia 1973 Chapter 2: Localization of
Intrathoracic Disease. pp 22-70.
• Pare JAP and Fraser RG Synopsis of Diseases of
the Chest W.B. Saunders Co, Philadelphia 1983.
Chapter 4: Roentgenologic Signs in the diagnosis
of Chest Disease. pp164-187.
The End

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