Chest

Radiography
Interpretation

M Chadi Alraies, MD
Chief Medical Resident
Case Western Reserve University
SVCH

M C Alraies 1
 Reading CXR’s
 Have a structured method!
 Be consistent with that method
 Don’t take short cuts
 LOOK AT ALL YOUR PATIENTS XRAYS
YOURSELF (and with your resident of
course!)
 PRACTICE…PRACTICE… PRACTICE
What is a Chest Radiograph?

SHADOW
 Start at the beginning

Identification
! Correct patient
 Correct date and time
 Correct examination

 Areold films available?

 DO THIS EVERYTIME – It buys you time and is
 Approach to the CXR: Technical Aspects

 Projection – PA or AP
 Position – Upright or Supine (Supine folks are
sick)
 Inspiratory effort
 9-10 posterior ribs
 Penetration
 thoracic intervertebral disc space just visible
 Positioning/rotation
 medial clavicle heads equidistant to spinous process
Projection
Portable (AP or Antero-
posterior)
FILM
PA (Postero-anterior)
FILM
 Projection

PA AP
Low Lung Volumes
Over Exposure Proper Exposure
9
Mental Break
 Anatomy

RUL

RML
RUL (Right Upper Lung)
RML (Right Middle Lung)
RLL (Right Lower Lung)
Right Sided Fissures
LUL (Left Upper Lung)
LLL (Left Lower Lung)
Left Side Fissure

LUL

LLL
 What to Evaluate

 Lungs
 Pleuralsurfaces
 Cardiomediastinal contours
 Bones and soft tissues
 Abdomen
 Where to Look

 Apices
 Retrocardiacareas (left and right)
 Below diaphragm
Apical TB
Left Retrocardiac Opacity
Normal Anatomy: Frontal CXR

 Heart
 Aorta
 Pulmonary arteries
 Airways
 Diaphragm/costophrenic sulci
 Normal Anatomy: Lateral

 Heart
 Aorta
 Pulmonary arteries
 Airways
 Spine
 Maximum x-ray Blackest
Transmission
air
(least dense tissue)
fat
soft tissue
calcium
bone
x-ray contrast
Maximum x–ray metal
Absorption
(densest tissue) Whitest
 Chest Radiography: Basic Principles

A structure is rendered visible on a

radiograph by the juxtaposition of two
different densities
 Silhouette Sign

 Loss of the expected interface normally

created by juxtaposition of two structures
of different density
 No boundary can be seen between two
structures of similar density
Right Lower Lobe Pneumonia
 Differential X-Ray Absorption

 The absence of a normal interface may

indicate disease;
 The presence of an unexpected
interface may also indicate disease
 The presence of interfaces can be used
to localize abnormalities
 Chest Radiographic
Patterns of Disease
 Air space opacity
 Interstitial opacity
 Nodules and masses
 Lymphadenopathy
 Cysts and cavities
 Lung volumes
 Pleural diseases
LUL Pneumonia
 Air Space Opacity

 Components:
 airbronchogram: air-filled bronchus
surrounded by airless lung
 confluent opacity extending to pleural
surfaces
 segmental distribution
 Air Space Opacity: DDX

 Blood (hemorrhage)
 Pus (pneumonia)
 Water (edema)
 hydrostatic or non-cardiogenic
 Cells (tumor)
 Protein/fat: alveolar proteinosis and
lipoid pneumonia
Interstitial Opacity: Small Nodules
Interstitial Opacity:
Lines
Interstitial Opacity: Lines & Reticulation
 Interstitial Opacity

 Hallmarks:
 small, well-defined nodules
 lines
 interlobular septal thickening
 fibrosis

 reticulation
 Interstitial Opacity: DDX
 Idiopathic interstitial pneumonias
 Infections (TB, viruses)
 Edema
 Hemorrhage
 Non–infectious inflammatory lesions
 sarcoidosis

 Tumor
Well-Defined

Calcification

Ill-Defined Mass
 Nodules and Masses

 Nodule: any pulmonary lesion represented in

a radiograph by a sharply defined, discrete,
nearly circular opacity 2-30 mm in diameter
 Mass: larger than 3 cm
 Nodules and Masses

 Qualifiers:
 single or multiple
 size
 border definition
 presence or absence of calcification
 location
Right Paratracheal
Lymphadenopathy
Right Hilar LAN
Right Hilar LAN
Left Hilar LAN
Subcarinal LAN

*
AP Window LAN
 Lymphadenopathy

 Non-specific presentations:
 mediastinal widening
 hilar prominence

 Specific patterns:
 particular station enlargement
 Cysts & Cavities

 Cyst: abnormal pulmonary parenchymal

space, not containing lung but filled with air
and/or fluid, congenital or acquired, with a
wall thickness greater than 1 mm
 epithelial lining often present
 Cysts & Cavities
 Cavity:abnormal pulmonary parenchymal
space, not containing lung but filled with air
and/or fluid, caused by tissue necrosis, with
a definitive wall greater than 1 mm in
thickness and comprised of inflammatory
and/or neoplastic elements
Benign Lung Cyst : PCP Pneumatocele
• Uniform wall thickness
• 1 mm
• Smooth inner lining
 Benign Cavities :
Cryptococcus

• max wall thickness ≤ 4 mm

• minimally irregular inner lining
 Indeterminate Cavities

• max wall thickness 5-15 mm

• mildly irregular inner lining
Malignant Cavities: Squamous Cell Ca
• max wall thickness ≥ 16 mm
• Irregular inner lining
 Cysts & Cavities

 Characterize:
 wallthickness at thickest portion
 inner lining
 presence/absence of air/fluid level
 number and location
Pleural Effusion
Pleural Effusion
Pleural Calcification
Pleural Disease: Basic Patterns
 Effusion
 angle blunting to massive
 mobility
 Thickening
 distortion, no mobility
 Mass
 Air
 Calcification
Thoracic Aorta Aneurysm
Chest breast implants
◆ Rib fx’s
◆ Mediast. OK
◆Pulmonary
contusion
◆ Subcu air
◆ Chest tube
◆ NG tube
MVC victim
Tip of ET tube Carina

Deep Right Mainstem Intubation

 Tip of ET

Pneumomediastinum
 Potential X ray
findings

 wide
mediastinum
 obliteration of
aortic knob
 Rt mainstem
shift up and
right
 NG deviate
to right
 pleural cap
Major Vessel Injury
Pneumothoraces
 Expiration reduces lung volume,
making a small pneumo easier to see
Irregular linear opacities are present in both lungs, especially in the periphery
and the bases of the lungs. The heart is slightly enlarged, but this is not related
to the pulmonary abnormalities in this case.
Hodgkin’s Disease
 Ao

SVC

Mediastinal Hematoma
 ET tube
Obliterated aortic knob First rib fx

Tracheal deviation to Rt.

Chest tube

NG shift to Rt.
 Lt. Internal Carotid
Rt. Subclavian Art. Artery

ET
Lt. Subclavian
Artery
NG
Aortic
Rupture
Tension Pneumothorax on CT

Tension Pneumo
Mediastinum
Rt. Lt.

Ao
Hemothoraces
 Hemothorax

Supine Upright
Hemopneumothorax
Indistinct diaphragm
Elevated, irregular
hemidiaphragm
 Clavicle fx
Suspicious

Rib fxs
Close-up
Indistinct, elevated diaphragm

Chest tube
Crushed right chest
After ventilated with PEEP