Basic Chest XBasic Chest X--ray ray Interpretation for the FY1 Interpretation for the FY1

DoctorDoctorDr. Herbert M. Imalingat Dr. Herbert M. Imalingat

ST2 RadiologyST2 Radiology

PosteriorPosterior--Anterior (PA) FilmAnterior (PA) Film

Densities on XDensities on X--raysraysIn increasing order of densityIn increasing order of density

•• AIR AIR –– black e.g. Lungs, bowel, stomachblack e.g. Lungs, bowel, stomach

•• FAT FAT –– dark grey e.g. subcutaneous or dark grey e.g. subcutaneous or retroperitonealretroperitoneal

•• SOFT TISSUES including body fluids SOFT TISSUES including body fluids ––light grey e.g. solid organs, muscle, light grey e.g. solid organs, muscle, vesselsvessels

•• BONE BONE –– offoff--whitewhite

•• METAL/CONTRAST MATERIAL METAL/CONTRAST MATERIAL –– bright bright whitewhite

SimplySimply……

•• Remember that an abnormality can only Remember that an abnormality can only be one of 3 things:be one of 3 things:–– An OPACITY (Something which An OPACITY (Something which

stops/absorbs/attenuates Xstops/absorbs/attenuates X--rays rays –– appears appears White)White)

–– A RADIOLUCENCY (Something which allows A RADIOLUCENCY (Something which allows XX--rays to pass with little absorption)rays to pass with little absorption)

–– A DISTORTION/DISPLACEMENT of a normal A DISTORTION/DISPLACEMENT of a normal structure.structure.

Projections used in CXRsProjections used in CXRs

Erect P.A.Erect P.A. Routine for fit and able bodied personsRoutine for fit and able bodied persons

LateralLateral To localise opacityTo localise opacity

Erect A.P Erect A.P Mobile and the infirmMobile and the infirm

Supine A.P Supine A.P Very ill patients and those with multiple injuriesVery ill patients and those with multiple injuries

ExpiratoryExpiratory Shallow pneumothorax may become more obviousShallow pneumothorax may become more obviousChildren with suspected foreign body inhalation Children with suspected foreign body inhalation causing bronchial obstruction.causing bronchial obstruction.

Decubitus (pt lying on Decubitus (pt lying on their side)their side)

To visualise small effusions, & determine solid / fluid.To visualise small effusions, & determine solid / fluid.

PA Vs AP Essential differencesPA Vs AP Essential differences

StructureStructure PA RadiographPA Radiograph AP RadiographAP Radiograph

HeartHeart Little magnificationLittle magnification Magnified imageMagnified image

ScapulaScapula Rotated away from lungsRotated away from lungsfieldsfields

Superimposed on lungSuperimposed on lungfields.fields.

ClavicleClavicle 2 inches below apex2 inches below apex Above ApexAbove Apex

Implications of an AP Supine Implications of an AP Supine FilmFilm

•• Exaggerated heart sizeExaggerated heart size•• Gravity related :Gravity related :

–– Pleural fluid layers posteriorly, giving increased Pleural fluid layers posteriorly, giving increased density to the hemithorax.density to the hemithorax.

–– A Pneumothorax will lie anteriorly & will be A Pneumothorax will lie anteriorly & will be difficult to detectdifficult to detect

–– The diaphragm will be higher & reduce the lung The diaphragm will be higher & reduce the lung volumesvolumes

–– Prominence of the upper zone vessels is normal Prominence of the upper zone vessels is normal and does not reflect left heart failure as is often and does not reflect left heart failure as is often the case in an Erect PA film.the case in an Erect PA film.

SystemSystem

•• IntroductionIntroduction

•• A A –– AdequacyAdequacy

•• B B –– BreathingBreathing

•• C C –– CirculationCirculation

•• D D –– DiaphragmDiaphragm

•• E E –– Everything elseEverything else

•• Review areas Review areas –– A B C D S A B C D S

•• IntroductionIntroduction–– Name, DOB/ageName, DOB/age–– Male or female? Look for the presence of breast Male or female? Look for the presence of breast

shadows (this will help you to notice a shadows (this will help you to notice a mastectomy too).mastectomy too).

–– Type of film (chest PA/AP)Type of film (chest PA/AP)–– (Can mention now if a strikingly obvious (Can mention now if a strikingly obvious

abnormality)abnormality)

•• A A –– adequacyadequacy–– Can you see everything? (top of first rib to below Can you see everything? (top of first rib to below

diaphragm)diaphragm)–– Penetration (lower thoracic spine just visible)Penetration (lower thoracic spine just visible)–– Inspiration (diaphragms at 5Inspiration (diaphragms at 5thth or 6or 6thth anterior rib)anterior rib)–– Rotation (spinous processes of upper vertebrae Rotation (spinous processes of upper vertebrae

midway between end of clavicles)midway between end of clavicles)

Presentation part 1Presentation part 1

•• ““This is a PA chest radiograph of a 33 year This is a PA chest radiograph of a 33 year old male patient. Mr. John Smith, date of old male patient. Mr. John Smith, date of birth 11/02/1975 The patient has taken a birth 11/02/1975 The patient has taken a good/adequate inspiration and is not good/adequate inspiration and is not rotated; the film is well penetrated."rotated; the film is well penetrated."

•• B B –– breathingbreathing–– ApicesApices

–– TracheaTrachea

–– Move down lung fieldsMove down lung fields

–– PleuraPleura

•• C C ––circulationcirculation–– Cardiac shadow Cardiac shadow ––size, shape, well defined?size, shape, well defined?

–– MediastinumMediastinum

–– Hilar Hilar ––position, size, densityposition, size, density

•• D D –– diaphragmdiaphragm–– Costophrenic angles clear?Costophrenic angles clear?

–– ShapeShape-- flat? well defined?flat? well defined?

–– Look under diaphragmLook under diaphragm

•• E E –– everything elseeverything else–– Bones Bones –– ribs, shouldersribs, shoulders

–– Soft tissues Soft tissues -- breasts, surgical emphysemabreasts, surgical emphysema

–– Any surgical material, ECG leads, etc.Any surgical material, ECG leads, etc.

Review areasReview areas

““ I have not seen any obvious abnormalities I have not seen any obvious abnormalities yet, so I will now look at my review yet, so I will now look at my review areasareas…”…”

•• A A -- ApicesApices

•• B B -- BonesBones

•• C C -- Cardiac i.e. behind the heart, hilar Cardiac i.e. behind the heart, hilar

•• D D -- DiaphragmDiaphragm

•• S S –– Soft tissuesSoft tissues

Presentation part 2Presentation part 2

•• "The trachea is central, the mediastinum is "The trachea is central, the mediastinum is not displaced. The cardiac and mediastinal not displaced. The cardiac and mediastinal contours appear normal. The lungs appear contours appear normal. The lungs appear clear, with no evidence of a clear, with no evidence of a pneumothorax. There is no free air under pneumothorax. There is no free air under the diaphragm. The bones and soft tissues the diaphragm. The bones and soft tissues appear normal."appear normal."

OpacitiesOpacities

•• LargeLarge

-- ConsolidationConsolidation

-- CollapseCollapse

-- Pleural fluidPleural fluid

ConsolidationConsolidation•• Also known as Also known as ‘‘airair--space (acinar) diseasespace (acinar) disease’’

or or ‘‘alveolar opacityalveolar opacity’’..

•• Is seen when a substance, usually fluid, Is seen when a substance, usually fluid, fills the alveolar spaces but not the fills the alveolar spaces but not the airways (bronchial tree)airways (bronchial tree)

•• Fluid can be Fluid can be Transudate Transudate pulmonary pulmonary oedema, oedema, Pus Pus of infection/pneumonia or of infection/pneumonia or Blood Blood from trauma, tumour, infarction& from trauma, tumour, infarction& haemorrhage, vasculitishaemorrhage, vasculitis

Collapse/AtelectasisCollapse/Atelectasis

•• Collapse is demonstrated by an opacity and Collapse is demonstrated by an opacity and loss of volume.loss of volume.

•• Causes: Obstruction of an airway, Relaxation Causes: Obstruction of an airway, Relaxation of the lung parenchyma e.g. with a of the lung parenchyma e.g. with a pneumothorax or pleural effusion, Fibrosispneumothorax or pleural effusion, Fibrosis

•• Signs: Signs: -- small hemithoraxsmall hemithorax-- deviation of the mediastinumdeviation of the mediastinum-- raised hemiraised hemi--diaphragmdiaphragm-- shift of a fissureshift of a fissure-- hilar shifthilar shift

Pleural FluidPleural Fluid•• Detectable once there is more than 100mls Detectable once there is more than 100mls

present.present.

•• Seen in the lateral or posterior costophrenic Seen in the lateral or posterior costophrenic angles as a meniscus curving up the chest wall.angles as a meniscus curving up the chest wall.

•• Bilateral Effusions Bilateral Effusions -- Often the result of Often the result of Cardiogenic or NonCardiogenic or Non--cardiogenic pulmonary cardiogenic pulmonary oedema.oedema.

•• Unilateral Effusion Unilateral Effusion –– due to infection, infarction, due to infection, infarction, tumour, trauma, surgery, immunological diseasetumour, trauma, surgery, immunological disease

The Silhouette SignThe Silhouette Sign

•• Indicates air space diseaseIndicates air space disease

•• Obscuration of a normally seen border e.g. Obscuration of a normally seen border e.g. heart or diaphragmheart or diaphragm

Localising disease from the Silhouette Localising disease from the Silhouette SignSign

Other OpacitiesOther Opacities

•• Nodules(from 1mm) and masses Nodules(from 1mm) and masses (>3cms)(>3cms)

•• Linear opacities can be:Linear opacities can be:-- straightstraight-- curvilinear curvilinear -- circularcircular-- acute or chronicacute or chronic-- localised or diffuselocalised or diffuse

RadiolucenciesRadiolucencies

•• Emphysema is the most common cause Emphysema is the most common cause of radiolucent lungsof radiolucent lungs

•• A pulmonary embolus(PE) can cause A pulmonary embolus(PE) can cause lung oligaemia (decreased blood lung oligaemia (decreased blood volume)volume)

•• Air in the pleural cavity (Pneumothorax)Air in the pleural cavity (Pneumothorax)

•• Absent breast tissue(mastectomy) gives Absent breast tissue(mastectomy) gives a more diffuse radiolucencya more diffuse radiolucency

Distortion/displacement of a normal structureDistortion/displacement of a normal structure

If the structure is the wrong shape or in If the structure is the wrong shape or in the wrong place there MUST be a reasonthe wrong place there MUST be a reason

•• Is the structure being pulled or pushed Is the structure being pulled or pushed from its usual position?from its usual position?

•• Pushed: by a pneumothorax, pleural Pushed: by a pneumothorax, pleural effusion, neoplasm, pectus excavatum effusion, neoplasm, pectus excavatum moving the heart to the leftmoving the heart to the left

•• Pulled: by lung collapse or fibrosisPulled: by lung collapse or fibrosis

Case 1 Case 1 –– 65 Male, Pleuritic Chest Pain 65 Male, Pleuritic Chest Pain

Pulmonary EmbolismPulmonary Embolism

•• CXR:CXR:-- Often normalOften normal-- Linear atelectasis/bluntingLinear atelectasis/blunting

of costophrenic anglesof costophrenic angles-- Raised hemidiaphragmRaised hemidiaphragm-- Pulmonary oligaemia Pulmonary oligaemia

(Westermark(Westermark’’s sign)s sign)-- Wedge shaped infarctWedge shaped infarct

CaseCase-- 24 Male Sudden Chest Pain & 24 Male Sudden Chest Pain & SOBSOB

Tension PneumothoraxTension Pneumothorax

•• Increased radiolucencyIncreased radiolucency

•• Lung compressed against mediastinum, Lung compressed against mediastinum, so lung vasculature not visibleso lung vasculature not visible

•• Tracheal and Mediastinal Shift to the Tracheal and Mediastinal Shift to the opposite side opposite side

Case 3Case 3-- 72 Female Increasing SOB72 Female Increasing SOB

Heart FailureHeart Failure

•• Upper lobe venous congestion due to blood Upper lobe venous congestion due to blood diversiondiversion

•• Interstitial pulmonary oedema with blurring of Interstitial pulmonary oedema with blurring of the hilar outlinesthe hilar outlines

•• Kerley B (septal) lines at the lung bases due Kerley B (septal) lines at the lung bases due to lymphatic engorgement of the interlobular to lymphatic engorgement of the interlobular septa.septa.

•• Alveolar pulmonary oedema resulting in Alveolar pulmonary oedema resulting in Consolidation, air bronchograms and the Consolidation, air bronchograms and the production of pink frothy sputum.production of pink frothy sputum.

Case 4 Case 4 –– 59 Female, smoker 59 Female, smoker

Case 5 Case 5 ––65 Female known Lung Ca, 65 Female known Lung Ca, Sudden Increase in SOBSudden Increase in SOB

Case 6 Case 6 –– 79 male, vomiting ++, 79 male, vomiting ++, SOBSOB

Case 7Case 7-- 85 male weightloss, Increased 85 male weightloss, Increased SOBSOB

Case 8Case 8-- 49 Male Fever, Malaise, 49 Male Fever, Malaise, CoughCough

Case 9 Case 9 –– 67 Female failed Central line 67 Female failed Central line insertioninsertion

Case 10 Case 10 -- 22 Female tender skin rash, 22 Female tender skin rash, arthralgiaarthralgia