VENU MADHAVVENU MADHAV

NORMAL CHEST NORMAL CHEST RADIOGRAPHRADIOGRAPH

Male or female?Male or female? Look for the Look for the

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

Old or young?Old or young?

Try to use the patient's age Try to use the patient's age to your advantage by making to your advantage by making sensible suggestions. A 20 sensible suggestions. A 20 year old is much less likely to year old is much less likely to have malignancy than have malignancy than someone who is 70.someone who is 70.

Child or Neonate?Child or Neonate?Apparent Apparent

superior superior mediastinal mediastinal widening in a widening in a child due to child due to normal THYMUS normal THYMUS should not be should not be mistaken for a mistaken for a pathologypathology..

VIEWSVIEWSPA PA APAPLATERAL (LEFT AND RIGHT)LATERAL (LEFT AND RIGHT)SUPINESUPINELATERAL DECUBITUS (LEFT AND RIGHT)LATERAL DECUBITUS (LEFT AND RIGHT)OBLIQUEOBLIQUEAPICAL/LORDOTIC APICAL/LORDOTIC PAIRED INSPIRATORY AND EXPIRATORYPAIRED INSPIRATORY AND EXPIRATORY

The PA viewThe PA viewPatient faces the film chin up with Patient faces the film chin up with

the shoulders rotated forward to the shoulders rotated forward to displace the scapulae from the displace the scapulae from the lungs.lungs.

Exposure should me made on full Exposure should me made on full inspiration (centering at T5)and inspiration (centering at T5)and breasts should be compressed breasts should be compressed against the film for optimal against the film for optimal visualisation of lung bases. visualisation of lung bases.

Low kVp: (60-80 kV) Low kVp: (60-80 kV)

High contrast film.High contrast film.

Miliary shadowing and Miliary shadowing and calcification more calcification more clearly seen. clearly seen.

•High kVp: (120-170 kV)High kVp: (120-170 kV)

Low contrast film.Low contrast film.

Hidden areas of lung could be Hidden areas of lung could be better visualized.better visualized.

A FFD of 1.85m (6 feet) A FFD of 1.85m (6 feet) reduces magnification and reduces magnification and produces a sharper image.produces a sharper image.

A Grid or Air Gap is necessary A Grid or Air Gap is necessary to reduce scatter and to reduce scatter and improve contrast.improve contrast.

APAPDone in patients who are unable Done in patients who are unable

to stand or portable radiographs.to stand or portable radiographs.

The ribs are projected over The ribs are projected over different areas of the lung from different areas of the lung from the PA view and posterior chest the PA view and posterior chest is well shown.is well shown.

PA or AP?PA or AP?

PAPAIn a PA film, the heart is In a PA film, the heart is

closer to the film and thus closer to the film and thus less magnified.less magnified.

The standard chest x-ray is a The standard chest x-ray is a PA film.PA film.

APAP

•In an AP film, the heart is farther In an AP film, the heart is farther from the film and is more from the film and is more magnified.magnified.

On the AP supine film there is On the AP supine film there is more equalization of the more equalization of the pulmonary vasculature when the pulmonary vasculature when the size of the lower lobe vessels are size of the lower lobe vessels are compared to the upper.compared to the upper.

APAPScapulae overlie the upper Scapulae overlie the upper

lungs.lungs.Clavicles are projected more Clavicles are projected more

cranially over the apices.cranially over the apices.The disc spaces of the lower The disc spaces of the lower

cervical spine are more clearly cervical spine are more clearly seen.seen.

The Lateral ViewThe Lateral ViewWith shoulders parallel to the With shoulders parallel to the

film the arms are elevated, or film the arms are elevated, or displaced back if the anterior displaced back if the anterior mediastinum is of interest.mediastinum is of interest.

For sharpness the side of interest For sharpness the side of interest is nearest the film. is nearest the film.

SUPINE and DECUBITUSSUPINE and DECUBITUS

To distinguish a SUBPULMONARY To distinguish a SUBPULMONARY EFFUSION from an elevated EFFUSION from an elevated diaphragm or consolidation. diaphragm or consolidation.

In the supine and decubitus In the supine and decubitus positions, the free fluid becomes positions, the free fluid becomes displaced.displaced.

DECUBITUS FILMDECUBITUS FILMPatient is placed lying on the Patient is placed lying on the

cassette with either the left or right cassette with either the left or right side dependent. side dependent.

It is most frequently used for It is most frequently used for evaluating the presence of free-evaluating the presence of free-moving pleural fluid. moving pleural fluid.

The usual technique is to have the The usual technique is to have the patient lie on the side with the fluid patient lie on the side with the fluid and look for a radiodense fluid line and look for a radiodense fluid line along the dependent side. along the dependent side.

With small amounts of pleural With small amounts of pleural fluid, it is helpful to have the fluid, it is helpful to have the patient lie with the normal side patient lie with the normal side dependent and see if the dependent and see if the diaphragmatic angle on the diaphragmatic angle on the involved side becomes sharp, involved side becomes sharp, thus indicating the presence of thus indicating the presence of a small, free-moving effusion. a small, free-moving effusion.

OBLIQUEOBLIQUE

Retrocardiac area, the Retrocardiac area, the posterior costophrenic posterior costophrenic angles and the chest wall angles and the chest wall with pleural plaques are with pleural plaques are clearly demonstrated.clearly demonstrated.

APICAL VIEWAPICAL VIEWThe x-ray beam is angled in a slightly The x-ray beam is angled in a slightly

upward projection, causing anterior upward projection, causing anterior thoracic structures to be projected thoracic structures to be projected above the posterior thoracic structures. above the posterior thoracic structures.

The clavicle and first several sets of The clavicle and first several sets of ribs are projected above the apices of ribs are projected above the apices of the lung, allowing a good view of this the lung, allowing a good view of this area. area.

It is particularly useful in evaluating the It is particularly useful in evaluating the upper lobes for evidence of tuberculous upper lobes for evidence of tuberculous disease. disease.

LORDOTIC VIEWLORDOTIC VIEWWith the patient in lordotic With the patient in lordotic

PA position, the tube is PA position, the tube is angled downwards.angled downwards.

Best to visualize a middle Best to visualize a middle lobe collapse, seen as a well-lobe collapse, seen as a well-defined triangular shadow.defined triangular shadow.

PAIRED INSP AND EXP FILMSPAIRED INSP AND EXP FILMS

Demonstrate air trapping Demonstrate air trapping and diaphragm movement.and diaphragm movement.

Useful in children with a Useful in children with a possible diagnosis of an possible diagnosis of an INHALED FOREIGN BODY.INHALED FOREIGN BODY.

What is a technically What is a technically adequate Chest X Ray?adequate Chest X Ray?

AdequateAdequate PenetrationPenetrationInspirationInspirationRotationRotationAngulationAngulation

Good inspiration?Good inspiration?

The The diaphragms diaphragms should lie should lie at the level at the level of the sixth of the sixth ribs ribs anteriorly.anteriorly.

About 10 About 10 posterior ribs posterior ribs visible is anvisible is anexcellent excellent inspiration.inspiration.

In many In many hospitalized hospitalized patients 9patients 9posterior ribs posterior ribs is an is an adequateadequateinspiration.inspiration.

•On expiration On expiration heart shadow heart shadow appears larger.appears larger.

•Poor inspiration Poor inspiration will crowd lung will crowd lung markings and markings and make it appear make it appear asasthough the though the patient has patient has airspace airspace disease.disease.

Good penetration?Good penetration?

You should You should just be able to just be able to see the lower see the lower thoracic thoracic vertebral vertebral bodies bodies through the through the heart.heart.

If the film is If the film is under penetrated, under penetrated, the left hemi the left hemi diaphragm (and diaphragm (and leftleftlung base) will lung base) will not be visible and not be visible and the pulmonary the pulmonary markings willmarkings willappear more appear more prominent than prominent than they actually are.they actually are.

Over Over penetration penetration results in results in loss of loss of visibility of visibility of low-density low-density lesions such lesions such as early as early consolidationconsolidation..

Is the patient rotated?Is the patient rotated? The spinous The spinous

processes of processes of the thoracic the thoracic vertebrae vertebrae should be should be midway midway between the between the medial ends of medial ends of the clavicles.the clavicles.

LEFT ROTATIONLEFT ROTATIONIf spinous process If spinous process

appears closer to appears closer to the right clavicle, the right clavicle, the patient is the patient is rotated toward rotated toward their own left sidetheir own left side..

If the medial end If the medial end of the clavicle is of the clavicle is farther on the left farther on the left side, then the side, then the patient is rotated patient is rotated left.left.

RIGHT ROTATIONRIGHT ROTATIONIf spinous process If spinous process

appears closer to appears closer to the left clavicle, the left clavicle, the patient is the patient is rotated toward rotated toward their own right their own right side.side.

If the medial end If the medial end of the clavicle is of the clavicle is farther on the farther on the right side, then right side, then the patient is the patient is rotated right.rotated right.

Small degrees of rotation Small degrees of rotation distort the mediastinal distort the mediastinal borders, and the lung nearer borders, and the lung nearer the film appears less the film appears less translucent.translucent.

Severe rotation may make the Severe rotation may make the

pulmonary arteriespulmonary arteriesappear larger on the side appear larger on the side nearer the film.nearer the film.

Thoracic deformities like Thoracic deformities like Scoliosis, negate the value of Scoliosis, negate the value of conventional centering.conventional centering.

ANGULATIONANGULATIONIf the x-ray beam is angled If the x-ray beam is angled

toward the head (mostly toward the head (mostly because the patient is semi-because the patient is semi-recumbent), the film so recumbent), the film so obtained is called an “apical obtained is called an “apical lordotic” view.lordotic” view.

Anterior structures (like the Anterior structures (like the clavicles) will be projected clavicles) will be projected higher on the film thanhigher on the film thanposterior structures.posterior structures.

The factors to evaluate the The factors to evaluate the quality of a chest x-ray are:quality of a chest x-ray are:

Penetration – see spine through Penetration – see spine through the heartthe heart

Inspiration – at least 8-9 posterior Inspiration – at least 8-9 posterior ribsribs

Rotation – spinous process Rotation – spinous process between clavicles.between clavicles.

Angulation – clavicle over 3rd ribAngulation – clavicle over 3rd rib

Viewing a PA filmViewing a PA film

TRACHEATRACHEAMidline in its upper part, Midline in its upper part,

then deviates slightly to the then deviates slightly to the right around the aortic right around the aortic knuckle.knuckle.

On expiration, deviation to On expiration, deviation to the right becomes more the right becomes more marked. marked.

In addition, there is In addition, there is shortening in expiration.shortening in expiration.

Normal maximum coronal Normal maximum coronal diameter is 25mm for males diameter is 25mm for males and 21mm for females.and 21mm for females.

Its calibre should be even, Its calibre should be even, with translucency of the with translucency of the tracheal column decreasing tracheal column decreasing caudally.caudally.

The trachea should be The trachea should be examined for narrowing, examined for narrowing, displacement and displacement and intraluminal lesions.intraluminal lesions.

Right Paratracheal StripeRight Paratracheal StripeRight tracheal margin, where the Right tracheal margin, where the

trachea is in contact with the trachea is in contact with the lung.lung.

Seen in 60% of patients, normally Seen in 60% of patients, normally measuring <5mm.measuring <5mm.

Widening of this stripe occurs in Widening of this stripe occurs in cases of mediastinal cases of mediastinal lymphadenopathy, tracheal and lymphadenopathy, tracheal and mediastinal malignancies, mediastinal malignancies, mediastinitis and pleural mediastinitis and pleural effusion.effusion.

Left paratracheal stripe is Left paratracheal stripe is not visualised because the not visualised because the left tracheal border is left tracheal border is adjacent to the great adjacent to the great vessels and not the lung.vessels and not the lung.

CARINA CARINA The normal angle is 60-75 The normal angle is 60-75

degrees.degrees.Widening of the carina Widening of the carina

occurs in inspiration.occurs in inspiration.Pathological causes of Pathological causes of

widening:widening:Enlarged left atrium.Enlarged left atrium.Enlarged carinal nodes. Enlarged carinal nodes.

AZYGOS VEINAZYGOS VEINLies in the angle between the Lies in the angle between the

right main bronchus and right main bronchus and trachea.trachea.

On the erect film, it should be On the erect film, it should be less than 10mm in diameter.less than 10mm in diameter.

Its size decreases inIts size decreases in Inspiration Inspiration Valsalva manoeuvre.Valsalva manoeuvre.

Size of Azygos vein Size of Azygos vein increases inincreases in::

Supine position.Supine position. Pregnancy.Pregnancy. Enlarged subcarinal nodes.Enlarged subcarinal nodes. Portal hypertension.Portal hypertension. IVC and SVC obstruction.IVC and SVC obstruction. Right Heart Failure.Right Heart Failure. Constrictive Pericarditis.Constrictive Pericarditis.

MEDIASTINUMMEDIASTINUMLook at the overall size and Look at the overall size and

shape of the entire mediastinum shape of the entire mediastinum on the frontal and lateral views on the frontal and lateral views

Look for obvious masses and Look for obvious masses and calcifications, check for tubes, calcifications, check for tubes, electrical leads, a pacemaker,or electrical leads, a pacemaker,or artificial valves. artificial valves.

Check for evidence of Check for evidence of mediastinal shift and if present, mediastinal shift and if present, is the entire mediastinum is the entire mediastinum shifted, or just a section of it? shifted, or just a section of it?

SUPERIOR MEDIASTINUMSUPERIOR MEDIASTINUMThe superior mediastinum The superior mediastinum

begins at the root of the neck begins at the root of the neck and ends caudally at a line and ends caudally at a line drawn between T-4 vertebra drawn between T-4 vertebra and the sternomanubrial and the sternomanubrial junction. junction.

The area between this line and The area between this line and the diaphragm is further the diaphragm is further divided into three regions, divided into three regions, anterior, middle, and posterior. anterior, middle, and posterior.

Basically, the heart and Basically, the heart and pericardium form the middle pericardium form the middle section, everything anterior section, everything anterior to the heart is the ANTERIOR to the heart is the ANTERIOR MEDIASTINUM, and MEDIASTINUM, and everything posterior to the everything posterior to the heart back to the spine is the heart back to the spine is the POSTERIOR MEDIASTINUM.POSTERIOR MEDIASTINUM.  

The right superior The right superior medastinal shadow is medastinal shadow is formed by SVC and formed by SVC and Innominate vessels. A Innominate vessels. A dilated Aorta may dilated Aorta may contribute to this border.contribute to this border.

Left mediastinal border is Left mediastinal border is less sharp. It is formed by less sharp. It is formed by subclavian artery and subclavian artery and above the aortic knuckleabove the aortic knuckle..

Anterior Middle and Posterior Anterior Middle and Posterior MediastinumMediastinum

These regions are superimposed These regions are superimposed on the frontal view. on the frontal view.

The major structure is the heart. The major structure is the heart. For all practical purposes the For all practical purposes the pericardium will be inseparable pericardium will be inseparable from the heart on plain film views. from the heart on plain film views.

Review the heart for overall size Review the heart for overall size and shape. Look carefully for and shape. Look carefully for calcifications, pneumopericardium, calcifications, pneumopericardium, pneumomediastinum, sutures, pneumomediastinum, sutures, prosthetic valves etc.prosthetic valves etc.

CARDIAC SHADOWCARDIAC SHADOWWith good centering, 2/3rds With good centering, 2/3rds

of the cardiac shadow lies to of the cardiac shadow lies to the left of midline and 1/3the left of midline and 1/3rdrd to the right.to the right.

TRANSVERSE CARDIAC TRANSVERSE CARDIAC DIAMETERDIAMETER::

Normal for females <14.5cm Normal for females <14.5cm and for males <15.5cm.and for males <15.5cm.

CARDIO THORACIC RATIOCARDIO THORACIC RATIO::

The ratio of the widest diameter of The ratio of the widest diameter of the heart to the widest width of the the heart to the widest width of the thoracic cage as measured from thoracic cage as measured from inner aspect of rib to rib. This inner aspect of rib to rib. This cardiac-thoracic ratio should be cardiac-thoracic ratio should be less than 50%.  less than 50%. 

•An increase in excess of 1.5cm in An increase in excess of 1.5cm in the transverse diameter on the transverse diameter on comparable serial films is comparable serial films is significant.significant.

False enlargement of False enlargement of heart:heart:

Short FFD.Short FFD.Expiration.Expiration.AP projection.AP projection.When diaphragms are When diaphragms are

elevated.elevated.

AORTAAORTATry tracking it from the root to distal Try tracking it from the root to distal

descending aorta. descending aorta. In the young adult the ascending In the young adult the ascending

aorta usually is hidden in the aorta usually is hidden in the mediastinum, in older people it may mediastinum, in older people it may swing to the right enough to cast a swing to the right enough to cast a soft tissue bulge. soft tissue bulge.

The arch should always be seen, The arch should always be seen, make sure it is to the left of the distal make sure it is to the left of the distal trachea and actually pushes the trachea and actually pushes the distal trachea slightly to the right. distal trachea slightly to the right.

Check for aortic calcifications and Check for aortic calcifications and size. The left lateral border of the size. The left lateral border of the descending aorta abuts the left lungdescending aorta abuts the left lung

PULMONARY ARTERYPULMONARY ARTERYOn the frontal view, the only part On the frontal view, the only part

of the main pulmonary artery of the main pulmonary artery seen is the left lateral border seen is the left lateral border where it meets the left lung.where it meets the left lung.

It can be relatively straight or It can be relatively straight or convex (most commonly in young convex (most commonly in young females). females).

The left pulmonary artery is The left pulmonary artery is directly behind the main directly behind the main pulmonary artery, and is visible pulmonary artery, and is visible on frontal films as a branching on frontal films as a branching structure.structure.

AORTICOPULMONARY AORTICOPULMONARY WINDOWWINDOW

• It is formed by a portion of the It is formed by a portion of the upper lobe sitting in the space upper lobe sitting in the space immediately lateral to the area immediately lateral to the area between the aortic arch and left between the aortic arch and left pulmonary artery.pulmonary artery.

The AP window should have a The AP window should have a concave or straight border.concave or straight border.

If there is a mediastinal mass in If there is a mediastinal mass in the AP window region, the lung the AP window region, the lung will be pushed laterally and the will be pushed laterally and the border becomes convex.border becomes convex.

THYMUSTHYMUSSeen in children.Seen in children.Normal thymus is a triangular or Normal thymus is a triangular or

sail-shaped structure with well sail-shaped structure with well defined borders projecting from one defined borders projecting from one or both sides of the mediastinum.or both sides of the mediastinum.

Both borders may be wavy in Both borders may be wavy in outline, the outline, the “wave sign of “wave sign of MUVLEY” MUVLEY” as a consequence of as a consequence of indentation by costal cartilages.indentation by costal cartilages.

Thymus is absent in Thymus is absent in DI GEORGE DI GEORGE SYNDROMESYNDROME..

Large thymus may be seen Large thymus may be seen commonly in boys and also commonly in boys and also following recovery from an following recovery from an illness.illness.

Thymic size decreases on Thymic size decreases on inspiration and in response to inspiration and in response to stress and illness.stress and illness.

PARASPINAL LINESPARASPINAL LINES

These lines run adjacent to the These lines run adjacent to the vertebral bodies.vertebral bodies.

On left this is normally <10mm On left this is normally <10mm wide.wide.

On the right, <3mm.On the right, <3mm.The left paraspinal line is wider The left paraspinal line is wider

due to the Descending thoracic due to the Descending thoracic aorta.aorta.

Causes of enlargement of Causes of enlargement of Paraspinal lines:Paraspinal lines:

Osteophytes.Osteophytes.Tortuous Aorta.Tortuous Aorta.Vertebral and adjacent soft-Vertebral and adjacent soft-

tissue masses.tissue masses.Paravertebral hematomas.Paravertebral hematomas.Dilated Azygos system.Dilated Azygos system.

JUNCTION LINESJUNCTION LINESFormed by pleura being Formed by pleura being

outlined by the adjacent air-outlined by the adjacent air-filled lung.filled lung.

They areThey are::Anterior junction line.Anterior junction line.Posterior junction line.Posterior junction line.Azygo oesophageal interface.Azygo oesophageal interface.Pleuro-oesophageal stripe.Pleuro-oesophageal stripe.

ANTERIOR JUNCTION LINEANTERIOR JUNCTION LINE

It is formed by the lungs meeting It is formed by the lungs meeting anterior to the ascending aorta.anterior to the ascending aorta.

It is 1mm thick.It is 1mm thick.Overlying the tracheal Overlying the tracheal

translucency, it runs downward translucency, it runs downward from below the suprasternal from below the suprasternal notch, slightly curving from left notch, slightly curving from left to right.to right.

POSTERIOR JUNCTION LINEPOSTERIOR JUNCTION LINE

Formed where the lungs meet Formed where the lungs meet posteriorly behind the posteriorly behind the oesophagus.oesophagus.

It is 2mm wide.It is 2mm wide.Straight or curved line convex to Straight or curved line convex to

the left.the left.Extends from the lung apices to Extends from the lung apices to

the aortic knuckle or below.the aortic knuckle or below.

AZYGO-OESOPHAGEAL AZYGO-OESOPHAGEAL INTERFACEINTERFACE

Has the shape of an Has the shape of an “inverted “inverted hockey stick”hockey stick”

It runs from the diaphragm on It runs from the diaphragm on the left of midline up and to the the left of midline up and to the right extending to the tracheo-right extending to the tracheo-bronchial angle where the bronchial angle where the Azygos vein drains into the IVC.Azygos vein drains into the IVC.

PLEURO-OESOPHAGEAL PLEURO-OESOPHAGEAL STRIPESTRIPE

It is formed by the lung and It is formed by the lung and right wall of the oesophagus.right wall of the oesophagus.

Extends from the lung apex to Extends from the lung apex to the Azygos.the Azygos.

Visualised only if the Visualised only if the oesophagus contains air.oesophagus contains air.

THE DIAPHRAGMTHE DIAPHRAGMIn most patients, right hemi In most patients, right hemi

diaphragm is higher than the left.diaphragm is higher than the left.This is due to the heart depressing the This is due to the heart depressing the

left side and not due to the liver left side and not due to the liver pushing the right hemi diaphragm.pushing the right hemi diaphragm.

The hemidiaphragms may lie at the The hemidiaphragms may lie at the same level normally, or if the stomach same level normally, or if the stomach or splenic flexure is distended with or splenic flexure is distended with gas.gas.

In 3% subjects, the left hemi In 3% subjects, the left hemi diaphragm is higher.diaphragm is higher.

A difference >3cm in height is A difference >3cm in height is considered significant.considered significant.

On inspiration, the domes are at On inspiration, the domes are at the level of 6the level of 6thth rib anteriorly and rib anteriorly and at or below the 10at or below the 10thth rib rib posteriorly.posteriorly.

Loss of outline indicates that the Loss of outline indicates that the adjacent tissue does not contain adjacent tissue does not contain air, for example in consolidation air, for example in consolidation or pleural disease.or pleural disease.

THE FISSURESTHE FISSURESThese fissures separate the These fissures separate the

lobes of the lung but are usually lobes of the lung but are usually incomplete allowing collateral air incomplete allowing collateral air drift to occur between adjacent drift to occur between adjacent lobes.lobes.

Main fissuresMain fissures:: HorizontalHorizontal Oblique (Left and Right)Oblique (Left and Right)

Horizontal (or lesser) Horizontal (or lesser) fissure:fissure:

Seen, often incompletely on Seen, often incompletely on the PA film running from the the PA film running from the hilum to the region of the 6hilum to the region of the 6thth rib in the axillary line.rib in the axillary line.

On the lateral film, it runs On the lateral film, it runs anteriorly and often slightly anteriorly and often slightly downwarddownward..

Oblique fissures:Oblique fissures: Both oblique fissures Both oblique fissures

commence posteriorly at the commence posteriorly at the level of T4 or T5, passing level of T4 or T5, passing through the hilum.through the hilum.

The left is steeper and The left is steeper and finishes 5cm behind the finishes 5cm behind the anterior costophrenic angle, anterior costophrenic angle, whereas the right ends just whereas the right ends just behind the angle.behind the angle.

ACCESSORY FISSURESACCESSORY FISSURES

Azygos fissure.Azygos fissure.Superior accessory fissure.Superior accessory fissure.Inferior accessory fissure.Inferior accessory fissure.Left sided horizontal fissure.Left sided horizontal fissure.

AZYGOS FISSUREAZYGOS FISSUREComma shaped with a triangular Comma shaped with a triangular

base peripherally.base peripherally.Nearly always right-sided.Nearly always right-sided.It forms in the apex of the lung.It forms in the apex of the lung.Consists of paired folds of Consists of paired folds of

parietal and visceral pleura plus parietal and visceral pleura plus the Azygos vein which has failed the Azygos vein which has failed to migrate normally.to migrate normally.

SUPERIOR ACCESSORY SUPERIOR ACCESSORY FISSUREFISSURE

Separates the apical from the Separates the apical from the basal segments of the lower lobes.basal segments of the lower lobes.

Commoner on the right side.Commoner on the right side.On the PA film, it resembles the On the PA film, it resembles the

horizontal fissure.horizontal fissure.But on lateral film, it can be But on lateral film, it can be

differentiated as it runs posteriorly differentiated as it runs posteriorly from the hilum.from the hilum.

INFERIOR ACCESSORY INFERIOR ACCESSORY FISSUREFISSURE

Appears as an oblique line Appears as an oblique line running from the cardiophrenic running from the cardiophrenic angle toward the hilum and angle toward the hilum and separating the medial basal separating the medial basal from the other basal segments.from the other basal segments.

Commoner on the right side.Commoner on the right side.Incidence: 5-8%Incidence: 5-8%

LEFT SIDED HORIZONTAL LEFT SIDED HORIZONTAL FISSUREFISSURE

Separates the lingula from Separates the lingula from the other upper lobe the other upper lobe segments.segments.

Rare Rare

COSTOPHRENIC ANGLESCOSTOPHRENIC ANGLES

Sharply defined acute angle which Sharply defined acute angle which is formed by the lateral is formed by the lateral attachment of the diaphragm to attachment of the diaphragm to the ribs.the ribs.

They become obliterated when the They become obliterated when the diaphragms are flat or when there diaphragms are flat or when there is pleural effusion or effusion is pleural effusion or effusion associated with consolidation.associated with consolidation.

CARDIOPHRENIC ANGLESCARDIOPHRENIC ANGLESMedially, the diaphragm meets the Medially, the diaphragm meets the

heart at the Cardiophrenic angle.heart at the Cardiophrenic angle.This is higher than Costophrenic angle.This is higher than Costophrenic angle.Ill-defined owing to the presence of Ill-defined owing to the presence of

fat.fat.Prominent fat pads at the Prominent fat pads at the

cardiophrenic angles are an occasional cardiophrenic angles are an occasional cause of over estimation of the cause of over estimation of the transverse cardiac diameter, esp if the transverse cardiac diameter, esp if the film is underexposed.film is underexposed.

THE LUNGSTHE LUNGS

Compare overall size of one Compare overall size of one lung to the other.lung to the other.

Look for major areas of Look for major areas of abnormal lucency or density.abnormal lucency or density.

Look through the heart and Look through the heart and upper abdomen to lung upper abdomen to lung posterior to these areas.posterior to these areas.

THE HILATHE HILA Pulmonary arteries and Upper lobe Pulmonary arteries and Upper lobe

veins contribute significantly to the veins contribute significantly to the hilar shadows on the plain hilar shadows on the plain radiograph.radiograph.

The left pulmonary artery is always The left pulmonary artery is always more superior than the right, thus more superior than the right, thus making the left hilum appear making the left hilum appear higher.higher.

Normal lymph nodes are not seen.Normal lymph nodes are not seen.

The hila should be of equal The hila should be of equal density and similar size with density and similar size with clearly defined concave lateral clearly defined concave lateral borders where the superior borders where the superior pulmonary vein meets the pulmonary vein meets the basal pulmonary artery.basal pulmonary artery.

Air can be identified within the Air can be identified within the proximal bronchi but normal proximal bronchi but normal bronchial walls are only seen bronchial walls are only seen end-on.end-on.

PULMONARY VESSELSPULMONARY VESSELSThe left pulmonary artery lies The left pulmonary artery lies

above the left main bronchus above the left main bronchus before passing posteriorly.before passing posteriorly.

The right pulmonary artery is The right pulmonary artery is anterior to the bronchus resulting anterior to the bronchus resulting in the right hilum being the lower.in the right hilum being the lower.

The max diameter of the The max diameter of the descending branch of pulmonary descending branch of pulmonary artery is 16mm for males and artery is 16mm for males and 15mm for females(measured 1cm 15mm for females(measured 1cm medial and lateral to hilar point)medial and lateral to hilar point)

PULMONARY VESSELSPULMONARY VESSELSAt the 1At the 1stst intercostal space the intercostal space the

normal vessels should not exceed normal vessels should not exceed 3mm in diameter.3mm in diameter.

The lower lobe vessels are larger The lower lobe vessels are larger than those of the upper lobes in than those of the upper lobes in erect position, perfusion and erect position, perfusion and aeration of the upper zones being aeration of the upper zones being reduced.reduced.

In supine position, the vessels In supine position, the vessels equalise.equalise.

PULMONARY VESSELSPULMONARY VESSELSThe peripheral lung markings are The peripheral lung markings are

mainly vascular, veins and arteries mainly vascular, veins and arteries having no distinguishing having no distinguishing characteristics.characteristics.

The arteries accompany the bronchi, The arteries accompany the bronchi, lying posterosuperior, whereas veins lying posterosuperior, whereas veins do not follow the bronchi.do not follow the bronchi.

Pulmonary veins have fewer branches Pulmonary veins have fewer branches than arteries and are straighter, than arteries and are straighter, larger and less well defined.larger and less well defined.

THE BRONCHIAL VESSELSTHE BRONCHIAL VESSELS

These are normally not visualised These are normally not visualised on a plain film.on a plain film.

They arise from the ventral They arise from the ventral surface of the descending aorta at surface of the descending aorta at T5/6 level.T5/6 level.

2 branches: left and right.2 branches: left and right.On entering the hila, they On entering the hila, they

accompany the bronchi. accompany the bronchi.

Enlarged bronchial Enlarged bronchial arteriesarteries

They appear as multiple small They appear as multiple small nodules around the hilum and as nodules around the hilum and as short lines in the proximal lung fields.short lines in the proximal lung fields.

CAUSES:CAUSES: General: Cyanotic congenital heart General: Cyanotic congenital heart

diseasedisease Local: Bronchiectasis, Bronchial Local: Bronchiectasis, Bronchial

carcinomacarcinoma

PULMONARY SEGMENTS AND PULMONARY SEGMENTS AND BRONCHIBRONCHI

The pulmonary segments are The pulmonary segments are served by segmental bronchi served by segmental bronchi and arteries but unlike the lobes and arteries but unlike the lobes are not separated by pleura.are not separated by pleura.

Normal bronchi are not Normal bronchi are not visualised in the peripheral one visualised in the peripheral one thirds of lung fields.thirds of lung fields.

THE LYMPHATIC SYSTEMTHE LYMPHATIC SYSTEM

They run in the interlobular They run in the interlobular septa, connecting with septa, connecting with subpleural lymphatics and subpleural lymphatics and draining via the deep lymphatics draining via the deep lymphatics to the hilum.to the hilum.

Normal lymphatics are not seen Normal lymphatics are not seen but thickening of the lymphatics but thickening of the lymphatics and sorrounding connective and sorrounding connective tissue produces tissue produces KERLEY LINESKERLEY LINES..

KERLEY LINESKERLEY LINESKerley AKerley A: : Unbranching lines coursing Unbranching lines coursing

diagonally from the periphery toward diagonally from the periphery toward the hila in the inner half of the lungs. the hila in the inner half of the lungs.

Kerley BKerley B: Short parallel lines at the : Short parallel lines at the lung periphery. These lines represent lung periphery. These lines represent interlobular septa, which are usually interlobular septa, which are usually less than 1 cm in length and parallel less than 1 cm in length and parallel to one another at right angles to the to one another at right angles to the pleura.pleura.

Kerley CKerley C: They are short, fine lines : They are short, fine lines throughout the lungs, with a reticular throughout the lungs, with a reticular appearance. appearance.

BRONCHOPULMONARY BRONCHOPULMONARY SEGMENTSSEGMENTS

UPPER LOBEUPPER LOBE::

1.1. Apical bronchus.Apical bronchus.

2.2. Posterior bronchus.Posterior bronchus.

3.3. Anterior bronchus.Anterior bronchus.

RIGHT-MIDDLE LOBE:RIGHT-MIDDLE LOBE:4.4. Lateral bronchus.Lateral bronchus.5.5. Medial bronchus.Medial bronchus.

LEFT-LINGULA:LEFT-LINGULA:4.4. Superior bronchus.Superior bronchus.5.5. Inferior bronchus.Inferior bronchus.

LOWER LOBELOWER LOBE

6.6. Apical Apical bronchus.bronchus.

7.7. Medial basal Medial basal (Cardiac)(Cardiac)

8.8. Anterior basal.Anterior basal.

9.9. Lateral basal.Lateral basal.

10.10.Posterior basalPosterior basal

6.6. Apical Apical bronchus.bronchus.

8.8. Anterior Anterior basal.basal.

9.9. Lateral basal.Lateral basal.

10.10.Posterior Posterior basal.basal.

LYMPH NODESLYMPH NODESAnterior MediastinalAnterior Mediastinal: Lie in the : Lie in the

region of aortic arch and drain the region of aortic arch and drain the thymus and right heart.thymus and right heart.

Intrapulmonary nodesIntrapulmonary nodes: Lie along : Lie along the main bronchi.the main bronchi.

Middle Mediastinal nodesMiddle Mediastinal nodes: Drain : Drain the lungs, bronchi, left heart and the lungs, bronchi, left heart and visceral pleura.visceral pleura.

4 groups4 groups

Bronchopulmonary (hilar)nodes.Bronchopulmonary (hilar)nodes. Carinal nodes.Carinal nodes. Tracheobronchial nodes.Tracheobronchial nodes. Paratracheal nodes.Paratracheal nodes.

•Posterior Mediastinal nodesPosterior Mediastinal nodes: : Drain posterior diaphragm and Drain posterior diaphragm and lower oesophagus.lower oesophagus.

•Parietal nodesParietal nodes: drain soft : drain soft tissues and parietal pleura.tissues and parietal pleura.

BELOW THE DIAPHRAGMBELOW THE DIAPHRAGM Look for other abnormal gas Look for other abnormal gas

shadows such as dilated bowel, shadows such as dilated bowel, abscesses, displaced gastric abscesses, displaced gastric bubble, intramural gas as well as bubble, intramural gas as well as calcified lesions.calcified lesions.

Interposition of colon between Interposition of colon between liver and diaphragm, liver and diaphragm, CHILADITI’S CHILADITI’S SYNDROME SYNDROME is a common and is a common and transient finding usually seen in transient finding usually seen in elderly.elderly.

SOFT TISSUESSOFT TISSUESShoulder girdle:Shoulder girdle:

Look for Look for calcifications, calcifications, obvious mass effect, obvious mass effect, abnormal air abnormal air collections collections (subcutaneous (subcutaneous emphysema), and emphysema), and soft tissue soft tissue companion shadow companion shadow for the clavicle.for the clavicle.

CHEST WALLCHEST WALLLook for Look for

overall overall thickness, thickness, subcutaneous subcutaneous emphysema, emphysema, calcification. calcification.

Look for Look for sharp, distinct sharp, distinct muscle fat muscle fat planesplanes

BREAST TISSUEBREAST TISSUEConfirm presence Confirm presence

or absence of or absence of breast shadows.breast shadows.

Breasts may Breasts may partially obscure partially obscure lung bases.lung bases.

Nipple shadows Nipple shadows are often well-are often well-defined laterally defined laterally and may have a and may have a lucent halo.lucent halo.

ABDOMENABDOMEN Gastric and Gastric and

bowel gas.bowel gas. Check for organ Check for organ

size of liver, size of liver, spleen, and spleen, and kidneys if visible.kidneys if visible.

Check for free Check for free peritoneal airperitoneal air

Look for Look for calcifications and calcifications and masses.masses.

NECK AND SPINENECK AND SPINE Check, position and Check, position and

size of trachea.size of trachea. For the cervical For the cervical

spine, check spine, check alignment and note alignment and note any major congenital any major congenital abnormalities. abnormalities.

Look at specific Look at specific parts of the vertebra parts of the vertebra and disc spaces, and disc spaces, checking for checking for erosions, lytic or erosions, lytic or blastic lesions, disc blastic lesions, disc and synovial joint and synovial joint narrowing or other narrowing or other abnormalitiesabnormalities..

THORACIC SPINETHORACIC SPINE

Look for height of vertebral Look for height of vertebral bodies and disc spaces, bodies and disc spaces, integrity of cortical margins integrity of cortical margins around the bodies, pedicles, around the bodies, pedicles, and lamina.and lamina.

And also for presence of any And also for presence of any lytic or sclerotic areas, normal lytic or sclerotic areas, normal spacing of synovial joints.spacing of synovial joints.

RIBSRIBSCompare individual ribs side Compare individual ribs side

to side, check specific parts, to side, check specific parts, cortical margins, trabecular cortical margins, trabecular patterns. patterns.

See if the anterior cartilages See if the anterior cartilages are calcified, frequently the are calcified, frequently the first one does so irregularly first one does so irregularly and may obscure or mimic and may obscure or mimic underlying lung lesionsunderlying lung lesions. .

VIEWING THE LATERAL VIEWING THE LATERAL FILMFILM

Routinely the left side is Routinely the left side is adjacent to the film because adjacent to the film because more of the left lung than the more of the left lung than the right is obscured on the PA view.right is obscured on the PA view.

But, if there is a specific lesion But, if there is a specific lesion the side of interest is positioned the side of interest is positioned adjacent to the film.adjacent to the film.

THE CLEAR SPACESTHE CLEAR SPACES

Retrosternal space.Retrosternal space.Retrocardiac space.Retrocardiac space.

Loss of translucency of these Loss of translucency of these areas indicates local pathology.areas indicates local pathology.

Widening occurs in Widening occurs in Emphysema.Emphysema.

VERTEBRAL TRANSLUCENCYVERTEBRAL TRANSLUCENCY

The vertebral bodies become The vertebral bodies become progressively more progressively more translucent caudally.translucent caudally.

Loss of this translucency may Loss of this translucency may be the only sign of be the only sign of posterior posterior basal consolidationbasal consolidation..

DIAPHRAGM OUTLINEDIAPHRAGM OUTLINE

Both diaphragms are visible Both diaphragms are visible through out their length, except through out their length, except the left anteriorly where it merges the left anteriorly where it merges with the heart.with the heart.

The posterior cardiophrenic The posterior cardiophrenic angles are acute and small angles are acute and small amounts of pleural fluid may be amounts of pleural fluid may be detected by blunting of these detected by blunting of these angles.angles.

TRACHEATRACHEA

Passes down in a slightly posterior Passes down in a slightly posterior direction to T6/7 level of the spine.direction to T6/7 level of the spine.

The normal posterior wall The normal posterior wall measures 5mm, this measurement measures 5mm, this measurement includes tracheal and oesophageal includes tracheal and oesophageal walls plus the pleura.walls plus the pleura.

Widening may occur with disease Widening may occur with disease of all the above structures.of all the above structures.

CHECK LISTCHECK LISTCheck patient name, Check patient name,

position, technical quality.position, technical quality. Soft tissue including Soft tissue including

breast, chest wall, breast, chest wall, companion shadow.companion shadow.

Review soft tissues and Review soft tissues and skeletal structures of skeletal structures of shoulder girdles and chest shoulder girdles and chest wall.wall.

CHECK LISTCHECK LISTReview abdomen for bowel gas, Review abdomen for bowel gas,

organ size, abnormal organ size, abnormal calcifications, free air, etc.calcifications, free air, etc.

Review soft tissues and spine Review soft tissues and spine of neck.of neck.

Review spine and rib cage: Review spine and rib cage: check alignment, disc space check alignment, disc space narrowing, lytic or blastic narrowing, lytic or blastic regions, etc.regions, etc.

CHECK LISTCHECK LISTReview mediastinumReview mediastinum:: Overall size and shapeOverall size and shape Trachea: positionTrachea: position Margins: SVC, ascending aorta, Margins: SVC, ascending aorta,

right atrium, left subclavian right atrium, left subclavian artery, aortic arch, main artery, aortic arch, main pulmonary artery, left ventriclepulmonary artery, left ventricle

Lines and stripes: paratracheal, Lines and stripes: paratracheal, paraspinal, paraesophageal paraspinal, paraesophageal (azygoesophageal), paraaortic(azygoesophageal), paraaortic

Retrosternal clear space.Retrosternal clear space.

CHECK LISTCHECK LISTReview hilaReview hila:: Normal relationshipsNormal relationships SizeSize

Review lungs and pleuraReview lungs and pleura:: Compare lung sizesCompare lung sizes Evaluate pulmonary vascular Evaluate pulmonary vascular

pattern: pulmonary parenchymapattern: pulmonary parenchyma Pleural surfacesPleural surfaces

fissures - major and minor - if seenfissures - major and minor - if seen compare hemidiaphragmscompare hemidiaphragms follow pleura around rib cagefollow pleura around rib cage