1. Chest Radiography Interpretation
Dr. Raghu Ram
Uppalapati

2. Lung Anatomy Trachea Carina Right and Left Pulmonary Bronchi
Secondary Bronchi
Tertiary Bronchi
Bronchioles
Alveolar Duct
Alveoli

3. Lung Anatomy Right Lung Left Lung Superior lobe Middle lobe
Inferior lobe
Left Lung

4. Lung Anatomy on Chest X-ray
PA View:
Extensive overlap
Lower lobes extend high
Lateral View:
Extent of lower lobes

5. Lung Anatomy on Chest X-ray
The right upper lobe (RUL) occupies the upper 1/3 of the right lung.
Posteriorly, the RUL is adjacent to the first three to five ribs.
Anteriorly, the RUL extends inferiorly as far as the 4th right anterior rib
The right upper lobe (RUL) occupies the upper 1/3 of the right lung. Posteriorly, the RUL is adjacent to the first three to five ribs. Anteriorly, the RUL extends inferiorly as far as the 4th right anterior rib.

6. Lung Anatomy on Chest X-ray
The right middle lobe is typically the smallest of the three, and appears triangular in shape, being narrowest near the hilum
The right middle lobe is typically the smallest of the three, and appears triangular in shape, being narrowest near the hilum.

7. The right lower lobe is the largest of all three lobes, separated from the others by the major fissure.
Posteriorly, the RLL extend as far superiorly as the 6th thoracic vertebral body, and extends inferiorly to the diaphragm.
Review of the lateral plain film surprisingly shows the superior extent of the RLL.
Posteriorly, the RLL extend as far superiorly as the 6th thoracic vertebral body, and extends inferiorly to the diaphragm. Review of the lateral plain film surprisingly shows the superior extent of the RLL; there is considerable overlap between the more anterosuperiorly located RUL and the RLL. Similarly, the deep posterior gutters extend considerably inferiorly; with full inspiration, the lower lobe can extend may as low as L2, becoming superimposed over the upper poles of the kidneys.

8. Lung Anatomy on Chest X-ray
These lobes can be separated from one another by two fissures.
The minor fissure separates the RUL from the RML, and thus represents the visceral pleural surfaces of both of these lobes.
Oriented obliquely, the major fissure extends posteriorly and superiorly approximately to the level of the fourth vertebral body.
Grossly, these lobes can be separated from one another by two fissures which anatomically correspond to the visceral pleural surfaces of those lobes from which they are formed. The minor fissure separates the RUL from the RML, and thus represents the visceral pleural surfaces of both of these lobes. The minor fissure is oriented horizontally, extending ventrally from the chest wall, and extending posteriorly to meet the major fissure. Generally, the location of the minor fissure is approximately at the level of the fourth vertebral body and crosses the right sixth rib in the midaxillary line. The right major fissure is more expansive in size than the minor fissure, separating the right upper and middle lobes from the larger right lower lobe. Oriented obliquely, the major fissure extends posteriorly and superiorly approximately to the level of the fourth vertebral body. The major fissure extends anteroinferiorly, intersecting the diaphragm at the anterior cardiophrenic angle

9. The lobar architecture of the left lung is slightly different than the right.
Because there is no defined left minor fissure, there are only two lobes on the left; the left upper
The lobar architecture of the left lung is slightly different than the right. Because there is no defined left minor fissure, there are only two lobes on the left; left upper

10. Lt Lower Lobes
Left lower lobes
and left lower lobes

11. Lung Anatomy on Chest X-ray
These two lobes are separated by a major fissure, identical to that seen on the right side, although often slightly more inferior in location.
The portion of the left lung that corresponds anatomically to the right middle lobe is incorporated into the left upper lobe.
These two lobes are separated by a major fissure, identical to that seen on the right side, although often slightly more inferior in location. The portion of the left lung that corresponds anatomically to the right middle lobe is incorporated into the left upper lobe.
It is important to understand that in most individuals, interlobar fissures are usually not completely formed; in some individuals there may be complete absence of a fissure thus losing the demarcation between lobes on gross examination.
In general, fissures are not readily identifiable on plain films, with only small portions typically visualized at best. This is because fissures which are composed of only two layers of visceral pleura, may not present a significant radiographic interface and will not produce a shadow. However, if there is fluid within the pleural space or if the visceral pleura is thickened, fissures may be seen in their entirety.

12. RUL (Right Upper Lung)

13. RML (Right Middle Lung)

14. RLL (Right Lower Lung)

16. LUL (Left Upper Lung)

17. LLL (Left Lower Lung)

18. Left Side Fissure
LUL
LLL

19. Chest Radiography: Basic Principles
A structure is rendered visible on a radiograph by the juxtaposition of two different densities

20. 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

21. Right Lower Lobe Pneumonia

22. 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

23. Chest Radiographic Patterns of Disease
Air space opacity
Interstitial opacity
Nodules and masses
Lymphadenopathy
Cysts and cavities
Lung volumes
Pleural diseases

24. LUL Pneumonia

25. Air Space Opacity Components:
air bronchogram: air-filled bronchus surrounded by airless lung
confluent opacity extending to pleural surfaces
segmental distribution

26. Air Space Opacity: DDX Blood (hemorrhage) Pus (pneumonia)
Water (edema)
hydrostatic or non-cardiogenic
Cells (tumor)
Protein/fat: alveolar proteinosis and lipoid pneumonia

27. Interstitial Opacity: Small Nodules

28. Interstitial Opacity:
Lines

29. Interstitial Opacity: Lines & Reticulation

30. Interstitial Opacity Hallmarks: small, well-defined nodules lines
interlobular septal thickening
fibrosis
reticulation

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

32. Nodules and Masses
Nodule: any pulmonary lesion represented in a radiograph by a sharply defined, discrete, nearly circular opacity mm in diameter
Mass: larger than 3 cm

33. Nodules and Masses Qualifiers: single or multiple size
border definition
presence or absence of calcification
location

34. Well-Defined
Calcification
Ill-Defined
Mass

35. Lymphadenopathy Non-specific presentations: Specific patterns:
mediastinal widening
hilar prominence
Specific patterns:
particular station enlargement

36. Right Paratracheal
Lymphadenopathy

37. Right Hilar LAN

38. Right Hilar LAN

39. Left Hilar LAN

41. Subcarinal LAN *

42. AP Window LAN

44. 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

45. 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

46. Cysts & Cavities Characterize: wall thickness at thickest portion
inner lining
presence/absence of air/fluid level
number and location

47. Benign Lung Cyst : PCP Pneumatocele
Uniform wall thickness
1 mm
Smooth inner lining

48. Benign Cavities :
Cryptococcus
max wall thickness 4 mm
minimally irregular inner lining

49. Indeterminate Cavities
max wall thickness 5-15 mm
mildly irregular inner lining

50. Malignant Cavities: Squamous Cell Ca
max wall thickness 16 mm
Irregular inner lining

51. Pleural Disease: Basic Patterns
Effusion
angle blunting to massive
mobility
Thickening
distortion, no mobility
Mass
Air
Calcification

52. Pleural Effusion

53. Pleural Effusion

54. Pleural Calcification

56. SOME INTERESTING X-RAYS & DISCUSSIO N

57. Chest breast implants

58. Tip of ET
Pneumomediastinum

59. 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

60. Expiration reduces lung volume, making a small pneumo easier to see

67. 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.

70. Hodgkin’s Disease

72. A single, 3cm relatively thin-walled cavity is noted in the left midlung. This finding is most typical of squamous cell carcinoma (SCC). One-third of SCC masses show cavitation

74. LUL Atelectasis: Loss of heart borders/silhouetting
LUL Atelectasis: Loss of heart borders/silhouetting. Notice over inflation on unaffected lung

76. Right Middle and Left Upper Lobe Pneumonia

78. Pseudotumor: fluid has filled the minor fissure creating a density that resembles a tumor (arrow). Recall that fluid and soft tissue are indistinguishable on plain film. Further analysis, however, reveals a classic pleural effusion in the right pleura. Note the right lateral gutter is blunted and the right diaphram is obscurred.

80. Pneumonia:a large pneumonia consolidation in the right lower lobe
Pneumonia:a large pneumonia consolidation in the right lower lobe. Knowledge of lobar and segmental anatomy is important in identifying the location of the infection

83. 24 hours after diuretic therapy

84. CHF:a great deal of accentuated interstitial markings, Curly lines, and an enlarged heart. Normally indistinct upper lobe vessels are prominent but are also masked by interstitial edema.