1. Chest X-ray Interpretation
Dr C. Lokubalasooriya

2. Introduction Single most common basic examination Low cost examination
More information

3. X-rays were first discovered accidentally by Wilhelm Conrad Röntgen in 1895.
X-rays are waves of electromagnetic energy that have a shorter wavelength than normal light
He discovered that these new invisible rays could pass through most objects that casted shadows including human tissue but not human bones and metals.
Within a year of the discovery many scientists replicated the experiment Röntgen performed and began using it in clinical settings
In 1901 Röntgen won the first Nobel Prize in Physics

4. Essentials Before Getting Started
Identification
Exposure
Overexposure
Underexposure
Sex of Patient
Male
Female

5. Essentials Before Getting Started
Path of x-ray beam PA AP
Patient Position
Upright
Supine

6. Essentials Before Getting Started
Breath
Inspiration
Expiration

7. Systematic Approach Bony Framework Soft Tissues Lung Fields and Hila
Diaphragm and Pleural Spaces
Mediastinum and Heart
Abdomen and Neck

8. Systematic Approach Bony Fragments Ribs Sternum Spine Shoulder girdle
Clavicles

9. Systematic Approach Soft Tissues Breast shadows Supraclavicular areas
Axillae
Tissues along side of breasts

10. Systematic Approach Lung Fields and Hila Hilum Lungs Blood vessels
Pulmonary arteries
Pulmonary veins
Lungs
Linear and fine nodular shadows of pulmonary vessels
Blood vessels
40% obscured by other tissue

11. Systematic Approach Diaphragm and Pleural Surfaces Diaphragm
Dome-shaped
Costophrenic angles
Normal pleural is not visible
Interlobar fissures

12. Systematic Approach Mediastinum and Heart Heart size on PA Right side
Inferior vena cava
Right atrium
Ascending aorta
Superior vena cava

13. Systematic Approach Mediastinum and Heart Left side Left ventricle
Left atrium
Pulmonary artery
Aortic arch
Subclavian artery and vein

14. Systematic Approach Abdomen and Neck Abdomen Neck Gastric bubble
Air under diaphragm
Neck
Soft tissue mass
calcifications

15. Pitfalls to Chest X-ray Interpretation
Poor inspiration
Over or under penetration
Rotation
Forgetting the path of the x-ray beam

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

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

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

19. 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

20. 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

21. Lung Anatomy on Chest X-ray
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.

22. Lung Anatomy on Chest X-ray
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

23. Lung Anatomy on Chest X-ray
Left lower lobes

24. The Normal Chest X-ray PA View: Aortic arch Pulmonary trunk
Left atrial appendage
Left ventricle
Right ventricle
Superior vena cava
Right hemidiaphragm
Left hemidiaphragm
Horizontal fissure

25. The Normal Chest X-ray Lateral View: Oblique fissure
Horizontal fissure
Thoracic spine and retrocardiac space
Retrosternal space

26. The Silhouette Sign
An intra-thoracic radio-opacity, if in anatomic contact with a border of heart or aorta, will obscure that border. An intra-thoracic lesion not anatomically contiguous with a border or a normal structure will not obliterate that border.

27. Putting It All Together

29. Understanding Pathological Changes
Most disease states replace air with a pathological process
Each tissue reacts to injury in a predictable fashion
Lung injury or pathological states can be either a generalized or localized process

30. Liquid Density Liquid density Increased air density Generalized
Localized
Diffuse alveolar
Diffuse interstitial
Mixed
Vascular
Infiltrate
Consolidation
Cavitation
Mass
Congestion
Atelectasis
Localized airway obstruction
Diffuse airway obstruction
Emphysema
Bulla

31. Stages of Evaluating an Abnormality
1. Identification of abnormal shadows
2. Localization of lesion
3. Identification of pathological process
4. Identification of etiology
5. Confirmation of clinical suspension
Complex problems
Introduction of contrast medium
CT chest
MRI scan

32. Putting It Into Practice

33. Case 1

35. 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

36. Case 2

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

39. Case 3

41. Right Middle and Left Upper Lobe Pneumonia

42. Case 4

44. Cavitation:cystic changes in the area of consolidation due to the bacterial destruction of lung tissue. Notice air fluid level.

45. Cavitation

46. Case 5

48. Tuberculosis: bilateral upper lobe consolidations

49. Case 6

51. Bronchial Harmatoma: popcorn calcifications with defined margins

52. Case 7

54. Nipple shadow: bilateral symmetrical lower zone opacity.

55. Case 8

57. Extra medullary haemopoasis: enlarged paravertebral soft tissues
D/D neurofibroma

58. Case 9

60. Dextracardia : gastric air bubble seen under right hemi diaphram.

61. Case 10

63. Chest wall lesion: arising off the chest wall and not the lung

64. Case 11

66. Pleural effusion: Note loss of left hemidiaphragm
Pleural effusion: Note loss of left hemidiaphragm. Fluid drained via thoracentesis

67. Case 12

69. Lung Mass

70. Case 13

72. Small Pneumothorax: LUL

73. Case 14

75. Right Middle Lobe Pneumothorax: complete lobar collapse

76. Case 15

78. Metastatic Lung Cancer: multiple nodules seen

79. Case 16

81. Mycetoma: left upper zone intracavitatory lesion

82. Case 17

84. Perihilar mass: Hodgkin’s disease

85. Case 18

87. Widened Mediastinum with illdefined aortic outline: Aortic Dissection

88. Case 19

90. Achalasia cardia: dilated oesophagus.

91. Case 20

93. Pneumo mediatinum : the lucent line adjascent to the pericardium continues in the diaphramatic surface:

94. Case 21

96. Sarcoidosis : bilateral symmetrical hilar LNs

97. Case 22

99. Cystic bronchiectasis : bilateral multiple cystic air spaces with fluid level

100. Case 23

102. Gas under diaphram : lucent gas shadow under the diaphram

103. Questions?