Chest X-Ray

Chest X-ray
Interpretation
Bucky Boaz, ARNP-C
Introduction
Routinely
obtained
Pulmonary specialist consultation
Inherent physical exam limitations
Chest x-ray limitations
Physical exam and chest x-ray provide
compliment
Essentials Before Getting

Started
Exposure
Overexposure
Underexposure
Sex
of Patient
Male
Female

Started
Path
of x-ray beam
PA
AP
Patient
Position
Upright
Supine

Started
Breath
Inspiration
Expiration
Systematic Approach
Bony
Framework
Soft Tissues
Lung Fields and Hila
Diaphragm and Pleural Spaces
Mediastinum and Heart
Abdomen and Neck
Systematic Approach
Bony
Fragments
Ribs
Sternum
Spine
Shoulder girdle
Clavicles
Systematic Approach
Soft
Tissues
Breast shadows
Supraclavicular areas
Axillae
Tissues along side of
breasts
Systematic Approach
Lung
Fields and Hila
Hilum
Pulmonary arteries
Pulmonary veins
Lungs
Linear and fine nodular

shadows of pulmonary
vessels
Blood vessels
40% obscured by other
tissue
Systematic Approach
Diaphragm
and
Pleural Surfaces
Diaphragm
Dome-shaped
Costophrenic angles
Normal pleural is not
visible
Interlobar fissures
Systematic Approach
Mediastinum
and
Heart
Heart size on PA
Right side
Inferior vena cava

Right atrium
Ascending aorta
Superior vena cava
Systematic Approach
Mediastinum
and
Heart
Left side
Left ventricle
Left atrium
Pulmonary artery
Aortic arch
Subclavian artery and
vein
Systematic Approach
Abdomen
and Neck
Abdomen
Gastric bubble
Air under diaphragm
Neck
Soft tissue mass

Air bronchogram
Summary of Density
Air
Water
Bone
Tissue
Tissue
Pitfalls to Chest X-ray

Interpretation
Poor
inspiration
Over or under penetration
Rotation
Forgetting the path of the x-ray beam
Lung Anatomy
Trachea
Carina
Right and Left Pulmonary
Bronchi
Secondary Bronchi
Tertiary Bronchi
Bronchioles
Alveolar Duct
Alveoli
Lung Anatomy
Right
Lung
Superior lobe
Middle lobe
Inferior lobe
Left
Lung
Superior lobe
Inferior lobe
Lung Anatomy on Chest X-ray

PA View:
Extensive overlap
Lower lobes extend
high
Lateral
View:
Extent of lower lobes
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 middle lobe

is typically the
smallest of the three,
and appears triangular
in shape, being
narrowest near the
hilum
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.
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.

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

Left
lower lobes
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.
The Normal Chest X-ray
PA View:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Aortic arch
Pulmonary trunk
Left atrial appendage
Left ventricle
Right ventricle
Superior vena cava
Right hemidiaphragm
Left hemidiaphragm
Horizontal fissure
The Normal Chest X-ray
Lateral View:
1. Oblique fissure
2. Horizontal fissure
3. Thoracic spine and
retrocardiac space
4. Retrosternal space
The Silhouette Sign
An intra-thoracic radioopacity, if in anatomic

contact with a border of
heart or aorta, will obscure
that border. An intrathoracic lesion not
anatomically contiguous
with a border or a normal
structure will not
obliterate that border.
Putting It All Together
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
Liquid Density
Liquid density
Generalized
Localized
Diffuse alveolar
Diffuse interstitial
Mixed
Vascular
Infiltrate
Consolidation
Cavitation
Mass
Congestion
Atelectasis
Increased air density
Localized airway obstruction

Diffuse airway obstruction
Emphysema
Bulla
Consolidation
Lobar
consolidation:
Alveolar space filled with
inflammatory exudate
Interstitium and
architecture remain intact
The airway is patent
Radiologically:
A density corresponding to
a segment or lobe
Airbronchogram, and
No significant loss of lung
volume
Atelectasis
Loss
of air
Obstructive atelectasis:
No ventilation to the lobe
beyond obstruction
Radiologically:
Density corresponding to a
segment or lobe
Significant loss of volume
Compensatory
hyperinflation of normal
lungs
Stages of Evaluating an
Abnormality
1.
2.
3.
4.
5.
Identification of abnormal shadows

Localization of lesion
Identification of pathological process
Identification of etiology
Confirmation of clinical suspension
Complex problems
Introduction of contrast medium

CT chest
MRI scan
Putting It Into Practice
Case 1
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
Case 2
LUL Atelectasis: Loss of heart borders/silhouetting. Notice

over inflation on unaffected lung
Case 3
Right Middle and Left Upper Lobe Pneumonia
Case 4
Cavitation:cystic changes in the area of consolidation due to the

bacterial destruction of lung tissue. Notice air fluid level.
Cavitation
Case 5
Tuberculosis
Case 6
COPD: increase in heart diameter, flattening of the diaphragm, and

increase in the size of the retrosternal air space. In addition the
upper lobes will become hyperlucent due to destruction of the lung
tissue.
Chronic emphysema effect on the lungs
Case 7
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.
Case 8
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
Case 9
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.
24 hours after diuretic therapy
Case 10
Chest wall lesion: arising off the chest wall and not the lung
Case 11
Pleural effusion: Note loss of left hemidiaphragm. Fluid drained

via thoracentesis
Case 12
Lung Mass
Case 13
Small Pneumothorax: LUL
Case 15
Right Middle Lobe Pneumothorax: complete lobar collapse
Post chest tube insertion and re-expansion
Case 16
Metastatic Lung Cancer: multiple nodules seen
Case 17
Right upper lower lobe pulmonary nodule
Case 18
Tuberculosis
Case 19
Perihilar mass: Hodgkins disease
Case 20
Widened Mediastinum: Aortic Dissection
Case 21
Pulmonary artery stenosis with cardiomegally likely

secondary to stenosis.
Questions?

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Chest X-ray

Bucky Boaz, ARNP-C

Essentials Before Getting

Essentials Before Getting

Essentials Before Getting

Fields and Hila

Linear and fine nodular

Normal pleural is not

Inferior vena cava

Soft tissue mass

Pitfalls to Chest X-ray

Lung Anatomy on Chest X-ray

Extent of lower lobes

Lung Anatomy on Chest X-ray

The right upper lobe

Lung Anatomy on Chest X-ray

right middle lobe

Lung Anatomy on Chest X-ray

The right lower lobe is the

Lung Anatomy on Chest X-ray

These lobes can be separated

Lung Anatomy on Chest X-ray

Lung Anatomy on Chest X-ray

Lung Anatomy on Chest X-ray

These two lobes are

The Normal Chest X-ray

The Normal Chest X-ray

The Silhouette Sign

An intra-thoracic radioopacity, if in anatomic

Putting It All Together

disease states replace air with a

Increased air density

Localized airway obstruction

Alveolar space filled with

Identification of abnormal shadows

Introduction of contrast medium

Putting It Into Practice

A single, 3cm relatively thin-walled cavity is noted in the left

LUL Atelectasis: Loss of heart borders/silhouetting. Notice

Right Middle and Left Upper Lobe Pneumonia

Cavitation:cystic changes in the area of consolidation due to the

COPD: increase in heart diameter, flattening of the diaphragm, and

Chronic emphysema effect on the lungs

Pneumonia:a large pneumonia consolidation in the right lower

CHF:a great deal of accentuated interstitial markings,

24 hours after diuretic therapy

Pleural effusion: Note loss of left hemidiaphragm. Fluid drained

Small Pneumothorax: LUL

Right Middle Lobe Pneumothorax: complete lobar collapse

Post chest tube insertion and re-expansion

Metastatic Lung Cancer: multiple nodules seen

Right upper lower lobe pulmonary nodule

Perihilar mass: Hodgkins disease

Widened Mediastinum: Aortic Dissection

Pulmonary artery stenosis with cardiomegally likely

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