Chest Radiography For Interns

CHEST RADIOLOGY
Scope
I. Introduction
II. Radiographic views
III. Proper radiographic technique
IV. Special techniques
V. Sample readings
Image Generation
• X-rays are a form of radiant energy similar in many ways to visible
light.
• X-rays differ from visible light in that they have a very short
wavelength and are able to penetrate many substances that are
opaque to light.
• The x-ray beam is produced by bombarding a tungsten target with an
electron beam within an x-ray tube.
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Schematics of a conventional X-ray tube: the electrons (e − ) are emitted

from the cathode and collected at the anode releasing X-ray radiation
WHAT IS ATTENUATION?
• process by which a beam of radiation is reduced in
intensity when passing through material
• If a tissue has low attenuation it would suggest that it
is relatively transparent and appears dark (air)
• high attenuation is a denser material and (bone)
objects appear brighter
• In general, the denser the material, the better its
ability to attenuate x-ray beam, the brighter/whiter it
would appear on x-ray images
5 BASIC RADIOGRAPHY DENSITIES
• Air density
• lungs
• Fat density
• Subcutaneous tissue
• Soft tissue density
• Heart
• Bone density
• ribs
• Metal/contrast density
• pacemaker
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NAMING RADIOGRAPHIC VIEWS
• Most x-ray views are named on the basis of the way
that an x-ray beam passes through the patient
• Views are also named by the position of the patient

NAMING RADIOGRAPHIC
VIEWS
Chest posteroanterior (PA) Chest anteroposterior (AP)
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NAMING RADIOGRAPHIC
VIEWS
Abdomen left lateral decubitus Abdomen upright
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PAL view
• posteroanterior (PA)
and lateral chest
radiographs are the
mainstays of thoracic
imaging
• initial imaging study in
patients with thoracic
disease
• focus-to-film distance
of 6 feet
• Lateral view
– for anatomical
localization of lung
abnormality
AP view
• Antero-posterior view (AP
view)
– requested if PA view
cannot be done;
– reserved for very ill
patient or patients who
cannot stand erect
(babies).
AP view
• requires longer
exposures to penetrate
cardiomediastinal
structures
• magnification of
intrathoracic structures
• widening of the upper
mediastinum
• normal gravitational
effect
Portable Radiograph
• obtained when
patients cannot be
safely mobilized
• taken on AP view
(sitting or supine)
• Focus-to-film distance
of 40 inches
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PA VS AP
POSTERO-ANTERIOR ANTERO-POSTERIOR
• Ribs: angulated • Straighter
• Clavicle: V- shape • Horizontal
• Scapula: Winging • No winging
• Heart: Not magnified • Magnified
• Gastric bubble: Present • Absent
POSTERO-ANTERIOR ANTERO-POSTERIOR
4 Basic features of proper radiographic
technique
• Penetration
• Rotation
• Inspiration
• Motion
Penetration
Proper penetration is present when there is faint visualization of the
thoracic intervertebral disk spaces and discrete branching vessels can
be identified through the cardiac shadow and the diaphragm.
Rotation
Rotation is assessed by noting the relationship between a vertical line
drawn midway between the medial cortical margins of the clavicular
heads and one drawn vertically through the spinous processes of the
thoracic vertebrae.
Inspiration
An appropriate deep inspiration in a normal individual is present when the
apex of the right hemidiaphragm is visible below the 10th posterior rib.
Motion
The cardiac margin, diaphragm, and pulmonary vessels should be
sharply marginated in a completely still patient who has suspended
respiration during the radiographic exposure
No motion With motion
CHEST FINDINGS:
-No active lung infiltrates seen.
-Pulmonary vascular markings are within normal limits.
-Heart is not enlarged.
-Diaphragm and sulci are intact.
-Visualized bones are intact.
NOTE of (TUBES/ CHEST LEADS/ other Pathologies seen in chest)
IMPRESSION:
Unremarkable chest
ABDOMEN UPRIGHT AND SUPINE
- There are normal gas filled bowel loops with minimal amount of fecal
materials within the colon.
- Rectal gas is present.
- Soft tissue outlines are intact.
- No demonstrable pneumoperitoneum, ascites or abnormal calcifications.
- Visualized bones are intact.
IMPRESSION:
-Unremarkable abdominal radiograph
Special Techniques
• lateral decubitus
• expiratory radiograph
• apical lordotic view
• chest fluoroscopy
Lateral decubitus
• obtained with a horizontal x-ray beam while the
patient lies in the decubitus position
• used to detect small effusions or pneumothorax
Expiratory radiograph
• obtained at residual volume (end of maximal
forced expiration)
• detection of a small pneumothorax
Apical lordotic view
• Caudocephalad
angulation of the tube
projects the clavicles
and first costochondral
junctions superiorly,
providing an
unimpeded view of the
apices.
Chest fluoroscopy
• assess chest dynamics on patients with
suspected diaphragmatic paralysis
Sample Diagnoses
• Pneumonia
• Atelectasis
• Pneumothorax
• Pleural effusion
• Pulmonary edema
• Pneumoperitoneum
Pneumonia
Atelectasis
• Direct signs
• Displacement of interlobar fissure
• Increased density of atelectatic lung
• Indirect signs
• Bronchovascular crowding
• Ipsilateral diaphragm elevation
• Ipsilateral tracheal / cardiac / mediastinal shift
• Hilar elevation (upper lobe atelectasis) or
depression (lower lobe atelectasis)
• Compensatory hyperinflation of other lobes
• Shifting granuloma
• Ipsilateral small hemithorax
• Ipsilateral rib space narrowing
Pneumothorax
Pleural Effusion
Pulmonary edema
Pneumoperitoneum
Thank you!

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CHEST RADIOLOGY

Schematics of a conventional X-ray tube: the electrons (e − ) are emitted

• Views are also named by the position of the patient

Chest posteroanterior (PA) Chest anteroposterior (AP)

Abdomen left lateral decubitus Abdomen upright

NOTE of (TUBES/ CHEST LEADS/ other Pathologies seen in chest)

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