Chest Xray - How to read & interpret
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This document provides an overview of chest x-ray interpretation for clinical medicine. It discusses techniques, basic anatomy, common indices used and commonly encountered conditions. It covers determining image orientation, inspiration depth, rotation and penetration/exposure quality. Specific signs like air bronchograms and silhouette signs are described. Common lung opacities patterns of consolidation, interstitial, nodules/masses and atelectasis are outlined. Examples of different lung lobe collapses are shown and their characteristic x-ray findings explained. Radiation dose from chest x-rays is noted to be low but cumulative exposure should be limited.
Chest Xray - How to read & interpret
- 1. Chest X-Ray Interpretation in Clinical Medicine Presenter: Dr. Pratap singh chauhan Dept. Of Medicine, NSCB MCH Jabalpur
- 2. Technique, Basic Anatomy & Concepts Chest X-Ray indices Commonly encountered conditions
- 3. (180 cm)
- 10. Left hilar point should be always above Right.
- 13. Vanishing Tumor
- 14. Left and Right oblique fissures
- 15. Accessory Azygous FissureAccessory Azygous Fissure
- 18. Aortic Knuckle
- 21. Determining orientation: • Label • Cardiac shadow • Aortic Knuckle • Gastric air bubble • Level of Diaphragm
- 22. PA vs AP View: • Superior Mediastinum appears widened on AP view due to maginification. • Cardiac shadow appears enlarged due to magnification. • Medial border of scapula significantly covers lung fields in AP view. • AP projection images are of lower quality than PA images.
- 23. Why magnification in AP view
- 24. Inclusion: Must be visible: • First rib • Costo-phrenic angles. • Lateral ends of ribs.
- 26. • The diaphragm should be intersected by the 5th to 7th anterior ribs in the mid-clavicular line. Less is a sign of incomplete inspiration. • If the image is acquired in the expiratory phase, the lungs are relatively airless and their density is increased, particularly at bases, sometimes falsely labelled as basal pneumonitis.
- 28. Hyperexpansion: • If > 7th Anterior rib intersects diaphragm in midclavicular line. • Also can be assessed by apparent flattening of diaphragm.
- 29. This should be > 1.5 cm
- 32. Left rotation may produce false cardiomegaly.
- 33. Penetration/Exposure: • Vertebra not clearly visible through heart shadow. • Left hemi-diaphragm can not be traced to vertebral border. • Pulmonary vessels can not be traced till the end. • Vertebra clearly visible through heart shadow. • Left hemi-diaphragm can be traced to vertebral border. • Pulmonary vessels can be traced till the end. Under Penetration Good Penetration
- 35. Air Bronchogram: • Normally bronchial walls are not visible on X-ray. • Air containing Lung parenchyma and Bronchi with air form homogenous darkness. • When the internal tubular outline of a bronchus is visible within a thoracic opacity…that is an air bronchogram. • It is most commonly associated with a simple pneumonia. Sometimes it occurs with pulmonary oedema. • Hyperdensity due to pneumonia provides background (or foreground) to create contrast for visualization of air column within bronchi. • It is usually very good news for the patient. An air bronchogram excludes a bronchial obstruction
- 38. Silhouette Sign: • The silhouette sign is a misnomer! It should be called the 'loss of silhouette' sign. • Normal adjacent anatomical structures of differing densities form a crisp 'silhouette,' or contour. Loss of a specific contour can help determine the position of a disease process. • E.g. Loss of clarity of the right heart contour (formed by the right atrium) implies disease of the right middle lobe which lies next to the right atrium.
- 39. Loss of Silhouette of Right heart border: Pathology in right middle lobe which is next to right atrium
- 40. Cardio-Thoracic Ratio: Normal < 50 %
- 41. Opacities on Chest X-Ray: Lung abnormalities with an increased density - also called opacities - are the most common. A practical approach is to divide these into four patterns: • Consolidation • Interstitial • Nodules or masses • Atelectasis (Collapse)
- 43. • Consolidation Lobar consolidation Diffuse consolidation Multifocal ill-defined consolidations • Interstitial Reticular interstitial opacities Fine Nodular interstitial opacities • Nodule or mass Solitary Pulmonary Nodule Multiple Masses • Atelectasis
- 44. Clinical Data
- 45. For consolidation key-findings on the X-ray are: • ill-defined homogeneous opacity obscuring vessels • Silhouette sign: loss of lung/soft tissue interface • Air-bronchogram • Extention to the pleura or fissure, but not crossing it • No volume loss Volume Loss: • Pulling of Trachea • Pulling of Hemidiaphragm • Associated Pneumothorax
- 46. For collapse key-findings on the X-ray are: • Sharply-defined opacity obscuring vessels without air-bronchogram. • Volume loss resulting in displacement of diaphragm, fissures, hili or mediastinum
- 47. Right upper lobe collapse
- 48. Right upper lobe collapse with Pulled diaphragm
- 49. Right Lower Lobe collapse • Abnormal right border of the heart. • The right interlobar artery is not visible, because it is surrounded by the collapsed lower lobe
- 50. Usually right middle lobe atelectasis does not result in noticeable Findings. Right Middle Lobe collapse • Blurring of the right heart border (silhouette sign) • Triangular density on the lateral view as a result of collapse of the middle lobe
- 51. Right Middle Lobe collapse
- 52. Left Upper Lobe collapse • Minimal volume loss with elevation of the left diaphragm • Band of increased density in the retrosternal space, which is the collapsed left upper lobe • Abnormal left hilus, i.e. possible obstructing mass
- 53. Left Lower Lobe collapse • Triangular density seen through the cardiac shadow(posterior to heart) • This is confirmed on the lateral view. • Contour of the left diaphragm is lost from anterior to posterior. • Lower lobe vessels not visible as surrounded by the atelectatic lobe.
- 54. THANK YOU One Chest X-ray delivers radiation dose of 0.1 msv to patient . Yearly permissible radiation dose in 1 msv. Limit X-Ray chest to less than 10 times a year.
Editor's Notes
- #4: Setup is standard and important with respect to radiological indices. Those indices are not applicable for digital films. Where ratio are measured.
- #5: AP view films are of poorer quality and are not generally preferred. Done when patient is critically ill and not able to stand.
- #6: It is done to assess location of any pathology in anterior – posterior plane.
- #7: Everyone knows structures, Important is to know anatomical orientation and how they are translated on xray film.
- #12: To describe pathology on Xray film it is arbitrarily divided in 3 regions.
- #13: Tilted or curved horizontal fissures indicates pathology. Consolidation well delineated by fissure suggests Lobar consolidation. Phantom or Vanishing tumor is fissural edema.
- #15: Fissures are not readily visible , but if you search for it ,they can be detected.
- #17: Right oblique view showing relations of Azygos vein entering superior vena cava.
- #18: In PA view right diaphragm is higher than left. But posteriorly due to sloping and also due to beam centralization this may not hold true in lateral view. Both anterior and posterior ends of right diaphragm are visible throughout. It is higher anteriorly. Left hemidiaphragm anterior end is obscured by cardiac shadow.
- #20: aorto-pulmonary window : This is a potential space in the mediastinum where abnormal enlargement of lymph nodes can be seen on a chest x-ray.
- #23: AP views are of poorer quality , haziness should not be mistaken for Basal pneumonitis. Note that in both views Posterior ribs are prominent.
- #26: If the xray appears to be of poorer quality first : it might be an AP view film & secondly it could have been taken in partial inspiration.
- #31: In such cases there is no need to count ribs, as flattening is evident.
- #33: Now when we say that Patient is in LEFT or RIGHT rotation. Side away from film is rotation to that side.
- #39: Silhouette simply means delination
- #41: Since this is a ratio can be considered in digital films of variable magnification.
- #53: Vascular markings are still visible due to inflated lower lobe in same plane.