Chest x-ray reading

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Chest x-ray reading

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Check List(1)

• Check patient data, position, technical quality
  and normal anatomy.
• Review systematically
• Initial survey
• Review skeletal structures of shoulder girdles
  and chest wall
• Review mediastinum
• overall size and shape
• trachea position
• margins SVC, ascending aorta, right atrium, left
  subclavian artery, aortic arch, main pulmonary
  artery, left ventricle
• lines and stripes paratracheal, paraspinal,
  paraesophageal (azygoesophageal), paraaortic
• retrosternal clear space
• Review hila
• normal relationships
• size

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Check List(2)

• Review lungs and pleura
• compare lung sizes
• evaluate pulmonary vascular pattern compare
  upper to lower lobe, right to left, normal
  tapering to periphery
• pulmonary parenchyma
• pleural surfaces
• fissures - major and minor - if seen
• compare hemidiaphragms
• follow pleura around rib cage
• Soft tissue including breast, companion shadow .
• Review abdomen for bowel gas, organ size,
  abnormal calcifications, free air, etc.
• Review soft tissues and spine of neck.
• Review spine and rib cage check alignment, disc
  space narrowing, lytic or blastic regions, etc.

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Check List

• Check patient data, position, technical quality
  and normal anatomy.
• Review systematically
• Initial survey
• Review skeletal structures of shoulder girdles
  and chest wall
• Review mediastinum
• Review hila
• Review lungs and pleura
• Soft tissue including breast, companion shadow

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1. Data base

• Name
• Date - important for comparing prior exams-
  Serial image
• Position markers - right(R) vs. left(L)
• Type of film
• Patients position
• supine, upright, lateral, etc.
• 6. Technical quality

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1
2
3
(erect)
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4
1
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Introduction

• Serial image Doubling time
• Point of disease(location/size)
• Make diagnosis easily
• Pneumonia
• Edema
• Tumor

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Position

• Chest x-ray
• P-A view
• A-P
• A-P supine
• Lateral (Lt/Rt)
• Lateral decubitus (Lt/Rt)
• Lordotic
• Oblique(Rt/Lt post/anterior)

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Position

• Speical position for special purpose
• A-P supine Ambulatory limit
• A-P Lateral (Lt/Rt) Anatomy reading
• Lateral decubitus Effusion or thickening
• Lordotic Apical lesion
• Oblique Eliminate superimposed lesion
• Affect read result- eg. redistritubion
  Phenomenon (slide 183)

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P-A view
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Rt Lateral view
Rt Lateral decubitus view
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Technical quality

• Ideal KV exposure
• Key points
• Apex
• Retrocardiac lung marking
• Trachea position
• Spine
• Scapula
• You can't find a subtle pneumothorax if there is
  patient motion or the film is overexposed.
• 4 basic radiographic densities

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Technical quality

• Ideal KV exposure
• 4 basic radiographic densities
• Air
• Fat
• Water(soft tissue)
• Bone(metal)

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Normal Anatomy

• Anatomy projection
• General anatomy
• Lobar anatomy
• Segmental anatomy
• The sihouette sign

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Normal Anatomy

• Anatomy projection
• General anatomy
• Posterior process
• Rib(Ant/Post)
• Left 2/Right 4
• Costothoracic ratio
• Central trachea
• Hilar LtgtRt
• Lung field Centralgt Peripheral/ Peripheral clear
  zone
• Pleura Linear
• Diaphragm Right gtleft/ Angle/Gastric pattern
• Subcutaneous tissue
• Lobar anatomy
• Segmental anatomy

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Normal Anatomy

• Anatomy projection
• General anatomy of lateral view
• Right diaphragm
• Left diaphragm
• Spine
• Scapula
• Axiallary fold
• Sternum
• Subcutaneous tissue
• Trachea
• Aortic arch
• Main bronchus
• Pulmonary artery
• Heart
• Retrosternal clear space
• Retrocardiac clear space
• Costophrenic angle
• Costocardiac angle

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5
8
4
13
9
6
10
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12
3
7
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1
2
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16
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Normal Anatomy

• Anatomy projection
• General anatomy
• Lobar anatomy
• Fissures
• Def Pleura surround by air
• 3 main(1 minor 2 major)
• 3 accessory(Azygos inferior superior
  accessory)
• If fissure do not appear a thin line?
• - Ans ?
• Segmental anatomy
• The sihouette sign

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Normal Anatomy

• Anatomy projection
• General anatomy
• Lobar anatomy
• Fissures
• Def Pleura surround by air
• 3 main(1 minor 2 major)
• 3 accessory(Azygos inferior superior
  accessory)
• If fissure do not appear a thin line-
  Pneumonia(Bulging)- Atelectasis (Deviation) -
  Pleural effusion (Pseudotumor)
• Segmental anatomy
• The sihouette sign

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Lobar anatomy
1
2
1
2
3-4
5
3-4-5
3-4-6
6
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Normal Anatomy

• Anatomy projection
• The sihouette sign
• Define
• Interface is invisible when two areas of similar
  radiodensity touch.
• Position

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Normal Anatomy

• Anatomy projection
• The sihouette sign
• Define
• Location
• Heart/Asending aorta
• Desending aorta/Diaphragm
• Airbronchogram
• Incomplete border

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Normal Anatomy

• Anatomy projection
• General anatomy
• Lobar anatomy
• Segmental anatomy
• Rt 1-10
• Lt 1-10 (12, 78)

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1
1
2
2
3
3
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4
5
5
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6
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7
9
9
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8
10
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12
12
3
3
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4
4
5
5
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78
9
10
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Check List

• Check patient data, position, technical quality
  and normal anatomy.
• Review systematically
• Initial survey
• Review skeletal structures of shoulder girdles
  and chest wall
• Review mediastinum
• Review hila
• Review lungs and pleura
• Soft tissue including breast, companion shadow

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Systematic review

• A-B-C-D-E-F-G-H or
• ? ? ? ?
• Try interpret and understand what you see
• D.D. normal v.s. abnormal?

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Systematic review

• A-B-C-D-E-F-G-H
• A Airway
• B Bone
• C CV
• D Diaphragm
• E Extra-pulmonary
• F Lung field
• G Gastric bubble
• H Hilum/Hernia

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Systematic review

• ? ? ? ?
• Initial survey
• Review skeletal structures of shoulder girdles
  and chest wall
• Review mediastinum
• Review hila
• Review lungs and pleura
• Soft tissue including breast, companion shadow. .

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Check List

• Check patient data, position, technical quality
  and normal anatomy.
• Review systematically
• Initial survey
• Review skeletal structures of shoulder girdles
  and chest wall
• Review mediastinum
• Review hila
• Review lungs and pleura
• Soft tissue including breast, companion shadow

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Initial survey

• General Body Size, Shape, and Symmetry
• Sex
• Age(cartilage/aortic arch /asending
  aorta/Pulmonary trunk)
• Infant/ child/ young adult/ elderly person
• Foreign objects
• tubes, IV lines, EKG leads, surgical drains,
  prosthesis
• non-medical objects, bullets, shrapnel, glass,
  etc

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Check List

• Check patient data, position, technical quality
  and normal anatomy.
• Review systematically
• Initial survey
• Review skeletal structures of shoulder girdles
  and chest wall
• Review mediastinum
• Review hila
• Review lungs and pleura
• Soft tissue including breast, companion shadow

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Skeletal structures

• Overall size, shape, contour of each bone.
• Density( mineralization)
• Compare cortical thickness to medullary cavity,
  trabecular pattern,
• Erosions, fractures, any lytic or blastic
  regions.
• Joints
• Articular relationships
• Joint spaces narrowed, widened
• Calcification in the cartilages
• Air in the joint space, abnormal fat pads
• Refresh gross anatomy radiology

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Neck and Cervical spines

• Overall(soft tissue)
• amounts
• calcifications,
• subcutaneous emphysema
• Trachea
• position
• size
• Cervical spine,
• alignment
• note any major congenital abnormalities.
• Specific parts of the vertebra and disc spaces
• Checking
• erosions
• lytic or blastic lesions
• disc and synovial joint narrowing
• Other abnormalities.

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Thoracic spine and Rib cage

• Overall alignment- spine
• Symmetry - rib cage
• Double check bone density
• Two reminders at this point
• Principle of general
• More detailed review in each section.
• concentrate on the skeletal detail
• Look through" the mediastinum and lungs.

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Thoracic spine

• Specific parts(Each)
• Vertebra
• Disc spaces
• height
• integrity of cortical margins/pedicles/lamina
• presence of any lytic or sclerotic areas
• synovial joints(normal /narrowing /sclerosis
  spacing )
• Compare frontal lateral projections

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Thoracic spine
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Ribs

• 1. Posterior Rib
• 2. Anterior Rib

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Ribs

• Compare
• Side to side,
• Cortical margins,
• Trabecular patterns.
• Note calcified anterior cartilages
• may obscure or mimic underlying lung lesions.

• 1. Posterior rib, 2.Ant rib

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Lt/Rt SHOULDER GIRDLE
3
7
8
1
6
4
2
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Check List

• Check patient data, position, technical quality
  and normal anatomy.
• Review systematically
• Initial survey
• Review skeletal structures of shoulder girdles
  and chest wall
• Review mediastinum
• Review hila
• Review lungs and pleura
• Soft tissue including breast, companion shadow

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Mediastinum

• Define
• Area between the lung
• Water density
• Surrounded two air filled lungs and
• Intersected by the air filled trachea and major
  bronchi.
• Key is knowledge of anatomical relationships and
• how structures project on a radiograph.
• CT and MRI is helpful.
• Interfaces of air-soft tissue margins may be
  distorted by pathological lesion
• Masses
• otherwise

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Mediastinum

• Define
• Area between the lung
• Water density
• Surrounded two air filled lungs and
• Intersected by the air filled trachea and major
  bronchi.
• Key is knowledge of anatomical relationships and
• how structures project on a radiograph.
• CT and MRI is helpful.
• Interfaces of air-soft tissue margins may be
  distorted by pathological lesion
• Masses
• otherwise

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MEDIASTINUM
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Mediastinum

• Define
• Area between the lung
• Water density
• Surrounded two air filled lungs and
• Intersected by the air filled trachea and major
  bronchi.
• Key is knowledge of anatomical relationships and
• how structures project on a radiograph.
• CT and MRI is helpful.
• Interfaces of air-soft tissue margins may be
  distorted by pathological lesion
• Masses
• otherwise

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Anatomy
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Project
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Anatomy project

• 1. Carina
• 2. Left Main Stem Bronchus
• 3. Descending Aorta
• 4. Main Pulmonary Artery
• 5. Aorticopulmonary Window
• 6. Arch of Aorta

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MEDIASTINUM

• Anatomy dividing region
• SUPERIOR MEDIASTINUM
• Begins - root of the neck and
• Ends - line drawn T-4 vertebrae ---
  sternomandible junction.
• line skims the top of the aortic arch. T
• Mediastinum
• Begins - this line
• End- diaphragm
• Further divided into three regions
• Anterior
• Middle
• Posterior.

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4
1cm
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Mediastinum

• Overall size and shape
• Trachea position
• Margins
• Lines and stripes
• Retrosternal clear space

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Mediastinum

• Overall size and shape
• Trachea- position
• Margins
• SVC- Ascending aorta
• Right atrium
• Left subclavian artery- Aortic arch
• Main pulmonary artery
• Left antrium
• Left ventricle
• Lines and stripes
• Retrosternal clear space

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Margins
I
I
II
III
II
IV
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Venography

• 1. Right Brachiocephalic Vein
• 2. Superior Vena Cava
• 3. Left Brachiocephalic Vein

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Axial plan of computer tomography

1. Right Brachiocepahlic Artery
2. Superior Vena Cava
3. Right Paratracheal Stripe
4. Esophagus
5. Left Subclavian Artery
6. Left Common Carotid Artery
7. Left Brachiocephalic Vein

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4
1cm
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Mediastinum

• Overall size and shape
• Trachea position
• Margins
• Lines and stripes
• Paratracheal
• Paraspinal
• Paraesophageal (azygoesophageal)
• Paraaortic
• Retrosternal clear space

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Edge of Superior vena cave (SVC)

• Seen PA(AP) view only
• Often only a portion
• Never bulge into the lung with a convex border.

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Right Pratracheal stripe
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Right Pratracheal stripe

• Normal- lt 5 mm, usually 2-3 mm.
• Important marker for subtle adenopathy.
• Distal end - formed by azygous vein
• Distended vein, stripe gt 1 cm.
• Medial margin -soft tissue interface /right
  mucosal surface of trachea.
• Outer margin -begins medial end of
  clavicle/formed by plural surface of right upper
  lobe (RUL).
• Normal structures in soft tissue density between
  air trachea and the RUL
• Right wall of the trachea
• Nerves
• Fat
• Lymph nodes
• Pleura of the RUL.
• Azygous vein - anteriorly to empty into the
  posterior surface of the SVC. 

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Right paratracheal stripe(TOMOGRAM )
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CT of Paratracheal stripe

• 1. Asending aorta
• 2. Azygous vein
• 3. Esophagus
• 4. Desending aorta
• 5. Pulmonary trunk

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Left Subclavian stripe

• Width- normal 1.0-1.5 cm.
• Inner margin-
• Air mucosal interface -mucosal surface of
  the trachea,
• Outer margin interface - Medial aspect of left
  upper lobe
• Upper- outer edge Level of the clavicle and will
  be able to follow it
• End- Bulge of the aortic arch.

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Paraspinal stripe
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• Sometimes() on the frontal view
• Plural edge parallel to the lateral margins of
  the vertebral bodies.
• Edge gt millimeters beyond the vertebral bodies
• Should not be lumpy or bulging.

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Pleural mediastinal interface

1. Superior Vena Cava
2. Right Paratracheal Stripe
3. Left Subclavian Stripe

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Azygoesophageal line or Paraesophageal line
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• On the forntal view only
• Formed by the right lower lobe Mediastinum,
  containing
• Esophagus
• Azygous vein.
• Overlies the thoracic spine
• Near the midline
• Fairly straight, vertically.
• Bulges convex to lung
• S/p mediastinal mass, eg.
• subcarinal lymph nodes
• Enlarged left atrium.

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CT of the Azygoesophageal line

• 1. Esophagus
• 2. Azygous Vein
• 3. Descending Aorta

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Lateral view of tracheal wall

• Posterior tracheal lt 4mm

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MEDIASTINUM

• Overall size/ shape on PA lateral views
• Decide if it is normal age.
• Look for
• Obvious masses
• Calcifications
• Double check for foreign projects
• Tubes
• Electrical leads
• Pacemaker
• Artificial valves

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MEDIASTINUM

• Evidence of
• Mediastinal shift
• Entire or
• Section of it.
• Look trachea/major bronchus
• Size
• Position
• Intraluminal masses

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SUPERIOR MEDIASTINUM - PA

• Overall width for normal size,
• Look for
• Masses
• Calcifications
• Free air.
• Detailed search for subtle distortion of
• several major pleural mediastinal interfaces.
• Not all of the following structures are seen on
  every film
• Try to find them

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Mediastinum

• Define
• Area between the lung
• Water density
• Surrounded two air filled lungs and
• Intersected by the air filled trachea and major
  bronchi.
• Key is knowledge of anatomical relationships and
• how structures project on a radiograph.
• CT and MRI is helpful.
• Interfaces of air-soft tissue margins may be
  distorted by pathological lesion
• Masses
• otherwise

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HEART

• 1 Edge of superior vena cava
• 2. Right atrium
• 3. Aortic arch
• 4. Edge of main pulmonary artery
• 5. Left atrial appendage
• 6. Left ventricle

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• Superimposed on the frontal view.
• The major structure is the heart.
• Pericardium and heart is inseparable on plain
  film views.
• Review the heart for overall size and shape.
• Rough yardstick - cardiac-thoracic ratio
• Widest diameter of the heart /widest width of the
  thoracic cage( inner aspect of rib to rib).
• gt 50
• Check
• Calcifications
• Pneumopericardium
• Pneumomediastinum
• Sutures
• Prosthetic valves etc.,
• You may have overlooked on the general survey of
  the entire mediastinum.

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Lateral view of heart

• 1. Trachea
• 2. Right Ventricle
• 3. Left Ventricle
• 4. Left Atrium
• 5. Right Pulmonary Artery

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Aorta
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• Try tracking
• Root
• Distal descending aorta.
• Young adult - hidden in the mediastinum
• Older - swing to the right to cast a soft
  tissue bulge.
• Arch- always be seen
• make sure left to distal trachea
• Pushes trachea slightly to the right actually .
• Check aortic calcifications and size.
• Left lateral border of descending aorta
• abuts the left lung (column of dots on the pt's.
  left, on the annotated image).
• Lateral view- aorta is usually not seen. 

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Pulmonary artery

• 1. Carina
• 2. Left Main Stem Bronchus
• 3. Descending Aorta
• 4. Main Pulmonary Artery
• 5. Aorticopulmonary Window
• 6. Arch of Aorta

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• Main pulmonary artery
• Straight or
• Convex (most commonly in young females).
• "middle mogul" - when convex
• Upper "mogul" - aortic knob
• Lower mogul - left ventricle.
• Left pulmonary artery- branching of main
  pulmonary artery
• Right pulmonary artery-
• Proximal- not seen, ( buried in the mediastinum)
• Branches can see ( as the right hilum)

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Blood vesseles in the lung
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Pulmonary arteries, Lateral view

• 1. Trachea
• 2. Right Ventricle
• 3. Left Ventricle
• 4. Region of left Atrium
• 5. Right Pulmonary Artery
• 6. Left Pulmonary Artery

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Pulmonary artery

• Right pulmonary artery
• Ovoid branching structure- easily seen,
• Just anterior to the air column of the trachea
  and main bronchi.
• Left pulmonary artery
• Never seen as clearly as the right
• Unless markedly enlarged.
• Curved shadow, similar to the aorta
• just behind the air column

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Aorticopulmonary window(AP WINDOW)
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• Double check area - for subtle mediastinal
  masses.
• Between
• Aortic arch
• Left pulmonary artery
• Residual portion
• Ligamentum arteriosum
• left recurrent laryngeal nerve
• Should concave or straight border.
• Mediastinal mass()
• Lung pushed laterally ? border becomes convex.

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MISCELLANEOUS

• Lateral view
• Adult
• anterior mediastinum cephalad to the heart
• Lung-air density, not soft tissue density.
• Infants and young children
• Thymus fills this area.
• Check posterior sternal margin
• Small masses internal thoracic lymph node
  enlargement.

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Check List

• Review hila
• normal relationships
• size
• Review lungs and pleura
• compare lung sizes
• evaluate pulmonary vascular pattern compare
  upper to lower lobe, right to left, normal
  tapering to periphery
• pulmonary parenchyma
• pleural surfaces
• fissures - major and minor - if seen
• compare hemidiaphragms
• follow pleura around rib cage

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Frontal view of the hila
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Frontal view of the hila

• Frontal view, hilar shadows most
• left pulmonary arteries.
• right pulmonary arteries.
• Bronchi(with the arteries)
• Radiolucent.
• Pulmonary veins
• Not clearly seen
• they are behind the widest parts of the heart,
  inferior to the hila, where they converge into
  the left atrium.
• Left pulmonary artery always more superior gt
  right, ? left hilum higher.
• Calcified lymph nodes may be visible within the
  hilar shadows. 

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Lateral view of the hila

• 1. Trachea
• 2. Lower lobe bronchi (left and right
  superimposed)
• 3. Right Pulmonary Artery

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Check List

• Review hila
• normal relationships
• size
• Review lungs and pleura
• compare lung sizes
• evaluate pulmonary vascular pattern
• compare upper to lower lobe, right to left,
  normal tapering to periphery
• pulmonary parenchyma
• pleural surfaces
• fissures - major and minor - if seen
• compare hemidiaphragms
• follow pleura around rib cage

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Lung size
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Lung

• Compare overall size of one lung bilateral,
• Also a double check on your earlier look at the
  rib cage size.
• Look for major areas of abnormal lucency/or
  density
• Train your eyes to look through the heart and
  upper abdomen to lung posterior to these areas.

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Blood vesseles in the lung
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Blood vesseles in the lung

• Distribution- side to side
• Compare right/left upper lobes and lower lobes
  for roughly equal.
• Distribution- upper to a lower
• Vessel in the same middle zone of the lung.
• Upright person- pressure differential
• lower lobe vessel wider (i.e., larger)
• If same size or reversed in size,
• Redistribution of flow has occurred.
• Phenomenon does not apply, if the person is
  semi-recumbent or supine. 

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Blood vesseles of lung
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PARENCHYMA
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PARENCHYMA

• Large abnormalities/small lesion
• Masses
• Infiltrates
• calcifications
• Compare- side to side at a time.
• Now ignore the bone but lung.
• 3 areas easily overlooked
• Behind the calcified anterior first rib
  cartilage,
• Behind the heart
• Behind the diaphragm

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LATERAL VIEW OF THE LUNG

• Lateral view
• Help to look
• Posterior costophrenic recess
• Anterior mediastinum.

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Pleura

• PA view
• Minor fissue thickness and location
• Lateral view
• minor fissures
• major fissures (even if you do not see them in
  their entirety which you rarely will).

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AP VIEW OF THE PLEURA

• Follow the pleural surface around the lung
  periphery making the following observations.
• On the frontal view, the apex of the
  hemidiaphragms should be in the mid third of each
  hemithorax with the right hemidiaphragm usually
  2-2.5 cm higher than the left.
• The costophrenic angles laterally should be
  sharp.
• The lung should abut right up against the inner
  margins of the rib cage.
• If the pleural space is widened by fluid or mass,
  the lung will be pushed away by soft tissue
  density.
• Also check for pleural calcifications, and
  presence of pneumothorax. 

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LATERAL VIEW OF THE PLEURA

• Lateral view
• ,follow the pleura into the posterior
  costophrenic recess
• along the inner aspect of the posterior ribs, if
  possible.
• Recheck Posterior sternal margin.

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Soft tissues

• Overall
• Following
• Calcifications
• Bony defect
• Soft tissue companion shadow for the clavicle
• Supraclavicular LAP

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Lt/Rt CHEST WALL

• Overall thickness, subcutaneous emphysema,
  calcification.
• Muscle-fat planes (sharp, distinct dots).

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BREAST TISSUE

• Symmetry (Normal variation Standing(PA view)
  unequal pressure against the film holder)
• Notice lung density changes (lung area /- soft
  tissue of the breast )

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ABDOMEN

• Highly variable
• look for following
• Gastric and bowel gas
• Amount/ location( normal? )
• Organ size
• liver, spleen, kidneys
• Free peritoneal air
• Position will change location of free air.
• Calcifications and masses
• can they be localized to a specific structure.

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Final Notes
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• This completes an introduction into the
  beginnings of chest review.
• Be aware there are many more detailed
  observations to learn in the future.
• Go through the sections until you understand the
  anatomy, and then start practicing a continuous
  review looking at a full frontal and lateral
  view.
• When you have developed a review system that
  works for you (remember the order here is only a
  guide) go to the next section that has the check
  off list type of review.
• Many people find it helpful to talk their way
  through the film, the eye-brain-mouth loop does
  work.
• Finally look at films on a variety of normal
  people of all ages, sizes, and both sexes to
  develop a data base of normal references.
• Practice the review sequence that works best for
  you until it is automatic, and then you can
  concentrate on the diagnostic findings. 

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Check List (1)

• Check patient name, position, technical quality.
• Initial survey
• Soft tissue including breast, chest wall,
  companion shadow.
• Review soft tissues and skeletal structures of
  shoulder girdles and chest wall.
• Review abdomen for bowel gas, organ size,
  abnormal calcifications, free air, etc.
• Review soft tissues and spine of neck.
• Review spine and rib cage check alignment, disc
  space narrowing, lytic or blastic regions, etc.
• Review mediastinum
• overall size and shape
• trachea position
• margins SVC, ascending aorta, right atrium, left
  subclavian artery, aortic arch, main pulmonary
  artery, left ventricle
• lines and stripes paratracheal, paraspinal,
  paraesophageal (azygoesophageal), paraaortic
• retrosternal clear space

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Check List (2)

• Review hila
• normal relationships
• size
• Review lungs and pleura
• compare lung sizes
• evaluate pulmonary vascular pattern compare
  upper to lower lobe, right to left, normal
  tapering to periphery
• pulmonary parenchyma
• pleural surfaces
• fissures - major and minor - if seen
• compare hemidiaphragms
• follow pleura around rib cage