CHEST X-RAY

CONTENTS
● How to interpret chest X-ray

Frontal view

Lateral view

● Lobar anatomy, alveolar vs interstitial disease,

● Consolidation- focal and diffuse
● Pneumonia and silhouette sign
● Lobar collapse
● The normal hila and hilar abnormalities
● Pleural abnormalities
● Cardiac radiography
● COPD, Emphysema
● CLINICAL PROBLEMS
HOW TO INTERPRET A CHEST X-RAY
Basic densities in radiology.

Tissue Effect on X-
absorption ray

Least Air/gas Black

Fat Dark grey

Soft tissue Grey

Most Bone White

FRONTAL CHEST X-RAY
THE TEN-POINT CHECKLIST

1. AP or PA X-ray view
2. Depth of inspiration
3. Rotation
4. Cardiothoracic ratio- should be less than 50%
on a PA view
5. Both domes of diaphragm should be clearly
seen and well defined
6. Heart borders- clearly seen and well defined
7. Hila- density, position and size- The left hilum
should be at the same level or higher than the
rights. Never lower. The hilar density on each
side should be similar.
8. Bones- should be normal
9. Hidden areas - lung apex, superimposed over
the heart, around each hilum, below the
diaphragm.
10. Clinically correlate
FRONTAL CHEST X-RAY
● Obtained at a distance between the x-ray tube and the cassette of 180 cm (6 ft). The
patient faces the cassette and the x-ray beam passes through in the posterior to
anterior direction, i.e. PA
● The PA CXR is preferred.
● Frail/ sick patients, anteroposterior (AP) view is obtained.

THE BEDSIDE AP CXR HAS DISADVANTAGES

● The mediastinum is magnified giving impression of cardiomegaly.

● A supine patient unable to take a full inspiration/ rotation maybe present.

Standard PA CXR
 AP V/S PA VIEW
AP VIEW PA VIEW

CLAVICLE Above lung fields Over lung apex

SCAPULA Over lung fields Away from

lung fields

RIBS Anterior ribs Posterior ribs

distinct distinct

HEART Enlarged
DEPTH OF INSPIRATION

Adequate inspiration- 6 complete

anterior ribs. 10 complete posterior ribs
should be visible.

Shallow inspiration causes

● The heart to appear larger.

● Crowding of vessels at the lung
bases. May simulate basal lung
infection or areas of subsegmental
collapse.

*Expiratory film is better for

viewing Pneumothorax/ foreign
body
PATIENT ROTATION
A vertical line drawn through the centre of the
vertebral bodies (T1–T5) should be equidistant
from the medial end of each clavicle. Rotation
is present when one of the clavicles is further
away from this vertical line.

● Rotation to the right on PA CXR causes the

manubrium and / or superior vena cava
and / or vessels arising from the arch of
the aorta may become unusually
prominent on the right. This can simulate
a mediastinal mass. Rotation to right Rotation to left
● Rotation to the left on an AP CXR the
aortic arch may appear enlarged.
● Causes lung appearing blacker than the
opposite side.
LOBAR ANATOMY

The major fissures are not normally

visible on a frontal view. The minor
fissure is visible in 50% to 80% of
cases,at or near the level of the anterior
fourth rib.

Lateral projection. The major fissures

originate posteriorly above the level of
the aortic arch and near the level of the
fifth thoracic vertebra.
ALVEOLAR VS INTERSTITIAL DISEASE
CHEST X-RAY FINDINGS

Alveolar disease Interstitial disease

Fluffy/blobby Small nodules

Ill defined Linear / reticular

margins

Coalescing/ Linear / reticular with

merging septal lines

Segmental/lobar Reticulo-nodular

Air bronchogram Reduced lung Alveolar Interstitial disease

volume (extensive disease
disease)
Alveolar disease/Consolidation

Fluffy/homogeneous
Lobar/segmental pattern

Air
bronchogram

Pulmonary edema
Differential diagnosis of airspace
pattern/consolidation

● Pulmonary Edema
Cardiac
Non cardiac Alveolar disease/ consolidation
● Lobar pneumonia
● Haemorrhage
● Aspiration pneumonia
● ARDS Focal. Diffuse.
● Lymphoma
● Bronchiolo alveolar
carcinoma

Pneumonias.
Pulmonary edema
Interstitial pattern

Reticular/ reticular-nodular pattern

Differential diagnosis of interstitial
pattern
● Pulmonary edema
● Pneumonia- viral/ pneumocystis
jirovecii
● Tuberculosis
● Sarcoidosis
● Idiopathic pulmonary fibrosis
● Rheumatoid
FOCAL CONSOLIDATION

Focal consolidation may represent

● pneumonia:
● postobstructive pneumonia
● aspiration; pulmonary adenocarcinoma
● lymphoma or other lymphoproliferative disease
● infarction
● hemorrhage due to trauma
● granulomatosis with polyangiitis (GPA) formerly known as
Wegener’s granulomatosis
● pulmonary infarction
● organizing pneumonia
● eosinophilic pneumonia
● atelectasis
 Consolidation involving a single (or
more than one) lobe is most typical
of pneumonia (including
Streptococcus pneumoniae,
Klebsiella, Legionella, and TB) and
abnormalities associated with
bronchial obstruction.

Bulging Fissure Sign in Lobar pneumonia due

to Klebsiella
1) On the initial XRAY, a
patient with Legionella
pneumonia shows
consolidation in the right
upper lobe

2) Over few days,

consolidation increases in size 1 3
because of local interalveolar
spread.

3) Further progression results

in consolidation of the right
upper lobe, marginated by
the minor fissure.

4) A lateral view at the same

time as (3)

2 4
DIFFUSE CONSOLIDATION
Perihilar “bat-wing” consolidation- Most typical of pulmonary edema
(hydrostatic )

Central consolidation with sparing of the lung periphery. Most typical of pulmonary
edema (hydrostatic or permeability).
HYDROSTATIC PULMONARY EDEMA

Increased intravascular
pressure due to pulmonary
venous hypertension is the
predominant cause. This
may result from
● left heart failure,
● left atrial or pulmonary
venous obstruction,
● volume overload in
renal failure

Kerley’s A and B lines are visible, with a perihilar predominance.

Thickening of the right minor fissure also is visible as a result of subpleural
edema.
Chest X-ray findings

● Pulmonary vascular
congestion
● Cephalization
● Peribronchial cuffing
● Increased interstitial marking
(starts in the perihilar region)
● Kerley B lines (pleural-based, 2
horizontal interstitial lines)
● Fluffy alveolar opacities
● Pleural effusions
● Enlarged cardiac silhouette
Stages of congestive heart
failure

Stage 1- Redistribution Redistribution of pulm.

(pcwp 13-18 mmHg) vessels (cephalisation)
Cardiomegaly

Stage 2- Interstitial Kerley lines

edema (pcwp 18-25 Peribronchial cuffing
mmHg) Thickened interlobar
cuffing

Stage 3- Alveolar Consolidation

edema (> 25 mmHg) Air bronchogram
Pleural effusion
The Acute Respiratory Distress Syndrome ( Permeability
pulmonary edema )

ARDS - progressive dyspnea and hypoxemia over a period of hours to days.

Berlin criteria for the diagnosis and classification of ARDS :

● Acute onset, within a week of a known clinical insult or new or worsening

respiratory symptoms.
● Bilateral opacities on chest radiographs or CT, not fully explained by effusions,
lobar or lung atelectasis, or nodules
● Respiratory failure not explained by cardiac failure or fluid overload. Need
objective assessment (e.g., echocardiography) to exclude hydrostatic edema.

ARDS severity categories:

Mild: PaO 2 /FIO 2 >300 mm Hg with PEEP ≥ 5 cm H 2 O

Moderate: 200 mm Hg < PaO 2 /FIO 2 ≤ 300 mm Hg with PEEP or CPAP ≥ 5 cm H 2 O

Severe: PaO 2 /FIO 2 ≤ 100 mm Hg with PEEP ≥ 5 cm H 2 O

ARDS associated with sepsis. patchy opacities are visible peripherally, with a predominance
at the lung bases. There has been progressive consolidation, with a peripheral predominance
and air bronchograms are visible.
PNEUMONIA AND SILHOUETTE SIGN

On the frontal radiograph, obscuration of specific

contours may be related to abnormalities (e.g.,
consolidation or mass) involving specific lobes.

Obscuration of the borders shown in this diagram is

associated with consolidation of the listed lobes.

RUL, right upper lobe

RML, right middle lobe
RLL, right lower lobe
LUL, left upper lobe
LLL, left lower lobe.
RIGHT UPPER LOBE CONSOLIDATION

Typical findings of right upper lobe consolidation: (1) obscuration of the right superior mediastinum, (2)
obscuration of the superior right hilum, and (3) opacity marginated inferiorly by the minor fissure.
RIGHT MIDDLE LOBE CONSOLIDATION

Typical findings of right middle lobe consolidation: (1) the right heart border is obscured, (2) the opacity is
marginated superiorly by the minor fissure, and (3) the right diaphragm remains visible.
RIGHT LOWER LOBE CONSOLIDATION

Typical findings of right lower lobe consolidation: (1) the superior mediastinum is well seen, (2) the
inferior right hilum is obscured, (3) the right heart border remains visible, (4) the right
hemidiaphragm is obscured, and (5) the right minor fissure remains visible as a line.
LEFT UPPER LOBE CONSOLIDATION

Typical findings of left upper lobe (LUL; and lingular) consolidation: (1) the left superior mediastinum and
aortic arch are obscured, (2) the superior left hilum is obscured, (3) the descending aorta remains
visible, (4) the left heart border is obscured, and (5) the left hemidiaphragm remains visible.
LEFT LOWER LOBE CONSOLIDATION

Typical findings of left lower lobe (LLL) consolidation: (1) the left superior mediastinum and aortic arch
remain visible; (2) the inferior left hilum is obscured; (3) the descending aorta is obscured; (4) the left
heart border remains visible; and (5) the left hemidiaphragm is obscured.
LUNG ATELECTASIS(COLLAPSE)
Used to indicate loss of lung volume,
associated with a decrease in the
amount of air within alveoli.

Collapse of a lobe:
● Evidence of volume loss (e.g.
displacement of a fissure , hilum, trachea,
or mediastinum).
● elevation of a dome of the diaphragm /
decreased spacing between the ribs.
● evidence of compensatory over-inflation
of adjacent unaffected lobe.
● the vessels in over-expanded lobe - more
widely separated
RIGHT LOWER LOBE COLLAPSE
● Oblique fissure moves
posteriorly and
medially. Forms the
lateral edge of a
triangular density over
the heart.
● Right hilum depressed.
● Right lower lobe
pulmonary artery not
visualised.
● Medial aspect of right
dome of diaphragm
obscured.

Collapsed right lower lobe. Classic triangular shadow.

Effacement of part of the dome of the diaphragm.
LEFT LOWER LOBE COLLAPSE

● Oblique fissure moves posteriorly and medially.

● Left hilum lies at a lower level than usual.
● Left lower lobe pulmonary artery is not visualised.
● Medial aspect of the left dome of the diaphragm is obscured.
MIDDLE LOBE COLLAPSE

● Horizontal fissure moves inferiorly visible only in 67% of normal CXR.

● Blurring of the right heart border.
● Position of the hilum does not alter.
● Middle lobe collapse is evident when the two views are assessed as a pair. The subtle
density (between the arrows) is the collapsed lobe on Lateral CXR.
RIGHT UPPER LOBE COLLAPSE

● Horizontal fissure
moves superiorly
● Right hilum is elevated.
● Collapsed lung is dense
● Golden’s S sign

Young patient. Asthmatic. A

mucus plug has caused
collapse of the right upper
lobe.
LEFT UPPER LOBE COLLAPSE

● A veil-like density covers much of the left hemithorax.

● Left heart border is obscured — in whole or in part.
● Left hilum is elevated.
● The Luftsichel sign may be present ( arrow) i.e. a crescentic lucency around the left
side of the aortic knuckle. caused by the overexpanded apical segment of the left lower
HILA
The hilar shadows are
Components: due to pulmonary
arteries and pulmonary
99% of each hilar shadow is due to veins. X marks the main
vessels pulmonary arteries and to a pulmonary trunk.
lesser extent veins.
Blue = pulmonary trunk
**The important rule: The left hilum and pulmonary arteries;
should never be lower than the right. brown = pulmonary
veins; pink = part of left
atrium...atrial
appendage not shown.

The main lower

lobe pulmonary
arteries looks like a
little finger pointing
downwards.
HILAR ENLARGEMENT

An enlarged hilum may be

due to

● large nodes- appear

lumpy bumpy
● tumour infiltration ,
● enlarged arteries -
seen to be emerging
from the hilar “mass”
Both hila are enlarged and Both hila are prominent. The Enlarged left hilum. It has a lumpy
lumpy, bumpy with right margins of the hilar vessels bumpy appearance. Associated left
paratracheal shadowing are smooth. Pulmonary pleural effusion. Primary tuberculosis.
suggestive of sarcoidosis. arterial hypertension.
PLEURAL ABNORMALITIES
Imaging criteria in pleural effusion

● Homogenous density
● Density in dependent portion
● Upper margin high in axilla in
PA view (yellow arrows)
● Upper margin high anteriorly
and posteriorly in lateral view
● Mediastinal shift

Mechanisms
● Transudate: hydrostatic pressure changes as
in CHF, cirrhosis and hypoalbuminemia.
● Exudate: inflammation of pleura as in
malignancy, rheumatoid arthritis, etc.
● Pus: Empyema from infections.
● Blood: Trauma.
● Chyle: From rupture of thoracic duct.
● Urine: Urinothorax in hydronephrosis.
Blunting of the right Rough assessment of the volume of pleural fluid
costophrenic angle (black (a) Approximately 200–300 ml.
arrow). indicates 175 mL of (b) Approximately 2 litres.
pleural fluid. Fluid entering the (c) Approximately 5 litres.
minor fissure (white
arrow)-“thorn” sign of pleural
Loculated pleural effusion
Subpulmonic effusion

Left subpulmonary
Empyema effusion. The pool of fluid
All loculated effusions as
displacing the gastric air
empyema unless proven
bubble inferiorly.
otherwise.
Pneumothorax

Three cardinal features:

1. A clearly defined line (i.e. the visceral

pleura) parallels the chest wall.

2. The upper part of the line is curved at

the lung apex.

3. An absence of lung markings, i.e.

vessels, between the lung edge and the
chest wall.

Chest radiograph shows a large right pneumothorax

(white arrows). An air-fluid level (black arrows) is
visible at the right base.
 TENSION PNEUMOTHORAX ( a
medical emergency)
Supine CXR. Rightsided
The ipsilateral dome of the
pneumothorax showing:
Supine CXR. Right-sided diaphragm is nearly always
(a) hyperlucent right
pneumothorax revealed by depressed and flattened.
upper quadrant of the
the very sharply defined
abdomen
margin to the dome of the 2. The mediastinum and heart
(b) a deep sulcus sign (i.e.
diaphragm. are usually — but not always —
intrapleural air collected
pushed to the opposite side.
in the lateral costophrenic
COPD AND EMPHYSEMA
Radiographic findings
Bullae on chest radiographs is the only specific sign of lung
destruction caused by emphysema. Bullae visible in the
lung periphery, have thin walls, and appear lucent, and
CARDIAC RADIOLOGY

The CT ratio is calculated using the

● thoracic diameter as the distance from
the inner margin of the ribs at the level of
the dome of the right hemidiaphragm
● the cardiac diameter as the horizontal
distance between the most rightward and
most leftward margins of the cardiac
shadow

Measuring the CTR. On a PA chest radiograph

obtained in full inspiration, if a / b > 50% the
heart is likely to be enlarged1 . (a =
maximum transverse diameter of the heart; b
= maximum internal diameter of the thorax.)
Cardiac chambers
Specific chamber enlargement

Left Atrial Enlargement

1. Right retrocardiac double

density. In cases of severe left
atrial enlargement, the right
atrial border extend to the
right than the right atrial
border ( black arrow)
2. Enlargement of the left atrial
appendage. seen as a bulge
along the left cardiac border
just beneath the main
pulmonary artery segment
( black arrow head)
3. Splaying of the carina and/or
elevation of the left bronchus
4. Horizontal orientation of the
distal portion of the left
Mitral and tricuspid
regurgitation.

Frontal (left) and lateral (right)

radiographs show prominent
double densities on both sides
of the spine due to left atrial
enlargement.

Right atrial enlargement -

elongation of the right-sided
convexity on the front view.

Lateral view shows posterior

displacement of the left
bronchus (arrow)
Right atrial enlargement

1.Lateral bulging of the right heart border on

the posteroanterior radiograph.

2. Elongation of the right heart border on the

posteroanterior view.

A rough rule is that a right atrial border

exceeding 60% in length of the mediastinal
cardiovascular shadow -a sign of right atrial
enlargement

Tricuspid regurgitation
Left ventricle enlargement

Left/left and
Left and up
down

Aortic regurgitation.
The ventricular contour is enlarged along a left inferolateral
vector.
Concavity along the upper left cardiac border indicates that
the right ventricle is not enlarged.
Right ventricle enlargement

Mitral stenosis with pulmonary arterial

hypertension and interstitial pulmonary
edema.

Right ventricular enlargement. The vector

of enlargement of the ventricle is directly
lateral.(red arrows)

The most lateral portion of the apex is

located above the diaphragm.

Left atrial enlargement is indicated by

double density (arrow).

Pulmonary arterial hypertension is

indicated by pulmonary arterial
enlargement.
Tetralogy of Fallot

Substantial right ventricular enlargement is

evident.
The vector of enlargement of the ventricle is
leftward and cranial, causing uplifting of the
apex in relation to the diaphragm.
 Volume overload
Pressure overload