Normal chest x ray and collapse

1. NORMAL CHEST X RAY AND
COLLAPSE
Dr .Aabid Al Rahiman

2. REVIEW
• Normal chest x ray
• Collapse of lung
• Types and radiologic appearances

3. A routine pattern of plain x-ray film reporting can be
ensured for proper scrutiny.The 14 step is listed below
1. Name
2. Date
3. IP/OP No
4. Markers(R/L)
5. Orientation
6. Penetration
7. Inspiration
8. Rotation
9. Angulation
Pre read
Quality

4. 10.Soft tissue/bony structures
11.Meadiastinum
12.Diaphragms
13.Lung fields
14.Abdominal structures
Findings

5. Technical adequacy
Factors to be considered include
• Orientation
• Inspiration
• Penetration
• Rotation
• Angulation

6. ORIENTATION
• Position of patient and the x ray beam
• PA radiograph is obtained with x ray traversing the patient from
posterior to anterior and striking the film
• AP radiograph is obtained with the x ray traversing the patient from
anterior to posterior striking the film.
• The cardiac border will appear larger on an AP x ray due to
magnification effect of more anteriorly located heart relative to the
film

7. PA vs AP
In PA view
• Clavicles don’t project too high into apices or thrown above the
apices (more horizontal)
• Heart magnification reduced, preventing appearance of cardiomegaly
• Scapula are away from lung fields
• Ribs are obliquely oriented in PA view
• Spine and posterior ends of ribs are clearly seen

8. Why PA is preferred over AP?
• Reduces magnification of heart-preventing appearance of cardiomegaly.
• Reduces radiation dose to radiation sensitive organs such as thyroid, eye,
breast.
• Visualised maximum areas of lung
• Moves scapula away from lung field
• More stable positioning for the patient as they can hold on to the unit-
reduces patient movement
• Compression of breast tissue against the film cassette reduces the
density of tissue around CP bases therefore visualizing them more
clearly.

10. Inspiration
• The volume of air in the hemi thorax will affect the configuration of
heart in relation to cardiac size
• The vascular patterns in lung fields will be accentuated with a shallow
inspiration
• The level of inspiration can be done by counting ribs
• Visualization of 10 posterior ribs or six anterior ribs on an upright PA
radiograph projecting above the diaphragm would indicate a satisfactory
inspiration

13. Penetration
• Refers to adequate photons traversing the patient to expose the
radiograph
• The lack of penetration renders the area whiter than with an
adequate film and can simulate effusion or pneumonia
• In an ideal x ray the thoracic spine should be barely visible
• In lateral view 2 sets of ribs should be seen ,sternum seen, spine
appears clearer as it goes down

16. Rotation
• Ideally clavicle should be equidistant from the spinous process
• Rotation of the radiograph is assessed by judging the position of
clavicle heads and thoracic spine process
• Rotation of patient distorts mediastinal anatomy and makes
assessment of cardiac chambers and their hilar structures difficult
• Chest wall tissue also contributes to increased density over the lower
lobe fields simulating disease

20. Angulation
• With patient in a more lordotic projection and in apicogram the
clavicles will project superiorly relative to the upper thorax again
causing some distortion of the normal mediastinal anatomy.
• With the lordotic projection of the ribs assume a more horizontal
orientation
• Occasionally a lordotic x ray can be obtained intentionally to better
visualize structures in thoracic apex obscured by overlying bony
structures

22. VIEWS OF X RAY

23. Significance of different views
• AP view
It is useful in differentiating free and loculated fluid
• Lateral view
• The only view that provides information of localization of different
lobes and segments
• Observation on lateral view include –clear spaces, vertebral
translucency and outline of diaphragms

24. • Oblique view
oIt is helpful in localizing a lesion, in visualizing its borders and in
projecting it free of overlying structures
oOblique view is preferred to lateral view in case of bilateral disease
• Decubitus view
Its helpful in demonstrating small pneumothorax or pleural effusions.

25. • Lordotic view
 This view helps in confirming middle lobe and lingular abnormalities
• This view is also helpful in determining the anteroposterior location of
a lesion
Apicogram view
when there is doubt in apical area

32. SOFT TISSUES
• Soft tissues cast shadow on plain radiographs which have less dense
radio opacity
• Breast shadow result in increased opacity over lower thorax
bilaterally
• Nipple shadow may appear as round opacities in the 4th or lower
anterior intercostal space
• Breast and nipple shadow are usually bilateral and symmetrical
• Linear shadow may result from loose skin fold
• A faint soft tissue shadow parallel to the clavicle results from over
lining skin fold and subcutaneous tissue(clavicular companion
shadow)

34. BONY THORAX
• Outlines the shoulder girdle, ribs, cervical and thoracic vertebrae
• Sternum is often well outlined
• Shape of thorax varies with age and body habitus
• Angulations of ribs varies with body types.
downward angulations :minimal in short hypersthenic individual and
maximal in asthenic patient.

37. • Intercostal spaces are numbered according to the intercostal rib
above them. The ribs and interspaces are designated into 2 groups:
anterior and posterior
• The costal cartilages are not visible except when calcified which then
assume characteristic mottled appearance(periphery in males and
central in females)
• Diaphragm in a normal adult is slightly higher on right compared to
the left.

38. MEDIASTINUM
• Space between the right and left pleura in and near the median
sagittal plane of the chest
• It is bounded by posterior surface of sternum and anterior surface
thoracic vertebrae
• It contains all the thoracic viscera except for the lungs
• It is divided into superior and inferior parts by an imaginary horizontal
line passing through the sternal angle of Louis backwards to the lower
border of T4 vertebrae
• The inferior mediastinum is further divided into the anterior, middle
and posterior mediastinum by fibrous pericardium.

39. DIVISION OF MEDIASTINUM
1. FELSON’S CLASSIFICATION
2. SUTTONS CLASSIFICATION

40. FELSONS CLASSIFICATION
• The mediastinum is divided into anterior, middle and posterior
compartments
• An imaginary line is traced upward from the diaphragm along back of
the heart and front of the trachea to the neck. This divides the
anterior from middle mediastinum
• A secondary imaginary line connects a point on each of the thoracic
vertebrae 1 cm behind its anterior margin. This divides the middle
from posterior mediastinum.

44. SUTTONS CLASSIFICATION
• Mediastinum is divided into three parts
1. Anterior
2. Middle
3. Posterior
• Anterior division lies in front of the anterior pericardium
• Middle division within the pericardial cavity
• Posterior divison lies beyond the post pericardium and trachea

45. Mediastinal structures
• The hila is made up of the main pulmonary arteries and major
bronchi
• The left hilum is higher than right
• Lymph nodes are not normally seen on a chest x ray.

47. The main pulmonary artery on the right side passes anterior to the
right main bronchus, whereas the main pulmonary artery on left side
passes posteriorly and hooks over the main bronchus.

48. • On lateral projection the left pulmonary artery is posterior to a line
drawn down the tracheal air column.

49. • The trachea appears an air shadow coursing down (c6) the midline of
chest and terminating at the carina
• The left and right main stem bronchi, as well as the lobar bronchi may
be evident
• A very subtle deviation to the right at the level of aortic arch,
moderate deviation to the right is common in infants.

50. • Thymus is usually visible in infants and occupies the superior part of
anterior mediastinum(causes widening of mediastinum when
present).lateral view to confirm it.
• When there is enough air in the oesophagus a trachea oesophageal
stripe may be seen.

52. HEART
• Size
• Shape
• Diameter(>1/2 thoracic diameter is enlarged heart)
• AP views make heart appear larger than it actually is.

57. • The dotted line extends from
carina to the anterior
costophrenic angle.

58. Cardiothoracic ratio (CTR) =
Cardiac Width : Thoracic Width

59. Aortopulmonary window
• A space located underneath the aortic arch and above the left
pulmonary artery
• Contains fat
• On a PA projection ,it appears as a concave shadow. If adenopathy is
present, it manifests as a convex shadow.

61. DIAPHRAGM
• The left and right diaphragm appear as sharply marginated domes.
• The peripheral margins of the diaphragm define the costophrenic
sulci
• The right diaphragm is higher than left and will appear larger on
lateral chest film
• A difference greater than 3 cm in the level of two hemi diaphragm is
significant.

64. Cardiophrenic angle &
costophrenic angle

65. Posterior costophrenic
recess/sulci

66. Lung zones

67. PULMONARY FISSURES
• Formed with visceral pulmonary pleura
• Major fissure-oblique fissure
• Minor fissure-horizontal
fissure
Right lung
• Major fissure-oblique fissure
Left lung

68. • Oblique fissure more clearly seen on lateral view from T4-T5
vertebrae to reach the diaphragm.
• Right oblique fissure lies at most inferior 4-5 cm behind the sternum
and left oblique is positioned more posterior.
• Horizontal fissures are more clearly seen on PA view extending from
right hilum to sixth rib in axillary line

72. Fissures divide lungs into lobes
• Right lung
Upper
Middle
Lower
• Left lung
Upper
Lower

76. Interfaces and stripes
• There are six mediastinal stripes.
1. Paravertebral stripe
2. Right paratracheal stripe
3. Azygoesophageal stripe
4. Anterior junction line
5. Posterior junction line
6. Aortopulmonary stripe

77. Paravertebral stripe
• Left paravertebral stripe is almost always visualised on well
penetrated frontal cxr.
• This is because the descending aorta displaces the adjacent lung
laterally. This displacement causes pleural surface and lung edge to be
seen tangentially as they pass lateral to paravertebral soft tissues
from front to back.
• Right paravetrbral stripe is not visualised until middle age, when age
related osteophytes are present and displaces the adjacent pleura
laterally.

80. Right paratracheal stripe
• Formed where right lung abuts the right side of trachea.
• Left side of trachea does not abut with left lung-so no stripe on left
side.

82. Azygo oesophageal line
• Right lung abuts right side of oesophagus and azygous vein.
• Extends below aortic arch to diaphragm

84. Anterior junction line
• Formed where two lungs abut each other anteriorly below the
manubrium
• Line made up of four layers of pleura(parietal and visceral layer pleura
surrounding both lungs)

86. Posterior junction line
• Formed where the lungs abut each other posteriorly
• It extends above clavicle to the level of arch of aorta
• Also formed of four layers of pleura

88. Aorto pulmonary stripe
• In some people a segment of mediastinal pleura does not blend with
outline of mediastinum ,but is reflected as a straight line between
main pulmonary artery and aortic arch.

90. COLLAPSE

91. TYPES OF COLLAPSE OR ATELECTASIS
• OBSTRUCTIVE
• COMPRESSIVE
• CICATRISATION (FIBROTIC)
• ADHESIVE COLLAPSE

92. OBSTRUCTIVE (RESORPTIVE)
• Intrinsic occlusion
1. Tumour
2. Mucus plug
3. Foreign body

93. Compressive(passive, relaxation)
• Pleural fluid
• Pneumothorax
• Adjacent intrapulmonary space occupying lesion

94. Fibrotic contraction
• Tuberculosis
• Radiotherapy
• Pulmonary fibrosis

95. Adhesive collapse
• Neonatal surfactant deficiency
• Adult respiratory distress syndrome
• Complication of smoke inhalation

96. Lobar collapse
• Cardinal features –increased opacity of collapsed lobe and volume
loss.
• DIRECT SIGNS OF VOLUME LOSS
1. Displacement of fissures –most reliable sign
2. Pulmonary vessels and bronchi becomes more crowded on
collapsed lung.
3. Hilar elevation in upper lobe collapse
4. Hilar depression or small hila-in lower lobe collapse

97. • Indirect signs
1. Compensatory hyperinflation of other lobes
2. Mediastinal shift
3. Elevation of hemi diaphragms-not reliable sign
4. Shifting granuloma sign- Hyper expansion results in change in
position of lung lesions like granuloma

99. JUXAPHRENIC PEAK
SIGN
• Ancillary sign in upper lobe
collapse.

101. Collapse of the right lower lobe
• Oblique fissure moves posteriorly and medially. The medial
displacement of this fissure causes it to be seen in profile and it forms
the lateral edge of triangular density projected over heart.
• Right hilum is depressed
• Right lower lobe pulmonary artery not visualized
• Medial aspect of right dome of diaphragm is obscured
• Lateral margin of adjacent vertebrae is effaced.

103. • Right lower lobe
collapse with
triangular opacity
not obscuring the
diaphragm

104. • Increased density over of
posterior costophrenic
angle and loss of
silhouette of right
diaphragm posteriorly

105. Superior triangle sign
• Triangular density to the right of
mediastinum due to
displacement of anterior
junctional structures

106. Left lower lobe
• Oblique fissure moves posteriorly and medially. The medial displacement
and rotation of the fissure causes it to be seen in profile and it forms lateral
edge of triangular density superimposed over heart.
• Left hilum lies lower than usual
• Left lobe pulmonary artery not visualized
• Medial aspect of left dome of diaphragm obscured
• Lateral margin of adjacent vertebrae effaced

109. Spinnaker Sail sign

110. Flat waist sign
• Seen in extensive left lower lobe collapse
• Flattening of aortic knuckle and main pulmonary artery-due to cardiac
rotation and displacement to left
• Loss of superior aortic knuckle

112. Collapse of middle lobe
• Horizontal fissure moves inferiorly
• Blurring of right heart border
• Position of hilum doesn’t alter
• Density in collapsed lobe may be obvious or very subtle

114. Right upper lobe
• Horizontal fissure moves superiorly
• Right hilum is elevated
• Collapsed lung is white
• In adults look for GOLDEN S Sign-when a tumour at the right hilum is
the cause of the collapse.
• This reversed S is made up of an elevated horizontal fissure and a
bulky tumour at the hilum.

117. Collapse of left upper lobe
• Veil like density covers much of left hemi thorax. This is due to lack of
aeration within collapsed upper lobe
• Left heart border is obscured-in whole or part
• Left hilum is elevated
• LUFTSICHEL SIGN- cresentic lucency around the left side of aortic knuckle.
It is caused by the over expanded apical segment of left lower lobe
positioning between the collapsed lobe and the aortic arch.

120. Lingular collapse

121. Whole lobe collapse

122. Combination of collapse

124. THANK YOU