One of the easiest made approach for learning health care buddies about the Chest X-ray Interpretation with Case studies including the Radiological findings, Differential Diagnosis, Radiological Diagnosis, Causes & treatment of each Disease.
3. INTRODUCTION
The range of densities one is attempting to image on a chest radiograph
(CXR) is larger than at any other site in the body, ranging from very
dense bone to very low-density air filled lungs.
As a result, the quality of the CXR is very dependent on the technique
used in its production.
4. PRELIMINARY FOR CHEST X-RAY
ABCDEF
A- AP or PA View
B- Body Position
C- Confirm Name
D- Date
E- Exposure
F- Films for Comparison
5. PRELIMINARY FOR CHEST X-RAY
AP or PA view
A CXR taken with the patient standing erect in front of X-ray film and the X-ray tube is
positioned behind the patient hence the X-rays pass from posterior to anterior (PA).
For patients confined to bed or chair, the PA technique is not possible, therefore the X-
ray film is placed behind the patient and the X-ray tube in front so that the X-rays pass
from anterior to posterior (AP).
6. PRELIMINARY FOR CHEST X-RAY
AP or PA view
The heart is an anterior organ in the chest and its size is magnified on an AP view.
<60% of chest Diameter in AP.
<50% of chest Diameter in PA.
On AP films, the clavicles cast a broader shadow and typically overlay the apices
making interpretation of these areas difficult.
In general, the AP film should be interpreted with caution.
7. PRELIMINARY FOR CHEST X-RAY
EXPOSURE
Well Exposed films have good details and an outline of Spinal column.
8. PRELIMINARY FOR CHEST X-RAY
FILMS FOR COMPARISON
There is a saying in radiology that the most important X-ray is the previous one.
It is always helpful to compare the current X-ray with previous X-rays and imaging to
see if there has been any change in the findings.
11. INTERPRETATIONS FOR CHEST X-RAY
ASSESSMENT OF QUALITY
1. POSITION:- PA/AP/LATERAL
2. INSPIRATION:- Count the number of POSTERIOR RIBS.
(You should be able to see atleast 10-11 RIBS.)
3. EXPOSURE:- Well defined exposed films have good lungs details and an outline of
spinal column.
Left Hemidiaphragm visible to the spine.
Vertebrae visible behind Heart.
4. ROTATION:- Space b/w medial clavicle and margin of adjacent vertebrae should
be roughly equal.
12. INTERPRETATIONS FOR CHEST X-RAY
ASSESSMENT OF AIRWAYS
TRACHEA:-
Location- Normally central or slight deviation to the right.
PATHOLOGY:- Pushing of Trachea- Pleural Effusion or Pneumothorax
Pulling of Trachea- Consolidation or Lobar collapse.
CARINA:-
Location- Point at which the trachea divides into left & right Bronchus.
Important Landmark:- During Nasogastric tube placement ( As the NG bisects the
carina if placed correctly.
BRONCHUS:-
Right bronchus are wider, shorter and more vertical than left bronchus.
13. INTERPRETATIONS FOR CHEST X-RAY
ASSESSMENT OF AIRWAYS
HILAR STRUCTURE
It consist of main Pulmonary vasculature
Major Bronchus
Lymph nodes.
PATHOLOGY:- Important Landmark for enlarged Lymph nodes and Lung Tumour.
15. INTERPRETATIONS FOR CHEST X-RAY
ASSESSMENT OF BONES & SOFT TISSUES
1. Scan the Bones for SYMMETRY
FRACTURES
OSTEOPOROSIS
LESIONS
2. Evaluate the soft tissues mainly LUNGS & PLEURA
A] LUNGS
Divide each Lung into 3 zones (Irrespective of their lobes).
Compare each zone between the lungs, paying attention for any asymmetry.
PATHOLOGY:- Increased air space shadowing in given area may suggest consolidation or
malignancy.
2. Complete absence of the lung field should raise suspicion of Pneumothorax.
16. INTERPRETATIONS FOR CHEST X-RAY
ASSESSMENT OF BONES & SOFT TISSUES
1. Scan the Bones for SYMMETRY
FRACTURES
OSTEOPOROSIS
LESIONS
2. Evaluate the soft tissues mainly LUNGS & PLEURA
B] PLEURA
It is not visible in healthy individual.
Inspect the borders of each of the lungs to ensure lungs markings
PATHOLOGY:- Area lacking lung markings with decreased density may suggest presence of
Pneumothorax.
2. Fluid (hydrothorax) or blood (haemothorax) can also accumulate in pleural space.
18. INTERPRETATIONS FOR CHEST X-RAY
ASSESSMENT OF CARDIAC & C.P. ANGLE
A] CARDIAC
The heart is an anterior organ in the chest and its size is magnified on an AP view.
<60% of chest Diameter in AP.
<50% of chest Diameter in PA.
The right atrium makes up most of the right heart border.
The left ventricle makes up most of the left heart border.
PATHOLOGY:- The heart border may become difficult to distinguish in various
pathological processes (e.g. Consolidation).
19. INTERPRETATIONS FOR CHEST X-RAY
ASSESSMENT OF CARDIAC & C.P. ANGLE
B] Costophrenic Angles (C.P. Angle)
Check the sharpness of the angle.
PATHOLOGY:- Blunted angle indicates Pleural Effusion.
21. INTERPRETATIONS FOR CHEST X-RAY
ASSESSMENT OF DIAPHRAGM
Check the hemidiaphragm for position
The right is slightly higher than the left
Look below the diaphragm for the free gas (Gastric Bubble in left side).
The diaphragm should remain indistinguishable from the underlying liver.
PATHOLOGY:-It may be flattened Bilaterally in Asthma or Emphysema.
2. Unilaterally in Tension Pneumothorax or Foreign body aspiration.
3. Loss of Diaphramatic outline indicates fluid (Pleural Effusion).
4. No Free gas should be present below the hemidiaphragm in right side (indicates
rupture of abdominal hollow viscus).
5. Raising of Diaphragm occurs in Phrenic Nerve Palsy.
23. INTERPRETATIONS FOR CHEST X-RAY
ASSESSMENT OF EFFUSION
It may be large and obvious or small and subtle(Lateral Films).
All check Costophrenic angles for the sharpness.
PATHOLOGY
Unilateral Pleural Effusion suggests- Pulmonary Tuberculosis
Pulmonary Infarction
Parapneumonic
Bronchial Carcinoma.
Bilateral Pleural Effusion suggests- Cirrhosis of liver
Nephrotic Syndrome
Congestive Cardiac Failure
Bilateral Extensive Tuberculosis
Rheumatoid Arthritis & SLE.
24. INTERPRETATIONS FOR CHEST X-RAY
ASSESSMENT OF EXTRATHORACIC SOFT
TISSUES
Trace the outline of the left and right Lungs for the evidence of Pneumothorax
Bullae
Collapse
Effusion
Masses & Nodules.
PATHOLOGY
Neoplastic Nodules
Nodules due to infection (TB, Chicken Pox, Pneumonia, Fibrotic Lungs Disease)
Nodules due to vasculature (Hamartoma, Pulmonary Embolus).
26. INTERPRETATIONS FOR CHEST X-RAY
ASSESSMENT OF FIELDS, FISSURES &
FOREIGN BODIES
Check for Infiltrates (Interstitial v/s Alveolar).
Masses & Consolidations.
Evaluate the major and minor fissures for thickening, fuid or change in position.
Check position of foreign bodies.
Example:- ETT, NGT, Pacemaker Leads etc.
Comment for previous surgeries if any.
28. INTERPRETATIONS FOR CHEST X-RAY
ASSESSMENT OF GREAT VESSELS
Check Aortic size and shape and the outline of pulmonary vessels.
The aortic knob should be clearly visible
29. INTERPRETATIONS FOR CHEST X-RAY
ASSESSMENT OF GASTRIC BUBBLE
The Gastric bubble should be clearly visible
It shouldnot be displaced.
31. INTERPRETATIONS FOR CHEST X-RAY
ASSESSMENT OF HILA & MEDIASTINUM
HILA:-
Evaluate hila for Lymphadenopathy
Calcification
Masses
Left Hilum is slightly higher as compared to right.
PATHOLOGY:- Important Landmark for enlarged Lymph nodes and Lung Tumour.
MEDIASTINUM
Check for the widening for the mediastinum
PATHOLOGY
Widening of Mediastinum indicates Aortic dissection.
Tracheal deviation indicate a mass effect (large Goitre or Pneumothorax).
47. MASS LESION (CARCINOMA)
RADIOLOGICAL FINDINGS:-
1. Opacity with irregular margin, in the right upper
and part of the mid zone.
2. Hilar Lymphadenopathy in left side.
DIFFERENTIAL DIAGNOSIS
1. Tuberculosis
2. Consolidation
3. Bronchial Carcinoma
RADIOLOGICAL DIAGNOSIS
Bronchial Carcinoma
CONFIRMATORY INVESTIGATIONS
1. Sputum for Malignant Cells
2. CT guided Fine Needle Aspiration Cytology (FNAC)
3. Lymph node biopsy or FNAC
50. MASS LESION (CARCINOMA)
RADIOLOGICAL FINDINGS:-
1. Opacity with irregular margin in the left upper
part and mid zone
2. Left dome of Diaphragm is raised.
RADIOLOGICAL DIAGNOSIS
Bronchial Carcinoma with Left Phrenic Nerve Palsy.
51. MASS LESION (CARCINOMA)
RADIOLOGICAL FINDINGS:-
1. Opacity with irregular margin in the left upper
part and mid zone
2. Left dome of Diaphragm is raised.
RADIOLOGICAL DIAGNOSIS
Bronchial Carcinoma with Left Phrenic Nerve Palsy.
CASE-05
53. SOLITARY PULMONARY NODULE
RADIOLOGICAL FINDINGS:-
1. Homogenous, Rounded, Nodular Shadow with
clear margin in the left middle zone.
RADIOLOGICAL DIAGNOSIS
Pulmonary Nodule (Neurofibroma or dermoid cyst)
(Confirm using the lateral View X ray
Neurofibroma lies in posterior region
Dermoid Cyst lies in anterior region).
CONFIRMATORY INVESTIGATION
CT-guided FNAC
62. CONSOLIDATION
RADIOLOGICAL FINDINGS:-
1. Dense Homogenous opacity in the right upper
and part of the mid zone.
DIFFERENTIAL DIAGNOSIS
1. Pulmonary TB
2. Consolidation
3. Bronchial Carcinoma
RADIOLOGICAL DIAGNOSIS
Consolidation
CONFIRMATORY INVESTIGATIONS
1. CBC with ESR
2. Sputum for AFB
3. Sputum for Gram Staining (Pneumococcus)
4. Sputum for C/S
5. Sputum for Malignant celss
64. CONSOLIDATION
Consolidation means Pneumonia.
TYPES OF PNEUMONIA
1. Anatomically
A] Lobar Pneumonia- Involves one or more lobes
B] Lobular Pneumonia- Non patchy alveolar opacity commonly involes both lobes
2. Clinically
A] Community acquired Pneumonia
B] Nosocomial Pneumonia
C] Pneumonia in Immunocompromised
D] Suppurative & Aspiration Pneumonia
PATHOLOGICAL STAGES
1. Stage or congestion- persist for 1-2 days
2. Stage of red hepatization (Red & Solid Liver)- Persist for 2-4 days
3. Stage of Grey hepatization- Persist for 4-8 days
4. Stage of resolution- Persist for 8-10 days or more.
65. CONSOLIDATION
Consolidation means Pneumonia.
TYPES OF PNEUMONIA
1. Anatomically
A] Lobar Pneumonia- Involves one or more lobes
B] Lobular Pneumonia- Nonpatchy alveolar opacity commonly involes both lobes
2. Clinically
A] Community acquired Pneumonia
B] Nosocomial Pneumonia
C] Pneumonia in Immunocompromised
D] Suppurative & Aspiration Pneumonia
PATHOLOGICAL STAGES
1. Stage or congestion- persist for 1-2 days
2. Stage of red hepatization (Red & Solid Liver)- Persist for 2-4 days
3. Stage of Grey hepatization- Persist for 4-8 days
4. Stage of resolution- Persist for 8-10 days or more.
CASE-09
67. PULMONARY TUBERCULOSIS
RADIOLOGICAL FINDINGS:-
1. Patchy Opacity with some translucent shadows
within right upper and part of mid zone.
RADIOLOGICAL DIAGNOSIS
Right side Pulmonary Tuberculosis
INVESTIGATIONS
1. CBC with ESR
2. Sputum for AFB
3. Tuberculin Test
4. PCR for TB
74. PULMONARY TUBERCULOSIS
RADIOLOGICAL FINDINGS:-
1. Patchy opacities involving both upper and middle
zones in both right and left lungs.
RADIOLOGICAL DIAGNOSIS
Billateral Extensive Tuberculosis.CASE-12
79. LUNG ABSCESS
CONFIRMATORY INVESTIGATIONS
1. CBC with ESR
2. CT- Chest
3. Sputum for Gram staining, CS & AFB.
RADIOLOGICAL FINDINGS:-
1. Cavity with air filled level in the right middle and
lower zone.
RADIOLOGICAL DIAGNOSIS
Right sided Lung Abscess
CAUSES
Mainly aspiration of any infected surface.
87. EMPHYSEMA (COPD)
RADIOLOGICAL FINDINGS:-
1. Low & Flat Diaphragm
2. Lung Fields are hypertranslucent
RADIOLOGICAL DIAGNOSIS
Pulmonary Emphysema
INVESTIGATIONS
1. Lung Function Test
2. HRCT
88. EMPHYSEMA (COPD)
CRITERIA ASTHMA COPD
Age of onset Typically early in life but may
occur at any age.
Onset is middle (usual age >40
years)
Etiology Relate to allergies
Family history of atopic disease
H/o smoking or long exposure
to environmental toxins.
Clinical course Intermittant & Variable Persistant & Progessively
worsening
Symptoms Episodic attacks caused by
exposure to allergens & Irritants
Present everyday, usually occur
upon exertion.
Reversibility of
airflow limitation
May normalize with treatment May improve but never
normalizes.
DIFFERENCE
89. EMPHYSEMA (COPD)
TYPES OF COPD
1. Emphysema
2. Chronic Bronchitis
3. Bronchietasis
4. Small airway Disease
5. Asthma (after the age of 40 years)
ROLE OF NEUTROPHILS & SMOKING IN EMPHYSEMA
NEUTROPHILS
They’re the source for the
- Elastase Activity
- Cellular protease
- Matrix Metalloprotease
All the above aids in the tissue destruction.
SMOKING
It increases the Elastase activity
94. PNEUMOTHORAX
PNEUMOTHORAX means presence of air in the pleural cavity.
Usual presentation is sudden onset of unilateral pleuritic chest pain & breathlessness.
TYPES
1. Closed type Pneumothorax- Communication between the lung & pleural space is sealed off.
2. Open type Pneumothorax- Communcation between the lung & pleural space is present.
Example:- Hydropneumothorax.
3. Valvular type Pneumothorax- Communication is one way (allows air to enter pleural space).
Example:- Tension Pneumothorax.
95. PNEUMOTHORAX
TREATMENT
1) Closed type Pneumothorax
- Resolve own it’s own (Chest X-Ray after 15 days)
- Avoid strenous exercise.
- Avoid Swimming and Diving for lifetime.
2) Open type Pneumothorax
- Chemical Pleurodosis:- Done by injecting Tetracycline(500mg)+ Kaolin+ Talc into pleural cavty
through intercostal tube.
- Surgical Pleurodosis.
3) Valvular Pneumothorax
- Patient is in sitting position with O2 Inhalation.
- Morphine is given Subcutaneously.
- Immediate insertion of wide bore needle in 2nd intercostal space in midclavicular line.
- Insertion of Intrathoracic tube in 4th or 5th intercostal space in midaxillary line.
- Tip of the Intrathoracic tube is connected to an underwater seal.
- Bubbling with start. (It should be maximum upto 5-7 mins).
- If persist more than surgical interventions are needed.
98. HYDROPNEUMOTHORAX
RADIOLOGICAL FINDINGS:-
1. Increased transluceny on the ride side.
2. Horizontal fluid level with obliteration of the right
costophrenic angle and cardiophrenic angles.
RADIOLOGICAL DIAGNOSIS
Right sided Hydropneumothorax
CAUSES
Iatrogenic (during pleural fluid aspiration)
Trauma
Rupture of lung Abscess
Erosion of Bronchial carcinoma
101. LUNG COLLAPSE
RADIOLOGICAL FINDINGS
1. Homogenous Opacity involving the whole left
lung field.
2. Trachea & Heart is shifted to the left
3. Hypertranslucency of right lung field
DIFFERENTIAL DIAGNOSIS
1. Massive Pleural Effusion
2. Massive Consolidation
3. Complete collapse of the lung
RADIOLOGICAL DIAGNOSIS
Complete Collapse of the lungs.
CONFIRMATORY INVESTIGATION
1. CT- Chest
2. Bronchoscopy
107. BRONCHIECTASIS
RADIOLOGICAL FINDINGS
1. Multiple ring shadows involving the mid and
lower zones of both the lung field (more on the
right side).
RADIOLOGICAL DIAGNOSIS
Bilateral Bronchiectasis
CAUSES
Cystic Fibrosis
INVESTIGATION
HRCT-Chest
110. GAS UNDER THE DIAPHRAGM
RADIOLOGICAL FINDINGS
1. Gas under the right dome of Diaphragm
RADIOLOGICAL DIAGNOSIS
Perforation of gas containing hollow viscus
CAUSES
Perforation of the Ileum
Perforation of Duodenal Ulcer
TREATMENT
1. Nothing by mouth
2. Nasogastric suction
3. IV-Fluid
4. Broad spectrum antibiotics
5. Surgical repair
