3. Proper exposure
A well penetrated chest X-ray is one
where the vertebrae are just visible
behind the heart.
Over exposure- black lung field
clear vertebral bodies
Underexposure- hazy lung field
4. Proper centering
The clavicle should be at the same level
Clavicles should be equidistant from
the midline.
5. Proper labeling
The side determination
◦ Label L or R
◦ Apex of heart on left
◦ Fundal gas shadow on left
◦ Right dome of diaphragm placed higher
than left
◦ Aortic knuckle on left
*(NOT for dextrocardia with Situs inversus)
6. How to read a chest x-ray
View (PA, AP, lat)
Exposure
Centralization
Position of trachea
Skeletal structures
Lung fields including blood vessels and pleura
Cardiovascular silhouette
Costophrenic and cardiophrenic angles
Soft tissue abnormalities
Final diagnosis or conclusion
7. Describe a normal chest x-ray
This is a PA view of the chest with normal
exposure, proper centering and without any
apparent bony abnormality.
The lung fields are clear with normal
bronchovascular markings; cardiovascular
silhouette is within normal limit with normal
cardiothoracic ratio.
Mediastinum, costophrenic and
cardiophrenic angles, domes of the
diaphragm and soft tissue shows no
abnormality.
8. Skeletal structure abnormalities
Kyphosis, scoliosis
Crowding or widely spaced ribs
Absence of clavicle
Erosion of clavicle
Rib erosion
Rib notching
Presence of cervical rib
12. Lung field
Accentuated pulmonary arteries
Distension of pulmonary arteries
Accentuation of bronchial pattern
Prominent lymphatic vessels
Thickened alveolar septum
13. Hilar shadows
PA, PV, bronchi, lymph gland,
lymphatics, connective tissue.
The lung field is divided in three zones
◦ Upper, middle and lower
◦ Do not corresponds with lobes of lung
16. Cardiothoracic ration
Ratio between max diameter of heart to
max internal diameter of chest.
Normal ≤ 1:2
2/3 of cardiac
shadow lies
on the left.
(a+b)/(c+d)
18. BORDERS OF HEART
Right border:
◦ SVC
◦ RA
Left border:
◦ Aortic arch
◦ Pulmonary trunk
or LPA (bay)
◦ LAA
◦ LV
19. Cardiac enlargement
Left atrial enlargement
◦ Straightening of the left border of heart.
◦ Prominent LAA
◦ Double contour of rt border of heart (upper
outer border is LA)
◦ Widening of carinal angle
◦ Posterior displacement of barium filled
esophagus (rt lat view)
23. RA enlargement
enlarged, globular heart
narrow vascular pedicle
gross enlargement of the right atrial
shadow, i.e. increased convexity in the
lower half of the right cardiac border
34. description
This is a PA view of the chest with normal
exposure, proper centering and without any
apparent bony abnormality.
Lung fields shows bat-wing appearance of
confluent shadows which extends from the
hilum to mid and upper zones.
Cardiac silhouette is enlarged.
No mediastinal shifting, both CP angles are
obscured.
36. When there is redistribution of pulmonary blood flow
there will be an increased artery-to-bronchus ratio in the
upper and middle lobes
Artery-to-bronchus ratio
37. Stage II - Interstitial edema
When fluid leaks into the peripheral interlobular septa it is seen as
Kerley B or septal lines.
Kerley-B lines are seen as peripheral short 1-2 cm horizontal lines near
the costophrenic angles.
These lines run perpendicular to the pleura.
38. Stage III - Alveolar edema
This stage is characterized by continued fluid
leakage into the interstitium, which cannot be
compensated by lymphatic drainage.
This eventually leads to fluid leakage in the alveoli
(alveolar edema) and to leakage into the pleural
space (pleural effusion).
40. Pulmonary artery hypertension
Main pulmonary artery usually prominent
Right and left pulmonary arteries large and
taper rapidly
Peripheral pulmonary arteries are narrow and
inconspicuous
Diffuse oligemia of the lungs
43. Increase Qp (pulmonary flow)
Prominent MPA, RDPA
Pulmonary plethora
◦ Vascular markings of lung fields can be
traced up to lateral third of it.
End-on vessels (3 in rt, or 5 in both)
44. Cardiac temponade
there can be globular enlargement of the cardiac
shadow giving a water bottle configuration
widening of the subcarinal angle without other
evidence of left atrial enlargement may be an
indirect clue
lateral CXR may show a vertical opaque line
(pericardial fluid) separating a vertical lucent line
directly behind sternum (epicardial fat) anteriorly
from a similar lucent vertical lucent line (pericardial
fat) posteriorly; this is known as the Oreo cookie
sign
49. ASD
can be normal in early stages +/- when the ASD is
small signs of increased pulmonary flow (shunt
vascularity) enlarged pulmonary vessels
upper zone vascular prominence
vessels visible to the periphery of the film
eventual signs of pulmonary arterial hypertension
chamber enlargement right atrium
right ventricle
note: left atrium is normal in size
note: aortic arch is small to normal (narrow pedicle)
52. VSD
The chest radiograph can be normal with a small
VSD.
Larger VSDs may show cardiomegaly (particularly
left atrial enlargement although the right and left
ventricle can also be enlarged).
A large VSD may also show features of pulmonary
edema, pleural effusion and/or increased pulmonary
vascular markings
Wide pedicle
54. PDA
Chest radiographic features may vary depending on
whether it is isolated or associated with other cardiac
anomalies and with direction of shunt flow (right to
left or left to right).
Can have cardiomegaly (predominantly left atrial
and left ventricular enlargement if not complicated).
Obscuration of the aortopulmonary window and
features of pulmonary oedema may be evident
Wide pedicle
56. TAPVR
The right heart is prominent in TAPVR because of the
increased flow volume, but the left atrium remains
normal in size. Types I and II result in cardiomegaly.
The supracardiac variant (type I) can classically depict a
snowman appearance on a frontal chest radiograph, also
known as figure of 8 heart or cottage loaf heart 2-3.
The dilated vertical vein on the left,
brachiocephalic vein on top, and
superior vena cava on the right form the head of the
snowman; the body of the snowman is formed by the
enlarged right atrium
59. TOF
Plain films may classically show a "boot shaped"
heart with an upturned cardiac apex due to right
ventricular hypertrophy and concave pulmonary
arterial segment. Most infants with TOF however
may not show this finding .
Pulmonary oligemia due to decreased pulmonary
arterial flow. Right sided aortic arch is seen in 25%.