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INTERPRETATION OF
NORMAL
CHEST X-RAY
By-Dr Saket Jain
Dr Setu Satani
Dept. of RADIO DIAGNOSIS
MGM HOSPITAL
A routine pattern of plain x-ray film
reporting can be ensured for proper
scrutiny. The 14-Step is listed below.
1.Name
2....
10.Soft tissues / bony structures
11.Mediastinum
12.Diaphragms
13.Lung Fields
14.Abdominal structures

FINDINGS

Cont’d
CHEST INTRODUCTION
Technical Adequacy
In trying to determine if pathology is present in a chest
radiograph several factors...
Orientation:
In this we are making reference to the position of the patient
and the x ray beam.
A PA radiograph is obtai...
Difference between P.A & A.P VIEW
In PA view
 Clavicles don’t project too high into the apices or
thrown above the apices...
Why is PA preferred over AP
Reduces magnification of heart therefore
preventing appearance of cardiomegaly
 Reduces radia...
Orientation

PA

AP
PA
AP
Inspiration:
The volume of air in the hemithorax will affect the
configuration of the heart in relation to cardiac size.
...
Inspiration

Expiration
Inspiration
Expiration

NOTE - CHANGE IN HEART SIZE AND
VASCULARITY DUE TO EXPIRATION
Penetration:
Refers to adequate photons traversing the patient to expose the
radiograph.

 The lack of penetration rende...
Penetration
SEE THE NODULE ON THE
PREVIOUS FILM
Rotation

Ideally the clavicle heads should be equidistant

from the spinous process.

Rotation of the radiograph is ass...
Rotation
Angulation:
With the patient in a more lordotic projection and in
Apicogram the clavicles will project superiorly relativ...
Angulation
VIEWS OF CXR
P.A VIEW
AP VIEW
LATERAL VIEW
LATERAL DECUBITUS VIEW
LORDOTIC VIEW
Normal Radiographic Anatomy
WITH
VIEWING CHEST RADIOGRAPH
SOFT TISSUE
Soft tissues cast shadow on plain radiographs
which have less dense radio-opacity.
 Breast shadow result in i...
NIPPLE SHADOWS
NIPPLE SHADOW
Cont’d
Linear shadow may result from loose skin
fold
 A faint soft- tissue shadow parallel to the
clavicle results from o...
BONY
THORAX
Bony thorax
Chest x-ray primarily visualizes intrathoracic
structure but also outline the shoulder girdle
,ribs, cervical...
Cont’d
Intercostal space are numbered according to
the intercostal rib above them .The ribs and the
interspaces are design...
MEDIASTINUM.







This is the space between the right and left pleurae in
and near the median sagittal plane of the...
DIVISION OF MEDIASTINUM
1.

Felson’s Classification

2.

Sutton’s Classification

3.

Haaga’s Classification

4.

Heitzman...
1. FELSONS CLASSIFICATION



The mediastinum can be divided into
anterior, middle and posterior
compartments.
An imaginary line is
traced upward from the
diaphragm along the
back of the heart and
front of the trachea to
the neck. T...
A secondary
imaginary line connects
a point on each of the
thoracic vertebrae 1 cm
behind its anterior
margin. This divid...
2.Suttons Classification

1.
2.
3.

Mediastinum is divided into 3 parts
Anterior division
Middle division
Posterior divis...
3.Heitzmans division


Heitzman divided the mediastinum into
the following anatomic regions: the
thoracic inlet, the supr...
SUPERIOR MEDIASTINUM
It is located above a
horizontal line drawn from
the angle of Louis posteriorly
to the spine.
 Also ...
ANTERIOR MEDIASTINUM






This is bounded above by thoracic inlet,
laterally by the pleural , anteriorly by the
sternu...
MIDDLE MEDIASTINUM




It is also referred to as vascular
space.
It is bounded by anterior and
posterior mediastinum.
I...
POSTERIOR MEDASTINUM
It is also known as post
vascular space.
 It lies btw the heart
anteriorly and the thoracic
vertebra...
MEDIASTINAL STRUCTURES
The hila are made up
of the main pulmonary
arteries and major
Bronchi
-The left hilum is higher
tha...
On the left side, the left
pulmonary artery is directed
posterolaterally, toward the
left scapula and goes over
the left m...
• On the lateral projection,
the left pulmonary artery is
posterior to a line drawn
down the tracheal air
column.
The trachea appears as an
air-shadow coursing down
(c6) the midline of the chest
and terminating at the carina
(T5).
The...
OTHER FINDINGS –

Thymus is usually visible in infants and occupies
the superior part of ant. Mediastinum (causes
wideni...
HEART
Size
 Shape
 Diameter (>1/2 thoracic diameter is
enlarged heart)


Remember: AP views make heart appear larger th...
P.A. CARDIAC VIEW
Superior Vena Cava
Aortic Arch

Ascending Aorta

Pulmonary Artery

Left Atrium
Right Atrium
Left Ventric...
P.A. CARDIAC VIEW
LATERAL CARDIAC VIEW

Aortic Knob/Arch
Descending Aorta
Ascending Aorta

Left Atrium
Right Ventricle

Left Ventricle
Infer...
AORTOPULMONARY WINDOW
A "space" located
underneath the aortic
arch and above the left
pulmonary artery.
 Contains fat.
 ...
DIAPHRAGM
The left and right diaphragm appear as
sharply marginated domes.
 The peripheral margins of the diaphragm
defin...
The right
hemidiaphragm is
higher than the left
( the heart is pushing
the left hemidiaphragm
down)
-A gas bubble beneath
...
RT
LT
Cardiophrenic Sulci
(Recesses, Angles)

Lateral Costophrenic
Sulci
(Recesses, Angles)
Posterior
Costophrenic
Sulci
(Recesses,
Angles)
LUNG FIELDS
UPPER ZONE

MIDDLE ZONE

LOWER ZONE
Pulmonary Fissures
Pulmonary fissures are formed with visceral
pulmonary pleura.
RIGHT LUNG

MAJOR FISSURE
OBLIQUE FISSURE...
Oblique fissure more clearly seen on Lateral view from
T4-T5 vertebrae to reach the diaphragm and 5 cm
behind the costoph...
RT. MAIN BRONCHUS

LT. MAIN BRONCHUS

6TH
RIB
CARINA

HORIZONTAL
FISSURE
minor

OBLIQUE
FISSURE
major

OBLIQUE
FISSURE
(ma...
Horizontal Fissure
Right Oblique Fissure
Left Oblique Fissure
FISSURES DIVIDE
LUNGS INTO LOBES

HORIZONTAL FISSURE

RIGHT lung has:
UPPER
MIDDLE
lobes
LOWER
LEFT lung has:
UPPER
lobes
...
RUL

LUL
RML

RLL

LLL
Retrosternal Clear Space

Retrocardiac Clear Space
Left Hemidiaphragm
Stomach gas bubble
Splenic flexure of the
large intestines
Right Hemidiaphragm
Liver
some of the visual...
Significance of different views
Anteroposterior view


It is useful in differentiating free and loculated
pleural fluid

...
OBLIQUE VIEW
It is helpful in localizing a lesion , in visualizing its borders
and in projecting it free of overlying str...
LORDOTIC VIEW
It is particularly useful for lung apices
This view helps in conforming middle lobe and lingular
abnormali...
THANK YOU
Chest x ray
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Chest x ray

  1. 1. INTERPRETATION OF NORMAL CHEST X-RAY By-Dr Saket Jain Dr Setu Satani Dept. of RADIO DIAGNOSIS MGM HOSPITAL
  2. 2. 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. Pre Read 3.IPD/OPD NO. 4.Markers (R/L) 5.Orientation 6.Penetration 7.Inspiration 8.Rotation 9.Angulation Quality Control
  3. 3. 10.Soft tissues / bony structures 11.Mediastinum 12.Diaphragms 13.Lung Fields 14.Abdominal structures FINDINGS Cont’d
  4. 4. CHEST INTRODUCTION Technical Adequacy In trying to determine if pathology is present in a chest radiograph several factors have to be considered in the overall judgment of the radiograph to determine if the visual findings are pathologic or in part are related to the radiograph itself. Factors to be considered on all chest x-rays include:  Orientation  Inspiration  Penetration  Rotation  Angulation
  5. 5. Orientation: In this we are making reference to the position of the patient and the x ray beam. A PA radiograph is obtained with the x-ray traversing the patient from posterior to anterior and striking the film. Similarly an AP radiograph is positioned with the xray traversing the patient from anterior to posterior striking the film.  The cardiac border will appear larger on an AP radiograph due to the magnification effect of the more anteriorly located heart relative to the film.
  6. 6. Difference between P.A & A.P VIEW In PA view  Clavicles don’t project too high into the apices or thrown above the apices (more horizontal)  Heart wont be magnified over the mediastinum therefore preventing the appearance of cardiomegaly  Scapula are away from the lung fields  Ribs are obliquely oriented in PA view  Spine and posterior ends of ribs are clearly seen
  7. 7. Why is PA preferred over AP Reduces magnification of heart therefore preventing appearance of cardiomegaly  Reduces radiation dose to radiation sensitive organs such as thyroid,eyes,breasts  Visualised maximum areas of lung  Moves scapula away from the lung fields  More stable positioning for the patient as they can hold onto the unit – this reduces patient movement.  Compression of breast tissue against the film cassette reduces the density of tissue around the CP bases therefore visualizing them more clearly 
  8. 8. Orientation PA AP
  9. 9. PA
  10. 10. AP
  11. 11. Inspiration: The volume of air in the hemithorax will affect the configuration of the heart in relation to cardiac size. The vascular pattern in the lung fields will be accentuated with a shallow inspiration. The level of inspiration can be estimated by counting ribs. Visualization of nine posterior ribs, or seven anterior ribs on an upright PA radiograph projecting above the diaphragm would indicate a satisfactory inspiration
  12. 12. Inspiration Expiration
  13. 13. Inspiration
  14. 14. Expiration NOTE - CHANGE IN HEART SIZE AND VASCULARITY DUE TO EXPIRATION
  15. 15. 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 pneumonia or effusion.  In an ideal radiograph the thoracic spine should be barely perceptual viewing through the cardiac shadow , the left hemidiaphragm behind heart and vessels only up to 2/3 of lung area In lateral view 2 sets of ribs should be seen, sternum seen, spine appears clearer as it goes down.
  16. 16. Penetration
  17. 17. SEE THE NODULE ON THE PREVIOUS FILM
  18. 18. Rotation Ideally the clavicle heads should be equidistant from the spinous process. Rotation of the radiograph is assessed by judging the position of the clavicle heads and the thoracic spinous process.  Rotation Of patient distorts mediastinal anatomy and makes assessment of cardiac chambers and the hilar structures especially difficult. Chest wall tissue also contributes to increased density over the lower lobe fields simulating disease.
  19. 19. Rotation
  20. 20. Angulation: With the 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 the thoracic apex obscured by overlying boney structures.
  21. 21. Angulation
  22. 22. VIEWS OF CXR
  23. 23. P.A VIEW
  24. 24. AP VIEW
  25. 25. LATERAL VIEW
  26. 26. LATERAL DECUBITUS VIEW
  27. 27. LORDOTIC VIEW
  28. 28. Normal Radiographic Anatomy WITH VIEWING CHEST RADIOGRAPH
  29. 29. SOFT TISSUE Soft tissues cast shadow on plain radiographs which have less dense radio-opacity.  Breast shadow result in increased opacity over the lower thorax bilaterally.  Nipple shadow may appear as round opacities in the 4th or lower ant. Intercostal space.  Breast and nipple shadow are usually bilateral and symmetrical. 
  30. 30. NIPPLE SHADOWS
  31. 31. NIPPLE SHADOW
  32. 32. Cont’d 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.) 
  33. 33. BONY THORAX
  34. 34. Bony thorax Chest x-ray primarily visualizes intrathoracic structure but also outline the shoulder girdle ,ribs, cervical and thoracic vertebrae. Sternum is often well outlined . Shape of the thorax varies with age and body habitus. Angulations of the ribs varies with body types. downward angulations: minimal in short hypersthenic individual. And maximal in asthenic patient.
  35. 35. Cont’d Intercostal space are numbered according to the intercostal rib above them .The ribs and the 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 male but central in female).  Diaphragm in a normal adult is slightly higher on right compared to the Left. 
  36. 36. MEDIASTINUM.      This is the space between the right and left pleurae in and near the median sagittal plane of the chest. It is bounded by posterior surface of the sternum and the anterior surface of the 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 the fibrous pericardium
  37. 37. DIVISION OF MEDIASTINUM 1. Felson’s Classification 2. Sutton’s Classification 3. Haaga’s Classification 4. Heitzman’s Classification
  38. 38. 1. FELSONS CLASSIFICATION  The mediastinum can be divided into anterior, middle and posterior compartments.
  39. 39. An imaginary line is traced upward from the diaphragm along the back of the heart and front of the trachea to the neck. This divides the “anterior” from the “middle” midiastinum
  40. 40. 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.
  41. 41. 2.Suttons Classification  1. 2. 3. Mediastinum is divided into 3 parts Anterior division Middle division Posterior division Anterior Divison lies infront of the anterior pericardium  Middle division within the pericardial cavity  Posterior division lies beyond the post pericardium and trachea 
  42. 42. 3.Heitzmans division  Heitzman divided the mediastinum into the following anatomic regions: the thoracic inlet, the supraaortic area (above the aortic arch), the infraaortic area (below the aortic arch), the supraazygos area (above the azygos arch), and the infraazygos area (below the azygos arch).
  43. 43. SUPERIOR MEDIASTINUM It is located above a horizontal line drawn from the angle of Louis posteriorly to the spine.  Also defined as the space between thoracic inlet and superior aspect of the aortic arch (ref. JOHN.R.HAAGA)  Structures include the thyroid gland, aortic arch and great vessels, proximal portions of the vagus and recurrent laryngeal nerves, esophagus and trachea. 
  44. 44. ANTERIOR MEDIASTINUM    This is bounded above by thoracic inlet, laterally by the pleural , anteriorly by the sternum and posteriorly by the pericardium and the great vessels. It contains loose areolar tissue , lymph nodes, lymphatic vessels , thyroid, thymus, parathyroid and internal mammary vessels. It is seen as a triangular area of radiolucency between the sternum and heart on lateral view radiograph .
  45. 45. MIDDLE MEDIASTINUM    It is also referred to as vascular space. It is bounded by anterior and posterior mediastinum. It contains the heart ,pericardium ,ascending and transverse arch of the aorta, SVC and azygos veins that empties into it brachiocephalic vessels , the phrenic nerve , the upper vagus nerves, the trachea and its bifurcation, the main bronchi, the pulmonary veins
  46. 46. POSTERIOR MEDASTINUM It is also known as post vascular space.  It lies btw the heart anteriorly and the thoracic vertebrae from the thoracic inlet to the T12.  It contains descending aorta ,oesophagus, thoracic duct ,azygos and hemiazygos vein, lymph nodes ,sympathetic chains and inferior vagus nerves. 
  47. 47. MEDIASTINAL STRUCTURES The hila are made up of the main pulmonary arteries and major Bronchi -The left hilum is higher than the right -Lymph nodes are not normally seen on a chest X-ray TRACHEA HILUM carina
  48. 48. On the left side, the left pulmonary artery is directed posterolaterally, toward the left scapula and goes over the left main stem bronchus. The left pulmonary artery is therefore located higher than the right pulmonary artery. The right hilar shadow is inferior to the left on the PA projection ( 70%). Hilar shadows are equal in height (30%). The right hilum is never superior to the left hilum
  49. 49. • On the lateral projection, the left pulmonary artery is posterior to a line drawn down the tracheal air column.
  50. 50. The trachea appears as an air-shadow coursing down (c6) the midline of the chest and terminating at the carina (T5). The left and right mainstem bronchi, as well as the lobar bronchi may be evident A very slight deviation to the right at the level of aortic arch, moderate deviation to the right is common in infant.
  51. 51. OTHER FINDINGS – Thymus is usually visible in infants and occupies the superior part of ant. Mediastinum (causes widening of the mediastinum when present) .There is need for a lateral view to confirm it.  When there is enough air in the oesophagus a tracheo - oesophageal stripe may be seen, however oesophagus may be outlined by barium meal to clearly define it’s relation to other mediastinal structures & detection of abnormality .
  52. 52. HEART Size  Shape  Diameter (>1/2 thoracic diameter is enlarged heart)  Remember: AP views make heart appear larger than it actually is
  53. 53. P.A. CARDIAC VIEW Superior Vena Cava Aortic Arch Ascending Aorta Pulmonary Artery Left Atrium Right Atrium Left Ventricle INFERIOR VENA CAVA
  54. 54. P.A. CARDIAC VIEW
  55. 55. LATERAL CARDIAC VIEW Aortic Knob/Arch Descending Aorta Ascending Aorta Left Atrium Right Ventricle Left Ventricle Inferior Vena Cava
  56. 56. AORTOPULMONARY WINDOW A "space" located underneath the aortic arch and above the left pulmonary artery.  Contains fat.  On the PA projection, it appears as a concave shadow. If adenopathy is present, it manifests as a convex shadow. 
  57. 57. 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 {usually 1-2 cm } & Will appear larger on a lateral chest film  A difference greater than 3 cm in the level of two hemi diaphragms is significant 
  58. 58. The right hemidiaphragm is higher than the left ( the heart is pushing the left hemidiaphragm down) -A gas bubble beneath the left hemidiaphragm
  59. 59. RT LT
  60. 60. Cardiophrenic Sulci (Recesses, Angles) Lateral Costophrenic Sulci (Recesses, Angles)
  61. 61. Posterior Costophrenic Sulci (Recesses, Angles)
  62. 62. LUNG FIELDS UPPER ZONE MIDDLE ZONE LOWER ZONE
  63. 63. Pulmonary Fissures Pulmonary fissures are formed with visceral pulmonary pleura. RIGHT LUNG MAJOR FISSURE OBLIQUE FISSURE MINOR FISSURE HORIZONTAL FISSURE LEFT LUNG MAJOR FISSURE OBLIQUE FISSURE
  64. 64. Oblique fissure more clearly seen on Lateral view from T4-T5 vertebrae to reach the diaphragm and 5 cm behind the costophrenic angle on left And just behind the angle on right. Horizontal fissure more clearly Seen on P.A view extending from Right hilum to 6th rib in the axillary line
  65. 65. RT. MAIN BRONCHUS LT. MAIN BRONCHUS 6TH RIB CARINA HORIZONTAL FISSURE minor OBLIQUE FISSURE major OBLIQUE FISSURE (major)
  66. 66. Horizontal Fissure Right Oblique Fissure Left Oblique Fissure
  67. 67. FISSURES DIVIDE LUNGS INTO LOBES HORIZONTAL FISSURE RIGHT lung has: UPPER MIDDLE lobes LOWER LEFT lung has: UPPER lobes LOWER
  68. 68. RUL LUL RML RLL LLL
  69. 69. Retrosternal Clear Space Retrocardiac Clear Space
  70. 70. Left Hemidiaphragm Stomach gas bubble Splenic flexure of the large intestines Right Hemidiaphragm Liver some of the visual abdominal structures
  71. 71. Significance of different views Anteroposterior view  It is useful in differentiating free and loculated pleural 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. 
  72. 72. OBLIQUE VIEW It is helpful in localizing a lesion , in visualizing its borders and in projecting it free of overlying structures Oblique view is preferred to lateral view in case of bilateral disease DECUBITUS VIEW It is helpful in demonstrating small pneumothorax or pleural effusions
  73. 73. LORDOTIC VIEW It is particularly useful for lung apices This view helps in conforming middle lobe and lingular abnormalities This view is also helpful in determining the anteropostero location of a lesion APICOGRAM VIEW APICOGRAM is done when there is doubt about the apical area
  74. 74. THANK YOU
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