how read chest xr 2

HOW READ CHEST XR -2

ANAS SAHLE ,MD

Technical Quality

Is the film centered? Rotation

Is it PA or AP film ? Positioning

Is it exposed properly ? Penetration

Is it a good inspiration film? Inspiration

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RPPI

observing the clavicular headsdetermining whether they are equal distance from the spinous process of the thoracic vertebral bodies

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RPPI

If the scapulae no longer overlie the lung fields then the film is PA

If the scapulae overlie the lung fields then the film is AP





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RPPI

Normal Penetrated PA film

An overpenetrated PA film

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Normal Penetrated PA film underpenetrated PA film





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RPPI

The diaphragm should be found at about the level of the 8th - 10th posterior rib or 5th - 6th anterior rib on good inspiration

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look at the lungs

Scan both lungs

starting at the apices and working down

comparing left with right at the same level

Compare and contrast vascular markings in upper vs. lower lung fields in PA view

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List conditions, where vascular markings are prominent in upper lung fields

• Mitral stenosis • Congestive heart failure • Alpha one antitrypsin deficiency

Compare and contrast vascular markings in outer third vs. inner two thirds of lungs

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increased markings in outer third of lung fields?

• In:1. Left to right shunts (ASD, VSD, PDA)

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increased pulmonary flow

increased markings in outer third of lung fields?

• In :2. Interstitial disease3. Lymphangitic malignant spread4. CHF with increased lymphatic flow

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Fissures

Localizing lesions

The position of lesioncan be described in terms ofzones

To accurately localize a lesion on chest X ray you need to look at both the PA and lateral films

First look at thePA film

The upper zone lies above the anterior border of the 2nd rib

The middle zone lies between the right anterior borders of the 2nd and 4th ribs

The lower zone lies between the right anterior border of the 4th rib and the diaphragm

It does not give any information about the

lobes of the lung

Look at the borders of the lesion

• If the lesion is next to a dense (white) structure then the border between the lesion and that structure will be lost

This is calledthe silhouette sign

Now look at thelateral film

Lateral Positioning

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A brief look at the lateral CXR

Key points• There should be a decrease in density from superior to inferior in the posterior mediastinum.• The retrosternal airspace should be of the same density as the retrocardiacairspace.

Identify the oblique fissure

• (pass obliquely downwards from the T4/T5 vertebrae through the hilum ending at the anterior third of the diaphragm)

Identify the horizontal fissure

• (pass horizontally from the midpoint of the hilum to the anterior chest wall)

If the lesion lies posterior to the oblique fissure it must lie within the lower lobe

If the lesion lies anterior to the oblique fissure it may be in the upper or middle lobe

If the lesion is below the horizontal fissure it is in the middle lobe

If the lesion is above the horizontal fissure it is in the upper lobe

There is no middle lobe on the left

CASE-1

This elderly male had recent onset of streaky

hemoptysis?.

POSITION •AP CXR

QUALITY •Poor Technical Quality

LESION •homogeneous density in the right upper zone , elevation of the transverse fissure

MEDIASTINAL •Central trachea and mediasteinal

ANGELS •Free costo-phrenic angels

OTHER •NO

S sign

• homogeneous density in the right upper zone• elevation of the transverse fissure

( Instead of the transverse fissure being straight)

• there is a bulge at the medial end giving it an inverted S shape.

• Golden described this sign and the explanation for it is that the upper lobe

collapse is due to a right hilar mass which accounts for the medial bulge

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Atelectasis Right Upper LobeHomogenous density right upper lung field.

Mediastinal shift to right.

Loss of silhouette of ascending aorta.

Movement of oblique and transverse fissures.

Case-2

This middle-aged female complained of :•Hemoptysis•loss ofweight two months’ duration.

POSITION •PA CXR

QUALITY •Poor Technical Quality•(poor penetration).

LESION •hazy, veil-like opacification•in the left upper zone,obscured aortic arc,from hilar to peripheral

MEDIASTINAL •Central trachea and mediasteinal

ANGELS •Obscured left costo-phrenic angels•Elevate left hemidiaphragm

OTHER •NO

Illustration

• The CXR shows evidence of left upper lobe collapse. • There is a hazy, veil-like opacification in the left upper lobe, which does not have a sharp

inferior margin unlike right upper lobe collapse.• This is because there is usually no left transverse

fissure and the lobe collapses anteriorly.. • There is also volume loss in the left hemithorax as

evidenced by an elevated left hemidiaphragm and crowding of the left upper ribs.

• Sometimes the trachea may also be deviated to the same side and the aortic knuckle may be obscured by the collapse

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Mediastinal shift to left.

Density left upper lung field.

Loss of aortic knob and left hilar silhouettes.

Atelectasis Left Upper Lobe

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A: Forward movement of oblique fissureC: Atelectatic LULB: Herniated right lung

Atelectasis Left Upper Lobe

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Bowing sign

•LUL atelectasis or following resection

•The oblique fissure bows forwards

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Bowing sign

CASE-3

• 50-year-old female with a past history of tuberculosis had

• chronic cough over the past year.

POSITION •PA CXR

QUALITY •GOOD Technical Quality

LESION •No•Left lung smaller than right

MEDIASTINAL •Left deviation trachea and mediasteinal

ANGELS •Obscured left costo-phrenic angels•Elevate left hemidiaphragm

OTHER •NO

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Inhomogeneous cardiac density.

Triangular retrocardiac density.

Left hilum pulled down.

AtelectasisLeft Lower Lobe

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•Lateral left diaphragm not visible•Increased density over lower spine

Left Lower Lobe Atelectasis

how read chest xr 2

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