PA

NAME THE DIRECTION OF THE CXR

LATERAL FILM; NOTE RECEPTOR IS AGAINST

LEFT CHEST

NAME THE DIRECTION OF THE CXR

RIGHT RIBS: USUALLY PROJECTED POSTERIOR TO LEFT

RIBS IF PATIENT WAS EXAMINED IN TRUE LATERAL

POSITION.

RED ARROWS: RIGHT RIBS; BLUE ARROWS: LEFT RIBS

WHICH RIBS ARE LARGER ON LATERAL CXR?

RIGHT IS USUALLY HIGHER. HEART LIES PREDOMINANTLY ON LEFT SIDE.

R DIAPHRAGM CONTINUES ANTERIORLY, LEFT DISAPPEARS BECAUSE

SILOUHETTING OF HEART. R DIAPHRAGM AT BLUE ARROWS CONTINUES PAST

THE SMALLER L RIBS AND ENDS AT LARGER AND MORE POSTERIOR R RIBS

WHICH SIDE OF THE DIAPHRAGM IS HIGHER?

TRACHEA

CARINA

RIGHT MAIN BRONCHUS

BRONCHUS INTERMEDIUS

LEFT MAIN BRONCHUS

IDENTIFY THE AIRWAYS

TRACHEA

RIGHT MAIN BRONCHUS

BRONCHUS INTERMEDIUS

LEFT MAIN BRONCHUS

IDENTIFY THE AIRWAYS

TELL ME ABOUT LUNG MARGINS

A: Minor (horizontal) fissure: separating upper R lobe from middle R lobe

B: Major (oblique) fissure: suparates inferior lobe of either lung from the remainder of the lung.

Inferior border (first image): borders of major fissure. Lateral CXR are better for observing major fissure.

Superior border (second image)

PA CXR: FISSURES

• Left lung will only have major fissure (B): dividing upper and lower left lung.

• Right lung will have major (B) and minor (A) fissures• Major fissure separates inferior lobe from middle lobe• Minor (horizontal) fissure separates superior from middle lobe

LATERAL CXR: FISSURES

NO LOSS OF SILHOUETTE, SO MEDIASTINAL MASS

MUST LIE ANTERIOR OR POSTERIOR TO HEART

MASS LOCATION RELATIVE TO HEART?

(ANTERIOR/ POSTERIOR OR IN CONTACT WITH?)

LOSS OF SILHOUETTE FLUID IN RIGHT MIDDLE

LOBE OF LUNG IS IN CONTACT WITH HEART

MASS LOCATION RELATIVE TO HEART?

(ANTERIOR/ POSTERIOR OR IN CONTACT WITH?)

CXR OPACITIES

Too white, increased opacity

• Consolidation, pneumonia

• Atelectasis

• Nodule/ mass

• Interstitial disease

• Pleural effusion

Too dark, decreased opacity

• Emphysema (COPD)

• Large pneumothorax

• Large pulmonary embolus (massive)

WHAT ARE SIGNS OF ATELECTASIS?Increase in density of the affected lung

(Atelectasis is volume loss/ collapse= decreased air in lung)

Displacement of the fissures or the mediastinum towards the

atelectasis

Elevation of the diaphragm

WHAT ARE CAUSES OF ATELECTASIS?

ETIOLOGY: PROXIMAL OCCLUSION OF A BRONCHUS

INFANT: FOREIGN BODY (EX: PEANUT)

CHILD/ YOUNG ADULT: MUCOUS PLUG/ ASTHMA

MIDDLE AGED/ ELDERLY: CENTRAL LESIONS (EX:

CARCINOMA)

HOSPITALIZED: MUCOUS PLUG

POST OP!!!

RIGHT UPPER LUNG ATELECTASIA: IPSILATERAL MEDIASTINAL SHIFT

(SHIFT TO SAME DIRECTION AS ATELECTASIA)

NAME THE PATHOLOGY

WHAT ARE SIGNS OF PLEURAL EFFUSION?• An effusion will appear as a graded haze that is denser at the base

(increased opacity; lighter)

• Outside of the lung: fluid buildup within potential space of pleural

cavity (between visceral and parietal pleura)

• The most common radiographic sign is a pleural meniscus

PULMONARY EFFUSION: MOST CXRS IN PE WILL BE NORMAL. THIS CXR

HAS HAMPTON’S HUMP: WEDGE SHAPED OPACITY.

OTHER SIGNS: INCREASED HILUM SIZE (CAUSED BY THROMBUS

IMPACTION; ATELECTASIS; PLEURAL EFFUSION; CONSOLIDATION

NAME THE PATHOLOGY

WHAT ARE SIGNS OF PNEUMOTHORAX?Visceral pleura (very thin white line) is displaced from right lateral chest wall

Increased lucency (darker) on lateral side represents air in pleural space

Air appears black on CXR

Lucency on the medial side is normal as it represents air in the lung

There will also be an absence of pulmonary vessels lateral to the pleural line (see no

white streaks)

Is this Westermark’s Sign?

NO! You don’t see any of the white streaks (vasculature) because it’s

just air in the pleural cavity. Westermark’s sign is due to decreased

vasculature but it’s still lung (seen in pulmonary embolus).

WHAT ARE SIGNS OF EMPHYSEMA?Hyperinflated lungs:

• enlarged intercostal spaces

• low set diaphragm

Reduced pulmonary vasculature resulting in hyperlucent lungs

(darker)

• Due to more air left in lungs, and because white stuff in a normal

CXR are usually vessels, so if they’re not around, lung = more black

Presence of bullae (arrows)

• lucent, air-containing sacs

• ATELECTASIS (NOTE THE STRAIGHT UPWARDS LINE):

THIS IS THE HORIZONTAL FISSURE; IT HAS BEEN DISPLACED

RUL COLLAPSES UPWARD, MEDIALLY, ANTERIORLY;SHIFT OF MINOR FISSURE, INCREASED DENSITY AGAINST MEDIASTINUM, TRACHIAL

SHIFT, HILAR SHIFT

ATELECTASIS OR PNEUMONIA?

RUL

Collapse

PNEUMONIA (NOTE THE STRAIGHT SIDEWAYS LINE)

ATELECTASIS OR PNEUMONIA?

RUL Pneumonia

RIGHT MIDDLE LOBE PNEUMONIA

NAME THE PATHOLOGY

RIGHT CXR: HEART IS BARELY VISIBLE (IT HAS SHIFTED LEFT)

WHICH SHOWS COLLAPSE?

WHICH SHOWS VOLUME EFFUSION?

RIGHT CXR: COLLAPSE

LEFT CXR: EFFUSION

WHICH CXR SHOWS VOLUME LOSS?

CONSOLIDATION: “FLUFFY”. REGION OF NORMALLY COMPRESSIBLE LUNG

TISSUE THAT HAS FILLED W/FLUID.

-SIGN CAN INDICATE PATHOLOGY LIKE PNEUMONIA, PULMONARY EDEMA ETC.

-THEY MAY HAVE POOR MARGINS, MAY HAVE AIR BRONCHOGRAMS (SEEN ON

LATERAL CXR)

NAME THE SIGN

MASS: ANOTHER MEDICAL SIGN THAT CAN BE INDICATIVE

OF CANCER, FUNGAL OR PNEUMONIA

NAME THE SIGN

MASS: DISCRETE, WITH BORDERSTHINK CANCER, METASTATIC DZ// DISSEMINATED INFECTION

NAME THE SIGN

PULMONARY NODULES: DISCRETE OPACITY WITHIN THE

LUNG< 3 CM DEFINED AS A NODULE

> 3 CM DEFINED AS A MASS

NAME THE SIGN

MEDIASTINAL MASS: CXR AND CT

NAME THE PATHOLOGY

HYLAR LYMPHADENOPATHY: HILA (LUNG ROOTS) CONTAIN MAJOR

BRONCHI, PULMONARY VEINS + ARTERIES, +LYMPH NODES (LN)

-HILAR LN ARE NOT VISIBLE ON A NORMAL CXR

-HILAR ENLARGEMENT IS OFTEN DUE TO LN ENLARGEMENT

-BILATERAL, BUT ASYMMETRICAL

NAME THE PATHOLOGY

NORMAL Hilar

points

MEDIASTINAL LYMPHADENOPATHY: ENLARGEMENT OF

MEDIASTINAL LYMPH NODES (ARROWS)

NAME THE PATHOLOGY

PLEURAL MENISCUS (PLEURAL EFFUSION), WITH IPSILATERAL

MEDIASTINAL SHIFT (SHIFT TO SAME DIRECTION AS ATELECTASIA)

NAME THE SIGN/ PATHOLOGY

PNEUMONIA

NAME THE PATHOLOGY

LOBAR PNEUMONIA: INFLAMMATORY CONDITION OF THE

LUNG, MOST COMMONLY CAUSED BY VIRUS, BACTERIA,

OR FUNGI.

NAME THE PATHOLOGY

DIFFUSE ALVEOLAR PNEUMONIA: INFLAMMATORY

CONDITION OF THE LUNG, MOST COMMONLY CAUSED BY

VIRUS, BACTERIA, OR FUNGI.

NAME THE PATHOLOGY

PLEURAL EFFUSION: FLUID BUILDUP IN PLEURAL SPACE (B/W VISCERAL &

PARIETAL PLEURA);

-MOST COMMON RADIOGRAPHIC FINDING IN PLEURAL EFFUSION IS PLEURAL

MENISCUS (FLUID IN THE COSTOPHRENIC ANGLE; SEE ARROWS)

HORIZONTAL FLUID LEVEL IS DIAGNOSTIC OF AIR AND FLUID IN THE PLEURAL

SPACE (HYDROPNEUMOTHORAX)

NAME THE PATHOLOGY

PULMONARY EFFUSION: MOST CXRS IN PE WILL BE NORMAL. THIS CXR HAS

WESTERMARK’S SIGN: DECREASE OF VASCULARIZATION AT THE PERIPHERY

OF THE LUNGS.

OTHER SIGNS: INCREASED HILUM SIZE (CAUSED BY THROMBUS IMPACTION;

ATELECTASIS; PLEURAL EFFUSION; CONSOLIDATION

NAME THE PATHOLOGY

PLEURAL EFFUSION: FLUID BUILDUP IN PLEURAL SPACE (B/W

VISCERAL & PARIETAL PLEURA); THIS IS AN UPRIGHT CXR; FLUID

IS NOT FALLING TO BOTTOM, NOT LAYERING. PT HAD EMPYEMA

NAME THE PATHOLOGY

PULMONARY EDEMA: ABNORMAL FLUID IN PULMONARY

INTERSTITIUM AND ALVEOLI

NAME THE PATHOLOGY

PULMONARY EDEMA: ABNORMAL FLUID IN PULMONARY INTERSTITIUM AND ALVEOLI

ARROW: KERLEY A LINES; ARROWHEAD: KERLEY B LINES; ENLARGED CARDIAC

SILHOUETTE

NAME THE PATHOLOGY

NOTHING?

WHAT THE HECK ARE THESE ARROWS POINTING AT?

WHAT THE HECK ARE THESE ARROWS POINTING AT?

JK! PERIBRONCHIAL CUFFING: VISUALIZATION OF SMALL

DOUGHNUT-SHAPED RINGS REPRESENTING FLUID IN

THICKENED BRONCHIAL WALLS. SIGN OF PULMONARY EDEMA

PULMONARY EDEMA: ABNORMAL FLUID IN PULMONARY

INTERSTITIUM AND ALVEOLI

NAME THE PATHOLOGY

ATELECTASIS

ATELECTASIS OR EFFUSION?

INTERSTITIAL DISEASE:

“SCRATCHY”: THESE ARE CALLED LUNG MARKINGS; LINEAR OPACITIES

NON-BACTERIAL INFECTIONS (MYCOPLASMA, VIRAL); DIFFUSE LUNG DISEASE (PULMONARY FIBROSIS),

INTERSTITIAL EDEMA

CAN’T FOLLOW VESSELS LIKE WE NORMALLY WOULD. (ORANGE LINES FOR COMPARISON, ON NORMAL)

NAME THE PATHOLOGY

Normal

INTERSTITIAL DISEASE: VARIETY OF CONDITIONS CAN LEAD TO DIFFUSE

PARENCHYMAL LUNG DISEASE (E.G. TB, SARCOIDOSIS, AMIODARONE

INDUCED PULMONARY FIBROSIS ETC.)

“SCRATCHY”: THESE ARE CALLED LUNG MARKINGS.

NAME THE PATHOLOGY

TENSION PNEUMOTHORAX: COLLAPSED R LUNG, R SIDED

LUCENCY AND LEFTWARD MEDIASTINAL SHIFT.

NAME THE PATHOLOGY

PNEUMOTHORAX: AIR IS WITHIN POTENTIAL SPACE

NAME THE PATHOLOGY

TENSION PNEUMOTHORAX CAUSES SHIFT OF MEDIASTINAL

STRUCTURES AWAY FROM THE PNEUMOTHORAX, WHEREAS

ATELECTASIS MAY CAUSE DISPLACEMENT TOWARDS

ATELECTASIS.

CONSIDER THE FOLLOWING: