EVALUATION OF THE CHEST X-RAY

Technical quality
1. DENSITY or X-Ray Penetration
2. POSITION of the scapulae
3. ROTATION of the C X-R
4. DEGREE of inspiration
DENSITY

Vertebral bodies must be VISIBLE through the cardiac shadow
POSITION of the SCAPULAE

They should project outside the lung fields

wrong--->

correct:
ROTATION

Medial ends of the claviculae should be EQUIDISTANT from the spinous process
INSPIRATION

Anterior segment of the 6th rib
Posterior segment of the 9th rib

                   

ABOVE the DIAPHRAGM
INSPIRATION

Poor Inspiration (picture to the right -->):

* False enlarged heart
* Difficult evaluation of the lungs

Same patient on inspiration (below):
THE NORMAL CHEST X-RAY

1. Heart
2. Hila
3. Mediastinum
4. Lungs
5. Diaphragm
6. Chest wall
7. Pleura + sinuses
The Heart

1. Always look at both films

2. Right border: Edge of (r) Atrium

3. Left border: (l) Ventricle + Atrium
The Heart - lateral film

4. Posterior border: left Ventricle

5. Anterior border: right Ventricle
The Hila

1. Made of:
  * Pulmonary Art. + Veins
  * The Bronchi
2. Left Hilus higher (max 1-2,5 cm)

3. Identical: size, shape, density
The Mediastinum

1. Look at both films
2. The edges should be clear
3. Right sup.border: 
  * Innominate vessels + Sup. vena cava

4. The (r) paratracheal line (2-3 mm)
5. Left sup. border: 
  * Subclav.art. + Arcus aorticus (2-3 cm)
The LUNGS

1. Equal density

2. Symmetrical

3. Look for the Minor Fissure
    (from the right hilus to 6th rib)

4. Look for the Major fissure (lateral) 
    (from T4-5 to the diaphragm)
The diaphragm

1. Both Hemi. clearly VISIBLE
2. Both have CONVEX shape
3. The right is HIGHER (1-3 cm)
The Lateral Films

1. Lung Fields in front and behind the heart 
     = Same Density

2. Density over the heart 
     = density over upper thoracic spine
The Lateral Films

3. Check the position of FISSURES

4. The Hila (density, size, etc)

5. Vertebral bodies
Additional Views

1. Expiration views Pneumothorax

2. Decutitus (lateral) Pleural fluid

3. Rib views Fractures. Other lesions
The Abnormal Chest X-Ray

1. Heart failure
2. Enlarged Hila
3. Enlarged Mediastinum
4. Lung disease: (infection, emboli, pneumothorax, emphysema, "Coin lesion")
1. Heart failure

Radiological Signs:

a) Enlarged heart shadow
     C.T. index > 50 %

b) Vascular redistribution
1. Heart failure

c) Kerley lines "B"

d) Pulmonary Edema:
     Interstitial
     Alveolar (bilateral)

e) Pleural fluid
The Enlarged Hila

Causes:

1. Adenopathies (neoplasia, infection)

2. Primary Tumor

3. Vascular

4. Sarcoidosis
The Enlarged Hila

Diagnostic approach:

Chest X-Ray (2 planes) CT scan
The Enlarged Mediastinum

1. Always EXCLUDE rotation

2. Causes: Superior / Anterior
     * Thymoid
     * Thymus
     * Innominate artery
     * Lymphoma
Aortic aneurysmThe Enlarged Mediastinum

3. Causes: Middle / Inferior
     * Lymphoma
     * Aortic aneurysm
     * Dilated eosophagus
The Lung diseases

1. INFECTIONS
    a) TBC
    b) Pneumonia
Tuberculosis

TBC signs:

1. Reticulo - Nodular

2. Apical + Parahilar

3. Uni- og Bilateral
Pneumonia

Characteristics:

1. Infiltrate + "Air bronchogram"

2. Diffuse, Homogeneous

3. Location: 
     * Uni- og Bilateral
     * Segmental or Lobar
Pneumonia

The "Silhouette" Sign  = Indistinct Heart Border

Location: Middle lobe or Lingula

Example: Pneumonic infiltrate in upper segment of middle lobe (r) visible as indistinct heart border in frontal projection

and clearly visible in lateral projection
   

Fibrosis Vs Infiltrate
Fibrosis

FIBROSIS
 INFILTRATE
Apical
 +++
 +
Basal
 +
 +++
Bilateral
 ++
 ++
Small lungs
 +++
 no
 
Pulmonary emboli

Frequent Signs:

1. Darker area of Reduced Perfusion 
      (Westermark's sign)

2. "Cut off" sign

3. Focal Consolidation (infarction)

       CT scan
Pneumothorax

X-Ray signs:

1. Pleural line

2. No parenchym behind the line

3. Displacement of mediastinum
The "Coin Lesion"

Definition:
"A well circumsc. shadow in the lungs"

Causes:
  * Tumor (benign or malignant)
  * Infection (eg. abscess, TBC)
  * Cyst (Hydatid), Rheuma, nodule
The "Coin Lesion"

# Always look at old films

   Signs of Malignency:

     * Irregular borders
     * Prominence of additional lesions
     * Parahilar mass + bone lesion(s)
The Coin Lesion

# If Malignant signs present
          or if (?)

      CT Scan MRI
CONCLUSION

1. "Good" Technique

2. "Good" Look at both films
           
3. "Good" LUCK
Author: Claude Pierre-Jerome
Edited by: Arne Westgaard, 14.12.2000. Updated 31.03.2003.

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