CHEST X-RAY

CHEST X-RAY
CXR


Chest X-Ray Interpretation Explained Clearly

The chest x-ray is the most frequently requested radiologic examination.
In fact every radiologst should be an expert in chest film reading.
The interpretation of a chest film requires the understanding of basic principles.
In this article we will focus on:

• Normal anatomy and variants.
  
  
• Systematic approach to the chest film using an inside-out approach.
  
  
• Pathology of the heart, mediastinum, lungs and pleura.
  
  
  

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PA view

On the PA chest-film it is important to examine all the areas where the lung borders the diaphragm, the heart and other mediastinal structures.
At these borders lung-soft tissue interfaces are seen resulting in a:

• Line or stripe - for instance the right para tracheal stripe.
  
  
• Silhouette - for instance the normal silhouette of the aortic knob or left ventricle
  
  

These lines and silhouettes are useful localizers of disease, because they can be displaced or obscured with loss of the normal silhouette. This is called the silhouette sign, which we will discuss later.
The paraspinal line may be displaced by a paravertebral abscess, hemorrhage due to a fracture or extravertebral extension of a neoplasm.
Widening of the paratracheal line (> 2-3mm) may be due to lymphadenopathy, pleural thickening, hemorrhage or fluid overload and heart failure.
Displacement of the para-aortic line can be due to elongation of the aorta, aneurysm, dissection and rupture.
The anterior and posterior junction lines are formed where the upper lobes join anteriorly and posteriorly. These are usely not well seen and we will not discuss them.
(An important mediastinal-lung interface to look for is the azygoesophageal line or recess (arrow 


GO ON 

Systematic Approach

Whenever you review a chest x-ray, always use a systematic approach.
We use an inside-out approach from central to peripheral.
First the heart figure is evaluated, followed by mediastinum and hili.
Subsequently the lungs, lungborders and finally the chest wall and abdomen are examined.
You have to know the normal anatomy and variants.
Find subtle abnormalities by using the sihouette sign and mediastinal lines.
Once you see an abnormality use a pattern approach to come up with the most likely diagnosis and differential diagnosis.

Old films

It is extremely important to always compare with old films, as we will demonstrate in this case.
Actually someone said that the most important radiograph is the old film, since it gives you so much information.
For instance a lung mass, which hasn't changed in many years is not a lung cancer.
First study the chest films.
Then continue.
Based on the CXR that you just saw, you could have made the diagnosis of congestive heart failure, but the findings are very subtle.
However once you compare it to the old film, things become more obvious and you will be much more confident in your diagnosis:
[list="color: rgb(51, 51, 51); font-family: verdana, tahoma, arial, sans-serif; font-size: 12.8px;"]
[*]The size of the heart is slightly increased compared to the old film.

[*]The pulmonary vessels are slightly increased in diameter indicating increased pulmonary pressure.

[*]There are subtle interstitial markings as a result of interstitial edema.

[*]There is pleural fluid bilaterally. Notice that the inferior border of the lower lobes has changed in position.

[/list]
All these findings indicate the presence of heart failure.
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Silhouette sign
This is a very important sign. It enables us to find subtle pathology and to locate it within the chest.
The loss of the normal silhouette of a structure is called the silhouette sign.

Here an example to explain the silhouette sign:
The heart is located anteriorly in the chest and it is bordered by the lingula of the left lung.
The difference in density between the heart and the air in the lung enables us to see the silhouette of the left ventricle.
When there is something in the lingula with the same 'water density' as the heart, the normal silhouette will be lost 
 (blue arrow).

When there is a pneumonia in the left lower lobe, which is located more posteriorly in the chest, the left ventricle will 
 (still be bordered by air in the lingula and we will still see the silhouette of the heart (red arrow 
see ilms

The PA-film shows a silhouette sign of the left heart border.
Even without looking at the lateral film, we know, that the pathology must be located anteriorly in the left lung.
This was a consolidation due to a pneumonia caused by Sterptococcus pneumoniae.

Hidden areas

There are some areas that need special attention, because pathology in these areas can easily be overlooked:

• apical zones
  
  
• hilar zones
  
  
• retrocardial zone
  
  
• zone below the dome of diaphragm
  
  

These areas are also known as the hidden areas.

(Notice that there is quite some lung volume below the dome of the diaphragm, which will need your attention (arrow 


etc.....


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Chest X-ray Tutorials

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Chest X-ray   Introduction



This tutorial demonstrates some of the important anatomical structures visible on a chest X-ray. These structures are discussed in a specific order to help you develop your own systematic approach to viewing chest X-rays.By the end of the tutorial you will be familiar with all the important structures of the chest, which should be checked whenever you look at a chest X-ray. The tutorial also discusses anatomical structures that are not easily seen, but become visible when abnormal due to disease. You will learn more about these structures and diseases in the tutorial on chest X-ray pathology.Before you start, have a look at the normal chest X-ray below.Normal chest X-ray anatomyHover on/off image to show/hide findings Normal chest X-ray anatomy



• How many anatomical structures can you see on this X-ray?
  
  
• Can you think of any important structures in the chest that are difficult to see on the X-ray?
  
  

Visible structures



• 1 - Trachea
  
  
• 2 - Hila
  
  
• 3 - Lungs
  
  
• 4 - Diaphragm
  
  
• 5 - Heart
  
  




• 6 - Aortic knuckle
  
  
• 7 - Ribs
  
  
• 8 - Scapulae
  
  
• 9 - Breasts
  
  
• 10 - Bowel gas
  
  

Important obscured/invisible structures



• Sternum
  
  
• Oesophagus
  
  
• Spine
  
  




• Pleura
  
  
• Fissures
  
  
• Aorta
  
  

Chest X-ray anatomyMany structures of the chest are readily visible on a chest X-ray, but others, are difficult to see. In fact, some important structures, such as the phrenic nerve, are not visible at all.Other anatomical structures, such as the pleura, only become clearly visible when abnormal.Normal chest X-ray anatomyHow many anatomical structures can you see on this X-ray?Can you think of any important structures in the chest that are difficult to see on the X-ray?Visible structures1 - Trachea2 - Hila3 - Lungs4 - Diaphragm5 - Heart6 - Aortic knuckle7 - Ribs8 - Scapulae9 - Breasts10 - Bowel gasImportant obscured/invisible structuresSternumOesophagusSpinePleuraFissuresAortaChest X-ray anatomyMany structures of the chest are readily visible on a chest X-ray, but others, are difficult to see. In fact, some important structures, such as the phrenic nerve, are not visible at all.Other anatomical structures, such as the pleura, only become clearly visible when abnormal.

[size=30]Chest X-Ray (CXR) Analysis in a Nutshell[/size]


LEARN to Read a Chest Xray in 5 minutes!

(How to Interpret a Chest X-Ray (Lesson 2 - A Systematic Method and Anatomy 

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7. Recognizing Airspace Versus Interstitial Disease
 
8. Recognizing a Pneumothorax
[url=http://learningradiology.com/medstudents/recognizingseries/Recognizing a PTX-2012/Rocognizing a PTX-2012.html][/url]
10. Recognizing the Placement of ICU Tubes and Lines

14. Recognizing Free Air

15. Recognizing Abdominal Calcifications
[url=http://learningradiology.com/medstudents/recognizingseries/Recognizing Abd Calc-2012/Recognizing Abd Calc-2012.html][/url]
 
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8. Recognizing a Pneumothorax

10. Recognizing the Placement of ICU Tubes and Lines
[url=http://learningradiology.com/lectures/chestlectures/icutubesandlines2012/ICU Tubes and Lines-2012/ICU Tubes and Lines-2012.html][/url]
[rtl] 14. Recognizing Free Air[/rtl]

15. Recognizing Abdominal Calcifications
[url=http://learningradiology.com/medstudents/recognizingseries/Recognizing Abd Calc-2012/Recognizing Abd Calc-2012.html][/url]
 

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