Normal Chest X- Ray

- Dr Sandeep Singh Awal

Dept of Radiodiagnosis GRMC

The PA View

• Positioning :

• All radio-opaque objects on the patient to be removed

• Patient ,upright, faces the cassette chin up• Shoulders rotated forward ,pressed in

contact with the cassette • side marker • Centering at T5 at right angles• Focus to Film Distance of 6 feet• Exposure made on full inspiration

AP VIEW

• Positioning :

• Patient back against the cassette, with the upper edge of cassette above the lung apices.

• Shoulders are rotated laterally and supported by the side of the trunk

• Centering : middle of the cassette at right angle

• Side marker

• Exposure made on full inspiration

LATERAL VIEW

• Positioning :

• patient turned to bring the side under investigation in contact with the cassette

• Arms raised over the head

• Mid-axillary line - coincides with middle of the film

• Centering : middle of the cassette at right angles

• EXPOSURE done in full inspiration

Film Quality

1. PA or AP view.

2. Upright/Erect or Supine

3. Breath : Inspiration or Expiration

4. X-ray penetration : Under- or Over-

5. Rotation

PA VIEW AP VIEW SCAPULA DO NOT OVERLAP THE LUNG FIELDS SCAPULA OVERLAPPING THE LUNG FIELDS

CLAVICLES PROJECT On THE LUNG FIELDS CLAVICLES ARE ABOVE THE APICES OF LUNG

NO CARDIAC MAGNIFICATION CARDIAC MAGNIFICATION

PA view AP view

Viewing the CHEST X RAY

• Patient details,history

• Technical aspects

• Bones

• Trachea and mediastinum

• Diaphragm and costophrenic angles

• Hila

• Lungs

• Soft tissues

TECHNICAL ASPECTS

• CENTERING/ROTATION : medial aspects of clavicles-equidistant from vertebral spinous processes

Spinous process is closer to right clavicle => left sided rotation seen

L

•ADEQUATEPENETRATION –

• Vertebral bodies and disc spaces should be just visible through the cardiac shadow.

Underpenetration – miss an abnormality hidden by another structure

Overpenetration – loss of visibility of low density lesions

• ADEQUATE INSPIRATORY EFFORT

Good inspiratory film :

6 complete Anterior ribs

10 complete Posterior ribs

Poor Inspiratory film :

Less than 6 anterior ribs seen

• Poor inspiratory film

4 anterior ribs visible

False postitive findings :

o cardiomegaly (ctr 0.55)

o opacity adjacent to aortic knuckle

o inhomogenous opacification of bilateral lower lung fields

Bones

• Each rib - anomaly

• Clavicles

• Scapulae and b/lhumerus if visible

• Lower cervical and thoracic spine

• LOOK FOR ANY FRACTURES OR LESIONS

Bifid left 4th rib

Fracture clavicle

Soft tissues

• Confirm presence or absence of breast shadows. Breast shadows may obscure lung bases or costophrenic angles

• Skin folds may mimic pneumothorax

• Lateral chest wall (subcutaneous emphysema)

Left sided mastectomy

Trachea

• Trachea – midline translucency, slight inclination to right in its lower half

• If Trachea shifted-

pneumothorax

Collapse

fibrosis

HEART

• Position

• Cardiothoracic ratio :ratio betnthe max transverse diam of heart and max width of the thorax above the costophrenicangles

• CTr = A+B / C

• If >0.5(adults) and >0.6(children) in a good quality film => Cardiomegaly

A=3 B = 5C = 12 A+B = 8 units

CTr = A+B/C= 8/12= 0.66

Imp -Cardiomegaly

• RIGHT HEART BORDER

SVC

RIGHT ATRIUM

IVC

• LEFT HEART BORDER

AORTIC KNUCKLE

PULMONARY TRUNK

LEFT VENTRICLE

svc

RA

IVC

A

P

LV

HILAR REGIONS

• 97% of subjects- left hilum is higher than right.

formed where superior pulmonary vein meets the lower pulmonary artery

Clearly defined CONCAVElateral borders

Normal lymph nodes not visible

Lung

• There are 3 lobes in right lung and 2 in left.

Right lung

• Upper lobe

• Middle lobe

• Lower lobe.

Left lung : also contains the lingula,part of the upper lobe.

• Upper lobe; this contains the lingula

• Lower lobe.

LUNG

• On a PA VIEW , for descriptivepurposes the lungs are divided into three zones separated by imaginary horizontal lines

• Upper zone - above the anterior end of the second ribs

• Midzone - between the second and fourth anterior ribs

• Lower zone - below the level of the fourth anterior rib.

Analyse each lung separately

Identify any change in density

Compare with opposite lung

Compare upper, mid and lower zones

Bronchovascular markings –prominent if present on more than 2/3rds of lung laterally

Inferior markings are normally more prominent

Lobes• Right upper lobe:

• Right middle lobe:

• Right lower lobe:

• Left lower lobe:

• Left upper lobe with Lingula:

• Lingula:

• Left upper lobe - upper division:

Oblique/major fissure – separates upper lobe from lower lobe

• seen on lateral view

• Extends from T4/T5 posteriorly to diaphragm anterioinferiorly.

Horizonta/minor fissure – separates upper and middle lobes of Right lung.

• Can be seen on PA and lateral views

• Seen running from the hilum to sixth rib in axillary line in pa film.

• Posteriorly ends at the right major/oblique fissure

Accessory fissures

• Azygous fissure (0.4 % of pop) – comma shaped, mostly right sided in the apex of the lung

• Forms due to abnormal migration of azygous vein during development.

• invagination of the azygousvein through the apical portion of right upper lung.

• Inferior accessory fissure –oblique line running from the cardiophrenic angle toward the hilum. separates medial basal from other basal segments. Commoner on right side.

• Superior accessory fissure –separates the right lower lobe into superior and basal segments.

Inferior accessory fissure

Diaphragm

• Right hemidiaphragm is higher than the left.

• Assess curvature of b/lhemidiaphragms to identify diaphragmatic flattening or bulge

• Assess bilateral Costophernic angles-normally acute & well defined

• Rule out any free gas under hemidiaphragm

•Thank you