1. HOW READ CHEST XR -5
ANAS SAHLE ,MD

2. Brief review

3. POSITION
PA AP
QUALITY
ROTATION PENETRATION INSPIRATION
LESION
Homo
Densityinfiltratio Heterogenous Centralperiph Silhouet
n
Wellill defined Zone eral
Necrotic sign
MEDIASTINAL
Central deviasionwided
COSTO-PHRENIC ANGEL
Freeoblitern
OTHER
Bone soft tissuediaphragm

4. Consolidation
Infection
causes Non-infection causes
Broncho-
WEGNER Cardiac
Pneumonia Lymphoma alveolar COP Sarcoid
disease failure
carcinoma

5. Abscess
1. Cavitating infective consolidation.
2. Single or multiple lesions.
3. organisms.
1. Bacterial (Staphylococcus aureus, Klebsiella, Proteus,
Pseudomonas, TB and anaerobes).
2. fungal pathogens are the most common causative
4. ‘Primary’ lung abscess – large solitary abscess without
underlying lung disease is usually due to anaerobic bacteria.
5. Associated with aspiration and/or impaired local or systemic
immune response (elderly, epileptics, diabetics, alcoholics
and the immunosuppressed)

6. Radiological features
• Most commonly occur in the apicoposterior
aspect of the upper lobes or the apical
segment of the lower lobe.
• CXR may be normal in the first 72 h.
• CXR – a cavitating essentially spherical area of
consolidation usually>2 cm in diameter, but
can measure up to 12 cm.
• There is usually an air-fluid level present.

7. Heart failure
Radiological features:
• Right heart failure (this is usually due to chronic
airways disease).
– the heart size is normal with a prominent elevated
apex due to right ventricular hypertrophy.
– Pulmonary arterial enlargement and venous upper
lobe diversion in keeping with pulmonary arterial
and venous hypertension.
– There may be pleural effusions with fluid tracking in
the oblique and horizontal fissures.
– Beware these may look like mass lesions on the
frontal radiograph.

8. Heart failure
• Left heart failure:
• Stage 1 – there is venous upper lobe blood diversion with thickened
upper lobe veins bilaterally.
• Stage 2 – interstitial pulmonary oedema – prominent peripheral
interstitial thickening (Kerley B lines) bilaterally at both bases with
apparent peribronchial thickening at both hila
• Stage 3 – alveolar (air space) pulmonary oedema – patchy bilateral
perihilar air space consolidation giving a ‘Bat’s wing’ appearance.
• The consolidation may become confluent and xtensive.
• Occasionally asymmetry may be misleading and can be due to the
way in which the patient had been lying or the presence of
concomitant chronic lung disease.
• There is venous upper lobe blood diversion with thickened upper
lobe veins bilaterally.

9. Left heart failureradiology feature
Stage-1
Stage-2
Stage-3

10. Sarcoidosis
Radiological features:
• Stage 1 – bilateral hilar and mediastinal lymphadenopathy
(particularly right paratracheal and aortopulmonary window
nodes).
• Stage 2 – lymphadenopathy and parenchymal disease.
• Stage 3 – diffuse parenchyma disease only.
• Stage 4 – pulmonary fibrosis
• The parenchymal disease involves reticulonodular shadowing in a
perihilar, mid zone distribution.
• There is bronchovascular and fissural nodularity.
• Rarely air space consolidation or parenchymal bands may also be
present.
• Fibrosis affects the upper zones where the hilar are pulled
superiorly and posteriorly.
• Lymph nodes can demonstrate egg shell calcification

11. Case-1
• 55-year-old male was admitted in shock.
• He was recently diagnosed with inoperable
lung cancer.
• Clinical exam also showed distended neck
veins and muffled heart sounds.

12. CASE-1

13. POSITION •PA CXR
QUALITY •Poor Technical Quality
•(PENETRATION,ROTATION?)
•Heterogenous density
•In right middle zone from hilum to
LESION chest wall.
•That obliterate right heart border
•With silhouet sign.
•Central trachea and mediasteinal.
MEDIASTINAL •Cardiomegaly .
ANGELS •Free costo-phrenic angels.
OTHER •No

14. discussion
• Beck described a triad of hypotension, muffled heart sounds, and elevated
jugular venous pressure due to cardiac tamponade from pericardial
effusion.
• Immediate pericardiocentesis is life-saving.
• The common causes of pericardial effusion Include:
• malignancy,
• congestive heart failure.
• Tuberculosis.
• systemic lupus erythematosus.
• Dressler’s syndrome.
• uremia.
• This CXR shows :
• a globular enlargement of the heart, typical of a large pericardial
effusion.
• In addition, there is a mass in the right lung in keeping with the
primary lung cancer.

15. Case-2
• This 40-year-old
male of African
origin was
asymptomatic.

16. POSITION •PA CXR
•Poor Technical Quality
QUALITY •(PENETRATION?)
•Bi-lateral hilar enlargement.
LESION
•Central trachea and mediasteinal.
MEDIASTINAL
•Free costo-phrenic angels.
ANGELS
•No
OTHER

17. discussion
Sarcoidosis.
• The main differential diagnoses would be:
• Lymphoma.
• Tuberculosis.
• but the lymphadenopathy would then be
asymmetrical.

18. Case-3
• This elderly
male has
exertional
dyspnea,
orthopnea,
and
paroxysmal
a
nocturnal b
dyspnea. c
A+b>c2

19. POSITION •AP CXR
•Poor Technical Quality
QUALITY •(rotation ?)
•Bi-lateral perihilar infeltration.
LESION •With upper zone diversion
•Kerley b line?
•Central trachea and mediasteinal.
MEDIASTINAL •Cardiomegaly.
ANGELS •Free costo-phrenic angels.
•There are sternotomy wires.
OTHER •right internal jugular central venous line.

20. After diuresis

21. Discussion
• The CXR shows classic evidence of left ventricular failure, :
– cardiomegaly (cardiothoracic ratio 50%),
– upper lobe pulmonary venous diversion,
– and Kerley B lines (which indicate distension of
lymphatics).
• In addition, there is evidence of sternotomy wires,
suggesting previous coronary artery bypass surgery (CABG).
• Following diuresis, the pulmonary infiltrates have cleared
Only fluid and blood on the chest radiograph can clear
rapidly (within days).
• This patient also has a right internal jugular central venous
line.

22. Case-4
• This elderly
female
presented with
left-sided chest
pain of three
months’
duration

23. POSITION •AP CXR
QUALITY •Poor Technical Quality
•(rotation ?)
•Homogenous density in left upper
zone obscured aortic arc.
LESION •Many opacity at left peripheral
chest wall
•Right pushed trachea.
MEDIASTINAL •Cardiomegaly.
ANGELS •Left obliterans costo-phrenic angels.
•No .
OTHER

24. Discussion
• The CXR shows a moderate-sized left pleural
effusion, which is loculated.
• There is also globular cardiomegaly,
suggesting a pericardial effusion.
• Pleural tap showed malignant cells consistent
with the diagnosis of adenocarcinoma of the
lung.
• In addition, the second, third, and fourth ribs
on the left side demonstrate lytic lesions in
keeping with bony metastases.

25. Case-5
• This 24-year-old female was asymptomatic.
• Six months ago, she presented with
pneumonia-like symptoms of cough, fever,
and purulent sputum.

26. POSITION •PA CXR
QUALITY •Good Technical Quality
•Ill defined opacity in right lower
zone close to chest wall
LESION
•Central trachea ,mediastinal.
MEDIASTINAL
ANGELS •Hazy costo-phrenic angels.
•No .
OTHER

27. Discussion
• The CXR shows a right lower lobe infiltrate
• In addition, there seems to be a beady
appearance to the infiltrates.
• Pneumonic changes on CXR typically resolve
within three months.
• She subsequently underwent a bronchoscopy
and transbronchial lung biopsy which showed
BOOP.