Basic CXR Interpretation_Diagnostic Radiographs

1. Diagnostic Radiographs
Basic CXR Interpretation
Marc Imhotep Cray, M.D.

2.  Review of normal chest x-ray
 Administrative
 Initial survey
Introduction
2

3. Review of normal chest x-ray
A systematic approach to film review is most important
skill to develop major areas of should be viewed in a
sequential order
3

4. 1. Check patient name, position, technical quality
2. Soft tissue including breast, chest wall, companion
shadow
3. Review soft tissues and skeletal structures of shoulder
girdles and chest wall
4. Review abdomen for bowel gas, organ size, abnormal
calcifications, free air, etc.
5. Review soft tissues and spine of neck
Review of Normal CXR (2)
Sequenced Checklist:
4

5. 5
6. Review spine and rib cage: check alignment, disc
space narrowing, lytic or blastic regions, etc.
7. Review mediastinum:
a. overall size and shape
b. trachea: position
c. margins: SVC, ascending aorta, right atrium, left subclavian
artery, aortic arch, main pulmonary artery, left ventricle
d. lines and stripes: paratracheal, paraspinal, paraesophageal
(azygoesophageal), paraaortic
e. retrosternal clear space
Review of Normal CXR (3)
Sequenced Checklist:

6. 8. Review hila:
a. normal relationships
b. size
9. Review lungs and pleura:
a. compare lung sizes
b. evaluate pulmonary vascular pattern: compare upper
to lower lobe, right to left, normal tapering to
periphery
c. pulmonary parenchyma
d. pleural surfaces
• fissures - major and minor - if seen
• compare hemidiaphragms
• follow pleura around rib cage
6
Review of Normal CXR (4)
Sequenced Checklist:

7. Administrative
Get in habit of always
checking following items
before anything else
takes a few seconds and is
an important legal safe
guard as well
1. Patient's name
2. Date exam done (very
important if comparing prior
exams)
3. Check for position markers -
right vs. left, upright
7

8. Other items to check before commencing w clinical review of film include:
1.Type of film (practice noticing if it is a plain film, CT, angio, MRI, etc.)
2.Patients position - supine, upright, lateral, decubitus
3.Technical quality of exam - learn what are acceptable limits for exam Ex. You
can't find a subtle pneumothorax if there is patient motion or the film is
overexposed.
Administrative (2)
8

9.  A basic principle to adopt  going from general
observations to specific details  sometimes a change
may be so major that old saying “missing the forest for
the trees” comes true
o For instance, an absent breast shadow on a film of a patient
after a mastectomy
 After completing your administrative housekeeping, get
a general overview of film before zooming in on tiny
detail
Administrative (3)
9

10. 10
 Notice following b/c may change baseline normals you
use as reference points, and you may be sensitized to
look for specific findings
1.General Body Size, Shape, and Symmetry
2.Male vs. Female
3.Is this an infant, child, young adult, elderly person?
4.Survey for foreign objects - tubes, IV lines, EKG leads, surgical
drains, prosthesis, etc., as well as non-medical objects, bullets,
shrapnel, glass, etc.
Administrative (4)

11. The Chest X-Ray
Following radiographic plates are scan-ins from:
Felson, B., et al.: Principles of Chest Roentgenology. Philadelphia, W.B.
Saunders Co., 1973.
Fraser, R., et al.: Diagnosis of Diseases of the Chest, 3rd edition. Philadelphia,
W.B. Saunders Co., 1988.
11

12. Discussion Outline
•Densities
•Techniques
•Anatomy
•CXR Interpretation
•Common Pathologies
12

13. Densities
The big two densities are:
(1) WHITE - Bone
(2) BLACK - Air
The others are:
(3) DARK GREY- Fat
(4) GREY- Soft tissue/water
And if anything Man-made is
on film, it is:
(5) BRIGHT WHITE – Man
made
13

14. Techniques - Projection
P-A (relation of x-ray beam to patient)
14

15. Techniques – Projection cont’d.
Lateral
15

16. Techniques - Projection cont’d.
Lateral Decubitus
16

17. 17
Assessment
 Assess quality of film using mnemonic PIER:
 Position: Is this a supine AP film? PA? Lateral?
 Inspiration: Count posterior ribs. You should see 8–9 ribs with
a good inspiratory effort
 Exposure: Well-exposed films have good lung detail and show
a detailed outline of spinal column. Overpenetration leads to
a dark film with more spinal detail. Underpenetrated films
are whiter with little spinal detail.
 Rotation: Space between medial clavicle and margin of
adjacent vertebrae should be roughly equal on each side.
 Also look for indwelling lines or objects (eg,
endotracheal tube, feeding tube, airway obstruction)
that may reveal clues to pathology in film
“The A-B-C-D Sequence”

18. Penetration (Exposure)
18
OverpenetratedUnderpenetrated

19. Inspiration/Expiration
19

20. Rotation
20

21. Rotation cont’d.
21

22. Anatomy
22

23. Anatomy
23

24. Anatomy
24

25. Lobes
Right upper lobe:
25

26. Lobes cont’d.
Right middle lobe:
26

27. Lobes cont’d.
Right lower lobe:
27

28. Lobes cont’d.
Left lower lobe:
28

29. Lobes cont’d.
Left upper lobe with Lingula:
29

30. Lobes cont’d.
Lingula:
30

31. Lobes cont’d.
Left upper lobe - upper division:
31

32. Heart
Right border: Edge of (r)
Atrium
2. Left border: (l) Ventricle
+ Atrium
3. Posterior border: Left
Ventricle
4. Anterior border: Right
Ventricle
32

33. Heart cont’d
33

34. Heart cont’d.
Valves
34

35. Mediastinum
35

36. Hilum
Made of:
1. Pulmonary Art. + Veins
2. The Bronchi
Left Hilus higher (max 1-2,
5 cm)
Identical: size, shape,
density
36

37. Ribs
37

38. Lateral CXR
38

39. Lateral CXR cont’d.
Tracheoesophageal Stripe
39

40. Lateral CXR cont’d.
40

41. CXR Interpretation
41

42. Technical Details
• Type
• Orientation
• Rotation
• Inspiration/expiration
• Penetration
42
To be studied along side Reading Chest X-Ray Notes.pdf
(“The A-B-C-D Sequence”)

43. Lungs:
•Lungs
• Density
• Symmetry
• Lesions
43

44. Heart
Size:
44

45. Heart
• Size of heart
• Size of individual
chambers of heart
• Size of pulmonary vessels
• Evidence of stents, clips,
wires and valves
• Outline of aorta and IVC
and SVC
45

46. Mediastinum:
• Width
• Contour
• AP window
• Size
• Location
46

47. Review areas:
• Apices
• Behind the heart
• CP angles
• Below diaphragm
• Soft tissues ( breast, surgical emphysema)
• Ribs & clavicle
• Vertebrae
47

48. Identify the lesion → localize lesion →
describe lesion → give a DDx
Never stop looking, carry on w your systematic
approach!!
48

49. Pathology
49
Following radiographic plates are scan-ins from:
Felson, B., et al.: Principles of Chest Roentgenology. Philadelphia,
W.B. Saunders Co., 1973.
Fraser, R., et al.: Diagnosis of Diseases of the Chest, 3rd edition.
Philadelphia, W.B. Saunders Co., 1988.

50. RUL pneumonia 50

51. RML pneumonia
51

52. RLL pneumonia 52

53. LUL pneumonia 53

54. LLL pneumonia 54

55. • Consolidation on CT 55

56. Hilar mass 56

57. The Enlarged Hila
• Causes:
1. Adenopathies (neoplasia, infection)
2. Primary Tumor
3. Vascular
4. Sarcoidosis
57

58. • Multiple Masses
58

59. Hilar Lymphadenopathy - BL
59

60. 60Hilar Lymphadenopathy - BL

61. Pleural Effusion
61

62. Pulmonary Fibrosis 62

63. Heart failure 63

64. Pneumothorax 64

65. RUL collapse
65

66. LLL collapse
66

67. Air under diaphragm 67

68. Emphysema
68

69. Cavitating lesion 69

70. Hiatus hernia 70

71. Miliary shadowing 71

72. Chest Tube, NG Tube, Pulm. artery cath.
72

73. 73See next slide for links to tools and resources for further study.

74. 74
IVMS CXR Video Education Cloud folder
Reading Chest X-Ray Notes.pdf (“The A-B-C-D Sequence”)
eBook
Eng P, Cheah KF. Interpreting Chest X-Rays: 100 Illustrated Cases.
Cambridge: Cambridge University, 2005.
Radiology Online Study Resources:
RadiologyEducation.com, curated by Michael P. D'Alessandro, M.D.
http://www.radiologyeducation.com/
Further study: