Positioning

Posterioranterior and Lateral

The standard chest examination consists of a PA (posterioranterior) and lateral chest x-ray. The films are read together. The PA
exam is viewed as if the patient is standing in front of you with their right side on your left. The patient is facing towards the
left on the lateral view. Comparison films can be invaluable - Old Gold! If you have comparison films, the old PA film is
displayed adjacent to the new PA film and the old lateral is displayed adjacent to the new lateral.

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On the left is a simulated patient in position for a standard PA (posterioranterior) chest x-ray. On the right is a normal PA film.

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On the left is a simulated patient in position for a lateral chest x-ray and on the right is a normal lateral film.
Note that the receptor or film is against the left chest.

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When reading a patient's chest films you should look at both the PA and the lateral films and hang them in this manner (PA on
left and lateral on right).

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Lateral Positioning

The lateral view is obtained with the left chest against the cassette. This diminishes the effect of magnification on the heart.
Looking carefully at the posterior aspect of the chest on the lateral view, which ribs are left and right? Which is the right/left
hemidiaphragm?

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The right ribs (red arrows below) are larger due to magnification and usually projected posterior to the left ribs if the patient
was examined in a true lateral position. This can be very helpful if there is a unilateral pleural effusion seen only on the lateral
view.

By zooming in on the image you can clearly notice the increased width and posterior location of the right ribs (red arrows) as
compared to the left ribs (blue arrows) on CXR.

The left hemidiaphragm is usually lower than the right. Also, since the heart lies predominantly on the left hemidiaphragm the
result on a lateral film is silouhetting out of the anterior portion of the hemidiaphragm, whereas the anterior right
hemidiaphragm remains visible.

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Notice how the right diaphragm (red arrows) continues anteriorly, while the left diaphragm disappears (black arrow) because of
the silouhetting caused by the heart. Also notice how the right diaphragm at the blue arrows continues past the smaller left ribs
and ends at the larger and more posterior right ribs.

PA vs AP

The PA (posterioranterior) film is obtained with the patient facing the cassette and the x-ray tube 6 feet away. This distance
diminishes the effect of beam divergence and magnification of structures closer to the x-ray tube. On the film below the exam
was obtained in an AP or anteroposterior position. Note that the chest has a difference appearance. The heart shadow is
magnified because it is an anterior structure. The pulmonary vasculature is also altered when patients are examined in the
supine position. On the AP supine film there is more equalization of the pulmonary vasculature when the size of the lower lobe
vessels are compared to the upper.

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This is the simulated patient in PA (posterioranterior) position. Note that the x-ray tube is 72 inches away.

Left, in the supine AP (anteriorposterior) position the x-ray tube is 40 inches from the patient.

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This is a PA film on the left compared with a AP supine film on the right.
The AP shows magnification of the heart and widening of the mediastinum. Whenever possible the patient should be imaged in
an upright PA position. AP views are less useful and should be reserved for very ill patients who cannot stand erect.

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Inspiration

The patient should be examined in full inspiration. This greatly helps the radiologist to determine if there are intrapulmonary
abnormalities. The diaphragm should be found at about the level of the 8th - 10th posterior rib or 5th - 6th anterior rib on good
inspiration.

A patient can appear to have a very abnormal chest if the film is taken during expiration. Look at the case below - on the first
film, the loss of the right heart border silhouette would lead you to the diagnosis of a possible pneumonia. However, the patient
had taken a poor inspiration. On repeat exam with improved inspiration, the right heart border is normal.

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 Penetration

Adequate penetration of the patient by radiation is also required for a good film. On a good PA film, the thoracic spine disc
spaces should be barely visible through the heart but bony details of the spine are not usually seen. On the other hand
penetration is sufficient that bronchovascular structures can usually be seen through the heart.

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On the lateral view, you can look for proper penetration and inspiration by observing that the spine appears to be darken as you
move caudally. This is due to more air in lung in the lower lobes and less chest wall. The sternum should be seen edge on and
posteriorly you should see two sets of ribs.

Left, an example of a normal PA film that is underpenetrated. Right, an overpenetrated PA film.

Rotation

The technologists are usually very careful to x-ray the patient flat against the cassette. If there is rotation of the patient, the
mediastinum may look very unusual. One can access patient rotation by observing the clavicular heads and determining
whether they are equal distance from the spinous process of the thoracic vertebral bodies.

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 This is a normal PA film without any rotation.

Magnification of clavicular head and spinous process alignment demonstrating a straight film.

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 In this rotated film skin folds can be mistaken for a tension pneumothorax (blue arrows).
Notice the skewed positioning of the heads of the clavicles (red arrows) and the spinous processes.

Opacity

Mass vs. Infiltrate

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 The basic diagnostic instance is to detect an abnormality. In both of the cases above, there is an abnormal opacity. It is most
useful to state the diagnostic findings as specifically as possible, then try to put these together and construct a useful differential
diagnosis using the clinical information to order it.In each of the cases above, there is an abnormal opacity in the left upper
lobe. In the case on the left, the opacity would best be described as a mass because it is well-defined. The case on the right has
an opacity that is poorly defined. This is airspace disease such as pneumonia. The table below shows distinguishing
characteristics of each.

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 Intraparenchymal vs. pleural vs. extrapleural

This diagram shows three locations that a mass can exist in the thoracic cavity.

A = intraparenchymal
B = pleural
C = extrapleural

CT showing a mass that is likely pleural based (red arrow). Note the pleural effusion posteriorly.

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 Mediastinum and Lungs

The radiologist needs to know both the structures within the mediastinum forming the mediastinal margins and the lobes of the
lungs forming the margins of the lungs along the mediastinum and chest wall. If a mass or pneumonia "silhouettes" (obscures) a
part of the lung/mediastinal margin, the radiologist should be able to identify what part of the lung and what organ within the
mediastinum are involved. The margins of the mediastinum are made up of the structures shown below. Trace the margin of the
mediastinum with your eye all the way around the margin. Think of the mediastinal structures that comprise this interface. If
the margin were abnormal you could diagnose the cause.

This image outlines the specific anatomy of the PA chest x-ray.

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 This image indicates the locations of each lung margin on chest x-ray.

Trace the margin of the lung with your eye in the image below thinking about what mediastinal structure and what lobe of the
lung is present at this margin.

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 Bronchi

A physician should absolutely know the anatomy of the bronchi. Look at the drawing on the left and compare it to the chest x-
ray on the right. You can see that the major bronchi are visible if you look carefully. It may be beneficial to practice drawing
the bronchi and labeling them until you are entirely familiar with their names and locations. The table below shows the
segmental bronchi and their designated numbers.

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A = Right Main Stem Bronchus
B = Right Upper Lobe Bronchus
B1 = Apical Segmental Bronchus
B2 = Anterior Segmental Bronchus
B3 = Posterior Segmental Bronchus
C = Bronchus Intermedius
D = Right Middle Lobe Bronchus
D4 = Lateral Segmental Bronchus
D5 = Medial Segmental Bronchus
E = Right Lower Lobe Bronchus
E6 = Superior Segmental Bronchus
E7 = Medial Basal Segmental Bronchus
E8 = Anterior Basal Segmental Bronchus
E9 = Lateral Basal Segmental Bronchus
E10 = Posterior Basal Segmental Bronchus
F = Left Main Stem Bronchus
G = Left Upper Lobe Bronchus
G1, G2 = Apicoposterior Segmental Bronchus
G3 = Anterior Segmental Bronchus
H = Lingular Bronchus
H4 = Superior Lingular Segmental Bronchus
H5 = Inferior Lingular Segmental Bronchus
I = Left Lower Lobe Bronchus
I6 = Superior Segmental Bronchus
I7 = Medial Basal Segmental Bronchus
I8 = Anterior Basal Segmental Bronchus
I9 = Lateral Basal Segmental Bronchus
I10 = Posterior Basal Segmental Bronchus
SMALP = "Suppose My Aunt Loves Peaches" is a helpful way to remember the segmental lower lobe bronchi.

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 Pulmonary Vasculature

The following drawings show the major pulmonary vessels within the mediastinum. The bronchi that you have already learned
are the same as on the prior drawing. These structures are obviously present on every chest x-ray but are usually unrecognized.
If you learn the location of these structures, this will help you understand the anatomy as shown on chest x-rays and chest CT.

A drawing representing the pulmonary vasculature.

The following schematic drawing should help you sort out these structures. After the bronchi, remember that the left
pulmonary artery arches over the left upper lobe bronchus and the right pulmonary artery passes posterior to the ascending aorta
to divide into the truncus anterior and the descending RPA. Note that except in the right upper lobe, the pulmonary veins are
generally anterior to the pulmonary arteries.

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A = Apical segmental bronchus
B = Posterior segmental bronchus
C = Anterior segmental bronchus
D = Bronchus intermedius
E = Truncus anterior
F = Carina
G = Right main pulmonary artery
H = Left main pulmonary artery
I = Right inferior pulmonary artery
J = Right superior pulmonary vein
K = Right middle lobe bronchus
L = Right lower lobe bronchus
M = Right inferior pulmonary vein
N = Left Atrium
O = Left superior pulmonary vein
P = Apicoposterior segmental bronchus
Q = Left upper lobe bronchus
R = Lingular bronchus
S = Left inferior pulmonary artery
T = Left inferior pulmonary vein

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Left, left pulmonary artery on CT. Right, right pulmonary artery on CT. Note how the left pulmonary artery passes over the
left mainstem bronchus to descend behind it, while the RPA passes behind the ascending aorta.

How to Read a Chest X-Ray

Turn off stray lights, optimize room lighting, view images in order

Patient Data (name history #, age, sex, old films)

Routine Technique: AP/PA, exposure, rotation, supine or erect

Trachea: midline or deviated, caliber, mass

Lungs: abnormal shadowing or lucency

Pulmonary vessels: artery or vein enlargement

Hila: masses, lymphadenopathy

Heart: thorax: heart width > 2:1 ? Cardiac configuration?

Mediastinal contour: width? mass?

Pleura: effusion, thickening, calcification

Bones: lesions or fractures

Soft tissues: dont miss a mastectomy

ICU Films: identify tubes first and look for pneumothorax

Looking for abnormalities

It is best to do a directed search of the chest film rather than simply gazing at the film. An abnormality will not likely hit you
over the head. Remember that detail vision is only permitted at the fovea centralis of your retina. This area contains only cones
and is the part that you use to read. The remainder of the retina helps you to put this detailed portion in context and helps to
determine whether this is a saber tooth tiger sneaking up on you. Therefore, it is best to look for abnormalities and to have a
planned search in mind. Your eye gaze should scan all portions of the film, follow lung/mediastinal interfaces and look again
carefully in areas where you know that mistakes are easily made, such as over the spine on the lateral view and in the apex on
the PA view.

The above diagrams depict the human eye and light waves hitting the fovea, the area of detailed vision.

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Stare at the 'X' in the center of the image above. Note how you cannot read the letters in the corner unless you are looking
directly at them (ie unless the letter you are trying to read is hitting your retina at the fovea).

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PA technique for looking at films. Encompassing the entire lung boundaries (left) , scanning with fovea over each part of lung
(right).

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 Lateral scanning technique

Signs

Silhouette sign

One of the most useful signs in chest radiology is the silhouette sign. This was described by Dr. Ben Felson. The silhouette sign
is in essence elimination of the silhouette or loss of lung/soft tissue interface caused by a mass or fluid in the normally air filled
lung. In other words, if an intrathoracic opacity is in anatomic contact with, for example, the heart border, then the opacity will
obscure that border. The sign is commonly applied to the heart, aorta, chest wall, and diaphragm. The location of this
abnormality can help to determine the location anatomically.

Take a moment to review the makeup of the mediastinal margins and the lobes of the lungs that interface with the
mediastinum. Use the back button on your browser to return here.

For the heart, the silhouette sign can be caused by an opacity in the RML, lingula, anterior segment of the upper lobe, lower
aspect of the oblique fissure, anterior mediastinum, and anterior portion of the pleural cavity. This contrasts with an opacity in
the posterior pleural cavity, posterior mediastinum, of lower lobes which cause an overlap and not an obliteration of the heart
border. Therefore both the presence and absence of this sign is useful in the localization of pathology.

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The right heart border is silhouetted out. This is caused by a pneumonia, can you determine which lobe the pneumonia
affects?

Air Bronchogram

An air bronchogram is a tubular outline of an airway made visible by filling of the surrounding alveoli by fluid or inflammatory
exudates. Six causes of air bronchograms are; lung consolidation, pulmonary edema, nonobstructive pulmonary atelectasis,
severe interstitial disease, neoplasm, and normal expiration.

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This patient has bilateral lower lobe pulmonary edema. The alveoli are filled with fluid making the bronchi visible as an air
bronchogram. The upper right is a closeup of the right side of the film with arrows outlining a prominent air bronchogram.
The lower right is a CT scan demonstrating an air bronchogram clearly.

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 Here is another example of air bronchograms in both a PA and Lateral film. Can you spot them?

Solitary Pulmonary Nodule

A solitary nodule in the lung can be totally innocuous or potentially a fatal lung cancer. After detection the initial step in
analyis is to compare the film with prior films if available. A nodule that is unchanged for two years is almost certainly
benign. If the nodule is completely calcified or has central or stippled calcium it is benign. Nodules with irregular
calcifications or those that are off center should be considered suspicious, and need to be worked up further with a PET scan or
biopsy. Be sure to evaluate for the presence of multiple nodules as this finding would change the differential entirely. If the
nodule is indeterminate after considering old films and calcification, subsequent steps in the work-up include ordering a CT and
a tissue biopsy. The patient may choose to have an indeterminate nodule removed if there is no evidence of spread on CT as
this would diagnose and treat a cancer if present.

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This patient clearly has a solitary lung nodule present on chest x-ray. Can you tell which lobe it's in? Did you spot the other
nodule? Some early lung cancers are missed on the initial chest x-ray because they are small and faint. CT may detect these
early cancers.

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 PA and Lateral of a subtle right lower lobe cancer. Can you find it in the frontal projection?

Atelectasis

Atelectasis is collapse or incomplete expansion of the lung or part of the lung. This is one of the most common findings on a
chest x-ray. It is most often caused by an endobronchial lesion, such as mucus plug or tumor. It can also be caused by extrinsic
compression centrally by a mass such as lymph nodes or peripheral compression by pleural effusion. An unusual type of
atelectasis is cicatricial and is secondary to scarring, TB, or status post radiation.

Atelectasis is almost always associated with a linear increased density on chest x-ray. The apex tends to be at the hilum. The
density is associated with volume loss. Some indirect signs of volume loss include vascular crowding or fissural, tracheal, or
mediastinal shift, towards the collapse. There may be compensatory hyperinflation of adjacent lobes, or hilar elevation (upper
lobe collapse) or depression (lower lobe collapse). Segmental and subsegmental collapse may show linear, curvilinear, wedge
shaped opacities. This is most often associated with post-op patients and those with massive hepatosplenomegaly or ascites .

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Note the loss of the right heart border silhouette due to partial atelectasis of the RML. Atelectasis is usually, but not always, a
benign finding as in this example which was caused by an endobronchial mass in the RML.

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This is a PA and lateral film showing round atelectasis, where the lung becomes attached to the chest wall by an area of
previous inflammation. The lung then rolls up, causing this opacity.

Left Lung Atelectasis

Left Upper Lobe

The left lung lacks a middle lobe and therefore a minor fissure, so left upper lobe atelectasis presents a different picture from
that of the right upper lobe collapse. The result is predominantly anterior shift of the upper lobe in left upper lobe collapse, with
loss of the left upper cardiac border. The expanded lower lobe will migrate to a location both superior and posterior to the upper
lobe in order to occupy the vacated space. As the lower lobe expands, the lower lobe artery shifts superiorly. The left mainstem
bronchus also rotates to a nearly horizontal position.

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This patient suffered from left upper lobe atelectasis following right upper lobectomy.

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PA and Lateral of a patient with Left Upper Lobe Collapse (arrows). This characteristic finding on CXR is known as the
Luftsichel Sign and may represent collapse due to obstruction from a bronchogenic carcinoma. The lucency between the
mediastinum and the collapsed LUL is caused by hyperexpansion of the superior segment of the LLL.

Left Lower Lobe

Atelectasis of either the right or left lower lobe presents a similar appearance. Silhouetting of the corresponding
hemidiaphragm, crowding of vessels, and air bronchograms are sometimes seen, and silhouetting of descending aorta is seen on
the left. It is important to remember that these findings are all nonspecific, often occuring in cases of consolidation, as well. A
substantially collapsed lower lobe will usually show as a triangular opacity situated posteromedially against the mediastinum.

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These radiographs demonstrate left lower lobe atelectasis followed by partial resolution, respectively.

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 Another PA film of LLL atelectasis (arrows). Note the elevation of the left hemidiaphragm.

Right Lung Atelectasis

Right Upper Lobe

Right upper lobe atelectasis is easily detected as the lobe migrates superomedially toward the apex and mediastinum. The minor
fissure elevates and the inferior border of the collapsed lobe is a well demarcated curvilinear border arcing from the hilum
towards the apex with inferior concavity. Due to reactive hyperaeration of the lower lobe, the lower lobe artery will often be
displaced superiorly on a frontal view.

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 Note the elevation of the horizontal fissure (arrows) caused by RUL atelectasis.

Right Middle Lobe

Right middle lobe atelectasis may cause minimal changes on the frontal chest film. A loss of definition of the right heart border
is the key finding. Right middle lobe collapse is usually more easily seen in the lateral view. The horizontal and lower portion
of the major fissures start to approximate with increasing opacity leading to a wedge of opacity pointing to the hilum. Like
other cases of atelectasis, this collapse may by confused with right middle lobe pneumonia.

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Right middle lobe atelectasis can be difficult to detect in the AP film. The right heart border is indistinct on the AP film. The
lateral, though, shows a marked decrease in the distance between the horizontal and oblique fissures.

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 Right Lower Lobe

Silhouetting of the right hemidiaphragm and a triangular density posteromedially are common signs of right lower lobe
atelectasis. Right lower lobe atelectasis can be distinguished from right middle lobe atelectasis by the persistance of the right
heart border.

Notice the stretched vessels in the hyperexpanded right upper lobe in right lower lobe atelectasis. The right hilum is also
displaced inferiorly. This is a tough one.

Pulmonary Edema

There are two basic types of pulmonary edema. One is cardogenic edema caused by increased hydrostatic pulmonary capillary
pressure. The other is termed noncardogenic pulmonary edema, and is caused by either altered capillary membrane
permeability or decreased plasma oncotic pressure.

A helpful mnemonic for noncardiogenic pulmonary edema is NOT CARDIAC (near-drowning, oxygen therapy, transfusion or
trauma, CNS disorder, ARDS, aspiration, or altitude sickness, renal disorder or resuscitation, drugs, inhaled toxins, allergic
alveolitis, contrast or contusion.

On a CXR, cardiogenic pulmonary edema can show; cephalization of the pulmonary vessels, Kerley B lines or septal lines,
peribronchial cuffing, "bat wing" pattern, patchy shadowing with air bronchograms, and increased cardiac size. Unilateral,
miliary and lobar or lower zone edema are considered atypical patterns of cardiac pulmonary edema. A unilateral pattern may
be caused by lying preferentially on one side. Unusual patterns of edema may be found in patients with COPD who have
predominant upper lobe emphysema.

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PA film of a patient with pulmonary edema showing cephalization of pulmonary veins and indistinctness of the
vascular margins. The heart is enlarged.

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Would you favor pneumonia or CHF in this patient? Why? What pattern is shown?

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Above are two films from the same patient. The left film clearly shows diffuse pulmonary edema with loss of both
hemidiaphragms and silouhetting of the heart. The film on the right was taken two days later after partial resolution of the
edema.

Congestive Heart Failure

Congestive heart failure (CHF) is one of the most common abnormalities evaluated by CXR. CHF occurs when the heart fails
to maintain adequate forward flow. CHF may progress to pulmonary venous hypertension and pulmonary edema with leakage
of fluid into the interstitium, alveoli and pleural space.

The earliest CXR finding of CHF is cardiomegaly, detected as an increased cardiothoracic ratio (>50%). In the pulmonary
vasculature of the normal chest, the lower zone pulmonary veins are larger than the upper zone veins due to gravity. In a patient
with CHF, the pulmonary capillary wedge pressure rises to the 12-18 mmHg range and the upper zone veins dilate and are
equal in size or larger, termed cephalization. With increasing PCWP, (18-24 mm. Hg.), interstitial edema occurs with the
appearance of Kerleys lines. Increased PCWP above this level is alveolar edema, often in a classic perihilar bat wing pattern
of density. Pleural effusions also often occur.

CXR is important in evaluating patients with CHF for development of pulmonary edema and evaluating response to therapy as
well.

This is a typical chest x-ray of a patient in severe CHF. Note the cardiomegaly, alveolar edema, and haziness of vascular
margins.

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The left image demonstrates a patient with a severe pulmonary edema as a result of CHF. The right image is the same patient
after significant resolution.

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 Kerley B lines

These are horizontal lines less than 2cm long, commonly found in the lower zone periphery. These lines are the thickened,
edematous interlobular septa. Causes of Kerley B lines include; pulmonary edema, lymphangitis carcinomatosa and malignant
lymphoma, viral and mycoplasmal pneumonia, interstital pulmonary fibrosis, pneumoconiosis, sarcoidosis. They can be an
evanescent sign on the CXR of a patient in and out of heart failure.

The patient above is suffering from congestive heart failure resulting in interstitial edema. Notice the Kerley's B lines in right
periphery (arrows).

Pneumonia

Pneumonia is airspace disease and consolidation. The air spaces are filled with bacteria or other microorganisms and pus.
Other causes of airspace filling not distinguishable radiographically would be fluid (inflammatory), cells (cancer), protein
(alveolar proteinosis) and blood (pulmonary hemorrhage), Pneumonia is NOT associated with volume loss. Pneumonia is
caused by bacteria, viruses, mycoplasmae and fungi.

The x-ray findings of pneumonia are airspace opacity, lobar consolidation, or interstitial opacities. There is usually considerable
overlap. Again, pneumonias is a space occupying lesion without volume loss. What differentiates it from a mass? Masses are
generally more well-defined. Pneumonia may have an associated parapneumonic effusion.

The type of pneumonia is sometimes characteristic on chest x-ray:

Lobar - classically Pneumococcal pneumonia, entire lobe consolidated and air bronchograms common
Lobular - often Staphlococcus, multifocal, patchy, sometimes without air bronchograms
Interstitial - Viral or Mycoplasma; latter starts perihilar and can become confluent and/or patchy as disease progresses,
no air bronchograms
Aspiration pneumonia - follows gravitational flow of aspirated contents; impaired consciousness, post anesthesia,
common in alcoholics, debilitated, demented pts; anaerobic (Bacteroides and Fusobacterium)
Diffuse pulmonary infections - community acquired (Mycoplasma, resolves spontaneoulsy) nosocomial
(Pseudomonas, debilitated, mechanical vent pts, high mortality rate, patchy opacities, cavitation, ill-defined nodular)
immunocompromised host(bacterial, fungal, PCP)

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 Major differentiating factors between atelectasis and pneumonia

Atelectasis Pneumonia

Volume Loss Normal or Increased Volume

Associated Ipsilateral Shift No Shift, or if Present Then Contralateral

Linear, Wedge-Shaped Consolidation, Air Space Process

Apex at Hilum Not Centered at Hilum

Air bronchograms can occur in both.

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 These are PA and lateral films of RML pneumonia (arrows).
Note the indistinct borders, air bronchograms, and silhouetting of the right heart border.

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 PA and Lateral films of RUL pneumonia

Tuberculosis

Primary tuberculosis (TB) is the initial infection with Mycobacterium tuberculosis. Post-primary TB is reactivation of a
primary focus, or continuation of the initial infection. Radiographically, TB is represented by consolidation, adenopathy, and
pleural effusion. A Ghon focus is an area of consolidation that most commonly occurs in the mid and lower lung zones. A
Ghon complex is the addition of hilar adenopathy to a Ghon focus.

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Radiographic features of post-primary TB are; focal patchy airspace disease "cotton wool" shadows, cavitation, fibrosis, nodal
calcification, and flecks of caseous material. These occur most commonly in the posterior segments of the upper lobes, and
superior segments of the lower lobes.

Endobronchial TB involves the wall of a major bronchus. Complications of endobronchial TB are cicatrical stenosis and
obstruction.

This is a PA film of a patient who has had tuberculosis for years. This shows fibrosis, cavitation, and calcification, particularly
in the left upper lobe.

Pulmonary Hemorrhage

Pulmonary hemorrhage has an appearance like that of other airspace filling processes (pneumonia, edema) which have opacity
often with air bronchograms. It is caused by trauma, Goodpastrue's syndrome, bleeding disorders, high altitude, and mitral
stenosis. Blood fills the bronchi and eventually the alveoli. Pulmonary hemorrhage is notable in that it may clear more quickly
than other alveolar densities such as pneumonia.

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 PA and Lateral films of a patient with right upper lobe hemorrhage. Notice the large pleural effusion in the left hemithorax.

Pulmonary Embolism

Pulmonary embolism (PE) is not uncommon in the inpatient setting. The primary source is thrombus from the deep veins of the
legs. Roughly ten percent of pulmonary embolisms result in pulmonary infarction, but many patients die of PE without being

64
diagnosed. The primary purpose of a chest film in suspected PE is to rule out other diagnoses as a cause of dyspnea or
hypoxia. Most CXRs in patients with a PE are normal. Signs that may be present in PE are; Westermark's sign (oligemia in
area of involvement), increased size of a hilum (caused by thrombus impaction), atelectasis with elevation of hemidiaphragm
and linear or disk shaped densities, pleural effusion, consolidation, and Hampton's hump (rounded opacity). In the case of
pulmonary infarctions, the main radiographic feature is multifocal consolidation at the pleural base in the lower lungs. Several
other important modalities are used when investigating possible PE. These modalities are venous ultrasound, V/Q scan,
pulmonary arteriogram, and CT angiogram (CTA). Remember, if the CXR of a patient with hypoxia is normal you should
consider PE.

The workup of suspected PE can be divided into two populations. In the inpatient setting a CTPA will likely be more definitive
than a V/Q scan, as it may disclose other causes of hypoxia not shown on CXR. If the patient has leg swelling, a venous
ultrasound of the leg veins should be done to exclude DVT. In the outpatient setting a V/Q scan should be the first test and will
less likely be indeterminate than in the inpatient setting. There is also a lower radiation dose for V/Q scans than for CTPA. If
these studies are inconclusive a pulmonary arteriogram is the definitive, but more invasive test.

These are two PA fiilms demonstrating Hampton's hump (rounded opacities) in patients with pulmonary embolism.
What is the most common chest x-ray finding in PE? (Click for answer)

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Above are 2 CT scans from the same patient demonstrating a large pulmonary embolus.Which vessel is it affecting? (Click for
answer and arrows)

Pleural Effusion

Common causes for a pleural effusion are CHF, infection (parapneumonic), trauma, PE, tumor, autoimmune disease,
and renal failure.

On an upright film, an effusion will cause blunting on the lateral and if large enough, the posterior costophrenic sulci.
Sometimes a depression of the involved diaphragm will occur. A large effusion can lead to a mediastinal shift away from
the effusion and opacify the hemothorax. Approximately 200 ml of fluid are needed to detect an effusion in the frontal
film vs. approximately 75ml for the lateral. Larger effusions, especially if unilateral, are more likely to be caused by
malignancy than smaller ones.

In the supine film, an effusion will appear as a graded haze that is denser at the base. The vascular shadows can usually
be seen through the effusion. An effusion in the supine view can veil the lung tissue, thicken fissure lines, and if large,
cause a fluid cap over the apex. There may be no apparent blunting of the lateral costophrenic sulci.

A lateral decubitis film is helpful in confirming an effusion in a bedridden patient as the fluid will layer out on the
affected side (unless the fluid is loculated). Today, ultrasound is also a key component in the diagnosis. Ultrasound is
also used to guide diagnostic aspiration of small effusions.

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PA and lateral film of a patient with bilateral pleural effusions. Note the concave menisci blunting both posterior costophrenic
angles.

The CT above on the left demonstrates a large infected pleural fluid collection, an empyema. Compare and contrast that to the
image on the right which is an intrapulmonary abscess.

Mastecomy

One must carefully examine the soft tissues. The patient below has had a mastectomy. The hemithoraces are asymmetric in
density. The finding of a mastectomy should also make you look even closer at the bones and lungs for metastases.

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 PA and Lateral films of a patient post left mastectomy

This case shows the importance of examining the soft tissues carefully. At first, it may appear that the asymmetry in density
between the two hemithoraces is caused by a left pleural effusion, giving the appearance of a graded density. A closer look
reveals that the asymmetry is due to the removal of the left breast.

Pneumothorax

A pneumothorax is defined as air inside the thoracic cavity but outside the lung. A spontaneous pneumothorax (PTX) is one
that occurs without an obvious inciting incident. Some causes of spontaneous PTX are; idiopathic, asthma, COPD, pulmonary
infection, neoplasm, Marfans syndrome, and smoking cocaine. However, most pneumothoraces are iatrogenic and caused by a
physician during surgery or central line placement. Trauma, such as a motor vehicle accident is another important cause. A
tension PTX is a type of PTX in which air enters the pleural cavity and is trapped during expiration usually by some type of ball
valve-like mechanism. This leads to a buildup of air increasing intrathoracic pressure. Eventually the pressure buildup is large
enough to collapse the lung and shift the mediastinum away from the tension PTX. If it continues, it can compromise venous
filling of the heart and even death.

On CXR, a PTX appears as air without lung markings in the least dependant part of the chest. Generally, the air is found
peripheral to the white line of the pleura. In an upright film this is most likely seen in the apices. A PTX is best demonstrated
by an expiration film. It can be difficult to see when the patient is in a supine position. In this position, air rises to the medial
aspect of the lung and may be seen as a lucency along the mediastinum. It may also collect in the inferior sulci causing a deep
sulcus sign.
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A hydropneumothorax is both air and fluid in the pleural space. It is characterized by an air-fluid level on an upright or
decubitus film in a patient with a pneumothorax. Some causes of a hydropneumothorax are trauma, thoracentesis, surgery,
ruptured esophagus, and empyema.

This image shows a close-up of a pneumothorax in an upright PA film as a white pleural line (red arrow) with atmospheric air
outside of it. No pulmonary vascular markings are seen outside of the line. Notice the predilection to the apices and the
periphery.

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The above film shows a right sided tension pneumothorax with right sided lucency and leftward mediastinal shift. This is a
medical emergency. Failure to place a right chest tube immediately could allow venous return to diminish and lead to possible
death.

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Left is a supine view of a PTX, note the medial position of the air. Right is an image demonstrating the deep sulcus sign (letter
D in the image) in supine views of a PTX.

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The above three images show a hydropneumothorax in three different views. The PA, lateral, and right decube reveal a
layering out of the air and fluid.The right decube film demonstrates a right hydropneumothorax. Note the pleural air/fluid level
demonstrated by the horizontal air/fluid interface (arrows).

Interstitial Pulmonary Fibrosis

Interstitial pulmonary fibrosis has many causes. The six most common causes of diffuse interstitial pulmonary fibrosis are
idiopathic (IPF, >50% of cases), collagen vascular disease, cytotoxic agents and nitrofurantoin, pneumoconioses, radiation, and
sarcoidosis. Clinically the patient with IPF will present with progressive exertional dyspnea and a nonproductive cough.
Radiographically, IPF is associated with hazy "ground glass" opacification early and volume loss with linear opacities
bilaterally, and honeycomb lung in the late stages. IPF carries a poor prognosis with death due to pulmonary failure usually
occurring within 3-6 years of the diagnosis unless lung transplant is performed.

Interstitial Pulmonary Fibrosis

Emphysema

Emphysema is loss of elastic recoil of the lung with destruction of pulmonary capillary bed and alveolar septa. It is caused
most often by cigarette smoking and less commonly by alpha-1 antitrypsin deficiency. Functional hallmarks are decreased
airflow (decreased FEV1) and diffusing capacity (decreased DLCO2).Emphysema is commonly seen on CXR as diffuse

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hyperinflation with flattening of diaphragms, increased retrosternal space, bullae (lucent, air-containing spaces that have no
vessels that are not perfused) and enlargement of PA/RV (secondary to chronic hypoxia) an entity also known as cor
pulmonale. Hyperinflation and bullae are the best radiographic predictors of emphysema. However, the radiographic findings
correlate poorly with the patients pulmonary function tests. CT and HRCT (high resolution CT) has emerged as a technique to
evaluate different types, panlobular, intralobular, paraseptal and for guidance prior to volume reduction surgery.Occasionally
the trachea is very narrow in the mediolateral plane in emphysema. "Saber sheath" tracheal deformity is when the coronal
diameter is less than 2/3 that of the sagittal.In smokers with known emphysema the upper lung zones are commonly more
involved than the lower lobes. This situation is reversed in patients with alpha-1 anti-trypsin deficiency, where the lower lobes
are affected. Chronic bronchitis commonly occurs in patients with emphysema and is associated with bronchial wall thickening.

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Note bilateral flattening of the diaphragms and significant hyperinflation as demonstrated by visualization of 11 posterior ribs.

Trauma - Rib fracture

Rib fractures have the appearance of an abrupt discontinuity in the smooth outline of the rib. A lucent fracture line may be
seen. A rib fracture may not be visible on a CXR. CXR is taken to assess for pneumothorax, but it may show them. If it is
necessary to exclude a rib fracture, oblique rib detail films should be obtained.

A common pattern for evaluating the ribs is to examine the posterior portions of the ribs first, then the anterior portions, and
finish be examining the lateral aspects of each rib. If you see an abnormality, follow that rib in its entirety.

Fracture of the upper three ribs is associated with an increased risk of aortic injury because of the excessive force needed to
fracture these ribs. Fracture of the lower three ribs can be associated with liver or spleen injury. Multiple bilateral rib fractures
in various stages of healing are associated with child abuse in children or alcohol abuse.

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PA and Lateral films of right ninth rib fracture. No PTX was present.

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CT from the same patient in the PA and lateral films above. This clearly shows the rib displacement near the liver on the right.

This PA film shows a left flail chest, or multiple rib fractures, that can now move paradoxically with the rest of the thoracic
cage.

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 Anterior Mediastinal Mass

Anterior mediastinal masses consist of the 4 "T's" (Terrible lymphadenopathy, Thymic tumors, Teratoma, Thyroid mass) and
aortic aneurysm, pericardial cyst, epicardial fat pad. Usually CT or fine needle aspiration is needed to make the definitive
diagnosis of an anterior mediastinal mass.

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T-cell Lymphoma
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Note in these images that the hilum can be seen through the mass. It is not a hilar mass. The lateral shows nothing abnormal
posteriorly.

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The CT sections demonstrate the mass in the anterior mediastinum (arrows) at the aortopulmonary window which was a
thymoma.

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 Middle Mediastinal Mass

The most common cause of a middle mediastinal mass is lymphadenopathy due to metastases or primary tumor. Other causes
include hiatial hernia, aortic aneurysm, thyroid mass, duplication cyst, and bronchogenic cyst.

Can you spot the abnormality? (Click each of the images for arrows)This mass above the aortic arch can be seen to be posterior
to the aorta on the lateral. It does not silhouette out the superior margin of the aorta. A chest CT was performed to further
evaluate the mass.

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This CT scan shows that the mass is posterior to the aorta, smoothly marginated, low density, and associated with the
esophagus. It is an esophageal duplication cyst.

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 Above is a PA, lateral, and aortogram of a saccular aortic aneurysm, another cause of a middle mediastinal mass.

Posterior Mediastinal Mass

The differential for a posterior mediastinal mass includes; neoplasm, lymphadenopathy, aortic aneurysm, adjacent pleural or
lung mass, neurenteric cyst or lateral meningocele, and extramedullary hematopoiesis.

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Note that this mass is detected by a pleural margin search as you move your eye along the superomedial part of the right lung.
The interface is interrupted. Think about the anatomy of the lung in this area. The anterior mediastinum ends at the level of the
clavicles. Any abnormality in the apex of the thorax must be posterior in the chest.

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The mass projects above the clavicles, therefore it is not an anterior structure.

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 This MRI shows the mass is extrapleural and associated with the spinal nerves. It is a schwannoma, a benign tumor of the
nerve sheath.

Pleural and Extra-pleural Masses

The differential for pleural mass includes; metastases (especially adenocarcinoma and malignant thymoma), loculated pleural
effusions (pseudotumor), malignant mesothelioma, pleural plaques from asbestosis (bilateral densities), and lymphoma. The
differential for extrapleural mass includes rib tumor, rib infection (including chest wall fungal infection), neurofibroma or
schwannoma (may erode a rib, but does not destroy it), and lipoma. One must first determine whether a mass arises from inside
the lung or outside, an oblique margin with lung tissue indicates that the process is pleural or extrapleural. Distinguishing
between a pleural and extrapleural mass can be challenging. If the center of the lesion is inside the chest wall, a pleural process
is likely. Rib destruction indicates extrapleural involvement and possibly the origin of the mass.

Lateral film of an intraparenchymal mass. Note acute margins like "A" in the diagram on the right. Both "B" and "C" have
oblique margins. "B" demonstrates a pleural mass while "C" is an extrapleural chest wall mass.

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 Pericardial Effusion

Pericardial effusion causes an enlarged heart shadow that is often globular shaped (transverse diameter is disproportionately
increased). A "fat pad" sign, a soft tissue stripe wider than 2mm between the epicardial fat and the anterior mediastinal fat can
be seen anterior to the heart on a lateral view. Serial films can be helpful in the diagnosis especially if rapid changes in the size
of the heart shadow are observed. Approximately 400-500 ml of fluid must be in the pericardium to lead to a detectable change
in the size of the heart shadow on PA CXR. Pericardial effusion can be definitively diagnosed with either echocardiography or
CT. It can be critical to diagnose pericardial effusion because if it is acute it may lead to cardiac tamponade, and poor cardiac
filling. In the postoperative patient it could be a sign of bleeding, necessitating a return to the OR.

PA of a patient with a pericardial effusion.

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A lateral film and closeup of a pericardial effusion showing the anterior mediastinal fat (blue arrows) and epicardial fat (red
arrows) separated by a soft tissue stripe reflecting the pericardial effusion seen edge-on.

Pneumomediastinum

Findings for pneumomediastinum include; streaky lucencies over the mediastinum that extend into the neck, and elevation of
the parietal pleura along the mediastinal borders.Causes of pneumomediastinum include; asthma, surgery (post-op
complication), traumatic tracheobronchial rupture, abrupt changes in intrathoracic pressure (vomiting, coughing, exercise,
parturition), ruptured esophagus, barotrauma, and smoking crack cocaine.Pneumomediastinum should be distinguished from
pneumopericardium and pneumothorax. In pneumopericardium, air can be present underneath the heart, but does not enter the
neck.

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 PA film of a pneumomediastinum.

Diaphragmatic hernia

There are 3 types of diaphragmatic hernia that may be seen in CXR. By far the most common is a hiatal hernia - the stomach
slips through the esophageal hiatus into the chest. A Bochdalek hernia is through a weakness in the diaphragm, and usually
occurs on the left side posteriorly (Bochdalek - back and to the left). Morgagni hernias typically occur medially. Weakness of
the diaphragm can occur without frank herniation of abdominal contents. This is termed an eventration, and it usually occurs
on the right with a portion of the liver bulging cephalad.

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PA and lateral of hiatal hernia. Can you see the air-filled "mass" posterior to the heart?

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