NORMAL CHEST

X-RAY
BABIN BASNET

VIEWS OF CHEST X RAY

POSTEROANTERIOR VIEW- BASIC
ANTEROPOSTERIOR VIEW- ERECT ,SUPINE
AND SEMIERECT-ALTERNATIVE VIEWS
POSTEROANTERIOR EXPIRATORYPNEUMOTHORAX, AIR TRAPPING ASSOCIATED
WITH FOREIGN BODY
LATERAL VIEW- LOCALISATION OF LESION AND
DEMONSTRATION OF MEDIASTINAL MASS
APICAL VIEW-OPACITY IN APICAL REGION
LORDOTIC VIEW-RIGHT MIDDLE LOBE
COLLAPSE OR INTER-LOBAR PLEURAL
EFFUSION

POSTERO ANTERIOR VIEW

ANTEROPOSTERIOR
ERECT

ANTEROPOSTERIOR
SUPINE

ADVANTAGES OF PA OVER AP
VIEW

Easy positioning
Heart magnification low
Breast compression-low radiation
Thyroid- low radiation
Better visualization of lung parenchyma

SHORTCOMINGS OF PA
VIEW
Mediastinal & heart shadow-obscure lung field
Other hidden areas

POINTS TO BE
REMEMBERED OF APSUPINE
HEART SIZE MAGNIFIED.
RELATIVE PROMINENCE OF UPPER LOBE VEINS
THAT MIMICS THE SIGN OF HEART FAILURE.
PLEURAL FLUID WILL LAYER AGAINST THE
POSTERIOR CHEST WALL PRODUCING ILL
DEFINED INCREASED DENSITY OF THE
AFFECTED HEMOTHORAX RATHER THAN THE
USUAL BLUNTING OF COSTO PHRENIC ANGLE.
PNEUMOTHORAX IF PRESENT WILL BE
LOCATED AT THE FRONT OF THE CHEST IN
THE SUPINE POSITION

LATERAL

APICAL VIEW

LORDOTIC VIEW

HOW TO DIFFERENTIATE
AP FROM PA VIEW
SCAPULA OVERLIE THE UPPER
LUNG.
CLAVICLES ARE PROJECTED MORE
CRANIALLY OVER THE APICES.
RIBS LIE HORIZONTAL.
HEART APPEARS MAGNIFIED.
THE DISC SPACE OF LOWER
CERVICAL SPINE ARE MORE
CLEARLY SEEN.

PA VIEW CHEST X-RAY

REQUEST FORM- NAME, AGE DATE SEX AND CLINICAL
INFORMATION
TECHNICAL ASPECTS
TRACHEA
MEDIASTINUM &HEART
HILA
DIAPHRAGM
CP ANGLES
LUNGS
FISSURES
HIDDEN AREAS
PULMONARY VESSELS
BRONCHIAL VESSELS
BONY STRUCTUTRES
SOFT TISSUE

TECHNICAL ASPECTS

Centering & rotation

Penetration:Vertebral bodies & IVDs T8/9
Degree of inspiration
Motion
Side markers

Rotation
Can be assessed by observing the clavicular
heads and determining whether they are equal
distance from the spinous process of the
thoracic vertebral bodies.

Normal non-rotated film

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.

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.

BASAL OPACITY CAND BE PRESENT DUE TO

CROWDING OF VESSELS

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

 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.

Left, an example of a normal PA film

that is underpenetrated. Right, an
overpenetrated PA film.

Underpenetration: Likelihood of
missing an abnormality
overlying by another structure

Overpenetration: results in loss of

visibility of low density lesion
e.g. early consolidation

Motion:
Cardiac margin, diaphragm and pulmonary
vessels should be sharply marginated in a
completely still patient.

TRACHEA

Should be examined for:

Narrowing
Displacement
Intraluminal lesions

Position: Central, slightly deviated towards Rt around the

aortic knuckle
Calibre-

Even
Translucency decreasing caudally
Max. Coronal: 25mm(M) 21mm(F)

 Rt paratracheal stripe
60%
Less than 5mm width
Pathological widening
1.Mediastinal
lymphadenopathy
2.Tracheal malignancy
3.Mediastinal tumors
4.Mediastinis
5.Pleural effusion

Lt paratracheal stripenot visualized

 Azygos vein

Position-BETWEEN

RT MAIN BRONCHUS
AND TRACHEA

Less than 10mm

diameter-erect
Carinal angle

60-750
widening

MEDIASTINUM & HEART

Central dense shadow is
formed by
Heart
Mediastinum
Sternum
Spine

Cardiac shadow
Good centring-

Heart:
2/3 left,
1/3 right
In chest x-ray heart examined for size, shape,
position, silhouette.

 Size
measurement CT ratio: <50%
Transverse cardiac
diameter:
<15.5cm (M),
<14.5cm (F)

CARDIOMEGALY
CARDIO THORACIC RATIO >50% IN PA VIEW AND
>60%AP VIEW.
TRANSVERSE CARDIAC DIAMETER IS >14.5 FOR
FEMALE AND >15.5 IN MALES.
IF PREVIOUS FILM IS AVAILAIBLE , AN INCREASE IN
EXCESS OF 1.5 CM IN TRANSVESE CARDIAC
DIAMETER ON COMPARABLE SERIAL FILMS.

Heart size appears enlarged (APPARENT

CARDIOMEGALY) in short FFD ,on
expiration,supine film,AP film &when
diaphragms are elevated

 Borders

Thymus-.
In babies &young children upto 3yrs
Normally triangular sail shaped with well defined
borders projecting from one or both sides of
mediastinum
Borders may be wavy due to indentation by costal
cartilage wave sign of Mulvey
Right border straighter than left which may be
rounded

Thymic wave sign and sail sign in a 5-month-old girl with mild respiratory distress.

CONTD.
In the mediastinum search should be made for
abnormal densities

Fluid levels
Mediastinal emphysema
Calcifications
Mediastinum divided into

Anterior
Middle
Posterior

 Anterior border of trachea, posterior border of

heart and inf vancava
Line drawn 1cm posterior to the ant border of
vertebral bodies

HILA

Formed by sup
pulm vein&
basal pulm
artery
(radiological
hilum)
97%-lt higher
3%-same level
Hila should be of
equal
density,similar
size & clearly
defined concave
lateral borders

 Structures in the hilum

1.Pulm arteries &upper lobe veins-significant
contribution to hilar shadow
2.Normal LN-not seen in plain radiography
3.Bronchi- walls seen end on

Anterior segment bronchus

of upper lobe-ring adjacent
to upper hilum-rt 45% lt 55%

PULMONARY VESSELS
Lt pulm artery above lt main bronchus
Rt pulm artery-ant to bronchus
Diameter-16mm M

-15mm F
At first intercostal space normal vessels not more
than 3mm in diameter
Erect-lower lobe vessels prominent
Supine-equalize
Vascular lung markings-central 2/3

DIAPHRAGM
Right higher (not more than 3 cm)
May lie in same level & in small % left>right
higher(3%)
On inspiration -6th rib ant,10th rib post (erect film)

DIAPHRAGM(contd.)
Both domes gentle curves- steepen towards
posterior angles
The upper borders are clearly defined except
where heart rests & anterior cardiophrenic angles
(fat pad)
Loss of outline indicates the adjacent tissue
doesnot contain air s/o consolidation or pleural
effusion

DIAPHRAGM(NORMAL
VARIANTS)
SCALLOPING-rt side; short curves convex upwards
MUSCLE SLIPS-rt side; short curves concave
upwards
DIAPHRAGM HUMP &DROMEDARY DIAPHRAGM-rt
side anteriorly
ACCESSORY DIAPHRAGMrare;asymptomatic;usually rt side

CP ANGLES
Acute and well
defined
Obliterated when
diaphragms are
flat
Frequently cp
angles contain
low density ill
defined opacity
caused by fat
pads.

LUNGS
Zones: 3 zones
Lobes

FISSURES
Main fissures
Rt-horizontal(minor)
,oblique
Lt-oblique

 Major fissure
Similar in both right and left lungs
Extends from T4/T5 posterior to diaphragm anterioinferior

Transverse minor fissure

Runs horizontally from the hilum to the anterior and
lateral surface of right at the level of 4th costal cartilage
and meets at the level of 6th rib in midaxillary line

On the lateral view, both lungs are superimposed.

Think about them separately, the left lung has only a
major
fissure
as
shown.
The right lung will have both the major and minor
fissure.

The left image shows the right minor fissure

(A) and the inferior borders (B) of the major
fissures bilaterally.The right image shows
the superior border of the major fissures (B)
bilaterally.

Figure 2. Normal major fissures.

Accessory fissures
Azygos fissure:

-comma shaped;
rt side mostly;
forms in apex of lungs;
Consists of parietal &visceral pleura with azygos vein which
has failed to migrate normally ;
incidence-0.4%(rad),1%(pm);
when lt sided contain hemi-azygos vein

Accessory fissures
Azygos fissure:

-comma shaped;
rt side mostly;
forms in apex of lungs;
Consists of parietal &visceral pleura with azygos vein which
has failed to migrate normally ;
incidence-0.4%(rad),1%(pm);
when lt sided contain hemi-azygos vein

 Superior accessory fissure

separates apical from basal
segments of lower lobe;
Right common;
5% incidence;
On PA film resembles horizontal
fissure but in lateral film can be
differentiated as it runs
posteriorly from hilum.

 Inferior accessory fissure separates medial basal from other basal segments;
appears as an oblique line from cardiophrenic angle
towards hilum;
Right commoner;
incidence 5-8% on chest film

Lt sided horizontal fissure- separates lingula

from other upper lobe segments; rare case.
8% of cases

This image indicates the locations

of each lung margin on chest xray.

HIDDEN AREAS
Apices: partially obscured by ribs, costal cartilage,
clavicles & soft tissues
Central lesions obscured by mediastinum and hila
Posterior &lateral basal segments of lower lobes
are obscured by the downward curve of the
posterior diaphragm
Hidden areas due to bones

BONY STRUCTURES

RIBS
SCAPULA
CLAVICLES
SPINE
STERNUM

NORMAL VARIANTS IN BONES

STERNUM-

Ossification centres and parasternal ossicles may be confused

with lung masses

Clavicles

Rhomboid fossa
Sup comp shadow
Medial epiphysis-fuses at 25 yrs appear as lung nodule
occasionally

 Scapula
PA film spine seems to be pleural shadow
Lateral film inferior angle seems to be lung mass

Ribs
Comp shadow common in upper ribs
Costal cartilage calcification:

Spines
PA film end of transeverse process-may simulate a
lung nodule

SOFT TISSUE
General survey in chest wall,shoulders &
lower neck.
Breast shadows-absence u/l or b/l ; nipple
shadows
Skin folds-may simulate pneumothorax
Anterior axillary fold-curvilinear,axilla to lung
field
Apices-opacity of sternocleidomastoid
Floor of supra clavicular fossa-often
resembles fluid level
Apical pleural thickening ~the apical cap~has
a reported incidence of 7%- most commonly
on the left side

LATERAL VIEW
Routinely left lateral film obtained
In specific lesion, the side of the interest is
positioned adjacent to the film

PA and Lateral of a subtle right lower lobe

cancer. Can you find it in the frontal
projection?

CLEAR SPACES
VERTEBRAL TRANSLUCENCY
DIAPHRAGM OUTLINE
FISSURES
TRACHEA
HEART
SHADOWS OF AXILLRY FOLDS &SCAPULA
STERNUM

Clear Spaces:
Retrosternal, retrocardiac and retrotracheal
Retrosternal space:
<3cm deep
Obliteration: anterior mediastinal mass
Widening: Emphysema

Lt Vs Rt dome of
diaphragm:
Anterior left hemidiaphram is
obliterated by the cardiac contact;
right is seen in entirity
By identifying the fissures: left oblique
fissure is contacts diaphragm ~5cm
behind the anterior costophrenic angle
On left lateral film, the right anterior
and posterior costophrenic sulci should
project beyond the corresponding left
sided sulci as a result of x-ray beam
divergence
By seeing air in stomach and splenic
flexure below the left hemidiaphragm

Lt Vs Rt dome of
diaphragm:
Anterior left hemidiaphram is
obliterated by the cardiac contact;
right is seen in entirity
By identifying the fissures: left oblique
fissure contacts diaphragm ~5cm
behind the anterior costophrenic angle
On left lateral film, the right anterior
and posterior costophrenic sulci should
project beyond the corresponding left
sided sulci as a result of x-ray beam
divergence
By noting air in stomach and splenic
flexure below the left hemidiaphragm

Lines and stripes

Lines: <1mm
Stripes: thicker
Edges and interfaces:Ffrmed when structures of
different densities come in contace with one
another. E.g: Rt & Lt paraspinal lines. E.g
Azygoesophageal recess

Junctional line
ANTERIOR- LUNGS MEETING ANT TO ASCENDING
AORTA, 1MM THICK, OVERLY TRACHEAL LUCENCY
RUNS DOWNWARD AND BEOW FROM
SUPRASTERNAL NOTCH FROM RIGHT TO LEFT.
POSTERIOR-LUNGS MEETING POSTERIORLY
BEHIND ESOPHAGUS, 2MM WIDE , RUNS FROM
LUNGS APICES TO AORTIC KNUCKLE.

Anterior junctional line

Posterior junctional line

Right paratracheal strip

PARASPINAL LINES
Adjacent to vertebral bodies
Lt-normally less than 10mm
Rt-normally less than 3mm
Wider lt side is due to descending
thoracic aorta
Enlargement
Osteophytes
Tortuous aorta,
Vertebral and adjacent soft tissue
masses,
Paravertebral hematoma
Dilated azygos system

Left Paraspinal Line

The left paraspinal line is formed by tangential
contact of the left lung and pleura with the
posterior mediastinal fat, left paraspinal muscles,
and adjacent soft tissues

Tracheo-esophageal stripe
Combined
thickness of
posterior wall of
trachea,
esophageal walls
and intervening
fat
Normally <5mm
Widening most
commonly in
esophageal Ca

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