What is shown on the radiograph on the right?
Enlarged right ventricle
What is the silhouette sign? (e.g. where is the disease when the right and left heart borders are obscured? the hemidiaphragms?)
The absence of a silhouette suggests a disease process
- when you can't see the left heart border, there is disease in the lingula
- when you can't see the right heart border there is disease in the right middle lobe
- when you can't see the hemidiaphragms there is disease in the lower lobes
What makes up the technical quality of a radiograph?
Rotation: spinous processes should be equidistant from clavicular heads
Inspiration: diaphragm crosses 6th interspace anteriorly or 10th interspace posteriorly in the midclavicular line
Penetration (exposure): should be able to see vertebral disks through the heart
Also, make sure you can see everything (nothing is cut off)
What is the suggested approach for reviewing a chest radiograph?
chest wall/soft tissues
What to pay attention to in written data?
Ward (ICU, CCU?)
What to check for when you check soft tissues?
- become more lucent inferiorly
- should be able to see 10 posterior ribs on inspiration
- absence of one indicates masectomy
soft tissue masses
On a lateral film, does the lucency of the veterbrae change?
inferior vertebrae should become more lucent compared to superior vertebrae
What do you check when you check the abdomen?
calcifications (?gall stones)
What do you check for when you check the diaphragm?
Convexity (vs. flat in emphysema)
Right should be higher than left
Is it easier to detect pleural effusion on lateral or PA films?
Lateral (need 75 cc of fluid) vs. PA (need 200 cc fluid)
What are you checking when you check the pleura?
separation of the two pleura (pneumothorax)
pleural effusions (will see a meniscus)
pleural calcifications (e.g. asbestos)
pleural thickening (e.g. mesothelioma from asbestos exposure)
Where does the pleura extend in the midclavicular, midaxillary lines and posteriorly?
8th rib, 10th rib and 12th rib
What are you checking for when you check the mediastinum?
masses (need lateral view to localize)
retrosternal space (as in emphysema)
What are you checking for when you check the heart
Cardiomegaly (<0.5 is PA or 0.6 AP is normal)
visible heart borders
What are you checking for when you check the hila?
Left side is normally higher than right
check for enlargement (lymph nodes, arteries, veins...)
Check for masses
What do the blue and orange arrows show?
Enlarged pulmonary arteries (blue) with peripheral pruning of arteries (orange). Pulmonary hypertension.
What are you checking when you check the lung parenchyma?
Air space disease (fluid in the alveoli)
- diffuse, confluent opacities with air bronchogram sign
- ground glass opacity if combined with interstitial disease.
- ground glass opacity if combined with air space disease
- e.g. miliary TB
Lucent lung disease
- emphysema- flat diaphragm and increased AP diameter
What is the air bronchogram sign?
It indicates that alvoeli are filling up with something (pus,
What does ground glass opacity signify?
A combination of alveolar and interstitial disease.
It is increased density that doesn't obscure the vessels
What is this lung filled with?
cystic spaces ( >1cm)
What does this lung have?
Honeycombing: peripheral stacked, small cystic spaces
What does this lung have?
some kind of micro-nodular process (e.g. miliary TB, silicosis)
*can also have macronodular (>8mm) where nodules can cavitate
Advantages and disadvantages of CXR vs. CT vs. MRI vs US vs. PET
(when they are good to use)
- 2D representation
- higher radiation
- excellent spatial resolution
- good for bone, lung
- no radiation
- good spatial resolution
- good for soft tissue (lung neoplasm, cardiac)
- no radiation
- cannot see through air or bone
- can see pneumothorax and pleural effusion better than CXR
- low resolution
- pulmonary embolism assessment
What does this radiograph show?
An endotracheal tube pushed into the right bronchus (too far..). That's why you should xray after the tube has been placed.
What does PACS stand for?
Picture archiving and communication system
What are Kerley B lines and when would you see them?
They are ~1cm long markings on the periphery of the lungs indicating thickening of interlobular septae.
Seen when lymphatics are distended as in interstitial pulmonary edema, interstitial disease.
Name the lymphatics of the lung
What does the L and the RP signify?
L signifies the patient's left side
RP is the initials of the technologist
The patient's identifying information would be on the other side (top left of picture)
What does this show?
A right-side pleural effusion
What does the arrow show?
An enlarged hilar focal mass
enlarged hila/lobulated lymphadenopathy
What do red and orange arrows show?
What might the diagnosis be?
End stage interstitial fibrosis
Find the hilar points (and what are they?)
Hilar points are the angle formed by the descending upper lobe veins, as they cross behind the lower lobe arteries. Not every normal patient has a very clear hilar point on both sides
When the alveoli and small airways fill with fluid/pus
How to spot a tension pneumothorax?
-trachea deviated AWAY from involved side (i.e. pushed away)
Find the horizontal fissure
What is the abnormality?
Azygous fissure (when the azygos vein runs more deeply in the lung than usual). Occurs normally in 1-2% of the population
What do the left and right heart borders represent?
Where is the aorto-pulmonary window?
Between the aortic knuckle and the left pulmonary artery
Is the costphrenic angle blunted?
No. The patient is rotated so there is more breast tissue overlying the costophrenic recess.
What is happening here?
-trachea is deviated to the left
-large soft tissue mass PUSHING trachea
What is the differential for consolidation?
- alveoli filled with pus
- alveoli filled with cells
- alveoli filled with fluid
- alveoli filled with blood
How to characterize this radiograph?
bilateral lung nodules
This patient has a pneumothorax. Because the trachea is midline, it is not a tension pneumothorax.
pleural plaques from asbestos exposure
cavitation in the left lung
Lateral chest radiograph anatomy