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Reading Chest Xrays

Brenda Buikema, MD
M3 Inpatient Internal Medicine
Curriculum
Images taken from www. google.com unless labelled
Normal Anatomy
Things To Know
• Cardiac Anatomy

• Lung anatomy

• Bones
Heart Borders
• PA
– Right Border - Right Atrium
– Left Border–Left ventricle
• Lateral
– Anterior Border–right ventricle
– Posterior Border–left ventricle/left atrium
• Overall size – Less than 50% of the
transthoracic width is normal
Aortic Arch
Right
Pulmonary
Artery Left
Pulmonary
Artery

Left
Ventricle
Right
Atrium
Aortic arch

Left Atrium/
Left
ventricle

Right
Ventricle
Right
diaphragm

Left diaphragm
IVC
Valves

• Remember the approximate positions of


the valves. . . .
Pulmonic
Valve

Aortic
Valve

1. Superior vena cava


2. Inferior vena cava
3. Right atrium (blue)
4. Right ventricle (blue)
5. Left ventricle (red)
6. Aorta
7. Pulmonary trunk
Mitral valve

Tricuspid
Valve
Abnormalities with Heart Borders
• Left Atrial Enlargement –Multiple changes
– Third Mogul sign –
• 1st – aortic knob
• 2nd – pulmonary artery
• 3rd – Left Atrium
– Splaying upward of the left mainstem bronchus
– Double density –a shadow to the right of the T spine –
superimposed behind the right atrial shadow
– Remember that the left heart border should be
concave –NOT CONVEX!!
Abnormalities with Heart Borders
• Right Atrial enlargement – Prominent right
heart border
• Right ventricular enlargement – if large
enough will produce a Boot-Shaped Heart
– We depend on the Lateral more for this (see
later)
• Left Ventricular enlargement – depend
more on lateral for this – left ventricle will
project 2 centimeters behind the IVC
Left Atrial Enlargement

Note: is
more
convex
here
than
concave
(third
mogul)
Lung Anatomy
• Right side –
– 3 lobes – right upper, middle and lower
• Remember right middle lobe abuts the right heart border,
right lower lobe does not
• Left side –left upper and lower lobes and lingula
• Other structures –
– Pulmonary vessels
– Diaphragms –right hemidiaphragm should always lie
higher than the left
Trachea

Right
main Carina
stem
bronchus

Left main
stem
bronchus
Right
hemidiaphragm
Left
Right hemidiaphragm
costophr-
enic
Angle
(off the Gastric
screen) bubble
Lung Anatomy
• Right upper lobe and Right middle lobe
separated by the horizontal (minor) fissure
• Right lower lobe separated from middle
and upper by the oblique (major) fissure
• Left lower lobe separated from left lower
lobe by the oblique (major) fissure
Lung Anatomy

Minor
(horizontal)
fissure
Right Lung on PA

Right
upper
lobe

Horizontal
fissure

Right
middle
lobe
Right Lung on Lateral

Minor
(horizontal)
fissure

Major
(oblique)
fissure
Spaces on Lateral
• Retrocardiac –
– Look for infiltrates here
• “spine sign” –as the spine goes down, the T spine should
stay clear – when it does not – this is likely infiltrate
• This is also where the IVC is –if “filled up” think left
ventricular enlargement
• Retrosternal –
– if too small –think right ventricular enlargement
– If too big –think COPD
Retrosternal
space

Retrocardiac
space
Bones
• Ribs –beware fractures
• Clavicles –check the heads
• Spinous processes
• T spine
First rib Clavicles

Spinous
process T spine
Systematic Approach
To Interpreting Chest Xrays
On the PA/AP. . . . .
1. A -Adequacy
• 1. Check the name and date
• 2. Organize –check right and left
• 3. AP vs PA?
– Heart will look slightly larger on the AP as compared
to the PA
• 4. Check for rotation
– Clavicles centered evenly over the vertebral column
– Measure the distance from the medial end of each clavicle to
the spinous process of the vertebrae at the same level – should
be equal
1. A -Adequacy
• 5. Check for penetration –especially when
comparing to priors –should be able to
barely see the thoracic vertebrae behind
the heart
• 6. Exposure – Make sure you can see the
whole film –need to be able to identify the
costophrenic angles and the apices
1. A -Adequacy
• 7. How many posterior ribs should be
seen in order to consider a chest Xray
adequate in terms of inspiration?
– A. 6
– B. 7
– C. 8
– D. 9
1. A -Airway
• Ensure the airway is visible
– If not midline:
• Pushes away from abnormality –pleural effusion, tension
pneumothorax
• Pulls towards abnormality -atelectasis

– Trachea normally narrows at the vocal cords


– View the carina -angle should be 60-100 degrees
• Beware things that may increase this – left atrial enlargement,
lymph node enlargement, left upper lobe atelectasis
– follow out both main stem bronchi
• If an endotracheal tube is in place, check the
positioning – should be 3-4 cm above the carina
1. A -Airway
• Check for widened mediastinum –
– Masses
– Inflammation –mediastinitis, granulomatous
inflammation
– Trauma and dissection (hematoma)
– Aneurysm of the vessels
2. B- Bones
• Check for fractures/lytic lesions in the
– Clavicle
– Ribs
– Thoracic spine
– Humerus
– Shoulder dislocations/OA
• At this time – also check the soft tissues
– Subcutaneous air, foreign bodies, surgical clips, etc
– Caution with nipple shadows –may appear to be
intrapulmonary nodules
• compare side to side – if on both sides in same position are
likely to be due to this
3. C -Cardiac
• Heart size
• Borders –to see if appropriate/blunted
• Aorta -For widening, tortuosity,
calcification
• Valves
• SVC/IVC/azygous –for widening,tortuosity
• Thin rim of air around the heart? Think
pneumomediastinum
4. D –Diaphragms
• Right should be higher than the left
– If much higher- think effusion, lobar collapse,
diaphragmatic paralysis
• If cannot see – consider infiltrate or
effusions
• If upright -may see free air under the
diaphragm if intrabdominal perforation
5. E- Effusion, Esophagus
• Difficult to see esophagus unless airfilled
• Effusions –
– Look for blunting at the costophrenic angle
– Look for fissures – if see means fluid is
tracking
– Check out the pleura here as well –
loculations, calcifications
6. F- Fields (Lung)
• Here check for infiltrates
– know placing of them –loss of borders of the diaphragms and
the heart
– Remember that right middle lobe abuts the heart, right lower
lobe does not
– Lingula abuts the left side of the heart
– Interstital (reticular) vs. Alveolar (patchy/nodular)
– Lobar collapse?
• Look for
– Air bronchograms
– Tram tracking
– Nodules
– Kerley B lines
6. F- Fields (Lung)
• Pay attention to the apices
– Granulomas
– Tumor
– Pneumothorax
• Remember if AP and at 45 degrees, will not see as
well as if PA as is completely upright (air goes up!)
7. G- Gastric Air Bubble
• In the correct position
– Beware hiatal hernias
8. H -Hilum
• Check the position/size bilaterally
– Calcified nodules
– Too full? –Think LAD
– Here, concentrate on the pulmonary arteries –
if greater than 1.5 cm think about possible
causes of enlargement
9. Other
• Check for lines (PICC or central) –should
see at the junction of the SVC/atrium
• Check for Dobhoff tubes –should be in the
stomach, ideally pointed towards the
pylorus
• EKG leads
In addition, on the Lateral. . . .
On the Lateral. .
• B- Bones – check the vertebral bodies and the
sternum for fractures
• C –Cardiac – Check for enlargement of the right
ventricle/ right atrium
– Check the retrosternal and retrocardiac spaces
– Trace the Aorta
• D – Diaphragm – check for fluid tracking up –
costophrenic blunting and the associated
hemidiaphragm
• E –Effusions – check to see the fissures here as
well – both major fissures and the horizontal
may be seen well
On the Lateral. .
• F –Fields –Check for positive spine sign –
as the spine goes more inferiorly suddenly
see it get more dense – likely infiltrate
– Also try to find the infiltrate that you think you
saw on the PA film
– Pay attention to the lower lobes
On to the Second Part of the
Tutorial. . . .

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