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.

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.
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.

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.

OPACITY

Mass vs. Infiltrate

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.

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.
HOW TO READ 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

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 .
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.

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.

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

Would you favor pneumonia or CHF in this patient? Why? What pattern is shown?
(Click image for answer)

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

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

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, Marfan's 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.

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.

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.
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).

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 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.

Note bilateral flattening of the diaphragms and significant hyperinflation as demonstrated by

visualization of 11 posterior ribs.

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.
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.