BASIC OF THORAX

IMAGING

Radiology Department of Hasan Sadikin

Hospital
Medical Faculty of Padjadjaran University
INTRODUCTION
ANATOMY
POSITIONING
15 STEPS TO READ CHEST X-RAY
LATERAL CHEST X RAY
INTRODUCTION
INTRODUCTION

Plain chest radiograph is one of the

most commonly performed imaging
procedures
Up to 50% of studies in radiology
practices.
Countless volumes of radiology
textbooks have been dedicated
solely to thoracic imaging.
 INTRODUCTION

Indication :
Screening.

Preoperative underlying pulmonary

and cardiovascular diseases.
Febrile patient pulmonary sources of fever

Trauma patient.

Contraindication (relative):

Pregnant women especially 1st & 2nd

trimester.
Neonates and children.
ANATOMY
LUNG ANATOMY
LUNG ANATOMY
Right Lung
o 3 lobes
(divided by major fissure and
minor fissure)
o 10 segments
Left Lung :
o 2 lobes
(divided by major fissure)
o 8 segments
o Lingula segments ~ medial lobe
of the right lung
LUNG ANATOMY

Minor (horizontal )fissure divides the

superior lobe and the middle lobe of the right lung .

There is no minor fissure in the left lung.

 LUNG ANATOMY

In the right lung, the major fissure (oblique)

divides the inferior lobe with the middle and
superior lobes.
In the left lung, the major fissure (oblique)
divides the inferior lobe with the superior lobe.
RIGHT LUNG SEGMENTATION

Superior Lobe Apical segment (1)

Posterior segment (2)
Anterior segment (3)
Middle Lobe Lateral segment (4)
Medial segment (5)
Inferior Lobe Apicobasal segment (6)
Mediobasal segment (7)
Anterobasal segment (8)
Laterobasal segment (9)
Posterobasal segment (10)
 LEFT LUNG SEGMENTATION
Superior Lobe Apicoposterior segment (1)
Anterior segment (2)
Lingula Superior segment (3)
segments Inferior segment (4)
Inferior Lobe Apical segment (5)
Anteromedial basal
segment (6)
Laterobasal segment (7)
Posterobasal segment (8)
 RESPIRATORY TRACT ANATOMY
Trachea :
Begins at the lower border of the cricroid cartilage at the level of C6
vertebra.
Extend to the carina at the level of the sternal angle (T5 level)
T4 level on expiration
T6 level on inspiration
The trachea is 1,5 cm and 2 cm in diameter.
 RESPIRATORY TRACT ANATOMY
Trachea :
The trachea in children is very pliable.
It may be deviated to the right in normal expiratory film.
It only deviates to the left if the aortic arch is on the right side.
RESPIRATORY TRACT ANATOMY
RESPIRATORY TRACT ANATOMY
 RESPIRATORY TRACT ANATOMY
Primary lobule
The smallest functional unit of the lung
Comprises all the structures distal to a respiratory bronchiole
including 16-40 alveoli.
Normal adult has approximately 23 million primary lobules.
 RESPIRATORY TRACT ANATOMY
Acinus
Consists of all structures distal to the terminal bronchiole,
including vessels, nerves, and connective tissue.
It has a diameter 4-8mm
Contains approximately 10-20 primary lobules
 RESPIRATORY TRACT ANATOMY
Secondary Lobule
The smallest structural unit of lung parenchyma that is
surrounded by a connective tissue septum.
Contains 3-12 acini and measures 1,0-2,5 cm in diameter.
RESPIRATORY TRACT ANATOMY
RESPIRATORY TRACT ANATOMY
TRACHEOBRONCHIAL SYSTEM

23
 ACINUS

Lobulus primer

5/28/17 WWW.BRAINYBETTY.COM 24
ALVEOLI
Alveoli pore:
Canals of Lambert
between alveoli and
terminal bronchiole
Pores of Kohn
between alveoli.

25
RADIOANATOMI POSTEROANTERIOR CHEST X RAY
POSITIONING
CHEST X-RAY POSITION

POSTER0ANTERIOR
ANTEROPOSTERIOR
RIGHT/LEFT LATERAL
RIGHT ANTERIOR OBLIQUE
LEFT ANTERIOR OBLIQUE
RIGHT POSTERIOR OBLIQUE
LEFT POSTERIOR OBLIQUE
TOP LORDOTIC
RIGHT/LEFT LATERAL DECUBITUS
POSTEROANTERIOR

Indication:
Routine
Screening TB
Pre-operative
Technique:
The patient stand between the film and the x-ray tube.
The patient faced the film.
The hands are put in the waist with the elbow flexed to the anterior
(to open scapula so it doesnt superimposed with the lung)
The distance of the film to the x-ray tube :
Lung 1.5m
Heart 2.0m
Centre : 6th 7th thoracic spine
50-60 KV
10-20 MAs
 ANTEROPOSTERIOR

Indication:
(cannot be taken with PA )

Severely ill patient

Children
Infant and neonates

Obese
Pregnant

Ascites
Intraabdominal tumor
Technique:

1. The patient lie on the table with the arms put beside the body or
put up.
2. The film was placed behind the back.
3. Centre : 6th -7th thoracic spine
DISTORTION IN ANTEROPOSTERIOR CHEST X-RAY

Heart enlargement
Mediastinal widening
Crowded bronchovascular marking at the basal
zone.
 HOW TO DIFFERENTIATE PA & AP
PA
V shaped clavicles

No lung superposition

with the scapula AP

No mediastinal Straight clavicles

Lung superposition with the scapula

widening

Mediastinal widening
Distinct posterior aspect of the costa
Distinct anterior Crowded bronchovascular marking especially at the
basal zone.

aspect of the costa.

Less crowded

bronchovascular
marking
PA VS AP CXR
 LATERAL CHEST X-RAY

Indication:
Look at mediastinal abnormalities.
Look at anomalies that wasnt clear at
posteroanterior position.
Heart assessment.
To look for minimal fluid collection in
the pleural cavity (75cc) that can not
be seen in the PA chest x-ray
LATERAL CHEST X-RAY

Technique:
1. The patient stand between the film
and the x-ray tube.
2. The lateral side of the anomalies
(right/left) was closed to the film.
3. Both arms was lifted up.
4. Centre: 6th -7th thoracic spine
R
L AORTIC ARCH
TRACHEA

OBLIQUE FISSURE

POSTERIOR RIBS
RT. HEMI
DIAPHRAGM

LT. HEMI DIAPHRAGM

COLON GAS
THORAX LATERAL
 OBLIQUE POSITION
Indication:
To look at anomalies that were not clear at PA and
lateral position.

Type:
Right anterior oblique (RAO)
Left anterior oblique (LAO)
Right posterior oblique (RPO)
Left posterior oblique (LPO)

The side that is mentioned is the side that was close

to the film
RAO: The right side and the anterior side was close to the film
LPO: The left side and the posterior side was close to the film.
 OBLIQUE POSITION
Indication:
To look at anomalies that were not clear at PA and lateral position.

Techniques:
1. The patient stand between the film and the x ray tube.
2. The side that is mentioned is the side that is close to the film
3. The angle of obliquity is approximately 45 0.
4. The arm that was close to the film was put over the head, while the
other hand was put on the waist with the elbow flexed to the
posterior.
5. Centre: 6th -7th thoracic spine
RAO LAO
LATERAL DECUBITUS

Indication:
To look for minimal fluid
collection in the pleural
cavity (15-20cc) that can
not be seen in the PA chest
x-ray

Technique:
1. The patient lying in the table with the lateral side close to the
table.
1. RLD : The right side of the body is close to the table
2. LLD : The left side of the body is close to the table
2. Both arms are lifted.
3. Centre: 6th 7th thoracic spine
LLD/RLD
TOP LORDOTIC

Indication:
To look for
anomalies at
the apex of the
lung.
Technique:
1. The patient stand between the film and the x-ray tube.
2. The patient is facing the x-ray tube.
3. The distance between the patient and the film is 30cm
4. The patient then rest the back of his shoulder to the film.
5. The upper border of the film is approximately 1 inch above the
shoulder.
6. Centre: manubrium of the sternum
TOP LORDOTIK
15 STEPS TO READ CHEST X-RAY
 15 STEPS TO READ CHEST X-RAY

}
1: Name & Age
2: Date
3: Medical record number Administration
4: Previous examination
5: Position/View: PA/AP/Marker

}
6: Penetration
7: Rotation
Quality
8: Inspiration
9: Magnification
10: Angulation

}
11: Trachea, heart, sinuses, diaphragm
12: Hilum, bronchovascular marking
13: Lung field, hemithorax Diagnostic
14: Soft tissue, bone
15: Conclusion
 ADMINISTRATION

Identity: Name & Age

Date
Medical record number
Previous examination
Position/view: PA/AP/Marker
QUALITY

Penetration
Rotation
Inspiration
Magnification
Angulation
 PENETRATION

Higher kV higher penetration ability of the x-ray. (quality of the x-

ray)
Higher mAs higher quantity of the x-ray higher amount of x ray
that penetrate the body
Higher kV lower contrast resolution
The ability to differentiate between high density and low density
object will be decreased with higher kV.
PENETRATION
So to get a good penetration film with a good contrast resolution,
we should use low kV with high mAs. But there is a problem
because the radiation dose will be higher with lower kV and
higher mAs.

Our goal is to get the best quality of the image with the lowest
radiation dose to the patient.
PENETRATION
Fine vascular markings within the lung should be seen.
Faint outlines of at least mid and upper thoracic vertebra
3rd thoracic vertebra in conventional radiograph
All of the thoracic vertebra in digital radiograph
Faint outlines of posterior ribs through heart and mediastinal
structures.
PENETRATION

Conventional Digital
PENETRATION
ROTATION
It should be symetrical.
Look at the distance from the medial end of both the clavicles to
the spine process in the midline.
INSPIRATION
Level inspirasimaksimal
Apex of the diaphragm at the level 5 th-6th anterior ribs.
9th 10th posterior ribs at the level of right cardiophrenic
sulcus.
2
3 1
4
5
6

10
HOW TO DIFFERENTIATE ANTERIOR RIBS
FROM POSTERIOR RIBS
 EXAMPLE OF POOR INSPIRATION

Spurious findings : cardiomegaly, mass at

the aortic arch, patchy opacification in
 EXAMPLE OF POOR INSPIRATION

Spurious findings : cardiomegaly, mass at

the aortic arch, patchy opacification in
MAGNIFICATION

Influence the heart size assessment.

Depend on the patient position toward the film.
PA chest x-ray is more accurate in depicting the heart size than
AP chest x-ray.
Reason:
The distance between the heart and the film is closer
in PA chest x-ray.
Not significant in patient < 4 years old.
MAGNIFICATION

AP PA
DISTORTION IN AP CHEST X-RAY
 ANGULATION

In erect chest x ray (without cephalad or caudal angulation) the

beam of the x-ray is paralel to the floor and perpendicular to the
thorax the clavicle is projected below the posterior aspect of the
first rib.
In top lordotic (cephalad angulation) the clavicle (anterior
structure) is projected above the posterior aspect of the first rib
(posterior structure).
In top lordotic, the normal S shaped clavicle will be seen as
straight structure.
The assessment of thoracic structure will be influenced by the
angulation.
TRACHEA
Lucent structure contain air.
Centrally located.
Normal diameter : 1,5 cm
Look for deviation.
Extend to the carina at the level of the sternal angle (T5 level)
T4 level on expiration
T6 level on inspiration
Tracheal bifurcation (carina) normal angle <90 0
>900 in left atrial enlargement.
Trachea
HEART
Size : Cardiothoracic Ratio (CTR)
Shape
Position
SIZE

CTR : a+b
c+d
a
b
c
c d
SIZE

Normal CTR
Adult (PA) < 50%
Adult (AP) < 55%
Normal CTR (PA)
Neonates (<1month) < 60%
Infant (1 month 1 year) < 55%
Children (>1 year) < 50%
SINUSES OR SULCI

Costophrenicus
Cardiophrenicus
 DIAPHRAGM
Right diaphragm is higher
than the left diaphragm.
Normal : 2.5 cm
> 3 cm: abnormal
Shape :
Tenting
Scalloping
DIAPHRAGM

Diaphragm flattening
N>1,5cm
<1,5 flattening
 LUNG

Lungs contain air that will

give negative contrast
black (lucent)
Compare the right lung
with the left lung
 LUNG ZONE

Apex
From the apex to the clavicle
Upper lung field
From the clavicle to the 2 nd
anterior rib
Middle lung field
From the 2nd anterior rib to
the 4th anterior rib
Lower lung field
From the 4th anterior rib to
the diaphragm
 OTHER DIVISION OF THE LUNG ZONE

Divided by the upper and

lower border of the
hilum.
Upper zone
Above the upper border of
the hilum
Middle zone
From upper border of the
hilum to the lower border of
the hilum
Lower zone
Below the lower border of
the hilum
 HILUM (PLURAL: HILA)
LATIN: HILUS (PLURAL: HILI)

The area where the vessels

(artery and vein), bronchus,
and lymphatic vessels come
in to and come out from the
lung.
Normal left hilum is higher
than the right hilum (about 1
rib)
The diameter is about 9-16
mm or not bigger than
trachea
PULMONARY ARTERY
PULMONARY VEIN
BRONCHOVASCULAR MARKING
Extend from the central to the peripheral area.
Decreasing in quantity and calibre from the central to the
peripheral.
Increased bronchovascular marking if > 2/3 of the hemithorax.
More crowded in the basal region.
BRONCHOVASCULAR MARKING
Cranialization or cephalization :
Upper zone bronchovascular marking is more prominent
than the lower zone
Ratio 3-5:1
BRONCHOVASCULAR MARKING

NORMAL INCREASED
SOFT TISSUE AND SKELETAL

SKELETAL:
Ribs
Clavicles
Scapula
SOFT TISSUE
Breast shadow
Skin fold.
 EXPERTISE
International : peripheral to central
RSHS: central to peripheal
 CONTOH EKPERTISE
Foto asimetris, inspirasi cukup
Soft tissue dan skeletal masih dalam batas normal
Trakea di tengah
Mediastinum tidak melebar
Cor tidak membesar
Sinuses dan diafragma normal
Pulmo:
Hili normal
Corakan bronkovaskuler normal
Tidak tampak bercak lunak
Kesan:
- Tidak tampak TB paru/kelainan paru lainnya
- Tidak tampak kardiomegali
LATERAL CHEST X RAY
 HOW TO READ LATERAL CHEST X RAY
Quality
Retrosternal space
Retrocardiac space
Posterior sinus
Anterior sinus
Diaphragm
Hilar area
Lung field
 HOW TO READ LATERAL CHEST X RAY

Quality
From apex to the sinus.
From sternum to the
posterior ribs.
Chin and arms elevated
sufficiently
No rotation
No motion (sharp outlines)
Visualize rib outlines and
lung marking through the
heart shadow
 HOW TO READ LATERAL CHEST X RAY

Retrosternal
space
Covered by heart
shadow < 1/3
bottom
Abnormal >
Retrocardiac
space
Clear triangular
shaped
HOW TO READ LATERAL CHEST X RAY

Anterior sinus
Sharp

Sometimes

covered by
mediastinal fat
Depend on the

exposure of the
film.
Posterior sinus
Sharp
HOW TO READ LATERAL CHEST X RAY

Diaphragm
Right diaphragm is

higher.
Right diaphragm is

seen from the

posterior to the
anterior.
Anterior aspect of left

diaphragm is covered
by the heart shadow.
Gastric bubble below

the left diaphram.

HOW TO READ LATERAL CHEST X RAY

Hilar area
Mass will make

this area more

opaque
Vascular

opaque
Bronchi lucent
HOW TO READ LATERAL CHEST X RAY

Lung field
Clear lung at the

anterio and
posterior of the
heart.
Decrease density

from superio to
inferior in the
posterior
mediastinum.
 CONTOH EKPERTISE
Retrosternal dan retrocardiac space cerah.
Sinus anterior tajam.
Sinus posterior tajam.
Diafragma jelas.
Tidak tampak infiltrat.

Kesan :
Tidak tampak TBC paru aktif
THANK YOU