Final Year: Approach

to CXR
By Muhammad Mohsin Ali Dynamo (KEMU ‘18)
Derived from Radiology Masterclass and The Radiology Assistant
With Sample OSCE Images from KemUnited, Geeky Medics
Start with Patient and Image Data
• Patient ID, DOB (mostly you will see this in digital xrays)
• Date and Time of film
• Image Projection: PA or AP?  Assume CXR is PA (standard projection)
unless otherwise indicated. Quick tip: AP view is taken only for very ill
patients who cannot stand erect. In the AP supine view, the heart shadow
is magnified and there is more equalization of pulmonary vasculature when
we compare size of lower and upper lobe vessels (don’t fret if you don’t get
this!)
• Image Annotation: Mostly, images are annotated for projection (AP or PA
 if not annotated, always assume PA) as well as for side marker (LLeft,
RRight). Always check this!
• Previous Images: v.v.imp! We will give details later.
Can you tell which is an AP view and which is a PA view? Hint: heart shadow is over magnified on AP
view
Image Quality
• There is a simple “pneumonic” for image quality: RIPE
• R: Rotation the spinous processes should be in the midpoint
between the two medial ends of clavicles
• I: Inspiration at full inspiration, the diaphragm should be
intersected by 5-7 ribs in the MCL
• P: Penetration The spine should be visible behind the heart
• E: Exposure Left hemidiaphragm visible to the spine and vertebrae
visible behind heart (essentially same as Penetration)
• If image quality is inadequate the clinical question can’t be answered.
Also look for any medical artifacts in the image.
The Obvious Abnormality
• In the exam, don’t waste time on thorough systematic examination
while ignoring obvious abnormalities!
How to describe abnormalities?
• This is where we make a lot of blunders. Instead of describing
abnormalities systematically, we just mention the diagnosis, which
doesn’t make us better clinicians.
• Remember the ODPARA for presenting complaints in history? We do
something similar over here: Lesion Descriptors
• Tip: You will see some people who are sticklers for exclusive terms, as
to opacification, shadowing, increased density etc. Don’t worry. All of
these are interchangeable terms, so don’t fret over them.
• Head over to the next page for lesion descriptors!
Lesion Descriptors
• Tissue involved - Lung, heart, aorta, bone etc
• Size - Large/Small/Varied
• Side - Right/Left - Unilateral/Bilateral
• Number - Single/Multiple
• Distribution - Focal/Widespread
• Position - Anterior/Posterior/Lung zone etc
• Shape - Round/Crescentic/etc
• Edge - Smooth/Irregular/Spiculated
• Pattern - Nodular/Reticular(net-like)
• Density - Air/Fat/Soft-tissue/Calcium/Metal
Example!
INTERVENTION: What is a lung zone on CXR
vs anatomical lung lobes?
• There is a difference between the anatomical lung lobes, and the
zones described as upper, middle and lower on CXR.
Silhouette Sign OR Loss of Silhouette Sign?
• Here is a thing that will make your lives somewhat miserable: the
silhouette sign. It is a sign that helps to locate abnormalities in the 3D
space in the chest.
• So let’s say there are two structures adjacent to each other: the
heart, and the lungs. The heart is a soft-tissue density structure that
appears near-white on CXR. Lung tissue has near-air density so it
appears black. Between these structures, a crispy contour or
“silhouette” is formed. If there is any loss of this contour or
silhouette, it can indicate a disease process going on.
• The loss of the normal silhouette of a structure is called the
silhouette sign.
Adjacent Structures and Silhouettes
• Left heart border (left ventricle) - Lingula
• Right heart border (right atrium) - Right middle lobe
• Left hemidiaphragm - Left lower lobe
• Right hemidiaphragm - Right lower lobe
• Aortic knuckle - Left upper lobe/middle mediastinum
• Descending aorta - Left lower lobe
• Right paratracheal stripe - Right upper lobe/anterior mediastinum
• Paraspinal lines - Medial lung/Posterior mediastinum
In this image, we see a silhouette sign at the left heart border. Without brooding over it, we can
assume that the pathology must be located anteriorly in the left lung
Another example
Now we are approaching the good stuff:
What do we actually see on a CXR?
So should we look at all that at once?
• Obviously no.
• We can have one of two approaches: the Inside-Out Approach, or the
ABCDER approach.
Inside-Out Approach: from central to
peripheral.
ABCDER Approach
• A: Airway (Trachea, Carina and Bronchi, Hilar Structures)
• B: Breathing (Lungs, Pleura)
• C: Cardia (Heart Size, Heart Borders)
• D: Diaphragm (Diaphragm, Costophrenic Angles)
• E: Everything Else (Mediastinal Contours, Bones, Soft tissues,
Tubes/valves/pacemakers)
• R: Review Areas (Lung Apices, Retrocardiac, Behind Diaphragm,
Peripheral Lungs, Hilar)
Which approach to use?
• Essentially all approaches are doing the same thing: examining each
and every structure visible in X-ray in a systematic manner
• You can use any of these approaches. For convenience, we will use
the ABCDER approach because it covers everything.
• Inside Out Approach:
http://www.radiologyassistant.nl/en/p497b2a265d96d/chest-x-ray-
basic-interpretation.html
Airway
• We have to check 3 things
1. Trachea
2. Carina and bronchi
3. Hilar structures
Trachea
• Normal location of trachea: central or slightly on right
• Is the trachea deviated? Look for anything pushing or pulling the
trachea.
• Inspect for paratracheal masses/LAD
• A trachea deviation may be seen if rotation of patient has occurred.
Therefore check that the medial aspects of both clavicles are
equidistant from the spinous processes.
• Pushing of trachea – e.g. large pleural effusion / tension
pneumothorax
• Pulling of trachea – e.g. consolidation with lobar collapse
Example: Large pleural effusion pushing
trachea to right
Carina and Bronchi
• Carina: point where trachea divides into right and left bronchi (what
are you doing if you don’t know this mate?)
• If CXR has good quality: carina should be visible.
• Imp in NGT placement: NGT must BISECT the carina so that we know
its not in the airway.
• The main bronchi can also be seen on a good CXR. In awesome CXRs
we can even see structures beyond that.
• The Right Main Bronchus is shorter, vertical and wider and hence the
preferred site for foreign body lodgement.
Let’s see them…
Hilar Structures
• Includes: main pulmonary vasculature (99% of what we see on CXR), the major
bronchi, collection of lymph nodes (NOT SEEN in healthy persons)
• The left hilum is often positioned slightly higher than the right. Left Hilum can
NEVER be lower than right.
• The hilar are usually the same size, so asymmetry should raise suspicion of
pathology
• Hilar Point: point where the descending pulmonary artery intersects the superior
pulmonary vein. If lost, think of a lesion here (e.g. lung tumour or enlarged lymph
nodes).
• Bilateral symmetrical enlargement is typically associated with sarcoidosis.
• Unilateral / asymmetrical enlargement may be due to underlying malignancy.
• Look for evidence of hilar being pushed or pulled as with trachea
Causes of Hilar Enlargement
Example: Bilateral Hilar Enlargement in
Sarcoidosis
• Here we see the 1-2-3 sign of
sarcoidosis: enlargement of
right hilar, left hilar and
paratracheal regions
• This can be due to enlarged
vessels or enlarged lymph
nodes
Breathing
• Look at
1. Lungs
2. Pleura
Lungs
• Recall: lungs have 3 zones on CXR different from anatomical lobes
• Inspect all zones in systematic manner
• First ensure that lung markings occupy entire zone. If there is absence of
lung markings within segment of lung fields: suspect pneumothorax
• Next, compare each zone between the two lungs and look for any
asymmetry (there may be normal anatomical asymmetry due to structures
like heart)
• Sometimes pathology e.g. Pulmonary edema can cause symmetrical
changes in the lung fields
• If there is increased airspace shadowing in any area of the lung field:
suspect consolidation or malignant lesion
Recall…
Example: Left sided lung tumor in middle
zone
Patterns of lung abnormalities
• There are 4 main patterns
presenting as increased density
1. Consolidation
2. Atelectasis
3. Nodule or mass:
solitary/multiple
4. Interstitial
• There can be some patterns of
decreased density as well
1. Emphysema
2. Lung Cysts
A lot coming up!
• You don’t need to remember the next 4 slides. Just remember the
main causes of each of those patterns and you will be good to go! I
added them as recall for your respiratory module.
Consolidation
Atelectasis
Nodules
Interstitial
Pleura
• Normal individuals: Pleura not visible unless pleural thickening is
present (may be due to mesothelioma)
• Inspect borders of each side of lung: ensure lung markings extend all
the way to edges of lung fields. If there is an area with no lung
markings + decreased density: suspect pneumothorax
• If there is an area with no lung markings and increased opacity, it can
either of hydrothorax, hemothorax or hydropneumothorax.
• If pneumothorax suspected: look at trachea: if deviated  TENSION
PNEUMOTHORAX treat as emergency with immediate intervention.
Do not wait for radiology if tension pneumothorax is suspected
clinically (SOB + Tracheal deviation)
Causes of Pneumothorax
There are no straight lines in the human
body….
• If you see a straight line
on a CXR: its an Air-Fluid
Level. Suspect
hydropneumothorax
immediately.
• Now look at the image.
What do you see with
your radio-eyes?
 A hydropneumothorax
Blue arrow
shows retracted
visceral pleura,
indicating
pneumothorax.
Yellow arrow
shows horizontal
straight line,
indicating air
fluid level
Right Sided Pneumothorax on CXR
Other Things to Look In Pleura
• Pleural Opacities
• Pleural Plaques (asbestos related)
• Pleural calcifications (unilateral due to infection [TB], empyema,
hemorrhage)
• Pleural hematoma

• At your level no one would expect you to look this far. So chill.
Cardiac
• 2 things to do
1. Assess heart size
2. Assess heart borders
 Assess Heart Size

• In PA film, heart size should be

less than 50% of the thoracic
width (cardiothoracic ration <
0.5)
• If heart size >50% on PA film (we
are mentioning PA again and
again as heart is magnified extra
on AP films. So always look at PA
films) CARDIOMEGALY.
• On CXR we see only outer
contours of heart.
Cardiomegaly (note pacemaker device)
Assess Heart Borders
• Inspect the borders of the heart which should be well defined in healthy
individuals:
• Right Atrium: most of the right heart border
• Left ventricle: most of the left heart border.
• The heart borders may become difficult to distinguish from the lung fields
as a result of various pathological processes (e.g. consolidation) which
cause increased opacity of the lung tissue.
• Loss of definition of the right heart border is associated with right middle
lobe consolidation
• Loss of definition of the left heart border is associated with lingular
consolidation
 Never
Forgetti:
Dextrocardia
Diaphragm
• Due to liver: right hemidiaphragm is higher than left
• Left-hemidiaphragm: overlies stomach (identified by Gastric Bubble)
• In Erect CXR: right hemidiaphragm and liver SHOULD be inseparable:
if you see these 2 separated free gas due to bowel perforation or
other cause pneumoperitoneum order extra scans
• Pseudopneumoperitoneum: Chilaiditi syndrome colon gets
interposed between liver and diaphragm so air bubble in colon is seen
as free gas between liver and diaphragm discuss with senior. Don’t
waste your brain cells here!
Pneumoperitoneum
 Costophrenic Angles

• Formed by dome of each hemi-

diaphragm plus lateral chest wall.
• Healthy person: clearly visible as well-
defined acute angle
• Loss of acute angle costophrenic
blunting: suggests air/fluid in this area
(consolidation).
• Blunting can also be secondary to lung
hyperinflation in COPD due to
diaphragmatic flattening. This is a tell-
tale pitfall: do not jump to a diagnosis of
consolidation without checking for lung
hyperinflation.
Everything Else
• This includes
1. Mediastinal contours
2. Bones
3. Soft Tissues
4. Tubes/Valves/Pacemakers
Mediastinal Contours
• Mediastinum has three compartments: anterior, middle and
posterior, each with their own pathology.
• Mediastinum includes heart, great vessels, lymph nodes, and
potential spaces where pathology can occur
• Mediastinal lines or stripes are interfaces between the soft tissue of
mediastinal structures and the lung. Displacement of these lines is
helpful in finding mediastinal pathology.
Mediastinal Lines
 Azygoesophageal Recess
• The most important
mediastinal line to
look for is the
azygoesophageal line,
which borders the
azygoesophageal
recess.
• This line is visible on
most frontal CXRs.
 Aorto-pulmonary
Window

• The aorto-pulmonary
window is a space located
between the arch of the
aorta and the pulmonary
arteries.
• This space can be lost as a
result of mediastinal
lymphadenopathy (e.g.
malignancy).
Aortic Knuckle
• Left lateral edge of the aorta as it arches back over the left main
bronchus.
• Loss of definition of the aortic knuckles contours can be caused by an
aneurysm.
Bones and Soft Tissues
• Inspect the visible skeletal structures looking for any
abnormalities (e.g. fractures / lytic lesions).
• Inspect the soft tissues for any obvious abnormalities (e.g. large
haematoma).
Tubes/Valves/Pacemakers
• Tubes – nasogastric tubes are something you’ll often be asked to
assess on a chest x-ray to confirm it is safe for feeding—look to see if
NGT crosses the carina or not
• Lines (e.g. central line / ECG cables).
• Artificial valves (e.g. aortic valve replacement).
• Pacemaker (often located below the left clavicle).
Review Areas
• Apices – check for Pneumothorax or tumors (Pancoast tumor much?)
• Edge of the image - Unexpected findings (like an absent humerus :O)
• Retrocardiac
• Behind the diaphragm
• Peripheral lungs
• Hilar
Piecing it all Together
• Remember: you have to treat the patient, not the CXR!
• Here is a quick flowchart to follow in case you see a CXR:
Now to Apply…
• An Xray is given on the next slide. We will demonstrate how to
approach it systematically.
• P.S. Ignore the copyrighted signs all over the x-ray :D
Now for the Approach
• Patient ID: Anonymous
• Projection: PA
• Image Quality:
1. Rotation: Patient is slightly rotated to right
2. Inspiration: Adequate—7 anterior ribs visible
3. Penetration: adequate—vertebral bodies just visible behind heart
Airway
• Trachea central (once we factor in the slight rotation to the right)
• Carina and Bronchi are not that clearly visible in this x-ray.
Breathing
• Right side: upper zone mass projected over the anterior aspect of 1st
and 2nd ribs.
• Left side: Multiple small pulmonary nodules visible in left hemithorax.
• Lungs not hyperinflated.
• Pleural thickening at Right lung apex
• Normal pulmonary vascularity.
Lesion Descriptors for Right Sided Mass
• Tissue involved - Lung
• Size - > 2 cm
• Side - Right, Unilateral
• Number - Single
• Distribution - Focal
• Position - Mainly upper zone, projecting over upper aspect of 1st and 2nd
ribs
• Shape - Irregular, almost round
• Edge - Smooth
• Pattern -
• Density - Soft-tissue
Cardiac
• Heart not enlarged.
• Heart borders clear
• Normal aorta
• Mediastinum: central with normal width. Mass in Right upper zone is
contiguous with superior mediastinum
• Right hilum dense, appears slightly higher.
• Left hilum normal in size, shape and position
Diaphragm
• Normal position/appearance of both hemidiaphragms
• No pneumoperitoneum
• Costophrenic angles normal
Everything Else
• Skeleton intact with no fractures/destructive bony lesions visible
anywhere
• Soft tissues are unremarkable.
• No tubes/lines/valves in place
Review Areas
• Apices: Right apical pleural thickening
• Hila: dense right hilum; normal left hilum
• Behind heart: normal
• Below diaphragm: normal
Couldn’t see all that? Never fret….
Here is an image detailing everything we just described above.
Ending this Presentation
• This presentation was a systematic approach to the CXR.
• In the next presentation, we will look at Xrays from OSPE samples,
and try to apply the systematic approach there as well. Stay tuned for
that!
• Interested only in viewing X-Rays with a 30 second diagnosis to be
made? Hang in there, the next presentation will cater to that need!
• Toodle-oo!