Basics of chest x-ray

Rabi Dhakal
The most common radiography equipment
used for chest x-rays consists of a box-like
apparatus containing the recording material
such as film or a digital recording plate
against which the individual places his/her
chestand the apparatus containing the x-ray
tube, usually positioned about six feet away.
Radiography involves exposing a part of the body to a small dose of
radiation to produce an image of the internal organs.
When x-rays penetrate the body, they are absorbed in different amounts by
different parts of the organ. The ribs and spine, for example, absorb much
of the radiation(x-rays ) and appear white or light gray on the image. Lung
tissue absorbs little radiation and appears dark on the image.

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 Routine chest radiography consists of:

View Position

Posteroanterior(P- Patient standing. Anterior chest

wall placed against film cassette.
A)/Frontal view
Left /Right lateral Left/Right lateral chest wall placed
against film cassette

Anteroposterior(A Patient supine or upright with

his/her back against film cassette
-P)
Lateral decubitus An AP view with patient lying in
lateral decubitus position

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Imaging technique (Choices of views)

Postero-anterior (PA) or antero-posterior (AP) for

children
Sufficient in most of the cases
Lateral view if any suspected abnormality is noted
Lateral view
Left lateral view taken unless unless the pathology on the
right side
Position of patient
Erect or sitting position whenever possible
Apical (lordotic) view
When abnormality in the apical areais seen..
Decubitus views
Ifstrong suspicion of pleural fluid but none can be seen on
the PA or lateral
Rib oblique film
Only for rib abnormalities (e.g., local swelling)
Localised, unexplained chest pain
Rib fractures if not seen in PA
Expiratory film
Clinically
suspected pneumothorax or an inhaled foreign
body which is not shown by PA or AP views..
Limitations of chest x-ray
A normal chest-ray does NOT exclude developing pulmonary disease,
especially in children
Abnormalities visible on chest x-ray may take longer to develop than clinical
abnormalities
Cases like interstitial, airway and pulmonary vascular diseases cannot be
recognized by chest x-ray.
Disease of the chest with a normal radiograph
1. Obstructive airways disease: asthma, acute bronchiolitis, etc
2. Small lesions: less than 1 cm, hiden by heart or other structures
3. Pulmonary emboli without infarction
4. Partial infections: early stage of infections
5. Diffuse pulmonary disease: widespread pulmonary fibrosis
6. Pleural abnormality: dry pleurisy, small amounts of pleural fluid..
Systemic Approach to Interpretate Chest X-ray
Request form: name, age, date, sex, clinical information and PA /AP or
lateral views
EVALUATING THE CHEST RADIOGRAPH FOR TECHNICAL ADEQUACY

The spine should be visible through

Penetration
the heart
Inspiration Adequate inspiration is when the 8-
9th posterior rib is visible or 6th
anterior rib
Spinous process should fall
Rotation equidistant between the medial ends
of the clavicles

Magnification AP films (mostly portable chest x-rays)

will magnify the heart slightly
Angulation Clavicle normally has an "S" shape
and superimposes on the 3rd or 4th rib
Trachea: position, outline
Heart and mediastinum: size, shape, displacement
 CARDIOTHRORACIC RATIO

It is the ratio between the maximum transverse diameter of the heart and the maximum width of thorax above
the costophrenic angles. Normal cardiothoracic ratio is less than 1:2. On an anteroposterior (AP) chest
radiograph (the usual bedside, portable chest radiograph in which the x-ray beam enters anteriorly and exits
posteriorly where the cassette is positioned), the heart is slightly magnified because it is farther from the
imaging surface.
Diaphragms: outline, shape, relative position

we refer to the right half of the diaphragm as the right hemidiaphragm and the left half
of the diaphragm as the left hemidiaphragm. The right hemidiaphragm is slightly
higher than the left
Pleura: fissure, costopheric angle, cardiophrenic angles

Horizontal fissure might be seen on the right side as a thin white line that
runs from right hilum to sixth rib laterally.
Lung fields: local/generalised abnormality, Comparison of the
translucency and vascular marking of the lings

On a PA film, lung is divided radiologically into three

zones:
1. Upper zone extends from apices to lower border of 2nd
rib anteriorly.
2. Middle zone extends from the lower border of 2nd rib
anteriorly to lower border of 4th rib anteriorly.
3. Lower zone extends from the lower border of 4th rib
anteriorly to lung
bases.
 Hila: density, position, shape

The hilar shadows are caused by

arteries and veins with a small
contribution from the walls of the
major airways.
Below diaphragms: gas shadow, calcification
 Soft tissue

Breast , nipple, tissue

Bones
 Hidden areas

After scrutinising the bones and soft tissues, one should look for pathology in
the hidden areas.
The lung apices
Look behind the heart
Under the diaphragms.
Thank You