CHEST X RAY AND COLLAPSE

Dr.Brigit Thomas
 Five basic radiographic densities which appear on
X rays as various shades of black and white

 Lungs – black
 Fat – dark grey

 Heart and blood vessels – light grey

 Clavicle and ribs – off white

 Metals / labels – bright white

RADIOGRAPHIC TECHNIQUES

 PA Chest Xray :
1. Preferred - standard

2. Accurate and valid comparisons

TECHNIQUE
 Fixed distance between xray tube and cassette
of 180cm
 The patient faces the cassette and the xray
beam passes through in the posterior to
anterior direction
 Taken during Inspiration
 On full Inspiration, the diaphragm should lie at
the level of 8th to 10th rib posteriorly or 5th – 6th
anterior ribs
INTERPRETATION

 Request form
 Name , age , sex and clinical presentation

 Trachea

 Heart and mediastinum

 Diaphragm

 Lungs

 Hilum
 Below diaphragm
 Soft tissues and bones
LATERAL CHEST X RAY
 AP Chest Xray

 Patient lies supine

 The distance between the x ray to the cassette
is much less than 18o cm
DISADVANTAGES

 False impression of Mediastinum , cardiac and

aortic enlargement
 In lying supine – unable to do a full inspiration

 Rotation can happen

 Scapulae is super imposed over the lung fields

 Elevation of the clavicles

LATERAL CHEST XRAY
 :
 1.Check if equivocal frontal cxr shadow is actually present / not

 2.Position an abnormality
 Ant/post
 Which lobe
 In lung / mediastinum

 3.Check tricky areas

 Behind heart
 Behind/front of hila
 Behind domes of diaphram
OTHER VIEWS
 Oblique view:
 the patient may be erect or supine with their
right (RPO) or left posterior (LPO) side closest to
the image receptor
 affected side is rotated 45 degrees towards the
IR
 the patient’s arm closest to the receptor is
raised and placed on their head, with the other
on their hip
DECUBITUS

 Useful for small pneumothorax/ effusions

 Lordotic view:
 the patient is standing with feet approximately
30cm away from the image receptor, with back
arched until upper back, shoulders and head
are against the image receptor
 the shoulders and elbows are rolled anteriorly
DIFFERENT ASPECTS
 Inspiration:
 Visualisation of 9-10 posterior ribs or 6 anterior
ribs on an upright pa radiograph projecting above
diaphragm.

 Shallow—less than 6 anterior ribs lie above dome

of diaphragm
 Elderly
 Pain/unconscious
 Bed side radiography
 Rotation :
 The spinous processes of the thoracic
vertebrae are in the midline at the back of the
chest. They should form a vertical line that lies
equidistant from the medial ends of the
clavicles, which are at the front of the chest.
Rotation of the patient will lead to off-setting of
the spinous processes so they lie nearer one
clavicle than the other.
EXPOSURE
 Scapula Position :
 Ideal-scapula rotated off the thorax and
projected well away from the lungs

 Difficult in elderly, frail or sick people

 Spurious pneumothorax produced when part of

scapula overlies a lung
 Mediastinum : FELSON’S CLASSIFICATION
 The mediastinum is divided into anterior, middle and
posterior compartments

 An imaginary line is traced upward from the diaphragm along

back of the heart and front of the trachea to the neck. This
divides the anterior from middle mediastinum

 A secondary imaginary line connects a point on each of the

thoracic vertebrae 1 cm behind its anterior margin. This
divides the middle from posterior mediastinum.
 Trachea: position and outline
INTEREFACE LINES AND STRIPES

 RIGHT PARATRACHEAL STRIPE:

 Paravertebral stripes : The left paratracheal stripe
is visualised on almost all well penetrated cxr-
descending aorta displaces the adjacent lung
laterally—causes the pleural surface and lung edge
to be seen tangentially as they pass lateral to the
paravertebral soft tissues from front to back.

 Rt paravertebral stripe not visualised untill middle

age-osteophytes displaces adjacent pleura
laterally.
 Azygo-oesophageal line : formed when the right
lung abuts the right side of the oesphagus and
the azygos vein
 Extends below the aortic arch of the diaphragm
 Anterior junction line:
 Formed where the two lungs abut each other
anteriorly below the level of the manubrium.
Line is made up of four layers of pleura.
Posterior junction line : two lungs abut each other
posteriorly . Extends from the clavicles to the
level of arch of aorta
AORTO- PULMONARY STRIPE

 A segment of mediastinal pleura does not

blend with the outline of the mediastinum but
is reflected as a straight line between the main
pulmonary artery and aortic arch
HEART
 Size:
 the heart size is assessed as the cardiothoracic ratio (CTR)
 A CTR of >50% is abnormal - PA view only
 Cardiothoracic ratio (CTR)
 Cardiac size is measured by drawing vertical parallel lines
down the most lateral points on each side of the heart, and
measuring between them.
 Thoracic width is measured by drawing vertical parallel lines
down the inner aspect of the widest points of the rib cage,
and measuring between them.
 The cardio-thoracic ratio can then be calculated.
 Site : left / right
 Shadows : any change in density

 Borders : clear / well defined

HILA

 Of the soft tissue density at each hilum , 95% is

due solely to pulmonary artery and veins
 The main pulmonary artery on the right side
passes anterior to the right main bronchus,
whereas the main pulmonary artery on left side
passes posteriorly and hooks over the main
bronchus.
 Left hilus is higher than the right on a PA chest
as left pulmonary artery is higher than the left
DIAPHRAGM
 The left and right diaphragm appear as sharply
marginated domes.

 The peripheral margins of the diaphragm define the

costophrenic sulci

 The right diaphragm is higher than left and will appear

larger on lateral chest film

 A difference greater than 3 cm in the level of two hemi

diaphragm is significant.
 Normally—two domes are easy to separate
 the right dome visualised all the way back to front
 The left dome only extends from costophrenic recess
posteriorly to back of cardiac shadow anteriorly— b/c
heart obliterates lung/diaphram interphase
 Occasionally –difficult to separate b/c
 Domes may overlap precisely
 If Base of heart is narrow—obliteration of anterior aspect
of left dome is minimal and shadow will extend all the
way to sternum
CARDIOPHRENIC AND COSTOPHRENIC ANGLES
 Each costophrenic recess represents the most
inferior part of the lung and pleura on an erect
CXR , this is where most pleural effusions will
collect
LUNG ZONES
FISSURES

 Right lung – 2  major – Oblique

 minor – Horizontal

 Left lung – 1  major - Oblique

 Fissures divide the lungs into lobes

RIGHT
LEFT
BONY THORAX
HIDDEN AREAS
COLLAPSE
COLLAPSE

 Total loss of volume of a lung or a lobe

 Chest X ray- it appears as white

 The affected tissue lung occupy a smaller

volume
 It has no air within

 Mucous secretion back up and collect in the

alveoli
 The key-findings on the X-ray are:
 Sharply-defined opacity obscuring vessels
without air-bronchogram
 Volume loss resulting in displacement of
diaphragm, fissures, hilum or mediastinum
 Exceptions :
 Lobar collapse may be rapid and collapses to a
thin structure, the collapsed lobe will not
necessarily be white
 Long standing collapse – lead to scarring and
contraction of the lobe
TYPES OF COLLAPSE

 Obstructive : the obstructing lesion arising

from with respect to the bronchial lumen
 Tumour

 Mucus plug

 Foreign body
 Compressive :
 occurs as a result of any space-occupying
lesion compressing the lung and forcing air out
of the alveoli
 Pneumothorax

 Pleural fluid

 Pleural effusion
 Cicatrisation :which occurs as a result of
scarring or fibrosis that reduces lung
expansion.

 Fibrotic contraction due to

 TB , Radiotherapy , pulmonary fibrosis

SIGNS

 Direct signs :
 Displacement of interlobar fissure – most
reliable
 Crowding of bronchovascular markings

 Increased lung opacity

 Indirect Signs:
 Hilar displacement

 Mediastinal shift

 Diaphragmatic elevation

 Rib approximation

 Compensatory hyperinflation
RIGHT LOWER LOBE COLLAPSE

 Oblique fissures moves posteriorly and medially

.The medial displacement causes it to be seen in
profile and it forms the lateral edge of a triangular
density projected over heart
 Right hilum is depressed

 Right lower lobe pulmonary artery is not visualised

 Medial aspect of the right dome of the diaphragm

is obscured
LEFT LOWER LOBE COLLAPSE
 Oblique fissure moves posteriorly and medially.
The medial displacement and rotation of the
fissure causes it to be seen in profile and it
forms the lateral edge of a triangular density
superimposed over the heart
 Left hilum is lower
 Left lower lobe pulmonary artery is not
visualized
COLLAPSE OF MIDDLE LOBE

 Horizontal fissure moves inferiorly

 Blurring of the right heart border .

 Collapsed lobe may be dense .

RIGHT UPPER LOBE COLLAPSE

 Horizontal fissure moves superiorly

 Right hilum is elevated

 Collapsed lung is dense

 A common cause of lobar collapse is a hilar

mass. When a right hilar mass is combined
with collapse of the right upper lobe, the result
is an S shape to elevated horizontal fissure.
This is known as Golden S sign
 Atelectasis, Right Upper Lobe. There is a triangular
or wedge-shaped density at the right apex (black
arrow) that displaces the minor fissure upward
(red arrow). The right hilum is elevated from
volume loss (yellow arrow). There is a right
juxtaphrenic peak (white arrow) of the right
hemidiaphragm, which is also elevated in its
entirety (blue arrow). The patient had a
bronchogenic carcinoma obstructing the RUL
bronchus.
LEFT UPPER LOBE COLLAPSE

 Veil like density covers the left hemithorax , this

is due to the lack of aeration within the
collapsed upper lobe
 Left heart border is obscured

 Left hilum is elevated

 Luftsichel sign may be present

THANK YOU