Questions and Answers
What is the maximum transverse diameter of the heart in relation to the maximum transverse diameter of the chest?
What is the criteria for ensuring a satisfactory chest radiograph has no rotation?
What is the purpose of ascertaining that there are ten ribs visible posteriorly in the mid clavicular line on the frontal chest radiograph?
What is the effect of gravity on the pulmonary vascular structures?
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What is the name of the sign that describes the visibility of densities on a radiograph?
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What should be barely visible in an X-ray with good penetration?
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What is the orientation of the standard chest radiograph where the heart size is measured?
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How many densities are visible on any radiograph according to Benjamin Felson?
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What does the disappearance of a normal silhouette imply?
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What is the main reason to evaluate the lung apices?
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What is the simplest solution to diagnostic uncertainty in the lung apices?
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What is the commonest neck mass to displace the trachea?
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What does the trachea deviated to the contralateral side indicate?
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What is the hilar point on either side of the heart?
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What is the significance of the gastric air bubble on the left side?
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What is the purpose of reviewing the subdiaphragmatic region?
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What is the normal relationship between the left and right hilar points?
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What is the significance of the aorto-pulmonary window?
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Why is bone review important in chest radiographs?
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What is a feature of cardiac failure in chest radiographs?
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What is the principle used to diagnose lobar consolidation?
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Which of the following is not a feature of lobar consolidation?
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Which pulmonary lobe is associated with the left hemidiaphragm?
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What is the significance of the transverse or minor fissure?
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What is the characteristic of a pneumothorax on an erect radiograph?
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What is the characteristic of a pleural effusion on an erect radiograph?
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What is the characteristic of a right upper lobe consolidation?
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What is the characteristic of a right middle lobe consolidation?
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What is the characteristic of a left upper lobe consolidation?
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What is the characteristic of a tension pneumothorax?
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What is the indication of a horizontal fluid level within the chest?
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When should an expiratory view be requested?
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Study Notes
Normal Features of a Chest X-ray
- A satisfactory chest radiograph should have:
- No rotation, confirmed by ensuring the medial borders of the clavicle are equidistant from the spinous processes of the vertebral bodies.
- Good inspiration, confirmed by ascertaining that there are ten ribs visible posteriorly in the mid clavicular line on the frontal chest radiograph.
- Good penetration, where the vertebrae behind the heart are barely visible, and the diaphragm can be traced up until reaching the edge of the spine.
A System for Reviewing the Chest Radiograph
- Check for AP or PA orientation
- Evaluate the heart size:
- The maximum transverse diameter of the heart should not exceed 50% of the maximum transverse diameter of the chest on a standard posteroanterior (PA) radiograph.
- This measurement is known as the Cardiothoracic Ratio.
- Assess pulmonary vascularity:
- Pulmonary venous vessels should not be discretely visible in the outer third of the lung fields.
- Approximately 90% of the pulmonary vascular structures are appreciated at the mid and lower zones due to the effect of gravity.
- Review the lung fields:
- The Silhouette Sign: only three densities are visible on any radiograph (bone, air, and soft tissue).
- The diaphragm and heart borders are adjacent to lung lobes.
Review Areas
- Subdiaphragmatic region:
- No free gas should be present under the diaphragm on an erect chest radiograph.
- A gastric air bubble is frequently seen on the left side, while interposed small or large bowel may occasionally be seen on the right.
- The lung apices:
- Evaluating the lung apices can be difficult, particularly in older patients where there is asymmetrical calcification of the costochondral junctions.
- Request a supplementary apical view if there is diagnostic uncertainty or an asymmetry in the apical appearances.
- The trachea:
- The trachea should be midline, and any deviation may be due to pathology within the neck or chest.
- The hilum:
- The hilar point on either side of the heart represents the intersection of the pulmonary arteries and veins.
- The left hilar point normally lies higher than the right.
- The hila should always be equal in size and density.
- The aorto-pulmonary window:
- The reviewer should follow the left edge of the mediastinum from its superior aspect to identify the aortic knuckle and pulmonary artery.
- There should be no convexity or mass within the aorto-pulmonary window.
- Bones:
- Review bones for two reasons:
- Trauma: to exclude fractures or dislocations, particularly at shoulder level.
- Neoplasia: to exclude infiltration and destruction, particularly in metastatic disease and myeloma.
- Review bones for two reasons:
Common Pathologies
- Cardiac Failure:
- Increased cardiothoracic ratio
- Increased (venous) pulmonary vascularity
- Kerley B lines
- Pleural Effusions
- Bat or Angel Wings
- Lobar Consolidation:
- The confident and accurate diagnosis of lobar consolidation rests on an understanding of the Silhouette Sign.
- Identify the missing silhouette to determine which pulmonary lobe is affected.
- Pneumothorax:
- Divided into simple and tension pneumothorax.
- Tension pneumothorax is diagnosed radiologically when the mediastinum is displaced to the contralateral side and there is inferior displacement of the ipsilateral hemidiaphragm.
- Accompanying clinical distress is also present.
- Pleural Effusions:
- Typical appearances on an erect radiograph are those of an area of increased density with a meniscus rising up the lateral chest wall.
- A horizontal fluid level within the chest suggests a hydropneumothorax with air in the pleural space.
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Description
This quiz covers the normal features of a chest X-ray, including the positioning, inspiration, and penetration of the image. Understand the key characteristics of a satisfactory chest radiograph.