Chest X-rays

ANUSUYA R.
RADIOGRAHER,
DEPARTMENT OF RADIOLOGY,
MMCH & RI
 Relative Densities
The images seen on a chest radiograph result from the differences in
densities of the materials in the body.

The hierarchy of relative densities from least dense (dark on the radiograph)
to most dense (light on the radiograph) include:
• Gas (air in the lungs)
• Fat (fat layer in soft tissue)
• Water (same density as heart and blood vessels)
• Bone (the most dense of the tissues)
• Metal (foreign bodies)
 Three Main Factors Determine the Technical
Quality of the Radiograph
• Inspiration

• Penetration

• Rotation
 Inspiration
The chest radiograph should be obtained
with the patient in full inspiration to help
assess intrapulmonary abnormalities.

At full inspiration, the diaphragm should

be observed at about the level of the 8th to
10th rib posteriorly, or the 5th to 6th rib
anteriorly.
 Penetration
On a properly exposed chest radiograph:

• The lower thoracic vertebrae should be

visible through the heart

• The bronchovascular structures behind

the heart (trachea, aortic arch, pulmonary
arteries, etc.) should be seen
 Underexposure
In an underexposed chest radiograph, the
cardiac shadow is opaque, with little or no
visibility of the thoracic vertebrae.

The lungs may appear much denser and

whiter, much as they might appear with
infiltrates present.
 Overexposure
With greater exposure of the chest
radiograph, the heart becomes more
radiolucent and the lungs become
proportionately darker.

In an overexposed chest radiograph, the air-

filled lung periphery becomes extremely
radiolucent, and often gives the appearance
of lacking lung tissue, as would be seen in a
condition such as emphysema.
 Rotation
Patient rotation can be assessed by observing the clavicular
heads and determining whether they are equal distance from
the spinous processes of the thoracic vertebral bodies.
 Anatomical Structures in the Chest
• Mediastinum
• Hilum
• Lung Fields
• Diaphragmatic Domes
• Pleural Surfaces
• Bones
• Soft Tissue
 Mediastinum
• The trachea should be centrally
located or slightly to the right
• The aortic arch is the first convexity
on the left side of the mediastinum
• The pulmonary artery is the next
convexity on the left, and the
branches should be traceable as it
fans out through the lungs
• The lateral margin of the superior
vena cava lies above the right heart
border
 The Heart
• Two-thirds of the heart should lie on the left side
of the chest, with one-third on the right

• The heart should take up less that half of the

thoracic cavity (C/T ratio < 50%)

• The left atrium and the left ventricle create the left
heart border

• The right heart border is created entirely by the

right atrium (the right ventricle lies anteriorly
and, therefore, does not have a border on the PA)
 Hilum
• The hila consist primarily of the
major bronchi and the
pulmonary veins and arteries
• The hila are not symmetrical, but
contain the same basic structures
on each side
• The hila may be at the same level,
but the left hilum is commonly
higher than the right
• Both hila should be of similar size
and density
 Lungs
• Normally, there are visible markings
throughout the lungs due to the
pulmonary arteries and veins,
continuing all the way to the chest
wall
• Both lungs should be scanned,
starting at the apices and working
downward, comparing the left and
right lung fields at the same level
 Diaphragm

• The left dome is normally slightly lower

than the right due to elevation by the liver,
located under the right hemidiaphragm.
• The costophrenic recesses are formed by the
hemidiaphragms and the chest wall.
• On the radiograph, the costophrenic recess
is seen on each side where an angle is
formed by the lateral chest wall and the
dome of each hemidiaphragm (costophrenic
angle).
 Pleura
• The pleura and pleural spaces will
only be visible when there is an
abnormality present

• Common abnormalities seen with

the pleura include pleural
thickening, or fluid or air in the
pleural space.
 Soft Tissue
Thick soft tissue may obscure underlying
structures:
• Thick soft tissue due to obesity may
obscure some underlying structures such
as lung markings
• Breast tissue may obscure the
costophrenic angles
 Bones
The bones visible in the chest radiograph include:
• Ribs
• Clavicles
• Scapulae
• Vertebrae
• Proximal humerus

The bones are useful as markers to assess patient rotation, adequacy of

inspiration, and x-ray penetration.
 Postero anterior view
Positioning
• Patient positioned facing the cassette,
with the chin extended and centered
to the middle of the top of the
cassette
• The mid sagittal plane should be
perpendicular to the middle of the
cassette
• The dorsal aspect of the hands
should be placed behind and below
the hips, with the elbows brought
forward
 Postero anterior view
Centering
• The horizontal center beam is
directed at right angles to the
cassette at the level of eight thoracic
vertebra (spinous process of T7)
• The surface marking of T7 spinous
process can be assessed by using
the inferior angle of scapula before
the shoulders are pushed forward
• Exposure is made in full normal
arrested inspiration
 Antero-posterior erect
Positioning
• The patient may be standing or sitting with
their back against the cassette, which is
supported vertically with the upper edge
above the apices
• The median sagittal plane is adjusted at the
right angles to the mid line of the cassette
• The shoulders are brought forward
• So the scapula will not over lap the lung field
• In unwell patients it may not possible to
perform so the patients arm is rotated
laterally and the palm facing forward
 Antero-posterior erect
Direction and centering
• The horizontal central ray is directed at
right angles to the cassette and towards
the sternal notch
• The central ray is then angled until it
coincident with the middle of the
cassette, thus avoiding unnecessary
exposure to eyes
• The exposure is taken in full inspiration
 Antero-posterior supine
Positioning
• Cassette should carefully positioned
under the patients chest and the upper
end of the cassette should be placed one
inch above the shoulder joint
• The median sagittal plane is adjusted at
the right angles to the mid line of the
cassette
• The arms are rotated laterally and
supported by the side
 Antero-posterior supine
Centering
• The horizontal central ray is directed
at right angles to the cassette and
towards the sternal notch

• The central ray is then angled until it

coincident with the middle of the
cassette, thus avoiding unnecessary
exposure to eyes
 Lateral
• Lateral projections are usefull in certain clinical
circumstances for localizing the lesion and demonstrating the
anterior mediastinal masses
• FFD is 150cms
 Lateral
Positioning
• The patient is changed to bring the side
under investigation in contact with the
cassette
• The median sagittal lane is adjusted parallel
to the cassette
• The arms are raised or folded above the heads
• The upper border of the cassette is placed one
inch above the cassette and the central ray is
directed to the center of the cassette
 Lateral
Centering
• The horizontal central ray is directed at right angles to the
middle of the cassette
 Apices
Positioning and centering
• It is the modification of PA view

• With the patient in the PA projection the

central ray is angled 30º caudally
towards the seventh cervical spinous
process coincident with the sternal angle

• With the patient in the AP projection the

central ray is angled 30º cephalad
towards the sternal angle
 Apices
Antero-posterior 30 degrees cephalad Antero-posterior: coronal plane 15 degrees,
central ray 15 degrees cephalad
 Lordotic
This technique is used to demonstrate the right middle lobe-
collapse or an inter lobar pleural effusion
The patient is positioned to bring the middle-lobe fissure
horizontal
 Lordotic

Positioning
• The patient is positioned for PA Projection

• Then by holding the sides of the vertical Bucky

, the patient bends backwards at the waist

• The degree of dorsiflexion is about 30-40º

 Lordotic
Centering
• The horizontal ray is directed at right-angles to the cassette and
towards the middle of the cassette
 Right anterior oblique
• This projection is used to separate the heart, aorta and the
vertebral column, thus enabling the path of the ascending
aorta, aortic arch and descending aorta

• FFD is 150cms
 Right anterior oblique
Positioning
• The patient is initially positioned facing the cassette, which is supported vertically
on the cassette holder
• The right side of the trunk is kept in contact with the cassette, the patient is
rotated to bring the left side away from the cassette , so that the coronal plane
forms the angle of 60 degrees to the cassette
 Right anterior oblique

Centering
• Central ray is directed at the level of T6 vertebra
 Essential image characteristics
• Full lung field with scapula projected laterally away from the lung
fields
• The clavicles symmetrical and equidistant from the spinous processes
• The lungs should be inflated
• The costropheric angles and the diaphragm outlined clearly
• The mediastinum and heart are defined sharply
• The fine demarcation of lung tissues shown from the hilum to the
periphery