UPENN SCHOOL OF MEDICINE || CXR LEARNING WEB SITE

– developed by David G. Chu, MD –

Welcome! This website was created to help introduce medical students to chest radiology. One of the most difficult things to learn when first reading Chest X-Ray (CXR) films is what is “normal” and what is really “active disease.” This website aims to help students become comfortable with accepting artifacts of blood vessels as “normal,” with the hopes that students will then more easily identify “abnormal” signs of active disease.

We have assembled 100 “normal” Chest X-Rays that were given the Diagnosis of “No Active Disease” (NAD) at the Hospital of the University of Pennsylvania (HUP). By reading this series of Normal CXR, students will learn to appreciate the range of “normal” markings, the basics of CXR reading, and how patient age and sex influence differentials. Use the Navigation Bar to the right to either begin the Learning Module from the begining or jump to any case within the module.

Chest X-Ray Teaching Lessons:

• Introduction
• Anatomy
• Soft Tissues and Bone
• Black vs. White
• Infiltrates vs. Consolidation
• Differentials

Other Radiology Resources:

• Intro Chest Radiology Tutorial
• CXR Dx of Disease
• ICU Chest X-Ray Atlas
• Chest X-Ray Atlas
• Chest X-Ray Education (by finding)
• Chest X-Ray Education (by topic)
• CT Imaging
• CT Dx of Diffuse Lung Disease
• CT Lung Atlas
• Cardiothoracic Imaging
• Congenital Heart Disease
• Chest Radiology Journal Articles
• Chest Radiology/Pathology Practical (cases)
• STR Thoracic Imaging Syllabus (no images)
• Thoracic Imaging Disease Reference (no images)

About the Authors:

This website was created in 2005 by Dr. David G. Chu and Dr. Wallace Miller, Jr. at the University of Pennsylvania School of Medicine. We are especially grateful to Anthony Robertson and Alethea Pena of the University of Penn SOM Web Design Team for their expertise.

David G. Chu, MD

David G. Chu graduated from the University of California at San Diego in 1999 and graduated from the University of Pennsylvania School of Medicine in 2005. He is currently completing his internship at the Presbyterian Medical Center of UPHS and his residency in ophthalmology at the UC Davis Medical Center.

Wallace Miller, Jr, MD

Dr. Wally Miller, Jr. has been the recipient of numerous teaching awards at the University of Pennsylvania School of Medicine, and is dedicated to clinical, academic, and teaching excellence. He graduated from University of Pennsylvania School of Medicine and completed his residency in radiology at the Hospital of the Univ of Penn of UPHS.

Navigation

Launch the 100 Normal CXR Leaning Module

Click on the link above to launch the 100 Normal CXR learning module, and begin with Case 1.

Use the dropdown menu below to jump to a specific case within the module.

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Radiology Chest Xray Normal

It is important to know the normal chest radiograph and common landmarks so that you can recognize what is abnormal.  

Cardiac Silhouette

On an antero-posterior (AP) or postero-anterior (PA) view of the chest, the borders of the heart have common landmarks:

• Right Border:  Formed by the right atrium which is in between the SVC and IVC
• Left Border: Formed by the left ventricle & portion of the left auricle
• Anterior Surface or Sternocostal Surface:  Mainly the right ventricle (not seen on AP view)
• Inferior Border:  Combination of the right & left ventricles

Aortic Knob

The aortic knob should be visualized in the normal chest radiograph around the level of T3 to T4 or just lateral to the carina.  In patients with aortic aneurysm, this can be the area contributing to the “widened mediastinum”. 

Costocardiac & Costophrenic Angles

The costocardiac angles (as well as the costophrenic angles) should fairly sharp and well defined if the patient does not have significant effusions or pulmonary edema.  

• If they are blunted or lost, you should be concerned for the presence of fluid in the lung or a mass obstructing the view. Additional imaging with a chest CT may sometimes be warranted if the etiology is not clear from the patient’s presentation. 

Carina

The carina is the point or level at which the trachea divides into the right and left main bronchi.  This is usually midline with the spinous process being behind it.  The carina is also the location that is used by healthcare providers when assessing the proper position of an endotracheal tube (ET) after intubation.  Typically, the tip of the ET tube should be 3-4 centimeters above the carina so that both lungs are properly oxygenated.  

Clavicle

The head of the clavicle is attached to the lateral surface of the sternum. The location of the clavicular heads in relation to the trachea can help determine proper positioning of the patient at the time the chest radiograph was taken.  The two clavicular heads should be on either side of the trachea and with the spinous processes being in the middle.

Hemidiaphragms

The right hemidiaphragm normally sits slightly higher than the left due to the presence of the liver under the diaphragm which prevents the right hemidiaphragm from going down further with inspiration.  Important clinical pearls include:

• Each dome of the diaphragm is innervated by its own nerve supply from the phrenic nerve.  Therefore, damage to the nerves for one side will not affect the other. On chest radiograph you would see the the paralyzed hemidiaphragm as being higher than the other hemidiaphragm during inspiration (creating a paradoxical pattern of movement with respiration).
• You should also not see free air under the hemidiaphragm.  If free air is found you will see a black line under the hemidiaphragm which would be concerning for a bowel perforation. This requires emergent evaluation with a CT scan and surgical consult. Do not confuse the normal gastric bubble seem on many chest radiographs with free air.

Trachea

The trachea should sit midline and be in between the right and left clavicular heads.  Any deviation from the midline could suggest that the patient was either rotated at the time of the chest radiograph, the presence of a mediastinal mass, or presence of a tension pneumothorax.  

Other Related Anatomy

Click on the images below to see related anatomy:

             

Editors & Reviewers

Editors:

• Anthony J. Busti, MD, PharmD, FNLA, FAHA
• Dylan Kellogg, MD

Last Reviewed:  July 2015

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References

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• Terminologia anatomica: international anatomical terminology By the Federative Committee on Anatomical Terminology (FCAT). Stuttgart: George Thieme Verlag. ISBN-10: 3-13-114361-4. ISBN-13:978-3-13-114361-7
• Pocket Atlas of Human Anatomy: 5th edition – W. Dauber, Founded by Heinz Feneis
• Pocket Atlas of Radiographic Anatomy – Torsten B. Moeller, E. Reif – Thieme
• Cardiac silhouette findings and mediastinal lines and stripes: X-ray and computed tomography correlation- R. Marano et Al. – ECR 2009 – DOI : 10.1594/ecr2009/C-222
• Mediastinal lines, stripes and interfaces on PA chest radiograph with CT correlations – N. Bystrická, H. Poláková, J. Sykora; Bratislava/SK – poster C-0442 – ECR 2013 – DOI: 10.1594/ecr2013/C-0442
• La radiographie pulmonaire – TP de radioanat – IFMEM – Montpellier
• L’abdomen sans préparation – TP de radioanat – IFMEM – Montpellier

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Visibility of the mediastinal organs on a chest x-ray

When a chest x-ray is taken, the mediastinal organs, such as the heart and lungs, can be seen and evaluated in photographs. But for accurate diagnosis and assessment of the condition, other factors must be taken into account, such as the patient’s position and anatomy. Therefore, to obtain the most objective information, it is recommended to consult with a radiologist.

Chest x-ray is one of the main methods for diagnosing diseases of the mediastinal organs. On the x-ray, you can see the heart, lungs, bronchi and other elements of the chest cavity. But in order to get a high-quality picture, it is necessary to correctly perform the procedure and recognize those areas that are hidden behind the shadows of bones and tissues.

Knowledge of the anatomy of the mediastinum and its elements is essential in order to correctly interpret chest x-rays. There are many different methods and techniques that help identify diseases of the cardiovascular system, but the beginning of any study is a mandatory chest x-ray, on which all elements of the mediastinum are projected.

A properly performed x-ray can provide information about the size of the heart, its shape, the condition of the lungs, pleura, and other factors. It will be useful in diagnosing diseases of the heart and lungs, such as bronchitis, pneumonia, tumors, emphysema, and more.

Chest x-ray is a simple procedure that can help diagnose heart and lung disease, and rotational tomography can give a more accurate understanding of the location. But before you start the study, you need to prepare and consult with your doctor.

What is the mediastinum and what organs are in it?

The mediastinum is the space between the heart and chest, bounded by the lungs and chest wall. It contains various organs necessary for the functioning of the body.

One of the main organs of the mediastinum is the heart. It is located in the middle of the chest and provides blood circulation throughout the body. Near the heart are large vessels – the aorta, pulmonary artery and veins. They transport blood to and from the heart.

The mediastinum also contains the lungs, two organs that are used for respiration and gas exchange. They are located on the sides of the heart and occupy most of the mediastinum. Between the lungs and the heart are the trachea and bronchi – the organs of ventilation of the lungs, which ensure the flow of air into the lungs and its exit from them.

Also located in the mediastinum is the esophagus, the organ that supplies the stomach with food. The esophagus passes through the mediastinum, passing between the trachea and the spine.

Finally, in the mediastinum there are also lymph nodes and glands that protect the body from infections and diseases.

Which x-ray projections are used to visualize the mediastinum?

Various projections are used to visualize the mediastinal organs on a chest x-ray. Depending on which organ needs to be studied, the appropriate projection is selected.

One of the most common projections is the direct lateral (lateral) projection. It allows you to study the state of the lungs, heart and blood vessels located in the mediastinum. In this projection, the lungs are represented in the form of blackouts, the heart is in the form of a base and apex, and the vessels are in the form of silhouettes.

To study the upper and lower cavities of the mediastinum, the projection of the upper and lower cavities is used, respectively. They allow you to see the boundaries of organs located at different levels of the mediastinum.

• The projection of the upper cavity shows the boundaries of the large vascular trunk, trachea, esophagus, thyroid gland.
• The projection of the lower cavity allows you to see the diaphragm, aorta, abdominal cavity.

Special views can also be used to view certain mediastinal organs, such as the oblique view to view the esophagus, or the right mediastinal view to view the right pulmonary artery and right heart.

How to properly prepare for an x-ray examination of the mediastinum?

The preparation for a mediastinal X-ray begins long before the examination. Be sure to tell your radiologist if you are taking any medications or have a chronic condition.

On the eve of the examination, it is important to follow a special diet. The amount of gases in the intestines can distort the results of the study, so it is necessary to exclude vegetables, fruits, fatty and heavy foods. Instead, light meals, liquids, and lean meats can be consumed.

All metal jewelery and clothing must be removed before the mediastinal x-ray. They may interfere with clear and accurate pictures.

Follow the instructions of the radiologist during the X-ray examination. He may ask you to hold a certain position, take a deep breath and hold your breath for a few seconds, or repeat the examination in a different position.

It is important to understand that the mediastinal x-ray is a safe and non-invasive diagnostic tool. It helps to identify various pathologies of the mediastinal organs and determine their exact position on the patient’s body.

Which diseases of the mediastinal organs can be detected on a chest x-ray?

Acute pneumonia. X-ray shows an intense shadow band in the lung tissue, more pronounced than usual. Perhaps also the appearance of a local hypersthenic reaction, a cortical mirror sign. These signs indicate damage to the lung tissue caused by pneumonia;

Bronchitis. With bronchitis, special changes may appear in the lungs – blocks of the pulmonary roots, uneven air filling and the formation of emphysema. Additional research methods are used to determine the location of the lesion. X-ray is one of the first and simplest ways to determine bronchitis.

Acute bronchiolitis. With bronchiolitis, the patient develops cough, shortness of breath, a vital disease that requires timely diagnosis and treatment. For diagnosis, an x-ray is used, which can detect a block of lung roots, uneven air filling and developing emphysema.

Pulmonary embolism. An x-ray can detect a pulmonary embolism, which is a blockage in the arteries of the lungs. On the lung x-ray, you can see a decrease in contrast, because not enough oxygen is supplied to the lung tissue.

Heart failure. An x-ray can detect heart failure when the heart is enlarged causing deformity of the lung tissue. In addition, there are violations of the hydrodynamics of blood circulation and additional research and treatment is necessary.

What is mediastinal enlargement and how can it be determined on an x-ray?

In medical terms, the mediastinum is the area of ​​the chest where the organs of the cardiovascular system, lungs, trachea and esophagus are located. The enlargement of the mediastinum means that the size of the organs in this area exceeds the norm.

Mediastinal enlargement can be determined by taking a chest x-ray. X-ray images show in detail the morphology of the organs and their location. On x-rays, an enlarged mediastinum can be determined visually by comparing the size of the heart and blood vessels with standard values.

In addition, x-rays can assess the symmetry of the mediastinum, identify possible anomalies in the esophagus and trachea, and detect the presence of fluid or air in the pleural cavity.

However, it is not always possible to see mediastinal enlargement on x-ray, as identification can be difficult due to opacification of the lungs, which reduces image clarity. In such cases, other methods for detecting pathologies in the chest are used.

If mediastinal enlargement is detected, it is necessary to consult a doctor who will confirm or refute the diagnosis, prescribe additional studies and choose the optimal treatment.

What changes in the mediastinum may indicate heart disease?

Heart enlargement is the most common sign of heart disease that can be detected on a chest x-ray. An enlarged heart means that the heart has grown in size and is often the result of chronic heart disease.

Another sign of heart disease that shows up on an x-ray is fluid in the lungs . Heart failure can lead to fluid retention in the lungs, which can lead to pressure on the lungs and inflammation. X-rays can show the effect of this fluid in the form of a thickening in the lung field.

The development of cardiomegaly is another sign of heart disease that can be seen on x-rays. Cardiomegaly means an enlarged heart and can be caused not only by heart disease, but also by other causes such as hypertension or aortic stenosis. This is often revealed on x-rays through an increase in the serration of the borders of the heart.

• Therefore, x-rays are an important test that can help detect heart disease;
• Enlargement of the heart, fluid in the lungs, and cardiomegaly are signs of heart disease that can be seen on x-ray;
• Regular medical examinations and x-rays of the heart can be helpful in identifying early stages of heart disease and treating it.

What do shadows in the mediastinum mean on a chest x-ray?

When a doctor orders a chest x-ray, he or she may see shadows in the mediastinum. What does this mean?

The mediastinum is the area between the two lungs in the chest that contains the heart, trachea and other organs. An x-ray may show shadows in this area, which can sometimes be indicative of abnormalities.

One of the most common cases where shadows can be seen in the mediastinum is when the heart is enlarged. In this case, the heart, enlarged due to diseases, takes up more space than usual, and therefore an increase in the shadow in the mediastinum is visible on the x-ray.

However, not all shadows in the mediastinum indicate serious diseases, and only a doctor can determine their cause. To do this, he may prescribe additional studies, such as ultrasound, CT or MRI.

If you notice shadows in the mediastinum on an x-ray, be sure to consult your doctor. Only he can give an accurate diagnosis and prescribe the necessary treatment.

Which lung diseases can be detected on mediastinal X-ray?

X-ray examination of the mediastinum can reveal a variety of lung diseases, such as:

• Pneumonia – inflammation of the lungs, which appears on the radiograph as dark spots on a light background of lung tissue.
• Tuberculosis is an infection of the lungs with a bacterium that can also appear as dark spots and nodules in the lungs on x-rays.
• Lung cancer is a malignant neoplasm that can be seen on x-ray as tumors, nodules, or solid shadows in the lungs.
• Emphysema is a disease in which lung tissue is destroyed, resulting in a decrease in its volume. On x-ray, this is manifested by an increase in the transparency of the lungs.

In addition, x-rays of the mediastinum can show fluid in the pleural cavity (pleurisy), air in the chest cavity (pneumothorax), and other diseases associated with the lungs and mediastinum.

What additional examination methods can be used to detect mediastinal diseases on X-ray?

In addition to a chest X-ray to check for mediastinal disorders, doctors may use other tests.

Computed tomography is an internal imaging technique that uses X-rays to create a three-dimensional image. Unlike conventional x-rays, computed tomography allows you to more accurately determine the size and shape of tumors, as well as identify abnormalities in the functioning of the cardiovascular system.

Magnetic resonance imaging is an imaging technique that uses strong magnetic fields and radio waves to produce detailed images of internal organs. MRI allows you to more clearly determine the presence of tumors and determine the degree of damage to the cardiovascular system.

Echocardiography is a cardiac imaging technique that uses ultrasound waves to produce images of the heart and blood vessels. This method allows you to determine the presence of violations in the work of the heart muscle, valves and blood vessels.

The choice of examination method depends on the specific situation and can only be determined by a cardiologist.

What complications can result from a mediastinal x-ray?

The X-ray examination of the mediastinum is one of the most effective methods for diagnosing diseases of the heart and lungs, however, like any other medical examination, it can be accompanied by the risk of various complications. Below we consider the main complications of mediastinal X-ray examination:

1. Changes in the patient’s health

During an X-ray examination, a sudden deterioration in the patient’s health may occur. This may be due to various factors, such as an allergic reaction to an injection of contrast agent or a general malaise in the area being treated.

In some cases, patients may feel unwell for several days after the procedure. This can manifest as headache, nausea, dizziness, or fever. In such cases, it is necessary to consult a doctor for advice and prescribe appropriate treatment.

2. Exposure to x-rays

X-ray examination of the mediastinum involves the use of x-rays, which can have a negative effect on the body. When receiving high doses of radiation, damage to tissues and organs can occur, which in turn can lead to various complications.

In most cases, the risk of exposure to X-rays is small, but people who are frequently exposed to X-rays may experience the effects of radiation in the form of serious diseases such as cancer.

3. Allergic reaction to a contrast agent

In some cases, for an x-ray examination of the mediastinum, it may be necessary to inject a contrast agent into the patient’s body. This can cause an allergic reaction in some patients, which can manifest as skin rashes, itching, redness of the skin and swelling.

In some cases, an allergic reaction may be severe and the patient may require immediate medical attention. Therefore, before an X-ray examination, it is necessary to warn the doctor about possible allergic reactions.

What restrictions should be considered after mediastinal x-ray?

After an x-ray examination of the mediastinum, certain restrictions must be observed to avoid undesirable consequences:

• X-rays should not be taken too often. Consecutive images may result in an overdose of radiation, which may adversely affect health.
• Food and liquids should be avoided before x-rays are taken. Otherwise, food and liquid may interfere with clear images.
• After an x-ray examination, you must remain still for a while. This will avoid unexpected movements and injury to internal organs.
• Physical activity should be avoided for at least a few hours after the X-ray examination. Physical exercise can lead to high blood pressure, which may be contraindicated in a mediastinal context.
• If you are taking medication, you should seek medical advice before having an x-ray. Some medicines can interact with radiation and cause unwanted effects.

Compliance with these restrictions will allow you to quickly conduct an x-ray examination of the mediastinum, without harm to the patient’s health.

What are the contraindications for X-ray examination of the mediastinum?

Pregnancy and breastfeeding

X-ray examination of the mediastinum is not recommended for women during pregnancy and breastfeeding. Ionizing radiation can damage the DNA of cells, which can lead to mutations and developmental disorders in the fetus. In addition, radiation exposure can lead to the formation of oncological diseases in a child, so an X-ray examination should only be ordered if absolutely necessary.

Allergy to a radiopaque agent

X-rays may use a radiopaque agent that allows you to see the fine structures of the heart and blood vessels on an x-ray. However, some people may have an allergic reaction to this substance, which can lead to severe swelling, itching, hives, and even anaphylactic shock. In this case, an x-ray examination may be dangerous to the health of the patient, and its implementation is not recommended.

Kidney and thyroid problems

For x-rays, a radiopaque contrast agent may be administered intravenously, which is removed from the body through the genitourinary system. Therefore, in patients with impaired renal function, there may be a problem with the excretion of this substance, which can lead to increased levels of toxicity and tissue damage. Also, an x-ray examination may be contraindicated in case of abnormal thyroid function, due to the need to use a radiopaque substance, which can increase the level of iodine in the patient’s body.

How to correctly interpret the results of an x-ray examination of the mediastinum?

X-ray examination of the mediastinum is one of the important methods for diagnosing diseases of the chest organs. However, the results of such a study can be difficult to interpret without knowing the underlying principles.

The first thing to do when interpreting an x-ray of the mediastinum is to evaluate the size of the organs: the heart, lungs, bronchi, and large vessels. For this, measurements are used, which are carried out along special lines in the image.

In addition to size, it is important to pay attention to the shape and position of organs, as well as signs of disease, such as tumors or inflammatory changes.

For ease of interpretation of the results, it is recommended to compare x-rays with previous or x-rays taken at different times.

It is also important to consider the patient’s age and gender, as well as their medical history and respiratory and cardiovascular problems.

In general, the interpretation of the results of a mediastinal x-ray requires some knowledge and experience, so it is recommended to consult a professional radiologist.

How can I reduce my exposure to radiation during a mediastinal x-ray?

X-ray examination is an important diagnostic method and allows visualization of the mediastinal organs. However, during the examination, some damage may be done to the patient due to exposure to radiation.

In order to reduce exposure to radiation, it is necessary to choose the optimal method of examination. There are alternative diagnostic methods that may be less harmful to the body, such as magnetic resonance imaging (MRI) or ultrasound. If an X-ray examination is necessary, then the doctor should prescribe the lowest possible dose of radiation.

In addition, there are several methods that can help reduce the effects of radiation on mediastinal x-rays. One such method is the use of lead shields. They can reduce the amount of radiation reaching the area of ​​​​high-density tissue that is not of interest to us, for example, testicles, head. This may be important in the study of men and children.

In addition, all instructions of the medical staff must be followed during the examination. The patient must be at a certain distance from the x-ray source, hold his breath during the x-ray and not move during the study. It is also important to inform the doctor about the state of health so that he can set up the equipment and choose the best research method.

What preventive measures can help reduce the risk of mediastinal disease?

Maintain a healthy lifestyle. Limit your alcohol and nicotine intake, watch your body weight, exercise and eat right.

Get regular medical check-ups. It is recommended to undergo examinations by a cardiologist and a polyclinic at least once a year.

Monitor your air quality. Avoid contaminated places, the antidote is not only for the lungs, but also for the heart and blood vessels.

Maintain normal blood pressure levels. If you have high blood pressure, you need to monitor its performance and take steps to reduce it.

Avoid stressful situations. Stress can put a lot of strain on the cardiovascular system, so some relaxation measures such as meditation or yoga should be taken.

Monitor your blood cholesterol levels. High cholesterol levels can lead to a variety of heart conditions, so if you’ve been diagnosed with elevated levels, always keep an eye on your levels.

Take the necessary measures to prevent disease. Take vitamins, minerals, and other medications periodically to keep your heart and blood vessels healthy.

Avoid bad habits. It is clear that smoking, alcohol and other bad habits have a strong negative impact on the health of the mediastinal organs. Therefore, the first step to maintaining your health is to avoid them.

Do not self-medicate. In case of any ailment, it is best to consult a doctor, rather than trying to identify the cause and treat the symptoms yourself. The doctor will be able to make the correct diagnosis and prescribe the necessary treatment.

Manage your diabetes if you have one. Diabetes is one of the main risk factors for heart and vascular diseases, so it is important to monitor its indicators and follow control measures.

How often should an X-ray examination of the mediastinum be performed to prevent and detect diseases?

X-ray examination of the mediastinum is an important method for diagnosing diseases of the chest organs such as the lungs, heart, blood vessels and diaphragm. However, like any other medical method, x-rays should not be taken too often or unnecessarily.

On average, a chest x-ray is recommended once a year if the patient is asymptomatic. However, if there are any complaints or the risk of developing the disease, the doctor may recommend an X-ray examination more often.

It is important to understand that an X-ray examination is a radiation procedure and can adversely affect the patient’s health if taken too frequently. Therefore, if the patient has alternative diagnostic methods such as ultrasound or MRI, then these may be preferable.

In general, it is recommended that you discuss the need for a mediastinal x-ray with your doctor and decide how often to do it based on individual patient factors and risks.