CXR & Lung fx

Interpretation

HPT workshop
 TABLE OF CONTENTS

CXR Lung Fx
Approach + Examples
01 Indications + Interpretation
02

Cases Cases
CXR easily missed
03 Lung Fx
04
CXR
Approach
AP view
Tips of ID of AP film

- Scapula spine within thorax

- Clavicle more oblique
- No fundic bubble
- C7-T1 Rectangular sign

Interpretation

- Projected Cardiomegaly concern

- Majority inpatient view
PA View
Tips of ID of PA film

- Hanging Scapula Spine intersect clavicle

- Clavicle more horizontal
- Usually standing - fundic bubble below
diaphragm
- C7-T1 Arrowhead sign

Interpretation

- Good for detection of air under diaphragm

- No projected cardiomegaly concern
Approach to CXR - ABCDEFG
A - Adequacy ;
Airways ; ALL LINES
B- Bone & soft tissue
C- Cardiac shadow
D- Diaphragm
E - Edges/ Effusion
F- Fissures
G - Great Vessels
H - Hilum +
mediastinum
Lateral CXR
1. Retrosternal clear space
2. Hilar region
3. Fissures
4. Thoracic spine
5. Diaphragm and posterior
costophrenic sulci
Normal Lateral Film Clear Space
Adequacy - penetration

Overpenetration -no thoracic spine Under-penetration -no ribs

 At least 9 -10 posterior ribs should be seen

Inspiration effort
Rotation
A- Airways
Airways
Steeple Sign
Airway Hyperlucency
Airway- Hyperlucency
Heavy Smoker
Heavy Smoker
PTX - Convex to chest
wall
Bullae - Concave to
chest wall
Key - Compare with OLD
FILM
Asymptomatic
Landsberg, J. (2018).
Clinical practice
manual for pulmonary
and critical care
medicine (1st ed.).
Elsevier.
Pathological Reticulation vs nodules
- Distal ⅓ lung should be devoid of lung
lines
- Dense
- atelectasis ( with bronchogram )
- pneumonia ( vague borders )
- mass ( well circumscribed with volume
loss )
- Ground glass - partially alveolar filling ( TB/
MOTT)
- Fine reticular lines - interstitial edema
- Coarse reticular line - large lattice like
pattern like fibrosis ( honeycombing -> UIP/
LCH / Sarcoidosis )
- Veil - homogenous increased in attenuation
Miliary Nodules
< 3cm = Nodules
> 3cm = Mass
Diffuse pulmonary nodules
Differentials - Mnemonic

TEMPeST

- TB
- Eosinophilic granuloma
- Metastasis ( usually larger)/
Microlithiasis
- Pneumoconiosis
- Sarcoidosis
Microliathiasis
B- Bone
Bone
C- Cardiac
 Cardiac borders

Bulge Sign

Water-flask sign
RETRO-Cardiac
D- Diaphragm vs pathological
D-Diaphragm
Deep Sulcus Sign
 Diaphragm

Landsberg, J. (2018).
Clinical practice
manual for pulmonary
and critical care
medicine (1st ed.).
Elsevier.
Reference - https://slideplayer.com/slide/3898061/

Subpulmonic effusion
Borders
Borders
Recessive skin folds compression

Normal lung marking beyond

tracing ( can invert brightness of
CXR to see )

RARELY to lung apex

In Doubt ?

- CXR upright or lateral with

pathological side up
- Plain CT Thorax
- USG - for lung slide vs lung
point
Borders
Borders
 F- Fissures

Lung Collapse
supportive signs :

- Crowding of ribs
- Tracheal deviation
- Tenting of
diaphragm
- Hilum/ fissure
displacement
- Spine sign
whitening
Fissures
Fissure
Right apical segment of lower lobe
LUL collapse

Luftsichel sign = around

aortic knob
 LUL+lingular collapse

Landsberg, J.
(2018). Clinical
practice manual for
pulmonary and
critical care
medicine (1st ed.).
Elsevier.
 RUL collapse

Landsberg, J.
(2018). Clinical
practice manual
for pulmonary
and critical care
medicine (1st
ed.). Elsevier.
RML Collapse
RLL Collapse
LLL collapse
Consolidation

< 3cm = Nodules COVID -

> 3cm = Mass reversed
Bat-wing
Fissures
Azygous lobe
Asymptomatic

Valsalva/ inspiration / supine

increase vein size

Recurrent hemoptysis can

occurs as consequence of
aneurysmal dilation/ PE
formation

Ca in Azygous lobe =>

regional LN -ve for
malignancy
G-Great Vessels
H- Hilum & Mediastinum
 Pneumomediastinum signs
1) Subcutaneous
emphysema
2) Thymic sail sign (
Pediatric)
3) Pneumopericardium
ring around the artery
sign
4) Tubular artery sign
5) Double bronchial wall
sign
6) Continuous
diaphragm sign
7) Extrapleural sign air in
the pulmonary
ligament
8) Haystack sign
 1) Substernal
air
2) Continuous
hemi-
diaphragm
sign
3) Ring-around
-the-artery
sign,
4) Halo sign
around heart

Double bronchial wall sign

Hilar calcification
Mediastinum
Mediastinum - remember LATERAL
Anterior - Terrible 4
Thymic mass ; Thyroid ; (Testicular tumor ) Germ
cell Tumor ; Terrible Lymphoma

Middle - Lymph Node ; Cystic Tumor ; Aneurysm ;

Esophageal Tumor

Posterior - Neurogenic ; Meningocele ; Thoracic

Spine Lesion
Iatrogenic
 Kalisz, K. (2017, August 1). Radiological evaluation of tubes, lines, drains, and other
devices ... Radiographic Assessment of Tubes, Lines, Drains, and Other Devices -

ALL-LINES
Normal Placement, Positioning Errors, Complications, and Indications for Radiological
Evaluation. Retrieved October 16, 2022, from
https://www.uhhospitals.org/-/media/Files/Medical-Education/im-radiology-lines-and-tub
es-kevin-kalisz.pdf?la=en&hash=C4D108DD80921CD9A81E60ACFFFE782CD3900FA
7
 Kalisz, K. (2017, August 1). Radiological evaluation of tubes, lines, drains, and other
devices ... Radiographic Assessment of Tubes, Lines, Drains, and Other Devices -
Normal Placement, Positioning Errors, Complications, and Indications for Radiological
Evaluation. Retrieved October 16, 2022, from
https://www.uhhospitals.org/-/media/Files/Medical-Education/im-radiology-lines-and-tub

ALL lines - ETT Placement

es-kevin-kalisz.pdf?la=en&hash=C4D108DD80921CD9A81E60ACFFFE782CD3900FA
7
 Kalisz, K. (2017, August 1). Radiological evaluation of tubes, lines, drains, and other devices ... Radiographic

ALL lines - ETT placement

Assessment of Tubes, Lines, Drains, and Other Devices - Normal Placement, Positioning Errors,
Complications, and Indications for Radiological Evaluation. Retrieved October 16, 2022, from
https://www.uhhospitals.org/-/media/Files/Medical-Education/im-radiology-lines-and-tubes-kevin-kalisz.pdf?la=
en&hash=C4D108DD80921CD9A81E60ACFFFE782CD3900FA7
ALL lines - ETT placement

Kalisz, K. (2017, August 1). Radiological evaluation of tubes, lines, drains, and other devices ... Radiographic Assessment of Tubes, Lines, Drains, and Other Devices - Normal Placement, Positioning Errors,
Complications, and Indications for Radiological Evaluation. Retrieved October 16, 2022, from
https://www.uhhospitals.org/-/media/Files/Medical-Education/im-radiology-lines-and-tubes-kevin-kalisz.pdf?la=en&hash=C4D108DD80921CD9A81E60ACFFFE782CD3900FA7
 Reference : 2022 Core IM, LLC

ETT Correct placement

Aim ETT at least 2cm above carina ( aim 3- 5 cm
above carina when neck in neutral position ) or below
medial heads of clavicle

Aim @ aortic arch level / T3 vertebra

Correct placement dependent on neck flexion &

extension

- Flexion ( mandible @ T1-2) then ETT can

DESCEND 2cm
- Extension ( mandible @ C4 ) then ETT can
ascend up to 2 cm

Tracheal cuff should fill tracheal wall NOT bulge

ALL lines- Tracheostomy
tube
Similar to ETT
Placement should be 3-5
cm above carina &
between medial heads of
clavicle
NO change in positioning
of ETT with head flexion
/extension

Kalisz, K. (2017, August 1). Radiological evaluation of tubes, lines, drains, and other devices ... Radiographic Assessment of Tubes, Lines, Drains, and Other Devices - Normal Placement, Positioning Errors,
Complications, and Indications for Radiological Evaluation. Retrieved October 16, 2022, from
https://www.uhhospitals.org/-/media/Files/Medical-Education/im-radiology-lines-and-tubes-kevin-kalisz.pdf?la=en&hash=C4D108DD80921CD9A81E60ACFFFE782CD3900FA7
ALL- lines
Tracheostomy
tube complication

Kalisz, K. (2017, August 1). Radiological evaluation of tubes, lines, drains, and other devices ... Radiographic Assessment of Tubes, Lines, Drains, and Other Devices - Normal Placement, Positioning Errors,
Complications, and Indications for Radiological Evaluation. Retrieved October 16, 2022, from
https://www.uhhospitals.org/-/media/Files/Medical-Education/im-radiology-lines-and-tubes-kevin-kalisz.pdf?la=en&hash=C4D108DD80921CD9A81E60ACFFFE782CD3900FA7
 Credits to 13th Oct Postgraduate Meeting
ALL- LINES- axillary/CVC Dr Jason Ng’s presentation
Correct Placement of lines
Placement should be
along brachiocephalic
vein at 1st anterior ICS
Proximal to cavo-atrial
opening -
approximately at
inferior border of right
bronchus intermedia (
in view risk of
arrhythmia)

Kalisz, K. (2017, August 1). Radiological evaluation of tubes, lines, drains, and other devices ... Radiographic Assessment of Tubes, Lines, Drains, and Other Devices - Normal Placement, Positioning Errors,
Complications, and Indications for Radiological Evaluation. Retrieved October 16, 2022, from
https://www.uhhospitals.org/-/media/Files/Medical-Education/im-radiology-lines-and-tubes-kevin-kalisz.pdf?la=en&hash=C4D108DD80921CD9A81E60ACFFFE782CD3900FA7
ALL - lines CVC line

Kalisz, K. (2017, August 1). Radiological evaluation of tubes, lines, drains, and other devices ... Radiographic Assessment of Tubes, Lines, Drains, and Other Devices - Normal Placement, Positioning Errors,
Complications, and Indications for Radiological Evaluation. Retrieved October 16, 2022, from
https://www.uhhospitals.org/-/media/Files/Medical-Education/im-radiology-lines-and-tubes-kevin-kalisz.pdf?la=en&hash=C4D108DD80921CD9A81E60ACFFFE782CD3900FA7
ALL lines- CVC

Kalisz, K. (2017, August 1). Radiological evaluation of tubes, lines, drains, and other devices ... Radiographic Assessment of Tubes, Lines, Drains, and Other Devices - Normal Placement, Positioning Errors,
Complications, and Indications for Radiological Evaluation. Retrieved October 16, 2022, from
https://www.uhhospitals.org/-/media/Files/Medical-Education/im-radiology-lines-and-tubes-kevin-kalisz.pdf?la=en&hash=C4D108DD80921CD9A81E60ACFFFE782CD3900FA7
ALL lines - PICC

Kalisz, K. (2017, August 1). Radiological evaluation of tubes, lines, drains, and other devices ... Radiographic Assessment of Tubes, Lines, Drains, and Other Devices - Normal Placement, Positioning Errors,
Complications, and Indications for Radiological Evaluation. Retrieved October 16, 2022, from
https://www.uhhospitals.org/-/media/Files/Medical-Education/im-radiology-lines-and-tubes-kevin-kalisz.pdf?la=en&hash=C4D108DD80921CD9A81E60ACFFFE782CD3900FA7
Lung Function Test
Indication
Diagnostic

- Cough/ Dyspnea evaluation

- Polycythaemia
- Screen perioperative risk
- Prognosis ( BODE index of COPD )
- Guidance of Treatment ( COPD GOLD guideline; Lung transplant listing
/ referral for ILD etc)

Monitoring

- Effectiveness of anti-inflammatory meds/ anti-fibrotic on autoimmune

related ILD/ IPAF
- Occupational disease progression monitoring
- Drug toxicity ( Amiodarone; Immunotherapy; Chemotherapy )
- Occupational fitness
- Rehabilitation monitoring
 Pulmonary Function

Flow-Volume loop - Level of

obstruction/ Restrictive disorder
Spirometry = Obstructive - FEV1
Lung volume = Restrictive - TLC
DLCO = Pulmonary Vascular disease &
ILD screening
Contraindication
Absolute - Recent illness
NOT recommended within
4 /52

- MI/ HF/ PE
- Eye/ Intracranial
- Sinus or ear
- Intrathoracic or
abdominal surgery
- > 28th week gestation
- TB / COVID

Relative - Pain /
Demented/ Poorly
controlled HT
Graham BL, et al. Am J Resp Crit Care Med 2019; 200(8):
e70-e88
Preparation prior lung function test
Activities to avoid :

1) Smoking / Vaping
1 hr prior
2) Exercise 1 hr prior
3) Restrictive clothes
4) Sedatives /
intoxicant /
alcohol 8 hrs prior
to test

Restrictive clothing to
lung function test
 Normal Cough Cough
> 1 sec
Acceptability
FEV1 ok FVC ok
Glottic Glottic Submaximal
closure closure effort
<1 sec >1 sec

FEV1 ok
Poor lip Slow Tongue
seal + start obstruction
Ensure quality of lung fx test free from artefact leak
Repeatability Criteria
Ensure variability between each
maneuver similar with not much
differences
 Usability
Although not acceptable ;
maybe clinically useful as
for some patients - the
observed spirometry
maybe their best effort

Particularly in groups

- Neuromuscular
disorders
- MND
- Facial trauma
- Bulbar weakness

Secondary measurement
against their personal
best in terms of disease Graham BL, et al. Am J Resp Crit Care Med 2019; 200(8): e70-e88
progression
Expiratory

Inpiratory
Flow loop -> Tell-tale of site of obstruction
Expiratory

FIF50 /FEF 50 can indicate

whether variable vs fixed
intrathoracic vs extrathoracic Extrathoracic
obstruction obstruction can
be due to
FIF50/ FEF50 >1: intrathoracic
obstruction (b,c) suboptimal
Inspiratory effort
FIF50/FEF50 = 1: Fixed
extrathoracic obstruction (d,e)
Expiratory
FIF50/FEF50 < 1: Variable
extrathoracic obstruction (f)

FEV1, FVC and FEV1/FVC values

may not be affected in all cases of
intrathoracic airway obstruction Inspiratory
Inspiratory curve

Inspiratory curve flattened / absent/ truncated= Variable extrathoracic obstruction

- Goitre
- Tracheal stenosis / Tracheomalacia above Thoracic inlet
- Vocal cord dysfunction
- OSA ( upper airway collapsibility )
- NMD
- Allergic rhinitis
- Reflux diseases
FVC & FEV1 & TLC relationship

Only TLC ↓

FEV1/ FVC & TLC ↓

Both FEV1/FVC & TLC

normal
Only FVC +/- FEV1 ↓
Spirometry Interpretation
Reduce VC

TLC ↑ but RV↑ (

normal RV/ TLC)
TLC N but RV↑ & Obstructive with
RV/TVC ↑ HYPERINFLATION
TLC↓ & RV↑
Obstructive with
Restrictive
Gas-trapping
TLC ↓& RV ↓ Neuromuscular
Restrictive or suboptimal
Normal= RV
effort
25% of TLC
hyperinflation

DLCO <80%

DLCO>120%
Ventilator pattern
Ventilator pattern
Thoracic cage pressure NOT Thoracic cage pressure EARLY detection - stridor only <
affecting extrathoracic affecting intra-thoracic 8mm or <80% tracheal reduction

Ventilator pattern Ventilator pattern

 DLCO interpretation
Carbon monoxide diffusing capacity (DLCO) =
mL/min/mm Hg or mmol/min/kPa
Measures quantity of carbon monoxide diffuse from
alveolar gas to hemoglobin
mL of CO transferred per minute for each mm Hg of
pressure difference across the total available
functioning lung gas exchange surface

Normal - 80 - 120 %

DLCO = Product of Alveolar Volume(VA) * Rate of

Alveolar carbon monoxide uptake (Kco)

DLCO/VA = Kco (Rate of CO uptake )

DLCO
Interpretation
DLCO< 50% pred with DLCO/VA > 150%
 Bronchial Challenge Test
High negative predictive value
More sensitive than exercise
challenge test
More specific ( -ve exclude asthma)

False+ve in
- 5-15% normal population
- 20 - 40% allergic rhinitis
Bronchial Challenge Test
Delivered dose of methacholine causing a 20% fall in FEV1 (provocative
concentration (PC20)

Indication

- Screening for asthma

- Occupational screening ( AHR lethal -> occupational exposure/ submarine/
diving)
- Occupational asthma diagnosis

● Cutoff for +ve response < 8-16

mg/ml
○ NICE/BTS guideline use <8 mg/ml
○ QEH use <16mg/ml
Type of Bronchoprovocation Test

Middleton’s Allergy 8th edition

Type of Bronchoprovocation Test Indication

Middleton’s Allergy 8th edition

THANK YOU for all
your patience 😍
CASE CHALLENGES
(if we have time)
REAL life
challenge
Is this obstructive ?
Mary Ip Criteria for Spirometry in Chinese
56 / M Ned Stark
Smoker X 50 packed years
Complain worsening of dyspnea recently with
chronic cough
General condition worsening with difficulty getting
outdoor
EASILY MISSED
CXR
Lesion overlapping ribs
Lung apex lesions - behind clavicles
Right Paratracheal strip blurring -> progress to bilateral
2nd case
3rd Case

Present with decreased GC weight loss

4th Case

Present with cough & weight loss

5th Case Cough / dyspnea when lying flat / valsalva manouvre
 Answer
CXR - PA & lateral shows
narrowing of mid & distal
trachea
Supporting -> Spirometer
with flattening of inspiratory
& expiratory
Diagnosis - Relapsing
Polychondritis ( dynamic)
7th Case
Endobronchial Lesion
8th Case
30/ M Chronic Cough & recurrent infection
Intralobular Sequestration + pulm venous
return
1st case
Cardiac Borders
Lung Function
Test Challenge