Interpreting Chest X-Rays

• 1. Technique1.1 Techniques available2. Anatomy2.1 Frontal CXR2.2 Lateral CXR2.3 Normal variants3. In-built errors of interpretation3.1 The eye–brain apparatus3.2 The snapshot3.3 Image misinterpretation3.4 Satisfaction of search3.5 Ignoring the ribs4. The fundamentals of CXR interpretation4.1 The silhouette sign4.2 Suggested scheme for CXR viewing4.3 Review areas4.4 Pitfalls5. Pattern recognition5.1 Collapses5.2 Ground glass opacity5.3 Consolidation5.4 Masses5.5 Nodules5.6 Lines5.7 Cavities6. Abnormalities of the thoracic cage and chest wall6.1 Pectus excavatum6.2 Scoliosis6.3 Kyphosis6.4 Bone lesions6.5 Chest wall / thoracic inlet6.6 Thoracoplasty7. Lung tumours7.1 CXR features of malignant tumours7.2 CXR features of benign tumours7.3 Metastases7.4 Bronchial carcinoma7.5 The solitary pulmonary nodule8. Pneumonias8.1 Pulmonary tuberculosis8.2 Pneumococcal pneumonia8.3 Staphylococcal pneumonia8.4 Klebsiella pneumonia8.5 Eosinophilic pneumonia8.6 Opportunistic infections9. Chronic airways disease9.1 Asthma9.2 Chronic bronchitis9.3 Emphysema9.4 Bronchiectasis10. Diffuse lung disease10.1 Interstitial disease – the reticular pattern10.2 LAM10.3 Langerhan’s cell histiocytosis10.4 Pulmonary sarcoid10.5 Hypersensitivity pneumonitis11. Pleural disease11.1 Effusion11.2 Pneumothorax11.3 Pleural thickening11.4 Pleural malignancy11.5 Benign pleural tumours12. Left heart failure13. The heart and great vessels13.1 Valve replacements13.2 Cardiac enlargement13.3 Ventricular aneurysm13.4 Pericardial disease13.5 Coarctation of the aorta 13.6 Aortic aneurysm13.7 Atrial septal defect13.8 Pacemakers14. Pulmonary embolic disease15. The mediastinum15.1 The ‘hidden’ areas of the mediastinum15.2 The hila15.3 Stents16. The ITU chest X-ray16.1 Adult respiratory distress syndrome16.2 The CXR following thoracic surgery17. The story filmsFurther readingIndex

Interpreting chest radiographs is one of the most – if not the most – difficult yet routine radiologic activity. In some respects, thoracic computed tomographic (CT) examinations are easier to correctly analyze, because among other reasons, the 3-dimensional anatomy is laid out much more clearly, and the density of structures is more readily discerned. Similarly, teaching the basics of chest radiographic (CXR) analysis can be surprisingly difficult, especially to the beginner. In Interpreting Chest X-Rays, a profusely- illustrated paperback book by the thoracic radiologist Dr. Stephen Ellis, a substantial amount of ground is covered on this difficult topic in 240 pages. Dr. Ellis is an outstanding teacher, with an appealing approach and writing style. I imagine, after reading this new introductory book, that anyone at any level, after spending a few weeks with Dr. Ellis on a chest imaging rotation, would learn an enormous amount of practical and valuable information. The book is very well written and organized. There are excellent, very instructive figure legends. Some points and a few images are repeated within the book, but this serves to reinforce important concepts. Helpful analogies are provided, as are useful and clear drawings (particularly the diagrams of lobar atelectasis). Some areas get minimal coverage (eg, CXR findings in aortic dissection, although a single case is shown), whereas a few unusual or rare disorders, which a beginning interpreter is highly unlikely to ever encounter, are covered in some detail or briefly mentioned (eg, Langerhans cell histiocytosis, lymphangioleiomyomatosis, and pulmonary alveolar microlithiasis). Overall, the cases shown are excellent, they cover substantial ground, and demonstrate numerous valuable teaching points, particularly for an introductory text. Putting together such a collection of images is not easy. I very much like the CXR–CT correlation, with universal superb reproduction of the CT images, although most of the CT images are quite small, and the novice interpreter may not be able to appreciate some of the findings on a minority of these images. I also very much like the magnification of areas of interest, which is provided for many of the chest radiographs. The emphasis on "review areas," and the potential pitfalls of CXR interpretation, is outstanding and relatively comprehensive, and important material is provided and reviewed for both the neophyte and the experienced health care practitioner. Thoracic anatomy (with CT correlation) and pathology is appropriately stressed throughout the text, as is the importance of a systematic search pattern. The chapter on atelectasis is extremely well done, and even seasoned CXR interpreters will benefit from this section. There is a concise but good discussion of pulmonary infection. The limitations of chest radiography for interstitial lung disease are accurately explained and demonstrated. Numerous pearls are included throughout the book (eg, that patients with sarcoid appear better clinically than radiographically), as are concise and relevant differential diagnoses (eg, for hilar lymphadenopathy). A substantial percentage of the CXRs illustrated are dark, with suboptimal contrast. This is due to the reproduction of the images, rather than the original images, and is my only major criticism of the book. Some of these are worse than others, although for the most part, the findings can be identified, particularly if attention is paid by the reader as to how the images are examined relative to the incident light falling on the book (however, this reviewer has not been exempt from this problem in his own publication efforts, and Dr. Ellis is likely as similarly frustrated by this as I have been). Hopefully, this problem can be corrected in future printings/ future editions. There are some charming "Britishisms", for example, "in theater" and "patients are invariably nursed supine," as well as the use of a few terms which will be foreign to American-based medical readers (eg, "hilar point" and "surgical emphysema"). Neither these nor the British spellings preclude the use of this book by Americans or others not familiar with the United Kingdom form of English. There are a few minor typographic errors (eg, Swan-Ganz, as in the physicians for whom the vascular catheter is named, is misspelled), one of which is rather amusing ("ecstatic" is used for a figure caption, rather than "ectatic," when referring to a tortuous aorta), and an atrial septal defect is referred to as a "right-to- left shunt" (which is true only when Eisenmenger's syndrome supervenes). A few captions incorrectly state the color or plurality/singularity of arrows, although this is a minor point. I could find essentially no substantial content errors, although one could argue with the issue that the lateral CXR is no longer used/should no longer be performed, or that a "limited volume CT" is actually done in practice for problem solving. Interpreting Chest X-Rays is highly recommended for anyone wishing to acquire a basic yet relatively comprehensive approach to the chest radiograph. The book is affordable, and is particularly suited for trainees, including pulmonary medicine fellows, medical students on a radiology rotation, physicians' assistant students or nursing students on a critical care or pulmonary rotation, and first-year radiology residents on a thoracic radiology rotation. Dr. Stephen Ellis makes the difficult seem easy, with his instructive teaching style and helpful approach to the surprisingly difficult topic of chest radiography interpretation.