Final Med Chest Radiology

Anatomy

Segments:

Apical
Anterior
Posterior

Right lower lobe

Segments:

Superior
Anterior
Posterior, medial, lateral

Right Middle lobe

Segments:

Medial
Lateral

Left Upper lobe

Segments:

Apico-posterior
Anterior
Superior lingular
Inferior lingular

Left lower lobe

LLL

Segments:

Superior
Anterior
Posterior
Lateral

Approach to Chest Radiograph

Name, Age, Sex

Date Chest radiograph taken
Side R and L Sidemarkers
-Beware dextrocardia!
Female-? Both breasts
present (Mastectomy)
Film rotation
Centering
Penetration

Approach to Chest Radiograph

Review areas

Trachea central ?
Apices
1st rib area-missed lung cancers
Hila
concave outwards
Symetricallly dense
Retrocardiac areas
Cardiophrenic / Costophrenic
angles
Posterior costodiaphragmatic
recesses

Terms Frequently Used

Density: whiteness or any area of whiteness

on an image
Lucency: blackness, or any area of
blackness on an image

Recognizing A Technically
Adequate Chest X-ray

Factors to Evaluate
- Penetration
- Inspiration
- Rotation
- Angulation

Penetration
You should be able
to just see the
thoracic spine
through the heart.

Underpenetration

The left hemidiaphragm (and left lung base) will not be visible

Pulmonary markings exagerated

Inspiration

About 10 posterior ribs visible is an excellent

inspiration
In many hospitalized patients 9 posterior ribs is
an adequate inspiration

Anterior vs. Posterior Ribs

Anterior

Posterior ribs
are those that
are most
apparent on
the chest xray. They run
more or less
horizontally.

ribs will be
visible but
are harder to
see.
They

run
more or less
at a 45
degree angle
downward
toward the
feet.

Pitfall Due to Poor Inspiration

About 8 posterior ribs are showing

Poor inspiration will crowd lung markings and make it
appear as though the patient has airspace disease

Same patient

About 8 posterior ribs are

showing

9-10 posterior ribs are

showing

Better inspiration and the disease

at the lung bases has cleared

Rotation
If the spinous process
of the vertebral body
is equidistant from the
medial ends of each
clavicle, there is no
rotation

Pitfall Due to Marked Rotation

Severe rotation may make the pulmonary arteries

appear larger on the side farther from the film

AP versus PA

The Effect of Magnification

In a PA film, the heart is closer to the film and thus less magnified

The standard chest x-ray is a PA film

In an AP film, the heart is farther from the film and is more

magnified

Portable chest x-rays are almost always done AP

AP versus PA

The Effect of Magnification

AP portable film makes the

heart look larger than it
does

On this PA film done on the

same patient an hour later

Important Points

The factors to evaluate the quality of a chest x-ray are:

Penetration see spine through the heart

Inspiration at least 8-9 posterior ribs

Rotation spinous process between clavicles

The Lateral Chest Film

Find abnormalities hidden

on the frontal film
Confirm abnormalities
suspected from frontal film
Dont be afraid to look at
it!

Pneumonia

Air space Opacification (Fluid, Pus,

Haemorrhage and Cells)

No mediastinal shift

Air bronchograms

Pneumonia

Pneumonia of LUL no shift of the mediastinal

structures to either side; multiple air bronchograms

Recognizing air space disease

Alveolar spaces filled withsomething.

Radiologist's report:
consolidation
air space opacity
fluffy density
infiltrate
Nonspecific:
Atelectasis, pneumonia, bleeding, edema, tumor

Air Bronchogram

Bronchi are not normally visible since their walls are

thin, they contain air and are surrounded by air

When something of fluid density fills alveoli, air in

bronchus becomes visible, e.g.

Pulmonary edema fluid

Blood

Gastric aspirate

Inflammatory exudate

Air Bronchogram

The visibility of air in the bronchi because of

surrounding airspace disease is called an air
bronchogram
An air bronchogram is almost always a sign of airspace
disease

Air bronchograms CT

Pneumonia

Lung cancer

The black
branching
structures are the
result of air in the
bronchi, now visible
because density
other than air
surrounds them (in
this case it is
inflammatory
exudate from a
pneumonia).

spine sign

The Silhouette Sign

Indicates air space disease.
Obscuration of a normally seen border, e.g.

diaphragm or heart.
Opacity with sharp edge along a fissure.

Localizing disease from the silhouette sign

RML
RLL

Lingula
LLL
LLL

Localizing disease from the silhouette sign

UL
RUL
RML
RML or
lingula

LL

Causes of Consolidation

Fluid-pulmonary edema
Pus- Pneumonia
Hemorrhage

Pleural effusions

57 year-old female with shortness of breath

Pleural Effusions

Meniscus-shaped opacities at both lung bases from

bilateral pleural effusions (red)

Pleural Effusions

Meniscus-shaped density at the lung bases from

bilateral pleural effusions (red)

Pleural Effusions :Effect of Position

Supine

Erect

In the supine position, the fluid layers out posteriorly and produces
a haziness, especially near the bases (since the patient is actually
semi-recumbent). In the erect position, the fluid falls even more to

Pleural Effusion

Large right pleural effusion - shift of the mediastinal structures

AWAY from the side of opacification

Pleural Effusion

Opacified hemithorax from large effusion

Shift of heart and mediastinal structures away

from side of opacified hemithorax

Congestive Heart Failure

Why is this patient 57 short of breath

Pulmonary Edema

Pulmonary Alveolar Edema

Bilateral, diffuse airspace disease more marked

centrally than at the periphery of the lung (bat-wing

Radiology of cardiac failure

Cardiac Enlargement (> 50% ofmaximal

internal dimension of chest)
Pulmonary venous hypertension
Interstitial pulmonary edema
Alveolar pulmonary edema

Pulmonary venous Hypertension

Vascular
Redistribution
Vascular
redistribution

Pulmonary arterial Hypertension

Interstitial Pulmonary edema

Septal lines or
Kerley B lines

Septal lines or
Kerley B lines

Pulmonary edema

Septal lines or
Kerley B lines

Alveolar Pulmonary edema

Alveolar Pulmonary edema

Post diuretic treatment

Alveolar Pulmonary edema

Mediastinum

63 year-old man with chest pain

Aortic Dissection

Chest pain

Widened
mediastinum

Dilated Aorta

Left pleural effusion

Aortic Dissection

Linear lucency in the contrast-filled descending aorta is

the intimal flap of an aortic dissection (red)

Classification of Dissecting Aneurysms

Stanford classification

Night sweats, weight loss

Hilar Adenopathy
1. Sarcoid
2. TB
3. Lymphoma
4. Bronchogenic ca
5. Mets

Atelectasis

Opacified hemithorax from volume loss

Shift of heart and mediastinal structures toward
opacified hemithorax

Diagnosis

10

Atelectasis/ Lung Collapse

Atelectasis of right lung shift of the mediastinal structures

TOWARD the side of opacification

Shortness of Breath

Opacified Hemithorax

Atelectasis shift towards

Pleural effusion shift away

Pneumonia no shift, air

bronchograms
And a fourth cause:
Post-pneumonectomy (removal
of an entire lung)

Misplaced Lines

ICU Patient

Misplaced ET Tube

Tip of endotracheal tube is in right mainstem bronchus (red

arrow) leading to atelectasis of the right upper lobe (yellow)

Cavitary Lung Lesions

Carcinoma of the lung

TB

Abscess

Cavitating Lung Lesion

Thick-walled cavity with nodular inner margin

carcinoma of the left lower lobe

Lung neoplasms

CT Guided Lung Biopsy

Lung metastases

Interstitial Pattern

Mechanism: diffuse or irregular thickening of

lung interstices or architectural destruction of
interstitium (honey comb or end stage lung)

UIP

Reticular Pattern:
Rheumatoid Arthritis

UIP

Interesting cases

Miliary TB

Air Bronchogram