The chest

Gemechu Geleto
MD, Radiologist
 Brain storming
• Chest
• Thoracic cage
• Airway
• Respiratory system
• Pulmonary system
• lung
Outline of presentation of the Chest
A. The normal chest; method of investigation and
differential diagnosis
B. The mediastinum
C. The pleura – collapse and consolidation
D. Tumors of the lung
E. Inflammatory disease of the lung
F. Chronic bronchitis and emphysema pneumoconiosis
G. Miscellaneous lung condition
H. Chest trauma
I. The chest in children
 A:1 The normal chest
• Bony Thorax
-Vertebrae - 12 thoracic
segments
-Ribs - 12 on each side,
articulate with the
vertebral bodies and
transverse processes
-Sternum - manubrium
and body
-Clavicles

4
• Lung
Lobes and Fissures

5
6
7
 Segments
Right Upper Lobe(3) - apical, posterior, and anterior
Right Middle Lobe (2) - medial and lateral
Right Lower Lobe( 5) - superior, medial basal, anterior basal, lateral basal, and posterior
basal
Left Upper Lobe (4)- apical-posterior, anterior, superior lingular, and inferior lingular
Left Lower Lobe (4) - superior, anteromedial basal, lateral basal, and posterior basal

8
lungs
 Pulmunary Acinus:

• The portion of lung distal to the terminal

bronchiole where gas exchange takes place.
• The basic anatomic and functional pulmonary unit
• It Contains:
(1)Respiratory bronchioles
(2) Alveolar ducts
(3) Alveolar sacs
(4) Alveoli
 Pulmonary lobule:
• The grouping of 3-5 acini

• It is a consistently recognizable structure

Anatomically and radiographically

• Diameter = l cm in an adult

• Each lobule is surrounded by its own

interlobular septa and interstitial structures .
Pulmonary lobule: diagram
13
Ht d/ce is 1.5-2cm

14
 15
Paratracheal stripe <4mm
Technical factors
 Inspiratory effort

 Anterior aspect of at least six ribs must be noted

above the dome of the right diaphragm
 Alternatively, posterior aspects of at least eight to
nine ribs should be visualized 1

 Poor effort: the cardiac shadow may appear

spuriously enlarged, crowding of vessels at lung
bases
Adequate inspiration
 Exposure/penetration

 Assessed by looking at the lower thoracic vertebral

bodies, whose outline should just be visible on a PA
projection
 The spine should be seen through the heart 1

 Poor penetration: pulmonary vessels and interstitial

markings appear more prominent, loss of detail at
the lung bases and vertebrae, results in increased
density
penetration
 Rotation

 Thoracic spinous processes are equidistant from the

medial end of each clavicle on a frontal image

 Rotation to the right may cause: pseudo-mediastinal

mass, hyperlucency of the right lung

 Rotation to the left may cause: aortic arch may

appear spuriously enlarged, hyperlucency of the left
lung
 Angulation

 Medial ends of the clavicles should be projected over

the posterior third or fourth ribs 1
 Clavicles will have a S shape 1
 Orientation
Magnification

 Films on anteroposterior views slightly

magnify the heart 1
 A:2 Method of Chest investigation
1:CXR:
. the most frequently requested of all
radiographs (>60%)
• Of all CXRs performed, only 30% yield
consistent findings with their clinical
indications in our setup.
• PA CXR: accounts for the majority of all CXRs
• Most CXR requests are unnecessary

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 Method of Chest investigation
2. Simple linear tomography
 assess peripheral lung masses, lung apices, &
abnormal hilum in absence of CT
3. Computerized tomography
 far superior than conventional tomography for:
. Staging malignancy
. Detecting pulmonary metastases
. Assessing chest wall and pleural lesions, lung
masses, the hilum and mediastinum
02/14/2024 29
 Method of Chest investigation
4. Radionuclide scanning:
 1st line for suspected pulmonary embolism
normal scan excludes PE
5. Pulmonary angiography:
 Gold standard for PE
 Usually done for pts with massive embolus
when embolectomy is contemplated

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 Method of Chest investigation
6. Ultrasound:
 For assessing lesions of the chest wall, pleura
and lung adjacent to the chest wall
 To detect loculated pleural fluid
 Can’t visualize the normal lung
7. MRI:
 hilar masses
 lymphadenopathy
 mediastinal lesions
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 Portable chest radiography (AP)
 Done on critical care setting
 To monitor cardiopulmonary status
 Assess the position of various tools
 Detect complications
 Limitations of portable radiography:

 Rotated, excessively lordotic

 motion blur
 Magnification
 Smaller lung volumes
 Vascular pattern lost
 Difficult to detect small pleural effusion &
pneumothorax
A:3 Diagnosis and Differential Diagnosis

Diagnosis
Generic
Specific
Definitive: biopsy proven /pathogen specific

Differential Diagnosis
– Are the Groups of specific diseases for likely
generic diagnosis
 Generic diagnosis
• Suggesting gross pathology based on the
elicited radiographic signs.
example:
-homogenous opacity
-ill-defined edges CONSOLIDATION
-air bronchograms

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• Consolidation
 Interstitial thickening

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 ILDs...

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 Pleural effusion…
 meniscus sign
 elevation of rt.
hemi diaphragm

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 Lung masses

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 specific diagnosis
• translate gross pathological findings to specific
diagnosis
example:
 consolidation = infection, pulmonary
edema, pulmonary hemorrhage, neoplasms,
etc…
 Pleural effusion: infection (TB,pneum), tumour,
Reactive, sytemic illness(CHF, NS, CTD)

02/14/2024 41
 Differential Diagnosis
• Consolidation:DDX
– pneumonia,
– lung hemorrhage/
contusion
– Lung ca (alveolar cell ca)
etc
• Pleural effusion:DDX
– TB pleurisy
– Pneumonia with
parapneumonic effusion
– CHF, NS, CTD etc
 Differential Diagnosis
• Lung mass:DDX
– Hydatid cyst
– Lung carcinoma
– Secondaries
– Abscess etc
• Interestitial thickening:DDX
– Pulm edema
– Hypersensitivity pneumonia
– Lymphangitis carcinomatosa
– ILD etc
 B: Mediastinum
Mediastinal Compartments
• Anterior
– Line runs along back of
IVC and heart and front
of trachea
• Middle A M P
– Between the lines
• Posterior
– Line runs across body of
each thoracic vertebra 1
cm from its anterior
margin
• superior mediastinum: above the upper level
of the pericardium and plane of Ludwig

• inferior mediastinum: below the

plane of Ludwig
 Mediastinal contour
“between the lungs”
• Right border created by (superior to inferior)
– Brachiocephalic vessels, SVC, azygos arch,
ascending aorta, R atrium

• Left border created by

– Brachiocephalic arteries, aortic arch, main
pulmonary artery, LV
Mediastinal contour
 B: Mediastinal Masses

• In general, a variety of clinical, historic and

radiological findings are used to predict the
nature of the lesion.
• Ultimately, the definite diagnosis rests in the
hands of the pathologist.
 Mediastinal masses
• Mediastinal masses are sometimes difficult to
separate from pulmonary parenchymal
masses.
 Clues to locate mass to mediastinum
• Mediastinal masses are • Masses in the lung
invested by parietal parenchyma typically:
pleura, so will have:
– Are surrounded by air
– Smooth contour – May contain air
– Tapered borders bronchograms
– May be seen bilaterally – Will be on one side only
Lung mass vs mediastinal mass
 Mediastinal Mass Vs lung mass
Mediastinal Mass Lung mass
– Unlike lung lesions, a • A lung mass abutts the
mediastinal mass will not
mediastinal surface and
contain air bronchograms.
– The margins with the lung will
creates acute angles with
be obtuse. the lung, while a
– Mediastinal lines mediastinal mass will sit
(azygoesophageal recess, under the surface creating
anterior and posterior junction obtuse angles with the lung
lines) will be disrupted.
– There can be associated spinal,
costal or sternal abnormalities.
Mediastinal mass
 Ddx of anterior mass
• The 4 T’s
– Thymoma
• Generally over age 40
– Teratoma
• Generally under age 40
– Thyroid
• Goiter or neoplasm
– Terrible lymphoma

Use clinical and radiographic clues

 Ddx of middle mass
• The 4 A’s
– Adenopathy
• TB/fungal
• Sarcoid
• Neoplasm (bronchogenic CA, mets, lymphoma, leukemia)
• Infections (EBV, AIDS)
– Awful primary neoplasm
• Tracheal
– Aneurysm/vascular
– Abnormalities of development
• Bronchogenic cyst- often between carina and esophagus
• Pericardial cyst
• Esophageal duplication cyst
 Posterior Mediastinum

• Nurogenic tumors,
esophageal and
vascular lesions, and P
LNs.
 See sharp
margin
above clavicle
 This
should
help!
 Mass
“disappears”
at clavicle
Thyroid goiter

Trachea is
deviated
to left
 Pleural Pathologies
• Pleural effusion
• pneumothorax
• Pleural tumors/mass
 Pleural pathologies
A: Pleural effusion:
• Accumulation of fluid between the layers of
the membrane that lines the lungs and the
chest cavity
 Types
• Hydrothorax: (Hydro – serous fluid)

• Hemothorax: (Hemo – blood; pleural fluid hematocrit

level of more than 50% of peripheral hematocrit level

• Chylothorax: (Chylo – lipid; milkly fluid due to lymphatic

obstruction or trauma to thoracic duct)

• Pyothorax or Empyema: (Pyo – pus; purulent, putrid

odor)
 Pleural effusion:

 It is a sign

 Occurs in a variety of pathologies including : infection,

embolism, neoplasm, CHF & trauma

 may be either free or loculated

 Pleural effusion:

Free:
 meniscus sign

 Increase in the over all opacity of one hemithorax on a

recumbent film.

 Mediastinal shift in massive effusions

 an apparent elevation of the “diaphragm” on the upright film

if it is subpulmonic effusion
 May be demonstrated in decubitus film
 Pleural effusion:

Loculated:
• loculation in the fissures => Form
“pseudotumour” or phantom tumor
• has tapered margins => spindle shaped
• Other signs
– Widening of the pleural space
– Blunting of costophrenic angles
• Upright…Meniscus
• Decubitus…Effusion layered on downside
What is a subpulmonic effusion ?

Fluid between the lung and diaphragm

 B: Pneumothorax

Pleura

Diaphragm Pleura
 Pneumothorax
• Pneumothorax - air gets
between your lungs and
your chest wall and the
lung collapses.
• Normally, two thin layers
of tissue (pleura) separate
the lung and chest wall.
• Any air that leaks into this
space (pleural space) will
cause the lung to
collapse..
 Causes of Pneumothorax
1) Air can collect inside
the chest for many
reasons, such as:
– An injury that
damages the chest
wall, such as a stab or
gunshot wound
– A broken rib that
punctures the lung
2.Iatrogenic:
– Intubation
– Pressurized positive ventilation
3. spontaneous
 Pleural tumours
a. Primary pleural tumours
b. Secondary pleural tumours
Secondary Pleural tumors
 Consolidation
Pulmunary Acinus:

• The portion of lung distal to the terminal

bronchiole where gas exchange takes place.

• The basic anatomic and functional pulmonary unit

• It Contains:
(1) Respiratory bronchioles
(2) Alveolar ducts
(3) Alveolar sacs
(4) Alveoli
 Pulmonary lobule:
• The grouping of 3-5 acini

• It is a consistently recognizable structure

Anatomically and radiographically

• Diameter = l cm in an adult

• Each lobule is surrounded by its own

interlobular septa and interstitial structures .
Pulmonary lobule: diagram
I. Consolidation(Air space pathology)

 Definition: Displacement of air in distal air-

way and alveoli by fluid and rarely by tissues.
 Causes:
Fluid => inflammatory exudates &
transudates, and blood
Cells=> neoplastic cells
 Radiographic appearance of consolidation:

There is increased density in the lungs. How

may the density appear?
Acinar nodules 4-10 mm in diameter
Ill-defined and fluffy margins
Segmental distribution
Air- bronchogram
consolidation
 Collapse (Atlectasis)
Definition: A condition of volume loss of the lung
 Patterns of the lung Collapse
• Complete collapse of the lung
• Lobar collapse
 Collapse (Atelectasis )
Definition: A condition of volume loss of the lung
Causes:
(1) obstructive atelectasis: the most common
 Results when a bronchus is obstructed by a
neoplasm, foreign body, mucous plug, or
inflammatory debris.
 Quite often, there is associated pneumonia distal to
the site of obstruction.

(2) Compressive atelectasis:

The lung is compressed by a tumor, emphysematous
bullae, pleural effusion, or enlarged heart.
 Contd…. Collapse:
(3) Cicatrisation atelectasis: is produced by organizing
scar tissue. This occurs most often in healing tuberculosis and
other granulomatous diseases.

(4) Adhesive atelectasis: is a unique type of volume loss

that occurs in the presence of patent air-ways. The
mechanism involved is believed to be the inactivation of
surfactant. Ex. HMD

(5) Passive atelectasis: results from the normal

compliance of the lung in the presence of either
pneumothorax or hydrothorax. The air-ways remain patent.
 The radiographic signs of lobar and
segmental collapse
a. Direct signs:
1. Displacement or deviation of a fissure => most reliable.
2. Increased opacity
3. Crowding of vessels
4. Silhouette sign.

b. indirect signs:
1. Displacement of the hilar vessels => most reliable.
2. Shift of the mediastinum
3. Elevation of the hemidiaphragm
4. Compensatory emphysema
5. Herniation of the lung across the midline
6. Crowding or approximation of the ribs in long standing cases
 Collapse contd…
Direction of collapse: for lobar collapse
• Rt upper lobe:
• Lt upper lobe => upward, medially, and anteriorly

• Middle lobe:
• Lingula => downward and medially

• Rt lower lobe:
• Lt lower lobe => posteriorly, medially and downward
Right lung Complete collapse
Thank you