CHEST

Indications for Chest X-ray

Cough Haemoptysis Fever Chest pain Trauma Pre-operative Check up Metastatic work & Staging

NORMAL CHEST X-RAY

Views PA Lateral Supine Deep Inspiration Centering
medial ends of clavicle equidistant from spine

PA VIEW

LAT VIEW

 When reading a patient's chest films you should look at both the PA and the lateral films and put them in this manner (PA on left and lateral on right).

This image outlines the specific anatomy of the PA chest x-ray.

HEART

How to read the chest X ray?

from the periphery towards the centre Via 4 circles

1st circle = outside the bony thorax (skin, soft tissues, breasts and subdiaphragmatic area)

2nd circle = the bony thorax and diaphragms

 3rd circle =
Pleura: Fissures, Angles Lungs: translucency vascular markings

Read the lung parenchyma from top to bottom and from left to right .

 4th circle = Mediastinum

Trachea. Heart. Vessels. Nodes.

Chest Radiographic Findings

Focal pulmonary lesion. Diffuse pulmonary lesion. Pleural diseases. Cardiomediastinal abnormalities. Lymphadenopathy. Bone and soft tissue abnormalities. Below the diaphragm.

localization

2nd

4th

Answer the following questions

Is there a lesion? Where is the lesion localization? What is the character of the lesion?

White

Black
White & Black

Mediastinal Pleural

White
ill defined Not a mass

Chest wall

lungs

Well defined

Collapse or fibrosis Loss of volume

infilterative

Mass or nodule Single or multiple

Alveolar
Air bronchogram silhouette

Interstitial
Nodular / Reticular

Black
Emphysema Bulla Air cyst pneumothorax

White & Black

Abscess
Bronchiectasis

cavitation
Diaphragm Pleura Achalasia

Opacity Mass vs Infiltrate

In each of the cases above, there is an abnormal opacity in the left upper lobe. In the case on the left, the opacity would best be described as a like a cancer because it is well-defined. The case on the right has an opacity that is poorly defined. This is airspace disease such as pneumonia.

Pulmonary Lesions
Focal:
Patchy area Nodular opacity Mass lesion Cavitary lesion

Diffuse:
Reticular Nodular Ground glass veiling Cystic

Patchy area
Pneumonia Infarct

RUL pneumonia

Right Lower Lobe Pneumonia

Pulmonary infarct

Embolus in right pulmonary artery

Multiple pulmonary infarctions

Nodules and Masses

Single or multiple Size Border definition Calcification Location

Pulmonary Nodule
1. 2. 3. 4. 5. Tuberculoma. Hamartoma. Peripheral Br. CA. Metastasis. AVM.

Pulmonary Mass
1. Br. CA. 2. Metastasis. 3. Hydatid (Cystic)

Pulmonary Nodule
Less than 3 cm is a nodule

Larger than 3cm is a mass

A nodule that is unchanged for two years is almost benign. If the nodule is completely calcified or has central or stippled calcium it is benign.

Well-Defined

Calcification

Ill-Defined

Mass

Apical TB

Pulm AVM

Lesion character

Lesion location

Lesion pathology

Peripheral & Central bronch Carcinomas

Bronchogenic Carcinoma

Alveolar Lung Diseases

Pneumonia Pulmonary edema Pulmonary hemorrhage Aspiration

 Fluffy Indistinct Confluent margins,

In both upper lobes

air bronchograms. This is an alveolar (airspace) disease,

Pulmonary edema

Butterfly or bats wing pattern

Alveolar pulmonary edema

Pulmonary Lesions
Focal:
Patchy area Nodular opacity Mass lesion

Diffuse:
Reticular Nodular Ground glass veiling Cystic

Cavitary lesion

Cysts & Cavities

Abnormal pulmonary parenchymal space.
Not containing lung but filled with air and/or fluid. Congenital or acquired. Wall thickness greater than 1 mm

Cavitary Lung Lesions

Carcinoma TB Abscess. Bulla Pneumatocele Thickness of the wall Inner margin Air-fluid level Number

Benign Cavities : Cryptococcus

max wall thickness 4 mm minimally irregular inner lining

Indeterminate Cavities

max wall thickness 5-15 mm mildly irregular inner lining

Malignant Cavities: Squamous Cell Ca max wall thickness 16 mm Irregular inner lining

Thick-wall with nodular inner margin carcinoma of left lower lobe

Thin-walled with smooth inner margins RUL Tuberculosis

Cavities
Thickness of Wall
Carcinoma Inner Margin A|F Level

Thick

Nodular

+/-

TB

Thin

Smooth

No

Abscess

Thick

Smooth

Yes

COPD
Emphysema is loss of elastic recoil of the lung with irreversible destruction of alveolar septa .

It is caused most often by cigarette smoking and less commonly by alpha-1 antitrypsin deficiency.

X-Ray findings are:

Diffuse hyperinflation Flattened diaphragms Increased retrosternal space (barrel shaped chest) Altered cardiac configuration (ribbon shaped heart) Attenuated peripheral vasculature

 Bullae (lucent, air-containing spaces that have no vessels), small or involve the whole hemithorax, infected (airfluid level) Enlargement of PA (cor pulmonale) Chronic bronchitis commonly occurs in patients with emphysema and is associated with bronchial wall thickening.

Bullae

Atelectasis
Atelectasis is collapse or incomplete expansion of the lung or part of the lung. It is most often caused by an endobronchial lesion, such as mucus plug or tumor. It can also be caused by extrinsic compression centrally by a mass such as lymph nodes or peripheral compression by pleural effusion.

Atelectasis
Partial or complete loss of lung volume.

Direct signs:
Displaced fissures. Loss of aeration (increased density). Vascular & bronchial crowding.

Indirect signs:
Elevated diaphragm. Mediastinal and hilar displacement. Rib crowding Compensatory hyperinflation.

Right Upper Lobe

Elevation of the horizontal fissure caused by RUL atelectasis.

Right Middle Lobe

Right middle lobe atelectasis can be difficult to detect in the PA film. The right heart border is indistinct on the PA film. The lateral shows marked decrease in the distance between the horizontal and oblique fissures.

Major differentiating factors between atelectasis and pneumonia

Atelectasis

Pneumonia
Normal or Increased Volume No Shift, or if Present Then Contralateral Consolidation, Air Space Process Not Centered at Hilum

Volume Loss Associated Ipsilateral Shift Linear, Wedge-Shaped Apex at Hilum

Air bronchograms can occur in both

Tuberculosis (TB)
Mycobacterium tuberculosis.

Primary TB:
The organism settle in an alveolus anywhere and spread to regional LN (Ghons focus)

Post primary TB:

Due to reinfection rather than reactivation.

Pulmonary changes:
1ry:

PRIMARY COMPLEX Ghons focus Ipsilateral lymphadenopathy Pleural effusion

Post 1ry:

Consolidation in the apical segments of the lower lobe, patchy, and may be bilateral Fibrosis and volume loss, pulled trachea Cavities (single or multiple, small or large) Calcification may occur

 Tuberculous bronchopneumonia: Patchy nodular infiltrations. Miliary TB: 1-2 mm discrete, small nodules (haematogenous spread) Tuberculmoa: Localized granuloma, commonly calcified. Airway involvement: Collapse by LN or bronchial stenosis

Bronchiectasis
Abnormal and permanent dilatation of the bronchi, most often secondary to an infectious process.

Types
Cylindrical (Tubular) Varicose Cystic (Saccular)

Etiology:
Cystic fibrosis Bronchial wall weakness Infection. Obstruction (e.g neoplasms, foreign body) Inhalation and aspiration (e.g ammonia, gastric aspiration, heroin overdose) Impaired host defense (e.g allergic bronchopulmonary aspergillosis). Inflammation (e.g bronchiolitis obliterans)

Bronchiectasis

Pleural Disease
Effusion
angle blunting to massive mobility

Thickening
distortion, no mobility

Mass Air Calcification

Pleural effusion
Transudate: Cardiac failure Hepatic failure Nephrotic syndrome Meigs syndrome Exudate Infection Malignancy Pulmonary infarction Collagen vascular diseases. Subphrenic abscess Pancreatitis

Haemprrhagic: Bronchogenic ca. Trauma Pulmonary infarction Bleeding disorders

Chylous: Obstructed thoracic duct Traumatic injury to the thoracic duct

Empyema

Subpulmonic Effusion

Pneumothorax
Spontaneous Traumatic Secondary to pneumomediastinum & pneumoperitoneum Secondary to lung dis (emphysema, cystic fibrosis, neoplasms)

PNEUMOTHORAX

PNEUMOTHORAX

Hydro-pneumothorax

Hydro-pneumothorax

Pleural Calcification

Pleural masses
Loculated pleural effusion Metastases Malignant mesothelioma Pleural fibroma

Opaque Hemi thorax

Pleural effusion Atelectasis Post Pneumonectomy Pneumonia Mass

 In atelectasis, there is s shift toward the side of the opacification In pleural effusion, there is a shift away from the side of the opacification In pneumonia, there is no shift, There may be an air bronchogram sign present In pneumonectomy, the 5th rib is usually absent

Which is this?

Which is this?

Which is this?

Which is this?

Lymphadenopathy
Non-specific presentations:
mediastinal widening hilar prominence

Specific patterns:
particular station enlargement

Right Paratracheal Lymphadenopathy

Right Hilar LAN

Right Hilar LAN

Left Hilar LAN

Subcarinal LAN

Aortic aneurysm

TRAUMA

 Pulmonary trauma (laceration) Pleural trauma (haemo, pneuomthorax). Skeletal trauma (ribs, sternum, spine, scapula, joints).

 Vascular trauma (dissection, rupture). Diaphragmatic trauma (rupture, hernia) Oesophygeal trauma (rupture, laceration, FB)

Pulmonary contusion

Pulmonary laceration

PNEUMOTHORAX

Tension ptx with collapsed lung

SC emphysema caused by multiple rib fractures

aortic dissection contrast-enhanced CT

Fracture ribs

Flair rib

Sternoclavicular dislocation

Complete atelectasis following FB inhalation

How to investigate case of chest

Plain X ray. CT (MSCT, CTA). U/S (effusion, echo). Techniques (angio, Ba). Intervention (drainage, biopsy, embo).

Lt. lower lobe pneumonia

Rt. Middle lobe pneumonia

TB

Pulmonary infarct

Complete atelectasis following FB inhalation

Radiological signs
Silhouette sign Air bronchogram Nodule opacity / Mass Atelectasis Pneumonia

Silhouette Sign

When two objects of the same density touch each other, the edge between them disappears

Using the Silhouette Sign

Right middle lobe silhouettes right heart border Lingula silhouettes left heart border Right lower lobe silhouettes right hemidiaphragm Left lower lobe silhouettes left hemidiaphragm

Using the Silhouette Sign

The mass (red arrow) silhouettes the right heart border which is to say there is no longer an edge of the right heart seen. That means the mass is touching the right heart border the mass is anterior) and the mass is the same density as the heart (fluid or soft tissue density). The mass is a thymoma.

The right heart border is silhouetted out. This is caused by a pneumonia, can you determine which lobe the pneumonia affects?

Air Bronchogram
An air bronchogram is a tubular outline of an airway made visible by filling of the surrounding alveoli by fluid or inflammatory exudates. Causes of air bronchogram: : lung consolidation Pulmonary edema Non obstructive pulmonary atelectasis Severe interstitial disease Neoplasm Normal expiration.

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).

HEART

ANATOMY

Anatomy

Size

VSD

Plethora=Shunt

TGV

Oligemia=PS