chest radiology med students2

8/18/2019 Chest Radiology Med Students2

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Anatomy

Segments: Apical

Anterior

Posterior


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Right lower lobe

Segments: Superior

Anterior

Posterior, medial, lateral


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Right Middle lobe

Segments: Medial

Lateral


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Left Upper lobe

Segments: Apico-posteriorAnterior

Superior lingular

Inferior lingular


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Approach to Chest Radiograph

• Name, Age, Se• !ate Chest radiograph ta"en• Side R and L Sidemar"ers

#$eware detrocardia%• Female#& $oth breasts

present 'Mastectomy(• Film rotation• Centering•

)enetration


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Approach to Chest Radiograph

Re*iew areas

• +rachea central &• Apices• st rib area#missed l-ng cancers• .ila

conca*e o-twardsSymetricallly dense

• Retrocardiac areas• Cardiophrenic / Costophrenic

angles•

)osterior costodiaphragmaticrecesses


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+erms Fre0-ently Used

• !ensity1 whiteness or any area of whiteness

on an image

• L-cency1 blac"ness, or any area of

blac"ness on an image


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Recognizing A Technically

Adequate Chest X-ray

• Factors to 2*al-ate

# )enetration# 3nspiration

# Rotation

# Ang-lation


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Penetration

You should be able

to just see the

thoracic spine

through the heart.


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nderpenetration

• !he left hemidiaphragm "and left lung base# $ill not be %isible

• Pulmonar& mar'ings e(agerated


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Inspiration

• About )* posterior ribs %isible is an e(cellent

inspiration

In man& hospitali+ed patients posterior ribs is

an adeuate inspiration


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Anterior vs. Posterior Ribs

Posterior ribs

are those thatare most

apparent on

the chest (-

ra&. !he& run

more or lesshori+ontall&.

•Anterior

ribs $ill be

%isible but

are harder to

see.•!he& run

more or less

at a /

degree angle

do$n$ard

to$ard the

feet.


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Pitfall 0ue to Poor Inspiration

Poor inspiration $ill cro$d lung mar'ings and ma'e it

appear as though the patient has airspace disease

About 1 posterior ribs are sho$ing

1


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Same patient

2etter inspiration and the 3disease4

at the lung bases has cleared

-)* posterior ribs are

sho$ing

About 1 posterior ribs are

sho$ing

1


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5otation

If the spinous process

of the %ertebral bod&

is euidistant from themedial ends of each

cla%icle, there is no

rotation


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Pitfall 0ue to Mar'ed 5otation

Se%ere rotation ma& ma'e the pulmonar& arteries

appear larger on the side farther from the film


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AP %ersus PA!he 6ffect 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 moremagnified

Portable chest x-rays are almost always done AP


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AP %ersus PA!he 6ffect of Magnification

AP portable film ma'es the

heart loo' larger than it

does7

8n this PA film done on the

same patient an hour later


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Important Points

!he factors to e%aluate the ualit& of a chest (-ra& are:

Penetration 9 see spine through the heart

Inspiration 9 at least 1- posterior ribs

5otation 9 spinous process bet$een cla%icles


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!he Lateral hest ;ilm

• ;ind abnormalities hiddenon the frontal film

• onfirm abnormalitiessuspected from frontal film

• 0on


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Pneumonia

Air space 8pacification ";luid, Pus,

>aemorrhage and ells# ?o mediastinal shift

Air bronchograms


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Pneumonia of LL 9 no shift of the mediastinal

structures to either side@ multiple air bronchograms

Pneumonia


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5ecogni+ing air space disease

• Al%eolar spaces filled $ith7something.• 5adiologists report:

− 3consolidation4

−

3air space opacit&4

− 3fluff& densit&4

− 3infiltrate4

• ?onspecific:

−

Atelectasis, pneumonia, bleeding, edema, tumor


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Air 2ronchogram

!he %isibilit& of air in the bronchi because of

surrounding airspace disease is called an 3air

bronchogram4

An air bronchogram is almost al$a&s a sign of airspace

disease


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Air bronchograms D !

Pneumonia Lung cancer


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!he blac'

branching

structures are theresult of air in the

bronchi, no$ %isible

because densit&

other than air

surrounds them "inthis case it is

inflammator&

e(udate from a

pneumonia#.


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“spine sign”


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!he Silhouette Sign

• Indicates air space disease.

• 8bscuration of a normall& seen border, e.g.diaphragm or heart.• 8pacit& $ith sharp edge along a fissure.


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Locali+ing disease from the silhouette sign

RLL

RML

LLL

Lingula

LLL

L li i di f h ilh i


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Locali+ing disease from the silhouette sign

RUL

RML

UL

LL

RML or

lingula


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Ca-ses of Consolidation

• Fluid-pulmonary edema

• Pus- Pneumonia

• Hemorrhage


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)le-ral eff-sions


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/E &ear-old female $ith shortness of breath

Pl l Eff i


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Pleural Effusions

Meniscus-shaped opacities at both lung bases from

bilateral pleural effusions "red#

Pl l Eff i


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Meniscus-shaped densit& at the lung bases from

bilateral leural effusions red

Pleural Effusions


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Pleural 6ffusions :6ffect of Position

Supine 6rect

In the supine position, the fluid la&ers out posteriorl& and producesa ha+iness, especiall& near the bases "since the patient is actuall&

semi-recumbent#. In the erect position, the fluid falls e%en more to


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Large right pleural effusion - shift of the mediastinal structures

ABAY from the side of opacification

Pleural Effusion


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Pleural 6ffusion

8pacified hemithora( from large effusion

Shift of heart and mediastinal structures a$a&from side of opacified hemithora(


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Congesti*e .eart Fail-re


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Bh& is this patient /E short of breath

Pulmonary Edema


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Pulmonary Edema


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Pulmonary Aleolar Edema


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2ilateral, diffuse airspace disease more mar'ed

centrall& than at the peripher& of the lung "3bat-$ing

Pulmonary Aleolar Edema


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Radiology of cardiac fail-re

• Cardiac 2nlargement '4 567 ofmaimal

internal dimension of chest(

• )-lmonary *eno-s hypertension• 3nterstitial p-lmonary edema

• Al*eolar p-lmonary edema

Pulmonar& %enous >&pertension


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“Vascular redistribution”“Vascular Redistribution”

Pulmonar& arterial >&pertension


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Interstitial Pulmonar& edema


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Septal lines orFerle& 2 lines


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)-lmonary edema


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y


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Al%eolar Pulmonar& edema


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Post diuretic treatment


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Mediastin-m


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Mediastin-m


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GH &ear-old man $ith chest pain

Aortic !issection


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Aortic !issection

•

hest pain• Bidened

mediastinum

• 0ilated Aorta

• Left pleural effusion


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Aortic !issection


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Linear lucenc& in the contrast-filled descending aorta is

the intimal fla of an aortic dissection red

Classification of !issecting Aneurysms


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Stanford classification


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Night sweats, weight loss


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Hilar Adenopathy


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1. Sarcoid

2. TB

3. Lymphoma

4. Bronchogenic ca

5. Mets

Atelectasis


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8pacified hemithora( from %olume loss

Shift of heart and mediastinal structures to$ard

opacified hemithora(


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!iagnosis

"#

Atelectasis$ %ung Collapse


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Atelectasis of right lung 9 shift of the mediastinal structures

!8BA50 the side of opacification

Shortness of $reath


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8pacified >emithora(


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Atelectasis shift to$ards Pleural effusion shift a$a&

Pneumonia no shift, air

bronchograms

And a fourth cause:

– Post-pneumonectom& "remo%alof an entire lung#

Misplaced Lines


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I Patient

&isplaced ET Tu'e


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!ip of endotracheal tube is in right mainstem bronchus "red

arro$# leading to atelectasis of the right upper lobe "&ello$#


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a%itar& Lung Lesions


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arcinoma of the lung

!2 Abscess


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Ca*itating L-ng Lesion


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!hic'-$alled ca%it& $ith nodular inner margin 9

carcinoma of the left lo$er lobe

L-ng neoplasms


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C+ 8-ided L-ng $iopsy


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Lung metastases


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3nterstitial )attern


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• Mechanism1 diff-se or irreg-lar thic"ening ofl-ng interstices or architect-ral destr-ction of

interstiti-m 'honey comb or end stage l-ng(


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UIP


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Reticular Pattern:

Rheumatoid Arthritis

U3)


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3nteresting cases


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Miliar !"


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Air "ronchogram


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chest radiology med students2

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