Chest x ray fundamentals

Chest X-Ray Fundamentals

Dr. Emad EfatShebin El kom Chest hospital

July 2016

Chest X-ray - Tutorials

1. Chest X-ray - Systematic approach

2. Chest X-ray - Quality

3. Chest X-ray - Anatomy

4. Chest X-ray - Abnormalities

5. Chest X-ray - Tubes

Chest X-ray - Systematic approach Anatomical structures to check:

1. Trachea and bronchi

2. Hilar structures

3. Lung zones

4. Pleura

5. Lung lobes and fissures

6. Costophrenic angles

7. Diaphragm

8. Heart

9. Mediastinum

10. Soft tissues

11. Bones

12. Below diaphragm and hidden areas

Systematic approach Anatomical structures to check:

Systematic approach - Patient and image data

Check the patient's identity

Note the image date and time

Note the image projection: Check if a posterior anterior (PA) or anterior posterior (AP) projection was used, and note if the patient was standing, sitting or supine? Was the mobile X-ray machine used?

The image annotations are often useful:

This is a mobile chest X-ray taken with the patient supine, at 11.25 am in the resuscitationroom. The patient's name, ID number and date of birth are annotated. Note the side marker is correct.

Systematic approach - projection

Chest x-ray :

1. P-A view

2. A-P view : for Ambulatory limit

3. Lateral ( Lt/Rt ) : for Effusion or thickening

4. A-P supine 5. Lateral decubitus (Lt/Rt) 6. Lordotic : for Apical lesion7. Oblique (Rt/Lt;

post/anterior)

Systematic approach - Image quality

Assess the image quality: The chest X-ray should be checked for rotation, inspiration and penetration (Mnemonic-RIP-Rest In Peace ).

Comment on the presence of medical artifacts

Can the clinical question still be answered?

Systematic approach - The obvious abnormality

It is often appropriate to start by describing the most striking abnormality. However, once you have done this, it is vital to continue checking the rest of the image. Remember that the most obvious abnormality may not be the most clinically important.

The elephant in the

image!

If there is an elephant

in the image, don't

ignore it! Describe it

in detail and then use

your system to

continue examining the image.

Systematic approach - Describing abnormalities

'Shadowing', 'Opacification', 'increased density',

'increased whiteness' are all acceptable terms

'Lesion descriptors' may lead you towards a diagnosis

Be descriptive rather than jumping to a diagnosis

'Lesion descriptors'6. Position Anterior/

Posterior/Lung zone etc.

7. Shape Round/ Crescentic/etc.

8. Edge Smooth/

Irregular/Spiculated

9. Pattern Nodular/

Reticular(netlike)

10.Density Air/ Fat/Soft tissue/ Calcium/Metal

1. Tissue involved Lung,

heart, aorta, bone etc.

2. Size Large/ Small/Varied

3. Side Right/ Left

Unilateral/ Bilateral

4. Number Single/ Multiple

5. Distribution Focal/

Widespread

Systematic approach - Describing abnormalities

'Shadows, opacities, densities'

Tissue involved: Lung

Size: Small (>2 cm)

Side: Bilateral

Number: Multiple

Distribution: Widespread

Position: Mainly middle

to lower zones

Shape: Round

Edge: Irregular

Pattern: Nodular

Density: Soft tissue

Diagnosis:

Description helps with diagnosis. Once you have put all the above terms

together, there can only be one diagnosis.

Metastatic disease

Systematic approach - Locating abnormalities

Consider its anterior-posterior position.

A lateral view may help, but 3D location may also be

possible on a posterior-anterior (PA) view if you have a

knowledge of chest X-ray anatomy and an understanding

of the 'silhouette' sign.

The 'silhouette' sign:

The silhouette sign is a misnomer !

It should be called the 'loss of silhouette' sign.

Normal adjacent anatomical structures of differing

densities form a crisp 'silhouette,' or contour.

Loss of a specific contour can help determine

the position of a disease process.


The 'silhouette' sign: Loss of contour of :

1 - Left heart border Lingula disease

2 - Hemidiaphragm Lower lobe lung disease

3 - Paratracheal stripe Paratracheal disease

4 - Chest wall Lung, pleural or rib disease


The 'silhouette' sign: Loss of contour of :

5 - Aortic knuckle Anterior mediastinal or left upper lobe disease

6 - Paraspinal line Posterior thorax disease

7 - Right heart border Middle lobe disease

Systematic approach - Review areas

After a systematic look at the whole chest X-ray, it is worth

re-checking hidden areas that may conceal important

pathology.

Hidden areas:

• Apical zones

• Hilar zones

• Retrocardial zone

• Zone below the dome of diaphragm

Systematic approach - Interpretation

Whatever the findings are, they should only be interpreted in view of the clinical setting.

Remember to treat the patient - not the X-ray!

Occasionally there will be an unexpected finding (Incidental Finding), which may need to be considered with caution, especially if equivocal or if it does not fit the clinical scenario.

Posteroanterior (PA) chest radiograph shows an incidental finding of a solitary pulmonary nodule adjacent to the left hilum.

Chest X-ray quality - Inclusion

Check the image for: Inclusion, Projection, Rotation, Inspiration, Penetration and Artifact.

Check to see if a poor quality X-ray demonstrates a life threatening abnormality before dismissing it.

Check to see if the clinical question still be answered?

Inclusion:A chest X-ray should include the entire thoracic cage ( first ribs, Costophrenic angles, Lateral edges of ribs ).

Chest X-ray quality - Projection

AP projection :

AP projection image is of lower quality than PA image.

The scapulae are not retracted laterally and they remain projected over each lung.

Heart size is exaggerated

Chest X-ray quality - Rotation

Rotation: The spinous processes should lie

half way between the medial ends of the clavicles

Rotation affects heart size & shape, aortic tortuosity, tracheal position and density of lung fields

Rotation can obscure a pneumothorax . Can also mimic a mediastinal shift.

Rotation may cause an increase in the transradiancy (blackness) of the lung on the side to which the patient is rotated.

Rotation will also alter the relative appearance on the hila and can mimic hilar asymmetry.


Frontal chest x-Ray (CXR) with subject rotated to the left. Note an enlarged heart and small left pleural effusion. The left hemithorax is darkerthan the right due to the rotation.

Chest X-ray quality - Inspiration & lung volume

Assessing inspiration:

Count ribs down to the diaphragm.

The diaphragm should be intersected by:

the 5th to 7th (right 6th anterior rib ) anterior ribs in the mid-clavicular line or

The 8th–10th (9th) posterior ribs . CXR in full inspiration

If the image is acquired in the expiratory phase or with a poor inspiratory effort:

1. The lungs are relatively airlessand their density is increased.

2. Increase in lower zone opacity

3. The hila are compressed and appear more bulky

4. Exaggeration of heart size

5. Obscuration of the lung bases.

Chest X-ray quality - Inspiration & lung volume

poor inspiratory effort

full inspiration the same patient

Chest X-ray quality - Penetration

Differential Absorption:

Penetration of the x-ray beam is dependent on tissue density

Denser object = Less beam striking the film (more absorption) = whiter

Less dense = More beam striking the film = blacker


A well penetrated (exposed) chest X-ray :

The end plates of the lower thoracic vertebral bodies

should be just visible through the cardiac shadow.

The left hemidiaphragm should be visible to the edge of the spine.


Good penetrationYou should be able to just see the thoracic spine through the heart


An under-penetrated film looks diffusely opaque (too white), structures behind the heart are obscured, and left lower lobe pathology may be easily missed.

An over-penetrated film looks diffusely lucent, the lungs appear blacker than usual and the vascular markings and lung detail are poorly seen.

Chest X-ray quality - Artifact

Radiographic artifact

Rotation, incomplete inspiration and incorrect penetration. Other radiographic artifact includes clothing or jewellery not removed.

Patient artifact

Poor co-operation with positioning or movement. Very often obesity exaggerates lung density. Occasionally normal anatomical structures such as hairor skin folds can cause confusion. Hair artifact

Chest X-ray anatomy - Airways

Assessing the airways

Start your assessment of every X-ray by looking at the airways.

The trachea should be centralor slightly to the right.

If the trachea is deviated:

If the patient is rotated, or if there is pathology.

If the trachea is deviated:

If it has been pushed or pulled by a disease process.

The trachea branches at thecarina, into the left and rightmain bronchi, and these canoften be followed as theybranch beyond the hila andinto the lungs.

Chest X-ray anatomy - Airways

large left pleural effusion, and tracheal shift away from the effusion

Tension pneumothorax with tracheal deviation to right

Tracheal shift to the right due to thyroidenlargement

Causes of tracheal deviation: Ipsilateral (To pull): Collapse and Fibrosis Contralateral ( To push): Apical mass , Pleural effusion

and Pneumothorax

Chest X-ray anatomy - Hilar structuresThe structures contributing to hilar shadows are:Major: Pulmonary artery and veins

Minor: Fat, Lymph nodes and Bronchial walls (not visible unless abnormal)

Normal Hilum: Position: Left hilum is slightly

higher than the right hilum, Only in a minority of cases the right hilus is at the same level as the left, but never higher.

Shape: Concave Size: Similar on both sides Density: Almost same on both sides

Deoxygenated blood (blue arrow) is pumped upwards out of the right ventricle (RV) via the main pulmonary artery (MPA). This divides into left (LPA) and right (RPA) which each pass via the lung hila into the lung tissue

Chest X-ray anatomy - Hilar structures

The hilar points: the angle formed by the descending upper lobe veins, as they cross behind the lower lobe arteries

Not every normal patient has a very clear hilar point on both sides, but if they are present then they can be useful in determining the position of the hila.

Identify main lower lobe pulmonary arteries: They can be compared to a little finger pointing downwards and medially.

Chest X-ray anatomy - Lung zones

The chest radiograph zones:

1. Apical zone: above the clavicles

2. Upper zone: below the clavicles and above the cardiac silhouette (i.e. up to lower margin of 2nd rib )

3. Mid zone: the level of the hilar structures (i.e. from lower margin of 2nd rib to lower margin of 4th rib )

4. Lower zone: the bases ( i.e. from 4th rib to diaphragm )

Chest X-ray anatomy - Pleura and pleural spaces

Trace round the entire edgeof the lung where pleural abnormalities are seen.

Start and end at the hila

Is there pleural thickening?

Is there a pneumothorax?

The lung markings should be visible to the chest wall

Is there an effusion? The costophrenic angles and hemidiaphragms should be well defined

Chest X-ray anatomy - Pleura and pleural spaces

Costophrenic recesses and angles:

The costophrenic angles are limited views of the costophrenic recess

On a frontal view the costophrenic angles should be sharp.

The costophrenic angles consist of the lateral chest wall and the dome of each hemidiaphragm.

Chest X-ray anatomy - Lung lobes and fissures

In the right lung there is an oblique fissure( of ) and a horizontal fissure ( hf ) , separating the lung into three lobes - upper, middle, and lower.

Each lobe has its own visceral pleural covering.

Chest X-ray anatomy - Lung lobes and fissures

The left lung is divided into two lobes, upper and lower.

These lobes have their own pleural covering and these lie together to form the oblique (major) fissure ( of ).

Chest X-ray anatomy - Diaphragm

The hemidiaphragms are not at the same level on frontal erect inspiratory chest radiographs, but are usually within one rib intercostal space height (2 cm) of each other.

The left hemidiaphragm is usually lower than the right.

If the left hemidiaphragm is higher than the right or the right is higher than the left by more than 3 cm, one of the many causes of diaphragmatic elevation should be considered.

Chest X-ray anatomy - Diaphragm

Hemidiaphragms - lateral view:

The left and right hemidiaphragms are almost superimposed on a lateral view.

Anteriorly the left hemidiaphragm blendswith the heart and becomes indistinct.

Chest X-ray anatomy - Heart size and contours

From superior to inferior:

1. Right paratracheal stripe:

made up of right brachiocephalic vein and SVC

2. Arch of the azygous vein

3. Ascending aorta in older individuals projects to the right of the SVC

4. Superior vena cava (SVC)

5. Right atrium

6. Inferior vena cava (IVC)

The normal contours of the heart and mediastinum (cardiomediastinal contour):

Right cardiomediastinal contour



Left paratracheal stripe

Made up of left common carotid artery, left subclavianartery and the left jugular vein

Aortic arch +/- aortic nipple (left superior intercostal vein)

Pulmonary artery

Auricle of left atrium

Left ventricle

The normal contours of the heart and mediastinum (cardiomediastinal contour):

Left cardiomediastinal contour


Lateral view: Anterior cardiomediastinal contour


1. Superior mediastinum

1. great vessels

2. thymus

2. Ascending aorta

3. Right ventricular outflow track

4. Right ventricle

Posterior cardiomediastinal contour


1. Left atrium and pulmonary veins

2. Right atrium

3. Inferior vena cava


Cardiothoracic ratio:

The cardiothoracic ratio should be less than 0.5. i.e. A+B/C<0.5

A cardiothoracic ratio > 0.5 suggests cardiomegaly in adults

A cardiothoracic ratio > 0.6 suggests cardiomegaly in newborn.


There are several structures in the superior mediastinum that should always be checked. These include the aortic knuckle, the aorto-pulmonary window, and the right para-tracheal stripe.


It is a space located between the arch of the aorta and the pulmonary arteries.

This space can be lost as a result of mediastinallymphadenopathy (e.g. malignancy).

The aorto-pulmonary window:

Aortic knuckle (red arrow) & Aortopulmonary window (green arrow)

Chest X-ray anatomy - Mediastinum In lateral CXR, mediastinum divided into : Superior mediastinum (S): above the

thoracic plane or the plane of Ludwig(a horizontal line that runs from sternal angle or angle of Louis) to the inferior endplate of T4)

Inferior mediastinum: below the plane of Ludwig Anterior mediastinum (A): anterior to

the pericardiumMiddle mediastinum (M): within the

pericardium Posterior mediastinum (P): posterior to

the pericardium In PA view, the mediastinum is that space

between the lungs and pleural surfaces (yellow lines).

Chest X-ray anatomy - Bones and Soft tissuesBones:

Ribs (anterior and posterior)

Clavicles and shoulders

Sternum

Vertebrae

Shoulder joints

Soft tissues :

Breast shadows

Skin folds

Muscles

Check for: Symmetry, Deformities, Fractures, Masses, Calcifications and Lytic lesions .

Chest X-ray anatomy - Lateral view

Interpretation of lateral film


Interpretation of lateral film

The clear spaces

Retrosternal space

Retrotrachealspace

Retro cardiac

Vertebral translucency

Diaphragm outline

The fissures

The trachea

The sternum


Retrosternal space Seen as a normal lucency

between the posterior aspect of the sternum and anterior aspect of the ascending aorta

This space should be visible and less than 2.5cm in width.

Can be demonstrated at point 3cm below manibrium sterni

An increased retrosternal airspace is a reliable sign of pulmonary emphysema, while obliteration indicates anterior mediastinal mass e.g. lymphoma.

Chest X-ray anatomy: Lateral view

Vertebral translucency

The ‘‘spine sign,’’ which states that the normal lateral chest film shows increasing overall lucencyas one looks down the thoracic vertebral bodies from the neck to the diaphragms.

Causes of failure to darken gradually above the diaphragms: Pleural thickening Lower lobe collapse Mediastinal mass


Diaphragm outline

Right hemidiaphragmcontinues anteriorly

left hemidiaphragmblends with the heart and becomes indistinct Anteriorly.


The fissures

How to speak - Normal CXR

This is chest radiograph, PA view with normal exposure, no rotation and without any apparent bony abnormality. Trachea is placed centrally & lung fields are clear with normal broncho-vescicular markings. Cardiovascular silhouette is within normal limits with normal cardiothoracic ratio. Mediastinum, costo-phrenic, cardio-phrenicangles, dome of diaphragm & soft tissue shadow within normal limits.

Chest X-ray Abnormalities - TracheaEnsure trachea is visible and in midline

1. Tracheal displacement (discussed previously)

2. Trachea normally narrows at the vocal cords

3. View the carina, angle should be between 60 –100 degrees. Beware of things that may increase this angle, e.g. left atrial enlargement, lymph node enlargement and left upper lobe atelectasis

4. Follow out both main stem bronchi

5. Check for tubes, foreign bodies etc.

6. If an endotracheal tube is in place, check the positioning, the distal tip of the tube should be 5-7cm above the carina

Chest X-ray Abnormalities - Trachea

Chest X-ray Abnormalities - Trachea

In this patient, the endotracheal tube is in the right mainstem bronchus, and the left sided is not being ventilated. That is why the left side is collapsed

Chest X-ray Abnormalities - The lung hilum

A. Hilar position: If a hilum has moved, you should try to determine if it has

been pushed or pulled, just like you would for the trachea.

The left hilum must never be lower than the right hilum. Whenever a left hilum appears lower than the right hilum – look for other evidence suggestive of: Collapse of either the left lower lobe or of the right

upper lobe Enlargement of the right hilum


A. Hilar position:

Superior displacement and horizontalization of the right hilum (white curved arrow) due to atelectasis of the right upper lobe (black arrows). the hilum (red arrow)

Left lower lobe atelectasis. The blue arrows point to the edge of a triangular region of atelectatic left lower lobe. Left Hilum displaced inferiorly. the hilum (red arrow)


B. Hilar enlargement: May be unilateral or bilateral, symmetrical or asymmetrical


Analyze the enlargement of hilum (if present):

1. Lymph Node enlargement: Lobulated appearance

(lumpy-bumpy opacity ) Presence of calcification

within the mass indicates usually tuberculosis.

Egg-shell calcificationindicates silicosis or sarcoidosis. Calcified bilateral hilar

lymphadenopathy in sarcoidosis

Chest X-ray Abnormalities - The lung hilum2. Arterial enlargement: Smooth margins In pulmonary arterial

hypertension the arteries in the outer two-thirds of each lung are smaller than those at the hila (peripheral pruning)

Primary pulmonary hypertension showing right heart enlargement and enlargement of the main pulmonary artery and its rightand left branches.

Chest X-ray Abnormalities - The lung hilum3. Malignancy: Spiculated irregular or

indistinct margins Hilar enlargement due to

malignant lung lesion is also associated with superior mediastinallymphadenopathy. Look at the lung fields (for presence of tumor) and bone/ribs for metastasis. This patient has a bulky right

hilum. This was shown to be due to a bronchogenic tumour.


C. Hilar density:May be due to : A mass or calcification in

the hilum Dense Hilum Sign:

superimposition of another abnormal density (pneumonia or a mass ) in the lung or mediastinum that projects over the hilum on the frontal image.

Here is increased density and enlargement of the right hilum with a multilobular contour. The CT scans show enlarged mediastinaland right hilar lymph nodes.


Dense Hilum Sign:

On the frontal (PA) image, the left hilum (red arrow) appears denser than the right hilum (white arrow). This may be caused by a hilar mass, but not necessarily. The lateral view shows airspace disease (pneumonia) in thesuperior segment of the left lower lobe (yellow arrow).

Chest X-ray Abnormalities - lung fields

Lung abnormalities:Abnormal whiteness (increased density):ConsolidationAtelectasisNodule or mass Interstitial

Abnormal blackness (decreased density):Cavity Cyst Emphysema

Assess the lungs by comparing the upper, middle and lower lung zones on the left and right

Chest X-ray Abnormalities - lung fieldsFour patterns of increased density: Consolidation Lobar Diffuse Multifocal ill-

defined Atelectasis Nodule or mass Solitary Pulmonary

Nodule Multiple Masses Interstitial Reticular Fine Nodular

lung field abnormalities - ConsolidationThe key-findings on the Ill-defined

homogeneous opacity obscuring vessels

Silhouette sign: loss of lung/soft tissue interface

Air-bronchogramExtention to the pleura

or fissure, but not crossing it

No volume lossMay be Blunting of

costophrenic angle

X-ray are:

lung field abnormalities - Consolidation Air bronchogram refers to the phenomenon of air-filled

bronchi (dark) being made visible by the opacification of surrounding alveoli (grey/white).

lung field abnormalities - Consolidation

lung field abnormalities - Consolidation Bat's wing appearance:

A bilateral perihilar distribution of consolidation. Reverse bat's wing appearance:

Peripheral or subpleural consolidation


Reverse bat's wing appearanceIn Chronic eosinophilic pneumonia


Right Upper Lobe Consolidation:


Right middle Lobe Consolidation:


Right lower Lobe Consolidation:


left upper Lobe Consolidation:


Lingular consolidation:


Left lower lobe consolidation:


Lymphoma: Imaging Findings:

Mediastinal widening due to mediastinal lymphadenopathy

Parenchymal lung involvement: Multiple nodules Consolidation with an

air - bronchogram Segmental or lobar

atelectasisPleural effusions (Mostly

small, unilateral, and exudative)

Destructive rib or vertebral body lesion

Chest X-ray reveals multiplescattered consolidation lesions involving both lungs


Tuberculosis (TB): Primary pulmonary tuberculosis:Imaging Findings:

Patchy or lobar consolidation Cavitation (uncommon) Caseating granuloma

(tuberculoma) which usually calcifies (known as a Ghonlesion)

Ipsilateral hilar and mediastinal (paratracheal) lymphadenopathy, usually right sided.

Calcification of nodes Atelectasis Pleural effusions

Chest X-ray shows right upper lobe and left midzone consolidationand adenopathy.


Tuberculosis: Post-primary pulmonary: Imaging Findings:

Almost always affect:1. Posterior segments of the

upper lobes2. Superior segments of the

lower lobes Patchy consolidation Poorly defined linear and

nodular opacities Cavitation, Aspergillomas,

fibrosis and Bronchiectasis pleural effusion Hilar nodal enlargement Lobar consolidation,

tuberculoma and miliary TB

Patchy bilateral opacification of the upper lung lobes with cavitation most marked on the left (arrow)


Tuberculoma and Miliary Tuberculosis: Imaging Findings:

Tuberculoma and miliary tuberculosis are rare

Miliary deposits are seen both in primary and post-primary tuberculosis. It appear as 1-3 mm diameter nodules, which are uniform in size and uniformly distributed

Tuberculomas are usually found as single nodules and they may include a cavity or a calcification with sharp margins. They are usually found in the upper lobes

Miliary Tuberculosis


Aspergillomas: Mass-like fungus balls of Aspergillus fumigatus, occur in patients

with normal immunity but with pre-existing cavities: pulmonary tuberculosis pulmonary sarcoidosis bronchiectasis bronchogenic cyst pulmonary sequestration Pneumocystis pneumonia (PCP)

associated pneumatocoeles Imaging Findings: Air crescent sign :

Rounded or ovoid soft tissue attenuatingmasses located in a surrounding cavity and outlined by a crescent of air. Differential diagnosis (DD); hydatid cyst, bronchogenic carcinoma and PCP.

Rounded density with an air crescent


Tuberculosis: Imaging Findings:


Aspiration Pneumonitis and Pneumonia: Imaging Findings:

Chest x-ray shows an infiltrate, frequently in the superior or posterior basal segments of a lower lobe orthe posterior segment of an upper lobe (The right lower lobe is the most frequent location).

Aspiration-related lung abscess

Interstitial or nodularinfiltrates, pleural effusion, and other changes may be slowly progressive.

Typically localized pneumonia in the right lower lobe.


Consolidation due to Lung infarction:

Hampton’s Hump: consists of a pleural based shallow, wedge-shaped consolidation in the lung periphery with the base against the pleural surface


Klebsiella pneumonia (Friedländer’s pneumonia): Imaging Findings:

Usually involves one of the upper lobes

Homogeneous, nonsegmental, lobar consolidation

Bulging Fissure Sign: bulging of usually minor fissure from heavy, exudate ( arrow)

Lung abscess (es) Pleural effusion (70%)

and/or empyema

Consolidation - Cardiogenic pulmonary edema

Cardiogenic pulmonary edema Consolidation due to Congestive Heart Failure (CHF) :


Stage I CHF – Redistribution:Redistribution of the pulmonary veins. This is know as

cephalization (blue arrow) because the pulmonary veins of the superior zone dilate due to increased pressure.

An increase in width of the vascular pedicle (red arrows)


The vascular pedicle is bordered on the right by the superior vena cava and on the left by the left subclavian artery origin


Stage II CHF - Interstitial edema Characterized by:1. Kerley’s A lines: extend radially from the hilum to the

upper lobes; represent thickening of the interlobular septa that contain lymphatic connections.

Consolidation - Cardiogenic pulmonary edema 2. Kerley’s B lines: are short horizontal lines situated

perpendicularly to the pleural surface at the lung base; they represent edema of the interlobular septa.

Consolidation - Cardiogenic pulmonary edema 3. Thickening of the bronchial walls (peribronchial cuffing)

and as loss of definition of these vessels (perihilar haze).

Consolidation - Cardiogenic pulmonary edema 4. Fluid in the major or minor fissure (shown here)

produces thickening of the fissure beyond the pencil-point thickness it can normally attain


Stage III CHF - Alveolar edema Characterized by:

Alveolar edema with perihilar consolidations and air bronchograms ( Bat's wing or butterflypulmonary opacities ) (yellow arrows)

Pleural fluid (blue arrow)Prominent azygos vein

and increased width of the vascular pedicle (red arrow)

An enlarged cardiac silhouette (arrow heads).


Adult Respiratory Distress Syndrome ( ARDS )ARDS versus Congestive Heart Failure:

Diffuse bilateralpatchy infiltrates

More uniformopacification

Homogenously distributed

No cardiomegalyNo cephalizationUsually no pleural

effusion or Kerley B lines

lung field abnormalities - ConsolidationBronchopneumonia characterised by:Multiple small nodular or reticulonodular opacities which

tend to be patchy and/or confluent. The distribution is often bilateral and asymmetric, and

predominantly involves the lung bases

lung field abnormalities - ConsolidationWegener's granulomatosis characterized by: Nodules or mass lesions, which may cavitate Fleeting focal infiltrates (lung consolidation )


It is a congenital abnormality. A nonfunctioning part of the lung lacks communication with the bronchial tree and receives arterial blood supply from the systemic circulation.

The plain X-ray often shows a triangular or oval-shaped, basal, posterior lung mass, or, less commonly, as a cyst more on the left

An infected sequestration may be associated with a parapneumoniceffusion, and may contain one or more fluid levels.

Pulmonary sequestration: This is an uncommon cause of lobar consolidation.

Chest radiograph showing left lower lobe consolidation(arrow)

lung field abnormalities - ConsolidationEosinophilic pneumonia (EP):

Acute EP : A pattern consistent with pulmonary edema, with extensive airspace opacity, interlobular septal thickening (ie, Kerley B-lines), and pleural effusions. The infiltrates are diffuse and not peripherally based.

Chronic EP : Nonsegmental peripheral airspace consolidation(“photographic negative shadow of pulmonary oedema” - reverse bat wing appearance) involving mainly the upper lobes .

Chronic EP: The chest x-ray shows bilateral peripheralpatchy infiltrates with relative sparing of the lower lobes.

lung field abnormalities - ConsolidationSeptic emboli:Usually present as multiple ill-defined densities, which

are probably consolidations. In about 50% cavitation is seen.

lung field abnormalities - Interstitial disease On a CXR the most common pattern is reticular. The ground-glass pattern is frequently not detected. The cystic pattern is also difficult to appreciate. High-resolution computed tomography (HRCT) has the ability

to better define diseases that have similar CXR patterns. There are many causes. For example:

lung field abnormalities - Interstitial disease

lung field abnormalities - Alveolar vs. Interstitial

Alveolar = air sacs

Radiolucent

Can contain blood, mucous, tumor, or edema (“airless lung”)

Interstitial = vessels, lymphatics, bronchi, and connective tissue

Radiodense

Interstitial disease: prominent lung markings with aerated lungs


Linear Pattern: There is thickening of the

interlobular septa (contain pulmonary veins and lymphatics ), producing Kerley lines.

DD of Kerly Lines: ( Pulmonary edema is the most common cause, Mitral stenosis, Lymphangiticcarcinomatosis, Malignant lymphoma, Congenital lymphangiectasia, Idiopathic

pulmonary fibrosis, Pneumoconiosis and Sarcoidosis )


Reticular Pattern: Fine "ground-glass" (1-2

mm): e.g. interstitial pulmonary oedema

Medium "honeycombing" (3-10 mm): commonly seen in pulmonary fibrosis

Coarse (> 10 mm): cystic Spaces caused by parenchymal destruction, e.g. usual interstitial pneumonia, pulmonary sarcoidosis, pulmonary Langerhans cell histiocytosis


Causes of Reticular Pattern: Pulmonary edema ( heart

failure, fluid overload, nephropathy )

Infection ( viral, mycoplasma, Pneumocystis, malaria )

Post-infectious scarring(tuberculosis, histoplasmosis, coccidioidomycosis)

Mitral valve disease Collagen vascular disorders Granulomatous disease

( pulmonary sarcoidosis, eosinophilic granuloma )

Drug reactions (e.g. amiodarone )

Pulmonary neoplasms ( lymphangitis carcinomatosis, pulmonary lymphoma )

Inhalational lung disease (asbestosis, silicosis, coal workers pneumoconiosis, hypersensitivity pneumonitis, chronic aspiration pneumonia)

Idiopathic (usual interstitial pneumonia, lymphangioleiomyomatosis, tuberous sclerosis, neurofibromatosis, amyloidosis )


Nodular pattern: A nodular pattern consists

of multiple roundopacities, generally ranging in diameter from 1 mm to 1 cm

Nodular opacities may be: Miliary nodules: <2 mm Pulmonary

micronodule: 2-7 mm Pulmonary nodule:

7-30 mm Pulmonary mass:

>30mm


Causes of Miliary opacities : Infection tuberculosis fungal (often febrile) healed varicella pneumonia viral pneumonitis nocardosis salmonella

Miliary metastases thyroid carcinoma renal cell carcinoma breast carcinoma malignant melanoma pancreatic neoplasms osteosarcoma trophoblastic disease

Sarcoidosis Pneumoconioses silicosis coal workers pneumoconiosis

Pulmonary haemosiderosis Hypersensitivity pneumonitis Langerhans cell histiocytosis pulmonary alveolar

proteinosis


Causes of Calcified pulmonary nodules: Healed infection Calcified granulomata, e.g.

Thoracic histoplasmosisRecovered miliary TB

Healed varicella pneumonia Pneumoconioseses silicosis coalworker's pneuomconiosis

Pulmonary hamartomas Metastatic pulmonary calcification Chronic renal failure Multiple myeloma Secondary hyperparathyroidism Massive osteolytic metastases IV calcium therapy

Pulmonary haemosiderosis idiopathic pulmonary

haemosiderosis Mitral stenosis Goodpasture syndrome

Pulmonary alveolarmicrolithiasis

Sarcoidosis Calcified pulmonary

metastases Pulmonary amyloidosis Pulmonary hyalinizing

granuloma Calcifying fibrous

pseudotumour of lung


A reticulonodularpattern results from a combination of reticularand nodular opacities.

A differential diagnosis should be developed based on the predominant pattern.

If there is no predominant pattern, causes of both nodular and reticular patterns should be considered.

Causes: the same disorders as reticular patterns

Reticulonodular pattern:


Ground-glass appearanceA hazy area of increased attenuation in the lung with preserved bronchial and vascular markings. Aetiology:Normal expiration Partial filling of air spaces Partial collapse of alveoli Interstitial thickening InflammationOedema FibrosisNeoplasm

Perihilar ground-glass appearance in the shape of bats-wings

lung field abnormalities - Interstitial diseaseCystic lung disease:A lung cyst is an air filled structure with perceptible wall typically 1 mm in thickness but can be up to 4 mm. The diameter of a lung cyst is usually < 1 cm.

Aetiology:

Acquired : Honeycombing in UIP

pattern Cystic bronchiectasis Sarcoidosis Pneumocystis

pneumonia Pulmonary laceration in

trauma

Primary : Pulmonary Langerhans cell

histiocytosis lymphangioleiomyomatosis with

or without tuberous sclerosis lymphocytic interstitial

pneumonitis (LIP) Tracheobronchial papillomatosis Sjogren syndrome Neurofibromatosis

lung field abnormalities - Interstitial diseaseHypersensitivity pneumonitis (HP) - (acute & Subacute):

PCX-ray may be normal PCX-ray commonly shows

a bilateral diffuse micro nodular infiltrate, usually dense towards hila, have a predilection for the midzones or lower zones. An irregular and linear infiltratemay be present in lower zones.

Acute severe attack : a pattern of diffuse airspace disease or a ground-glass pattern mimicking that of pulmonary edema or,

more rarely, as consolidation.

Bilateral reticulonodular interstitial infiltration secondary to subacute hypersensitivity pneumonitis.

lung field abnormalities - Interstitial diseaseHypersensitivity pneumonitis (HP) - (chronic):

Pulmonary fibrosis affects upper zones predominantly, loss of lung volume.

Reticular pattern and honeycombing, more severe in the upper lobes than in the lower ones

Larger ring shadows 1-4 mm in diameter are due to bullae, blebs, cysts, or bronchiectasis.

Parallel line shadows are caused by bronchiectasis or bronchial wall thickening

chronic HP—a pigeon fancier—shows reticular-nodularopacification.


Sarcoidosis; classified by chest x-ray into 5 stages : stage 0: normal chest

radiograph stage I: hilar or

mediastinal nodal enlargement only

stage II: nodal enlargement and parenchymal disease

stage III: parenchymal disease only

stage IV: end-stage lung (pulmonary fibrosis)

lung field abnormalities - Interstitial diseaseRadiographic varieties of Sarcoidosis : Hilar and mediastinal lymphadenopathy: Garland triad, also known

as the 1-2-3 sign is bilateral hilar and right paratracheallymphadenopathy.

Dystrophic calcification of involved lymph nodes: Calcification can be amorphous, punctate, popcorn like, or eggshell.

Parenchymal changes: including fine nodular; reticulonodular; acinar (poorly marginated, small to large nodules or coalescent opacities); and, rarely, focal (solitary nodule or mass).

Mycetomas: in stage IV sarcoidosis and apical bullous disease In stage IV : when fibrosis supervenes, hilar retraction, decreased

lung volume, and honeycomb lung may be present. Bullous disease, air trapping and diaphragmatic tenting may also be seen.

Pulmonary hypertension may develop: Prominent main pulmonary artery, enlarged right and left pulmonary arteries, right ventricular enlargement, and attenuation of peripheral vessels.


Can be even normal in patients with very early disease

In advanced disease: Decreased lung volumes Basal fine to coarse

reticulation due to more extensive involvement of the lower lobes

Honeycomb Lung and traction bronchiectasis

The major fissure is shifted inferiorly which is best seen on the lateral chest radiograph.

Usual interstitial pneumonia (UIP): Plain film features are nonspecific.

lung field abnormalities - Interstitial diseaseUsual interstitial pneumonia (UIP): Honeycombing:

The radiographic appearance of honeycombing comprises reticular densities caused by the thick walls of the cysts.

Chest radiograph demonstrates coarse bibasilarreticular interstitial disease ( honeycomping ) (red arrows)

lung field abnormalities - Interstitial diseaseBronchiectasis: CXR may be normal Volume loss Increased pulmonary markings Indistinct vessel margins due

to peribronchial fibrosis. Tram lines: dilated and thickened

airways Ring shadows: thickened and

abnormally dilated bronchial walls. Clusters of cysts in Cystic type Dextrocardia (Immotile cilia

syndrome) Mucus plugging (finger-in-glove)

appearance Atelectasis or diffuse lung fibrosis

Tram-Track sign

lung field abnormalities - Interstitial diseaseBronchiectasis:

Cystic bronchiectasis withmultiple cystic airspaces

Ring shadow ( red arrow) & Tram lines ( yellow arrow)

lung field abnormalities - Interstitial diseaseBronchiectasis: Location: Allergic bronchopulmonary

aspergillosis – central Childhood viral infections –

Lower lobe predominance Mounier-Kuhn syndrome –

First to fourth order bronchi Mycobacterial avium complex

- Right middle lobe and lingual Primary ciliary dyskinesia –

Fifty percent associated with situs inversus, middle lobe, and lingular predominance

Cystic fibrosis - Upper lobe, particularly right upper lobe

Postprimary mycobacterial tuberculosis (traction bronchiectasis) – Apicaland posterior segments of upper lobes

Sarcoidosis (traction bronchiectasis) – Upper lobe predominance

Usual interstitial pneumonitis (commonest cause of traction bronchiectasis) - Lowerlobe predominance, worse peripherally

lung field abnormalities - Interstitial diseasePneumocystis pneumonia (PCP) - CXR findings: Bilateral, diffuse, often perihilar,

fine, reticular interstitial opacification, which may appear somewhat granular.

Air-space consolidation Cystic lung disease, spontaneous

pneumothorax, and isolated lobar or focal consolidation, particularly with an upper-lobe predominance.

Miliary nodularity, bronchiectasis,endobronchial lesions, and mediastinal lymphadenopathy,which may show calcification

CXR may be normal

Typical bilateral air-space consolidation of PCP in acquired immunodeficiency virus infection.


Lymphangitic carcinomatosis: The term given to tumour spread

through the lymphatics of the lung, and is most commonly seen secondary to adenocarcinoma e.g. breast cancer, bronchogenic adenocarcinoma, colon cancer, stomach cancer, prostate cancer, cervical cancer, thyroid cancer, etc.

CXR may be normal or Appears as reticular or reticulonodularopacification, often with associated septal lines (Kerley A and B lines), peribronchial cuffing, pleural effusions, and mediastinal and/or hilar lymphadenopathy

Lymphangitic carcinomatosis. The radiographlike in the case of interstitial pulmonary oedema


Silicosis:1. Acute silicosis (silicoproteinosis):

Large bilateral perihiliar consolidationor ground glass opacities.

2. Chronic simple silicosis (common type ): CXR shows multiplenodular opacities:

Well-defined and uniform in shape and attenuation

From 1 to 10 mm in diameter Predominantly located in the upper

lobe and posterior portion of the lung Nodules may Calcify Lymph node enlargement common:

Eggshell calcification of hilar nodes (5%), DD: Sarcoidosis

Silicosis features a diffuse micronodular lung diseasewith an upper lobe predominance


Silicosis:3. Complicated silicosis

(progressive massive fibrosis (PMF), or conglomerate silicosis): CXR shows largesymmetric bilateral opacitiesthat are:

1 cm or more in diameter and with an irregular margin

Usually in mid-zone or periphery of upper lobes

Compensatory emphysemaoccurs in lower lung fields.

Progressive Massive Fibrosis (PMF) with scarring and retraction of hila upwards.

Progressive Massive Fibrosis. There are conglomerate soft-tissue densities in both upper lobes (black arrows) with linear scarring leading from the lower lobes (white arrows).


Silicosis:4.Complicated silicosis : Complicated

by tuberculous (Silicotuberculosis), non-tuberculous mycobacterial, and fungal infection, certain autoimmune diseases, and lung cancer.

Eggshell node calcification in silicosis

Silicotuberculosis, with bilateral conglomerate disease. Several cavities are present in the left upper lobe

lung field abnormalities - Atelectasis

CXR show direct and indirect signs of lobar collapse:Direct signs include displacement of fissures and

opacification of the collapsed lobe. Indirect signs include the following: Displacement of the hilum Mediastinal shift toward the side of collapse Loss of volume in the ipsilateral hemithorax Elevation of the ipsilateral diaphragm Crowding of the ribs Compensatory hyperlucency of the remaining lobes Silhouetting of the diaphragm or heart border


Complete atelectasis: Characterized by:Opacification of the entire hemithoraxAn ipsilateral shift of the mediastinum.


Right upper lobe collapse: Increased density in the upper medial

aspect of the right hemithorax Elevation of the horizontal fissure Loss of the normal right medial

cardiomediastinal contour Elevation of the right hilum Hyperinflation of the right middle and

lower lobe result in increased translucency of the mid and lower parts of the right lung

Right diaphragmatic tenting

Non-specific signs : Elevation of the hemidiaphragm Crowding of the right sided ribs Shift of the mediastinum and trachea to the right


Right upper lobe collapse: The Golden S-sign (or reverse S-sign of Golden): is seen on PA view and the appearance is that of right upper lobar collapse with a central mass expanding the hilum.

On the lateral projection it is harder to identify. Elevation of the horizontal fissure and upper part of the oblique fissure may be visible.


Right middle lobe collapse: On lateral projection, right

middle lobe collapse is usually relatively easy to identify,

Appearing as a triangular opacity in the anterior aspect of the chest overlyingthe cardiac shadow.

The horizontal fissure is displaced inferiorly and the inferior part of the oblique fissure, displaced anterosuperiorly.


Right middle lobe collapse:On frontal CXR, the findings are more subtle: The normal horizontal fissure is no

longer visible (as it rotates down) Blurring of the right heart border

(silhouette sign) (in atelectasis as well as consolidation)

Non-specific signs may be subtle or absent due to the small size of the right middle lobe : Elevation of the hemidiaphragm Crowding of the right sided ribs Shift of the mediastinum to the right

linear opacities in the lobe suggest that the collapse is chronic (right middle lobe syndrome), with associated bronchiectasis.


Right lower lobe collapse:On frontal CXR, the findings : Increased opacity (triangular in

shape) at the medial base of the right lung

Obliteration of the silhouette of the right hemidiaphragm

The right hilum is depressed Descending right lower lobe

pulmonary artery is not visualized Right heart border maintained. Non-specific signs :Elevation of the hemidiaphragmCrowding of the right sided ribsShift of the mediastinum to right

The collapsed right lower lobe is a triangular opacity (orange arrows).The right hemidiaphragmatic outline is lost (blue dashed line).


Right lower lobe collapse:On lateral projection: The right

hemidiaphragmaticoutline is lost posteriorly

The lower thoracic vertebrae appear denserthan normal (they are usually more radiolucent than the upper vertebrae) The collapsed right lower lobe a

triangular opacity (orange arrows). The right hemidiaphragmatic outline is lost (blue dashed line).


Left upper lobe collapse: Hazy or 'Veil-like' opacification of

the left hemithorax Right heart border not visible The left hemidiaphragm is still

visible Near-horizontal course of the left

main bronchus The luftsichel sign (next) Elevation of the hemidiaphragm Non-specific signs : 'peaked' or 'tented‘

hemidiaphragm: juxtaphrenicpeak sign

Crowding of the left sided ribsShift of the mediastinum to left

Left upper lobe collapse: Notice the ovoid density at the left hilum, CT confirmed a large left hilar mass, which occluded the left upper lobe bronchus


Left upper lobe collapse: The luftsichel sign:

In some cases the hyperexpanded superior segment of the left lower lobe insinuates itself between the left upper lobe and the superior mediastinum, sharply silhouetting the aortic arch and resulting in a lucency medially ( red arrow ).


Left upper lobe collapse:On lateral projections: left lower lobe is

hyperexpanded and the oblique fissure displaced anteriorly (arrows).

Increase in the retrosternal opacity.


Left lower lobe collapse:1. Triangular opacity in the

posteromedial aspect of left lung2. Edge of collapsed lung may

create a 'double cardiac contour'3. left hilum will be depressed4. loss of the normal left

hemidaphgragmatic outline5. loss of the outline of the

descending aorta6. Non-specific signs indicating

left sided atelectasis : Elevation of the hemidiaphragm Crowding of the left sided ribs Shift of the mediastinum to left


Left lower lobe collapse:7. The flat waist sign refers to flattening of

the contours of the aortic arch and adjacent main pulmonary artery. It is seen in severe left lower lobe collapse and is caused by leftward displacement and rotation of the heart.

8. On lateral projection: The left hemidiaphragmatic outline is

lost posteriorly The lower thoracic vertebrae appear

denser than normal (they are usually more radiolucent than the upper vertebrae)

lung field abnormalities - Nodules and Masses

A solitary pulmonary nodule:Defined as a discrete, well-marginated, rounded opacity less than or equal to 3 cm in diameter that is completely surrounded by lung parenchyma, does not touch the hilum or mediastinum, and is not associated with adenopathy, atelectasis, or pleural effusion.


A solitary pulmonary nodule: Differential diagnosis: Congenital Arteriovenous malformation Lung cyst and Intrapulmonary

Bronchogenic Cyst Bronchial atresia with mucoid

impaction Miscellaneous Pulmonary infarct Intrapulmonary lymph node Mucoid impaction Pulmonary haematoma Pulmonary amyloidosis Fungal infection Atelectasis

Neoplastic Malignant

• Bronchogenic carcinoma• Solitary metastasis• Lymphoma• Carcinoid tumours

Benign• Pulmonary hamartoma• Pulmonary chondroma

Inflammatory Granuloma (e.g. TB) lung abscess Rheumatoid nodule Plasma cell granuloma Round pneumonia


Other causes : Hyperdense pulmonary mass:

(a pulmonary mass with internal calcification)

Cavitating pulmonary mass: (gas-filled areas of the lung in the center of the mass. They are typically thick walled and their

walls must be greater than 2-5 mm. They may be filled with airas well as fluid and may also demonstrate air-fluid levels).

A Pulmonary mass:It is an area of pulmonary opacification that measures more than 3 cm. The commonest cause for a pulmonary mass is lung cancer.


Hyperdense pulmonary mass: They include: Granuloma: most common Pulmonary hamartoma Bronchogenic carcinoma Bronchogenic cyst Carcinoid tumours Pulmonary metastases Dystrophic calcification: Papillary thyroid carcinoma Giant cell tumour of bone Synovial sarcoma

Bone forming / cartilage mineralisation: Osteosarcoma Chondrosarcoma

A solitary well marginated homogeneous radiodensity is seen in the right upper zone with focal central area of increased density within.

lung field abnormalities - Cavities

Pulmonary cavities : Are gas-filled areas of

the lung in the center of a nodule, mass or area of consolidation.

They are typically thick walled and their walls must be greater than 2-5 mm.

They may be filled with air as well as fluid and may also demonstrate air-fluid levels.


Pulmonary cavities: A helpful mnemonic is CAVITY:

I: infection (bacterial/fungal) Pulmonary abscess Cavitating pneumonia Pulmonary tuberculosis Septic pulmonary emboli T: trauma - pneumatocoeles Y: youth (not true "cavity") Congenital cystic

adenomatoid malformation (CCAM)

Pulmonary sequestration Bronchogenic cyst

C: cancer Bronchogenic carcinoma:

(especially squamous cell carcinoma)

Cavitatory metastasis(es): Squamous cell carcinoma Adenocarcinoma, e.g.

gastrointestinal tract, breast Sarcoma

A: autoimmune; granulomas: Wegener's granulomatosis Rheumatoid nodules. V: vascular (both bland and

septic pulmonary embolus)


Multicystic mass with air in cysts CXR in type I ( large (2-10 cm)

cysts ) and II (small (< 2 cm) cysts) CCAM may demonstrate a multicystic (air-filled) lesion.

Type III ( microcysts ) CCAM appear solid.

Large lesions may cause mass effect with resultant, mediastinalshift, and depression and even inversion of the diaphragm.

The cysts may be completely or partially fluid filled, in which case the lesion may appear solid or with air fluid levels.

Congenital cystic adenomatoid malformation (CCAM):

Multiloculated cystic lesion in right hemithorax with marked mediastinal shift to the left.


It can be pulmonary 10-15% or

Mediastinal 65-90% Usually in the medial 1/3 of lungs With a lower lobe predilection Mediastinal cysts are visualized as

a mediastinal mass (image 1) Intrapulmonary cysts usually present

as a solitary pulmonary nodule unless the cyst contains air.

Cysts are usually fluid filled, occasionally a communication may develop following infection or intervention, resulting in an air-filledcystic +/- an air-fluid level (image 2)

Bronchogenic cyst: During development a portion of the tracheo bronchial tree gets separated. CXR :

lung field abnormalities - Decreased density

Unilateral hypertranslucent hemithorax: potential causes:

Pulmonary (ventilation)Pulmonary emphysemaCongenital lobar emphysema

unilateral bullus/bullaeCompensatory hyperinflationAirway obstruction e.g.

obliterative bronchiolitis Swyer-James syndromeUnilateral lung transplant Pleura and pleural spacePneumothoraxPleural effusion (contralateral) MediastinalMediastinal fibrosis

Rotation:Poor patient positioning Scoliosis Chest wall defectMastectomyPoland syndrome (absent

pectoralis major muscle) Vascular (perfusion)Pulmonary embolism i.e.

Westermark signCongenital heart disease Shunt (e.g. Blalock-Taussig)Unilateral absence pulmonary

artery


Pulmonary emphysema: 1. Hyperinflation Flattened hemidiaphragm (s):

most reliable sign Increased and usually irregular

radiolucency of the lungs Increased retrosternal airspace Increased antero-posterior

diameterObtuse costophrenic angle on

posteroanterior or lateral film. Widely spaced ribs A narrow mediastinum Sternal bowing Low diaphragm


Pulmonary emphysema: 2. vascular changes Paucity of blood vessels,

often distorted Pulmonary arterial

hypertension: Prominence of the

pulmonary hilum and enlargement of the main pulmonary arteries.

Right ventricular enlargement: encroachment into the retrosternal space on a lateral chest film

Pruning of peripheral vessels


Pulmonary emphysema: Flat diaphragm are present when the maximum perpendicular

height (red line) from the superior border of the diaphragm to a line drawn between the costophrenic and cardiophrenic angles in PA view or between the costophrenic and sternophrenic angles in lateral view is less than 1.5 cm.


An iatrogenic pulmonary condition of the premature infant with immature lungs. PIE occurs almost in association with mechanical ventilation.

CXR features : Subtle & often hidden by other

pathology linear, oval, and spherical cystic

air-containing spaces throughout the lung parenchyma.

Perivascular halos from air collections

Intra-septal air Subpleural cysts

Pulmonary Interstitial emphysema (PIE ):

CXR of the infant at 2 days of age, showing bilateral severe PIE and atelectasis of the right middle and lower lung lobes.

Pleural disease - Pneumothorax

Pneumothorax:Rotation of CXR can obscure a

pneumothorax . Rotation can also mimic a mediastinal shift.

Expiratory images are thought to better depicting minimal (subtle) pneumothoraces.

In erect patients: Pleural gas collects over the apex .


In the supine position:

The juxtacardiac area, the lateral chest wall, and the subpulmonic region are the best areas to search for evidence of pneumothorax.

The deep sulcus sign: (very wide and deep costophrenic angle)

An ipsilateral increased lucencyin the upper quadrant of the abdomen.

Double Diaphragm Sign: both the diaphragmatic dome and anterior portions of the diaphragm are visualized


Double Diaphragm Sign of Pneumothorax. Air in the right hemithoraxdisplaces both the dome (white arrow) and the anterior costophrenic angle (yellow arrow) in this patient with a large, right-sided pneumothorax. There is also a deep sulcus sign present (red arrow).


A large pneumothorax as being of greater than 2 cm width at the level of the hilum

The volume of a pneumothorax approximates to the ratio of the cube of the lung diameter to the hemithorax diameter

lateral decubitus studies: Should be done with the

suspected side up The lung will then 'fall'

away from the chest wall

Rib films are indicated

This chest X-ray shows a large pneumothorax (P) which is >2 cm depth at the level of the hilum.


A bulla or thin wall cyst can be

mistaken for loculatedpneumothorax. The pleural line caused by pneumothorax is usually bowed at its center towards lateral chest wall but the inner margins of bulla or cyst is generally concave rather than convex.

Pneumothorax with pleural adhesion may simulate bulla or lung cyst. Differential diagnosisby comparison with previous chest radiography, lateral decubitous or CT scanning

A chest radiograph shows

Right bullous formation


A skin fold can be mistaken for a pneumothorax. Unlike pneumothorax, skin folds usually continue beyond the chest wall, and lung markings can be seen beyond the apparent pleural line.


Deep sulcus sign (red arrow) in a supine patient in the ICU. The pneumothorax is subpulmonic.


Hydropneumothorax:

With the patient upright, there will be an air-fluid level in the thoracic cavity

On supine radiographs, a hydropneumothorax will be more difficult to see although a uniform grayness to the entire hemithorax with the absence of vascularmarkings suggest the diagnosis

Pleural disease - Pleural thickening

Best seen at the lung edges where the pleura runs tangentially to the x-ray beam. Causes:

Unilateral pleural thickening• Peripheral shadowing on the right• Loss of right lung volume• Shadowing over the whole right lung due to circumferential pleural thickening

Benign pleural thickening Recurrent inflammation Recurrent pneumothoraces Following a pleural empyema Complication of haemothorax Asbestosis & silicosisMalignant pleural thickening Primary pleural malignancy

• Mesothelioma• Primary pleural lymphoma

Pleural metastases Secondary pleural lymphoma

Pleural disease - Apical pleural cap

In normal asymptomatic individuals, the apical cap is an irregular density generally less than 5 mm high located over the apex of the lung.

Apical pleural cap (yellow arrows)

Causes: Pleural thickening/scarring Idiopathic: common

feature of advancing age Secondary to tuberculosis Radiation fibrosis Pancoast tumour Haematoma Lymphoma AbscessMetastases

Pleural disease - Pleural plaques

Asbestos related pleural plaques:

Ill-defined opacities over both mid and lower zones. Over the diaphragmatic domes, linear regions of calcification are noted.

Most pleural plaques are multiple, bilateral, and often symmetrical and are located inthe mid-portion of the chest wall between the seventh and tenthribs.

Plaques may be calcified (they are irregular, well-defined, and classically said to look like holly leaves), however, most (85-95%) are not

Visceral pleura, lung apices, and costophrenic angles are typically spared.

Pleural disease - Pleural effusionPleural effusion is an abnormal collection of fluid in the pleural space. Fluid may be (Transudate, Exudate, Pus, Blood, Chyle, Cholesterol, Urine )Erect frontal Chest X-ray:

1. Blunting of costophrenic angle 2. Blunting of cardiophrenic angle3. The diaphragmatic contour is

partially or completely obliterated, depending on the amount of the fluid (silhouette sign).

4. Fluid within the horizontal or oblique fissures

5. Concave meniscus seen laterally and gently sloping medially (horizontal

in case of hydropneumothorax)

Pleural disease - Pleural effusionErect frontal Chest X-ray:6. Massive pleural effusion: Opacification of entire hemithorax and

shifting of mediastinum to the opposite side (note: The mediastinal shift can be less prominent or even absent in the presence of underlying lung collapse or contralateral hemithorax abnormality)

Causes “white-out” lung Around 5-7 liters of pleural fluidGenerally, the pleural effusion is said to be massive if it crosses the anterior border of the 2nd rib. It is said to be moderate if it crosses the anterior border of the 4nd rib and is said to be mild or small if it is below that.

Massive right pleural effusion (1), with shift of mediastinum towards left (2)

Pleural disease - Pleural effusion

Erect frontal Chest X-ray:7. Lamellar effusions: Shallow collections between lung

surface and visceral pleural sometimes sparing the costophrenic angle. It represent interstial pulmonary fluid

Bilateral lamellar pleural effusions


Subpulmonic effusion. Note the increased distance between the air-filled fundus of the stomach and the left "hemidiaphragm" (arrow).

Erect frontal Chest X-ray:8. Subpulmonic effusion:Unilateral subpulmonary

effusion is more common on right side.

Right: appear as a raised diaphragm with flattening and lateral displacement of the dome.

Left: The distance between the lung and the stomach bubble will exceed 2 cm

Pleural disease - Pleural effusionErect frontal Chest X-ray:9. Encysted (encapsulated) pleural effusion: Loculation secondary to adhesions after an infected or

hemorrhagic effusion. Peripheral soft-tissue opacity with smooth obtuse tapering

margins

Pleural disease - Pleural effusionErect frontal Chest X-ray:10. Encysted (encapsulated) pleural effusion in the fissure:

Loculated effusion in the fissures appears as a well-defined elliptical opacity with pointed margins.

Pseudotumor/vanishing tumor (phantom tumor): Loculatedeffusion in the fissures , secondary to congestive heart failure, hypoalbuminemia, renal insufficiency or pleuritis. Radiologically simulating a neoplasm. It disappears rapidly in response to the treatment of the

underlying disorder


Lateral Chest X-ray: Small effusions appear as

a dependent opacity with posterior upward sloping of a meniscus-shapedcontour.

The opacity obliterates the underlying portion of the diaphragmatic contour (silhouette sign).

Can detect an effusion as small as 50–75 mL Note the concave meniscus

blunting posterior costophrenic angle.

Pleural disease - Pleural effusionSupine Chest X-ray: Due to the effect of gravity, the

pleural fluid is distributed throughout the posterior part of the pleural during supine position – this cause the hemithorax to appear whiter or paler grey compared to the normal side.

Vessels are often visible through the shadowing.

It is therefore especially difficult to identify similar sized bilateral effusions as the density of the lungs will be similar.

Requires about 200 ml fluid

Right-sided effusion. a veil-likeincreased density of the lower right hemithorax (blue arrow). Note that the pulmonary vascular structures are not obscured or silhouetted by the vague density but, rather, are still visible through it (open arrow).

Pleural disease - Pleural effusionlateral decubitus Chest X-ray: A small amount of fluid (10-25 mL) can be depicted on this

projection. The layering fluid can easily be detected as a dependent, sharply

defined, linear opacity separating the lung from the parietal pleural and chest wall, and

the parietal pleura–chest wall margin can be identified as a line connecting the inner apices of the curvature of the ribs.

Note in the film on right shows the findings of subpulmonic effusion (red arrow). In the lateral decubitus film fluid layers along the ribs (yellow arrow).


Complete white-out of a hemithorax: Trachea pulled toward the opacified

side: Pneumonectomy Total lung collapse Pulmonary agenesis Pulmonary hypoplasia

Trachea remains central in position: Consolidation Pulmonary oedema/ARDS Pleural mass: e.g. mesothelioma Chest wall mass: e.g. Ewing sarcoma

Pushed away from the opacified side: Pleural effusion Diaphragmatic hernia Large pulmonary mass


How do you determine the etiology of effusion from chest x-ray? Bilateral: consider transudative effusions first. You will need

clinical information. Bilateral effusions with cardiomegaly: Congestive heart failure Bilateral pleural effusions associated with ascites in a alcoholic:

Cirrhosis Unilateral: most of them are exudativeMassive unilateral effusion: Malignancy Pleural effusion with apical infiltrates: Tuberculosis Pleural effusion with nodes or mass or lytic bone lesions:

Malignancy Loculated effusions are empyemas Pleural effusion with a missing breast suggesting resection for

cancer: Malignancy Pleural effusion following chest trauma: Hemothorax In patients with mediastinal lymphoma: Chylothorax

Chest X-ray Abnormalities- Costophrenic angle

Costophrenic (CP) angle blunting: On a frontal CXR the costophrenic angles should form acute angles

which are sharp to a point. Often the term costophrenic "blunting" is used to refer to the

presence of a pleural effusion. This, however, is not always correct and costophrenic angle blunting can be related to other pleural disease, underlying lung disease or Lung hyper-expansion.

1- left CP angle blunting in effusion2- bilateral CP angles blunting in emphysema

Elevated hemidiaphragm: If the left hemidiaphragm is higher than the right or the right is higher than the left by more than 3 cm

Can result from: Above the diaphragm Decreased lung volume Atelectasis/collapse Lobectomy/pneumonectomy Pulmonary hypoplasia

Diaphragm Phrenic nerve palsy Diaphragmatic eventration Contralateral stroke: usually middle cerebral artery distribution

Below the diaphragm Abdominal tumour, e.g. liver metastases or primary malignancy Subphrenic abscess Distended stomach or colon

Chest X-ray Abnormalities - Diaphragm

Diaphragmatic hernia: defect in the diaphragm can result from: Congenital: Bochdalek hernia: most common, More frequent on left

side, located posteriorly and usually present in infancyMorgagni hernia: smaller, anterior and presents later,

through the sternocostal angles Acquired: Traumatic diaphragmatic rupture Hiatus hernia Iatrogenic


Morgagni hernia are: Anteromedialparasternal defect, small, Usually unilateral, more often right-sided (90%)


Bochdalek Hernia : Frontal view of the chest shows a large air-containing and walled structure in the region of the left lower lobe (white arrow). It is originating from below the diaphragm. The air-containing structure is seen posteriorly on the lateral view (red arrow).

Hiatus hernias occur when there is herniation abdominal contents through the oesophageal hiatus of the diaphragm into the thoracic cavity. Appears as retrocardiac opacity with air-fluid level


PA and lateral view of hiatal hernia. Can you see the air-filled "mass" posterior to the heart

Free gas under diaphragm (Pneumoperitoneum): It is a finding in the chest X-ray seen in case of perforation of hollow viscus.


CXR shows Minor opacity in the left lower zone. Large volume of free subdiaphragmaticgas ( yellow arrow).

Chest X-ray Abnormalities - DiaphragmChilaiditi syndrome: is a rare condition in which a portion of the colon is abnormally located (interposed) in between the liver and the diaphragm. It is one of the causes of pseudopneumoperitoneum. Features that suggest a Chilaiditi syndrome (i.e. Chilaiditi sign): Gas between liver and diaphragm Rugal folds within the gas suggesting that it is within the bowel.

Cardiophrenic angle lesions: The more common: Pericardial fat pad Pericardial cyst Morgagni's hernia Lymphadenopathy Pericardial fat necrosis Pericardial lipomatosisOther less common: Thymoma Hydatid cyst Right middle lobe collapse


Pericardial cyst: X-ray shows a well circumscribed mass in contact with right cardiac margin.

Cardiomegaly and heart failure: The heart is enlarged if the cardiothoracic ratio (CTR) is greater than 50% on a PA view. If the heart is enlarged, check for other signs of heart failure such as pulmonary oedema, septal lines (or Kerley B lines), and pleural effusions.

Chest X-ray Abnormalities - Heart

CXR shows:• Cardiomegaly CTR = 18/30 (>50%)• Upper zone vessel enlargement (1)

- a sign of pulmonary venous hypertension

• Pulmonary oedema (2) - bilateral increased lung markings (classically peri-hilar and shaped like bats wings - more widespread in this case)

• Septal (Kerley B) lines (3) • Pleural effusions (4)

left atrial enlargement: The double density sign: Right side of

the dilated left atrium is visible next to the right heart border (right atrium). It may extend out beyond the right heart border, an appearance known as atrial escape.

Oblique measurement of greater than 7cm (blue arrow).

Convex left atrial appendage; produces “straightening” of the left heart border - normally it is flat or concave.

Splaying of the carina to greater than a 90 degree angle (yellow lines).

Posterior displacement of the left main stem bronchus on lateral radiographs.


left ventricular enlargement: CXR shows: Left heart border is displaced leftward, inferiorly, or posteriorly Rounding of the cardiac apex The aorta is prominent Lateral view: Retrocardiac space become narrowed or disappeared,

esophageal space disappeaered



If we draw a tangent line from the apex of the left ventricle to the aortic knob (red line) and measure along a perpendicularto that tangent line (green line)

The distance between the tangent and the main pulmonary artery (between two small green arrows) falls in a range between 0 mm (touching the tangent line) to as much as 15 mm away from the tangent line

left heart border:


left heart border abnormalities: The main pulmonary artery may

project beyond the tangent line (greater than 0 mm). This can occur if there is increased pressure or increased flow in the pulmonary circuit.

The main pulmonary artery may project more than 15 mm away from the tangent line. This can occur in left ventricle enlargement and/or aortic knob enlargement e.g. atherosclerosis, aortic incompetence, and mitral incompetence.

Right atrial enlargement: Features are non-specific but include : Right heart enlargement (the right atrium and ventricle cannot be

separately identified on a radiograph) causes filling-in of the retrosternal clear space and prominence of the right heart border

A prominently convex lower right heart border Enlarged, globular heart Narrow vascular pedicle


Right ventricular enlargement: : Frontal view demonstrates: Rounded left heart border Uplifted cardiac apex


CXR showing right ventricular hypertrophy (arrows, note filling of the retrosternal space by an enlarged right ventricle in the lateral view) and enlarged central pulmonary arteries (arrowhead).

Lateral view demonstrates: Filling of the retrosternal

space Rotation of the heart

posteriorly

Ventricular aneurysm: A ventricular aneurysm is usually the sequel to a myocardial

infarct, thus cases of calcified ventricular aneurysm are rare.

Typically the left cardiac border changes shape and bulges.


Ventricular Pseudoaneurysm: It is caused by a

contained rupture of the LV free wall.

A chest radiograph may show cardiomegalywith an abnormal bulge on the cardiac border.


Pericardial effusion: It occurs when excess fluid collects in

the pericardial space (a normal pericardial sac contains approximately 30-50 mL of fluid).

CXR Suggestive but not usually diagnostic.

Globular enlargement of the cardiac shadow giving a water bottle configuration

Widening of the subcarinal angle without other evidence of left atrial enlargement may be an indirect clue


Pericardial effusion: lateral CXR may show: Loss of retrosternal clear space A vertical opaque line

Produced by pericardial fluid (yellow arrows) separating a vertical lucent line directly behind sternum Produced by epicardial fat (white arrows) anteriorly from a similar lucent vertical lucent line Produced by pericardial fat (red arrows) posteriorly; this is known as the Oreo cookie sign


Real Oreo cookies

Pulmonary Arterial Hypertension: Features include: Elevated cardiac apex due to right ventricular hypertrophy Enlarged right atrium Prominent pulmonary outflow tract Enlarged pulmonary arteries Pruning of peripheral pulmonary vessels


Transposition of the Great Vessels: The classic appearance described as an egg on a string sign Most common cyanotic congenital heart lesion The aorta arises from the morphologic right ventricle and the

pulmonary artery arises from the morphologic left ventricle Narrowing of the superior mediastinum on radiographs Patent ASD, VSD, Foramen ovale, systemic collaterals to sustain life The right atrial border is convex, and the left atrium is enlarged

CXR Abnormalities - Congenital heart disease

Total Anomalous Pulmonary Venous Return: Occurs when the pulmonary veins fail to drain into the left atrium

and instead form an aberrant connection with some other cardiovascular structure

2% of cardiac malformations SNOWMAN SIGN: resembles a snowman


Partial Anomalous Pulmonary Venous Return: Scimitar syndrome Anomalous pulmonary vein drains any or all of the lobes of the

right lung, and empties into the inferior vena cava, portal vein, hepatic vein, or right atrium

Vein appears like a scimitar, a sword with a curved blade that traditionally was used by Persian and Turkish warriors.

Hypoplasia of right lung, hypoplasia of right pulmonary artery, and anomalous arterial supply of the right lower lobe from abdominal aorta.


Tetralogy of Fallot: 10%–11% of cases of congenital heart disease Components: Ventricular septal defect, Infundibular pulmonary

stenosis, Overriding aorta, Right ventricular hypertrophy Blood flow to the lungs is usually reduced The heart has the shape of a wooden shoe or boot (in French,

coeur en sabot)


Aortic Coarctation: 5%–10% of congenital cardiac lesions Eccentric narrowing of the lumen of aorta at the level where the

ductus or ligamentum arteriosus inserts anteromedially Classic radiologic signs: Figure-of-three sign Reverse figure-of-three sign Rib notching on CXR pathognomonic


Mediastinal abnormalities - Mediastinal widening

Superior mediastinum: Should have a width less than 8 cm

on a PA CXR. A widened mediastinum can be

associated with: AP CXR view Unfolded aortic arch

(not pathological) or a thoracic aortic aneurysm

Mediastinal masses Oesophageal dilatation Ruptured aorta Mediastinal lipomatosis:

increased deposition of normal unencapsulated fat

Unfolded aorta: widened and 'opened up' appearance of the aortic arch. It is seen with increasing age

Mediastinal abnormalities - Aortic Dissection

Aortic Dissection: CXR findings include:

1. Mediastinal widening; it is noted in 60% of patients

2. Irregularity of the aortic contour

3. Double aortic contour

4. Double-calcium sign: Inward displacement of atherosclerotic calcification by more than 10 mm

5. Pleural effusion (more common on the left side; suggests leakage)

CXR shows; double density aortic arch (black/white arrows), Mediastinal widening, and Cardiac enlargement

Mediastinal abnormalities - Aortic Dissection

Aortic Dissection: CXR findings include:

6. Tracheal displacement to the right

7. Pericardial effusion

8. Cardiac enlargement

9. Displacement of a nasogastric tube

10. Left apical pleural capping (opacity)

11. Normal CXR in 12%of patients

CXR shows: rightward deviation of the trachea (red arrow); left apical pleural capping (blue arrow); aortic “double-calcium” sign (between white arrows); depression of the left bronchus (purple arrow); pleural effusion (green arrow); widened mediastinum and loss of the aorto-pulmonary window (not labeled).

Mediastinal abnormalities - Pneumomediastinum

Radiographic features of Pneumomediastinum

Small amounts of air appear as linear or curvilinear lucenciesoutlining mediastinalcontours and form:1. Subcutaneous

emphysema2. Air anterior to

pericardium:(Pneumoprecardium)

Pneumo-precardium

subcutaneous emphysema



3. air around pulmonary artery and main branches: ring around artery sign

4. air outlining major aortic branches: tubular artery sign

Tubular Artery Sign (Red arrows)

Ring around artery sign



5. Continuous diaphragm sign: due to air trapped posterior to pericardium

6. Spinnaker Sail Sign (angel wing sign) is seen on neonatal postero-anterior CXR when thymic lobes are displaced laterally by air, (Very typical sign in neonatal age).

Spinnaker Sail Sign (angel wing sign)

Continuous diaphragm sign



Naclerio V sign:It is seen as a V-shaped air collection. One limb of the V is produced by mediastinal air outlining the left lower lateral mediastinal border. The other limb is produced by air between the parietal pleura and medial left hemidiaphragm.

Lateral Chest X-RayRetrosternal air

Lateral Decubitus Chest X-RayAir will not move with change in position

Neck FilmsAir outlining fascial planes of the neck

Naclerio V sign

Mediastinal abnormalities - Masses

Clues to locate mass to mediastinum

Masses in the lungMediastinal masses

May contain air bronchograms

A lung mass abuttsthe mediastinalsurface and creates with lung an acute angles.

Not contain air bronchograms The margins with the lung will be obtuse. Mediastinal lines (azygoesophageal recess,

anterior and posterior junction lines) will be disrupted.

There can be associated spinal, costal or sternal abnormalities.

LEFT: A lung mass abutts the mediastinal surface and creates acute angles with the lung. RIGHT: A mediastinal mass will sit in the mediastinum, creating obtuse angles with the lung.


Clues to locate mass to mediastinum

LEFT: there is a lesion that has an acute border with the mediastinum. This must be a lung mass.RIGHT: shows a lesion with an obtuse angle to the mediastinum. This must be a mediastinal mass.

Localize mass within the mediastinumIn lateral CXR, mediastinum is divided into superior and Inferior. Inferior mediastinum is divided into anterior, middle, and posterior


Some causes of mediastinal masses in adults


Cervicothoracic sign: As the anterior

mediastinum ends at the level of the clavicles, the upper border of an anterior mediastinal lesion cannot be visualised extending above the clavicles.

Any lesions with a discernible upper border above that level must be located posteriorly in the chest, i.e. apical segments of upper lobes, pleura, or posterior mediastinum

Anterior ( A ) vs posterior ( B ) lesion


Thoracoabdominal sign:Posterior costophrenic

sulcus extends more caudally than anterior basilar lung

Lesion extending below the dome of diaphragm must be in posterior chest whereas lesion terminating at dome must be anterior.

Margin of mass is apparent and below diaphragm, therefore this must be in the middle or posteriorcompartments where it is surrounded by lung This example is a ‘Lipoma’


Hilum overlay sign:When a mass arises from

the hilum, the pulmonary vessels are in contact with the mass and as such their silhouette is obliterated.

If hilar vessels are sharply delineated it can be assumed that the overlying mass is anterior or posterior

“Hilum overlay” sign. Note that the vessels of the left hilum (yellow arrow) can be “seen through” the mass (red arrows) projected over the left hilum.


Hilum convergence sign: If branches of pulmonary artery converge toward central

mass, is an enlarged pulmonary artery (image A). If branches of pulmonary artery converge toward heart

rather than mass, is a mediastinal tumor (image B).

Mediastinal abnormalities - Paratracheal stripe

Right paratracheal stripe: Made up of right tracheal wall,

Paratracheal lymph nodes, adjacent pleural surfaces, mediastinal fat, right brachiocephalic vein and SVC

It normally measures less than 4 mm and thickening is non-specific but may represent: lipoma Paratracheal

lymphadenopathy Thyroid malignancy,

parathyroid neoplasms Tracheal carcinoma or stenosis Pleural effusion or thickening

Widening of the right paratracheal stripe (arrow) Abnormal right paratrachealstripe caused by a large ectopic parathyroid adenoma

Mediastinal abnormalities - Paratracheal stripe

Left paratracheal stripe: Made up of pleural surface of

the left upper lobe, tracheal border and mediastinal fat.

It is seen less frequently. It may not be visible if the left

upper lobe contacts the left subclavian artery or left common carotid artery.

Abnormal widening may be due:

Pleural effusion Mediastinal

lymphadenopathy or malignancy

Mediastinal haematoma

Widening of the left paratrachealstripe (arrows), with mass effect on the trachea. A 47-year-old patient with metastatic thyroid carcinoma

CXR Abnormalities - Soft tissue abnormalities

Breast tissue:

left-sided mastectomy: Increased density

over the right lungDecreased density

of the left lungBreast asymmetry

Gynaecomastia:Mobile AP Cardiac monitoring

leadsDense breast tissueMale patient

Breast cancer:PA Chest Xray: Increased soft tissue density with mass effect projected on left breast and axilla

CXR Abnormalities - Soft tissue abnormalities

Subcutaneous emphysema:There is often striated lucencies in the soft tissues that may outline muscle fibres. If affecting the anterior chest wall, subcutaneous emphysema can outline the pectoralis major muscle, giving rise to the ginkgo leaf sign.

Large left pneumothorax (white arrow) with mediastinal shift indicating tension. Left upper lobe cavitating lesion, the lesion which was recently biopsied. Extensive left chest wall (yellow arrow), ginkgo leaf sign (red arrow), and neck surgical emphysema.

CXR Abnormalities - Bones

Bones:

The bones are used as useful markers of CXR quality (rotation, adequacy of inspiration and CXR penetration).

Plain radiograph may miss up to 50% of rib fractures

Multiple fractures of the 4th right rib (yellow arrows), other visible fractures of 3rd, 5th, 6th and 7th right ribs (red arrows)

Old rib fractures: increased density (whiter areas) due to callus formation (red arrows)


Bones:

Malignant bone disease may manifest as either single or multiple lesions.

Bones may become denser (whiter) due to a scleroticprocess (often seen in prostate cancer), or less dense (blacker) due to a lytic process (as is often the case in renal cell cancer).

Primary bone tumours, both benign and malignant, are relatively uncommon

Expansile lytic metastasis of right 7th rib from carcinoma thyroid (red arrow).


Bones:

Cervical ribs: are usually bilateral but asymmetrical. Cervical rib is usually asymptomatic, but it can cause thoracic outlet syndrome.

Sclerotic metastases from carcinoma prostate.

Cervical rib (bilateral) with Cervical 7th transverse process directing inferiorly

Chest X-ray - Tubes

On a radiograph acquired with the neck in the neutral position, a distance of 5-7 cm above the carina is generally considered acceptable for adults.

In most individuals the carina is located between the levels of the 5th and 7th thoracic vertebral bodies. This is an inaccurate method for locating the carina If the carina is not clearly visible.

Intubation of a bronchus may lead to lung or lobar collapse

Endotracheal (ET) tube position:

Chest X-ray - Tubes

Tracheostomy tubes are positioned so that their tips are located at a midpointbetween the upper end of the tube and the carina.

It should occupy one-half to two-thirds of the tracheal lumen to minimize airway resistance.

Tracheostomy Tube:

Chest X-ray - Tubes

Chest X-rays are used to determine NG tube position if aspiration of gastric fluid is unsuccessful.

The tip of the tube must be visible below the diaphragm and on the left side of the abdomen - 10 cm or more beyond the gastro-oesophagealjunction.

Nasogastric (NG) tube:

Chest X-ray - Tubes

Catheter positioning:

The tip of a CVC is within the SVC at or just above the level of the carina (approximately 1-1.5 cm above the level of the carina) for most short-term uses.

Central venous catheter (CVC):

Right subclavian vein catheter

Right internal jugular vein catheter

Chest X-ray - Tubes


CVCs placed for the purpose of long term chemotherapy may be placed more inferiorly at the cavo-atrial junction - the junction of the SVC and right atrium (RA).

Catheters used for haemodialysis may be placed at the cavo-atrial junction or even in the RA itself.


Long term catheter - PICC line: This peripherally inserted central catheter (PICC) is correctly located with its tip at the level of the cavo-atrial junction - approximately the height of two vertebral bodies below the level of the carina

Chest X-ray - Tubes


Left-sided catheters approach the SVC at a shallow angle such that they may abut the right lateral wall of the SVC. They may need to be inserted further so the distal end obtains a vertical orientation. This may mean locating the tip below the level of the carina.


Chest X-ray - Tubes

For treatment of a pneumothorax the tube tip is aimed towards the upper pleural cavity and for treatment of a pleural effusion towards the lower part of the pleural cavity

Chest Drains:

Chest drain -treatment for pleural effusion

Chest drain - treatment for

pneumothorax

Thank you

Chest x ray fundamentals

Health & Medicine

Transcript of Chest x ray fundamentals