CHEST RADIOLOGY

12/09/13

Alex Nguyen FSU College of Medicine

MS4

Discovery of X-Rays

Wilhelm Conrad
Rntgen

German physicist
Won the first Nobel
Prize in Physics in
1901 for study of Xrays

Basic Radiographic
Densities

Able to distinguish four

densities:
Air
Fat
Soft

tissue (water)
Bone (metal)

Only four densities,

otherwise all looks the
same
Difficult to tell
difference between
types of same density
(muscle vs. artery)

One View = No View

Standard
Radiographs are
2D images of
three-dimensional
objects

Structures overlay
each other in
same plane
No depth with one
view

Standard Posterior-Anterior View

Whenever possible,
chest x-rays are
done in PA View

Heart closer to film

(less magnification)
Patient able to fully
inspire (show more
lung)
Sharper image
Moves scapulae out
of the way

Alternate Anterior-Posterior
View

When patients are too

sick and unable to
stand for a PA View,
we resort to an AP
View

Heart further away

from film (magnified)
Cannot measure
cardiothoracic ratio
Patient cannot take
deep breath
Image less sharp

PA vs. AP View

Lateral CXR

Difficult to see
behind the heart
with frontal views
Lateral view allows
better view of
mediastinum and
gives depth (two
views)
Can see lower lung
fields that are
behind diaphragm
on frontal views

Other Views

Lateral Decubitus

Helps identify pneumothorax or pleural

effusions
Air rises, water falls

Chest Anatomy

Important to know anatomy of the chest

to help read chest x-rays and identify
locations of pathology

Lobes of the lung

Mediastinum structures
Heart locations
Diaphragm

Chest Anatomy

Chest Anatomy

Right lung 3
lobes

Left lung 2 lobes

RUL
LUL
RML
RLL

LLL

Chest Anatomy

Right lung (3 lobes)

Minor horizontal
fissure
Frontal

and lateral

view

Major oblique fissure

Lateral

view

Left lung (2 lobes)

Major oblique fissure

Lateral

view

CHF producing increased fluid in minor fiss

Chest Anatomy

Chest Anatomy

Aorta starts on
right anterior,
courses to left
posterior

Abdominal aorta lies slightly left of

midline

Chest Anatomy

Diaphragm
normally higher
on right due to
liver
Upper abdomen
may show gas in
stomach or colon
(hepatic or
splenic flexure)

Reading a CXR

Compare to baseline previous

radiographic studies
Helps differentiate normal from disease
in complicated cases

Reading a CXR

Assess quality first:

Rotation clavicular
heads aligned with
spinous processes
Penetration
vertebral bodies
behind heart barely
visible
Inspiration
diaphragm down to
9-10th posterior rib or
5-7th anterior rib

*Posterior ribs are straight, anterior ribs are curved

Reading a CXR

Have a standard
method and use it
every time
Divide chest into
three vertical zones
helps eyes focus
Leave the most
important last the
lungs

Check bony anatomy,

upper abdomen first

Mediastinum

Main structures:

Trachea
Carina
Aortic arch
Left and Right Hilum
Right atrium
Left ventricle

Knowing which lobes of

the lung contact each
part of the contours can
help identify location of
pathology (silhouette
sign)

Mediastinal Contours

Mediastinal Contours

Silhouette Sign

X-Rays able to show

differences in
radiographic
densities by location
If similar radiographic
densities contact
each other, will not
show a difference
Thus, the basis for
the Silhouette Sign

There are normal anatomic silhouette

signs

Left diaphragm
and left heart
border

There are many abnormal silhouette

signs

Pneumonia in RML
and right heart
border
Both are water
density

Silhouette Sign

Name derived
from disruption of
normal silhouette
of anatomic
structures

Silhouette Sign

t Heart Border obscuring Left Diaphragm

RML Pneumonia obscuring Right Heart Borde
Anatomic

Pathologic

Silhouette Sign

Helps diagnose and localize lung

pathology

Air Bronchogram Sign

The opposite of
the Silhouette
Sign
Silhouette sign
takes advantage
of similar
radiographic
densities
Air Bronchogram
uses the idea of
dissimilar

Normally, bronchi are not seen in

lung periphery due to air on air
contact

When lungs become consolidated, if

bronchi are aerated, they will appear
on film

Air Bronchogram Sign

Seeing bronchi on CXR is abnormal Air

Bronchogram Sign

CT Scan demonstrating Air

Bronchogram Sign

Air Bronchogram Sign

Causes include:

Lung consolidation
Pulmonary edema
Non-obstructive pulmonary atelectasis
Neoplasm
Normal expiration

Air Bronchogram Sign

If bronchi are also obstructed, will not

see Air Bronchogram Sign pneumonia
with secretions filling bronchi, asthma,
bronchi tumor obstruction

Cross Sectional Radiology

CT Scan
MRI
Planes:

Axial (Transverse)
Sagittal
Coronal

Computed Tomography (CT)

CT Scanner takes
multiple X-Rays in
different angles and
computer constructs
them together
IV contrast dye may
be added to
distinguish vessels
Exposed to higher
radiation than
typical CXR

Computed Tomography (CT)

CT Scanner routinely produces Axial

images
Same data is reconstructed to produce:

Coronal
Sagittal images

Same data is reconstructed in Subsets to

optimize viewing of certain tissues
Lung

window
Mediastinal window
Bone window

Computed Tomography (CT)

Computed Tomography (CT)

CT has better contrast discrimination

than conventional X-rays

Able to distinguish different types of soft

tissue (muscle vs. fluid)
Hounsfield Units (HU) measurements:
Lung

-800
Fat -80
Fluid 0
Muscle +40
Bone > 350

Computed Tomography (CT)

Coronal view with accessory bronchus Sagittal view with coarctation of aorta

Computed Tomography (CT)

High-resolution CT scan:

Thinner sections
Reconstruction algorithms to sharpen
edges
Evaluates interstitial lung disease

Chest Radiology Pathology

Atelectasis
Pulmonary Edema
Pneumonia
Pleural Effusion
Pneumothorax
Interstitial Disease
Emphysema & COPD
Mediastinal Mass

Atelectasis

Collapse or incomplete
expansion of the lung
Surrounding structures
will deviate towards
collapsed lung

Trachea
Fissures
Mediastinum
Diaphragm

Can also see vascular

or bronchial crowding

Pleural Effusion

Can have similar

appearance to
Atelectasis
Surrounding
structures will deviate
away from pulmonary
effusion (must be
large)
Can move with
gravity

Lateral decubitus view

Pleural Effusion

Amount of fluid:

Clues:

Erect PA: 175 ml

Erect lateral: 75 ml
Lateral Decubitus: >5
ml
Supine: >500 ml
Blunted CVA
Meniscus
Thick fissure

Easier to see on lateral

with small effusions

Pleural Effusion

If unable to stand erect, can do Lateral

Decubitus on affected side must be
free, not loculated

Pleural Effusion

Loculated pleural
effusion in minor
fissure
Also called
Pseudotumor
because it often
resolves over
time

Pleural Effusion

Ultrasound now commonly used to

estimate fluid amount and plan for
thoracentesis

Pneumothorax

Causes:

Spontaneous
Iatrogenic (surgery,
central line
placement)
Asthma
Trauma

Clues:

Radiolucent air in
pleural space
Visceral pleura line

Pneumothorax

Can have a ball-valve

like mechanism only
allowing air in and
not out Tension
Pneumothorax

Compromise venous
return flow
Pushes mediastinum
away
Medical emergency
requiring needle
decompression

Pneumothorax

Signs of Tension PTX:

Rapid onset
respiratory failure
Decreased breath
sounds
Deviated trachea
Jugular venous
distention

Treatment:

Immediate needle
decompression

Pneumonia

Lung consolidation
without volume loss

Bacteria
Viral
Mycoplasma
Fungi

Usually no structural
shift towards lesion
Often confused with
Atelectasis volume
loss, structural shift
ipsilateral

Types:

Lobar Strep
pneumo
Lobular - Staph
Interstitial Mycoplasma
Aspiration
pneumonia

Pneumonia

Lobar Pneumonia
Interstitial Pneumonia

Interstitial Disease

Alveoli vs. Interstitium

Supporting structures:

Vessels
Lymphatics
Bronchi
Connective tissue

Normally visible within

2/3rd of lung, outer third
beyond resolution of
typical CXR
Appears white on film,
alveoli black when
aerated

Normal CXR

Interstitial Disease

Causes:

Idiopathic pulmonary
fibrosis (most common)
Autoimmune disease
Occupational exposure
Medications
Radiation

A type of restrictive
lung disease
Interstitium becomes
inflamed, scarred

Interstitial Disease

Interstitial Disease

Hazy, groundglass appearance

Volume loss
Honey-comb
appearance
Broad category of
diseases
High resolution
CT scan helpful to
differentiate

Pulmonary Edema

Two types:

Cardiogenic

CHF

Cardiogenic

Non-cardiogenic
Adult

Respiratory
Distress Syndrome,
ARDS
Near-drowning
Acute
glomerulonephritis
Allergic reaction
Inhalation injury
Aspiration

Fluid backs up
into pulmonary
veins, leaks out

Non-cardiogenic

Altered capillary
membrane
permeability

Pulmonary Edema

Cardiogenic
Pulmonary Edema

Cephalization of
pulmonary vessels
Kerley B lines
interlobar septa
Bat wing pattern
Large
cardiothoracic
ratio

PA View helpful

Pulmonary Edema

Kerley B Lines

CHF with Batwing Appearance

Pulmonary Edema

Non-Cardiogenic
Pulmonary Edema

Can have similar

appearance to
cardiogenic edema
More widespread and
diffuse
Will not resolve as
quickly as
cardiogenic edema
Air bronchograms
more common

Non-Cardiogenic Pulmonary Edema

Emphysema & COPD

Emphysema
loss of elastic
recoil of lung due
to destruction of
alveolar wall

Hyperinflation of
lung
Flattened
diaphragms
Bullae
Barrel chest

Mediastinal Mass

Anterior (4 Ts):

Middle:

Thymic tumors
Thyroid mass
Teratoma
Terrible
lymphadenopathy
Lymphadenopathy
Hiatal hernia
Aortic aneurysm

Posterior:

Lymphadenopathy
Aortic aneurysm
Nerve tumor

Mediastinal Mass

Watch for silhouette signs

Anatomy helps localize lesions watch
for shift

ICU Radiology

Films taken in ICU

are often AP
views
Identify correct
tubes and line
placement

Endotracheal
tubes
Nasogastric tubes
Central venous
catheters

ICU Radiology

Correct placement of ET tube

Correct placement of NG tube

ICU Radiology

NG tube into Right Lung Bronchi

Central Venous Catheter into SVC

References
1.

2.

Goodman, LR. Felsons Principles of

Chest Roentgenology: Third Edition.
Philadelphia: Saunders; 2007.
http
://[Link]/courses/rad
/cxr
/