The Normal Chest: Methods Of Investigation & DD RADIOLOGY BY Dr Nikhil Bansal

1. Presented by: Dr Nikhil Bansal

2.  Plain films:
• PA, Lateral
• AP, Decubitus, Supine, Oblique
• Inspiratory-Expiratory
• Lordotic, Apical, Penetrated
• Portable radiographs
 Tomography
 CT scanning

3.  Radionuclide studies
 Needle biopsy
 Ultrasound
 Floroscopy
 Bronchography
 Pulmonary angiography
 Bronchial arteriography
 MRI
 Digital radiography
 Lymphangiography

4.  THE PLAIN FILM
• The PA (postero-anterior) view:
It is the most frequently required radiological
examination. Comparison of current film with old
films is valuable.
Position: Patient facing the
film, chin up with the shoulders
rotated forwards to displaced
the scapulae from the lungs.
Exposure is made on full
inspiration, centering at T5.

5. kVp
 kVp = Energy of x-rays = higher penetrability, it moves
through tissue.
 The energy determines the QUALITY of x-ray
produced.
1. increase in kVp = electrons gain high energy
2. higher the energy of electrons = greater quality of x-
rays
3. greater quality = greater penetrability

6. kVp Low kVp
(60-80 kV)
High kVp
(120-170kV)
Produces High contrast films Low contrast films
Better •Miliary shadowing
•Calcification
•Hidden areas

7.  Lateral view:
Comparison with PA view:
Advantages : Anterior mediastinal
masses
Encysted pleural fluids
Posterior basal consolidation
Disadvantages : Lung collapse
Large pleural effusion.

8. Collapse of the Left lung. Only the right hemidiaphragm is visible.
PA View Lateral View

9. This is a PA film on the left compared with a AP supine film on the
right.
The AP shows magnification of the heart and widening of the
mediastinum.
AP film is taken mostly in very ill patients who cannot stand erect.

10.  Other views:
 Oblique view is better for:
• Retrocardiac area
• Posterior costophrenic
angles
• Chest wall
• Pleural plaques

12.  Lateral decubitus position:
It is helpful to assess the volume of pleural effusion
and demonstrate whether a pleural effusion is mobile
or loculated.
Lateral decubitus position film showing mobile pleural effusion (arrows)

13.  Viewing the PA film:
 Technical aspects:
• Well centered
• Clavicles should be equidistant
from the vertebral body's at
T4/5 level.
• Side markers should be place.

15. Poor inspiration can
crowd lung markings
producing pseudo-
airspace disease
With better
inspiration, the
“disease process” at
the lung bases has
cleared
About 8 posterior ribs are showing
8
9-10 posterior ribs are showing
9

16. If spinous process appears closer to the
right clavicle (red arrow), the patient is
rotated toward their own left side
If spinous process appears closer to the
left clavicle (red arrow),
the patient is rotated toward their own
right side

17.  Trachea:
• It should be examined for narrowing, displacement,
caliber and intraluminal lesions.
It is in midline in upper part, then deviates slightly to the
right around the aortic knuckle.
 The mediastinum and heart:
• Two-third of the cardiac shadow lies to the left of
midline and one-third to the right.
• CT ratio is less then 50% on PA film & 60% in AP film.
• In young children triangular sail shaped ‘Thymus’
makes ‘wave sign of Mulvey’.

18.  Soft Tissues
Breast shadows
Supraclavicular areas
Axillae
Tissues along side of breasts
 Abdomen
Gastric bubble
Air under diaphragm
 Neck
Soft tissue mass

19.  Bones:
Check the bones for any
fracture , lesions, density
or mineralization.
 Bony Fragments
Ribs
Sternum
Spine
Shoulder girdle
Clavicles

20.  Cardiac
 Heart size on PA
 Right side
 Inferior vena cava
 Right atrium
 Ascending aorta
 Superior vena cava
 Left side
 Left ventricle
 Left atrium
 Pulmonary artery
 Aortic arch
 Subclavian artery and vein

22.  Right Lung
 Superior lobe
 Middle lobe
 Inferior lobe
 Left Lung
 Superior lobe
 Inferior lobe

23.  The right middle lobe is
typically the smallest of
the three, and appears
triangular in shape, being
narrowest near the hilum.
 The right lower lobe is the
largest of all three lobes,
separated from the others
by the major fissure.
 Posteriorly, the RLL
extend as far superiorly as
the 6th thoracic vertebral
body, and extends
inferiorly to the
diaphragm.
 Review of the lateral plain
film surprisingly shows
the superior extent of the
RLL.

24.  Diaphragm:
• On inspiration the domes of the diaphragms are at the
level of the 6th rib anteriorly and 10th rib posteriorly.
• Check sharpness of borders.
• Right is normally higher than left.
• Check for free air, gastric bubble, pleural effusions.
 The Fissures:
 The main fissures:
 Horizontal fissure: On the PA film it running from the
hilum to the 6th rib in the axillary line.

25.  Oblique fissure: It separates the three lobes of right
side with horizontal fissure and two lobes of left side.
 Accessory fissures:
• Azygos fissure: It is a comma shaped fissure.
• The superior accessory fissure
• The inferior accessory fissure
• The left-sided horizontal fissure
 The hidden areas:
• The apices
• Mediastinum and hila
• Diaphragm
• Bones

26.  Hila: Look for nodes and masses in the hila of both
lungs. On the frontal view, most of the hilar shadows
represent the left and right pulmonary arteries. The
left pulmonary artery is always more superior than the
right, making the left hilum higher. Look for calcified
lymph nodes in the hilar, which may be caused by an
old tuberculosis infection.

27.  The Lungs:
 Lung anatomy:
• Trachea
• Carina
• Right and Left Pulmonary
Bronchi
• Secondary Bronchi
• Tertiary Bronchi
• Bronchioles
• Alveolar Duct
• Alveoli

29. Anatomy of main bronchi and segmental
division

30.  Viewing the lateral film: