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Chest X-Ray Fundamentals
Dr. Emad Efat
Shebin El kom Chest hospital
June 2017
Chest X-ray - Tutorials
1. Chest X-ray - Systematic approach
2. Chest X-ray - Quality
3. Chest X-ray - Anatomy
4. Chest X-...
Chest X-ray - Systematic approach
Anatomical structures to check:
1. Trachea and bronchi
2. Hilar structures
3. Lung zones...
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 imag...
Systematic approach - projection
 Chest x-ray :
1. P-A view
2. A-P view : for Ambulatory limit
3. Lateral ( Lt/Rt ) : for...
Systematic approach - Image quality
 Assess the image quality: The chest X-ray should be
checked for rotation, inspiratio...
Systematic approach - The obvious abnormality
 It is often appropriate to start by describing the most
striking abnormali...
Systematic approach - Describing abnormalities
 'Shadowing', 'Opacification', 'increased density',
'increased whiteness' ...
Systematic approach - Describing abnormalities
'Shadows, opacities, densities'
 Tissue involved: Lung
 Size: Small (>2 c...
Systematic approach - Locating abnormalities
 Consider its anterior-posterior position.
 A lateral view may help, but 3D...
Systematic approach - Locating abnormalities
The 'silhouette' sign: Loss of contour of :
1 - Left heart border Lingula dis...
Systematic approach - Locating abnormalities
The 'silhouette' sign: Loss of contour of :
5 - Aortic knuckle Anterior media...
Systematic approach - Review areas
 After a systematic look at the whole chest X-ray, it is worth
re-checking hidden area...
Systematic approach - Interpretation
Whatever the findings are,
they should only be
interpreted in view of the
clinical s...
Chest X-ray quality - Inclusion
Check the image for: Inclusion, Projection, Rotation,
Inspiration, Penetration and Artifa...
Chest X-ray quality - Projection
AP projection :
AP projection image is of
lower quality than PA image.
The scapulae are...
Chest X-ray quality - Rotation
Rotation:
 The spinous processes should lie
half way between the medial
ends of the clavic...
Chest X-ray quality - Rotation
Chest X-ray quality - Rotation
Frontal chest x-Ray (CXR) with subject rotated to
the left. Note an enlarged heart and smal...
Chest X-ray quality - Inspiration & lung volume
Assessing inspiration:
Count ribs down to
the diaphragm.
The diaphragm
s...
If the image is acquired in the
expiratory phase or with a
poor inspiratory effort:
1. The lungs are relatively airless
an...
Chest X-ray quality - Penetration
Differential Absorption:
Penetration of the x-ray
beam is dependent on
tissue density
 ...
Chest X-ray quality - Penetration
A well penetrated (exposed) chest X-ray :
 The end plates of the lower thoracic vertebr...
Chest X-ray quality - Penetration
Good penetration
You should be able to
just see the thoracic
spine through the heart
Chest X-ray quality - Penetration
An under-penetrated film looks diffusely opaque (too
white), structures behind the hear...
Chest X-ray quality - Artifact
Radiographic artifact
Rotation, incomplete inspiration
and incorrect penetration. Other
ra...
Chest X-ray anatomy - Airways
Assessing the airways
Start your assessment of
every X-ray by looking at the
airways.
The ...
Chest X-ray anatomy - Airways
large left pleural
effusion, and
tracheal shift away
from the effusion
Tension pneumothorax
...
Chest X-ray anatomy - Hilar structures
The structures contributing to
hilar shadows are:
Major: Pulmonary artery and vein...
Chest X-ray anatomy - Hilar structures
 The hilar points: the angle
formed by the descending upper
lobe veins, as they cr...
Chest X-ray anatomy - Lung zones
The chest radiograph zones:
1. Apical zone: above the
clavicles
2. Upper zone: below the
...
Chest X-ray anatomy - Pleura and pleural spaces
Trace round the entire edge
of the lung where pleural
abnormalities are s...
Chest X-ray anatomy - Pleura and pleural spaces
Costophrenic recesses and
angles:
The costophrenic angles
are limited vie...
Chest X-ray anatomy - Lung lobes and fissures
In the right lung there
is an oblique fissure
( of ) and a horizontal
fissu...
Chest X-ray anatomy - Lung lobes and fissures
The left lung is
divided into two
lobes, upper and
lower.
These lobes have...
Chest X-ray anatomy - Diaphragm
The hemidiaphragms are not
at the same level on frontal
erect inspiratory chest
radiograp...
Chest X-ray anatomy - Diaphragm
Hemidiaphragms - lateral
view:
The left and right
hemidiaphragms are
almost superimposed ...
Chest X-ray anatomy - Heart size and contours
From superior to inferior:
1. Right paratracheal stripe:
made up of right
br...
Chest X-ray anatomy - Heart size and contours
From superior to inferior:
 Left paratracheal stripe
Made up of left common...
Chest X-ray anatomy - Heart size and contours
Chest X-ray anatomy - Heart size and contours
Lateral view:
Anterior cardiomediastinal contour
From superior to inferior:
...
Chest X-ray anatomy - Heart size and contours
Cardiothoracic ratio:
The cardiothoracic ratio
should be less than 0.5. i.e...
Chest X-ray anatomy - Heart size and contours
 There are several structures in the superior mediastinum
that should alway...
Chest X-ray anatomy - Heart size and contours
It is a space
located between
the arch of the
aorta and the
pulmonary
arter...
Chest X-ray anatomy - Mediastinum
 In lateral CXR, mediastinum divided into :
 Superior mediastinum (S): above the
thora...
Chest X-ray anatomy - Bones and Soft tissues
Bones:
 Ribs (anterior
and posterior)
 Clavicles and
shoulders
 Sternum
 ...
Chest X-ray anatomy - Lateral view
Interpretation of lateral film
Chest X-ray anatomy - Lateral view
Interpretation of lateral film
The clear spaces
 Retrosternal space
 Retrotracheal
s...
Chest X-ray anatomy - Lateral view
Retrosternal space
 Seen as a normal lucency
between the posterior aspect
of the stern...
Chest X-ray anatomy: Lateral view
Vertebral translucency
 The ‘‘spine sign,’’ which
states that the normal
lateral chest ...
Chest X-ray anatomy - Lateral view
Diaphragm outline
 Right
hemidiaphragm
continues
anteriorly
 left
hemidiaphragm
blend...
Chest X-ray anatomy - Lateral view
The fissures
How to speak - Normal CXR
This is chest radiograph, PA view with
normal exposure, no rotation and without
any apparent bo...
Chest X-ray Abnormalities - Trachea
Ensure trachea is visible and in midline
1. Tracheal displacement (discussed previousl...
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...
Chest X-ray Abnormalities - The lung hilum
A. Hilar position:
If a hilum has moved, you should try to determine if it has...
Chest X-ray Abnormalities - The lung hilum
A. Hilar position:
Superior displacement and
horizontalization of the right hil...
Chest X-ray Abnormalities - The lung hilum
B. Hilar enlargement:
May be unilateral or bilateral, symmetrical or asymmetric...
Chest X-ray Abnormalities - The lung hilum
Analyze the enlargement of
hilum (if present):
1. Lymph Node enlargement:
 Lob...
Chest X-ray Abnormalities - The lung hilum
2. Arterial enlargement:
 Smooth margins
 In pulmonary arterial
hypertension ...
Chest X-ray Abnormalities - The lung hilum
3. Malignancy:
 Spiculated irregular or
indistinct margins
 Hilar enlargement...
Chest X-ray Abnormalities - The lung hilum
C. Hilar density:
May be due to :
 A mass or calcification in
the hilum
 Dens...
Chest X-ray Abnormalities - The lung hilum
Dense Hilum Sign:
On the frontal (PA) image, the left hilum (red arrow)
appears...
Chest X-ray Abnormalities - lung fields
Lung abnormalities:
Abnormal whiteness
(increased density):
Consolidation
Atelec...
Chest X-ray Abnormalities - lung fields
Four patterns of
increased density:
 Consolidation
 Lobar
 Diffuse
 Multifocal...
lung field abnormalities - Consolidation
The key-findings on the
Ill-defined
homogeneous opacity
obscuring vessels
Silho...
lung field abnormalities - Consolidation
 Air bronchogram refers to the phenomenon of air-filled
bronchi (dark) being mad...
lung field abnormalities - Consolidation
lung field abnormalities - Consolidation
lung field abnormalities - Consolidation
lung field abnormalities - Consolidation
lung field abnormalities - Consolidation
 Bat's wing appearance:
A bilateral perihilar distribution of consolidation.
 R...
lung field abnormalities - Consolidation
Reverse bat's wing appearance
In Chronic eosinophilic pneumonia
lung field abnormalities - Consolidation
Right Upper Lobe Consolidation:
lung field abnormalities - Consolidation
Right middle Lobe Consolidation:
lung field abnormalities - Consolidation
Right lower Lobe Consolidation:
lung field abnormalities - Consolidation
left upper Lobe Consolidation:
lung field abnormalities - Consolidation
Lingular consolidation:
lung field abnormalities - Consolidation
Left lower lobe consolidation:
lung field abnormalities - Consolidation
Lymphoma: Imaging Findings:
 Mediastinal widening due to
mediastinal lymphadenop...
lung field abnormalities - Consolidation
Tuberculosis (TB): Primary pulmonary tuberculosis:
Imaging Findings:
 Patchy or ...
lung field abnormalities - Consolidation
Tuberculosis: Post-primary pulmonary: Imaging Findings:
 Almost always affect:
1...
lung field abnormalities - Consolidation
Tuberculoma and Miliary Tuberculosis: Imaging Findings:
 Tuberculoma and miliary...
lung field abnormalities - Consolidation
Aspergillomas:
 Mass-like fungus balls of Aspergillus fumigatus, occur in patien...
lung field abnormalities - Consolidation
Tuberculosis: Imaging Findings:
lung field abnormalities - Consolidation
Aspiration Pneumonitis and Pneumonia: Imaging Findings:
 Chest x-ray shows an
in...
lung field abnormalities - Consolidation
Consolidation due to Lung infarction:
Hampton’s Hump: consists of a pleural based...
lung field abnormalities - Consolidation
Klebsiella pneumonia (Friedländer’s pneumonia):
Imaging Findings:
 Usually invol...
Consolidation - Cardiogenic pulmonary edema
Cardiogenic pulmonary edema
Consolidation due to Congestive Heart Failure (CHF...
Consolidation - Cardiogenic pulmonary edema
Stage I CHF – Redistribution:
Redistribution of the pulmonary veins. This is ...
Consolidation - Cardiogenic pulmonary edema
 The vascular pedicle is bordered on the right by the
superior vena cava and ...
Consolidation - Cardiogenic pulmonary edema
Stage II CHF - Interstitial edema Characterized by:
1. Kerley’s A lines: exten...
Consolidation - Cardiogenic pulmonary edema
2. Kerley’s B lines: are short horizontal lines situated
perpendicularly to th...
Consolidation - Cardiogenic pulmonary edema
3. Thickening of the bronchial walls (peribronchial cuffing)
and as loss of de...
Consolidation - Cardiogenic pulmonary edema
4. Fluid in the major or minor fissure (shown here)
produces thickening of the...
Consolidation - Cardiogenic pulmonary edema
Stage III CHF - Alveolar edema Characterized by:
Alveolar edema with
perihila...
lung field abnormalities - Consolidation
Adult Respiratory Distress Syndrome ( ARDS )
ARDS versus Congestive Heart Failure...
lung field abnormalities - Consolidation
Bronchopneumonia characterised by:
 Multiple small nodular or reticulonodular op...
lung field abnormalities - Consolidation
Wegener's granulomatosis characterized by:
 Nodules or mass lesions, which may c...
lung field abnormalities - Consolidation
 It is a congenital abnormality. A
nonfunctioning part of the lung lacks
communi...
lung field abnormalities - Consolidation
Eosinophilic pneumonia (EP):
 Acute EP : A pattern consistent
with pulmonary ede...
lung field abnormalities - Consolidation
Septic emboli:
Usually present as multiple ill-defined densities, which
are prob...
lung field abnormalities - Interstitial disease
 On a CXR the most common pattern is reticular.
 The ground-glass patter...
lung field abnormalities - Interstitial disease
lung field abnormalities - Alveolar vs. Interstitial
 Alveolar = air sacs
 Radiolucent
 Can contain blood,
mucous, tumo...
lung field abnormalities - Interstitial disease
Linear Pattern:
There is thickening of the
interlobular septa (contain
pu...
lung field abnormalities - Interstitial disease
Reticular Pattern:
Fine "ground-glass" (1-2
mm): e.g. interstitial
pulmon...
lung field abnormalities - Interstitial disease
Causes of Reticular Pattern:
 Pulmonary edema ( heart
failure, fluid over...
lung field abnormalities - Interstitial disease
Nodular pattern:
 A nodular pattern consists
of multiple round
opacities,...
lung field abnormalities - Interstitial disease
Causes of Miliary opacities :
 Infection
 tuberculosis
 fungal (often f...
lung field abnormalities - Interstitial disease
Causes of Calcified pulmonary nodules:
 Healed infection
 Calcified gran...
lung field abnormalities - Interstitial disease
 A reticulonodular
pattern results from a
combination of reticular
and no...
lung field abnormalities - Interstitial disease
Ground-glass appearance
A hazy area of increased
attenuation in the lung w...
lung field abnormalities - Interstitial disease
A lung cyst:
an air filled structure and occurs without associated pulmona...
lung field abnormalities - Interstitial disease
Hypersensitivity pneumonitis (HP) - (acute & Subacute):
 PCX-ray may be n...
lung field abnormalities - Interstitial disease
Hypersensitivity pneumonitis (HP) - (chronic):
 Pulmonary fibrosis affect...
lung field abnormalities - Interstitial disease
Sarcoidosis; classified by
chest x-ray into 5 stages :
 stage 0: normal c...
lung field abnormalities - Interstitial disease
Radiographic varieties of Sarcoidosis :
 Hilar and mediastinal lymphadeno...
lung field abnormalities - Interstitial disease
 Can be even normal in patients
with very early disease
 In advanced dis...
lung field abnormalities - Interstitial disease
Usual interstitial pneumonia (UIP):
 Honeycombing:
The radiographic appea...
lung field abnormalities - Interstitial disease
Bronchiectasis:
 CXR may be normal
 Volume loss
 Increased pulmonary ma...
lung field abnormalities - Interstitial disease
Bronchiectasis:
Cystic bronchiectasis with
multiple cystic airspaces
Ring ...
lung field abnormalities - Interstitial disease
Bronchiectasis: Location:
 Allergic bronchopulmonary
aspergillosis – cent...
lung field abnormalities - Interstitial disease
Pneumocystis pneumonia (PCP) - CXR findings:
 Bilateral, diffuse, often p...
lung field abnormalities - Interstitial disease
Lymphangitic carcinomatosis:
 The term given to tumour spread
through the...
lung field abnormalities - Interstitial disease
Silicosis:
1. Acute silicosis (silicoproteinosis):
Large bilateral perihil...
lung field abnormalities - Interstitial disease
Silicosis:
3. Complicated silicosis
(progressive massive fibrosis
(PMF), o...
lung field abnormalities - Interstitial disease
Silicosis:
4.Complicated silicosis : Complicated
by tuberculous (Silicotub...
lung field abnormalities - Atelectasis
CXR show direct and indirect signs of lobar collapse:
 Direct signs include displa...
lung field abnormalities – Atelectasis
Complete atelectasis: Characterized by:
Opacification of the entire hemithorax
An...
lung field abnormalities - Atelectasis
Increased density in the upper medial
aspect of the right hemithorax
 Elevation of...
Atelectasis - Lobar Atelectasis
Right upper lobe collapse:  The Golden S-sign (or reverse
S-sign of Golden): is seen on
P...
Atelectasis - Lobar Atelectasis
Right middle lobe collapse:
 On lateral projection, right
middle lobe collapse is
usually...
Atelectasis - Lobar Atelectasis
Right middle lobe collapse:
On frontal CXR, the findings are more
subtle:
 The normal hor...
Atelectasis - Lobar Atelectasis
Right lower lobe collapse:
On frontal CXR, the findings :
 Increased opacity (triangular ...
Atelectasis - Lobar Atelectasis
Right lower lobe collapse:
On lateral projection:
 The right
hemidiaphragmatic
outline i...
Atelectasis - Lobar Atelectasis
Left upper lobe collapse:
 Hazy or 'Veil-like' opacification of
the left hemithorax
 Rig...
Atelectasis - Lobar Atelectasis
Left upper lobe collapse:
 The luftsichel sign:
In some cases the
hyperexpanded superior
...
Atelectasis - Lobar Atelectasis
Left upper lobe collapse:
On lateral projections:
 left lower lobe is
hyperexpanded and
...
Lobar Atelectasis - Left upper lobe collapse
Lingular collapse:
The lingula collapses inferiorly and medially
This produ...
Atelectasis - Lobar Atelectasis
Left lower lobe collapse:
1. Triangular opacity in the
posteromedial aspect of left lung
2...
Atelectasis - Lobar Atelectasis
Left lower lobe collapse:
7. The flat waist sign refers to flattening of
the contours of t...
lung field abnormalities - Atelectasis
Rounded atelectasis:
 Classically associated with
asbestos exposure
 It is typica...
lung field abnormalities - Atelectasis
Segmental atelectasis:
 Collapse of one or several
segments of a lung lobe.
 It i...
lung field abnormalities - Atelectasis
Plate-like/subsegmental atelectasis:
 seen in smokers, elderly, after abdominal su...
lung field abnormalities - Atelectasis
Cicacitration atelectasis:
 Atelectasis can be the result of fibrosis of lungt iss...
lung field abnormalities - Nodules and Masses
A solitary pulmonary nodule:
Defined as a discrete, well-marginated, rounded...
lung field abnormalities - Nodules and Masses
A solitary pulmonary nodule: Differential diagnosis:
 Congenital
 Arteriov...
lung field abnormalities - Nodules and Masses
Other causes :
 Hyperdense pulmonary mass:
(a pulmonary mass with internal
...
lung field abnormalities - Nodules and Masses
Hyperdense pulmonary mass:
They include:
 Granuloma: most common
 Pulmonar...
lung field abnormalities - Cavities
Pulmonary cavities :
Are gas-filled areas of
the lung in the center
of a nodule, mass...
lung field abnormalities - Cavities
Pulmonary cavities: A helpful mnemonic is CAVITY:
 I: infection (bacterial/fungal)
 ...
lung field abnormalities - Cavities
 Multicystic mass with air in cysts
 CXR in type I ( large (2-10 cm)
cysts ) and II ...
lung field abnormalities - Cavities
 It can be pulmonary 10-15% or
Mediastinal 65-90%
 Usually in the medial 1/3 of lung...
lung field abnormalities - Decreased density
Unilateral hypertranslucent hemithorax: potential causes:
 Pulmonary (ventil...
lung field abnormalities - Decreased density
Pulmonary emphysema:
1. Hyperinflation
 Flattened hemidiaphragm (s):
most re...
lung field abnormalities - Decreased density
Pulmonary emphysema:
2. vascular changes
 Paucity of blood vessels,
often di...
lung field abnormalities - Decreased density
Pulmonary emphysema:
 Flat diaphragm are present when the maximum perpendicu...
lung field abnormalities - Decreased density
 An iatrogenic pulmonary
condition of the premature infant
with immature lun...
Pleural disease - Pneumothorax
Pneumothorax:
Rotation of CXR can obscure a
pneumothorax . Rotation can
also mimic a media...
Pleural disease - Pneumothorax
 In the supine position:
 The juxtacardiac area, the
lateral chest wall, and the
subpulmo...
Pleural disease - Pneumothorax
Double Diaphragm Sign
of Pneumothorax. Air in
the right hemithorax
displaces both the
dome ...
Pleural disease - Pneumothorax
 A large pneumothorax as
being of greater than 2 cm
width at the level of the
hilum
 The ...
Pleural disease - Pneumothorax
 A bulla or thin wall cyst can be
mistaken for loculated
pneumothorax. The pleural
line ca...
Pleural disease - Pneumothorax
A skin fold can be mistaken for a pneumothorax. Unlike
pneumothorax, skin folds usually co...
Pleural disease - Pneumothorax
 Deep sulcus sign (red arrow) in a supine patient in the ICU.
The pneumothorax is subpulmo...
Pleural disease - Pneumothorax
Hydropneumothorax:
 With the patient upright,
there will be an air-fluid
level in the thor...
Pleural disease - Pleural thickening
Best seen at the lung edges where the pleura runs tangentially to
the x-ray beam. Cau...
Pleural disease - Apical pleural cap
In normal asymptomatic individuals, the apical cap is an irregular
density generally ...
Pleural disease - Pleural plaques
Asbestos related pleural plaques:
Ill-defined opacities over both
mid and lower zones. O...
Pleural disease - Pleural effusion
Pleural effusion is an abnormal
collection of fluid in the pleural space.
Fluid may be ...
Pleural disease - Pleural effusion
Erect frontal Chest X-ray:
6. Massive pleural effusion:
 Opacification of entire hemit...
Pleural disease - Pleural effusion
Erect frontal Chest X-ray:
7. Lamellar effusions: Shallow collections between lung
surf...
Pleural disease - Pleural effusion
Subpulmonic effusion. Note the
increased distance between the air-
filled fundus of the...
Pleural disease - Pleural effusion
Erect frontal Chest X-ray:
9. Encysted (encapsulated) pleural effusion:
 Loculation se...
Pleural disease - Pleural effusion
Erect frontal Chest X-ray:
10. Encysted (encapsulated) pleural effusion in the fissure:...
Pleural disease - Pleural effusion
Lateral Chest X-ray:
 Small effusions appear as
a dependent opacity with
posterior upw...
Pleural disease - Pleural effusion
Supine Chest X-ray:
 Due to the effect of gravity, the
pleural fluid is distributed
th...
Pleural disease - Pleural effusion
lateral decubitus Chest X-ray:
 A small amount of fluid (10-25 mL) can be depicted on ...
Pleural disease - Pleural effusion
Complete white-out of a hemithorax:
 Trachea pulled toward the opacified
side:
 Pneum...
Pleural disease - Pleural effusion
How do you determine the etiology of effusion from chest x-ray?
 Bilateral: consider t...
Chest X-ray Abnormalities- Costophrenic angle
Costophrenic (CP) angle blunting:
 On a frontal CXR the costophrenic angles...
Elevated hemidiaphragm: If the left hemidiaphragm is higher
than the right or the right is higher than the left by more th...
Elevated diaphragm:
Can result from:
 Technical
supine position
poor inspiratory effort
 Patient factors
obesity
pre...
Chest X-ray Abnormalities - Diaphragm
Elevated hemidiaphragmElevated diaphragm
 Above the diaphragm
 Decreased lung volu...
Diaphragmatic hernia: defect in the diaphragm can result
from:
 Congenital:
 Bochdalek hernia: most common, More frequen...
Morgagni hernia
are: Anteromedial
parasternal defect,
small, Usually
unilateral, more
often right-sided
(90%)
Chest X-ray ...
Hiatus hernias occur when there is herniation abdominal contents
through the oesophageal hiatus of the diaphragm into the ...
Free gas under diaphragm (Pneumoperitoneum): It is a
finding in the chest X-ray seen in case of perforation of
hollow visc...
Chest X-ray Abnormalities - Diaphragm
Chilaiditi syndrome: is a rare condition in which a portion of the
colon is abnormal...
Cardiophrenic angle lesions:
 The more common:
 Pericardial fat pad
 Pericardial cyst
 Morgagni's hernia
 Lymphadenop...
Cardiomegaly and heart failure:
The heart is enlarged if the cardiothoracic ratio (CTR) is greater than
50% on a PA view. ...
left atrial enlargement:
 The double density sign: Right side of
the dilated left atrium is visible next to
the right hea...
left ventricular enlargement: CXR shows:
 Left heart border is displaced leftward, inferiorly, or posteriorly
 Rounding ...
Chest X-ray Abnormalities - Heart
If we draw a
tangent line
from the apex
of the left
ventricle to
the aortic knob
(red li...
Chest X-ray Abnormalities - Heart
left heart border abnormalities:
1. The main pulmonary artery may
project beyond the tan...
Right atrial enlargement: Features are non-specific but include :
 Right heart enlargement (the right atrium and ventricl...
Right ventricular enlargement: :
 Frontal view demonstrates:
 Rounded left heart border
 Uplifted cardiac apex
Chest X-...
Pulmonary embolism: Features include:
 Normal CXR
 Plate atelectasis
 Hampton hump: pleural-based
opacity (pulmonary in...
Heart- Pulmonary embolism
A chest radiograph shows a
Westermark sign (arrow), with a
focal area of oligemia in the right
m...
Pulmonary Arterial Hypertension: Features include:
 Elevated cardiac apex due to right ventricular hypertrophy
 Enlarged...
Ventricular aneurysm:
 A ventricular aneurysm is usually the sequel to a myocardial
infarct, thus cases of calcified vent...
Ventricular
Pseudoaneurysm:
 It is caused by a
contained
rupture of the LV
free wall.
 A chest
radiograph may
show
cardi...
Pericardial effusion:
 It occurs when excess fluid collects in
the pericardial space (a normal
pericardial sac contains a...
Pericardial effusion:
 lateral CXR may show:
 Loss of retrosternal clear space
 A vertical opaque line
Produced by peri...
Transposition of the Great Vessels:
 The classic appearance described as an egg on a string sign
 Most common cyanotic c...
Total Anomalous Pulmonary Venous Return:
 Occurs when the pulmonary veins fail to drain into the left atrium
and instead ...
Partial Anomalous Pulmonary Venous Return:
Scimitar syndrome
 Anomalous pulmonary vein drains any or all of the lobes of ...
Tetralogy of Fallot:
 10%–11% of cases of congenital heart disease
 Components: Ventricular septal defect, Infundibular ...
Aortic Coarctation:
 5%–10% of congenital cardiac lesions
 Eccentric narrowing of the lumen of aorta at the level where ...
Mediastinal abnormalities - Mediastinal widening
Superior mediastinum:
 Should have a width less than 8 cm
on a PA CXR.
...
Mediastinal abnormalities - Aortic Dissection
Aortic Dissection: CXR
findings include:
1. Mediastinal widening; it is
note...
Mediastinal abnormalities - Aortic Dissection
Aortic Dissection:
CXR findings include:
6. Tracheal
displacement to
the rig...
Mediastinal abnormalities - Pneumomediastinum
Radiographic features of Pneumomediastinum
Small amounts of air
appear as li...
Mediastinal abnormalities - Pneumomediastinum
Radiographic features of Pneumomediastinum
3. air around
pulmonary
artery an...
Mediastinal abnormalities - Pneumomediastinum
Radiographic features of Pneumomediastinum
5. Continuous diaphragm sign: due...
Mediastinal abnormalities - Pneumomediastinum
Radiographic features of Pneumomediastinum
 Naclerio V sign:
It is seen as ...
Mediastinal abnormalities - Masses
Clues to locate mass to mediastinum
Masses in the lungMediastinal masses
 May contain ...
Mediastinal abnormalities - Masses
Clues to locate mass to mediastinum
LEFT: there is a lesion that has an acute border
wi...
Mediastinal abnormalities - Masses
Some causes of mediastinal masses in adults
Mediastinal abnormalities - Masses
Cervicothoracic sign:
 As the anterior
mediastinum ends at the
level of the clavicles,...
Mediastinal abnormalities - Masses
Thoracoabdominal sign:
Posterior costophrenic
sulcus extends more
caudally than anteri...
Mediastinal abnormalities - Masses
Hilum overlay sign:
When a mass arises from
the hilum, the
pulmonary vessels are in
co...
Mediastinal abnormalities - Masses
Hilum convergence sign:
If branches of pulmonary artery converge toward central
mass, ...
Mediastinal abnormalities - Paratracheal stripe
Right paratracheal stripe:
 Made up of right tracheal wall,
Paratracheal ...
Mediastinal abnormalities - Paratracheal stripe
Left paratracheal stripe:
 Made up of pleural surface of
the left upper l...
CXR Abnormalities - Soft tissue abnormalities
Breast tissue:
left-sided mastectomy:
 Increased density
over the right lun...
CXR Abnormalities - Soft tissue abnormalities
Subcutaneous emphysema:
There is often striated lucencies in the soft tissue...
CXR Abnormalities - Bones
Bones:
 The bones are used as
useful markers of CXR
quality (rotation,
adequacy of inspiration
...
CXR Abnormalities - Bones
Bones:
 Malignant bone disease may
manifest as either single or
multiple lesions.
 Bones may b...
CXR Abnormalities - Bones
Bones:
 Cervical ribs: are usually bilateral
but asymmetrical. Cervical rib is
usually asymptom...
Chest X-ray - Tubes
 On a radiograph acquired with
the neck in the neutral position,
a distance of 5-7 cm above the
carin...
Chest X-ray - Tubes
Tracheostomy tubes
are positioned so that
their tips are located
at a midpoint
between the upper
end ...
Chest X-ray - Tubes
Chest X-rays are used to
determine NG tube
position if aspiration of
gastric fluid is
unsuccessful.
...
Chest X-ray - Tubes
 Catheter positioning:
The tip of a CVC is within the SVC at or just above the level of
the carina (...
Chest X-ray - Tubes
 Catheter positioning:
CVCs placed for the purpose of long term chemotherapy may be
placed more infe...
Chest x ray fundamentals
Chest x ray fundamentals
Chest x ray fundamentals
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Chest x ray fundamentals

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Chest x ray fundamentals

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Chest x ray fundamentals

  1. 1. Chest X-Ray Fundamentals Dr. Emad Efat Shebin El kom Chest hospital June 2017
  2. 2. 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
  3. 3. 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
  4. 4. Systematic approach Anatomical structures to check:
  5. 5. 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 resuscitation room. The patient's name, ID number and date of birth are annotated. Note the side marker is correct.
  6. 6. 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 lesion 7. Oblique (Rt/Lt; post/anterior)
  7. 7. 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?
  8. 8. 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.
  9. 9. 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
  10. 10. 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
  11. 11. 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.
  12. 12. Systematic approach - Locating abnormalities 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
  13. 13. Systematic approach - Locating abnormalities 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
  14. 14. 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
  15. 15. 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.
  16. 16. 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 ).
  17. 17. 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
  18. 18. 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.
  19. 19. Chest X-ray quality - Rotation
  20. 20. Chest X-ray quality - Rotation Frontal chest x-Ray (CXR) with subject rotated to the left. Note an enlarged heart and small left pleural effusion. The left hemithorax is darker than the right due to the rotation.
  21. 21. 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
  22. 22. If the image is acquired in the expiratory phase or with a poor inspiratory effort: 1. The lungs are relatively airless and 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
  23. 23. 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
  24. 24. Chest X-ray quality - Penetration 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.
  25. 25. Chest X-ray quality - Penetration Good penetration You should be able to just see the thoracic spine through the heart
  26. 26. Chest X-ray quality - Penetration 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.
  27. 27. 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 hair or skin folds can cause confusion. Hair artifact
  28. 28. Chest X-ray anatomy - Airways Assessing the airways Start your assessment of every X-ray by looking at the airways. The trachea should be central or 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 the carina, into the left and right main bronchi, and these can often be followed as they branch beyond the hila and into the lungs.
  29. 29. 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 thyroid enlargement Causes of tracheal deviation:  Ipsilateral (To pull): Collapse and Fibrosis  Contralateral ( To push): Apical mass , Pleural effusion and Pneumothorax
  30. 30. Chest X-ray anatomy - Hilar structures The 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
  31. 31. 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.
  32. 32. 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 )
  33. 33. Chest X-ray anatomy - Pleura and pleural spaces Trace round the entire edge of 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
  34. 34. 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.
  35. 35. 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.
  36. 36. 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 ).
  37. 37. 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.
  38. 38. Chest X-ray anatomy - Diaphragm Hemidiaphragms - lateral view: The left and right hemidiaphragms are almost superimposed on a lateral view. Anteriorly the left hemidiaphragm blends with the heart and becomes indistinct.
  39. 39. 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
  40. 40. Chest X-ray anatomy - Heart size and contours From superior to inferior:  Left paratracheal stripe Made up of left common carotid artery, left subclavian artery 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
  41. 41. Chest X-ray anatomy - Heart size and contours
  42. 42. Chest X-ray anatomy - Heart size and contours Lateral view: Anterior cardiomediastinal contour From superior to inferior: 1. Superior mediastinum 1. great vessels 2. thymus 2. Ascending aorta 3. Right ventricular outflow track 4. Right ventricle Posterior cardiomediastinal contour From superior to inferior: 1. Left atrium and pulmonary veins 2. Right atrium 3. Inferior vena cava
  43. 43. Chest X-ray anatomy - Heart size and contours 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.
  44. 44. Chest X-ray anatomy - Heart size and contours  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.
  45. 45. Chest X-ray anatomy - Heart size and contours It is a space located between the arch of the aorta and the pulmonary arteries. This space can be lost as a result of mediastinal lymphadenopathy (e.g. malignancy). The aorto-pulmonary window: Aortic knuckle (red arrow) & Aortopulmonary window (green arrow)
  46. 46. 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 pericardium  Middle 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).
  47. 47. Chest X-ray anatomy - Bones and Soft tissues Bones:  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 .
  48. 48. Chest X-ray anatomy - Lateral view Interpretation of lateral film
  49. 49. Chest X-ray anatomy - Lateral view Interpretation of lateral film The clear spaces  Retrosternal space  Retrotracheal space  Retro cardiac Vertebral translucency Diaphragm outline The fissures The trachea The sternum
  50. 50. Chest X-ray anatomy - Lateral view 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.
  51. 51. Chest X-ray anatomy: Lateral view Vertebral translucency  The ‘‘spine sign,’’ which states that the normal lateral chest film shows increasing overall lucency as 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
  52. 52. Chest X-ray anatomy - Lateral view Diaphragm outline  Right hemidiaphragm continues anteriorly  left hemidiaphragm blends with the heart and becomes indistinct Anteriorly.
  53. 53. Chest X-ray anatomy - Lateral view The fissures
  54. 54. 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-phrenic angles, dome of diaphragm & soft tissue shadow within normal limits.
  55. 55. Chest X-ray Abnormalities - Trachea Ensure 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
  56. 56. Chest X-ray Abnormalities - Trachea
  57. 57. 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
  58. 58. 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
  59. 59. Chest X-ray Abnormalities - The lung 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)
  60. 60. Chest X-ray Abnormalities - The lung hilum B. Hilar enlargement: May be unilateral or bilateral, symmetrical or asymmetrical
  61. 61. Chest X-ray Abnormalities - The lung hilum 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 calcification indicates silicosis or sarcoidosis. Calcified bilateral hilar lymphadenopathy in sarcoidosis
  62. 62. Chest X-ray Abnormalities - The lung hilum 2. 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 right and left branches.
  63. 63. Chest X-ray Abnormalities - The lung hilum 3. Malignancy:  Spiculated irregular or indistinct margins  Hilar enlargement due to malignant lung lesion is also associated with superior mediastinal lymphadenopathy. 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.
  64. 64. Chest X-ray Abnormalities - The lung hilum 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 mediastinal and right hilar lymph nodes.
  65. 65. Chest X-ray Abnormalities - The lung hilum 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 the superior segment of the left lower lobe (yellow arrow).
  66. 66. Chest X-ray Abnormalities - lung fields Lung abnormalities: Abnormal whiteness (increased density): Consolidation Atelectasis Nodule 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
  67. 67. Chest X-ray Abnormalities - lung fields Four patterns of increased density:  Consolidation  Lobar  Diffuse  Multifocal ill- defined  Atelectasis  Nodule or mass  Solitary Pulmonary Nodule  Multiple Masses  Interstitial  Reticular  Fine Nodular
  68. 68. lung field abnormalities - Consolidation The key-findings on the Ill-defined homogeneous opacity obscuring vessels Silhouette sign: loss of lung/soft tissue interface Air-bronchogram Extention to the pleura or fissure, but not crossing it No volume loss May be Blunting of costophrenic angle X-ray are:
  69. 69. 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).
  70. 70. lung field abnormalities - Consolidation
  71. 71. lung field abnormalities - Consolidation
  72. 72. lung field abnormalities - Consolidation
  73. 73. lung field abnormalities - Consolidation
  74. 74. lung field abnormalities - Consolidation  Bat's wing appearance: A bilateral perihilar distribution of consolidation.  Reverse bat's wing appearance: Peripheral or subpleural consolidation
  75. 75. lung field abnormalities - Consolidation Reverse bat's wing appearance In Chronic eosinophilic pneumonia
  76. 76. lung field abnormalities - Consolidation Right Upper Lobe Consolidation:
  77. 77. lung field abnormalities - Consolidation Right middle Lobe Consolidation:
  78. 78. lung field abnormalities - Consolidation Right lower Lobe Consolidation:
  79. 79. lung field abnormalities - Consolidation left upper Lobe Consolidation:
  80. 80. lung field abnormalities - Consolidation Lingular consolidation:
  81. 81. lung field abnormalities - Consolidation Left lower lobe consolidation:
  82. 82. lung field abnormalities - Consolidation Lymphoma: Imaging Findings:  Mediastinal widening due to mediastinal lymphadenopathy  Parenchymal lung involvement:  Multiple nodules  Consolidation with an air - bronchogram  Segmental or lobar atelectasis  Pleural effusions (Mostly small, unilateral, and exudative)  Destructive rib or vertebral body lesion Chest X-ray reveals multiple scattered consolidation lesions involving both lungs
  83. 83. lung field abnormalities - Consolidation Tuberculosis (TB): Primary pulmonary tuberculosis: Imaging Findings:  Patchy or lobar consolidation  Cavitation (uncommon)  Caseating granuloma (tuberculoma) which usually calcifies (known as a Ghon lesion)  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 consolidation and adenopathy.
  84. 84. lung field abnormalities - Consolidation Tuberculosis: Post-primary pulmonary: Imaging Findings:  Almost always affect: 1. Posterior segments of the upper lobes 2. 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)
  85. 85. lung field abnormalities - Consolidation 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
  86. 86. lung field abnormalities - Consolidation 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 attenuating masses 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
  87. 87. lung field abnormalities - Consolidation Tuberculosis: Imaging Findings:
  88. 88. lung field abnormalities - Consolidation Aspiration Pneumonitis and Pneumonia: Imaging Findings:  Chest x-ray shows an infiltrate, frequently in the superior or posterior basal segments of a lower lobe or the posterior segment of an upper lobe (The right lower lobe is the most frequent location).  Aspiration-related lung abscess  Interstitial or nodular infiltrates, pleural effusion, and other changes may be slowly progressive. Typically localized pneumonia in the right lower lobe.
  89. 89. lung field abnormalities - Consolidation 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
  90. 90. lung field abnormalities - Consolidation 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
  91. 91. Consolidation - Cardiogenic pulmonary edema Cardiogenic pulmonary edema Consolidation due to Congestive Heart Failure (CHF) :
  92. 92. Consolidation - Cardiogenic pulmonary edema 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)
  93. 93. Consolidation - Cardiogenic pulmonary edema  The vascular pedicle is bordered on the right by the superior vena cava and on the left by the left subclavian artery origin
  94. 94. Consolidation - Cardiogenic pulmonary edema 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.
  95. 95. 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.
  96. 96. Consolidation - Cardiogenic pulmonary edema 3. Thickening of the bronchial walls (peribronchial cuffing) and as loss of definition of these vessels (perihilar haze).
  97. 97. 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
  98. 98. Consolidation - Cardiogenic pulmonary edema Stage III CHF - Alveolar edema Characterized by: Alveolar edema with perihilar consolidations and air bronchograms ( Bat's wing or butterfly pulmonary 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).
  99. 99. lung field abnormalities - Consolidation Adult Respiratory Distress Syndrome ( ARDS ) ARDS versus Congestive Heart Failure: Diffuse bilateral patchy infiltrates More uniform opacification Homogenously distributed No cardiomegaly No cephalization Usually no pleural effusion or Kerley B lines
  100. 100. lung field abnormalities - Consolidation Bronchopneumonia 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
  101. 101. lung field abnormalities - Consolidation Wegener's granulomatosis characterized by:  Nodules or mass lesions, which may cavitate  Fleeting focal infiltrates (lung consolidation )
  102. 102. lung field abnormalities - 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 parapneumonic effusion, 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)
  103. 103. lung field abnormalities - Consolidation Eosinophilic 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 peripheral patchy infiltrates with relative sparing of the lower lobes.
  104. 104. lung field abnormalities - Consolidation Septic emboli: Usually present as multiple ill-defined densities, which are probably consolidations. In about 50% cavitation is seen.
  105. 105. 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:
  106. 106. lung field abnormalities - Interstitial disease
  107. 107. 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
  108. 108. lung field abnormalities - Interstitial disease 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, Lymphangitic carcinomatosis, Malignant lymphoma, Congenital lymphangiectasia, Idiopathic pulmonary fibrosis, Pneumoconiosis and Sarcoidosis )
  109. 109. lung field abnormalities - Interstitial disease 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
  110. 110. lung field abnormalities - Interstitial disease 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 )
  111. 111. lung field abnormalities - Interstitial disease Nodular pattern:  A nodular pattern consists of multiple round opacities, 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
  112. 112. lung field abnormalities - Interstitial disease 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
  113. 113. lung field abnormalities - Interstitial disease Causes of Calcified pulmonary nodules:  Healed infection  Calcified granulomata, e.g.  Thoracic histoplasmosis  Recovered 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 alveolar microlithiasis  Sarcoidosis  Calcified pulmonary metastases  Pulmonary amyloidosis  Pulmonary hyalinizing granuloma  Calcifying fibrous pseudotumour of lung
  114. 114. lung field abnormalities - Interstitial disease  A reticulonodular pattern results from a combination of reticular and 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:
  115. 115. lung field abnormalities - Interstitial disease Ground-glass appearance A 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  Inflammation  Oedema  Fibrosis  Neoplasm Perihilar ground-glass appearance in the shape of bats-wings
  116. 116. lung field abnormalities - Interstitial disease A lung cyst: an air filled structure and occurs without associated pulmonary emphysema 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:  Sjogren syndrome  light chain deposition disease  Amyloidosis Others:  Birt-Hogg-Dubé syndrome  Pulmonary trauma  Congenital cystic lung disease (congenital pulmonary airway malformation, pulmonary sequestration, bronchogenic cyst)  Tracheobronchial papillomatosis  Hydatid Cyst Interstitial disease:  Pulmonary Langerhans cell histiocytosis  lymphangioleiomyomatosis with or without tuberous sclerosis  Interstitial pneumonia (DIP, LIP)  Pneumatocele  Sarcoidosis  Neurofibromatosis  Cystic bronchiectasis  PCP  Honeycombing in UIP
  117. 117. lung field abnormalities - Interstitial disease Hypersensitivity 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 infiltrate may 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.
  118. 118. lung field abnormalities - Interstitial disease Hypersensitivity 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-nodular opacification.
  119. 119. lung field abnormalities - Interstitial disease 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)
  120. 120. lung field abnormalities - Interstitial disease Radiographic varieties of Sarcoidosis :  Hilar and mediastinal lymphadenopathy: Garland triad, also known as the 1-2-3 sign is bilateral hilar and right paratracheal lymphadenopathy.  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.
  121. 121. lung field abnormalities - Interstitial disease  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.
  122. 122. lung field abnormalities - Interstitial disease Usual interstitial pneumonia (UIP):  Honeycombing: The radiographic appearance of honeycombing comprises reticular densities caused by the thick walls of the cysts. Chest radiograph demonstrates coarse bibasilar reticular interstitial disease ( honeycomping ) (red arrows)
  123. 123. lung field abnormalities - Interstitial disease Bronchiectasis:  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
  124. 124. lung field abnormalities - Interstitial disease Bronchiectasis: Cystic bronchiectasis with multiple cystic airspaces Ring shadow ( red arrow) & Tram lines ( yellow arrow)
  125. 125. lung field abnormalities - Interstitial disease Bronchiectasis: 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) – Apical and posterior segments of upper lobes  Sarcoidosis (traction bronchiectasis) – Upper lobe predominance  Usual interstitial pneumonitis (commonest cause of traction bronchiectasis) - Lower lobe predominance, worse peripherally
  126. 126. lung field abnormalities - Interstitial disease Pneumocystis 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.
  127. 127. lung field abnormalities - Interstitial disease 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 reticulonodular opacification, often with associated septal lines (Kerley A and B lines), peribronchial cuffing, pleural effusions, and mediastinal and/or hilar lymphadenopathy Lymphangitic carcinomatosis. The radiograph like in the case of interstitial pulmonary oedema
  128. 128. lung field abnormalities - Interstitial disease Silicosis: 1. Acute silicosis (silicoproteinosis): Large bilateral perihiliar consolidation or ground glass opacities. 2. Chronic simple silicosis (common type ): CXR shows multiple nodular 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 disease with an upper lobe predominance
  129. 129. lung field abnormalities - Interstitial disease Silicosis: 3. Complicated silicosis (progressive massive fibrosis (PMF), or conglomerate silicosis): CXR shows large symmetric bilateral opacities that are:  1 cm or more in diameter and with an irregular margin  Usually in mid-zone or periphery of upper lobes  Compensatory emphysema occurs 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).
  130. 130. lung field abnormalities - Interstitial disease 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
  131. 131. 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  Atelectasis can be sub-categorized by morphology as follows:  linear (plate, band, discoid, subsegmental) atelectasis  lobar atelectasis  segmental and subsegmental atelectasis  round atelectasis
  132. 132. lung field abnormalities – Atelectasis Complete atelectasis: Characterized by: Opacification of the entire hemithorax An ipsilateral shift of the mediastinum.
  133. 133. lung field abnormalities - Atelectasis 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 Lobar Atelectasis: Right upper lobe collapse:
  134. 134. Atelectasis - Lobar Atelectasis 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.
  135. 135. Atelectasis - Lobar Atelectasis 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 overlying the cardiac shadow.  The horizontal fissure is displaced inferiorly and the inferior part of the oblique fissure, displaced anterosuperiorly.
  136. 136. Atelectasis - Lobar Atelectasis 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.
  137. 137. Atelectasis - Lobar Atelectasis 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 hemidiaphragm Crowding of the right sided ribs Shift 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).
  138. 138. Atelectasis - Lobar Atelectasis Right lower lobe collapse: On lateral projection:  The right hemidiaphragmatic outline is lost posteriorly  The lower thoracic vertebrae appear denser than 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).
  139. 139. Atelectasis - Lobar Atelectasis 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: juxtaphrenic peak sign Crowding of the left sided ribs Shift 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
  140. 140. Atelectasis - Lobar Atelectasis 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 ).
  141. 141. Atelectasis - Lobar Atelectasis Left upper lobe collapse: On lateral projections:  left lower lobe is hyperexpanded and the oblique fissure displaced anteriorly (arrows).  Increase in the retrosternal opacity.
  142. 142. Lobar Atelectasis - Left upper lobe collapse Lingular collapse: The lingula collapses inferiorly and medially This produces an opacity in contact with the left heart border, which causes loss of the normal silhouette Lingular collapse. (A) Frontal view of isolated collapse of the lingular segments of the left upper lobe showing loss of clarity of the left heart border and a raised hemidiaphragm. (B) The similarity to a right middle lobe collapse can be appreciated on the lateral view.
  143. 143. Atelectasis - Lobar Atelectasis Left lower lobe collapse: 1. Triangular opacity in the posteromedial aspect of left lung 2. Edge of collapsed lung may create a 'double cardiac contour' 3. left hilum will be depressed 4. loss of the normal left hemidaphgragmatic outline 5. loss of the outline of the descending aorta 6. Non-specific signs indicating left sided atelectasis :  Elevation of the hemidiaphragm  Crowding of the left sided ribs  Shift of the mediastinum to left
  144. 144. Atelectasis - Lobar Atelectasis 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)
  145. 145. lung field abnormalities - Atelectasis Rounded atelectasis:  Classically associated with asbestos exposure  It is typically found in lower lung lobes, particularly in posterior regions  Has the form of peripheral round, oval or fusiform lesion of diffuse outline.  The size of the lesion ranges from 2.5 to 8 cm.  Pleural thickening at the level of atelectasis is typical.  The volume of the affected lobe is reduced Posteroanterior chest radiography: peripheral, well-defined opacity (round atelectasis).
  146. 146. lung field abnormalities - Atelectasis Segmental atelectasis:  Collapse of one or several segments of a lung lobe.  It is a morphological subtype of lung atelectasis.  It is better appreciated on CT and Its radiographic appearance can range from being a thin linear to a wedge shaped opacity then does not abut an interlobar fissure. Plain radiograph: shows a band- like opacity with well-defined borders, perpendicular to costal surface, located in the left upper lobe.
  147. 147. lung field abnormalities - Atelectasis Plate-like/subsegmental atelectasis:  seen in smokers, elderly, after abdominal surgery, patients in the ICU and in pulmonary embolism .  linear shadows of increased density at the lung bases, usually horizontal, measure 1-3 mm in thickness and are only a few cm long. Plate-like atelectasis due to poor inspiration in a patient who had abdominal surgery
  148. 148. lung field abnormalities - Atelectasis Cicacitration atelectasis:  Atelectasis can be the result of fibrosis of lungt issue.  Seen after radiotherapy and in chronic infection, especially TB. Atelectasis of the right upper lobe as a result of TB. Notice the deviation of the trachea. There is also some atelectasis of the left upper lobe, which results in a high position of the left pulmonary artery as seen on the lateral view (red arrow)
  149. 149. 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.
  150. 150. lung field abnormalities - Nodules and Masses A solitary pulmonary nodule: Differential diagnosis:  Congenital  Arteriovenous malformation  Lung cyst and Intrapulmonary Bronchogenic Cyst  Bronchial atresia with mucoid impaction  Miscellaneous  Hydatid cyst  Pulmonary infarct  Intrapulmonary lymph node  Mucoid impaction  Pulmonary haematoma  Pulmonary amyloidosis  Fungal infection  Atelectasis  Wegener granulomatosis  Neoplastic  Malignant • Bronchogenic carcinoma • Solitary metastasis • Lymphoma • Carcinoid tumours • Sarcoma  Benign • Pulmonary hamartoma • Pulmonary chondroma  Inflammatory  Granuloma (e.g. TB)  lung abscess  Rheumatoid nodule  Plasma cell granuloma  Round pneumonia
  151. 151. lung field abnormalities - Nodules and Masses 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 air as 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.
  152. 152. lung field abnormalities - Nodules and Masses 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.
  153. 153. 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.
  154. 154. lung field abnormalities - Cavities 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)
  155. 155. lung field abnormalities - Cavities  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, mediastinal shift, 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.
  156. 156. lung field abnormalities - Cavities  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-filled cystic +/- an air-fluid level (image 2) Bronchogenic cyst: During development a portion of the tracheo bronchial tree gets separated. CXR :
  157. 157. lung field abnormalities - Decreased density Unilateral hypertranslucent hemithorax: potential causes:  Pulmonary (ventilation) Pulmonary emphysema Congenital lobar emphysema unilateral bullus/bullae Compensatory hyperinflation Airway obstruction e.g. obliterative bronchiolitis Swyer-James syndrome Unilateral lung transplant  Pleura and pleural space Pneumothorax Pleural effusion (contralateral)  Mediastinal Mediastinal fibrosis  Rotation: Poor patient positioning Scoliosis  Chest wall defect Mastectomy Poland syndrome (absent pectoralis major muscle)  Vascular (perfusion) Pulmonary embolism i.e. Westermark sign Congenital heart disease Shunt (e.g. Blalock-Taussig) Unilateral absence pulmonary artery
  158. 158. lung field abnormalities - Decreased density Pulmonary emphysema: 1. Hyperinflation  Flattened hemidiaphragm (s): most reliable sign  Increased and usually irregular radiolucency of the lungs  Increased retrosternal airspace  Increased antero-posterior diameter  Obtuse costophrenic angle on posteroanterior or lateral film.  Widely spaced ribs  A narrow mediastinum  Sternal bowing  Low diaphragm
  159. 159. lung field abnormalities - Decreased density 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
  160. 160. lung field abnormalities - Decreased density 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.
  161. 161. lung field abnormalities - Decreased density  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.
  162. 162. 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 .
  163. 163. Pleural disease - Pneumothorax  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 lucency in the upper quadrant of the abdomen.  Double Diaphragm Sign: both the diaphragmatic dome and anterior portions of the diaphragm are visualized
  164. 164. Pleural disease - Pneumothorax Double Diaphragm Sign of Pneumothorax. Air in the right hemithorax displaces 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).
  165. 165. Pleural disease - Pneumothorax  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.
  166. 166. Pleural disease - Pneumothorax  A bulla or thin wall cyst can be mistaken for loculated pneumothorax. 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 diagnosis by comparison with previous chest radiography, lateral decubitous or CT scanning A chest radiograph shows Right bullous formation
  167. 167. Pleural disease - Pneumothorax 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.
  168. 168. Pleural disease - Pneumothorax  Deep sulcus sign (red arrow) in a supine patient in the ICU. The pneumothorax is subpulmonic.
  169. 169. Pleural disease - Pneumothorax 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 vascular markings suggest the diagnosis
  170. 170. 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 & silicosis  Malignant pleural thickening  Primary pleural malignancy • Mesothelioma • Primary pleural lymphoma  Pleural metastases  ​Secondary pleural lymphoma
  171. 171. 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  Abscess  Metastases
  172. 172. 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 in the mid-portion of the chest wall between the seventh and tenth ribs.  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.
  173. 173. Pleural disease - Pleural effusion Pleural 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 angle 3. 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) 
  174. 174. Pleural disease - Pleural effusion Erect 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 fluid Generally, 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)
  175. 175. 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
  176. 176. Pleural disease - Pleural effusion 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
  177. 177. Pleural disease - Pleural effusion Erect 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
  178. 178. Pleural disease - Pleural effusion Erect 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): Loculated effusion 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 
  179. 179. Pleural disease - Pleural effusion Lateral Chest X-ray:  Small effusions appear as a dependent opacity with posterior upward sloping of a meniscus-shaped contour.  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.
  180. 180. Pleural disease - Pleural effusion Supine 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-like increased 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).
  181. 181. Pleural disease - Pleural effusion lateral 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 sub pulmonic effusion (red arrow). In the lateral decubitus film fluid layers along the ribs (yellow arrow).
  182. 182. Pleural disease - Pleural effusion 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
  183. 183. Pleural disease - Pleural effusion 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 exudative  Massive 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
  184. 184. 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 effusion 2- bilateral CP angles blunting in emphysema
  185. 185. 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
  186. 186. Elevated diaphragm: Can result from:  Technical supine position poor inspiratory effort  Patient factors obesity pregnancy  Diaphragmatic pathology bilateral phrenic nerve palsy pain following abdominal surgery  Abdominal pathology mass lesion massive ascites Chest X-ray Abnormalities - Diaphragm  Pulmonic pathology diffuse pulmonary fibrosis lymphangitis carcinomatosa disseminated lupus erythematosus
  187. 187. Chest X-ray Abnormalities - Diaphragm Elevated hemidiaphragmElevated diaphragm  Above the diaphragm  Decreased lung volume  Atelectasis/collapse  Lobectomy/pneumonectomy  Pulmonary hypoplasia  Diaphragm  Phrenic nerve palsy  Diaphragmatic eventration  Contralateral stroke  Below the diaphragm  Abdominal tumour, e.g. liver metastases or primary malignancy  Subphrenic abscess  Distended stomach or colon  Technical  supine position  poor inspiratory effort  Patient factors  obesity  pregnancy  Diaphragmatic pathology  bilateral phrenic nerve palsy)  pain following abdominal surgery  Pulmonic pathology  diffuse pulmonary fibrosis  lymphangitis carcinomatosa  disseminated lupus erythematosus  Abdominal pathology  mass lesion  massive ascites
  188. 188. 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 infancy  Morgagni hernia: smaller, anterior and presents later, through the sternocostal angles  Acquired:  Traumatic diaphragmatic rupture  Hiatus hernia  Iatrogenic Chest X-ray Abnormalities - Diaphragm
  189. 189. Morgagni hernia are: Anteromedial parasternal defect, small, Usually unilateral, more often right-sided (90%) Chest X-ray Abnormalities - Diaphragm 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).
  190. 190. 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 Chest X-ray Abnormalities - Diaphragm PA and lateral view of hiatal hernia. Can you see the air- filled "mass" posterior to the heart
  191. 191. Free gas under diaphragm (Pneumoperitoneum): It is a finding in the chest X-ray seen in case of perforation of hollow viscus. Chest X-ray Abnormalities - Diaphragm CXR shows Minor opacity in the left lower zone. Large volume of free subdiaphragmatic gas ( yellow arrow).
  192. 192. Chest X-ray Abnormalities - Diaphragm Chilaiditi 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.
  193. 193. Cardiophrenic angle lesions:  The more common:  Pericardial fat pad  Pericardial cyst  Morgagni's hernia  Lymphadenopathy  Pericardial fat necrosis  Pericardial lipomatosis  Other less common:  Thymoma  Hydatid cyst  Right middle lobe collapse Chest X-ray Abnormalities - Diaphragm Pericardial cyst: X-ray shows a well circumscribed mass in contact with right cardiac margin.
  194. 194. 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)
  195. 195. 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. Chest X-ray Abnormalities - Heart
  196. 196. 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 Chest X-ray Abnormalities - Heart
  197. 197. Chest X-ray Abnormalities - Heart If we draw a tangent line from the apex of the left ventricle to the aortic knob (red line) and measure along a perpendicular to 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:
  198. 198. Chest X-ray Abnormalities - Heart left heart border abnormalities: 1. 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. 2. 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.
  199. 199. 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 Chest X-ray Abnormalities - Heart
  200. 200. Right ventricular enlargement: :  Frontal view demonstrates:  Rounded left heart border  Uplifted cardiac apex Chest X-ray Abnormalities - Heart 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
  201. 201. Pulmonary embolism: Features include:  Normal CXR  Plate atelectasis  Hampton hump: pleural-based opacity (pulmonary infarction)  Small pleural effusion  Elevated hemidiaphragm  Fleischner’s sign (prominent amputated pulmonary artery)  Westermark’s sign (peripheral oligaemia)  Palla's sign: Enlarged right descending pulmonary artery  The more abnormal the CXR, the less likely is PE  Normal CXR in a breathless hypoxic person in the absence of bronchospasm means that PE is likely Chest X-ray Abnormalities - Heart
  202. 202. Heart- Pulmonary embolism A chest radiograph shows a Westermark sign (arrow), with a focal area of oligemia in the right middle zone and cutoff of the pulmonary artery in the upper lobe of the right lung. Fleischner sign: Refers to the prominence of central pulmonary artery caused either by pulmonary hypertension that develops secondary to PE or by distension of the vessel by a large clot
  203. 203. 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 Chest X-ray Abnormalities - Heart
  204. 204. 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. Chest X-ray Abnormalities - Heart
  205. 205. Ventricular Pseudoaneurysm:  It is caused by a contained rupture of the LV free wall.  A chest radiograph may show cardiomegaly with an abnormal bulge on the cardiac border. Chest X-ray Abnormalities - Heart
  206. 206. 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 Chest X-ray Abnormalities - Heart
  207. 207. 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 Chest X-ray Abnormalities - Heart Real Oreo cookies
  208. 208. 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
  209. 209. 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 CXR Abnormalities - Congenital heart disease
  210. 210. 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. CXR Abnormalities - Congenital heart disease
  211. 211. 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) CXR Abnormalities - Congenital heart disease
  212. 212. 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 CXR Abnormalities - Congenital heart disease
  213. 213. 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
  214. 214. 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
  215. 215. 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).
  216. 216. Mediastinal abnormalities - Pneumomediastinum Radiographic features of Pneumomediastinum Small amounts of air appear as linear or curvilinear lucencies outlining mediastinal contours and form: 1. Subcutaneous emphysema 2. Air anterior to pericardium: (Pneumoprecardium) Pneumo- precardium subcutaneous emphysema
  217. 217. Mediastinal abnormalities - Pneumomediastinum Radiographic features of Pneumomediastinum 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
  218. 218. Mediastinal abnormalities - Pneumomediastinum Radiographic features of Pneumomediastinum 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
  219. 219. Mediastinal abnormalities - Pneumomediastinum Radiographic features of Pneumomediastinum  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-Ray Retrosternal air Lateral Decubitus Chest X-Ray Air will not move with change in position Neck Films Air outlining fascial planes of the neck Naclerio V sign
  220. 220. Mediastinal abnormalities - Masses Clues to locate mass to mediastinum Masses in the lungMediastinal masses  May contain air bronchograms  A lung mass abutts the mediastinal surface 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.
  221. 221. Mediastinal abnormalities - Masses 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 mediastinum In lateral CXR, mediastinum is divided into superior and Inferior. Inferior mediastinum is divided into anterior, middle, and posterior
  222. 222. Mediastinal abnormalities - Masses Some causes of mediastinal masses in adults
  223. 223. Mediastinal abnormalities - Masses 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
  224. 224. Mediastinal abnormalities - Masses 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 posterior compartments where it is surrounded by lung This example is a ‘Lipoma’
  225. 225. Mediastinal abnormalities - Masses 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.
  226. 226. Mediastinal abnormalities - Masses 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).
  227. 227. 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 paratracheal stripe caused by a large ectopic parathyroid adenoma
  228. 228. 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 paratracheal stripe (arrows), with mass effect on the trachea. A 47-year-old patient with metastatic thyroid carcinoma
  229. 229. CXR Abnormalities - Soft tissue abnormalities Breast tissue: left-sided mastectomy:  Increased density over the right lung  Decreased density of the left lung  Breast asymmetry Gynaecomastia: Mobile AP Cardiac monitoring leads Dense breast tissue Male patient Breast cancer: PA Chest Xray: Increased soft tissue density with mass effect projected on left breast and axilla
  230. 230. 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.
  231. 231. 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)
  232. 232. CXR Abnormalities - Bones Bones:  Malignant bone disease may manifest as either single or multiple lesions.  Bones may become denser (whiter) due to a sclerotic process (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).
  233. 233. CXR Abnormalities - Bones 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
  234. 234. 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:
  235. 235. Chest X-ray - Tubes Tracheostomy tubes are positioned so that their tips are located at a midpoint between 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:
  236. 236. 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-oesophageal junction. Nasogastric (NG) tube:
  237. 237. 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) catheter: Right subclavian vein catheter Right internal jugular vein catheter
  238. 238. Chest X-ray - Tubes  Catheter positioning: 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. Central venous catheter (CVC) catheter: 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

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