most common symptoms being dyspnoea and / or a non-productive cough. In patients who are profoundly immunocompromised, onset may be more dramatic and resemble other pulmonary infectionsbilateral, diffuse, often perihilar, fine, reticular interstitial opacification, which may appear somewhat granularBat's wing or butterfly pulmonary opacities
Nodules are either sharply or poorly defined 1–4-mm in size Diffuse, random distributionImaging Findings Discrete Distinctive Pin-point opacities Nodule size 1 – 2 mm in diameter - SPHERICAL LESION IN Miliary ( millet seed ) Pattern INTERSTITIUM B/L even distribution - WELL CIRCUMSCRIBED Basal Predominance HOMOGENOUS PATTERN Rare or non-existent calcifications Upto 30 % no radiological signs Thickening of intralobar fissure / interlobular septa Nodular irregularity of vessels HRCT – more sensitiveAlveolar microlithiasisPNEUMOCONIOSIS - Coal Workers Pneumoconiosis - Silicosis - Siderosis - StannosisSARCOIDOSIS METASTATIC LUNG DISEASES NON TB INFECTIONS – Histoplasmosis - Blastomycosis - Cryptococcosis - Nocardiosis – Coccidiodomycosis BRONCHIOLITIS OBLITERANS
Many thoracic aneurysms are visible on chest x ray and are characterised by widening of the mediastinal silhouette, enlargement of the aortic knob or displacement of the trachea of the midline.
Tracheal shift to the left-PUSH effect, increased volume of the right hemithoraxHyperlucency of right hemithorax + absence of lung markings + margin of collapsed lung(compression collapsed) = pneumothoraxTotal collapse=collapse like a cricket ball towards the hilum
Loculated cavity with thin wall(myb post infective cyst, wall made upof a fibrous tissue)Presence of air fluid levelMild trachea shift to the left(probably due to rotation)Fundic air bubbles separately seend/d:lung abscess(unresolved pneumonia), primary tumor (?blood clot)
Trachea remains central-why?Cardiac shift to the opposite side ,lefthemithorax size reducedHomogenous opacity starts from right middle zone downwards +obliteration of right costophrenic & cardiophrenic angles = almost totally WHITE OUT LUNGNot WHITE OUT LUNG because,not involve entire lungd/d:consolidation, pleural effusion/thickening(heterogenous opacity), collapse, upward enlargement of the liver(r/o)Notes:left 4th rib…cavities???
Not WHITE OUT LUNG because,not involve entire lungWhy notConsolidation-no air bronchogramPleural thickening-heterogenous opacityCollapse-presence of lung markings
Changes of 1-6 indicates interstitial edema.7-9 indicates alveolar edema.10-11 likely present in the cardiogenic causes of pulmonary edema (LVH)
left border of heart obliterated:lesion in lingulaRight hemidiaphragmobliterated:lower lobe lesionParatracheal stripes obliteration :paratrachealdzIt can be either consolidation or superimposed mass lesion.p/s :tram track appearance near arrow 2?? : thickened bronchial wall..(d/d:bronchiectasis ,cystic fibrosis,allergicaspergillosis,recurrent asthma/bronchitis in child)Air under left diaphragm : colonic gas shadow overlapping fundic gas bubble…..you can see the haustration!! Volvulus??
Air under diaphragm:In normal x-ray :there will be a fundic bubble gas on right side.Presence of air under diaphragm here may be due to perforation of hollow viscus (stomach @ intestine) following procedures.examples following laparatomy.Laparoscopy??
As u can see a curved white line lying behind the heart.
20 Important Xrays Neil Dominic Fernandes 080201054
• First look at the mediastinal contours—run your eye down the left side of the patient and then up the right.• The trachea should be central.• The aortic arch is the first structure on the left, followed by the left pulmonary artery; notice how you can trace the pulmonary artery branches fanning out through the lung• Two thirds of the heart lies on the left side of the chest, with one third on the right. The heart should take up no more than half of the thoracic cavity.• The left border of the heart is made up by the left atrium and left ventricle.• The right border is made up by the right atrium alone. Above the right heart border lies the edge of the superior vena cava.• The pulmonary arteries and main bronchi arise at the left and right hila. Enlarged lymph nodes can also occur here, as can primary tumours. These make the hilum seem bulky.• Now look at the lungs.• Apart from the pulmonary vessels (arteries and veins),they should be black (because they are full of air).• Scan both lungs, starting at the apices and working down, comparing left with right at the same level. The lungs extend behind the heart, so look here too. Force your eye to look at the periphery of the lungs—you should not see many lung markings here; if you do then there may be disease of the air spaces or interstitium.• Don’t forget to look for a pneumothorax.• Make sure you can see the surface of the hemidiaphragms curving downwards, and that the costophrenic and cardiophrenic angles are not blunted—suggesting an effusion.• Check there is no free air under the hemidiaphragm
The Normal Cardiac Borders in the PA View: A) The left cardiac border is formed from above down by: 1. The aortic arch (= knob, knuckle). 2. The main pulmonary artery. 3. The left atrial appendage. 4. The left ventricle. B) The right border of the heart is formed by: 1. In the lower two thirds by the right atrium. 2. In the upper third by the superior vena cava.
How to read• This is a chest radiograph of a young male patient PA view.• The patient has taken a good inspiration and is not rotated; the film is well penetrated.• The trachea is central, the mediastinum is not displaced.• The mediastinal contours and hila seem normal.• The lungs seem clear, with no pneumothorax.• There is no free air under the diaphragm.• The bones and soft tissues seem normal
Features to look for Present features1. Opacification Dense opacification of the right upper zone, V shaped2. Horizontal fissure Has been displaced upwards from its original position3. Hilum enlarged or elevated Right hilum is elevated than left hilum4.Smaller lung, smaller hemithorax Not present5. Compensatory hyperinflation and Presenthyperlucency in other lobes6. Tracheal deviation Absent7. Elevated ipsilateral hemidiaphragm Present
Pneumothorax Increased volume of the right hemithorax with tracheal shift to the OPPOSITE side- ”PUSH” effect Hyperlucency on the right side Absence of lung markings Presence of margin of collapsed lung at the hilum D/D:Unilateral emphysema
Hydropneumothorax Horizontal fluid level with hyperlucent area above it Hyperlucent area with no lung markings Presence of air+fluid = Hydropneumothorax Trachea shifted to the SAME side-”PULL “ effect D/D:lung abscess
Lung abscess Loculated cavity with thin wall(maybe post infective cyst, wall made up of a fibrous tissue) Presence of air fluid level Mild trachea shift to the left(probably due to rotation) Fundic air bubbles separately seen
Lung abscess VSHydropneumothoraxFeature Lung Abscess HydropneumothoraxDefinition Intrapulmonary air- Intrapleural air- fluid collection fluid collectionShape of fluid Round, take up the Take up shape of the shape of cavity wall thoracic cavity & margin of collapsed lungCavity Wall Clearly seen Not seenMargin of collapsed Not seen May be seenlungLength of air-fluid Equal regardless of Length varies withlevel radiographic radiographic projection projection
Pleural effusion Homogenous opacity of right middle & lower zone = almost totally WHITE OUT LUNG Minimal tracheal shift to the left Cardiac shift to the opposite side with reduced left hemithorax size. Obliteration of right costophrenic & cardiophrenic angles D/D:consolidation, pleural thickening(heterogenous opacity), collapse.
Pulmonary Edema Bat wings/butterfly distribution Pleural effusion
Pulmonary Edema• Produces air space opacities with variable distribution.• Sparing of the apices and extreme lung bases.• “Butterfly” or “Bat wings” distribution – central lungs affected more.• With progression – opacities coalesce to form a “white-out” on chest radiograph.• Blurring of blood vessels occurs.• Air bronchogram – indicating intra alveolar edema.
Sequence of events on CXR in acute pulmonary edema. Early changes. Late changes. 1. Prominent pulmonary artery. 7. Fluffy shadows. 2. Prominent pulmonary lobe 8. Air bronchogram. veins. 3. Interlobar fissure. 9. Bat’s wing appearance. 4. Perivascular cuffing. 10. Cardiomegaly . 5. Peribronchial cuffing. 11. Pleural effusion. 6. Kerley B lines.
Differences..Criteria. Cardiogenic (LVH) Non cardiogenic(ARDS)1. Cardiomegaly . Comman +++ Uncomman+2. Alveolar edema. +++ +++3. Appearance of Bat’s wing /butterfly More patchy shadow . appearance4. Perivascular and More often seen Less likely peribronchial cuffing.5. Tendency for Yes No gravitational distribution.6. Pleural effusion. May be present Unlikely
Silhouette Sign• On the radiograph, loss of normal border of the heart, aorta, or diaphragm by intrathoracic lesions known as silhouette sign. Silhouete signs seen as Intrathoracic lesions Upper right heart Anterior segment of RUL border/ascending aorta Right heart border RML (medial) Upper left heart border Anterior segment of LUL Left heart border Lingula (anterior) Apical portion of LUL Aortic knob (posterior) Anterior hemidiaphragms Lower lobes (anterior)