by: dr. abasin tajmalzai

2. Chest Imaging
By: Dr. Abasin Tajmalzai

3. •
•
• Tracheobronchitis
• Pneumonia
• Bronchopneumonia
• Interstitial pneumonia
•
• Primary
• Post primary
• Bronchiectasis
• Pneumothorax
• Pleural effusion
•
•
•
• Fluoroscopy
• CT SCAN
• Magnetic Resonance Imaging ( MRI )
• Ultrasound
• Radionuclide lung scan
• Bronchography
• Pulmonary angiography
Terminology
• Silhouette sign
• Acinar pattern Alveolar pattern
• Reticulonodular pattern
• Air bronchogram
• Emphysema
• Bulla

4. •
•
• CT scan
• Radionuclide lung scan
• MRI
• Ultrasound
• Pulmonary angiography

5. Cont...
•
80.
•
• ( PA )
• )

6. A normal PA and lateral chest X-ray

7. AP PA

8. Cont…
•
• Oblique view
• Apical lordotic view
•
• Decubitus

9. Cont…
• Lateral:
• localizes an abnormality seen on the PA view.
• Anteroposterior (AP):
• used for ill patients
• Supine:
• used in infants and ill patients
• Erect:
• detects gas under the diaphragm in a suspected abdominal viscus perforation.
The following projections are occasionally used.
• Oblique:
• useful to demonstrate pleural, chest wall and rib abnormalities.
• Apical:
• the patient stands erect and leans backwards to give a bone - free view of the lung apices.
• Expiratory:
• a pneumothorax becomes more prominent.
Disadvantage:
Magnification of the heart size

10. THE LATERAL CHEST PROJECTION
Note that the lesion projected over the chest on the PA
projection ( a ), assumed to be an intrathoracic mass, is
actually in the soft tissues of the back, seen on the lateral ( b )

11. Cont…
• Advantages:
• Quick test, widely available, inexpensive
• can usually identify pneumonia, TB, CHF, ...
• Disadvantages:
• Not as comprehensive as a chest CT. For example, it cannot rule out
processes such as a pulmonary embolus.
• When to order:
• Shortness of breath
• Chest pain
• Trauma
• Cough (sometimes)

12. CXR Quality Assessment
Before assessing technical quality, check patient’s name, age, date and erect or supine marks and
then check for 5 things:
• Orientation
• R or L marking
• Adequate penetration
• lower thoracic spine just visible
• over penetrated :too clearly visible
• under penetrated:: lung fields will appear falsely white.
• Inspiration
• diaphragms at level of 5th ,6th or 7th ribs anteriorly
• Rotation
• the spinous processes of the upper thoracic vertebrae lie midway between the medial ends of the clavicles.
• Motion
• Outline of the chest structures should be sharp.

14. Effects of respiration
Poor inspiration Good inspiration

15. Overexposure Underexposure

16. Rotation

17. How to read & interpret a Chest X-ray?
• Systematic approach: ABCDE-F
• Airway:
• Check to see if the trachea is midline.
• Bone:
• Look for fractures, metastasis.
• Cardiac:
• Look to see if the heart is enlarged.
• Diaphragm:
• Check for free air under the diaphragm
• and pleural effusions.
• Extras:
• Identify all tubes and lines.
• Fields of the lung:
• Check the lung parenchyma
• for an atelectasis or consolidation.

19. OSSESOUS STRUCTURES

22. Assess for diaphragmatic flattening.
The distance between A and B should be at least 1.5 cm.

23. The ‘hidden’ areas

24. Key points
• There should be a decrease in
density from superior to inferior in
the posterior mediastinum.
• The retrosternal airspace should be
of the same density as the
retrocardiac airspace.

26. Attenuation of the x-ray beam
Tissue
absorpti
on
Least
Most
Air or gas
Fat
Soft tissue
Bone or
calcium
Black image
Dark grey image
Grey image
White image
Effect on the radiograph

28. Fluoroscopy
•
• air trapping .

29. Chest CT Scan
:
– Mediastinum .
– calcification .
–
– .
– Bronchiectasis Fibrosing alveolitis.

30. Chest CT scan, lung and mediastinal windows

31. Lung biopsy under CT control. The needle (arrow)
has been inserted through the posterior chest
wall.

32. Magnetic Resonance Imaging (MRI)
• MRI Mediastinum .
• MRI CT SCAN .

33. Ultrasound
• Pleural effusion .
• Collection
• Biopsy .

35. Radionuclide lung scan
• Lung scan :
1. Perfusion scan (Gama camera) .
2. Ventilation scan .
•. Lung scan
.

36. Bronchography
• bronchoscopic Bronchiectasis .

37. PulmonaryAngiography
•
• .

39. Normal Radiographic
Anatomy

40. Chest X-ray, PA view

41. Chest X-ray PA view shows lung zones

43. LUNG LOBES

46. RIGHT UPPER LOBE

47. RIGHT MIDDLE LOBE

48. RIGHT LOWER LOBE

49. LEFT UPPER LOBE

50. LEFT LOWER LOBE

51. Terminology
• Silhouette sign
• .

52. • Silhouette sign (+):
• An intrathoracic lesion touching a border of the heart, aorta, or
diaphragm will obliterate that border on the CXR.
• Silhouette sign (-):
• An intrathoracic lesion not anatomically contiguous with a border will not
obliterate that border.
Bronchial carcinoma.Pericardial cyst.

53. Cont…
Acinar pattern Alveolar pattern
CT scan:
• 4-8 mm .
• terminal distal acinus :
• Respiratory bronchus
• Alveolar duct
• Alveolar sac
• Alveoli

54. Acinar pattern, conventional radiography and CT scan

55. Cont…
• Reticulonodular pattern
• .

56. Reticular/ interstitial shadowing
• lung fibrosis
• pneumoconiosis
Nodulars hadowing
• miliary TB; pneumoconiosis;
sarcoidosis; neoplastic lesions

57. Cont…
• Air bronchogram
• Air bronchogram .

58. Cont…
• Emphysema
• (air space) terminal bronch distal .
• Bulla
•
.

59. Giant bullous emphysema

60. Emphysema with bulla formation, conventional radiography and CT scan

61. Consolidation
• The lung is said to be consolidated when the alveoli and
small airways are filled with dense material.
This dense material may consist of:
• Pus (pneumonia)
• Fluid (pulmonary edema)
• Blood (pulmonary hemorrhage)
• Cells (cancer)

62.  Obstructive airways disease:
Asthma Bronchiolitis Overinflation .

.
 Infarction
 (Miliary tuberculosis)
Pulmonary fibrosis
 Dry pleurisy

63. Overinflation in asthma

64. ?

65. Diseases

66. 1) Tracheobronchitis
2) Bronchiolitis
3) Pneumonia .

67. Tracheobronchitis
• .

68. Pneumonia
.
• .
• Pneumonia
1- Lobar pneumonia
• air-bronchogram .
• volume loss .
• patchy consolidation .

69. Rt. middle lobe pneumonia, CXR Rt. middle lobe pneumonia, CT

71. Bronchopneumonia
• Alveol .
•
• Patchy consolidation consolidation Multifocal .
• .
• .
• scar .

72. Severe bilateral
bronchopneumonia
Bronchopneumonia, before and
after treatment

74. Interstitial pneumonia
• :
• Linear Reticular
• Ground glass pattern
• consolidation .

75. Viral pneumonia
• Influenza, Measles, Adenovirus .
•
• Ground glass Patchy
• Reticular
• Consolidation .

76. Viral pneumonia

77. .
• Primary
• Post primary
•
•
•

80. Cont…
•
Primary
1) Consolidation
)(
2)
3) Pleural effusion
Primary
complex
Calcified

82. Primary tuberculosis. Magnified PA CXR demonstrates a right mid
lung calcified nodule (Ghon focus) together with ipsilateral right
hilar lymph node calcification (Ranke complex).

83. Right paratracheal and left hilar adenopathy.

84. Cont…
• Primary
• Bronchopneumonia
• TB Miliary
Intrabronchial dissemination in TB, radiograph & CT

85. Miliary TB

86. Cavitation due to TB

87. Cont…
• Post primary
• Consolidation )(
• Bronchopneumonia
• Cavitation
• Lymphadenopathy Mediastinal
• Pleural effusion and Pleural thickening

89. Old healed calcified tuberculous foci

90. Healed with fibrosis

91. Bronchiectasis
•
•
•
•
•
•
•
• elastic
• fibrosis .

93. Cont…
•
• Parallel line shadows
• cystic tubular)
• volume loss
•
•
• Hyperinflation .

95. Cont…
• CT scan
• Broncho-arterial
• Lack of tapering
• Contour abnormalities cystic tubular
•

96. Cylindrical bronchiectasis. The bronchi fail
to taper and have irregular thickened walls.

97. Cystic bronchiectasis

98. )Pleural effusion(
A fluid collection in the space between the parietal and visceral layers of the pleura.
• Contents
• Usually contains serous fluid.
• Haemothorax: Blood, usually following trauma.
• Empyema: Purulent fluid from extension of pneumonia or lung abscess.
• Chylothorax: Chyle from thoracic duct rupture or from malignant invasion.
• Hydropneumothorax: Fluid and air.
• Radiological investigations
• Chest film
• Ultrasound
• CT

100. Pleural effusion …
Radiological appearances:
Plain x-ray:
Erect position
Fluid gravitates to the lower-most part of the thorax
 homogeneous opacification, similar density as the cardiac shadow;
 loss of the diaphragm outline;
 no visible pulmonary or bronchial markings;
 concave upper border with the highest level in the axilla.
⇧ fluid collection  ⇩ lung volume  retracts towards the hilum.
Initially the fluid accumulates in the posterior, then the lateral costophrenic space.
Larger effusions  mediastinal shift to the opposite side.

101. Pleural effusion …
• Ultrasound:
• highly sensitive examination in detecting pleural fluid.
• CT:
• demonstrate pleural effusions
• visualize underlying abnormalities.

102. Pleural effusion …
• Subpulmonary effusion
• Fluid accumulating between the diaphragm and the inferior part of the lung.
• The upper margin of the shadow of the fluid runs parallel to the diaphragm.
• On the PA chest film mimics a high diaphragm.
• Loculated effusion
• Fluid can loculate in the fissures or against the chest wall.
• Occasionally seen in cardiac failure.
Key point:
• The minimum fluid volume that can be visualized on a chest film is 200-300ml;
this will blunt the costophrenic angle.

104. Large left pleural effusion (arrow).

106. White out.
A large left pleural effusion is displacing
the mediastinum to the right.
White out.
The mediastinum and trachea are
displaced to the right. Major collapse of
the right lung.

107. White out.
The mediastinum is not displaced and the trachea is midline.
Large left pleural effusion with major compression collapse of the left lung.
The CT section confirms the effusion and the collapsed left lung.

108. Large right subpulmonary effusion
• Almost all the fluid is between the lung and the diaphragm.
• The right hemidiaphragm cannot be seen, but its estimated
position has been pencilled in.

109. Loculated pleural fluid
Posteroanterior and lateral views showing an empyema
loculated against the posterior chest wall.

110. Ultrasound showing the effusion (black)
surrounding the retracted lung (arrows).

111. CT of pleural fluid. (bilateral pleural effusions)

112. Pneumothorax
• Air enters the pleural cavity via a
tear in either the parietal or visceral
pleura;
• The lung subsequently relaxes and
retracts to a varying extent towards
the hilum.
• Type:
• Severity

113. Pneumothorax …
Radiological features
• Best demonstrated on an
underpenetrated chest film.
• The following may be seen.
• Lung edge: a thin white line of the lung
margin, the visceral pleura.
• Absent lung markings between the
lung edge and chest wall.
• Mediastinal shift: when a tension
pneumothorax develops.

114. Pneumothorax …
Causes
• latrogenic (one of the commonest causes):
• Following lung biopsy, chest aspiration, thoracic surgery…
• Spontaneous:
• Rupture of a small pleural bleb.
• Trauma:
• Stab wounds, rib fractures
• Pre-existing lung disease:
• emphysema, cystic fibrosis or interstitial lung disease.

116. Right pneumothorax:
there are no visible markings beyond the
lung edge (arrows).

117. Tension pneumothorax with complete
collapse of the right lung (arrows) and
mediastinal shift to the left.

118. Pneumothorax …
• Complications
• Tension pneumothorax
• Hydropneumothorax
• fluid in a pneumothorax
• Key point:
• As air rises in an upright patient, a pneumothorax is most
commonly seen at the apex.

120. Bronchial carcinoma
1- Bronchial carcinoma (peripheral):
• Main types: small cell lung cancer (SCLC) and non - small cell lung cancer (NSCLC).
Bronchoscopy may be negative in peripheral lesions, as visualization is not possible distal
to the segmental bronchi. The following features may be present on a plain chest film.
• Radiological features
• ● Lobulated or spiculated mass but sometimes with a smooth outline.
• ● Associated hilar gland enlargement, pleural effusion, areas of collapse or consolidation.
• ● Cavitation found in 15% with central air lucency, an air/fluid level and a wall of variable
thickness. Squamous carcinomas frequently cavitate.
• ● Tumours at the lung apex (Pancoast’s tumour) can invade the brachial plexus, resulting in
shoulder and arm pain with wasting of the hand, or invasion of the sympathetic chain may give
rise to Horner’s syndrome.

121. Cont…
2- Bronchial carcinoma (central):
Central bronchial carcinoma arises from the major bronchi, causing a
mass in the hilar region.
• Radiological features
• On a CXR, the central mass causes the hilar shadow to enlarge,
assume an increased density or an irregular outline. As the tumour
increases in size, narrowing of the bronchial lumen may cause collapse
of the distal lung and consolidation due to secondary infection.
• A large tumour often gives rise to complete collapse of a lung and may
result in opacification of the entire hemithorax.

122. Appearance of peripheral lung carcinoma.
A lobulated mass (a) and a cavitating mass
(b) are shown on plain films.
a b

124. Typical appearance and small size of a carcinoma
of the bronchus discovered incidentally at CT.

125. Right hilar mass due to carcinoma of the bronchus.
There is also a patch of consolidation in the right upper
lobe laterally, from the central obstruction.

126. Metastatic neoplasms
• Primary source:
• Tumours of the lung, breast, renal tract, testis, GI tract, thyroid and bone.
Radiological features:
Metastatic disease to the chest may involve one or more of the following:
• Lungs
• Well-defined, multiple, round opacities of differing sizes in the lung fields.
• CT
• more sensitive than CXR
• monitoring response to chemotherapy.
• cavitation is occasionally present (indicating SCC)
• Key point
• Multiple lung lesions of varying size are invariably metastases
• Pleura:
• Lymph nodes:
• Skeletal system:

127. Focal lung secondary deposits
CT thorax showing multiple small
metastases (arrows)

128. SPN, Solitary Pulmonary Nodule; TNB, transthoracic needle biopsy; Bx, biopsy; F/U, follow-up.