chest x ray understanding is very important also complex. radiologist will many times need clinical correlation. but I have tried to cover a small bit of chest x ray pathologies. I HAVE REFFERED MANY ONLINE RADIOLOGY WEBSITES AND ALSO BOOKS FOR MAKING THIS PPT.

1. AL AMEEN MEDICAL COLLEGE
DEPT. OF RADIO DIAGNOSIS

2. NORMAL ANATOMY OF AIRWAYS
ALVEOLAR SAC= PARENCHYMA
INTERSTITIUM=ARTERIES,VEINS,BRONCHI

3. ALVEOLAR(AIR SPACE) DISEASE
ALVEOLI WITH SEROUS FLUID :
PULMONARY OEDEMA
ALVEOLI WITH BLOOD :
GOOD PASTURES ,WEGENERS
ALVEOLI WITH PUS : PNEUMONIA
ALVEOLI WITH PROTIENS : ALVEOLAR
PROTEINOSIS
ALVEOLI WITH MALIGNANT CELLS :
BRONCHOALVEOLAR
CA(ADENOCARCINOMA IN SITU)

4. INTERSTITIAL THICKENING
• IF THE INTERSTITIUM THICKENS, IT CAN BE
SEEN MORE PERIPHERALLY ON THE X-RAY OR
COMPUTED TOMOGRAPHY (CT) SCAN.
• IF THE INTERSTITIAL THICKENING IS
GENERALIZED, THE PATTERN IS LINEAR
(RETICULAR).
• IF THE THICKENING IS DISCRETE, IT FORMS
MULTIPLE NODULES

5. 1.MICRONODULES/ MILIARY NODULES
SEEN IN
TUBERCULOSIS
SILICOSIS
SARCOIDOSIS
METASTASIS
They are generally homogeneous
and are well-defined since their
margins are sharp and they are
surrounded by normal aerated
lung.

6. MACRONODULES/SMALLNODULES
SEEN IN:
SILICOSIS
SARCOIDOSIS
SEPTIC EMBOLI
MARGINS MAY BE SHARP OR INDISTINCT.
CAVITATION MAY OCCUR

7. RETICULAR (LINEAR AND IRREGULAR)
SEEN IN
PULMONARY EDEMA(KERLEY)
FIBROSIS
LYMPHANGITIC TUMORS
Linear interstitial patterns are seen in
processes that thicken the axial
(bronchovascular) interstitium or the
peripheral pulmonary interstitium

8. Alveolar pattern
Interstitial
pattern
Usual shadows
Fluffy or blobby Small nodules
Ill-defined margins Linear/reticular
Coalescing/merging
Linear/reticular
with septal lines
Segmental/lobar Reticulo-nodular
Additional
features
Air bronchogram
Reduced lung
volume
(extensive
disease)
Honey-comb
pattern (end-
stage disease)

9. SILHOUETTE SIGN
TWO SUBSTANCES OF SAME DENSITIES IN DIRECT CONTACT ,CANNOT BE
DIFFERENTIATED FROM EACHOTHER ON CHEST X RAY. IT IS USED TO
LOCALIZE THE DISEASE. IT IS CALLED LOSS OF NORMAL RADIOGRAPHIC
SILHOETTE .
WHERE ARE THE
HEART BORDERS ???

10. FINDINGS???

11. NEVER FORGET
ASCENDING
AORTA
RIGHT UPPER LOBE
RIGHT HEART
BORDER
RIGHT MIDDLE LOBE
RIGHT
HEMIDIAGPHRAGM
RIGHT LOWER LOBE
LEFT HEART
BORDER
LINGULA
LEFT
HEMIDIAGPHRAGM
/DESCENDING
AORTA
LEFT LOWER LOBE
AORTIC KNUCKLE LEFT UPPER LOBE

12. WHAT MARKINGS WE SEE ON NORMAL
CHEST X RAY?
WHAT MARKINGS
ARE NOT SEEN ON
NORMAL CHEST X
RAY?
TRACHEA AND
PROXIMAL BRONCHI IS
SEEN AS THEY ARE
SURROUNDED BY
SOFTTISSUE OF
MEDIASTINUM
PERIPHERAL BRONCHI
ARENT VISIBLE AS THEY
ARE SURROUNDED BY
ALVEOLI WHICH HAS
AIR WITHIN JUST LIKE
TERMINAL
BRONCHIOLES
THE ONLY BRANCHING STRUCTURES SEEN IS PULMONARY
VESSELS. THEY ARE SEEN AS WATER DENSITY WITHIN THEM IS
SURROUNDED BY AIR IN ALVEOLI.

13. AIR BRONCHOGRAM
AIR IN THE BRONCHI (PATENCY)
WITH ADJACENT LUNG CONSOLIDATION.

14. SIGNIFICANCE OF AIR BRONCHOGRAM
• INDICATES ALVEOLAR CONSOLIDATION.
• SEEN IN PNEUMONIA ALSO IN
PULMONARY EDEMA,PULMONARY
INFARCTION.
• EXCEPTIONS ARE
PATCHY CONSOLIDATION
INTERSTITIAL LUNG DISEASE
HYPERREACTIVE AIRWAY DISEASE
BRONCHIOGENIC CARCINOMA
ASPIRATED FOREIGN BODY
• CROWDED AIR BROCHOGRAM IS SEEN IN
NON OBSTRUCTIVE ATELECTASIS

15. CLASSIFY ALVEOLAR DISEASES BASED ON CONTENT
AND PATTERN

16. ACUTE VS CHRONIC
ACUTE CONSOLIDATION CHRONIC CONSOLIDATION
PULMONARY OEDEMA BROCHOALVEOLAR CA(ADENO CA INSITU)
PNEUMONIA EOSINOPHILIC PNEUMONIA
ASPIRATION ALVEOLAR PROTEINOSIS
INFARCTION
HEMMORHAGE

17. ALVEOLAR DISEASES
PULMONARY OEDEMA- SEROUS COLLECTION INVOLVING
DIFFUSE LUNG FIELDS
CAUSES
1. CARDIAC – Increased hydrostatic pressure in the vascular compartment Or
Decreased oncotic pressure(hypoalbuminemia).
2. NON CARDIAC- Increased permeability of alveolar-capillary barrier.
Major causes of noncardiogenic pulmonary edema are drowning, fluid overload,
aspiration, inhalation injury, neurogenic pulmonary edema, acute kidney disease,
allergic reaction, and adult respiratory distress syndrome.

18. STAG'S ANTLER SIGN,
HANDS-UP OR INVERTED MOUSTACHE SIGN
DIAMETER OF UPPER LOBE VEINS > LOWER LOBE VEINS
•Cephalisation/ Upper
lobe pulmonary venous
diversion(earliest)
•Seen in LHF , MS
•On auscultation : NVBS,
PCWP = 13- 18 mm Hg
•Never see for
cephalisation and
cardiomegaly on supine
films(ERRECT,FULL INSPI)

19. INTERSTILIAL EDEMA (PCWP=18-25 mm Hg)
•PERIHILAR HAZE :
PULMONARY VESSEL
MARGINS BECOME LESS
SHARP.
•PERIBRONCHIAL CUFFING
: THICK AND DISTINCT
AIRWAY WALL.
•FLUID IN SUBPLEURAL
SPACE EXTENDING INTO
INTERLOBAR FISSURES.
RESULTING IN KERLEY
LINES.

20. KERLEY B(WHITE
ARROW HEADS)
KERLEY A(WHITE
ARROWS)
3-6 CM 8-10 CM
SUBPLEURAL
PERPENDICULAR
TO PLUERAL
SURFACE
RADIALLY
ANGULATED
TOWARDS HILUM
DEPICTS
THICKENED
INTERLOBULAR
SEPTA
CAUSED BY
DISTENTION OF
ANASTOMOTIC
CHANNELS
BETWEEN
PERIPHERAL AND
CENTRAL
LYMPHATICS
PREDOMINANTLY
SEEN IN LOWER
LOBE.
PREDOMINANTLY
SEEN IN UPPER
LOBE.

21. ALVEOLAR OEDEMA(PCWP >25 mm Hg)
• SPARES THE APICES AND EXTREME LUNG BASES
• USUALLY THERE IS BILATERAL OPACIFICATION (IT CAN BE
UNILATERAL) OPACITIES MAY COALESCE TO PRODUCE A
GENERAL ‘WHITE-OUT’ (± AIR BRONCHOGRAMS)
• RESOLUTION OF ANY AIRSPACE OPACIFICATION MAY BE
RAPID (OVER HOURS)
• THE DISTRIBUTION OF PULMONARY OEDEMA CAN VARY
WITH POSTURE (DEPENDENT LUNG BECOMES MORE
OEDEMATOUS)

22. On the left a patient who first had a chest
film in a supine position.
Notice the pulmonary edema, which is
almost exclusively seen in the right lung.
A possible explanation for this
phenomenon could be, that the patient
had been lying on his right side for a while
before the x-ray was taken.

23. ALVEOLAR OEDEMA RADIATES
SYMMETRICALLY FROM THE HILAR
REGIONS IN A ‘BAT'S WING’ DISTRIBUTION
OF AIRSPACE SHADOWING

24. OTHER FINDINGS ON AN PA CHEST X RAY OF CARDIOGENIC PULMONARY EDEMA:
CARDIOMEGALY,
INCREASED VASCULAR PEDICLE WIDTH,
PLEURAL EFFUSION
The vascular pedicle width (VPW) is the distance between parallel lines drawn from
the point at which the superior vena cava intersects the right main bronchus and a
line drawn at the takeoff of the left subclavian artery from the aorta. The mean
vascular pedicle width is 38-58 mm on posteroanterior chest x ray.

25. CARDIAC VS NON CARDIAC
PULMONARY EDEMA

26. PNEUMONIA
• ACUTE LRTI+NEW RADIOGRAPHIC FEATURES
• ORGANISMS 1.STREPTOCOCCUS PNEUMONIA 2.KLEBSIELLA
• STREPTOCOCCUS PNEUMONIA:
THE MOST COMMON COMMUNITY-ACQUIRED ADULT BACTERIAL PNEUMONIA
PREDISPOSING FACTORS: CHRONIC ILLNESS ▸ ALCOHOLISM ▸ SICKLE-CELL DISEASE ▸
SPLENECTOMY
INFECTION STARTS IN DISTAL AIR SPACES,SPREADS TO ADJACENT ALVEOLI THROUGH PORES
OF KOHN RESULTS IN HOMOGENOUS OPACIFICATION OF ENTIRE LOBE,AS THE OPACIFICATION
IS LIMITED BY THE LUNG FISSURES.
AIR BRONCHOGRAMS CAN BE SEEN ,BUT WITHOUT VOLUME LOSS.RESOLVES WITHIN 2-6
WEEKS.
ROUND PNEUMONIA : SEEN IN CHILDREN DUE TO LACK OF COMMUNICATION BETWEEN
ADJACENT AIRSPACES.
USUALLY INVOLVES POSTERIOR LOWER LOBES

27. ROUND
PNEUMONIA

28. KLEBSIELLA PNEUMONIA=RED CURRENT
JELLY SPUTUM
•HOMOGENOUS OPACITY
•RAPID CAVITATION OF LOBAR
CONSOLIDATION
•EARLY ABSCESS FORMATION
•BULGING FISSURE
The “bulging fissure” sign of K. pneumoniae pneumonia refers to the
lobar consolidation where the affected portion of the lung is expanded
causing displacement of the adjacent fissure, resulting in a “bulge” in
the minor fissure on frontal radiographs and major fissure on lateral
films (DUE TO EXUDATES)

29. ATYPICAL PNEUMONIA
•CHEST X RAY FEATURES
ARE NON SPECIFIC
•SOMETIMES THERE IS
JUST A HINT :
MULTILOBAR
INVOLVEMENT AND
PLEURAL EFFUSION.

30. BRONCHOPNEUMONIA
(BRONCHITIS + PNEUMONIA
INVOLVEMENT OF BRONCHI >ALVEOLI)
•MULTIFOCAL INFECTION
•ALONG THE COURSE OF THE DISTAL
AIRWAYS
(PERIBRONCHIAL)
•PATCHY SEGMENTAL CONSOLIDATION
BECOMES DIFFUSE CONFLUENT(DON’T
CROSS FISSURE)

31. SPREAD OF INFECTION FOCI IN
BRONCHOPENUMONIA
MARTIN
LAMBERT
KOHN

32. STAPHYLOCOCCUS
•AIR FILLED SPACE IN LUNG
ADJACENT TO AN AREA OF
CONSOLIDATION
PNEUMATOCOELE
COMMON IN CHILDREN

33. PNEUMATOCOELE or ABCESS ???

34. PNEUMATOCOELE VS LUNG ABSCESS
• SMOOTH INNER MARGINS
• LITTLE IF ANY FLUID CONTENT
• THE WALL, IF VISIBLE, IS THIN AND REGULAR
• ASYMPTOMATIC PATIENT
• THICK,IRREGULAR WALLS WITH AN AIR FLUID LEVEL
• PATIENT TENDS TO BE VERY ILL

35. PNEUMONIA WITH
CAVITATION??
Staphylococcus
Pseudomonas
E.coli
Klebsiella
Streptococcus A GAS-FILLED SPACE, SEEN AS A LUCENCY OR
LOW-ATTENUATION AREA, WITHIN
PULMONARY CONSOLIDATION, A MASS, OR A
NODULE

36. ACUTE RESPIRATORY DISTRESS SYNDROME
(NON CARDIAC)
•Exudative phase: patchy, ill-
defined airspace opacities within
both lungs – these may progress
to more diffuse consolidation ▸
the opacities tend to have a more
peripheral distribution than those
seen with cardiogenic pulmonary
oedema
• Fibrotic phase: after a week or
so reticular opacities can be seen
(corresponding to fibrosis)

37. GROUND GLASS OPACITIES – PARTIAL ALVEOLAR
FILLING OR EXTREME INTERSTITIAL THICKENING
CAUSE : DECREASED AERATION OF ALVEOLI
CAN BE DUE TO PARTIAL ALVEOLAR FILLING.
DUE TO THICKENED INTERSTITIUM.
DUE TO HYPOVENTILATION AND ATELECTASIS.

38. CAUSES OF GROUND GLASS OPACITIES
• ACUTE PHASE OF PULMONARY
HEMMORHAGE
• ATELECATASIS
• ASPIRATION PNEUMONITIS
• ARDS

39. Sudden onset chest pain, dyspnea and
elevated levels of D-Dimer…?
Peripheral wedge of airspace opacity in the right
middle zone - "Hampton's hump"
Hampton hump refers to a dome-shaped
, pleural-based opacification in the lung
most commonly due to pulmonary
embolism and lung infarction

40. Fleischner sign: enlarged pulmonary artery (20%)
Hampton hump: peripheral wedge of airspace opacity and implies lung infarction
(20%)
Westermark sign: regional oligemia and highest positive predictive value (10%)
pleural effusion (35%) - pleural effusions in pulmonary embolism
knuckle sign
Palla sign : enlarged right descending pulmonary artery
Chang sign : dilated right descending pulmonary artery with sudden cut-off

41. REFERENCES
FELSON’S PRINCIPLES OF CHEST IMAGING
CHEST X RAY SURVIVAL GUIDE
RADIOPEDIA ARTICLES
RADIOLOGY ASSISTANT

42. THANK YOU
I HAVE TRIED TO COVER MOST OF THE TOPICS UNDER ACUTE
PARENCHYMAL LUNG DISEASES.
BUT ITS STILL INCOMPLETE...