RADIO

250: ICC in Radiology and Nuclear Medicine

LEC 06: CHEST RADIOLOGY
Exam 01| Dr. Manny Lopez | August 29, 2013

OUTLINE
I.
Anatomy Review
K. Cavity
II. Normal X-Ray
L. Abscess
III. Assessing Quality
M. Aspergilloma
IV. Radiographic Findings
N. Calcifications
A. Pneumonia
O. Granuloma
B. Consolidation
P. Nodule
C. Air Bronchogram
Q. Mass
D. Atelectasis
R. Adenopathy
E. Primary Pulmonary TB
S. Pulmonary Congestion
F. Fibrotic Infiltrates
T. Pulmonary Edema
G. Bronchiectasis
U. ARDS
H. Pulmonary Emphysema
V. Pulmonary Embolism
I.
Bulla
W. Pleural Abnormalities
J. Bleb
X. Additional Notes

I. ANATOMY REVIEW
A. LUNG LOBES AND BRONCHOPULMONARY SEGMENTS

Left lung
o Upper lobe
Apical posterior*, Anterior, superior (lingual)*, inferior
(lingula)*
o Lower lobe
anterior medial basal*, lateral basal, posterior basal
*segments that are not present in the R lung

B. MEDIASTINUM

Figure 3. Mediastinal Compartments.

Figure 1. Lung Lobes. There are 3 right and 2 left lung lobes. The left
lung has a concavity called the cardiac notch.

Figure 2. Bronchopulmonary Segments. There are 8 on the left and
10 on the right, which has a middle lobe.

Right lung
o Upper lobe
apical, posterior, anterior
o Middle lobe
lateral, medial
overlaps cardiac shadow
o Lower lobe
anterior basal, medial basal, lateral basal, posterior basal,
superior

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1. Anterior Mediastinum (prevasular space)
Screening tool for breast cancer
Difficult to
Loose areolar tissue
Lymph node, lymphatic vessels
Thymus
Thyroid, parathyroids
Internal Mammary artery and veins
Usual pathologies: thymus, enlarged lymph nodes

2. Middle Mediastinum (vasular space)
Heart
Pericardium
SVC, arch of the aorta
Azygos vein
Brachiocephalic artery
Phrenic and upper vagus nerve
Trachea, main bronchi
Pulmonary vessels and adjacent lymph nodes

3. Posterior Mediastinum (postvasular space)
Thoracic descending aorta
Esophagus
Thoracic duct
Azygos, hemiazygosvns
Lymph node, fat, autonomic nerves
Sympathetic nerves
Inferior Vagus nerve

II. NORMAL CHEST X-RAY
A. What to look for
For 2D presentations of 3D info need at least 2 views e.g. PA-L
views

Two Essential Views
1. AP view
o Lung parenchyma
o Lung fissures
Minor/horizontal fissure
Goes lateral
If you see this, normal
Not seen in left lung
Major/oblique fissure
Oblique
If seen, there is a pathology
Divides upper and middle from lower

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o Heart left ventricle
o Aortic knob
o Pulmonary vessels/lung hilum
Blood vessels are more prominent in the inner lung zones
and lower lung fields (due to gravity) and tapers as you go to
the periphery (blood vessels no longer seen 2-3 cm from the
chest wall)
When patient is supine, blood distribution is equal or more
prominent in the upper lung fields
When w/ congestion, cephalization occurs (more prominent
in middle and upper lobes)
L main pulmonary artery (above L mainstem bronchus)
higher than R (behind aorta, below R mainstem bronchus)
o Diaphragm
o Gastric bubble
o Esophagus
o Costophrenic angle
o Bones and soft tissues (axillary areas for lymph nodes,
supraclavicular area, thyroid)
o Clavicle
o Vertebrae
o Ribs
2. Lateral view
o Lung parenchyma
o Cardiac borders
Posterior: left ventricle (LVH obliterates retrocardiac space)
Anterior: right ventricle (RVH obliterates retrosternal space)
In a car accident, R ventricle affected since its directly
behind the sternum
o Right hemidiaphragm higher because of the liver
o Left hemidiaphragm lower and with gastric bubble
o Spine analyze each vertebral body for compression fractures,
degenerative osseous changes, spurs.

Figure 4. Normal PA and lateral chest radiographs.

Figure 5. Xray beam should be ideally six feet from target.

Proper positioning of the patient
o hands should be on the hips to wing out the scapula,
o elbows should touch the wall
o inhale hold breath to expand the lung

Radiographic Density
Higher tissue depth, atomic weight higher radiographic density
o Very radiolucent (black) gas
o Moderately radiolucent fatty tissue
o Intermediate connective tissue, muscle tissue, blood,
cartilage, epithelium, cholesterol stones, uric acid stones

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o Moderately radiopaque bone, calcium salts

o Very radiopaque (white) heavy metals

B. Other Views
If one is not sure about the findings in the Xrays, one should ask
for ancillary tests such as the ff:
o Decubitus - useful for differentiating pleural effusions from
consolidation (lie on the side for at least 30 mins then take a
cross-table lateral view)
o Apicolordotic view (ALV)- used to visualize the apex of the lung
o Expiratory view - helpful for the diagnosis of pneumothorax
o Oblique view- to visualize cardiac borders
o Frontal and lateral views are still better

III. ASSESSING QUALITY
First determine if the film is of good quality by analyzing the film:
1. PA projection/AP view
AP projection/PA view
2. Patient position
3. Adequacy of view
4. Exposure
5. Inspiratory effort
6. Obliquity

A. PROJECTION
PA vs. AP
o not 100% accurate, you have to have a good clinical eye
o AP
anterior posterior film. Done when patient cant
stand. X-ray taken in a supine position
Scapula not winged out
Ribs more horizontal
Mickey Mouse sign at C7
Elevated hemidiaphragms
o PA
the beam hits the posterior anterior film
Mongolian hat sign C7, T1
o *Marker depends on institution, but Is usually located on the
right
View vs projection
o View - How you view the film, opposite direction (ex. PA
projection, AP view)
o Kalimutan na lang ang view. Malilito lang tayo.

B. ADEQUACY
CXR plate must be able to show all structures:
o lungs
Whole lung parenchyma
Lung apices for TB
o Heart
o Cervical region
o Apices of the lungs
o Trachea
o Costophrenic angle
o Hemidiaphragm
o Osseus structures
o Soft tissue structures
There should be no cut-offs. The cervical region and lung apices
above, and the costophrenic angle below should be seen.
o You may not be able to see a pleural effusion if there is a cut-
off of the costophrenic angle
Right ventricle cant be seen since it is anteriorly located.
In looking at the diaphragm, check for:
o Eventration: a weak diaphragm may result in herniation
o Flattening: can be found in COPD, asthma, hyperaeration

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C. EXPOSURE
Good exposure if you see 4 thoracic vertebra (T4 as landmark)
Processing and exposure can affect the quality of the film and
may lead to false readings or misdiagnosis
Underdeveloped Air is not that black, too white (hilaw)
Overdeveloped
Air is too black (sunog)
Underexposed
Less of the bones are seen, <T4
Overexposed
More of the bones are seen, >T4

D. INSPIRATORY EFFORT
Good inspiratory effort: check if the hemidiaphragm meets the
th
th
9 -11 right ribs
th
Poor inspiratory effort: anything less than the 9 rib
o May cause magnification of the heart, crowding of pulmonary
vasculature, compressed lung (may look like discoid atelectasis,
infiltrates, congestion, lesion will be hidden)
>11th rib
o May be read as hyperaerated, usually seen in emphysema and
asthma

o May be normal in athletic people, thus, have to request for
complete information of the patient to correlate the xray
results

E. OBLIQUITY
the line connecting the spinous processes need to be straight and
perpendicular to the line connecting the clavicle heads
90 degree angle no obliquity
If you dont know the xray is oblique, might misdiagnose as
fibrosis, tumor, atelectasis wherein the mediastinal structures are
misplaced or deviated

IV. RADIOGRAPHIC FINDINGS
WHAT TO CHECK
Breast shadows
Bones, e.g. rib fractures and lytic bone lesions, scapula, clavicles
o Posterior and anterior ribs
Posterior ribs less oblique than anterior
o Scapula
o Humeral heads
o Clavicle
o Vertebral bodies
Cardiac silhoutte, detecting cardiac enlargement
o Cardiothoracic ratio crude way to measure heart size
widest heart diameter over widest inner diameter of thorax
Normal -<0.5
Mild cardiomegaly 0.5-0.55
Cardiomegaly >0.55
When supine, heart is magnified
In AP projection, the film is at the back so the heart is
farther from the film, resulting in cardiac magnification
Give leeway of 0.55 for adults, 0.6 for pediatric patients
Costophrenic angles
o Normally sharp, acute most dependent portion
o Blunted if there is pleural effusion
o Theres thickening if chronic
Diaphragm, e.g. evidence of free air
Edges, e.g. apices for fibrosis, pneumothorax, pleural thickening
or plaques
Extrathoracic tissues
Fields (lung parenchyma), being evidence of alveolar filling
o Zones divide the lung parenchyma vertically (inner, middle,
outer)
o Fields divide the lung parenchyma horizontally (upper,
middle, lower lung fields)
Failure, e.g. alveolar air space disease with prominent vascularity
with or without pleural effusions
Check for tracheal deviations
o Fibrosis, atelectasis pulls to the same side
o Tension pneumothorax, tumor pushes to the other side

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General Differences (FROM 2013)

o Age: pediatric hearts are more globular, less pulmonary
interstitium and diaphragm is higher compared to adults
o Gender: no marked difference aside from breast shadow;
silicone implants are usually central in females, lateral in males

Figure 6. Xray spectrum & corresponding pathologies.

When findings are black or white
When more air is inside an acinus, the black area becomes bigger
When fluid/exudates is inside, it becomes white
When the acini collapse, it becomes white because air is lost
*Acinus - The ending of a tiny airway in the lung, where the alveoli
(air sacs) are located

Infiltrates or Opacities
Single or multiple irregular shadows
Shadows of parenchymal abnormalities characterized
histologically by cellular infiltration whether interstitial or alveolar
Most common cause: pneumonia (middle lobe syndrome)
Lungs do not absorb radiation as much so opacities are
particularly important in the lungs
Obliterates structures on the same level= silhouette sign
Opacities may be classified into
o airspace-filling opacities
o opacity resulting from atelectasis
o interstitial opacities streaky
o nodular or mass-like opacities
o branching opacities

A. PNEUMONIA
Airspace disease opacity
With or without consolidation
NOT distinguishable radiographically from fluid (inflammatory),
cells (cancer), protein (alveolar proteinosis), and blood
(pulmonary hemorrhage)
Space occupying lesion WITHOUT volume loss
Air space opacity, lobar consolidation

Types of Pneumonia
Lobar - classically pneumococcal pneumonia, entire lobe
consolidated and air bronchogram common
Lobular - often Staphylococcus, multifocal, patchy, sometimes
without air bronchogram
Interstitial - viral or mycoplasma - starts perihilar & can become
confluent and/or patchy by progression, no air bronchograms
Aspiration pneumonia - diffuse, follow lung bases; follows
gravitational flow of aspirated contents; post anesthesia, common
in alcoholics, debilitated, demented pts, anaerobic (Bacteroides
and Fusobacterium) history of impaired consciousness
Diffuse pulmonary infections - community acquired
(Mycoplasma, resolves spontaneously), nosocomial
(Pseudomonas), debilitated, mechanical vent pts, high mortality
rate, patchy opacities, (cavitation, ill-defined nodules),
immunocompromised host (bacterial, fungal, PCP)

X-ray Findings
Airspace opacity, lobar consolidation, or interstitial opacities
Patterns:
o Lobar or segmental distribution
o Poorly marginated
o Airspace nodules
o Tendency to coalesce
o Air bronchograms

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o Bat's wing (butterfly) distribution
o Rapidly changing over time
o Develop when the air normally present within the terminal
airspaces of the lung is replaced by material of soft tissue
density (blood, transudate, exudate, or neoplastic cells)

Figure 9. Air bronchogram.

Figure 7. Pneumonia. Note the right airspace opacity & the positive
silhouette sign (see below).

How to Determine Which Lobes has the Opacity
RIGHT LUNG- with 3 lobes: upper lobe, middle lobe and lower
lobe
LEFT LUNG- with 2 lobes: upper lobe and lower lobe. The upper
lobe has a projection called lingula
If the opacity is in the upper lobe, you can see it above the minor
fissure (n the right lung)
If the opacity is on the middle lobe, look for silhouette sign
Silhouette sign indicates right middle lobe syndrome
o Infiltrate in the middle lobe overlaps the cardiac border and is
on the same level with the heart
o Loss of normal border that is contiguous with the pathology
o Loss of normal lung /soft tissue interface caused by an
abnormality (mass, fluid, cells) in the normally air filled lung
o described by Dr. Ben Felson
If it is in the lower lobe, the cardiac borders will still be distinct

B. CONSOLIDATION
Replacement of lung parenchyma & filling alveolar air spaces with
fluid and cells of other materials causing increased lung density
that obscure underlying blood vessels
Air bronchogram can be seen inside the consolidation, all midline
structure are intact and are not displaced, without associated
contraction or expansion of the lungs
Homogenous opacity without lung volume loss

D. ATELECTASIS
Collapse of the lung or any part of it
Loss of lung volume
Usually but not invariably associated with increased radiodensity
Air is absorbed within lung causing ipsilateral shift of mediastinal
structures including tracheal deviation.
There can also be narrow intercostals spaces in affected side.

Figure 10. Complete Atelectasis of the left lung. Mediastinal
displacement, opacification, & volume loss in the left hemithorax.

Table 1. Atelectasis vs. Pneumonia.
Atelectasis
Pneumonia
Volume loss
Normal or increased volume
No shift or if present
Associated ipsilateral shift
contralateral
Linear, wedge-shaped Consolidation, air space process
Apex at hilum
Not centered at hilum
Air bronchograms can occur in both

E. PRIMARY PULMONARY TUBERCULOSIS

Ghon Focus
initial focus of parenchymal disease
either enlarges or undergoes healing (more common)
T/CTB in children with pleural effusion

Figure 8. Lung consolidation

C. AIR BRONCHOGRAM
Air within bronchial tree with surrounding airless parenchyma;
Seen in consolidation, atelectasis, interstitial thickening.
Alveolar spaces are filled with fluid and cellular material &
become opaque, thus the normally aerated bronchi become
visible as faintly outlined tubular lucencies (black).
Implies parenchymal involvement withpatent proximal bronchi.

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Figure 11. Ghon focus.

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Ranke Complex
Ghon focus + affected lymph nodes
Lymph node inflammation usually greater than in parenchyma.
Lymph node enlargement may lead to:
1. Atelectasis
2. Extra nodal extension - mucosal edema, granuloma
3. Rupture into: adjacent bronchus (endobronchial spread) -
tuberculous pneumonia; arterial lumen - miliary TB

Post Primary Pulmonary Tuberculosis
Nodular opacities
1. Tuberculoma - < 3cm, well-defined
2. focal Nodular opacities
3. Endobronchial spread
4. Miliary TB - arterial spread, pinpoint lesions, diffusely-
scattered; very hard to identify nodules initially (may need CT)

Table 2. Primary (Childhood) vs. Postprimary (Adult) PTB.

Figure 13. Types of Bronchiectasis

Location
Appearance
Cavitation
Adenopathy
Effusion
Miliary pattern

Primary
Bases
Focal
No
Common
Common
Yes

Post-primary
Upper lobes
Patchy
Frequent
No
Uncommon
Yes

F. FIBROTIC INFILTRATES
Whiter, wiry/ streaky/ linear, rougher-looking infiltrates Vs.
pneumonia which is more hazy
Due to scarring of the lung parenchyma
Common in TB
Can use apicolodotic view when infiltrates are located apically
Cicatrization: superior traction of the hilar segments
Military TB: hematogenous spread of TB (check other organs!)
Adult TB can undergo endobronchial spread
If seen in upper lobes, might indicate healed PTB

Figure 12. Lung Fibrosis. Note the reticular nodular shadowing.

G. BRONCHIECTASIS
thick-walled bronchi filled with air that stand out in contrast to
the surrounding diseased lung, demonstrating a reticular pattern
or honeycombing on x-rays
Prominent in hilar and lower areas
Abnormal permanent dilatation of bronchi
Scarring, volume loss, and loss of the sharp definition of the
normal bronchovascular markings in the affected regions
early change in bronchiectasis can only be seen through CT,
where the walls appear prominent/thickened

Types of Bronchiectasis
Cylindric: mild diffuse dilatation of the bronchi
Varicose:
o cystic bronchial dilatation with focal areas of narrowing
o a string of pearls
Cystic: clusters of marked localized saccular dilatation

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Figure 14. Cystic bronchiectasis.

H. PULMONARY EMPHYSEMA
Hyperaeration/ overinflation of the lungs
Small peripheral &normal or enlarged pulmonary arteries
Abnormal, permanent enlargement of the airspaces distal to the
terminal bronchiole accompanied by destruction of alveolar walls
and without obvious fibrosis
Most common etiologic factor: cigarette smoking (COPD)

Radiographic Findings
Diffuse hyperlucency (panlobular)
Wide intercostal spaces
Flattening and depression of the hemidiaphragms (at or lower
than the level of T12)
Blunted costophrenic angles
Increased retrosternal airspace (panlobular>centrilobular)
There is also a condition called subcutaneous emphysema

Figure 15. Centrilobular vs.Panlobular emphysema. The former is
the most common type of emphysema.

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Figure 16. Hemidiaphragm flattening. It is the most reliable sign of
emphysema (here shown in a COPD patient).

I. BULLA
Thin-walled intrapulmonary cyst, attributed to excessive rupture
of alveolar walls that is in direct contact with lung parenchyma
May develop in the absence of generalized emphysema
Intraparenchymal gas collection
>1 cm in diameter
Has a thin wall < 3mm thick
Represents a focal area of parenchymal destruction (emphysema)
May contain fibrous strands, residual vessels, or alveolar septa
If it bursts, you can develop pneumothorax

Figure 17. Bulla. Two thirds of the right hemithorax is occupied,
compressing underlying lung upward & towards the mediastinum.

J. BLEB
Thin-walled cystic collection within the visceral pleura but outside
the lung parenchyma; entirely intrapleural cystic spaces
Seldom exceeds 1-2 cm in diameter
Usually found in the lung apices
Not seen on plain radiographs but may be visualized on chest CT
May coalesce to form a pulmonary bulla

K. CAVITY
Focus of increased opacity whose central portion has been
replaced by air
May or may not contain air-fluid levels
Surrounded by a wall usually a variable thickness
Wall of a cavity is usually irregular or lobulated and, by definition,
wall is > 2 mm thick (vs. bulla)
Form when a pulmonary mass undergoes necrosis and
communicates with an airway, leading to gas within its center

Figure 18. Left lung cavity. Take note of wall thickness (radio
opaque) vs. the wall thickness of bulla.

L. ABSCESS
Thick-walled cavity which contains air-fluid level (pus)
On x-ray: spherical opacities with air fluid levels
Usually develop as a complication of a bacterial pneumonia
Can be solitary or multiple
An important differential is cavitating neoplasm, especially in the
elderly; others include lung CA and aspergilloma

Figure 19. Lung abscess. Note the air fluid levels (radiolucent air
above radio-opaque fluid).

M. ASPERGILLOMA
Chronic tuberculous cavities that are colonized by Aspergillus
organisms that develop into fungus balls
Crescent sign: air pocket above the fungus ball
o Pathognomonic, but not always present

Figure 20. Aspergilloma. The fungus ball is located inside a cavity,
the remaining space of which is known as the crescent sign.

N. CALCIFICATIONS
Calcium containing density
Commonly dystrophic
Associated with healing of an infectious process

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Q. MASS
Well-defined confluence of dense cellularity with diameter > 3 cm
Pancoast tumor: apical location
Look at surrounding structures to see if there are erosion or
eating of margins suggestive of malignancy

Figure 21. Pulmonary calcifications.

(calcifications) due to asbestos exposure.

O. GRANULOMA
Well-defined small calcific density
Commonly residual of previous infections
Granular; calcium-containing
< 2 cm in size

Radio-opaque

dots

Figure 24. Ganglioneuroma. Chest PA of a 15/F reveals an oval,
vertically oriented, right-sided mediastinal mass (arrows).

Figure 25. Pancoast tumor. Increased opacification in the right apex
(arrows). Although this appearance may simulate benign apical
pleural thickening, the marked asymmetry and irregularity of the
right apical mass is suggestive of bronchogenic CA.

Pleural-based Masses
Extrapulmonary in origin (visceral pleura)
Tumors form an obtuse angle with the chest wall (VS
intrapulmonary masses which form acute angles with the chest
wall)
Can rarely present as a polyp (thus the angle formed with the
chest wall is acute)

R. ADENOPATHY
Enlarged lymph nodes, usually 1 cm or more in the short-axis,
because adenopathy becomes visible on radiograph if >1cm in
size
If <1cm request for CT scan
Usually found in the mediastinum (middle)

Figure 22. Granuloma of a healed TB infection

P. NODULE
focal, rounded opacity 3 cms or less in diameter, seen on plain
radiography or CT
Can be well defined or ill defined; can be solitary or multiple
Pulmonary metastases: cannonball lesions

Figure 23. Malignant Germ Cell Tumor. Chest PA of a 38/M showing
right mediastinal mass with discrete right lung nodules (arrows).

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Figure 26. Hodgkins Lymphoma. (L) Chest PA shows a large,

lobulated mediastinal mass. (R) CT with contrast (level of the aortic
arch) shows bulky anterior & middle mediastinal lymphadenopathy.

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S. PULMONARY CONGESTION
Primarily due to pulmonary hypertension

Radiographic Findings
Cephalization: prominence of vessels in the upper lung fields;
when upper lobe vessels tend to equalize with lower lobe vessels
Perivascular blurring: Loss of definition of outer bronchial wall
Hilar haze: loss of definition of large central pulmonary vessels
Kerley B lines: Dense, horizontal lines best seen in the lower lobes
& represent peripheral interlobular septal (periseptal) thickening
o represent beginning of interstitial edema
o Should not reach lateral 2-3 cm of the chest wall

Figure 29. Perihilar Bat's Wings in Pulmonary Edema. Chest AP of a
32/M with dilated cardiomyopathy reveals dense bilateral perihilar
airspace opacification resulting from pulmonary edema.

U. ACUTE RESPIRATORY DISTRESS SYNDROME
Clinical diagnosis
Respiratory failure develops as a result of rapidly progressive
respiratory compromise
a.k.a Hyaline Membrane Disease
Caused by leakage of protein-rich edema fluid into the lung
Damage to the pulmonary microcirculation associated with
increased lung stiffness (noncompliance)
With destruction of lung parenchyma
Initially looks like pulmonary edema. Request for serial x-rays.
Edema improves after a few days. ARDS does not.
Differentials: diffuse pneumonia, pulmonary edema

Figure 27. Pulmonary Congestion.

T. PULMONARY EDEMA
Bilateral opacities extending outward from the hilum in a fan-
shaped manner; bat-wing or butterfly distribution of infiltrates
Accumulation of fluid in interstitial spaces, and then, in alveoli
Usually seen with cardiomegaly

Figure 30. ARDS. A bilateral diffuse parenchymal disease. Note the
large left pneumothorax (with deep sulcus), a left chest tube, and an
endotracheal tube findings suggestive of ARDS. The pneumothorax
is a result of barotrauma, which results from high positive pressure
ventilation in the setting of stiff lungs.

V. PULMONARY EMBOLISM
Most common CXR finding is normal to r/o hypoxemia
Usually a clot from the deep veins blocking the pulmonary artery
Hamptons hump wedge-shaped opacity; seen in pulmonary
infarction

Figure 28. Interstitial pulmonary edema. Perihilar haze & loss of the
definition of pulmonary vascular markings. At the bases, note the
Kerley-B lines that represent fluid in the interlobular septa.

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Figure 31. Pulmonary infarction due to embolism. Chest PA of a
68/F with acute shortness of breath shows a pleural-based, rounded
opacity at the right costophrenic angle (Hamptons hump; arrows),
representing an acute parenchymal infarct. There is elevation of the
right hemidiaphragm from atelectasis and subpulmonic effusion.

W. PLEURAL ABNORMALITIES
Air Pneumothorax (look for viscera-pleural lines)
simple fluid - Effusion
pus - Pyothorax or Empyema
blood Hemothorax
lymph called - Chylothrorax
air and blood - Pneumohydrothorax
Mass
Calcification

Pleural Effusion
Fluid within the pleural space
Obscured costophrenic angles, heart, and diaphragm
Homogeneous lower zone opacity seen in the lateral
costophrenicsulcus
With a concave interface toward the lung
Meniscus Sign: laterally ascending homogenous band
Pleural meniscus: concave margin appears higher laterally than
medially on frontal radiographs
Another view: right lateral decubitus cross table lateral

Figure 32. Pleural Effusion. Upright radiograph.

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Figure 33. Pleural and pericardial effusions. Chest PA of a woman
with hypothyroidism shows blunting of theright costophrenic angle,
producing a meniscus (arrow).

Subpulmonic Effusion
Fluid located beneath the lung, above the hemidiaphragm
Takes the shape of the hemidiaphragm
Fluid collection mimics an elevated hemidiaphragm
Ancillary study: lateral decubitus view
o If there is no fluid shift:
elevated hemidiaphragm
technical problems; the X-ray must be taken after waiting for
5-10 minutes for fluid to shift
Radiographic clues
o apparent and new elevation of the diaphragm
o lateral peaking of the hemidiaphragm that is accentuated on
expiration
o a minor fissure that is close to the diaphragm (right-sided
effusions)
o increased separation of the gastric air bubble from the base of
the lung (left-sided effusions)
Massive pleural effusion highly suspect malignancy. Do
thoracocentesis then CT scan.

Figure 34. Subpulmonic Pleural Effusion. Right basal atelectasis
associated with elevation of the right hemidiaphragm.

Loculated Effusion
Encapsulated
Caused by adhesions between contiguous pleural surfaces (no
layering)
Fluid shift within that same area

Empyema
pus within the pleural space
most commonly appears as a loculated effusion
Thickened visceral and parietal pleura
Versus pleural effusion: does not move freely and will not layer on
decubitus view.
cant tell through x-ray but there are clues: inflamed periphery, air
bubbles (due to bacteria)

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Figure 35. Empyema. (L) Chest PA of a patient with recent right

lower field pneumonia demonstrates an oval opacity in the right
lateral costophrenicsulcus containing gas (arrow). (R). CT with
contrast shows a circumferential pleural fluid collection with
enhancing visceral (straight arrow) and parietal (curved arrow)
pleural layers representing an empyema. Note the contained gas
pockets, indicating loculations within the collection itself.

Fibrothorax
Maybe associated with deposition of dense fibrous tissue that
may be >2cm thick around whole lung
Destroyed lung
Mottled opacification of entire hemithorax
Pleural thickening extending over more than one fourth of the
costal pleural surface
Most commonly results from the resolution of an exudative
pleural effusion, empyema, or hemothorax
Results in ipsilateral shift of mediastinum
Results in massive volume loss; decreased lung volume leads to
decrease in pliability
Due to chronic inflammation and fibrosis

Figure 36. Fibrothorax. Note deviation of the trachea and
mediastinal structures.

Tension Pneumothorax
Air within the pleural space, seen in radiographs as an area of
lucency devoid of lung markings, at the periphery of the
hemithorax
There is mediastinal shift to contralateral side
This is an emergency and needs immediate CTT

SAN PEDRO, SANTOS B-C-G

Figure 37. Tension Pneumothorax. Portable chest film of a 43/F with
ARDS shows a large right pneumothorax with mediastinal shift &
ipsilateral diaphragmatic depression. Air was evacuated under
pressure during emergent placement of a right chest tube.

X. ADDITIONAL NOTES
Pleural-based mass attached to hemithorax, looks like a
mountain
Whiteout lung can be fluid, mass, atelectasis; request fot CT; if
purely fluid then mediastinum is shifted contralaterally
Tuberculoma solitary <3 cm, well-defined
Alveolar opacities appear sac-like
Endobronchial spread area of cavitation that ruptures into
bronchi
TB starts out as dots nodules consolidation cavitation
Diaphragmatic Hernia:
o Abdominal contents are found in the intrathoracic cavity
o A contrast medium is introduced to determine which structures
are part of the GIT.
o Morgagni hernia R
o Bochdalek hernia - L

END

Bobbie: Post-rummage message: Woohoo! Awesome! Ngayon ko
lang na-realize ang potential ng space-occupying stuff :>

Camille: RUMMAGE SALE na on Saturday!!! Lets earn money for our
HAPPINESS! :D See you there!

Ginnie: Im pretty sure her message will be like: Woohoo! Davao!
Good job sa rummage guys!

Josh: Greetings from Bayan-bayanan, Bataan J

UPCM 2016 7: XVI, Walang Kapantay!

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