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Chest Imaging

Imaging includes use of x-rays, MRI, nuclear scanning, and ultrasonography.

X-Ray Techniques
X-ray techniques that are used to image the chest include plain x-rays,
fluoroscopy, high-resolution and helical (spiral) CT, and CT angiography.

Chest x-ray
Plain chest x-rays and fluoroscopy are used to provide images of the lungs
and surrounding structures.

Plain chest x-rays provide images of structures in and around the thorax
and are most useful for identifying abnormalities in the heart, lung
parenchyma, pleura, chest wall, diaphragm, mediastinum, and hilum.

They are usually the initial test done to evaluate the lungs. The standard
chest x-ray is taken from back to front (posteroanterior view) to minimize x-
ray scatter that could artifactually enlarge the cardiac silhouette and from
the side of the thorax (lateral view).

Lordotic or oblique views can be obtained to evaluate pulmonary nodules


or to clarify abnormalities that may be due to superimposed structures,
although chest CT provides more information and has largely superseded
these views.

Lateral decubitus views may be used to distinguish free-flowing from


loculated pleural effusion, but CT or ultrasonography can provide more
information. End-expiratory views can be used to detect small
pneumothoraxes. Screening chest x-rays are often done but are almost
never indicated; one exception is in asymptomatic patients with positive
tuberculin skin test results, in whom a single posteroanterior chest x-ray
without a lateral view is used to make decisions regarding treatment for
pulmonary TB. Portable (usually anteroposterior) chest x-rays are almost
always suboptimal and should be used only when patients are too ill to be
transported to the radiology department.

Chest fluoroscopy is the use of a continuous x-ray beam to image


movement. It is useful for detecting unilateral diaphragmatic paralysis.
During a sniff test, in which the patient is instructed to forcibly inhale
through the nose (or sniff), a paralyzed hemidiaphragm moves cranially
(paradoxically) while the unaffected hemidiaphragm moves caudally.

Computed tomography
CT defines intrathoracic structures and abnormalities more clearly than
does a chest x-ray. Conventional (planar) CT provides multiple 10-mm
thick cross-sectional images through the thorax. Its main advantage is wide
availability. Disadvantages are motion artifact and limited detail from
volume averaging of tissue within each 10-mm slice.

High-resolution CT (HRCT) provides 1-mmthick cross-sectional images.


HRCT is particularly helpful in evaluating interstitial lung diseases (eg,
lymphangitic carcinomatosis, sarcoidosis, fibrosing alveolitis) and
bronchiectasis. Chest CT is normally done at full inspiration. Aeration of the
lungs during imaging provides the best views of the lung parenchyma,
airways, and vasculature, and of abnormal findings such as masses,
infiltrates, or fibrosis. Obtaining HRCT images at full expiration as well as
full inspiration can help. Expiratory imaging can increase visibility of air
trapping, which is typical of obliterative bronchiolitis. Images obtained with
the patient in the prone position can help differentiate dependent
atelectasis (which changes with changes in body position) due to lung
disorders that cause ground-glass attenuation in the dependent posterior
parts of the lungs, which persists despite changes in patient position (eg,
fibrosis due to idiopathic pulmonary fibrosis, asbestosis, or systemic
sclerosis).

Helical (spiral) CT provides multiplanar images of the entire chest as


patients hold their breath for 8 to 10 sec while being moved continuously
through the CT gantry. Helical CT is thought to be at least equivalent to
conventional CT for most purposes. Its main advantages are speed, less
radiation exposure, and an ability to construct 3-dimensional images.
Software can also generate images of bronchial mucosa (virtual
bronchoscopy). Its main disadvantages are less availability and the
requirement for breath-holding, which can be difficult for patients with
symptomatic pulmonary disease. Newer multidetector CT technology
allows more rapid scanning of the entire chest with imaging of thin slices at
high resolution.

CT angiography uses a bolus of IV radiopaque dye to highlight the


pulmonary arteries, which is useful in diagnosis of pulmonary embolism.
Dye load is comparable to that with conventional angiography, but the test
is quicker and less invasive. Several studies have confirmed CT
angiography provides sufficient accuracy for the detection of pulmonary
emboli, so it has largely replaced conventional pulmonary angiography and,
except in patients unable to tolerate contrast agents, ventilation/perfusion
(V/Q) scanning.

Magnetic Resonance Imaging


MRI has a relatively limited role in pulmonary imaging but is preferred over
CT in specific circumstances, such as assessment of superior sulcus
tumors, possible cysts, and other lesions that abut the chest wall. In
patients with suspected pulmonary embolism in whom IV contrast cannot
be used, MRI can sometimes identify large proximal emboli but usually is
limited in this disorder. The use of MRI to evaluate pulmonary hypertension
is being studied, and this practice may become more common.

Advantages include absence of radiation exposure, excellent visualization


of vascular structures, lack of artifact due to bone, and excellent soft-tissue
contrast. Disadvantages include respiratory and cardiac motion, the time it
takes to do the procedure, and the occasional presence of absolute or
relative contraindications.

Ultrasonography
Ultrasonography is often used to facilitate procedures such as
thoracentesis and central venous catheter insertion. Endobronchial
ultrasonography (EBUS) is increasingly being used in conjunction with
fiberoptic bronchoscopy to help localize masses and enlarged lymph
nodes. Diagnostic yield of transbronchial lymph node aspiration is higher
using EBUS than conventional unguided techniques. Ultrasonography is
also very useful for evaluating presence and size of pleural effusions and is
now commonly used at the bedside to guide thoracentesis.

Thoracentesis Using Ultrasonographic Guidance

Percutaneous Cannulation of the Internal Jugular Vein Using


Ultrasonographic Guidance

Nuclear Scanning
Nuclear scanning techniques used to image the chest include V/Q
scanning and positron emission tomography (PET).

V/Q scanning
V/Q scanning uses inhaled radionuclides to detect ventilation and IV
radionuclides to detect perfusion. Areas of ventilation without perfusion,
perfusion without ventilation, or matched increases and decreases in both
can be detected with 6 to 8 views of the lungs.

V/Q scanning is most commonly used for diagnosing pulmonary embolism


but has largely been replaced by CT angiography. Split-function ventilation
scanning, in which the degree of ventilation is quantified for each lobe, is
used to predict the effect of lobar or lung resection on pulmonary function;
postsurgical forced expiratory volume in 1 sec (FEV 1 ) is estimated as the
percentage of uptake of ventilation tracer in the healthy fraction of the lungs
multiplied by preoperative FEV 1 (in liters). A value of < 0.8 L (or < 40% of
that predicted for the patient) indicates limited pulmonary reserve and a
high likelihood of unacceptably high perioperative morbidity and mortality.

PET
PET uses radioactively labeled glucose (fluorodeoxyglucose) to measure
metabolic activity in tissues. It is used in pulmonary disorders to determine
whether lung nodules or mediastinal lymph nodes harbor tumor (metabolic
staging) and whether cancer is recurrent in previously irradiated, scarred
areas of the lung. PET is superior to CT for mediastinal staging because
PET can identify tumor in normal-sized lymph nodes and at extrathoracic
sites, thereby decreasing the need for invasive procedures such as
mediastinoscopy and needle biopsy. Current spatial resolution of PET is 7
to 8 mm; thus, the test is not useful for lesions < 1 cm. PET reveals
metastatic disease in up to 14% of patients in whom it would not otherwise
be suspected. The sensitivity of PET (80 to 95%) is comparable to that of
histologic tissue examination. False-positive results can occur with
inflammatory lesions, such as granulomas; slowly growing tumors (eg,
bronchoalveolar carcinoma, carcinoid tumor, some metastatic cancers)
may cause false-negative results. Newer combined CT-PET scanners may
become the most cost-effective technology for lung cancer diagnosis and
staging.

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