Pulmonary Radiology

Rui Domingues, MD
Lincoln Mental and Medical Center
September 2008

Pulmonary Imaging

Imaging techniques used to

investigate pulmonary pathology
include:
Plain film
Computed Tomography
Magnetic Resonance Imaging
Ultrasound
Angiography

Keys to reading X-rays well

1.

2.

A good understanding of normal

anatomy
A good search pattern

But before we can do this we need to

understand how x-rays are produced.

Things to cover

Radiographic basics
How to approach a chest x-ray
Normal radiographic anatomy

Radiographic Basics

What causes the blacks,

whites and grays of an x-ray
image?
X-ray beams contains x-ray

photons of differing energies

As these photons pass through a
patient

Some are absorbed completely

Some penetrated directly to the plain film
Some are absorbed partially, and
While others are deflected (Scatter)

Tissue Density

A product of the type of tissue and

the thickness of that tissue

Results in differential absorption

Differential Absorption

Penetration of the x-ray beam is

dependent on tissue density

Denser object = less penetration

Less beam striking the film (more

absorption) = WHITER
More beam striking the film = BLACKER

Air

Glass
Test
Tube

Fat
Water
Bone
+
Water

Metal

Differential Absorption
Black
Air (Lungs / Trachea / Outside the
body)

Fat (Perirenal fat / Fascial plane)

Water (Muscle / Organs)

Bone (Bone / Atherosclerotic plaquing)

White
Metal (Fillings / Markers / Ortho
devices)

Radiographic Image

Adjacent structures of similar

densities are not visualized

Kidney (water density) against

liver (water density)

Radiographic Image

Adjacent structures of different

densities are visualized

Liver (water density) next to Bowel

(air density)

Chest Films

Minimum Diagnostic Series

PA
Left Lateral

Additional Views

Apical Lordotic
Inspiration / Expiration

PA CXR

Left Lateral
CXR

Apical
Lordotic
CXR

Allows for
better
visualizati
on of the
Apices of
the lungs

Expiration
Inspiration
study
Normal positioning
for PA Chest

Inspiration
Expiration study
Helps visualize:
- Small Pneumothorax
- Air Trapping Dz
(Emphysema)
- Bronchial obstruction

Visualizes respiratory
excursion

How to approach an X-ray?

Reading a Chest X-ray

First thing:

Correctly put of the film

Then perform your search pattern

which you always follow when looking at

any film
this way you will miss fewer findings

Reading a radiograph

Start reading every radiograph by

scanning the areas of least interest
first, working your way to the more
important areas.

You will be less likely to miss

important secondary findings.

Chest Film Search Patterns

ABCs

Abdomen
Bone
Chest
Soft tissues

ATMLL

Abdomen
Thorax
Mediastium
Lung
Lung

These are the two main search patterns that

people use when evaluating a chest film.

ATMLL Search Pattern

Remember

A = Abdomen
T = Thorax
M = Mediastinum
L = Lungs (unilaterally)
L = Lungs (bilaterally)

Searching the Abdomen

Scan across the upper abdomen several

times

Evaluate normal gas containing structures:

Stomach
Hepatic flexure of the colon
Splenic flexure of the colon

Evaluate the liver and on occasion one can

visualize the spleen

Structures Visualized:
Stomach gas bubble
Splenic flexure
Liver
Hemidiaphragms
Abdomen dz that can
mimic Lung disease
include:
Subphrenic abscess
Diaphragmatic hernia
Hiatal Hernia

Searching the Bony

Thorax

Start at the right base, look at the soft

tissues of the chest wall, ribs, spine and
shoulder girdle

Go up one side and come down on

opposite side

Remember:

Posterior ribs descend medial to lateral

Anterior ribs descend lateral to medial

Structures Visualized:
Breast Tissue
Posterior Ribs
Anterior Ribs
Scapula
Clavicle
Spine
Thorax cage dz that
may stimulate chest
dz:
Bony metastasis
Rib / Clavicle fractures

Searching the
Mediastinum

An organized search of the

mediastinum is complicated
because of all the overlapping
structures.

Start with a global look for contour

abnormalities, then follow with a
more detailed search

Three searches of the

mediastinum:
1. Trachea
Tracheaand
andcarina
carina
2.
2. Aorta
Aortaand
and
the
the
heart
heart
2. Aorta and the heart
3.
3. Hilum
Hilum
3. Hilum

Searching the Lungs

Since most chest x-rays are ordered to

evaluated for lung disease, so the lungs
are examined last.

They are important, so their evaluation

should be more through, therefore we
evaluate them twice.

Once individually
Second time comparing right and left

Structures Visualized:
Costophrenic angles
Lung fields
Pulmonary vasculature
Right minor fissure

Left Lateral Chest Film

Valuable radiographic study

Helps to better localize lesions
Allows to visualize overlapping
tissues
Allows the visualization of hidden
pathology

Searching the Lateral Chest

Film

The pattern is the same:

1) Abdomen
2) Thoracic cage strutures
3) Mediastinum
4) Lungs

Search Pattern:
Abdomen
Abdomen
Thoraciccage
Thoracic
cageand
and
bones
bones
Mediastinum
Mediastinum
Lungs
Lungs

What to look for

Abnormal density

Abnormal shape

Lung field
Mediastinum

Abnormal size

Usually air versus water

Lung field
Mediastinum

Abnormal location

Hemidiaphragm, hila, mediastinum, trachea,

fissure, vasculature

But before that we need to

have a good
understanding of Normal
Radiographic Anatomy

Left
Hemidiaphragm
Stomach gas
bubble
Splenic flexure
the large
at some ofofthe
intestines
abdominalRight
Hemidiaphragm

Lets look
visual
structures

Liver

Lets look at the Bony

thorax
Ribs
Spine
Clavicle
Scapula
Chest

Lets look at
the Bony
thorax

Ribs
Spine
Clavicle
Scapula
Chest
wall

Trachea
on CXR
Hilum

Lets look at the normal

Mediastinal Structures

Superio
r Vena
Cava
Ascendin
g Aorta
Right
Atrium
Inferior
Vena
Cava

Vessels
Aortic
Arch
Pulmonary
Artery
Left
Atrium
Left Ventricle

Aortic
Knob/Arc
h
Descendin
g Aorta
Left
Atrium

Ascending
Aorta
Right
Ventricle

Left
Ventricle
Inferior Vena Cava

Lung
Fields

Uppe
r

Lets look at the normal

Lung Structures

Middle

Lower

Retrostern
al Clear
Space

Retrocardiac
Clear Space

Lateral
Costophrenic
Sulci
(Recesses,
Angles)
Cardiophreni
c Sulci
(Recesses,
Angles

Posterior
Costophreni
c Sulci
(Recesses,
Angles)

What are the Pulmonary

Fissures?

They are the coming together of the

visceral pulmonary pleura.

Right lung

Oblique (major) fissure

Horizontal (minor) fissure

Left Lung

Oblique (major) fissure

Right
Oblique
Fissure
Horizont
al
Fissure
Left
Oblique
Fissure

A closer
look at
the
fissures

RUL

LUL
RML
RLL

LLL

References

Felsons Principles of Chest Roentgenology: A

Programmed Test, 2nd Edition. Goodman, Lawrence R.;
W.B. Saunders Co., 1999.
Pocket Atlas of Radiographic Anatomy. Moller, TB et al.;
Thieme Medical Publishers, 1993
Clinical Imaging with Skeletal, Chest and Abdomen Pattern
Differentials, Dennis Marchiori, ed. (WN 180 M317c)