Thoracic Imaging

Radiographic
Basics
Thoracic Imaging
Chest X-ray
Computed tomography
Ultrasound
Magnetic resonance imaging
New advances
Basic Chest X-Ray Interpretation

Differenttissues in our body absorb X-rays at

different extents:

Bone- high absorption (white)

Tissue- somewhere in the middle absorption

(grey)

Air- low absorption (black)

Film Quality
First determine is the film a PA or AP view.

1. PA- the x-rays penetrate through the back of the

patient on to the film

2. AP-the x-rays penetrate through the front of the

patient on to the film.
Projections
 Is the film over or under
penetrated?
if under penetrated you
will not be able to see the
thoracic vertebrae.

Check for rotation

Does the thoracic spine align in the
center of the sternum and between the
clavicles?
Are the clavicles level?
How to determine if the patient is rotated.
A -Close-up view of the heads of the clavicles demonstrates that each (white arrows) is about equidistant from the spinous process of the vertebral body between them (black arrow). This indicates the patient is not rotated.

B- Close-up view of the heads of the clavicles in a patient rotated toward his own right (remember that you are viewing the study as if the patient were facing you).

C-Close-up view of the heads of the clavicles in a patient rotated toward his own left. The spinous process (black arrow) is much closer to the right clavicular head (solid white arrow) than it is to the left (dotted white arrow).
The spine sign
Assessing inspiration

Was film taken under full inspiration?

The diaphragm should be intersected by the 5th to

7th anterior ribs in the mid-clavicular line or 10
posterior ribs should be visible.
Check the costophrenic angles
Margins should
be sharp

Inclusion
A chest X-ray
should include
the entire
thoracic cage!
Non-inclusive X-ray Inclusive X-ray
image image
Things to see
ABCDE
Airways
Trachea, endotracheal tube, etc
Bones
Clavicles, ribs, etc
Cardiac
Diaphragm (Right hemidiaphragm slightly
higher (~1.5 cm)
Everything else (tubes), effusions
Soft Tissues
Breast shadows
Thoracic muscles
Piercing
Air in tissues
Tissue folds in obese
Medical equipment
Bony Structures
Ribs
Scapulae
Clavicles
Vertebrae
Trachea
Deviated
Carina
Artificial airway
Mediastinum
Deviated
Hilar shadows
Aortic arch
Diaphragm
Shape
Height: right 6rib ant, left 7 ant
Cardiophrenic angle
Costophrenic angle
Lung Anatomy
Trachea
Carina
Right and Left
Pulmonary Bronchi
Secondary Bronchi
Tertiary Bronchi
Bronchioles
Alveolar Duct
Alveoli
Lung Anatomy
Right Lung
Superior lobe
Middle lobe
Inferior lobe
Left Lung
Superior lobe
Inferior lobe
Lung Anatomy on Chest X-ray
PA View:
Extensive overlap
Lower lobes extend
high
Lateral View:
Extent of lower lobes
Lung Anatomy on Chest X-ray
The right upper lobe
(RUL) occupies the
upper 1/3 of the right
lung.
Posteriorly, the RUL is
adjacent to the first three
to five ribs.
Anteriorly, the RUL
extends inferiorly as far
as the 4th right anterior
rib
Lung Anatomy on Chest X-ray
The right middle lobe
is typically the
smallest of the three,
and appears
triangular in shape,
being narrowest near
the hilum
 Lung Anatomy on Chest X-ray
The right lower lobe is the
largest of all three lobes,
separated from the others
by the major fissure.
Posteriorly, the RLL
extend as far superiorly as
the 6th thoracic vertebral
body, and extends
inferiorly to the
diaphragm.
Review of the lateral plain
film surprisingly shows the
superior extent of the RLL.
 Lung Anatomy on Chest X-ray
These lobes separated
from one another by two
fissures.
The minor fissure
separates the RUL from
the RML, and thus
represents the visceral
pleural surfaces of both of
these lobes.
Oriented obliquely, the
major fissure extends
posteriorly and superiorly
approximately to the level
of the fourth vertebral
body.
Lung Anatomy on Chest X-ray
The lobar
architecture of the
left lung is slightly
different than the
right.
Because there is no
defined left minor
fissure, there are
only two lobes on the
left; the left upper
lobe.
Lung Anatomy on Chest X-ray
Left lower lobes
Lung Anatomy on Chest X-ray
These two lobes are
separated by a major
fissure, identical to that
seen on the right side,
although often slightly
more inferior in location.
The portion of the left
lung that corresponds
anatomically to the right
middle lobe is
incorporated into the left
upper lobe.
The Normal Chest X-ray
PA View:
1. Aortic arch
2. Pulmonary trunk
3. Left atrial appendage
4. Left ventricle
5. Right ventricle
6. Superior vena cava
7. Right hemidiaphragm
8. Left hemidiaphragm
9. Horizontal fissure
The Normal Chest X-ray
Lateral View:
1. Oblique fissure
2. Horizontal fissure
3. Thoracic spine and
retrocardiac space
4. Retrosternal space
 Hila
Right hilum:
Right mail bronchus
Right pulmonary artery brunches
Right pulmonary veins
Bronchopulmonary limph nodes

Left Hilum:
Left main bronchus
Left pulmonary artery
Left pulmonary veins
Bronchopulmonary limph nodes

E-ANATOMY: ANATOMY OF THE CHEST AND THE LUNGS : ANATOMICAL

ILLUSTRATIONS
http://www.imaios.com
Check the Heart

Size
Shape
Silhouette-margins should be sharp
Diameter (>1/2 thoracic diameter is
enlarged heart)

Remember: AP views make heart appear larger

than it actually is.
 1 1-2

2 3
3
4

4 5 5

8
8
 1-2 1

2
4 6 6
4

9 9
10 10
 Consolidation
Lobar consolidation:
Alveolar space filled with
inflammatory exudate
Interstitium and
architecture remain intact
The airway is patent
Radiologically:
A density corresponding to a
segment or lobe
Airbronchogram, and
No significant loss of lung
volume
 Atelectasis
Loss of air
Obstructive atelectasis:
No ventilation to the lobe
beyond obstruction
Radiologically:
Density corresponding to a
segment or lobe
Significant loss of volume
Compensatory hyperinflation
of normal lungs
 Thank
you for
your
attention!
 Understanding Pathological
Changes
Most disease states replace air with a
pathological process
Each tissue reacts to injury in a
predictable fashion
Lung injury or pathological states can
be either a generalized or localized
process
 Liquid Density

Liquid density Increased air density

Generalized Localized

Infiltrate
Diffuse alveolar Localized airway
Consolidatio
Diffuse obstruction
n
interstitial Diffuse airway obstruction
Cavitation
Mixed Emphysema
Mass
Vascular Bulla
Congestion
Atelectasis
Stages of Evaluating an
Abnormality
1. Identification of abnormal shadows
2. Localization of lesion
3. Identification of pathological process
4. Identification of etiology
5. Confirmation of clinical suspension
Complex problems
Introduction of contrast medium
CT chest
MRI scan
Chest X-ray abnormalities
 Tracheal displacement

Before deciding if the trachea is central it is

important to establish that the patient is not
rotated!

Trachea - Pushed or Pulled ?

Anything that increases pressure or volume
in one hemithorax will push the trachea and
mediastinum away from that side.
Any disease which causes volume loss in
one hemithorax will pull the trachea over
towards that side.
Tracheal displacement
Tracheal deviation - seen on CT
Hilar abnormalities

Hilar enlargement

Hilar enlargement may be unilateral or

bilateral, symmetrical or asymmetrical.
In combination with clinical information,
each of these patterns is often helpful in
reaching a diagnosis.
Bilateral hilar enlargement
Asymmetric hilar enlargement
Hilar position

Ifa hilum has moved, you should try to

determine if it has been pushed or
pulled, just like you would for the
trachea.
Ask yourself if there is a lung
abnormality that has reduced volume of
one hemithorax (pulled), or if there has
been increase in volume or pressure of
the other hemithorax (pushed).
Abnormal hilar position
 Soft tissue abnormalities

It is essential to assess the soft tissues

on every chest x-ray you examine. You
will often find important clues to help
come to a diagnosis. The soft tissues
are also often misleading and it is
important to be aware of the pitfalls.
Mastectomy
Surgical emphysema
Bone abnormalities

Rib fractures
Chest radiography is not indicated for
demonstration of a suspected simple rib
fracture. This is because many fractures
are not visible, and because
management is not altered even if it is
seen. If there is clinical suspicion of
complications such as a pneumothorax,
a chest X-ray is indicated.
Multiple acute rib fractures
Old rib fractures
Malignant bone disease
Diaphragmatic abnormalities
Raised hemidiaphragm

The right hemi-diaphragm usually lies at

a level slightly above the left. There are
many possible causes of a raised
hemidiaphragm such as damage to the
phrenic nerve, lung disease causing
volume loss, congenital causes such as
a diaphragmatic hernia, or trauma to the
diaphragm.
Diaphragmatic rupture
Phrenic nerve palsy
Costophrenic angle blunting
Lung hyperexpansion
 Mediastinal abnormalities

Key points
A widened mediastinum is often due to
technical factors
Genuine widening is usually due to a
vascular abnormality or a mediastinal
mass
A lateral view may help determine the
location of a mass
Mediastinal mass
Mediastinal mass - Lateral view (same patient)
Thoracic aortic aneurysm
 Heart contour abnormalities

Key points
If there is cardiomegaly - look for other
signs of heart failure
It may be possible to determine which
chamber is enlarged
An obscured heart border may indicate
disease of the adjacent lung
Signs of heart failure
Septal lines (Kerley B lines)
Left atrial enlargement
 Consolidation
Consolidation is the result of replacement of air in the alveoli
by transudate, pus, blood, cells or other substances.
Pneumonia is by far the most common cause of consolidation.
The key-findings on the X-ray are:
ill-defined homogeneous opacity obscuring vessels
Air-bronchogram
Extention to the pleura or fissure
No volume loss
An area of consolidation usually has ill-defined borders unless
when it is bordered by a fissure, which will result in a sharp
delineation, since consolidation will not cross a fissure.
As the alveoli that surround the bronchi become more dense,
the bronchi will become more visible, resulting in an air-
bronchogram (figure).
In consolidation there should be no or only minimal volume
loss, which differentiates consolidation from atelectasis.
Expansion of a consolidated lobe is not so common and seen
in Klebsiella pneumoniae, Streptococcus pneumoniae, TB and
lung cancer with obstructive pneumonia.
Interstitial lung disease
Nodules and Masses
Multiple masses
Lung diseases

Airspace (alveolar) disease

Interstitial (infiltrative) disease
 Airspace disease
the pattern can be described as fluffy, cloudlike, or hazy
may demonstrate the silhouette sign;
the margins of airspace disease are indistinct;
may be distributed throughout the lungs;
may contain air bronchograms:
The visibility of air in the bronchus because of surrounding
airspace disease is called an
air bronchogram.
An air bronchogram is a sign of airspace disease.
Air bronchogram
Causes of airspace disease
Pneumonia
Pulmonary alveolar edema
Aspiration
 PNEUMONIA: GENERAL CONSIDERATIONS

consolidation of lung produced by

inflammatory exudate, usually as a result of
an infectious agent.
Most pneumonias produce airspace
disease, either lobar or segmental
spread to the lungs via the tracheobronchial
tree, either through inhalation or aspiration
difficult to identify with certainty the
causative organism from the radiographic
presentation alone.
GENERAL CHARACTERISTICS OF PNEUMONIA

Pneumonia appear denser (whiter) than the surrounding,

normally aerated lung;
Pneumonia may contain air bronchograms;
Air bronchograms are much more likely to be visible when the
pneumonia involves the central portion;
An air bronchogram is not specific for pneumonia ;
Appears fluffy and its margins are indistinct;
Where pneumonia abuts a pleural surface it will be sharply
marginated;
Pneumonia is usually homogeneous in density;
The bronchi, as well as the airspaces, contain inflammatory
exudate;
Atelectasis sometimes associated with the pneumonia.
PATTERNS OF PNEUMONIA
lobar;
segmental;
interstitial;
round;
cavitary.
 Pattern of Disease Likely Causative Organism

Upper lobe cavitary pneumonia with spread to the opposite lower

lobe-Mycobacterium tuberculosis (TB)
Upper lobe lobar pneumonia with bulging interlobar
fissureKlebsiella pneumoniae
Lower lobe cavitary pneumonia-Pseudomonas aeruginosa or
anaerobic organisms (Bacteroides)
Perihilar interstitial disease or perihilar airspace disease-
Pneumocystis carinii (jiroveci)
Thin-walled upper lobe cavity-Coccidioides (Coccidiomycosis),
TB Airspace disease with effusion-Streptococci, staphylococci,
TB Diffuse nodules-Histoplasma, Coccidioides, Mycobacterium
tuberculosis (histoplasmosis, coccidiomycosis)
TB Soft-tissue, fingerlike shadows in upper lobes-
Aspergillus (allergic bronchopulmonary aspergillosis)
Solitary pulmonary nodule-Cryptococcus (cryptococcosis)
Spherical soft-tissue mass in a thin-walled upper lobe cavity-
Aspergillus (aspergilloma)
Right lower lobe pneumonia
Silhouette sign
Segmental Pneumonia (Bronchopneumonia)
Pneumocystis carinii (jiroveci) pneumonia (PCP)The
Round Pneumonia
 Primary tuberculosis (primary TB)
Cavitation is rare in primary TB.
Primary TB affects the upper lobes slightly more than the lower and produces airspace disease
that may be associated with ipsilateral hilar adenopathy (especially in children) and large, often
unilateral, pleural effusions (especially in adults)
Post-primary tuberculosis (reactivation tuberculosis)
Cavitation is common.
The cavity is usually thin-walled and has a smooth inner margin and no air-fluid level .
Post-primary tuberculosis almost always affects the apical or posterior segments of the upper
lobes or the superior segments of the lower lobes.
Bilateral upper lobe disease is very common.
Transbronchial spread (from one upper lobe to the opposite lower lobe or to another lobe in the
lung) should make you think of infection with Mycobacterium tuberculosis.
Healing of post-primary TB usually occurs with fibrosis and retraction.
Miliary tuberculosis
Considered to be a manifestation of primary TB, although the clinical appearance of miliary TB may
not occur for many years after the initial infection.
When first visible, the small nodules measure only about 1 mm in size; they can grow to 2-3 mm if
untreated.
When miliary TB is treated, clearing is usually rapid. Miliary TB seldom, if ever, heals with
residual calcification.
Other infectious agents that produce cavitary disease:
Staphylococcal pneumonia can cavitate and produce thin-walled pneumatocoeles.
Streptococcal pneumonia, Klebsiella pneumonia, and coccidiomycosis can also produce
cavitating pneumonias.
TB
HOW PNEUMONIA RESOLVES
Pulmonary alveolar edema
Pneumothorax
occurs when air enters the pleural space.
visceral pleura becomes visible as a thin, white line
the visceral pleural line parallels the curvature of the
chest wall
absence of lung markings peripheral to the visceral
pleural line.
absence of lung markings alone is not sufficient for the
diagnosis of pneumothorax nor is the presence of lung
markings distal to the visceral pleural line sufficient to
eliminate the possibility of a pneumothorax.
presence of an air-fluid interface in the pleural space is
indication that a pneumothorax is present; #
deep sulcus sign.
Recognizing Pneumothorax

You must be able to identify the visceral pleural line to

make the definitive diagnosis of a pneumothorax!
Recognizing Pneumothorax

http://onsurg.com/news/radiology-
Deep sulcus sign
 Recognizing a Pneumothorax-Signs
to Look For

Visualization of the visceral pleural line-a must for the diagnosis

Convex curve of the visceral pleural line paralleling the contour of the chest wall
Absence of lung markings distal to the visceral pleural line (most times)
Box 8-1 Recognizing a Pneumothorax-Signs to Look For
The deep sulcus sign of an inferiorly displaced costophrenic angle seen on a
supine chest
The presence of an air-fluid interface in the pleural space
Pitfalls
Pleural adhesions may keep part, but not all, of the visceral
pleura adherent to the parietal pleura, even in the presence
of a pneumothorax.

Absence of lung markings mistaken for a pneumothorax.

Mistaking a skin fold for a pneumothorax.

Mistaking the medial border of the scapula for a

pneumothorax.
Pitfall
Pitfall
Bullous disease or pneumothorax?
 Pleural effusions
Transudates tend to form when there is increased capillary
hydrostatic pressure or decreased osmotic pressure, such as
occurs in:
Congestive heart failure, primarily left heart failure, which is
the most common cause of a transudative pleural effusion
Hypoalbuminemia
Cirrhosis
Nephrotic syndrome
Exudates
Most common cause of an exudative pleural effusion is
malignancy.
Empyema-an exudate containing pus
Hemothorax-has a fluid hematocrit >50% blood hematocrit
Chylothorax-contains increased triglycerides or cholesterol
 Diseases that usually produce bilateral effusions:
Congestive heart failure
Usually about the same amount of fluid in each hemithorax.
If markedly different amounts are in each hemithorax, suspect
a parapneumonic effusion or malignancy on the side with the
greater volume of fluid.
Lupus erythematosus-usually bilateral, but when unilateral, the
effusions are usually left-sided.
Diseases that can produce effusions on either side (but are usually
unilateral):
Tuberculosis and other exudative effusions associated with
infectious agents, including viruses
Pulmonary thromboembolic disease
Trauma
Diseases that usually produce left-sided effusions:
Pancreatitis
Distal thoracic duct obstruction
Dressler syndrome
Diseases that usually produce right-sided effusions:
Abdominal disease related to the liver or ovaries-some ovarian
tumors can be associated with a right pleural effusion and ascites
(Meigs syndrome)
Rheumatoid arthritis-the effusion can remain unchanged for years
Proximal thoracic duct obstruction
Dressler syndrome
Right-sided subpulmonic
effusion.
Right pleural effusion, meniscoid
appearance.
 39 y.o. woman with pneumonia
Based on the front chest radiograph, the pneumonia is in the:

1- Right lower lobe

2- Right upper lobe
3- Right middle lobe
4- There is no way to
know without lateral
Right middle lobe
 Thank
you for
your
attention!