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1 Chest Radiography Interpretation Dr. Raghu Ram Uppalapati Slide 2 Lung Anatomy Trachea Trachea Carina Carina Right and Left Pulmonary Bronchi Right and Left Pulmonary Bronchi Secondary Bronchi Secondary Bronchi Tertiary Bronchi Tertiary Bronchi Bronchioles Bronchioles Alveolar Duct Alveolar Duct Alveoli Alveoli Slide 3 Lung Anatomy Right Lung Right Lung Superior lobe Superior lobe Middle lobe Middle lobe Inferior lobe Inferior lobe Left Lung Left Lung Superior lobe Superior lobe Inferior lobe Inferior lobe Slide 4 Lung Anatomy on Chest X-ray PA View: PA View: Extensive overlap Extensive overlap Lower lobes extend high Lower lobes extend high Lateral View: Lateral View: Extent of lower lobes Extent of lower lobes Slide 5 Lung Anatomy on Chest X-ray The right upper lobe (RUL) occupies the upper 1/3 of the right lung. 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. 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 Anteriorly, the RUL extends inferiorly as far as the 4th right anterior rib Slide 6 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 The right middle lobe is typically the smallest of the three, and appears triangular in shape, being narrowest near the hilum Slide 7 The right lower lobe is the largest of all three lobes, separated from the others by the major fissure. 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. 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. Review of the lateral plain film surprisingly shows the superior extent of the RLL. Slide 8 Lung Anatomy on Chest X-ray These lobes can be separated from one another by two fissures. These lobes can be 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. 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. Oriented obliquely, the major fissure extends posteriorly and superiorly approximately to the level of the fourth vertebral body. Slide 9 The lobar architecture of the left lung is slightly different than the right. 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 Because there is no defined left minor fissure, there are only two lobes on the left; the left upper Slide 10 Lt Lower Lobes Left lower lobes Left lower lobes Slide 11 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. 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 portion of the left lung that corresponds anatomically to the right middle lobe is incorporated into the left upper lobe. Slide 12 RUL (Right Upper Lung) Slide 13 RML (Right Middle Lung) Slide 14 RLL (Right Lower Lung) Slide 15 Slide 16 LUL (Left Upper Lung) Slide 17 LLL (Left Lower Lung) Slide 18 Left Side Fissure LUL LLL Slide 19 A structure is rendered visible on a radiograph by the juxtaposition of two different densities A structure is rendered visible on a radiograph by the juxtaposition of two different densities Chest Radiography: Basic Principles Slide 20 Silhouette Sign Loss of the expected interface normally created by juxtaposition of two structures of different density Loss of the expected interface normally created by juxtaposition of two structures of different density No boundary can be seen between two structures of similar density No boundary can be seen between two structures of similar density Slide 21 Right Lower Lobe Pneumonia Slide 22 Differential X-Ray Absorption The absence of a normal interface may indicate disease; The absence of a normal interface may indicate disease; The presence of an unexpected interface may also indicate disease The presence of an unexpected interface may also indicate disease The presence of interfaces can be used to localize abnormalities The presence of interfaces can be used to localize abnormalities Slide 23 Chest Radiographic Patterns of Disease Air space opacity Air space opacity Interstitial opacity Interstitial opacity Nodules and masses Nodules and masses Lymphadenopathy Lymphadenopathy Cysts and cavities Cysts and cavities Lung volumes Lung volumes Pleural diseases Pleural diseases Slide 24 LUL Pneumonia Slide 25 Air Space Opacity Components: Components: air bronchogram: air-filled bronchus surrounded by airless lung air bronchogram: air-filled bronchus surrounded by airless lung confluent opacity extending to pleural surfaces confluent opacity extending to pleural surfaces segmental distribution segmental distribution Slide 26 Air Space Opacity: DDX Blood (hemorrhage) Blood (hemorrhage) Pus (pneumonia) Pus (pneumonia) Water (edema) Water (edema) hydrostatic or non-cardiogenic hydrostatic or non-cardiogenic Cells (tumor) Cells (tumor) Protein/fat: alveolar proteinosis and lipoid pneumonia Protein/fat: alveolar proteinosis and lipoid pneumonia Slide 27 Interstitial Opacity: Small Nodules Slide 28 Interstitial Opacity: Lines Slide 29 Interstitial Opacity: Lines & Reticulation Slide 30 Interstitial Opacity Hallmarks: Hallmarks: small, well-defined nodules small, well-defined nodules lines lines interlobular septal thickening interlobular septal thickening fibrosis fibrosis reticulation reticulation Slide 31 Interstitial Opacity: DDX Idiopathic interstitial pneumonias Idiopathic interstitial pneumonias Infections (TB, viruses) Infections (TB, viruses) Edema Edema Hemorrhage Hemorrhage Noninfectious inflammatory lesions Noninfectious inflammatory lesions sarcoidosis sarcoidosis Tumor Tumor Slide 32 Nodules and Masses Nodule: any pulmonary lesion represented in a radiograph by a sharply defined, discrete, nearly circular opacity 2-30 mm in diameter Nodule: any pulmonary lesion represented in a radiograph by a sharply defined, discrete, nearly circular opacity 2-30 mm in diameter Mass: larger than 3 cm Mass: larger than 3 cm Slide 33 Nodules and Masses Qualifiers: Qualifiers: single or multiple single or multiple size size border definition border definition presence or absence of calcification presence or absence of calcification location location Slide 34 Mass Calcification Well-Defined Ill-Defined Slide 35 Lymphadenopathy Non-specific presentations: Non-specific presentations: mediastinal widening mediastinal widening hilar prominence hilar prominence Specific patterns: Specific patterns: particular station enlargement particular station enlargement Slide 36 Right Paratracheal Lymphadenopathy Slide 37 Right Hilar LAN Slide 38 Slide 39 Left Hilar LAN Slide 40 Slide 41 Subcarinal LAN * Slide 42 AP Window LAN Slide 43 Slide 44 Cysts & Cavities Cyst: abnormal pulmonary parenchymal space, not containing lung but filled with air and/or fluid, congenital or acquired, with a wall thickness greater than 1 mm Cyst: abnormal pulmonary parenchymal space, not containing lung but filled with air and/or fluid, congenital or acquired, with a wall thickness greater than 1 mm epithelial lining often present epithelial lining often present Slide 45 Cysts & Cavities Cavity : Abnormal pulmonary parenchymal space, not containing lung but filled with air and/or fluid, caused by tissue necrosis, with a definitive wall greater than 1 mm in thickness and comprised of inflammatory and/or neoplastic elements Cavity : Abnormal pulmonary parenchymal space, not containing lung but filled with air and/or fluid, caused by tissue necrosis, with a definitive wall greater than 1 mm in thickness and comprised of inflammatory and/or neoplastic elements Slide 46 Cysts & Cavities Characterize: Characterize: wall thickness at thickest portion wall thickness at thickest portion inner lining inner lining presence/absence of air/fluid level presence/absence of air/fluid level number and location number and location Slide 47 Benign Lung Cyst : PCP Pneumatocele Uniform wall thickness Uniform wall thickness 1 mm 1 mm Smooth inner lining Smooth inner lining Slide 48 Benign Cavities : Cryptococcus max wall thickness 4 mm max wall thickness 4 mm minimally irregular inner lining minimally irregular inner lining Slide 49 Indeterminate Cavities max wall thickness 5-15 mm max wall thickness 5-15 mm mildly irregular inner lining mildly irregular inner lining Slide 50 Malignant Cavities: Squamous Cell Ca max wall thickness 16 mm max wall thickness 16 mm Irregular inner lining Irregular inner lining Slide 51 Pleural Disease: Basic Patterns Effusion Effusion angle blunting to massive angle blunting to massive mobility mobility Thickening Thickening distortion, no mobility distortion, no mobility Mass Mass Air Air Calcification Calcification Slide 52 Pleural Effusion Slide 53 Slide 54 Pleural Calcification Slide 55 Slide 56 SOME INTERESTING X-RAYS & DISCUSSIO N Slide 57 Chest breast implants Slide 58 Tip of ET Pneumomediastinum Slide 59 wide mediastinum wide mediastinum obliteration of aortic knob obliteration of aortic knob Rt mainstem shift up and right Rt mainstem shift up and right NG deviate to right NG deviate to right pleural cap pleural cap Major Vessel Injury Potential X ray findings Slide 60 Expiration reduces lung volume, making a small pneumo easier to see Slide 61 Slide 62 Slide 63 Slide 64 Slide 65 Slide 66 Slide 67 Irregular linear opacities are present in both lungs, especially in the periphery and the bases of the lungs. The heart is slightly enlarged, but this is not related to the pulmonary abnormalities in this case. Slide 68 Slide 69 Slide 70 Hodgkins Disease Slide 71 Slide 72 A single, 3cm relatively thin-walled cavity is noted in the left midlung. This finding is most typical of squamous cell carcinoma (SCC). One-third of SCC masses show cavitation Slide 73 Slide 74 LUL Atelectasis: Loss of heart borders/silhouetting. Notice over inflation on unaffected lung Slide 75 Slide 76 Right Middle and Left Upper Lobe Pneumonia Slide 77 Slide 78 Pseudotumor: fluid has filled the minor fissure creating a density that resembles a tumor (arrow). Recall that fluid and soft tissue are indistinguishable on plain film. Further analysis, however, reveals a classic pleural effusion in the right pleura. Note the right lateral gutter is blunted and the right diaphram is obscurred. Slide 79 Slide 80 Pneumonia:a large pneumonia consolidation in the right lower lobe. Knowledge of lobar and segmental anatomy is important in identifying the location of the infection Slide 81 Slide 82 Slide 83 24 hours after diuretic therapy Slide 84 CHF:a great deal of accentuated interstitial markings, Curly lines, and an enlarged heart. Normally indistinct upper lobe vessels are prominent but are also masked by interstitial edema. Slide 85