Chest-Imaging techniquesChest-Imaging techniques * *Plain chest radiographyPlain chest radiography::

--Routine study (PA= frontal)± optional addition of Lat. ViewRoutine study (PA= frontal)± optional addition of Lat. View..--Both in erect position + full inspiration (ant. End of 6Both in erect position + full inspiration (ant. End of 6thth rib intersect dome of rt. rib intersect dome of rt.

DiaphragmDiaphragm..--Expiratory and supine film (hase base, ↑ cardiac shadow)Expiratory and supine film (hase base, ↑ cardiac shadow)

--Though CXR is the most commonly x-ray examination performed, it’s the most Though CXR is the most commonly x-ray examination performed, it’s the most difficult to interpretdifficult to interpret..

--We have to follow problem oriented approachWe have to follow problem oriented approach::) ) ask about the abnormality and clinical findingask about the abnormality and clinical finding((

How to read a CXRHow to read a CXR11--DiaphragmDiaphragm

→ → upper surface should clearly visualized from one costophrenic angle to upper surface should clearly visualized from one costophrenic angle to another except at Ht. and mediastinum another except at Ht. and mediastinum..

→ →Rt. hemidiaphragmRt. hemidiaphragm is 2.5 cm higher than Ltis 2.5 cm higher than Lt..

22--HeartHeart → → position 1/3 to the Rtposition 1/3 to the Rt..

→ → size (C/T ratio < 50%size (C/T ratio < 50% . .→ → shapeshape

33--MediastinumMediastinum::

→ → Tracheal position (midline from medial ends of clavicle)Tracheal position (midline from medial ends of clavicle)

→ → outline (should clearly seen except at contact with Ht& diaph.)outline (should clearly seen except at contact with Ht& diaph.)

→ → Rt. Border (Rt. Sup. Border either straight or slightly curved and emerge Rt. Border (Rt. Sup. Border either straight or slightly curved and emerge with Rt. Cardiac border, Lt. border is ill-defined above aortic nuckle with Rt. Cardiac border, Lt. border is ill-defined above aortic nuckle . .

→ → Thymus seen in young children “sail shapedThymus seen in young children “sail shaped.”.”

44--Hilar regionHilar region : :

→ → pul. A, pul. V, main bronchi & hilar LN (pul. A, pul. V, main bronchi & hilar LN (normaly too small to cast shadow)normaly too small to cast shadow)..

→ → Lt. hilum is slightly higher than RtLt. hilum is slightly higher than Rt..

→ → check size and densitycheck size and density..

55--LungLung

→ → only marking seen (Bl. vessel, large br. Wall seen end on & inter lobar only marking seen (Bl. vessel, large br. Wall seen end on & inter lobar fissure (fissure (two layers of pleuratwo layers of pleura): →determine lobar anatomy): →determine lobar anatomy

→ → Azygous F. seen in 1% of PAAzygous F. seen in 1% of PA..

→ → horiz. F. only seen in frontal, form Rt.h-6horiz. F. only seen in frontal, form Rt.h-6thth rib rib..

→ → oblique F. seen only in lat. Viewoblique F. seen only in lat. View..

→ → PA to assess zonal anatomy, Lat (↑ PA to assess zonal anatomy, Lat (↑ lucency downward dorsal spine)lucency downward dorsal spine)

““don’t mistake breast, nipple (5don’t mistake breast, nipple (5thth ant. Rib space), and hair for pulm. shadow ant. Rib space), and hair for pulm. shadow””

66 - -thoracic cagethoracic cage;;

→ → Bone (ribs, spine, clavicle and shoulder j)Bone (ribs, spine, clavicle and shoulder j)

→ → soft tissue (mastectomy)soft tissue (mastectomy)

Assess techniqueAssess technique::

→ → exposure factorexposure factor

→ → position of patientposition of patient..

**CT indicationsCT indications::

→ → presence, extent & nature (med. LN enlargmentin Ca & Lynphoma, diff. presence, extent & nature (med. LN enlargmentin Ca & Lynphoma, diff. vascular from non vascular, fat and wide mediastinum) vascular from non vascular, fat and wide mediastinum)..

→ → Pulm. And pleural masses (shape, outline, wall and calcification)Pulm. And pleural masses (shape, outline, wall and calcification)

→ → Bronchiectasis (presence, extent and severity)Bronchiectasis (presence, extent and severity)

→ → clinical suspision of intrathoracic path. + normal CXR (MG, pulm. 2clinical suspision of intrathoracic path. + normal CXR (MG, pulm. 2ndnd.).)

→ → Pulm. Embolysm (Ct pulm. Angiography)Pulm. Embolysm (Ct pulm. Angiography)

→ → diffuse pul. Disease (Dx and extent)diffuse pul. Disease (Dx and extent)

Technical factorsTechnical factors : :

→ → 5-105-10 mmmm..

± → ± → IVCMIVCM..

→ → lung, medias. And bone window & normal interpretation lung, medias. And bone window & normal interpretation (BV, pleura and bronchi) (BV, pleura and bronchi)

**MRIMRI

→ → limited role in (lung, pleura and media)limited role in (lung, pleura and media)..

→ → Ht and aortaHt and aorta

→ → helpful inhelpful in::

→ → Sup. Sulcus T. (chest wall, spinal extension)Sup. Sulcus T. (chest wall, spinal extension)

→ → neural t. (intraspinal extent.)neural t. (intraspinal extent.)

**USUS::

→ → Peripheral pleural lesion (effusion, mass)Peripheral pleural lesion (effusion, mass)

→ → Dx biopsyDx biopsy

→ → not central b., US waves will absorbe by airnot central b., US waves will absorbe by air..

→ → any mass in contact with chest wallany mass in contact with chest wall..

**Radionuclide lung scanRadionuclide lung scan::

→→ventilation (xenon-133, Xenon-127, Crypton-81m)ventilation (xenon-133, Xenon-127, Crypton-81m)

→→Perfusion scan (Perfusion scan (99m99mTc)Tc)

→→pulm. Embolism (major indication)pulm. Embolism (major indication)

*PET:*PET:

→→1818F-flourodeoxyglucose (FDG)F-flourodeoxyglucose (FDG)

→→Take-up (Ca. lung, 2ndary, active lymphatic tissue)Take-up (Ca. lung, 2ndary, active lymphatic tissue)

→→Dx or staging Ca and lymphoma.Dx or staging Ca and lymphoma.

→→solitary mass (sensitive but cannot diff. neoplasm from inflammatory)solitary mass (sensitive but cannot diff. neoplasm from inflammatory)

*Pulmonary angiography: (DSA)*Pulmonary angiography: (DSA)

→→Main indication prior to interventionMain indication prior to intervention

→→Pulm. CT-angiography (Dx embolism, Dx congenital AVM)Pulm. CT-angiography (Dx embolism, Dx congenital AVM)

Disease of chest with normal CXRDisease of chest with normal CXR

1- Obstructive airway dis. (Asthma, Acute bronchiolitis, Emphysema, 1- Obstructive airway dis. (Asthma, Acute bronchiolitis, Emphysema, chronic bronchitis, Bronchiectasis). chronic bronchitis, Bronchiectasis).

2- Small lesions 2- Small lesions (<1cm, hidden areas as ribs, clavicles, behind H. & Diaph.)(<1cm, hidden areas as ribs, clavicles, behind H. & Diaph.)

3- Pulmonary emboli without infarction.3- Pulmonary emboli without infarction.

4- Infectious (atypical pneumonia, Miliary TB.)4- Infectious (atypical pneumonia, Miliary TB.)

5- diffuse pulmonary dis.5- diffuse pulmonary dis.

6-Pleural abormalities (Dry pleuricy, small pleural effusion)6-Pleural abormalities (Dry pleuricy, small pleural effusion)

7- Mediastinal masses.7- Mediastinal masses.

Abnormal chest radiographyAbnormal chest radiography

11--Silhouette signSilhouette sign::

invaluable sign for localization of disease from CXRinvaluable sign for localization of disease from CXR..

It means loss of cardiac, mediastinal (aorta), and It means loss of cardiac, mediastinal (aorta), and diaphragmatic border when intra-thoracic lesion touching diaphragmatic border when intra-thoracic lesion touching that borderthat border..

It has two important applicationsIt has two important applications::

* *Localization of lesionLocalization of lesion..

* *Give Dx (consolidation, collapse), Give Dx (consolidation, collapse), wedge shaped or lens wedge shaped or lens shaped opacity has fade out margin so indicating shaped opacity has fade out margin so indicating dis. By silhouetting the cardiac or diaphragmatic borderdis. By silhouetting the cardiac or diaphragmatic border..

Abnormal chest radiographyAbnormal chest radiography

2-Radiological signs of lung diseases:2-Radiological signs of lung diseases:

Categorize any abnormal intrapulmonary shadow in to one of the Categorize any abnormal intrapulmonary shadow in to one of the following:following:

1- Air space filling shadow {transudative (pulm. Oedema) or exudative 1- Air space filling shadow {transudative (pulm. Oedema) or exudative (infection, infarction or hemorrhagic)}.(infection, infarction or hemorrhagic)}.

2- Collapse2- Collapse

3-Spherical shadow3-Spherical shadow

4- Linear shadow4- Linear shadow

5- wide spread small shadows.5- wide spread small shadows.

Signs of air-space fillingSigns of air-space filling1.1. Ill defined borders of pulmonary lesion except when it Ill defined borders of pulmonary lesion except when it

become in contact with fissure.become in contact with fissure.2.2. Air bronchogram.Air bronchogram.3.3. Silhoutte sign .Silhoutte sign .

Pulmonary oedemaPulmonary oedemaInterstitial Interstitial

Septal linesSeptal lines Thickening of the fissures Thickening of the fissures Pleural effusion .Pleural effusion .

Alveolar:Alveolar: all have interstitialall have interstitial Acute alwaysAcute always Almost always bilateral, if involve all lobesAlmost always bilateral, if involve all lobes Has appearance of batwings ; maximal density close to Has appearance of batwings ; maximal density close to

hila & fade out peripherally.hila & fade out peripherally.

CardiogenicCardiogenic:: acute H.F,MS, overtransfusionacute H.F,MS, overtransfusion..

Non Cardiogenic :Non Cardiogenic :

ARDS, Mandalson`s synd., inhalation of ARDS, Mandalson`s synd., inhalation of noxious gas.:noxious gas.:

pulmonary shadows become uniform over a pulmonary shadows become uniform over a period of days & eventually affect all period of days & eventually affect all parts equally.parts equally.

Cardiogenic oedema appear & dis appear Cardiogenic oedema appear & dis appear radiologically within 24hr which virtually radiologically within 24hr which virtually dx for cardiogenic oedema.dx for cardiogenic oedema.

Pulmonary consolidationPulmonary consolidation : :

a)a) Lobar consolidation ( strep. Pneumonia) which is Lobar consolidation ( strep. Pneumonia) which is virtually dx of bacterial pneumonia:virtually dx of bacterial pneumonia:

Homogenous opacity.Homogenous opacity. air bronchogram .air bronchogram . Silhoutte sign.Silhoutte sign.

b)b) Patchy consolidation :Patchy consolidation : One or more of ill defined shadows :One or more of ill defined shadows : PneumoniaPneumonia Infarction Infarction ContusionContusion Immunological disorders.Immunological disorders.

Cavitation ( abscess formation ) Cavitation ( abscess formation ) within consolidationwithin consolidation : :

occur due to bacterial or fungaloccur due to bacterial or fungal..

This only recognised by communication This only recognised by communication with the bronchial tree ( air fluid level).with the bronchial tree ( air fluid level).

Pulmonary collapsePulmonary collapseDefinition :Definition :

Loss of volume of a lobe or lung.Loss of volume of a lobe or lung.

CausesCausesI.I. Bronchial obstructionBronchial obstruction

The commoner cause of lobar collapse:The commoner cause of lobar collapse:1.1. Bronchial wall lesions:Bronchial wall lesions:

I CA.I CA.Rarely other bronchial tumours ,carcinoidsRarely other bronchial tumours ,carcinoidsRarely endobronchial TB.Rarely endobronchial TB.

2.2. intraluminal occlusion:intraluminal occlusion: mucus plugging:mucus plugging:

POPPOP AsthmaAsthma UnconsciousUnconscious Artificial ventilation Artificial ventilation

Inhaled FBInhaled FB3.3. Invasion or compression by adjacent mass Invasion or compression by adjacent mass

Malignant tumourMalignant tumourEnlarged LNEnlarged LN

2 .Pneumothorax or Pleural 2 .Pneumothorax or Pleural Effusion .Effusion .

NB: Sometimes its difficult to say that NB: Sometimes its difficult to say that collapse is due to pleural effusion or collapse is due to pleural effusion or whether both of them due to same process whether both of them due to same process ex. CA bronchus . ex. CA bronchus .

Radiological Signs Of Lobar Collapse :Radiological Signs Of Lobar Collapse :

11- The Shadow of the collapsed lobe ; - The Shadow of the collapsed lobe ; consolidation almost invariably consolidation almost invariably accompanies lobar collapse .accompanies lobar collapse .

2-2- Displacement of the structures ( Fissure , Displacement of the structures ( Fissure , mediastinum & diaphragm ) .mediastinum & diaphragm ) .

33-Silhutte sign ; it helps to Dx collapse & -Silhutte sign ; it helps to Dx collapse & which lobe is collapsed .which lobe is collapsed .

* Anteriorly located lobes (upper & * Anteriorly located lobes (upper & middle ) , causing obliteration of the middle ) , causing obliteration of the portions of the mediastinal & heart outline .portions of the mediastinal & heart outline .

* Lower lobes collapse , will obscure the * Lower lobes collapse , will obscure the outline of the adjacent diaphragm & outline of the adjacent diaphragm & descending aorta . descending aorta .

4.4. Indirect signs:Indirect signs:

Compensatory emphysemaCompensatory emphysema

i.e. compensatory expansion of the un i.e. compensatory expansion of the un obstructed lobe(s) on the side of obstructed lobe(s) on the side of collapse.collapse.

5.5. Collapse of the whole lung opaque Collapse of the whole lung opaque hemithorax hemithorax ++ substancial mediastinal & substancial mediastinal & tracheal shift.tracheal shift.

CT shows lobar collapse very well, but CT shows lobar collapse very well, but rarely necessary simply to dx collapse. rarely necessary simply to dx collapse.

ll

Spherical pulmonary shadows Spherical pulmonary shadows ( lung mass , lung nodule )( lung mass , lung nodule )

CausesCauses : :

1)1) Bronchial CA \ bronchial carcinoid .Bronchial CA \ bronchial carcinoid .

2)2) Benign tumours of the lung ; hamartoma (most Benign tumours of the lung ; hamartoma (most common) .common) .

3)3) Infective granuloma ; tuberculoma & fungal Infective granuloma ; tuberculoma & fungal granuloma .granuloma .

4)4) Metastasis .Metastasis .

5)5) Lung abscess .Lung abscess .

6)6) Rarely rounded pneumonia .Rarely rounded pneumonia .

Except for the abscess & pneumonia , others Except for the abscess & pneumonia , others found incidentally in the found incidentally in the CXR .CXR . > 40 y + smoker bronchial> 40 y + smoker bronchial CA is the major CA is the major considerationconsideration , but not if less than 30 y . , but not if less than 30 y .

To decide the nature of the lesion , look for the To decide the nature of the lesion , look for the following features :following features :

1.1. Comparison with previous filmsComparison with previous films (Growth Rate)(Growth Rate)::

If the growth rate 18 month or more benign If the growth rate 18 month or more benign tumour or inactive granuloma , if < 18 month tumour or inactive granuloma , if < 18 month CA bronchial or metastasis . CA bronchial or metastasis .

2.2. CalcificationCalcification : :Substantial Calcification , virtually rules Substantial Calcification , virtually rules out the dx of a malignant lesion . out the dx of a malignant lesion . Common in hamartoma , tuberculoma & Common in hamartoma , tuberculoma & fungal granuloma .fungal granuloma .Uniform calcification , concentric ring Uniform calcification , concentric ring calcification, popcorn calcificationcalcification, popcorn calcification ; ; whether seen on CXR or CT whether seen on CXR or CT bronchial CA can be excluded from the bronchial CA can be excluded from the DDX .DDX .

3.3. Involvement of the adjacent chest wallInvolvement of the adjacent chest wall : :Rib destructionRib destruction virtually dx of virtually dx of invasion by CAinvasion by CA . .

Pan coast’s tumour invade chest wall Pan coast’s tumour invade chest wall & ribs . & ribs . CT or bone scan for demonstration of CT or bone scan for demonstration of bone invasion & on the top PET/CT .bone invasion & on the top PET/CT .

4)4) ShapeShape : :Irregular , lobulated , infliterative , notched Irregular , lobulated , infliterative , notched outline , even in small portion of around outline , even in small portion of around lesion DX of primany CA should be lesion DX of primany CA should be considered .considered .

5)5) CavitationCavitation : :Center of mass necrosis & coughed up Center of mass necrosis & coughed up air seen within the mass air_ fluid air seen within the mass air_ fluid level .level .It’s almost always indicates significant It’s almost always indicates significant lesionlesion . .

Very common ( lung abscess ) relatively Very common ( lung abscess ) relatively common (Primary CA) & occasionally in common (Primary CA) & occasionally in metastasis ( seq.cell CA).metastasis ( seq.cell CA).

inactive granuloma .inactive granuloma .

Not occur Not occur

benign lesion . benign lesion .

S.T. very difficult to distinguish between S.T. very difficult to distinguish between lung abscess & cavitatory neoplasm ; lung abscess & cavitatory neoplasm ; especially if walls are thin & smooth .especially if walls are thin & smooth .

Irregular outer or inner walls mostly Irregular outer or inner walls mostly CA. CA.

6.6. SizeSize : :

> 4 cm + no calcification nearly > 4 cm + no calcification nearly always ; ( Primary CA ) , lung abscess always ; ( Primary CA ) , lung abscess (cavitation) , or rarely round pneumonia (cavitation) , or rarely round pneumonia ( clinical features ).( clinical features ).

7.7. Other lesionOther lesion : :

Metastasis is the commonest cause .Metastasis is the commonest cause .

Multiple pulmonary nodulesMultiple pulmonary nodules: :

1.1. Metastasis .Metastasis .

2.2. Hydatid cysts.Hydatid cysts.

3.3. Abscess .Abscess .

4.4. Fungal granuloma or tuberculomas .Fungal granuloma or tuberculomas .

5.5. Collagen vascular disease .Collagen vascular disease .

Line or band _ like shadowsLine or band _ like shadows: :

all line shadows within the lung are all line shadows within the lung are abnormal except fissures & the walls of abnormal except fissures & the walls of the large central bronchi .the large central bronchi .

1)1) Septal linesSeptal lines ::Pulmonary septa ; connective tissue Pulmonary septa ; connective tissue planes containing lymph vessels planes containing lymph vessels ; normally invisible ; only thickened ; normally invisible ; only thickened septa are visible :septa are visible :

1.1. Kerley A - lines : Kerley A - lines : radiating towards the radiating towards the hila , not branching thinner than B.V. hila , not branching thinner than B.V. mid & uppermid & upper zones .zones .

2.2. kerley B lines:kerley B lines: horizontal ; not more horizontal ; not more than 2 cm & at the periphery , reaching than 2 cm & at the periphery , reaching the lung edge .the lung edge .

Causes :Causes :

1.1. Pul. Odema .Pul. Odema .

2.2. Lymphangitis CA .Lymphangitis CA .

2)2) Pleural pulmonary scars :Pleural pulmonary scars :

Previous infection & infarction .Previous infection & infarction .

Reaching the pleura + pleural thickening. Reaching the pleura + pleural thickening.

3)3) Linear ( discoid ) atelectasis :Linear ( discoid ) atelectasis :

post operative post operative

Due to hypoventilation Due to hypoventilation

post traumaticpost traumatic

4)4) Pleural edge in pneumo thorax :Pleural edge in pneumo thorax :

|| to the chest wall , no B.V. beyond it .|| to the chest wall , no B.V. beyond it .

The pleuraThe pleura: : Pleural effusion : Transudate , exudate, Pleural effusion : Transudate , exudate, blood , pus same radiological blood , pus same radiological appearance .appearance .

Early pleural effusion seen by U/S .Early pleural effusion seen by U/S .

1.1. Free pleural effusion , assume two basic Free pleural effusion , assume two basic shapes:shapes:

1)1) obliterates the costo phrenic angle , & obliterates the costo phrenic angle , & then surrounds the lung , higher laterally then surrounds the lung , higher laterally than medially (meniscus sign ).than medially (meniscus sign ).

2)2) Sub pulmonary effusion apparent Sub pulmonary effusion apparent elevation of the diaphragm & it will not elevation of the diaphragm & it will not run up the chest wall but ,will take the run up the chest wall but ,will take the shape of diaphragm .shape of diaphragm .

C.TC.T. . Homogenous fluid density Homogenous fluid density between the lung & chest wall , & in the between the lung & chest wall , & in the dependent portion of the chest . dependent portion of the chest .

N.B. differentiate Between Pleural N.B. differentiate Between Pleural effusion & ascites by collection of fluid effusion & ascites by collection of fluid outside diaphragm effusion while outside diaphragm effusion while ascites seen posterior to diaphragm ascites seen posterior to diaphragm cover bare area .cover bare area .

DXDX

U\S U\S

control of Pleuralcontrol of Pleural fluid aspiration fluid aspiration

2.2. Loculated PleuralLoculated Pleural effusioneffusion ::

due to pleuraldue to pleural adhesion & it’s a particular adhesion & it’s a particular feature of empyma .feature of empyma .

1)1) Inter lobar fissure .Inter lobar fissure .

2)2) lateral chest wall .lateral chest wall .

3)3) Sub pulmonary .Sub pulmonary .

N.B. N.B. loculatedloculated effusioneffusion may simulatemay simulate lunglung tumor on CXRtumor on CXR

C.T. U\S (near diaphragm C.T. U\S (near diaphragm or chest or chest

wall ). wall ).

Causes of pleuralCauses of pleural effusion :effusion :

pneumonia small pleuralpneumonia small pleural effusion .effusion .

pneumonia + loculated pneumonia + loculated effusion empyma. effusion empyma.

1)1) infection infection

TB effusion ( may be TB effusion ( may be the only abnormally the only abnormally

& may be large . & may be large .

subphrenic abscess always subphrenic abscess always cause effusion . cause effusion .

2)2) Malignant neoplasm either pleural Malignant neoplasm either pleural secondary deposits , which are usually secondary deposits , which are usually not seen by CXR , occasionally seen as not seen by CXR , occasionally seen as nodular thickening by U\S , CT ,or MRI . nodular thickening by U\S , CT ,or MRI .

usually large .usually large . or ( primary CA ) ex. CA bronchus or ( primary CA ) ex. CA bronchus

or mesothelioma then other signs of or mesothelioma then other signs of primary T. seen .primary T. seen .

3)3) Cardiac failure :Cardiac failure :Acute LT VF small bilateral pleural Acute LT VF small bilateral pleural effusion .effusion .

Long standing congestive failure Long standing congestive failure large bilateral , more at Rt. + change large bilateral , more at Rt. + change shape &\ or size of the Ht + pul. Odema shape &\ or size of the Ht + pul. Odema + pul. Venous Hypertension .+ pul. Venous Hypertension .

4)4) Pul. Infarction small pleural effusion .Pul. Infarction small pleural effusion .

5)5) Collagen vascular disease unilateral Collagen vascular disease unilateral or bilateral . or bilateral .

6)6) Nephrotic syndrome , renal failure .Nephrotic syndrome , renal failure .

Pleural thickening ( fibrosis ) Pleural thickening ( fibrosis ) blunting of the costo phrenic angle , due to blunting of the costo phrenic angle , due to infection or hemorrhage .infection or hemorrhage .

Along lateral chest walls + calcification Along lateral chest walls + calcification asbestos exposure . asbestos exposure .

N.B. small pleural effusion difficult to N.B. small pleural effusion difficult to differentiate from pleural thickening by differentiate from pleural thickening by CXR U\S or CT .CXR U\S or CT .

22ndnd deposits most common deposits most common

primary mesothelioma primary mesothelioma relatively uncommon . relatively uncommon .

Pleural tumoursPleural tumours

pleural effusion that pleural effusion that abscure the tumour . abscure the tumour .

lobulated mass , based on lobulated mass , based on

CXRCXR pleural. pleural.

pleural calcification :pleural calcification :

Pleural irregular plaques of calcification &\ Pleural irregular plaques of calcification &\ or pleural thickening .or pleural thickening .

old haematoma .old haematoma .

pleural calcificationpleural calcification

old empyma usually old empyma usually T.B. T.B.

Bilateral pleural calcification with Bilateral pleural calcification with thickening often caused by asbestos thickening often caused by asbestos exposure .exposure .

PneumothoraxPneumothorax: : DX by CXR :DX by CXR :1.1. Pleural line forming the lung edge seprated Pleural line forming the lung edge seprated

from the chest wall , mediastinum or diaphragm from the chest wall , mediastinum or diaphragm by air .by air .

2.2. absence of vessles shadows outside this line absence of vessles shadows outside this line this alone is insufficient evidence to DX as in this alone is insufficient evidence to DX as in emphysematous bullae .emphysematous bullae .Small Pneumothorax ,may be dx on expiratory Small Pneumothorax ,may be dx on expiratory film .film .

3.3. After DX of Pneumothorax if it’s tension or After DX of Pneumothorax if it’s tension or not & this by mediastinal shift .not & this by mediastinal shift .

flat or inversion of the flat or inversion of the diaphragm . diaphragm .

causescauses of Pneumothorax :of Pneumothorax :

1.1. Majority occur in young people due to Majority occur in young people due to rupture of small blebs or bullae at the rupture of small blebs or bullae at the lung periphery.lung periphery.

2.2. Emphysema . Emphysema .

3.3. Truma .Truma .

4.4. Pul. Fibrosis .Pul. Fibrosis .

5.5. Pneumocystis carinii pneumonia .Pneumocystis carinii pneumonia .

6.6. Metastases (rarely ). Metastases (rarely ). Hydropneumothrax or Hydropneumothrax or

Haemopneumothrax .Haemopneumothrax .

The Mediastinum :The Mediastinum : for descriptive purpose ; the mediastinum is for descriptive purpose ; the mediastinum is divided in to anterior , middle & post. Division .divided in to anterior , middle & post. Division .If mediastinal mass is dx on frontal CXR If mediastinal mass is dx on frontal CXR lateral CXR .lateral CXR .The value of CT & MRI over CXR The value of CT & MRI over CXR

Cross sectional image differentiate fat , various Cross sectional image differentiate fat , various soft tissue & B.V. soft tissue & B.V. In chest CT is superior to MRI except in:In chest CT is superior to MRI except in:

1.1. Aneurysms & vascular anomalies , which Aneurysms & vascular anomalies , which needs no CM. needs no CM.

2.2. Posterior mediastinum mass , it’s relation to Posterior mediastinum mass , it’s relation to spinal canal .spinal canal .

Mediastinal Masses in CXRMediastinal Masses in CXR::1.1. Intrathorax thyroid goitres the most Intrathorax thyroid goitres the most

common cause of superior med. common cause of superior med. Widening .Widening .

CXR Dx mass extended from sup. CXR Dx mass extended from sup. Med. To neck .Med. To neck .

almost invariably compress almost invariably compress or displace trachea . or displace trachea .

2.2. enlarged LN ; the next common or enlarged LN ; the next common or frequent cause of med. Widening ; could frequent cause of med. Widening ; could occur in any one of three compartments. occur in any one of three compartments. . .

DX CXR lobulated outline .DX CXR lobulated outline . multiple location .multiple location .3.3. Neurogenic T. : the most common cause Neurogenic T. : the most common cause

of posterior med. Masses .of posterior med. Masses .DX ; pressure erosion or deformity of DX ; pressure erosion or deformity of adjacent ribs & thoracic spine .adjacent ribs & thoracic spine .

4.4. Thymoma & dermoid cysts Ant. Med. Thymoma & dermoid cysts Ant. Med. 5.5. Calcification occur in many conditions Calcification occur in many conditions

but not in malignant lymphadenopathy .but not in malignant lymphadenopathy .Calcification may have characteristics Calcification may have characteristics app. Aneurysm of aorta .app. Aneurysm of aorta .

egg shell. egg shell.

6.6. H.H. ; usually easy to dx on plain x-ray H.H. ; usually easy to dx on plain x-ray due to air or fluid level ( best on lateral due to air or fluid level ( best on lateral CXR ).CXR ).

7.7. Rt cardiophrenic angle ; nearly all benignRt cardiophrenic angle ; nearly all benign

Fat pad pericardial cyst hernia Fat pad pericardial cyst hernia through formen through formen of morgagn . of morgagn .

Pneumo mediastinum :Pneumo mediastinum : provided air has not tracked in to provided air has not tracked in to

mediastinum from neck root adjacent chest mediastinum from neck root adjacent chest wall or retro peritoneum , then comes wall or retro peritoneum , then comes from :from :

Tear esophagus Tear bronchi. Tear lung.Tear esophagus Tear bronchi. Tear lung. Spontaneous or truma Endoscopy or Spontaneous or truma Endoscopy or FBFBLinear streaks of transradiancy extended to Linear streaks of transradiancy extended to

the neck root .the neck root .

Hilar EnlargementHilar Enlargement: : 1.1. Enlarged pulmonary arteriesEnlarged pulmonary arteries : :

A.A. Branching pattern .Branching pattern .

B.B. Usually bilateral + Ht size + enlarged Usually bilateral + Ht size + enlarged MPA .MPA .

2.2. Enlarged hilar LN .:Enlarged hilar LN .:

A.A. Lobulated outlineLobulated outline . .

B.B. Unilateral or bilateral .Unilateral or bilateral .

C.C. Adjacent bronchi are normal or slightly Adjacent bronchi are normal or slightly narrowed . narrowed .

Unilateral enlargement of hilar LN Unilateral enlargement of hilar LN

Metastasis; CA bronchus.Metastasis; CA bronchus.

Malignant lymphoma .Malignant lymphoma .

Infection : TB Infection : TB (commonest cause of (commonest cause of unilateral hilar LN unilateral hilar LN

enlargement \ child ) or enlargement \ child ) or histoplasmosis. histoplasmosis.

bilateral enlargement of hilar LN :bilateral enlargement of hilar LN :

sarcoidosis (Commonest sarcoidosis (Commonest symmetrical , enlarged LN symmetrical , enlarged LN

, Rt. Paratrachel ). , Rt. Paratrachel ).

Malignant lymphoma .Malignant lymphoma .

Infection TB & fungal .Infection TB & fungal .

3.3. CA bronchus :CA bronchus :

hilar mass + lober collapsehilar mass + lober collapse \ \ consolidation or narrowing of adjacent consolidation or narrowing of adjacent bronchus is visible DX of CA bronchus is visible DX of CA bronchus is virtual . bronchus is virtual .

DiaphragmDiaphragm : : Unilateral elevation :Unilateral elevation :1)1) Loss of volume of theLoss of volume of the ipsilateral lung .ipsilateral lung .2)2) Abd . Mass .Abd . Mass .3)3) Subphrenic abscess .Subphrenic abscess .4)4) Apparent elevation sub Pul. Effusion .Apparent elevation sub Pul. Effusion .5)5) Marked elevation + no other visible Marked elevation + no other visible

abnormally paralysis or eventration. abnormally paralysis or eventration. Diaphragm paralysis due to disorder of Diaphragm paralysis due to disorder of

phrenic nerve due CA bronchus , which phrenic nerve due CA bronchus , which showed paradoxal movement U\S or showed paradoxal movement U\S or fluro scopy during inspiration .fluro scopy during inspiration .

eventration of the diaphragmeventration of the diaphragm : : congenital condition in which the mussels congenital condition in which the mussels replaced by thin membranous sheet , replaced by thin membranous sheet , except in neonatal period its symptom- except in neonatal period its symptom- less . When the whole hemi diaphragm is less . When the whole hemi diaphragm is involved ; it’s almost always the Lt _ side , involved ; it’s almost always the Lt _ side , also show either no or paradoxal also show either no or paradoxal movement & if involve part of one hemi movement & if involve part of one hemi diaphragm humpdiaphragm hump

chest wall :chest wall : Should be examined soft T. swelling. Should be examined soft T. swelling.

rib abnormally .rib abnormally . Oblique view should be obtained if rib Oblique view should be obtained if rib

abnormally is suspected because ribs are abnormally is suspected because ribs are foreshortened in frontal view .foreshortened in frontal view .

Soft T. swelling #Soft T. swelling #

infection .infection .

neoplasm . neoplasm .

S.T. soft Tissue swelling is more obvious S.T. soft Tissue swelling is more obvious than the rib lesion oblique or CT.than the rib lesion oblique or CT.

Bacterial pneumonia :Bacterial pneumonia : common feature of all pneumonias is common feature of all pneumonias is

cellular exudate within the alveoli .cellular exudate within the alveoli . Pneumo coccal Pn. Complete Pneumo coccal Pn. Complete

resolution.resolution. TB. klebsiella , staph , anaerobic TB. klebsiella , staph , anaerobic

cavitation . cavitation .

The basic radiological features The basic radiological features of Pn. areof Pn. are ::

1.1. One or more areas of consolidations .One or more areas of consolidations .

2.2. Consolidation may be accompanied by Consolidation may be accompanied by loss of volume of the affected lobe , loss of volume of the affected lobe , particularly in child .particularly in child .

3.3. Cavitation .Cavitation . Pn. May be secondary to bronchial Pn. May be secondary to bronchial

obstruction ( major bronchus ) , CA being obstruction ( major bronchus ) , CA being a common cause of obstruction .a common cause of obstruction .

bronchial obstruction should always be bronchial obstruction should always be considered in any Pt. presenting with considered in any Pt. presenting with consolidation of one or two lobes supplied consolidation of one or two lobes supplied by common bronchus (Rt Mid. & lower by common bronchus (Rt Mid. & lower lobes ), particularly if it associated with lobes ), particularly if it associated with volume loss . volume loss .

CXR :CXR : ill defined shadow , ranging from small to ill defined shadow , ranging from small to

large with air bronchogram ; involve one or large with air bronchogram ; involve one or more lobes lobar pneumonia .more lobes lobar pneumonia .

the common infect. organism lobar the common infect. organism lobar pneumonia strept. pneumonia , while pneumonia strept. pneumonia , while in pneumo coccal pneumonia dense in pneumo coccal pneumonia dense lobar consolidation + no loss of volume + lobar consolidation + no loss of volume + pleural effusion .pleural effusion .

patchy consolidation involve one or more patchy consolidation involve one or more lobes broncho Pn. Staph ., G negative lobes broncho Pn. Staph ., G negative bact. Anaerobic bact., mycoplasma Pn. bact. Anaerobic bact., mycoplasma Pn.

S.T. Difficult to differentiate Pn. From S.T. Difficult to differentiate Pn. From Pul. odema , or Pul. Infarction by CXR so Pul. odema , or Pul. Infarction by CXR so depend on clinical feature .depend on clinical feature .

Viral & Mycoplasma Pneumonia Viral & Mycoplasma Pneumonia (Atypical Pn . )(Atypical Pn . )

Radiological abnormality , may persist Radiological abnormality , may persist for many weeks after clinical recovery .for many weeks after clinical recovery .

CXR .CXR .

1.1. Wide spread ill defined consolidation .Wide spread ill defined consolidation .

2.2. Loss of clarity of the vascular markings.Loss of clarity of the vascular markings.

3.3. & \ or pleural effusion .& \ or pleural effusion .

DDx Pul. Odema .DDx Pul. Odema .

Lung Abscess :Lung Abscess : Localized suppurative lesion of lung Localized suppurative lesion of lung

parenchyma .parenchyma . causes :causes :

1.1. Aspiration of food or secretion ; usually Aspiration of food or secretion ; usually occur in the apical segment of lower occur in the apical segment of lower lobes or posterior segment of upper lobes or posterior segment of upper lobes .lobes .

2.2. Infection beyond obstructing lesion . Infection beyond obstructing lesion .

3.3. Infected emboli . Infected emboli .

CXR \ Lung abscessCXR \ Lung abscess1.1. Homogenous spherical shadow .Homogenous spherical shadow .2.2. Central lucency within shadow (air) .Central lucency within shadow (air) .3.3. Fluid level within shadow .Fluid level within shadow .DDx DDx : cavitary CA , cavitation with wegener’s : cavitary CA , cavitation with wegener’s

granuloma .granuloma .

Pulmonary T.B. :Pulmonary T.B. :1.1. Primary 1Primary 1stst infection with mycobacterium infection with mycobacterium

tuberculosis usually in child .tuberculosis usually in child .

2.2. Post primary : reinfection in adult after Post primary : reinfection in adult after developing relative immunity following the developing relative immunity following the primary infection .primary infection .

Primary T.B. Primary T.B.

CXR :CXR :1.1. Ghon focus : area of consolidation Ghon focus : area of consolidation

develop at the lung periphery in the upper develop at the lung periphery in the upper or mid zone .or mid zone .

2.2. Enlarged hilar LN .Enlarged hilar LN . primary complex .primary complex .3.3. Pleural effusion ; more often is the only Pleural effusion ; more often is the only

abnormally .abnormally .

most of primary TB cases , the primary most of primary TB cases , the primary complex whether treated or not heal complex whether treated or not heal with calcification which often remains with calcification which often remains visible throughout life .visible throughout life .

spread of infection :spread of infection :1.1. Bronchial tree bronchial Pn.Bronchial tree bronchial Pn.

CXRCXR patchy or lobar consolidation ; involve patchy or lobar consolidation ; involve one or more lobes + bilateral + freq. one or more lobes + bilateral + freq. cavitation.cavitation.

2.2. Blood miliary T.B.Blood miliary T.B.

CXR Miliary shadows + primary focus CXR Miliary shadows + primary focus + pleural effusion .+ pleural effusion .

post primary T.B.post primary T.B.1.1. Usually confined the upper posterior Usually confined the upper posterior

portions of the chest ; apical & posterior portions of the chest ; apical & posterior segments of upper lobes & the apical segments of upper lobes & the apical segment of lower lobes .segment of lower lobes .

2.2. Multiple small areas of consolidation & Multiple small areas of consolidation & are often bilateral .are often bilateral .

3.3. Occasionally lower or middle lobe Occasionally lower or middle lobe broncho pneumonia . broncho pneumonia .

4.4. Cavitation surrounded by Pul. Shadow .Cavitation surrounded by Pul. Shadow .

5.5. Healing by fibrosis + calcification , which Healing by fibrosis + calcification , which may be seen with continuing activity .may be seen with continuing activity .

6.6. Mediastinal & \ or hilar LN , is a Mediastinal & \ or hilar LN , is a predominant or sole feature in non predominant or sole feature in non Caucasians , not clear whether primary Caucasians , not clear whether primary or post primary tuber culosis .or post primary tuber culosis .

7.7. post primary T.B. may spread post primary T.B. may spread

bronchopneumonia Miliary T.B.bronchopneumonia Miliary T.B.8.8. Pleural effusion are frequent & often Pleural effusion are frequent & often

permanent pleural thickening which may permanent pleural thickening which may calcify. calcify.

9.9. Tuberculoma: tuberculosis granuloma , Tuberculoma: tuberculosis granuloma , most of them are inactive but viable most of them are inactive but viable bacilli may present even in calcified bacilli may present even in calcified lesion.lesion.

CXRCXR spherical mass , < 3 cm with sharp spherical mass , < 3 cm with sharp defined margin , & partly calcified.defined margin , & partly calcified.

Mycetoma : fungal bull with old T.B. Mycetoma : fungal bull with old T.B. cavity due to colonization of the fungal cavity due to colonization of the fungal aspergillus fumigatus . Mycetoma lie aspergillus fumigatus . Mycetoma lie freely with the cavity & air seen between freely with the cavity & air seen between ball & the cavity . & usually surrounded ball & the cavity . & usually surrounded by often evidence of old T.B. ( fibrosis + by often evidence of old T.B. ( fibrosis + calcification ). calcification ).

Is the diseaseIs the disease is active ?is active ?

by comparison of serial films overby comparison of serial films over prolonged period prolonged period are available . Valuable dx signs of activity :are available . Valuable dx signs of activity :

1.1. Development of new lesions on serial films .Development of new lesions on serial films .

2.2. Cavitation .Cavitation .

N.B.N.B. : :1.1. present of calcification dosn’t exclude activity present of calcification dosn’t exclude activity

2.2. the better defined the shadow & the greater the better defined the shadow & the greater the calcification less likely to be active the calcification less likely to be active while ill defined shadows active .while ill defined shadows active .

Fungal & parasiteFungal & parasite Fungal :Fungal :

Aspergillus fumigatus Mycetoma .Aspergillus fumigatus Mycetoma .

broncho Pn. broncho Pn. ( immunity ). ( immunity ).

allergic broncho- allergic broncho- Pul. Pul. Aspergillosis Aspergillosis

parasite ; H.C.parasite ; H.C. Echinococcus granulosus Echinococcus granulosus Single or multiple spherical shadows + very well - Single or multiple spherical shadows + very well -

defined border .defined border .Rupture abscess . Rupture abscess .

pneumonia in immune compromised pneumonia in immune compromised patient atypical Pn. Due to patient atypical Pn. Due to opportunistic infection : T.B. , fungi , opportunistic infection : T.B. , fungi , pneumocystis carinii .pneumocystis carinii .

Pneumocystis carinii uniform wide Pneumocystis carinii uniform wide spread Pul. Shadow in Pt. with AIDS .spread Pul. Shadow in Pt. with AIDS .

DDx T.B. & Kaposi's sarcoma . DDx T.B. & Kaposi's sarcoma .

sarcoidosis :sarcoidosis : Non caseating granuloma disease , affecting Non caseating granuloma disease , affecting

many organs ; lung , liver , spleen , LN ,skin & many organs ; lung , liver , spleen , LN ,skin & bone .bone .

Radiological manifestations largely confined to Radiological manifestations largely confined to the chest the chest

1.1. Hilar( symmetrical & bilateral ) & other Hilar( symmetrical & bilateral ) & other mediastinal enlarged LN (Rt _ paratracheal ). mediastinal enlarged LN (Rt _ paratracheal ).

DDx lymphoma ; the differentiating point is that DDx lymphoma ; the differentiating point is that in sarcoidosis LN enlargement never in sarcoidosis LN enlargement never predominant in anterior mediastinal .predominant in anterior mediastinal .

2.2. Reticulo nodular pulmonary shadowing : Reticulo nodular pulmonary shadowing : ( 10 % of Pt. ). Mainly at upper & mid ( 10 % of Pt. ). Mainly at upper & mid zone .zone .

Diffuse Pul. Fibrosis ; causes:Diffuse Pul. Fibrosis ; causes:1.1. Idiopathic Pul. Fibrosis or idiopathic fibro- Idiopathic Pul. Fibrosis or idiopathic fibro-

sing alveolitis .sing alveolitis .2.2. Extrinsic allergic alveolitis .Extrinsic allergic alveolitis .3.3. Collagen vascular dis. Ex: Rh. Arthritis , Collagen vascular dis. Ex: Rh. Arthritis ,

scleroderma .scleroderma .4.4. Pneumoconiosis .Pneumoconiosis .5.5. Sarcoidosis .Sarcoidosis .6.6. Drug - induced fibrosis .Drug - induced fibrosis .

CXR : haze shadow (base) loss of CXR : haze shadow (base) loss of clarity of B.V. Ground glass . clarity of B.V. Ground glass .

Later : ill - defined nodular + connecting Later : ill - defined nodular + connecting lines honey comb app. lines honey comb app.

marked decreased in lung vol.marked decreased in lung vol. Ht size & Pul. Arteries ( Pul. Arterial Ht size & Pul. Arteries ( Pul. Arterial

HTN). HTN). Pul. Fibrosis + substantial post or hilar Pul. Fibrosis + substantial post or hilar

mediastinal LN sarcoidosis .mediastinal LN sarcoidosis . Pul. Fibrosis + conglomerate masses in Pul. Fibrosis + conglomerate masses in

the mid & upper zones the mid & upper zones pneumoconiosis .pneumoconiosis .

Pul. Fibrosis + bilateral pleural thickening Pul. Fibrosis + bilateral pleural thickening + calcification asbestosis .+ calcification asbestosis .

Pul. Fibrosis + past or present pleural Pul. Fibrosis + past or present pleural effusion Rh. Arthritis .effusion Rh. Arthritis .

collagen vascular diseases :collagen vascular diseases : Rheumatoid lung :Rheumatoid lung : Pul. Fibrosis ; DDx cryptogenic or Pul. Fibrosis ; DDx cryptogenic or

idiopathic fibrosis alveolitis .idiopathic fibrosis alveolitis . pleural effusion ( most common finding ).pleural effusion ( most common finding ). Rh. Nodular < 3 cm ; &\ or cavitation Rh. Nodular < 3 cm ; &\ or cavitation

resolve . resolve .

asbestosis :asbestosis :1)1) Pleural thickening + calcification .Pleural thickening + calcification .2)2) Pul. Fibrosis .Pul. Fibrosis .3)3) Malignant mesothelioma + CA bronchus.Malignant mesothelioma + CA bronchus. Diseases of airwaysDiseases of airways : :

1.1. Asthma ; usually normal CXR , S.T. air Asthma ; usually normal CXR , S.T. air trapping the main purpose of CXR :trapping the main purpose of CXR :

1.1. Determine complicates ex. Collapse .Determine complicates ex. Collapse .2.2. Associated pneumonia .Associated pneumonia .3.3. Exclude other causes of acute dyspnoea Exclude other causes of acute dyspnoea

ex. Pul. Odema , pneumothorax , rarely ex. Pul. Odema , pneumothorax , rarely tracheal obst. tracheal obst.

2.2. Bronchiolitis ; young children :Bronchiolitis ; young children :

CXRCXR normal normal

hyper inflation of lung low hyper inflation of lung low diaphragm & \ or areas of consolidation . diaphragm & \ or areas of consolidation .

3.3. Acute bronchitis normal CXR unless Acute bronchitis normal CXR unless complicated by pneumonia .complicated by pneumonia .

4.4. Chronic obstructive airway diseases :Chronic obstructive airway diseases : Chronic bronchitis normal Chronic bronchitis normal

complications complications

Pn. Emphysema corpulmonalePn. Emphysema corpulmonale

Emphysema Emphysema

CXRCXR 1.1. Increased lung volume Increased lung volume over inflation over inflation

(mid (mid diaphragm diaphragm below 7 below 7 thth rib rib Anterior Anterior end or end or 12 12 thth rib rib posterior ).posterior ).

flat diaphragm .flat diaphragm .

enlongated & enlongated & narrowed narrowed

Ht Ht shadow . shadow .

2.2. Attenuation of the vessles ; size & \ or Attenuation of the vessles ; size & \ or

bullae bullae formation.formation.

number number

Bronchiectasis ; causes Bronchiectasis ; causes childhood childhood Pul. Infection Pul. Infection

Cystic Cystic fibrosis . fibrosis .

long long standing standing bronchial bronchial obst. obst.

CXRCXR 1.1. Dilated bronchi cyst .Dilated bronchi cyst . tubular shadows & \ tubular shadows & \

or fluid level . or fluid level .2.2. Persistent consolidation .Persistent consolidation .3.3. Volume loss is almost invariable .Volume loss is almost invariable .4.4. May be normal CXR .May be normal CXR .

Cystic fibrosisCystic fibrosis : : Inherited disorder of the exocrine glandsInherited disorder of the exocrine glands secretion of viscid mucus blocked secretion of viscid mucus blocked

small airways + secondary infection .small airways + secondary infection . High NaCl in sweat is Dx .High NaCl in sweat is Dx .

CXR :CXR :1.1. Bronchiectasis maximum in upper zone . Bronchiectasis maximum in upper zone .

2.2. Small ill- defined consolidation maximum in Small ill- defined consolidation maximum in upper zone & \ or cavitation .upper zone & \ or cavitation .

33 .Evidence of airways obstruction flat .Evidence of airways obstruction flat diaphragm diaphragm

narrowed narrowed vertical Ht.vertical Ht.

Respiratory distress in new born :Respiratory distress in new born :1.1. Hyaline membrane disease Hyaline membrane disease

premature infant deficiency of surfactantpremature infant deficiency of surfactant

alveoli collapse no alveoli collapse no gas exchange . gas exchange .

CXR :CXR :1.1. Granular opacities confluent Granular opacities confluent

opacities opacities

mild Moderatemild Moderate

2.2. Air broncho gram air broncho Air broncho gram air broncho gram gram

1.1. Uniform opaque lungs .Uniform opaque lungs .

more sever.more sever.

2.2. Air broncho gram .Air broncho gram .

2.2. Me conium aspiration :Me conium aspiration :

CXR:CXR:1.1. Patchy & streaky Pul. Shadowing .Patchy & streaky Pul. Shadowing .

2.2. Air broncho gram is not obvious feature .Air broncho gram is not obvious feature .

3.3. Air way obstruction low diaphragm .Air way obstruction low diaphragm .

N.B. N.B. complication of therapy complication of therapy

Pneumothorax Pneumothorax collapse pneumo collapse pneumo mediastinal mediastinal

Adult respiratory distress syndrome = non Adult respiratory distress syndrome = non cardiogenic Pul. Odema .cardiogenic Pul. Odema .

causes :causes :1.1. sever trauma .sever trauma .

2.2. Septicemia .Septicemia .

3.3. Hypotension .Hypotension .

4.4. Fat embolism .Fat embolism .

Path physiologyPath physiology : : extra vasationextra vasation of protienaceous of protienaceous fluid from Pul. Capillaries to Pul. Interstitium fluid from Pul. Capillaries to Pul. Interstitium & alveoli . & alveoli .

CXR :CXR : Normal up to 12 - 24 hour.Normal up to 12 - 24 hour. Wide spread Pul. Shadowing ( similar to cardiogenic Wide spread Pul. Shadowing ( similar to cardiogenic

Pul. Odema ) .Pul. Odema ) .

More wide spread & more uniform over the ensuring More wide spread & more uniform over the ensuring 24 - 48 hour .24 - 48 hour .

Complication of therapy Pneumothorax Complication of therapy Pneumothorax

Pneumo Pneumo mediastinal mediastinal

Pulmonary emboli & infarction :Pulmonary emboli & infarction : From DVT \ legs & pelvis .From DVT \ legs & pelvis . Bed ridden major surgery .Bed ridden major surgery .

Ht - disease .Ht - disease .

CXR:CXR:1.1. Normal even with massive Pul. Embolism .Normal even with massive Pul. Embolism .

2.2. Wedge shaped pleural based consolidation + pleural Wedge shaped pleural based consolidation + pleural effusion .effusion .

3.3. Linear atelactasis .Linear atelactasis .

4.4. Pul. Hypertension .Pul. Hypertension .

Radionuclide lung scan .Radionuclide lung scan . CT Pul. Angiography .CT Pul. Angiography .

Chest truma :Chest truma :1.1. Rib fractureRib fracture often invisible in the often invisible in the

standard projections , standard projections , esp. if below the esp. if below the diaphragm . diaphragm .

extra pleural soft tissue extra pleural soft tissue swelling may guide swelling may guide

towards towards the site of fracture . the site of fracture .

frequently are multiple frequently are multiple & result in flail segment & result in flail segment

often bloody pleural often bloody pleural effusion accompanies effusion accompanies rib fracture . rib fracture .

2.2. Pneumothorax :Pneumothorax : occur due to lung injury direct injury. occur due to lung injury direct injury.

sharp sharp edge edge of of fracturedfractured rib. rib.

Air - fluid level is common finding in such Air - fluid level is common finding in such

situation due to associated heamorrhage situation due to associated heamorrhage ( Haemo Pneumothorax ).( Haemo Pneumothorax ).

3.3. Surgical emphysemaSurgical emphysema of the chest wall , of the chest wall , due to injury of lung , presence of due to injury of lung , presence of pneumo mediastinal in absence of pneumo mediastinal in absence of surgical emphysema of the chest wall, surgical emphysema of the chest wall, un usual phenomenon of rupture un usual phenomenon of rupture bronchus . bronchus .

4.4. Pulmonary contusionPulmonary contusion : localized : localized traumatic alveolar heamorrhage & traumatic alveolar heamorrhage & odema may occur + \ - rib fracture odema may occur + \ - rib fracture Pul. Consolidation shadow .Pul. Consolidation shadow .

5.5. ARDS : ARDS : May occur after any sever trauma to any May occur after any sever trauma to any

part of the body .part of the body . Fat embolism is a specific subtype of ARDS.Fat embolism is a specific subtype of ARDS.

6.6. Rupture diaphragm :Rupture diaphragm : direct injury or direct injury or abd. abd.

Compression.Compression.

Lt > Rt . Lt > Rt .

hernination of hernination of stomach,S.Istomach,S.I

CXR ;invisible CXR ;invisible ruptured hemi ruptured hemi

diaphragm diaphragm +stomach gas +stomach gas

&small intestine &small intestine above the above the

presumed position presumed position . .

6.6. Rupture diaphragm : Rupture diaphragm : Ba meal & Ba meal & follow through follow through may needed may needed to establish to establish

the Dx . the Dx .

tear oftear of diaphragm it diaphragm it

self seen only self seen only by U\S , but by U\S , but

some time some time difficult even difficult even by expert by expert

hand. hand.

7.7. Rupture of aorta ;Rupture of aorta ;due to rapid due to rapid deceleration injury ; at site of ligamentum deceleration injury ; at site of ligamentum arteriosum .arteriosum .

CXR mediastinal widening with is non CXR mediastinal widening with is non specific .specific .

DSA or CT angiography is indicated in DSA or CT angiography is indicated in patients in whom chest CT showed patients in whom chest CT showed heamorrhage within mediastinum heamorrhage within mediastinum because mediastinal heamorrhage could because mediastinal heamorrhage could be due venous bleeding , which dosen’t be due venous bleeding , which dosen’t require emergency surgery & this can require emergency surgery & this can cause mediastinal widening .cause mediastinal widening .

8.8. Rupture of tracheo bronchial tree ; Rupture of tracheo bronchial tree ; only only in major chest trauma .in major chest trauma .

CXR : pneumo mediastinal or CXR : pneumo mediastinal or Pneumothorax that dosen’t response to Pneumothorax that dosen’t response to chest tube suction .chest tube suction .

Main complication :subsequent broncho_ Main complication :subsequent broncho_ stenosis .stenosis .

CA bronchus :CA bronchus : One of the most common primary One of the most common primary

malignant tumours , clear association malignant tumours , clear association with cigarette smoking .with cigarette smoking .

Radiological signs of central tumour:Radiological signs of central tumour:1.1. Tumour it self hilar mass & \ or Tumour it self hilar mass & \ or

narrowing of adjacent major bronchus .narrowing of adjacent major bronchus .

2.2. Collapse consolidation of the lung Collapse consolidation of the lung beyond the tumour .beyond the tumour .

RRadiological signs of peripheral adiological signs of peripheral tumour :tumour :

1.1. The peripheral tumour solitary The peripheral tumour solitary pulmonary nodule .pulmonary nodule .

2.2. < 1cm unable be seen by CXR , but few < 1cm unable be seen by CXR , but few mm could be seen by CT .mm could be seen by CT .

3.3. Rounded shadow , with irregular border Rounded shadow , with irregular border or lobulated , or notched or infiltrated or lobulated , or notched or infiltrated edge .edge .

Cavitation usually occur seq. cell CA , Cavitation usually occur seq. cell CA , usually thick & irregular walls but thin usually thick & irregular walls but thin _walled smooth cavities could occur with _walled smooth cavities could occur with CA.CA.

Spread of CA bronchus :Spread of CA bronchus :

mainly by ( chest & upper abd. CT. )mainly by ( chest & upper abd. CT. )

1.1. Lymphatic spread hilar & Lymphatic spread hilar & mediastinal LN enlargement :mediastinal LN enlargement :

Mainly to hilar & Rt - Para tracheal, sub Mainly to hilar & Rt - Para tracheal, sub carinal LN.carinal LN.

Enlarged LN not necessarily mean Enlarged LN not necessarily mean metastasis , but reactive hyperplasia metastasis , but reactive hyperplasia to tumour or associated infection , or to tumour or associated infection , or could be due to previous granulomatous could be due to previous granulomatous infection , sarcoidosis , coal workers infection , sarcoidosis , coal workers pneumoconiosis .pneumoconiosis .

LN < 1cm normal .LN < 1cm normal . LN 1_2 cm require biopsy prior to LN 1_2 cm require biopsy prior to

surgical resection of primary tumour . surgical resection of primary tumour . LN > 2cm almost invariably contain LN > 2cm almost invariably contain

metastasis CA .metastasis CA .

2.2. Pleural effusion : malignant involve Pleural effusion : malignant involve of pleura . of pleura .

secondary to secondary to associated lung associated lung

infection. infection.

coincidental as Ht coincidental as Ht failure . failure .

3.3. Mediastinal invasion: CXR : Mediastinal invasion: CXR : widening of widening of mediastinal & mediastinal & elevation of elevation of hemi hemi diaphragm diaphragm (phrenic nerve (phrenic nerve involvement ).involvement ).

CT will CT will accurately accurately

show show mediastinal mediastinal widening . widening .

4.4. Invasion of chest wall ; CXR : rib Invasion of chest wall ; CXR : rib destruction adjacent to Pul. Shadow destruction adjacent to Pul. Shadow virtually dx of CA bronchus with chest virtually dx of CA bronchus with chest wall invasion .wall invasion .

CT: can show rib destruction which not CT: can show rib destruction which not visible at CXR .visible at CXR .

MRI has particular role in pan coast T. MRI has particular role in pan coast T.

5.5. Blood Spread ( distant meta ; Blood Spread ( distant meta ; adrenal ,liver , brain , lung , skin ) . adrenal ,liver , brain , lung , skin ) .

Lumphangitis carcinomatasis :Lumphangitis carcinomatasis : Due to block of pulmonary lymphatic by Due to block of pulmonary lymphatic by

CA tissue .CA tissue . CXR : similar to interstitial pulmonary CXR : similar to interstitial pulmonary

odema ( Septal lines , loss of clarity of B.V. odema ( Septal lines , loss of clarity of B.V. & peri bronchus thickening ) + normal Ht & peri bronchus thickening ) + normal Ht size + hilar LN enlarged .the clinical history size + hilar LN enlarged .the clinical history very important as in Pul. Odema ; sudden very important as in Pul. Odema ; sudden SOB, while in lymph. CA slowly SOB SOB, while in lymph. CA slowly SOB over the preceding weeks or mounths .over the preceding weeks or mounths .

CA lung , breast , abdomen (pancreas , CA lung , breast , abdomen (pancreas , colon ).colon ).

Metastatic neoplasm :Metastatic neoplasm :1.1. Pulmonary metastasis :Pulmonary metastasis : Multiple + variable size + well defined Multiple + variable size + well defined

spherical shadows , though irregular out spherical shadows , though irregular out line could be seen .line could be seen .

CXR >= 1cm , CT 3 - 6 mm .CXR >= 1cm , CT 3 - 6 mm .2.2. Pleural metastasis :Pleural metastasis : thickening & pleuralthickening & pleural

effusion .effusion . 3.3. Rib metastasis :Rib metastasis : CA bronchus , breast , thyroid , kidney & CA bronchus , breast , thyroid , kidney &

prostate all except breast & prostate are prostate all except breast & prostate are exclusively osteolytic .exclusively osteolytic .

See the upper cortex of the rib , & not the See the upper cortex of the rib , & not the lower because these are ill-defined even lower because these are ill-defined even in normal. & see at the edge of the chest .in normal. & see at the edge of the chest .

Look for soft tissue swelling .Look for soft tissue swelling .Lymphoma : Lymphoma : HilarHilar & mediastinal LN enlarged .& mediastinal LN enlarged .Pleural effusion .Pleural effusion .Pul. Consolidation lymphoma . Pul. Consolidation lymphoma . infection.infection.Pul. Cavitatory lesion .Pul. Cavitatory lesion .Pleural masses are rare .Pleural masses are rare .Intra thoracic malignant lymphoma .Intra thoracic malignant lymphoma .

Mammography :Mammography : X-ray examination of the breast .X-ray examination of the breast . Normal mammography shows the ductal & Normal mammography shows the ductal &

connective tissue on background of fat .connective tissue on background of fat . With a increasing age , the glandular tissue will With a increasing age , the glandular tissue will

decrease & the CA become easier to detect .decrease & the CA become easier to detect . Cardinal signs of CA : Cardinal signs of CA : Mass with irregular or spiculated border .Mass with irregular or spiculated border . Malignant micro calcification : clustered , fine Malignant micro calcification : clustered , fine

linear or irregular calcification .linear or irregular calcification . Distorted breast stroma & skin thickening . Distorted breast stroma & skin thickening .

Benign masses : spherical well defined Benign masses : spherical well defined border , with larger courser & often ring _ border , with larger courser & often ring _ like calcification .like calcification .

U\S : diff. solid & cystic masses . & if solid ( U\S : diff. solid & cystic masses . & if solid ( benign or malig.) benign or malig.)

Breast screening .Breast screening .