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Chest Imaging
Densities
•
•
•
•
•

Four densities on XR
Black – air/gas
Dark grey – fat
Light grey – fluid/solid organ
White – bone/calcium

Increasing
opacification
CXR
• Rule No 1! – always check name of patient
and date
• Check orientation (L & R labeled correctly)
• Projection (PA or AP, lateral, decubitus,
supine)
• Accurate assessment of heart size and
mediastinum on PA views
• All supine/portable - AP
CXR - systematic
• ABCDE for both frontal & lateral projection
• A – airways
– Trachea/central bronchi midline or just to right, no narrowing, carinal
angle <90°

• B – breathing/lungs
– Parenchyma – too white or too black?
• Look at the fissures

– Bones – ribs, vertebrae, humeri clavicles, scapulae – for fractures,
lytic(black), sclerotic (white) lesions, vertebral body heights

• C – cardiac/vessels
– Cardiac silhouette & Mediastinum contours & width
– Hilum – normal hilar shadow made up of vessels, Lt is higher than right
by 0-2.5 cm. Must have concave shape
– Pulmonary vessels – upper zone vessels vessels smaller than lower
CXR - systematic
• D – look under the diaphragm
– free gas – perforated viscus
– Costophrenic angle for pleural effusion

• E – extremities
– The corners of the film

• Line position
• Hidden areas: lung apices, behind the heart,
breast shadows, paravertebral, thyroid
Normal CXR
Trachea

Aortic Arch
Rt Mainstem
bronchus
Pulm artery
RA

Pulm artery
Atrial
appendage
LV

Diaphragm
stomach
Normal CXR
Trachea
Pulmonary
artery

Aortic arch

LA
RV
LV

Costophrenic
angle
Anatomy
RUL

LUL

ML
RLL

LLL
Heart
• Cardiothoracic ratio (CTR)
– <50% adults
– PA film – AP magnifies heart
– Causes of increased CTR
• Obesity, pectus, portable film, cardiomegaly,
pericardial effusion

• Shape
• Valve calcification
Lungs
• Too black
• Too white
– Opacity, density, infiltrate, mass/nodule

• Alveolar air cells
– Normally contain air (black)
– Cells eg infection/inflam pus, tumour, eosinophils
– Fluid eg aspiration, drowning, oedema, haemorrhage

• Interstitial
• Collapse V consolidation
– Volume loss: mediastinal shift, fissures, diaphragm,
hilum, rib crowding
– Air bronchograms
Silhouette sign
• When air in alveoli replaced with fluid/cells
contrast between the lung and the
neighbouring structure (heart, diaphragm) is
lost and borders become indistinct.
• Use the silhouette sign to determine which
lobe of the lung consolidation is in.
14 y M
Hx: 61 y M SOB
10 y F bilateral crackles. No response to ventolin
Hx 60 y M, chronic cough, haemoptysis
Hx 12 Y F fever & cough
Hx: 5Y M reduced air sounds left chest, decrease O2 sat
Hx 23 F confusion
66 Y F SOB
FHx: 54 y M SOB
Hx 41 Y F
Hx 16 Y M known malignancy
Hx: 88 Y M fever weight loss
Hx 78 Y F previous rectal cancer
The Black Lung
• First consider Rotation:
– (look at the clavicles)
– The lung closer to the film plate will absorb
more of the x-rays and so be whiter, whilst the
lung further away allows distance for scattered
rays to get through, and so will be blacker
9 y M Wheeze
23 y M
21 y M chest pain
20 Y M
87 y M SOB

pseudopneumothorax
Pulmonary embolism
• Abnormalities seen on CXR in PE
–
–
–
–
–
–
–
–

MORE OFTEN NORMAL – never forget this!!
Segments/subsegments of linear atelectasis
Raised hemidiaphragm
Focal region of hyperlucency (oligaemia)
“Westermark’s sign” – black area of lung seen in
only 2%
Peripheral foci of consolidation (infarction) e.g.
Hampton’s Hump. <10% show infarction.
Dilated central arteries due to arterial hypertension.
Abrupt cut-off of a vessel – only if in the central
arteries
Pleural effusion
38 y M
Radiology: Chest Imaging
Pleural Plaques
• Associated with asbestos exposure
• Thickening of the parietal pleura which
calcifies, especially seen over the
diaphragmatic surface as dense linear
bands.
• Does NOT equal asbestosis, which is
pulmonary parenchymal disease related to
asbestos exposure
– can occur together.
77 y M
• Hilar Enlargement
– unilateral or bilateral
– Look for the convex contour

• Neoplasm:
– central bronchogenic tumour itself, or lymphadenopathy. e.g. Ca
Bronchus, lymphoma, Lymphangitis carcinomatosis

•
•
•
•
•

Infective e.g. TB (usually unilateral), Mycoplasma, Viral in children
Sarcoidosis rarely unilateral, very symmetrical
Post-stenotic dilatation of pulmonary artery
Pulmonary artery aneurysm (very rare)
All causes of pulmonary arterial hypertension: primary (idiopathic) or
secondary e.g. COAD, long- term PE, chronic left to right cardiac
shunt.
Mediastinum
•
•

•
•
•
•
•

When reviewing CXR, don’t forget this
region, which contains the oesophagus,
the trachea, the aorta, the thymus
Differential Diagnosis of an anterior
Mediastinal mass: “The 4 Ts”
Thymoma
Thyroid goitre
Teratoma
Terrible Lymphoma
Assessing the mediastinal width after
severe road trauma is important to assess
for
–

•

aortic rupture. However, these films are
always supine (so AP) so very variable!!

In practice, if the widest part of the upper
mediastinum is >30% of the total thorax
diameter at that level, suspect aortic
injury if clinically possible. However,
NEVER ignore high clinical suspicion
even if the xray seems normal.
14 y M

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Radiology: Chest Imaging

  • 2. Densities • • • • • Four densities on XR Black – air/gas Dark grey – fat Light grey – fluid/solid organ White – bone/calcium Increasing opacification
  • 3. CXR • Rule No 1! – always check name of patient and date • Check orientation (L & R labeled correctly) • Projection (PA or AP, lateral, decubitus, supine) • Accurate assessment of heart size and mediastinum on PA views • All supine/portable - AP
  • 4. CXR - systematic • ABCDE for both frontal & lateral projection • A – airways – Trachea/central bronchi midline or just to right, no narrowing, carinal angle <90° • B – breathing/lungs – Parenchyma – too white or too black? • Look at the fissures – Bones – ribs, vertebrae, humeri clavicles, scapulae – for fractures, lytic(black), sclerotic (white) lesions, vertebral body heights • C – cardiac/vessels – Cardiac silhouette & Mediastinum contours & width – Hilum – normal hilar shadow made up of vessels, Lt is higher than right by 0-2.5 cm. Must have concave shape – Pulmonary vessels – upper zone vessels vessels smaller than lower
  • 5. CXR - systematic • D – look under the diaphragm – free gas – perforated viscus – Costophrenic angle for pleural effusion • E – extremities – The corners of the film • Line position • Hidden areas: lung apices, behind the heart, breast shadows, paravertebral, thyroid
  • 6. Normal CXR Trachea Aortic Arch Rt Mainstem bronchus Pulm artery RA Pulm artery Atrial appendage LV Diaphragm stomach
  • 9. Heart • Cardiothoracic ratio (CTR) – <50% adults – PA film – AP magnifies heart – Causes of increased CTR • Obesity, pectus, portable film, cardiomegaly, pericardial effusion • Shape • Valve calcification
  • 10. Lungs • Too black • Too white – Opacity, density, infiltrate, mass/nodule • Alveolar air cells – Normally contain air (black) – Cells eg infection/inflam pus, tumour, eosinophils – Fluid eg aspiration, drowning, oedema, haemorrhage • Interstitial • Collapse V consolidation – Volume loss: mediastinal shift, fissures, diaphragm, hilum, rib crowding – Air bronchograms
  • 11. Silhouette sign • When air in alveoli replaced with fluid/cells contrast between the lung and the neighbouring structure (heart, diaphragm) is lost and borders become indistinct. • Use the silhouette sign to determine which lobe of the lung consolidation is in.
  • 13. Hx: 61 y M SOB
  • 14. 10 y F bilateral crackles. No response to ventolin
  • 15. Hx 60 y M, chronic cough, haemoptysis
  • 16. Hx 12 Y F fever & cough
  • 17. Hx: 5Y M reduced air sounds left chest, decrease O2 sat
  • 18. Hx 23 F confusion
  • 19. 66 Y F SOB
  • 20. FHx: 54 y M SOB
  • 21. Hx 41 Y F
  • 22. Hx 16 Y M known malignancy
  • 23. Hx: 88 Y M fever weight loss
  • 24. Hx 78 Y F previous rectal cancer
  • 25. The Black Lung • First consider Rotation: – (look at the clavicles) – The lung closer to the film plate will absorb more of the x-rays and so be whiter, whilst the lung further away allows distance for scattered rays to get through, and so will be blacker
  • 26. 9 y M Wheeze
  • 28. 21 y M chest pain
  • 30. 87 y M SOB pseudopneumothorax
  • 31. Pulmonary embolism • Abnormalities seen on CXR in PE – – – – – – – – MORE OFTEN NORMAL – never forget this!! Segments/subsegments of linear atelectasis Raised hemidiaphragm Focal region of hyperlucency (oligaemia) “Westermark’s sign” – black area of lung seen in only 2% Peripheral foci of consolidation (infarction) e.g. Hampton’s Hump. <10% show infarction. Dilated central arteries due to arterial hypertension. Abrupt cut-off of a vessel – only if in the central arteries Pleural effusion
  • 34. Pleural Plaques • Associated with asbestos exposure • Thickening of the parietal pleura which calcifies, especially seen over the diaphragmatic surface as dense linear bands. • Does NOT equal asbestosis, which is pulmonary parenchymal disease related to asbestos exposure – can occur together.
  • 36. • Hilar Enlargement – unilateral or bilateral – Look for the convex contour • Neoplasm: – central bronchogenic tumour itself, or lymphadenopathy. e.g. Ca Bronchus, lymphoma, Lymphangitis carcinomatosis • • • • • Infective e.g. TB (usually unilateral), Mycoplasma, Viral in children Sarcoidosis rarely unilateral, very symmetrical Post-stenotic dilatation of pulmonary artery Pulmonary artery aneurysm (very rare) All causes of pulmonary arterial hypertension: primary (idiopathic) or secondary e.g. COAD, long- term PE, chronic left to right cardiac shunt.
  • 37. Mediastinum • • • • • • • When reviewing CXR, don’t forget this region, which contains the oesophagus, the trachea, the aorta, the thymus Differential Diagnosis of an anterior Mediastinal mass: “The 4 Ts” Thymoma Thyroid goitre Teratoma Terrible Lymphoma Assessing the mediastinal width after severe road trauma is important to assess for – • aortic rupture. However, these films are always supine (so AP) so very variable!! In practice, if the widest part of the upper mediastinum is >30% of the total thorax diameter at that level, suspect aortic injury if clinically possible. However, NEVER ignore high clinical suspicion even if the xray seems normal.