Pulmonary Radiology

by
The Dark Horse
ATSU-SOMA
The Basics
• X-rays are attenuated as they pass through the patient’s
body.
• Two processes play a role: absorption and scatter.
Exposure Geometry:
For the naked eye of an observer, far objects result in a
small projection and close objects in a large projection
on our retina. In projection radiography it is just the
other way around!!!
Depth seen on X-ray:
Whatever is closer to the focus, i.e., farther away from
the detector, projects larger on the detector. (It is like
looking at your own shadow on a wall—the closer you
get to the wall the smaller the shadow gets.
Density:
• The less dense a material the fewer x-rays
it will absorb and therefore the darker it will
be (ex. air)
• The more dense a material the more x-
rays it will absorb and therefore the whiter it
will be (ex. Bone)
• The terms opaque (whiter) and lucent
(darker) are used to describe the density of a
structure compared to its surrounding tissue
 Densities
• Black
– Air
• Gray
– Water
– Fluid
• White
– Bone
– Calcifications
– Foreign objects
 Typical X-ray
Scanning Approach-
PA
• PA: patient’s chest
against X-ray film with
radiation exposure from
posterior to anterior
(most common). AP is
less desirable (leads to
magnification of
structures)
• PA technique for looking
at films. Encompassing
the entire lung
boundaries (left) ,
scanning with fovea
over each part of lung
(right).
 Typical X-ray
Scanning Approach-
Lateral
• Lateral: usually a left
lateral film is taken
unless specified
differently (left side
of patient is against
X-ray film) Scan lung
boundaries (left) ,
scanning with fovea
over each part of
lung (right).
 General Overviewing of a Patient’s X-ray
• General Body Size, Shape, and Symmetry
• Male vs. Female
• Is this an infant, child, young adult, elderly person?
• Survey for foreign objects –
– Tubes (endotracheal, NG, etc.)
– IV lines (peripheral, central)
– EKG leads
– Surgical drains
– Prosthesis
– Sutures, clips, staple lines
– Non-medical objects
• bullets
• shrapnel
• glass, etc.
Systematic Approach:
Concentrate on one thing
at a time and ignore
everything else on the
film. Your eye gaze should
scan all portions of the
film! Always compare sides
when looking at these
structures
1) soft tissue/chest wall
2) bones
3) mediastinum
4) diaphragm & abdomen
5) lungs & pleura
Areas of importance on X-ray
The Silhouette sign
• The silhouette sign is in essence
elimination of the silhouette or
loss of lung/soft tissue interface
caused by a mass or fluid in the
normally air filled lung.
• In other words, if an intrathoracic
opacity is in anatomic contact
with, for example, the heart
border, then the opacity will
obscure that border.
• The sign is commonly applied to
the heart, aorta, chest wall, and
diaphragm. The location of this
abnormality can help to
determine the location The right heart border is silhouetted out.
anatomically. This is caused by a pneumonia.
 Soft Tissues
Breast Tissue:
• Notice how the
apparent lung density
changes from the
lung area covered by
the soft tissue of the
breast to the lung
area inferior to the
breast.
 CHEST WALL
• Look for overall
thickness,
subcutaneous
emphysema,
calcification.
distinct muscle fat planes
• Look for sharp,
distinct muscle fat
planes as
illustrated on the
annotated image
(arrows).
Fat Chest Wall
 Subcutaneous
Emphysema Extrapleural Mass
(air in soft tissues)
 BONES
Lytic Lesions
• Look at each bone for the Ribs
following items:
– Overall size, shape, and contour
of each bone.
– The density or mineralization.
– Compare cortical thickness to
medullary cavity, trabecular
pattern, look for erosions,
fractures, any lytic or blastic
regions.
– At joints, are articular
relationships normal, joint
spaces narrowed, widened, any
calcification in the cartilages, air
in the joint space, abnormal fat
pads, etc. Multiple Rib Fractures
Bones on X-ray

Cervical Riib
 MEDIASTINUM
• At this time, look at the overall size
and shape of the entire
mediastinum on the frontal and
lateral view.
• Also look for obvious masses and
calcifications, double check for
tubes, electrical leads, a
pacemaker, or artificial valves.
• Check for evidence of mediastinal
shift and if present, is the entire
mediastinum shifted, or just a
section of it.
• Look at the trachea and major
bronchi for size, position, and
presence of intraluminal masses.
 Basic Chest X-Ray Abnormalities-
Mediastinum
Thoracic Aortic Aneurysm
• Mediastinum
– Widened
• Should be approximately
< 1/3 transthoracic width
(< 8cm)
• Cardiomegaly (enlarged
heart)
• Aortic Aneurysm
• Hilar mass
• Hiatal hernia
Cardiomegaly (enlarged heart)
Congestive Heart
Failure (CHF)
Pulmonary vascular
congestion and mild
cardiomegaly secondary
to CHF

The left image demonstrates

a patient with a severe
pulmonary edema as a result
of CHF. The right image is the
same patient after significant
resolution.
 Normal Hilum

HILUM
• Review hila:
– normal relationships
– size
– Look for masses or
widening

• Calcifications:
– Infections
• TB
• Histoplasmosis
• Others
Diaphragm/Abdo
men
• Level of right and left diaphragm
• Costophrenic angle
• Normal gastric air bubble
• Normal bowel gas
• Free air
• Mass
• Hiatal hernia (usually presents
as mediastinal mass)
• Rupture or herniation

Normal Gastric Bubble

 Bilateral free
Diaphragmatic Mass air under the diaphragm
Traumatic Rupture Diaphragm
 Sliding Hiatal Hernia

Can you see the air-filled

"mass" posterior to the heart?
 LUNGS and PLEURA
• Review lungs and pleura:
– compare lung sizes
– evaluate pulmonary
vascular pattern:
• compare upper to lower lobe,
• right to left,
• normal tapering to periphery
– pulmonary parenchyma
– pleural surfaces
• fissures - transverse and
oblique - if seen
• compare hemidiaphragms
• follow pleura around rib cage
 Basic Chest X-Ray Abnormalities
• Lungs/Pleura
– Too white
• Pneumonia
– Increased opacity (whiteness) usually confined to particular lobe or
segment
• Atelectasis
– Partial collapse of lobe or segment
• Pleural effusion
– Blunting of the costophrenic angles and possible air-fluid levels
• Congestive Heart Failure
– Congestion of pulmonary vasculature
– May have “Bat-wing” appearance
• Nodule/Mass
– Round, white, fluid density lesions
– May be calcified
 Pneumonia
• Consolidation
– Increased opacity
(whiteness) usually
confined to particular
lobe or segment
– In this case the Right
Upper Lobe is involved

PA film of RML pneumonia

(arrows).
Note the indistinct
borders, air bronchograms,
and silhouetting of the
right heart border.
 Silouhette Sign Lobe-Segment
• Right diaphragm • RLL/basal segment
• Right heart margin • RML/medial segment
• Ascending aorta • RUL/anterior segment
• Aortic knob • LUL/posterior segment
• Left heart margin • Lingula/inferior segment
• Descending aorta • LLL/sup. & med. segment
• LLL/basal segments
• Left diaphragm
RUL Pneumonia
RML Pneumonia
RLL Pneumonia
LUL Pneumonia
LLL Pneumonia
Round Pneumonia
 Atelectasis is collapse or
Atelectasis incomplete expansion of the
lung or part of the lung. This
is one of the most common
findings on a chest x-ray. It is
most often caused by an
endobronchial lesion, such as
mucus plug or tumor. It can
also be caused by extrinsic
compression centrally by a
mass such as lymph nodes or
peripheral compression by
pleural effusion. An unusual
type of atelectasis is
cicatricial and is secondary to
scarring, TB, or status post
radiation.
 Atelectasis

This is a PA and lateral film showing round atelectasis, where the lung becomes attached to
the chest wall by an area of previous inflammation. The lung then rolls up, causing this
opacity.
 Left Lung Upper
Lobe Atelectasis
• The left lung lacks a middle
lobe and therefore a minor
fissure, so left upper lobe
atelectasis presents a different
picture from that of the right
upper lobe collapse.
• The result is predominantly
anterior shift of the upper lobe
in left upper lobe collapse,
with loss of the left upper
cardiac border. The expanded
lower lobe will migrate to a
location both superior and
posterior to the upper lobe in
order to occupy the vacated
space.
 Left Lung Upper
Lobe Atelectasis
• PA and Lateral of a patient
with Left Upper Lobe
Collapse (arrows). This
characteristic finding on CXR
is known as the Luftsichel
Sign and may represent
collapse due to obstruction
from a bronchogenic
carcinoma.
• The lucency between the
mediastinum and the
collapsed LUL is caused by
hyperexpansion of the
superior segment of the LLL.
 Left Lower Lobe
Atelectasis
• Atelectasis of either the right
or left lower lobe presents a
similar appearance.
• Silhouetting of the
corresponding
hemidiaphragm, crowding of
vessels, and air bronchograms
are sometimes seen, and
silhouetting of descending
aorta is seen on the left.
• A substantially collapsed
lower lobe will usually show as
a triangular opacity situated
posteromedially against the
mediastinum.
 Right Upper Lobe
Atelectasis
• Right upper lobe
atelectasis is easily
detected as the lobe
migrates superomedially
toward the apex and
mediastinum.
• The minor fissure
elevates and the inferior
border of the collapsed
lobe is a well demarcated
curvilinear border arcing
from the hilum towards
the apex with inferior
concavity.
 Right Middle Lobe
Atelectasis
• Right middle lobe atelectasis may
cause minimal changes on the
frontal chest film.
• A loss of definition of the right
heart border is the key finding.
• Right middle lobe collapse is
usually more easily seen in the
lateral view.
• The horizontal and lower portion
of the major fissures start to
approximate with increasing
opacity leading to a wedge of
opacity pointing to the hilum.
• Like other cases of atelectasis,
this collapse may by confused with
right middle lobe pneumonia.
 Right Lowert Lobe
Atelectasis
• Silhouetting of the right
hemidiaphragm and a
triangular density
posteromedially are
common signs of right
lower lobe atelectasis.
• Right lower lobe
atelectasis can be
distinguished from right
middle lobe atelectasis by
the persistance of the
right heart border.
 Pleural Effusion
• Blunting of
Costophrenic angle
• In this case, right side.
• Also of note there is an
RML infiltrate
(consolidation)
 Basic Chest X-Ray Abnormalities
• Lungs/Pleura
– Too Black
• Pneumothorax
• Tension Pneumothorax
• Emphysema
• Mastectomy
 Pneumothorax
• Air between the
visceral and parietal
pleura
• Usually arising from
lung injury
 Tension Pneumothorax
• Large pneumothorax
• Absence of vascular
markings to air filled
peural space
• Causes mediastinal shift
away from affected side
• Increased haziness due
to atelectasis to
contralateral side
 Emphysema
• Darkened lung fields due to
Increased air secondary to
chronic obstruction
• Heart size may be
decreased due to lung
hyperinflation
– Tube heart
• Diaphragm may be
flattened due to
hyperinflation
• Note overly inflated lungs in
this female patient
Emphysema
 Mastectomy
• Absence of breast
shadow causes
relatively increased
darkness to right lung
field
• Although right side is
darker, lung markings
extend across entire
side
Tumor