CXR Simple by DrRaghu Ram

11
ChestChest
RadiographyRadiography
InterpretationInterpretation
Dr. Raghu RamDr. Raghu Ram
UppalapatiUppalapati

Lung AnatomyLung Anatomy
 TracheaTrachea
 CarinaCarina
 Right and LeftRight and Left
Pulmonary BronchiPulmonary Bronchi
 Secondary BronchiSecondary Bronchi
 Tertiary BronchiTertiary Bronchi
 BronchiolesBronchioles
 Alveolar DuctAlveolar Duct
 AlveoliAlveoli

Lung AnatomyLung Anatomy
 Right LungRight Lung
 Superior lobeSuperior lobe
 Middle lobeMiddle lobe
 Inferior lobeInferior lobe
 Left LungLeft Lung
 Superior lobeSuperior lobe
 Inferior lobeInferior lobe

Lung Anatomy on Chest X-rayLung Anatomy on Chest X-ray
 PA View:PA View:
 Extensive overlapExtensive overlap
 Lower lobes extendLower lobes extend
highhigh
 Lateral View:Lateral View:
 Extent of lower lobesExtent of lower lobes

 The right upper lobe (RUL) occupies the upper 1/3 of the rightThe right upper lobe (RUL) occupies the upper 1/3 of the right
lung.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 rightAnteriorly, the RUL extends inferiorly as far as the 4th right
anterior ribanterior rib

 The right middle lobe is typically the smallest of the three, andThe right middle lobe is typically the smallest of the three, and
appears triangular in shape, being narrowest near the hilumappears triangular in shape, being narrowest near the hilum

 The right lower lobe is the largest of all three lobes, separated from theThe right lower lobe is the largest of all three lobes, separated from the
others by the major fissure.others by the major fissure.
 Posteriorly, the RLL extend as far superiorly as the 6th thoracicPosteriorly, the RLL extend as far superiorly as the 6th thoracic
vertebral body, and extends inferiorly to the diaphragm.vertebral body, and extends inferiorly to the diaphragm.
 Review of the lateral plain film surprisingly shows the superior extent ofReview of the lateral plain film surprisingly shows the superior extent of
the RLL.the RLL.

 These lobes can be separated fromThese lobes can be separated from
one another by two fissures.one another by two fissures.
 The minor fissure separates theThe minor fissure separates the
RUL from the RML, and thusRUL from the RML, and thus
represents the visceral pleuralrepresents the visceral pleural
surfaces of both of these lobes.surfaces of both of these lobes.
 Oriented obliquely, the majorOriented obliquely, the major
fissure extends posteriorly andfissure extends posteriorly and
superiorly approximately to thesuperiorly approximately to the
level of the fourth vertebral body.level of the fourth vertebral body.

 The lobar architecture of the left lung is slightly differentThe lobar architecture of the left lung is slightly different
than the right.than the right.
 Because there is no defined left minor fissure, there areBecause there is no defined left minor fissure, there are
only two lobes on the left; the left upperonly two lobes on the left; the left upper

Lt Lower LobesLt Lower Lobes
 Left lower lobesLeft lower lobes

 These two lobes areThese two lobes are
separated by a majorseparated by a major
fissure, identical to thatfissure, identical to that
seen on the right side,seen on the right side,
although often slightlyalthough often slightly
more inferior in location.more inferior in location.
 The portion of the leftThe portion of the left
lung that correspondslung that corresponds
anatomically to the rightanatomically to the right
middle lobe ismiddle lobe is
incorporated into the leftincorporated into the left
upper lobe.upper lobe.

RUL (Right Upper Lung)RUL (Right Upper Lung)

RML (Right Middle Lung)RML (Right Middle Lung)

RLL (Right Lower Lung)RLL (Right Lower Lung)

LUL (Left Upper Lung)LUL (Left Upper Lung)

LLL (Left Lower Lung)LLL (Left Lower Lung)

Left Side FissureLeft Side Fissure
LUL
LLL

 A structure is rendered visible on aA structure is rendered visible on a
radiograph by the juxtaposition of tworadiograph by the juxtaposition of two
different densitiesdifferent densities
Chest Radiography: Basic PrinciplesChest Radiography: Basic Principles

Silhouette SignSilhouette Sign
 Loss of the expected interface normallyLoss of the expected interface normally
created by juxtaposition of two structurescreated by juxtaposition of two structures
of different densityof different density
 No boundary can be seen between twoNo boundary can be seen between two
structures of similar densitystructures of similar density

Right Lower Lobe PneumoniaRight Lower Lobe Pneumonia

Differential X-Ray AbsorptionDifferential X-Ray Absorption
 The absence of a normal interface mayThe absence of a normal interface may
indicate disease;indicate disease;
 The presence of an unexpectedThe presence of an unexpected
interface may also indicate diseaseinterface may also indicate disease
 The presence of interfaces can be usedThe presence of interfaces can be used
to localize abnormalitiesto localize abnormalities

Chest RadiographicChest Radiographic
Patterns of DiseasePatterns of Disease
 Air space opacityAir space opacity
 Interstitial opacityInterstitial opacity
 Nodules and massesNodules and masses
 LymphadenopathyLymphadenopathy
 Cysts and cavitiesCysts and cavities
 Lung volumesLung volumes
 Pleural diseasesPleural diseases

Air Space OpacityAir Space Opacity
 Components:Components:
air bronchogram: air-filled bronchusair bronchogram: air-filled bronchus
surrounded by airless lungsurrounded by airless lung
confluent opacity extending to pleuralconfluent opacity extending to pleural
surfacessurfaces
segmental distributionsegmental distribution

Air Space Opacity: DDXAir Space Opacity: DDX
 Blood (hemorrhage)Blood (hemorrhage)
 Pus (pneumonia)Pus (pneumonia)
 Water (edema)Water (edema)
hydrostatic or non-cardiogenichydrostatic or non-cardiogenic
 Cells (tumor)Cells (tumor)
 Protein/fat: alveolar proteinosis andProtein/fat: alveolar proteinosis and
lipoid pneumonialipoid pneumonia

Interstitial Opacity: Small NodulesInterstitial Opacity: Small Nodules

Interstitial Opacity:Interstitial Opacity:
LinesLines

Interstitial Opacity: Lines & ReticulationInterstitial Opacity: Lines & Reticulation

Interstitial OpacityInterstitial Opacity
 Hallmarks:Hallmarks:
small, well-defined nodulessmall, well-defined nodules
lineslines
 interlobular septal thickeninginterlobular septal thickening
 fibrosisfibrosis
reticulationreticulation

Interstitial Opacity: DDXInterstitial Opacity: DDX
 Idiopathic interstitial pneumoniasIdiopathic interstitial pneumonias
 Infections (TB, viruses)Infections (TB, viruses)
 EdemaEdema
 HemorrhageHemorrhage
 Non–infectious inflammatory lesionsNon–infectious inflammatory lesions
sarcoidosissarcoidosis
 TumorTumor

Nodules and MassesNodules and Masses
 Nodule: any pulmonary lesion represented inNodule: any pulmonary lesion represented in
a radiograph by a sharply defined, discrete,a radiograph by a sharply defined, discrete,
nearly circular opacity 2-30 mm in diameternearly circular opacity 2-30 mm in diameter
 Mass:Mass: larger than 3 cmlarger than 3 cm

Nodules and MassesNodules and Masses
 Qualifiers:Qualifiers:
single or multiplesingle or multiple
sizesize
border definitionborder definition
presence or absence of calcificationpresence or absence of calcification
locationlocation

MassMass
CalcificationCalcification
Well-DefinedWell-Defined
Ill-DefinedIll-Defined

LymphadenopathyLymphadenopathy
 Non-specific presentations:Non-specific presentations:
mediastinal wideningmediastinal widening
hilar prominencehilar prominence
 Specific patterns:Specific patterns:
particular station enlargementparticular station enlargement

Right ParatrachealRight Paratracheal
LymphadenopathyLymphadenopathy

Right Hilar LANRight Hilar LAN

Subcarinal LANSubcarinal LAN
*

Cysts & CavitiesCysts & Cavities
 CystCyst: abnormal pulmonary parenchymal: abnormal pulmonary parenchymal
space, not containing lung but filled with airspace, not containing lung but filled with air
and/or fluid, congenital or acquired, with aand/or fluid, congenital or acquired, with a
wall thickness greater than 1 mmwall thickness greater than 1 mm
 epithelial lining often presentepithelial lining often present

CavityCavity: Abnormal pulmonary: Abnormal pulmonary
parenchymal space, not containing lung butparenchymal space, not containing lung but
filled with air and/or fluid, caused by tissuefilled with air and/or fluid, caused by tissue
necrosis, with a definitive wall greater thannecrosis, with a definitive wall greater than
1 mm in thickness and comprised of1 mm in thickness and comprised of
inflammatory and/or neoplastic elementsinflammatory and/or neoplastic elements

 Characterize:Characterize:
wall thickness at thickest portionwall thickness at thickest portion
inner lininginner lining
presence/absence of air/fluid levelpresence/absence of air/fluid level
number and locationnumber and location

Benign Lung Cyst :Benign Lung Cyst : PCPPCP PneumatocelePneumatocele
• Uniform wall thicknessUniform wall thickness
• 1 mm1 mm
• Smooth inner liningSmooth inner lining

Benign Cavities :Benign Cavities :
CryptococcusCryptococcus
• max wall thicknessmax wall thickness ≤≤4 mm4 mm
• minimally irregular inner liningminimally irregular inner lining

Indeterminate CavitiesIndeterminate Cavities
• max wall thickness 5-15 mmmax wall thickness 5-15 mm
• mildly irregular inner liningmildly irregular inner lining

Malignant Cavities: Squamous Cell CaMalignant Cavities: Squamous Cell Ca
• max wall thicknessmax wall thickness ≥≥16 mm16 mm
• Irregular inner liningIrregular inner lining

Pleural Disease: Basic PatternsPleural Disease: Basic Patterns
 EffusionEffusion
angle blunting to massiveangle blunting to massive
mobilitymobility
 ThickeningThickening
 distortion, no mobilitydistortion, no mobility
 MassMass
 AirAir
 CalcificationCalcification

Pleural EffusionPleural Effusion

Pleural CalcificationPleural Calcification

SOME INTERESTINGSOME INTERESTING
X-RAYS & DISCUSSIO NX-RAYS & DISCUSSIO N

Chest breast implantsChest breast implants

 widewide
mediastinummediastinum
 obliteration ofobliteration of
aortic knobaortic knob
 Rt mainstemRt mainstem
shift up andshift up and
rightright
 NG deviateNG deviate
to rightto right
 pleural cappleural cap
Major Vessel Injury
Potential X ray
findings

Expiration reduces lung volume,Expiration reduces lung volume,
making a small pneumo easier to seemaking a small pneumo easier to see

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.

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

LUL Atelectasis: Loss of heart borders/silhouetting.
Notice over inflation on unaffected lung

Right Middle and Left Upper Lobe Pneumonia

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.

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

24 hours after diuretic therapy

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.

CXR Simple by DrRaghu Ram

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