Chest Film Primer Images and Material courtesy of: David S. Feigin, M.D. Colonel (Ret), USA, MC Professor of Radiology, Uniformed Services University of the Health Sciences “A Systematic Approach To Abnormal Chest Images: Radiographs And Computed Tomograms” Updates and compilation: Les Folio, DO, MPH Col, USAF, MC, SFS Associate Professor of Radiology,

Main Menu NORMAL ANATOMY A-P Chest Radiograph Lateral Chest Radiograph EXIT Main Menu NORMAL ANATOMY A-P Chest Radiograph Lateral Chest Radiograph 5 PATTERNS OF PATHOLOGY Mass Consolidative Interstitial Linear Nodular Vascular Airway Wall-Thickened Obstructive THE SEARCH PATTERN A-P Chest Radiograph Lateral Chest Radiograph

Normal Anatomy- AP  BACK MAIN MENU FORWARD  Cardiovascular System 1. Gross Specimen 2. The Respiratory System A. The Airway B. The Lungs and Diaphragm Cardiovascular System A. The Cavals B. The Heart SVC Edge Left paratracheal stripe C. The Pulmonary Arteries LUL D. The Pulmonary Veins RUL, next to minor fissure E. Aorta 3. The Bones, Bowel Gas, Azygous, etc. Right Atrium Left Ventricle RML, next to right heart border RLL LLL

Normal Anatomy- Lateral  BACK MAIN MENU FORWARD  Normal Anatomy- Lateral 1. Respiratory System A. The Airway B. The Lungs and Diaphragm RUL Trachea 2. Cardiovascular System Aorta A. The Vessels B. The Heart Right Pulmonary Artery Left Pulmonary Artery Left main bronchus RML, with minor fissure 3. The Bones (no link yet) Right Ventricle RLL, with major fissure Left Ventricle Inferior Vena Cava

Quiz yourself: Mediastinum Lines, Edges Recommendation: Test yourself before advancing to the answers 3 1 SVC Edge Rt Paratracheal Line Lt Paratracheal Stripe (both red and black lines) Aortic Arch Descending Aorta (only left edge seen, and not always) Rt Atrium Azygoesophageal edge Lt Ventricle Main Pulmonary Artery AKA: trunk, middle mogul 2 4 9 5 6 7 8 Mediastinum Mid

Right Pulmonary Artery (red) Trachea Lt MSB on end Right Pulmonary Artery (red) Left Pulmonary Artery (green) Left Ventricle (curved line) IVC can be seen as an edge because we only see the posterior edge of the IVC (arrows). IVC (arrows) Lateral

Main Menu NORMAL ANATOMY A-P Chest Radiograph Mass EXIT Main Menu NORMAL ANATOMY A-P Chest Radiograph Lateral Chest Radiograph The 5 PATTERNS OF PATHOLOGY Mass Consolidative Interstitial Linear Nodular Vascular Airway Wall-Thickened Obstructive THE SEARCH PATTERN A-P Chest Radiograph Lateral Chest Radiograph

Search Pattern- AP  BACK MAIN MENU FORWARD  PRELIMINARIES FRONTAL Verify patient info, date, L and R markers Note technique deficiencies Quick look at both films for obvious abnormalities FRONTAL 1. LUNGS Up and down Side to side Volume and Symmetry 2. PERIPHERY Pneumothorax (air) Effusions (fluid) 3. MEDIASTINUM Contours Edges Shape 4. TRACHEA AND MAIN BRONCHI 5. HILA Enlargement Abnormal bulges 6. PERIPHERY OF CHEST Neck Chest wall and bones Diaphragms Upper abdomen

Search Pattern- Lateral  BACK MAIN MENU FORWARD  Search Pattern- Lateral PRELIMINARIES Verify patient info, date, L and R markers Note technique deficiencies Quick look at both films for obvious abnormalities LATERAL 1. SIZE AND SHAPE OF LUNGS AND DIAPHRAGMS 2. AIRWAY Neck to Hilum Pulmonary Arteries 3. Back of heart and darkening downward 4. Up anterior mediastinum for darkening 5. Down spine for vertebral bodies and darkening 6. PERIPHERY Abdomen Anterior chest wall Posterior ribs Costophrenic angles

Main Menu NORMAL ANATOMY A-P Chest Radiograph Lateral Chest Radiograph EXIT Main Menu NORMAL ANATOMY A-P Chest Radiograph Lateral Chest Radiograph 5 PATTERNS OF PATHOLOGY Mass Consolidative Interstitial Linear Nodular Vascular Airway Wall-Thickened Obstructive THE SEARCH PATTERN A-P Chest Radiograph Lateral Chest Radiograph

1. Mass Mechanism - Local destruction of lung parenchyma  BACK MAIN MENU FORWARD  1. Mass Mechanism - Local destruction of lung parenchyma Radiological sign - Any localized opacity not completely bordered by fissures or pleura

1. Mass Differential Diagnosis  BACK MAIN MENU FORWARD  1. Mass Differential Diagnosis Malignancy - Primary or secondary Granulomatous disease - Infectious or noninfectious, active or inactive Other inflammation, including pneumonia and abscess, Benign neoplasm, Congenital abnormality Crucial appearance characteristics for inactivity Calcification – central, lamellar Evolution – 2-year stability or regression

2. Consolidative (Alveolar) Pattern  BACK MAIN MENU FORWARD  2. Consolidative (Alveolar) Pattern Mechanism Produced in pure form and by ALVEOLAR FILLING May be mimicked by alveolar collapse, as in airway obstruction Rarely, confluent interstitial thickening Radiological signs Fluffy, cloud-like, coalescent opacities Sharp edges when limited by fissures or pleura Complete air bronchograms through the clouds

Fluffy and cloud-like appearance Air bronchograms THROUGH clouds  BACK MAIN MENU FORWARD  Fluffy and cloud-like appearance Air bronchograms THROUGH clouds

Consolidated lung, with air in bronchioles  BACK MAIN MENU FORWARD  Air bronchogram Normal lung Consolidated lung, with air in bronchioles

2. Consolidative (alveolar) Pattern  BACK MAIN MENU FORWARD  2. Consolidative (alveolar) Pattern Differential Diagnosis (5 general) Hemorrhage - BLOOD - embolism, trauma Exudate - PUS - pneumonia, pneumonitis Transudate - WATER - congestion, ARDS Secretions - PROTEIN - Mucous plugging, Alveolar proteinosis Malignancy - CELLS - Alveolar cell carcinoma, Lymphoma

3. Interstitial Pattern Composition of pulmonary interstitium:  BACK MAIN MENU FORWARD  3. Interstitial Pattern Composition of pulmonary interstitium: Alveolar walls, septi Connective tissue surrounding bronchi and vessels (peribronchial and perivascular spaces) Mechanism Thickening of lung interstices Architectural destruction of interstitium (honeycomb or “end stage” lung)

3. Interstitial Pattern Radiological Signs:  BACK MAIN MENU FORWARD  3. Interstitial Pattern Radiological Signs: Linear form - reticulations (lines in all directions), septal lines (Kerley lines) Nodular form - small, sharp, numerous, evenly distributed, uniform (especially uniform in shape) nodules Destructive form - peripheral, irregular cyst formation

3. Interstitial Pattern Radiological Signs:  BACK MAIN MENU FORWARD  3. Interstitial Pattern Radiological Signs: Linear form - reticulations (lines in all directions), septal lines (Kerley lines) Nodular form - small, sharp, numerous, evenly distributed, uniform (especially uniform in shape) nodules Destructive form - peripheral, irregular cyst formation

Kerley B lines (horizontal septal)  BACK MAIN MENU FORWARD  Kerley B lines (horizontal septal) Reticular form (Lines in all directions)

3. Interstitial Pattern – Linear Form  BACK MAIN MENU FORWARD  3. Interstitial Pattern – Linear Form Differential Diagnosis: The “LIFE Lines” Lymphangitic spread of malignancy Inflammation Fibrosis Edema

3. Interstitial Pattern Radiological Signs:  BACK MAIN MENU FORWARD  3. Interstitial Pattern Radiological Signs: Linear form - reticulations (lines in all directions), septal lines (Kerley lines) Nodular form - small, sharp, numerous, evenly distributed, uniform (especially uniform in shape) nodules Destructive form - peripheral, irregular cyst formation

Multiple small nodules, uniform in shape and distribution  BACK MAIN MENU FORWARD  Multiple small nodules, uniform in shape and distribution

3. Interstitial Pattern- Nodular Form  BACK MAIN MENU FORWARD  3. Interstitial Pattern- Nodular Form Granulomatous Diseases: Infectious Tuberculosis Atypical mycobacterial diseases - especially MAI Fungal diseases, especially: Histoplasmosis Coccidioidomycosis Blastomycosis (N. A. and S. A.) Cryptococcosis Sporotrichosis Bacterial diseases, especially: Nocardiosis Actinomycosis Non-infectious Sarcoidosis Hypersensitivity Pneumonitis (HP) Vasculitis-granulomatosis diseases Wegener’s Lymphocytic Bronchocentric Allergic (Churg-Strauss) Langerhans Granulomatosis (eosinophilic granuloma, histiocytosis) (LCG) Differential Diagnosis Pneumoconiousus Granulomatous Silicosis Berylliosis “Benign” Coal Worker’s Pneumoconiosis Siderosis Stannosis 1. Granulomas 2. Hematogenous Spread of Malignancy 3. Pneumoconiosus

3. Interstitial Pattern Radiological Signs:  BACK MAIN MENU FORWARD  3. Interstitial Pattern Radiological Signs: Linear form - reticulations (lines in all directions), septal lines (Kerley lines) Nodular form - small, sharp, numerous, evenly distributed, uniform (especially uniform in shape) nodules Destructive form - peripheral, irregular cyst formation

Peripheral cyst formation, ‘Honeycomb’ lung  BACK MAIN MENU FORWARD  Early findings are non-specific. The peripheral cyst formation (“End-Stage Lung”) is a late finding. Peripheral cyst formation, ‘Honeycomb’ lung

 BACK MAIN MENU FORWARD  4. Vascular Patterns Mechanism - increased, or decreased perfusion, altering diameter of pulmonary vessels Radiological signs - changes in diameter of specific vessels

4. Vascular Patterns Common examples  BACK MAIN MENU FORWARD  4. Vascular Patterns Common examples Congestion - engorged veins, especially upper lungs Emphysema - diminished vessels Shunt vascularity - all vessels enlarged Lymphangitic carcinoma - irregular infiltration around vessels may resemble vessel enlargement Arterial hypertension - large central arteries with peripheral tapering Thromboembolism - locally diminished vessels with possible vessel mass centrally located Bronchial circulation - irregular vessels in unusual directions

Engorged vessels, especially upper lungs  BACK MAIN MENU FORWARD  Engorged vessels, especially upper lungs Congested vasculature

Diminished vasculature  BACK MAIN MENU FORWARD  Diminished vasculature Emphysematous changes

Enlarged pulmonary trunk (“middle mogul”)  BACK MAIN MENU FORWARD  Enlarged pulmonary trunk (“middle mogul”) Prominent left pulmonary artery

5. Airway (Bronchial) Patterns  BACK MAIN MENU FORWARD  5. Airway (Bronchial) Patterns Mechanism Complete or partial obstruction of airways Thickening of airway walls Forms Complete airway obstruction - opacity and decreased volume Partial obstruction - lucency and increased volume Wall thickening - tram tracks, central cystic spaces or circles

Bronchial wall thickening (circles and “tram tracks”)  BACK MAIN MENU FORWARD  Bronchial wall thickening (circles and “tram tracks”) Flattened diaphragms on lateral

5. Airway (Bronchial) Patterns  BACK MAIN MENU FORWARD  5. Airway (Bronchial) Patterns Differential diagnosis Opacities - endobronchial malignancies, granulomas, inflammatory, benign or congenital masses, mucous plugs, foreign bodies Lucencies - COPD, cysts, blebs, pneumatoceles Thickening - bronchiectasis, chronic bronchitis

5. Airway (Bronchial) Patterns  BACK MAIN MENU FORWARD 5. Airway (Bronchial) Patterns Lobar atelectasis (collapse) Primary Signs Vessel number assymetry Fissure as edge Secondary signs Volume loss Elevation of diaphragm Shift of mediastinum and ribs

Atelectasis Patterns Right Left Upper RUL LUL Lower LLL RLL ATELECTASIS:    Definition: Literally means incomplete expansion or loss of volume     4 Main Types of Mechanism:        1. Resorptive/Obstructive: This is caused by a complete bronchial obstruction. If there is no flow then air becomes absorbed from the lung. Oxygen gets absorbed much more rapidly than ambient air. (e.g. Ventilator patient on 100% Oxygen will collapse within minutes to hours)        2. Passive/Compressive: Extrinsic pressure from air, fluid or mass (tumors, bullae, or abscesses). A large pleural fluid collection or pneumothorax could produce virtual complete collapse of lobe.               3. Cicatricial: Areas of pulmonary fibrosis can cause reduced alveolar volume. It can be focal or diffuse. When focal it typically is associated with old granulomatous infection, typically TB. However, it may be diffuse, as seen typically in idiopathic pulmonary fibrosis.       4. Adhesive: This type occurs in association with surfactant deficiency and subsequent microatelectasis. Type II pneumocytes can be injured from inhaled anesthetic agents, ischemia or radiation. Therefore causes include general anesthesia, adult respiratory distress syndrome, hyaline membrane disease and acute radiation pneumonits.        Signs of Atelectasis:       1. Direct Signs: Displacement of interlobar fissures.       2. Indirect Signs: Opacification, mediastinal shift (ipsilateral), hilar displacement, elevation of hemidiaphragm, crowded vasculature, compensatory hyperinflation of unaffected lung, "shifting" granuloma sign and justaphrenic peak.    Lobar Patterns:       1. Lower Lobes: This pattern is similar on both sides. Collapse is in posterior, medial and inferior direction. The major fissure swings downward and backward. The hilum is displaced inferiorly, the hemidiaphragm is elevated. On the PA view there is a triangular opacity adjacent to the spine with the base on the hemidiaphragm. On lateral view there is increased opacity over the lower thoracic vertebrae with or without a smooth anterior margin, depending upon if the major fissure is tangential to the x-ray beam. The posterior aspect of the hemidiaphragm is obscured, unless the patient has an incomplete pulmonary ligament. Another indirect sign is the vascular nodular sign, which is result of compensatory hyperinflation of the upper lobe. This is radiographically seen as "hair-pin" turning of vessels and "too-many nodules" along the cardiac margin, which are end-on vessels. Kattan's triangle sign may also be seen, which is the shifted v-shaped opacity superior to the anterior junction line.             2. Right Upper Lobe: Collapse is superior and medially and creates a wedge shape opacity in the right upper paramediastinal area on frontal projection. The major fissure is displaced anteriorly and the minor fissure superiorly. There may be a triangular opacity with apex pointing towards hilum on lateral view. There is tracheal deviation to the right and superior displacement of the hilum. The right hemidiaphragm may be elevated. If there is a large central obstructing mass causing the atelectasis you may have a convex buldge into the central medial portion of the displaced minor fissure. This will give a "Reverse S-sign of Golden". There may be focal diaphragmatic tenting (juxtaphrenic peak sign) which is most commonly traction on the inferior accessary fissure.       3. Left Upper Lobe: Due to lack of a left minor fissure the appearance of LUL collapse is much different than RUL, except when an accessary left minor fissure is present, then the upper division of the LUL atelectasis will look like RUL atelectasis. The left major fissure is displaced anteriorly, roughly parallel to the anterior chest wall and there is a band of opacity anterior to the major fissure. On PA view there is a hazy opacity which silhouettes the left heart border. The apex of the left hemithorax may be lucent because of hyperinflation of the superior segment of ... Lower LLL RLL

Left lower lung collapse  BACK MAIN MENU EXIT  Vessel Asymmetry Left lower lung collapse