1. Introduction to Chest Radiology Dr. Ruba Khasawneh

2. Imaging Methods CXR-Will be discussed later Computed Tomography MRI
Ultrasound
Nuclear Medicine

3. Computed Tomography
Numerous protocols/techniques depending on clinical history
Types;
Helical/spiral; conventional
high resolution, used without contrast to investigate interstitial lung diseases.
CTA (CT angiography), the initial test of choice to diagnose PE.
Axial CT, old type, not used any more.
CT images used in chest are typically with contrast
Contrast risks
Renal failure, KFT should be performed before introducing the contrast
Allergy

4. Computed Tomography Role of CT
Main further investigation for most CXR abnormality (e.g nodule/mass) or to exclude disease with normal CXR
Main investigation for PE, dissection, trauma

5. MRI Multiple planes No ionized radiation Common Indication
Pancoast tumour, so you have to ask for MRI if you noticed an apical mass in the lung in CXR.
Brachial plexus tumors/injury
Cardiac (dynamic and anatomic study)
MRA
Usually targeted examination (unlike CT)
Coronal

6. Ultrasound Limited use in thorax (non cardiac) due to air in lungs
Assess pleural effusions.
Mainly used for procedures, , may be used as guidance for types of catheters that drain empyemas

7. Nuclear Medicine Variety of tests: functional rather than anatomic
V/Q specific to chest imaging, this method is more sensitive than CTPA (CT pulmonary angio) in detecting PE.
Others: bone scan, gallium, WBC etc.

8. Chest x-ray, contents Technique Routine:
PA vs. AP, AP is used in pediatric age group and unstable patients.
lateral CXR
The combination of these two views allows us to determine the site of pathology
Lateral decubitus film; When we say right lateral decubitus film, the right side is the dependant side of the patient.
Used to assess pleural effusion. If you suspect pleural effusion on the right side, then you have to take right lateral decubitus film.
Used to assess pneumothorax. If you suspect pneumothorax on the right side, then you have to take left lateral decubitus film.
lordotic view, used to assess pancoast tumors and right middle lung lobe collapse.
Determine technically adequate film ( inspiration, penetration and rotation)
Anatomy
Interpretation

9. Chest x-ray positioning - PA -
This position of the arm in order to displace the scapulae away from the lung field.
The image is taken on full inspiration

10. Chest x-ray positioning -lateral-
In lateral X-ray, the left side of the patient is the one that faces the film

11. Chest x-ray - AP -

12. Chest x-ray PA AP

13. CXR –lateral decubitus
This is a right lateral decubitus X-ray, as the right side of the patient is the dependent side when taking the image

14. Better assess apices without bone overlap
Lordotic View
Better assess apices without bone overlap
This view is used to assess pancoast tumors and right middle lung lobe collapse

15. 4 Basic Radiographic Densities
Radiographic Density
4 Basic Radiographic Densities
Bone ( white)
Soft tissue/ water
Fat
Air ( black)
barium
sulfate
lead
bone
muscle
liver (eg)
fat
air
X-ray film

16. Approach to Chest Radiograph: Technical Factors
Patient identification (name and date)
Markers (left, right). The photographic plates should be labeled for right and left before taking the image. If the plate is labeled after taking the image depending on heart apex or something else, then cases as dextrocardia may be missed.

17. Approach to Chest Radiograph: Technical Factors
3. Rotation; Assessed by measuring the distance from the spinous processes to the clavicles on both sides, the distance should be equal.

18. Counting posterior ribs
Clavicles
isnpexp
Spinous Process
Vertebral Body
Visible 6 7
Counting anterior
ribs 10 11
Counting posterior ribs

19. Approach to Chest Radiograph: Technical Factors
4. Penetration
In PA image, A good penetration means that you can count three visible thoracic vertebrae in the retrocardiac region. In both over and under penetrated CXR, it is difficult to count three vertebrae in retrocardiac region.
In lateral x-ray.
The spine darkens (increased radioluscency) as we go caudally
sternum should be seen edge on
Two sets of ribs posteriorly (the wider and more dorsal set represents the right ribs)

20. Underpenetrated
Over penetrated

21. CXR -penetration
The spine darkens (increased radioluscency) as we go caudally
sternum should be seen edge on
Two sets of ribs posteriorly (the wider and more dorsal set represents the right ribs)

22. Approach to Chest Radiograph: Technical Factors
5. Inspiration vs expiration
The normal X-ray is an inspiratory film.
normal inspiratory film shows 6 anterior ribs or 10 – 11 posterior ribs. The posterior ribs are the horizontal ones and they appear more clear than the anterior ones in PA.
Expiration
Heart size appears larger
Mediastinum is wider
Pulmonary vasculature indistinct

23. 4th Anterior
8th Posterior
Expiration Image

24. Inspiration: Same Patient
Expiration

25. Normal Anatomy

26. Bone-CT Reconstruction
PA View
Clavicle
Rib
Intercostal Space
Vertebral Column

27. Bone Anatomy
Sternum, edge on

28. Heart Size, PA view
The maximal horizontal diameter represents the farthest point in the right side from midline + the farthest point in the left side. “not necessarily both points to be at the same level” .
Normal is <50% on PA upright, full inspiration radiograph.

29. Heart size, Lateral view
As the heart enlarges, the posterior border of the heart may extend to, or overlap, the anterior border of the thoracic spine.

30. Cardiovascular: Heart
Axial CT Image R L
Right
Ventricle
Right atrium forms alone the right heart border
Right
Atrium
Right ventricle forms
Anterior heart border. It is the most anterior chamber of the heart

31. Cardiovascular: Heart
Axial CT Image R L
Left atrium forms Part of lateral and posterior
heart border
Left
Ventricle
Left
Atrium
Left ventricle forms
Left and posterior
heart border

32. Cardiac Anatomy: Right Sided Chambers

33. Cardiac Anatomy: Left Sided Chambers

35. isnpexp Vascular anatomy on CXR
SVC
Aortic Arch
Right Descending
Pulmonary Artery
Left Descending
Pulmonary Atery
Left descending pulmonary artery
Left hemidiaphragm is lower than the right because of the heart position. In isolated dextrocrdia, the right hemidiaphragm is lower than the left one.

36. On the right side of chest x-ray we can see the following structures: (from superior to inferior); Superior vena cava, ascending aorta, and right atrium.
On the left side we can see: aortic arch, pulmonary vessels, and the left ventricle
Between the left-sided structures we can see two concavities: - aortopulmonary window 2- the region of the left atrial appendage

37. inspexp
Retrosternal
Airspace
Scapula
IVC
Pulmonary
Vessels
Hilum
Lungs posteriorly should get darker as you go down more inferiorly
except in the case of effusion, Mediastinal mass.. Etc
Normally you can’t see more than two fingers size of the left ventricle behind the inferior vena cava except in the case of left ventricular enlargement.

38. Airway Anatomy Trachea Carina Bronchus Cartilage
Membranous posteriorly
Carina
Bifurcation
Bronchus
Left and right, the right one is wider and more straight
Lobar (RUL,RML,LUL,LLL)
Segmental (8 left, 10 right)

39. Trachea
R + L Main
Bronchi
Carina

40. Lung Anatomy Lobes are separated by fissures Right Left Upper Lobe
Middle Lobe
Lower Lobe
upper and middle lobes are separated by the transverse fissure (minor fissure). Upper and lower lobes are separated by oblique fissure (major
Left
Upper Lobe (includes lingula)

41. Lung lobes, anterior view

42. Lung lobes, lateral view

43. L

48. Lung fissures B represents the oblique fissure
A represents the horizontal fissure

49. Lung-Fissures

50. CT- fissure

51. Pleura
Pleura
Lubricates and prevents friction during respiration
Potential Space that contains about 10 cc of serous fluid – Don’t see unless abnormal (effusion, chylothorax, empyema, hemothorax)
Parietal pleura: Lines chest wall, mediastinal and diaphragmatic surfaces
Visceral pleura: Lines lungs, fissures

52. Parietal Pleura
Visceral pleura

53. normaldiag

54. Left diaphragm : left is lower because of the heart position
Right diaphragm
Right costophrenic angle
Left diaphragm
Left costophrenic angle

58. How to read CXR? Optimize room lights, view images in order
Patient data ( name, age, sex, old films), Right and left
Technique; rotation, penetration, inspiration
Trachea: position , caliber or mass
Lungs: abnormal lucency or opacity
Pulmonary vessels
Hilar or mediastinal LAP
Heart
Mediastinal contour : width, mass
Pleura : effusion , pneumothorax, thickening, calcifications
Soft tissues , bones, upper abdomen
*** In ICU films identify the position of the tubes first

59. Chest CT scan: Mediastinal window
Mediastinal window is better to show;
- Vessels
- Mediastinal masses
- Pleural effusion
Chest CT scan: Mediastinal window

60. Chest CT scan: Lung window
Lung window is better to show;
Mets
Cavitations
Airways
Pneumothorax
Interstitial lung diseases, high resolution CT
Chest CT scan: Lung window

61. The doctor tracked the structures in all the following CT images, so track them 
Esophagus, more to the left side.
On the right side, the brachiocephalic trunk gives rise to subclavian and common carotid
Trachea anterior to esophagus

63. Appears at a higher level than RPA

68. Azygous vein is located to the right side of esophagus, while the hemiazygous is located to the left side.

70. Thank you