1. 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,

2. 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

3. 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

4. Normal Anatomy- Lateral
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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

5. 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

6. 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

7. 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

8. 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

9. Search Pattern- Lateral
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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

10. 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

11. 1. Mass Mechanism - Local destruction of lung parenchyma
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1. Mass
Mechanism - Local destruction of lung parenchyma
Radiological sign - Any localized opacity not completely bordered by fissures or pleura

12. 1. Mass Differential Diagnosis
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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

13. 2. Consolidative (Alveolar) Pattern
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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

14. Fluffy and cloud-like appearance Air bronchograms THROUGH clouds
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Fluffy and cloud-like appearance
Air bronchograms THROUGH clouds

15. Consolidated lung, with air in bronchioles
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Air bronchogram
Normal lung
Consolidated lung, with air in bronchioles

16. 2. Consolidative (alveolar) Pattern
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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

17. 3. Interstitial Pattern Composition of pulmonary interstitium:
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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)

18. 3. Interstitial Pattern Radiological Signs:
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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

19. 3. Interstitial Pattern Radiological Signs:
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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

20. Kerley B lines (horizontal septal)
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Kerley B lines (horizontal septal)
Reticular form (Lines in all directions)

21. 3. Interstitial Pattern – Linear Form
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3. Interstitial Pattern – Linear Form
Differential Diagnosis: The “LIFE Lines”
Lymphangitic spread of malignancy
Inflammation
Fibrosis
Edema

22. 3. Interstitial Pattern Radiological Signs:
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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

23. Multiple small nodules, uniform in shape and distribution
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Multiple small nodules, uniform in shape and distribution

24. 3. Interstitial Pattern- Nodular Form
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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

25. 3. Interstitial Pattern Radiological Signs:
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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

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

27.  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

28. 4. Vascular Patterns Common examples
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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

29. Engorged vessels, especially upper lungs
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Engorged vessels, especially upper lungs
Congested vasculature

30. Diminished vasculature
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Diminished vasculature
Emphysematous changes

31. Enlarged pulmonary trunk (“middle mogul”)
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Enlarged pulmonary trunk (“middle mogul”)
Prominent left pulmonary artery

32. 5. Airway (Bronchial) Patterns
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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

33. Bronchial wall thickening (circles and “tram tracks”)
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Bronchial wall thickening (circles and “tram tracks”)
Flattened diaphragms on lateral

34. 5. Airway (Bronchial) Patterns
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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

35. 5. Airway (Bronchial) Patterns
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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

36. 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

37. Left lower lung collapse
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Vessel Asymmetry
Left lower lung collapse