1. Radiologic Examination of the Chest
Chapter 8
 Radiologic Examination of the Chest

2. Fundamentals of Radiography

3. Standard Positions and Techniques of Chest Radiography
Posteroanterior radiograph
Anteroposterior radiograph
Lateral radiograph
Lateral decubitus radiograph

4. Figure 8-1. Standard PA chest radiograph with the patient’s lungs in full inspiration.

5. Figure 8-2. A PA chest radiograph of the same patient shown in Figure 8-1 during expiration.

6. Figure 8-3. Compared with the PA chest radiograph, the heart is significantly magnified in the AP chest radiograph. In the PA radiograph the ratio of the width of the heart to the thorax is normally less than 1:2.

7. Figure 8-4. AP chest radiograph. The diaphragms are elevated, the lower lung lobes appear hazy, the ratio of the width of the heart to the thorax is greater than 2:1, and extraneous lines are apparent on the patient’s left side.

8. Figure 8-5. Lateral radiograph.
Figure 8-5. Lateral radiograph.

9. Figure 8-6. Subpulmonic pleural effusion. Right lateral decubitus view. Subdiaphragmatic fluid has run up the lateral chest wall, producing a band of soft tissue density. The medial curvilinear shadow (arrow) indicates fluid in the lips of the major fissure.

10. Inspecting the Chest Radiograph

11. Figure 8-7. Normal PA chest radiograph. 1, Trachea (note vertebral column in middle of trachea); 2, carina; 3, right main stem bronchus; 4, left main stem bronchus; 5, right atrium; 6, left ventricle; 7, hilar vasculature; 8, aortic knob; 9, diaphragm; 10, costophrenic angles; 11, breast shadows; 12, gastric air bubble; 13, clavicle; 14, rib.

12. Figure 8-8. Normal lateral chest radiograph. 1, Manubrium; 2, sternum; 3, cardiac shadow; 4, retrosternal air space in the lung; 5, trachea; 6, bronchus, on end; 7, aortic arch (ascending and descending); 8, scapulae; 9, vertebral column; 10, diaphragm; 11, breast shadow.

13. Table 8-1 Common Radiologic Terms
Air cyst
Bleb
Bulla
Bronchogram
Cavity
Consolidation
Homogeneous density
Honeycombing
Infiltrate

14. Table 8-1 Common Radiologic Terms, cont.
Interstitial density
Lesion
Opacity
Pleural density
Pulmonary mass
Pulmonary nodule
Radiodensity
Radiolucency
Translucent

15. Selected Examples of Common Radiologic Terms

16. Cavity Lung with TB cavities Radiograph of cavity Figure 17-1, C.
Figure 17-2; From Armstrong P et al: Imaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.

17. Consolidation or Opacity (Caused by a Right Lung Pneumonia)
Figure 15-1.
Figure 15-5.

18. Bronchogram
Figure Air bronchogram. (From Armstrong P et al: Imaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.)

19. Bronchogram Shown in chest CT Scan
Figure (From Armstrong P et al: Imaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.)

20. Honeycombing (as shown in interstitial pulmonary fibrosis)
Figure (From Armstrong P et al: Imaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.)

21. Infiltrate (As shown in patient with ARDS—general term)
Figure 27-2.

22. Pleural Density
Figure (From Armstrong P et al: Imaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.)

23. Pulmonary Mass
Figure (From Rau JL, Pearce DJ: Understanding chest radiographs, Denver, 1984, Multi-Media Publishing.)

24. Radiodensity (Caused by a Right Lung Pneumonia)
Figure 15-1.
Figure 15-5.

25. Translucency or Radiolucency (Caused by a Right Pneumothorax)
Figure 22-1.
Figure 22-10, B.

26. Translucency or Radiolucency (Caused by a Chronic Emphysema)
Figure 12-3.
Figure 12-2.

27. Technical Quality of the Radiograph
Exposure quality
Level of inspiration

28. First Technical Quality
Was the patient in the correct position?
Check the medial ends of the clavicles to the vertebral column
Even a small degree of patient rotation can create a false image
Erroneously suggesting tracheal deviation, cardiac displacement, or cardiac enlargement

29. Second Exposure Quality
Normal exposure is verified by determining whether the spinal processes of the vertebrae are visible to the 5th or 6th thoracic level
Compare the relative densities of the heart and lungs
Overexposure: heart and lungs more radiolucent
Underexposure: heart and lungs more dense or whiter

30. Third Level of Inspiration When Radiograph Was Taken
At full inspiration, the diaphragmatic domes should be at the level of the 9th to 11th ribs posteriorly
At expiration, the lungs appear denser, the diaphragm is elevated, and the heart appears wider and enlarged

31. Sequence of Examination
Mediastinum
Trachea
Heart
Hilar region
Lung tissue
Pleura
Diaphragm
Gastric air bubble
Bony thorax and soft tissues

32. Figure 8-7. Normal PA chest radiograph. 1, Trachea (note vertebral column in middle of trachea); 2, carina; 3, right main stem bronchus; 4, left main stem bronchus; 5, right atrium; 6, left ventricle; 7, hilar vasculature; 8, aortic knob; 9, diaphragm; 10, costophrenic angles; 11, breast shadows; 12, gastric air bubble; 13, clavicle; 14, rib.

33. Structure Abnormal Position Causes Mediastinum Leftward shift
Trachea
Carina
Heart
Major vessels
Abnormal Position
Leftward shift
Causes
Pulled left by upper lobe tuberculosis, atelectasis, or fibrosis
Pushed left by right upper lobe emphysematous bulla, fluid, gas, or tumor
Table 8-2. Examples of Factors That Pull or Push Anatomic Structures Out of Their Normal Position in the Chest Radiograph.

34. Structure Abnormal Position Causes Left diaphragm Upward shift
Pulled up by left lower lobe atelectasis or fibrosis
Pushed up by distended gastric air bubble
Table 8-2. Examples of Factors That Pull or Push Anatomic Structures Out of Their Normal Position in the Chest Radiograph, cont.

35. Structure Abnormal Position Causes Horizontal fissure Downward shift
Right lung
Right hilum
Abnormal Position
Downward shift
Causes
Pulled down by right middle lobe or right lower lobe atelectasis
Pushed down by right upper lobe neoplasm
Table 8-2. Examples of Factors That Pull or Push Anatomic Structures Out of Their Normal Position in the Chest Radiograph, cont.

36. Structure Abnormal Position Causes Left lung Rightward shift
Pulled right by right lung collapse, atelectasis, or fibrosis
Pushed right by left-sided tension pneumothorax or hemothorax
Table 8-2. Examples of Factors That Pull or Push Anatomic Structures Out of Their Normal Position in the Chest Radiograph, cont.

37. Other Radiologic Techniques
Computed tomography (CT)
CT scan
Position emission tomography (PET)
PET scan
Magnetic resonance imaging
Pulmonary angiography
Ventilation-perfusion scan
Fluoroscopy
Bronchography

38. Normal CT Scan Lung Window
Figure 8-9. Overview of normal lung window CT scan. The apex appears in the two views in the upper right hand corner of this figure; the diaphragm at the base of the lungs appears in the lower right hand view.

39. Example of Several Normal CT Scan Lung Window Slices

40. Normal CT Scan Lung WindowB
Figure Close-up of a normal lung window CT scan. A, The portion of the chest the CT scan is taken.
Figure 8-9 B. The actual cross-sectional slice, or axial view of the chest.

41. Normal CT Scan Lung Window
Figures 8-10, A, and 8-9, C.

42. Normal CT Scan Lung Window
Figures 8-10, A, and 8-9, D.

43. Normal CT Scan Lung Window
Figures 8-10, A, and 8-9, E.

44. Normal CT Scan Lung Window
Figures 8-10, A, and 8-9, F.

45. Normal CT Scan Lung Window
Figures 8-10, A, and 8-9, G.

46. Normal CT Scan Lung Window
Figures 8-10, A, and 8-9, H.

47. Normal CT Scan Lung Window
Figures 8-10, A, and 8-9, I.

48. Normal CT Scan Lung Window
Figures 8-10, A, and 8-9, J.

49. Normal CT Scan Lung Window
Figures 8-10, A, and 8-9, K.

50. Normal CT Scan Lung Window
Figures 8-10, A, and 8-9, L.

51. Example of Several Normal CT Scan Mediastinal Window

52. Normal CT Mediastinal Window

53. Normal CT Mediastinal Window

54. Normal CT Mediastinal Window

55. Normal CT Mediastinal Window

56. Normal CT Mediastinal Window

57. Normal CT Mediastinal Window
Figures Close up of normal CT mediastinal window. A, The portion of the chest the CT scan is taken. B, The actual cross-sectional slice, or axial view of the chest. Note that the lungs are overexposed and appear mostly black. The bone and mediastinal organs appear mostly white.

58. Normal CT Mediastinal Window

59. Normal CT Mediastinal Window

60. Normal CT Mediastinal Window

61. Normal CT Mediastinal Window

62. Normal CT Mediastinal Window

63. Positron Emission Tomography PET Scan

64. A B
Figure Chest radiograph identifying two suspicious findings: in the right upper lobe (A) and in the left lower lobe (B), just behind the heart (see white arrows).

65. CT scan, upper right lobe
Chest radiograph
CT scan, left lower lobe
Figure Same chest radiograph as shown in Figure Note the CT scan also identifies the suspicious nodules and their precise location.

66. Coronal View
Figure PET scan: coronal views. The last three views show a “hot spot” in left lower lung lobe.

67. Figure 8-15. PET scan: sagittal views
Figure PET scan: sagittal views. The encircled images show a “hot spot” in the lower left lobe.

68. Axial View
Figure PET scan: axial view. A “hot spot” is further confirmed in left lower lung lobe.

69. Axial View No hot spot seen
Figure PET scan: axial view. This image confirms that the small nodule identified in the upper right lobe in the chest radiograph and CT scan is benign (i.e., no “hot spot” is evident).

70. PET Scan and CT Scan

71. CT Scan CT/PET Fusion PET Scan
Axial View
Coronal View
Figure CT/PET scan (center). CT scan, CT/PET fusion, and PET scan, all showing the same malignant nodule in right upper lobe (see white arrow). Note: The CT/PET fusion is normally presented in color (e.g., red, blue, yellow).

72. Magnetic Resonance Imaging

73. Figure Anatomy of mediastinum on MRI. A, LBCV, Left brachiocephalic vein; RBCV, right brachiocephalic vein; Ao A, aortic arch; T, trachea; Es, esophagus. B, RV, Right ventricle; LV, left ventricle; RA, right atrium; LA, left atrium; D Ao, descending aorta; Es, esophagus; Az V, azygos vein. (From Armstrong P, Wilson AG, Dee P: Imaging of diseases of the chest, St. Louis, 1990, Mosby.)

74. Pulmonary Angiography

75. Figure Abnormal pulmonary angiogram. Radiopaque material injected into the blood is prevented from flowing into the left lung past the pulmonary embolism (arrow). No vascular structures are seen distal to the obstruction.

76. Bronchography

77. Figure Bronchogram obtained using contrast medium in a patient with a history of bronchiectasis. Arrows indicate the carina and the bronchi leading to the posterior basilar segment of the left lower lobe. (From Rau JL, Jr, Pearce DJ: Understanding chest radiographs, Denver, 1984, Multi-Media Publishing.)