Chest X-rays PDF Analysis

Chest Imaging CXR interpretation Chest radiographs Simple Low cost Sensitive Excellent resolution Postro - anterior PA Accurate patient positioning Full inspiration Adequate penetration 1 PA & AP chest...

Chest Imaging CXR interpretation Chest radiographs Simple Low cost Sensitive Excellent resolution Postro - anterior PA Accurate patient positioning Full inspiration Adequate penetration 1 PA & AP chest X-rays Supine & erect chest X-rays Widened superior mediastinum due to AP magnification. Enlarged heart-a combination of AP magnification and under inflation. Bilateral interstitial opacities- probably also due to under inflation. Same patient, repeat PA CXR the next day showing normal findings. CTR Cardio-thoracic ration This patient has mild cardiomegaly – note the technique for measuring the cardiothoracic ratio. Students occasionally make the mistake of drawing the lines at the same level (rather than the thoracic width being measured at the widest point in the chest) 2 CTR Cardio-thoracic ration PA chest x-ray demonstrates markedly enlarged cardiac silhouette. There is a double contour to the right heart border and splaying of the carina. The aorta is ectatic. There are no overt features of congestive cardiac failure at this time. Left Lateral Adequate penetration Optimal exposure Over exposure Under exposure Overexposure makes it easy to see behind the heart and the regions of the clavicles and thoracic spine, but the pulmonary vessels peripherally are impossible to see. Underexposure accentuates the pulmonary vascularity, but you cannot see behind the heart or behind the diaphragms. 3 Full inspiration & cupola level Inspiratory & expiratory chest X-rays On full inspiration, the right hemi diaphragm should project over the 10th rib posteriorly. Films taken without a full inspiration may result in enlargement of the cardiac silhouette and the pulmonary vasculature appears crowded and indistinct. This appearance is easily mistaken for pulmonary edema. The right diaphragmatic copula is normally higher than the left one, the accepted difference between both copulas is 1-3 cm. 4 Lateral X-ray Chest Proper penetration and inspiration is insured by observing that the spine appears to be darken as you move caudally. This is due to more air in lung in the lower lobes and less chest wall. Normal PA film without rotation CXR centralized. CXR rotated 5 Lung apex Zonal lung anatomy Zonal lung anatomy Zonal lung anatomy 6 Zonal lung anatomy Lung Pneumonia Abscess Lung TB Emphysema Lung fibrosis Pleura Air Fluid Pus Blood Pneumothorax Spontaneous Pneumothorax occurs without an obvious inciting incident. Other causes Asthma COPD Pulmonary infection Neoplasm Marfanâs syndrome Smoking cocaine Pneumothorax can be due to trauma or lung rupture. It causes shortness of breath and pain on breathing. It is treated by inserting a tube to drain the air over a period. 7 Pneumothorax Chest X-rays PA showing left sided pneumothorax totally compressing the left lung. Pneumothorax Axial CT scan showing left sided pneumothorax with partial compression of the left lung. The right lung is normal. The heart is central with no shift of the mediastinum. Tension pneumothorax. Chest X-rays PA showing left sided pneumothorax totally compressing the left lung with depression of the diaphragm and contra lateral mediastinal shift denoting tension pneumothorax. Tension pneumothorax Chest X-rays PA showing right sided pneumothorax compressing the right lung with depression of the diaphragm [red line] and contra lateral mediastinal shift [black line] denoting tension pneumothorax 8 Tension pneumothorax CT scan of the chest showing a large left sided pneumothorax compressing the left lung. The heart is displaced to the right -side denoting tension pneumothorax Pleural effusion Accumulation of fluid inside the pleural cavity. Detected when free fluid about 15-50 ml. 200 ml of fluid are detected in the PA. 75ml in the lateral view Left pleural effusions Note the concave menisci blunting both posterior costophrenic angles. Pleural effusion Chest X-rays PA and lateral showing small amount of pleural effusion seen in the lateral view, but not seen in the frontal views. 9 Meniscus sign CHF Para pneumonic Trauma Pulmonary embolism Tumors of the lung and pleura Autoimmune disease Renal failure Mild pleural effusion Moderate pleural effusion 10 Massive pleural effusion Bilateral pleural effusion Contrast enhanced CT scan of the chest showing bilateral pleural effusion more on the right side with underlying collapse of the right lower lobe. Hydro pneumothorax Chest X-ray showing left-sided pleural air-fluid level with mediastinal shift diagnostic of hydropneumothorax Hydro pneumothorax A nice example of a hydropneumothorax with a straight air-fluid interface. This occurred from air introduced during pleural drainage [iatrogenic]. Other common causes include post trauma and intra thoracic surgery. It is treated with pleural drain placement. 11 Hydro pneumothorax, 2 cases Contrast enhanced CT scans of the chest of two different patients showing large pleural effusion and air with compression collapse of the underlying lung Chest drain-treatment for pleural effusion: The tube is appropriately placed towards the lower part of the pleural cavity Chest drain - treatment for pneumothorax: A large chest drain is positioned with its tip pointing superiorly within the pleural cavity. 12 Pleural empyema Accumulation of pus in the pleural cavity Commonly arise from lung infection (pneumonia) Exudative stage, the pus accumulates. Fibrinopurulent stage, creation of pus pockets Organizing stage, pleural scarring may lead to lung entrapment. Encysted pleural effusion. Left sided encysted pleural collection along the lateral chest wall. The obtuse angle with the chest wall indicates this arising from the pleural space. Heart size normal. Right lung clear. Empyema Pleural empyema appears as pleural effusion, often with associated consolidation. Commonly unilateral, and if bilateral, the infected side is larger. Most of infected pleural effusions and empyemas are loculated on ultrasound. In US, note the loculations identified in the pleural fluid. On the CT scan, a large pleural effusion is noted. Also there is collapse of the underlying lung parenchyma as well as septations 13 Empyema CT of the chest demonstrates a very large right sided pleural collection with thickened surrounding pleura and multiple gas bubbles. The adjacent lung is compressed an collapsed. The findings are consistent with an empyema. Chronic empyema CT examination revealed left sided encysted pleural effusion with marginal calcification denoting chronic empyema likely of TB etiology. Chronic empyema A computed tomography image reveals right-sided volume loss and a pleural collection with dense marginal calcification affecting the parietal and visceral pleura as well as the crowding of the adjacent ribs on the right side 14 Empyema necessitans TB patient, presented with chest wall mass and pain A large fluid collection is seen in the right pleural cavity, with extension into the soft tissues of the chest wall, diagnostic of empyema necessitans. No evidence of calcification seen in the collection. Hemothorax Chest trauma Blood clotting disorder Lung cancer Pleural mesothelioma Pulmonary infarction Cardio thoracic surgery Tuberculosis Hemothorax Contrast enhanced CT scan of the chest showing right sided hyper dense pleural collection on the right side with underlying collapse of the right lung denoting hemothorax. 15  Chest Imaging CXR interpretation Part II Over view Ground glass Pneumonia Lung abscess Tuberculosis Atelectatic bands Lung emphysema Lung fibrosis GGO Ground glass opacities Is a descriptive term. Refers to an area of increased lung density on HRCT Preserved bronchial and vascular markings Anything involving the alveoli or interstitium or both can cause ground glass opacity The differential diagnoses depends on the clinical setting and imaging findings 16 COVID-19 pneumonia with typical imaging features according to RSNA chest CT classification system. Axial NCCT images with positive RT-PCR test results for SARS- CoV-2, show bilateral areas of ground-glass opacities in a peripheral distribution. Chest CT abnormalities of relatively high prevalence in COVID-19. Axial non enhanced chest CT image shows bilateral ground-glass opacities. Air bronchogram Pulmonary parenchymal disease Alveolar pathology Consolidation Replacement of air in the alveoli by any other material like fluid, pus, blood, tumor cells 17 Air bronchogram Chest X-ray showing extensive bilateral pneumonic consolidations with evident air bronchogram. Middle lobe pneumonia Pneumonic consolidation with air bronchogram seen in the right lower zone, clearly shown in the right middle lobe on the lateral view. Left lower lobe pneumonia Chest X-rays show pulmonary consolidation with air-bronchogram in the left lung base. In the lateral X-ray the consolidation is seen in the posterior basal segment of the left lower lobe 18 Pneumonic consolidation Chest X-rays show pulmonary consolidation with air-bronchogram in the right upper lobe and the left lung base. Mild left pleural effusion is seen obliterating the costophrenic angle Pneumonic consolidation, CXR, US CXR showed a right lung consolidation diagnostic of pneumonia, associated with hyperinflation and a mediastinal herniation of the left lung. Lung ultrasound showed a large hypo echoic consolidated area with sonographic air bronchograms with branching pattern, compatible with pneumonia. Pneumonic consolidation, CT Bilateral pulmonary pneumonic consolidation in the lower lobes with air bronchograms. Nasogastric tube is seen in the esophagus 19 Pneumonic consolidation, CT Left upper lobe pneumonic consolidation with patent bronchi [air bronchograms] Lung abscess Collection of purulent material in a destroyed part of the lung The incidence now is much lower due to improved antibiotic coverage The most common bacteria are, Staph aureus, Klebsiella, Proteus, Pseudomonas,… Aspiration is the mechanism of the bacteria to reach the lung Usually occur on the right side Symptoms are similar to pneumonia with fever, malaise, cough, chest pain and sputum Initially, there is an area of pneumonitis or aspiration pneumonia Typically it takes 7-14 days from aspiration to form an abscess cavity that is seen on CXR Lung abscess Risk factors Loss of consciousness Alcoholism Drug addiction. General anesthesia Seizure, sedatives Neurological and esophageal disease Nasogastric tube and tracheostomy Throat and dental surgeries. 20 Lung abscess Frontal and lateral chest X-rays showing a well defined cavitary lesion in the right upper lobe with a relatively thick wall. The cavity has a smooth inner margin and air-fluid level. Lung abscess Chest X-ray and axial CT scan image of the chest showing a well defined cavitary lesion in the right lower lobe with a relatively thick wall. The cavity has a smooth inner margin and air-fluid level. There is inflammatory reaction in the surrounding lung. Lung abscess Axial CT scan image of the chest showing a well defined cavitary lesion in the left lower lobe with a relatively thick wall. The cavity has a smooth inner margin and air-fluid level denoting acute lung abscess. After expectoration of pus, a cavity filled by air is seen denoting chronic lung abscess 21 Primary TB Mediastinal Lymphadenopathy Pulmonary parenchymal disease Pleural effusion Miliary T.B Two week history of fever and cough M 10Y CXR showing a small, right upper lobe peripheral focus of air-space density. Ipsilateral right superior hilar adenopathy is seen. A linear opacity of thickened lymphatic channel is noted between the parenchymal focus and the regional adenopathy, constituting Ranke’s complex. There are no radiological features which are diagnostic of primary tuberculosis infection but a chest X-ray may provide some clues to the diagnosis CXR shows consolidation of the upper zone with ipsilateral hilar enlargement due to lymphadenopathy. These are typical features of primary TB 22 Miliary disease Affects between 4% of patients with all forms of tuberculosis. Usually seen in the elderly, infants, and immunocompromised persons Secondary TB Post primary reactivation Post primary TB is a progressive disease A disease of adolescents and adults Generally called reinfection OR reactivation of TB. Secondary TB F 20Y Cough, fever, and weight loss Chest radiograph shows multifocal patchy opacities in the right upper lobe. These findings are consistent with and confirmed to be pulmonary tuberculosis Secondary TB TB can manifest as left upper lobe consolidation in a young adult.TB can also manifest as pulmonary nodules in the upper lobe with cavitary lesions and fibrotic strands 23 Secondary TB A posterior-anterior chest radiograph in a patient with typical adult-type smear- positive pulmonary tuberculosis. The major features are upper lung zone distribution; cavitation; and reticular opacities. Healed TB Following an immune response to post-primary infection, the affected area often becomes scarred and fibrotic with calcified foci. The combined fibrosis and calcification can be described as ‘fibro-calcific change. Healed TB Chest x-ray showing bilateral strandy nodular opacities with calcifications predominantly in the upper part of the lungs. Elevated left diaphragmatic copula due to distension of the colon below the diaphragm. 24 Atelectatic band, left LL Chest X-ray PA and lateral showing a thick atelectatic band in the left lower lobe Atelectatic band, right LL Chest X-ray showing a thick atelectatic band in the right lower lobe Atelectatic bands, CT Axial CT scan lung window showing multiple bilateral linear atelectatic bands are seen in both lower lung lobes, compare to the normal lung on the left image 25 Pulmonary emphysema Chronic Obstructive Pulmonary Disease (COPD) is now the preferred term for the conditions in patients with airflow limitation previously diagnosed as having chronic bronchitis and emphysema. Pulmonary emphysema Chest X-ray showing marked hyper inflation of both lungs with low flat diaphragm, attenuation of the peripheral vascular markings and ribbon shaped heart 26 Pulmonary emphysema Chest CT showing marked hyper inflation of both lungs with multiple variable sized emphysematous bullae, compared to the normal lung on the right side. Pulmonary emphysema Chest X-ray showing marked hyper inflation of both lungs with low flat diaphragm, attenuation of the peripheral vascular markings. Multiple large thin wall air filled cavities are seen in the left lung representing emphysematous bullae.Coronal and axial CT images clearly show the emphysematous bullae 27 Infected emphysematous bullae Chest X-ray showing hyper inflation of both lungs with multiple large thin wall air filled cavities are seen in the left lung representing emphysematous bullae. Some of the cavities contain air fluid level denoting secondary infection. IPF Idiopathic pulmonary fibrosis UIP Usual interstitial pneumonia A chronic progressive fibrosing interstitial lung disease No detectable cause= idiopathic pulmonary fibrosis Detectable cause = usual interstitial pneumonia Diagnosed by combinations of HRCT and surgical lung biopsy Typical findings on HRCT are highly accurate for diagnosis Anti fibrotic agents have recently been approved for use in IPF treatment. Clinically Progressive shortness of breath and nonproductive cough Usually present for more than 6 months The age at the time of presentation is usually over 50 years Women are affected slightly more often than men IPF does not usually respond to steroid treatment The prognosis of IPF is poor with median survival < 5 years Complications include: Accelerated progression Lung cancer Secondary infection 28 Pulmonary interstitial fibrosis Chest X-ray showing extensive bilateral linear opacities representing pulmonary fibrosis, compared to the normal x-ray on the left side UIP HRCT Findings Peripheral and basilar distribution Honeycombing Traction bronchiectasis Interlobular septal thickening Ground glass opacities Decreased lung volume unless associated with emphysema Pulmonary interstitial fibrosis Chest CT showing extensive bilateral linear opacities representing pulmonary fibrosis with typical areas of honey combing and traction bronchiectasis 29 Pulmonary interstitial fibrosis Chest CT showing extensive bilateral linear opacities representing pulmonary fibrosis with typical areas of honey combing and traction bronchiectasis Scleroderma Non contrast CT reveals marked, mainly basal destruction of lung parenchyma with traction bronchiectasis, areas of honey combing and reticular opacities. Also note dilatation of the esophagus with air- fluid level. These findings are compatible with scleroderma-associated pulmonary fibrosis 30