PULMONARY RADIOLOGY

Back to the Basics:Back to the Basics:

- Densities in Radiographs- Densities in Radiographs

- Common Radiographic Views- Common Radiographic Views

- Normal Chest Radiographic Interpretation- Normal Chest Radiographic Interpretation

- Anatomic and Physiologic Basis of - Anatomic and Physiologic Basis of Pulmonary DiseasesPulmonary Diseases

Cases:Cases:

Radiographic presentationRadiographic presentation

Clinical ApplicationClinical Application

Densities in Radiographs

BLACK( LUCENT )

AIR-FILLEDSTRUCTURES

WHITE ( DENSE )

BULLAE/PNEUMOTHORAX

CHYLO-THORAX

PLEURALEFFUSION

PUS/BLOOD

VARIOUSFLUIDS

FATTYTISSUE

(N) BREAST TISSUE =MAMMO

SOLIDTISSUES/MASSES

GRAY TOWHITE

( DENSE )

BONE/CALC’N

WHITE( DENSE )

CONTRASTBARIUM & IODINE

METALSLEAD

Lead blocks passage of x-rays & used for shielding

DENSITIESDENSITIES

Air < Fat < Liver < Blood < Muscle < Bone < Barium < Lead

Air — — density : allow x-ray beam to hit film density : allow x-ray beam to hit film black black ( lungs, gastric bubble, trachea, bifurcation of bronchi)( lungs, gastric bubble, trachea, bifurcation of bronchi) Fat — breasts — breasts Fluid — most of what you see — most of what you see ( vessels, heart, diaphragm, soft tissues, mediastinum)( vessels, heart, diaphragm, soft tissues, mediastinum) Minerals —— density (or radiopaque) of body structures; density (or radiopaque) of body structures; (mostly Ca++; bones ,vascular calc’ns ,granulomas; (mostly Ca++; bones ,vascular calc’ns ,granulomas; contrast , bullets, safety pins, etc. ) contrast , bullets, safety pins, etc. )

*Thickness & composition determine radiodensity *Thickness & composition determine radiodensity * * RadiologicRadiologic Image = sum and diffierences in densities Image = sum and diffierences in densities

between x-ray beam source & film between x-ray beam source & film

Radiographic Radiographic PositionsPositions

POSTERO-ANTERIOR VIEW POSTERO-ANTERIOR VIEW

upright position – better evaluation of vascular distribution upright position – better evaluation of vascular distribution deep inspiration – good aeration of lung deep inspiration – good aeration of lung volume volume crowding of structures & magnification crowding of structures & magnification

heart is closer to film, less magnification heart is closer to film, less magnification energy beam - better qualityenergy beam - better quality

Film

X-raytube

6 feet

ANTERO-POSTERIOR VIEWANTERO-POSTERIOR VIEW

heart magnified heart magnified higher diaphragms higher diaphragms lung volume (+) crowdinglung volume (+) crowding difficult to assess vascularity difficult to assess vascularity

X-raytube

film underpatient

film

light /X-ray

lesion/heart

Film

AP view:lesion/heartfar from film

heart & lesions should heart & lesions should be near the film be near the film distortion & magnification distortion & magnification

PA view:lesion/heartnear film

LEFT/RIGHTLEFT/RIGHT LATERALLATERAL (90°) (90°) & OBLIQUE (45°) VIEWS & OBLIQUE (45°) VIEWS

evaluate “blind spots” –sternum /retro-sternal & retro-cardiac evaluate “blind spots” –sternum /retro-sternal & retro-cardiac areas or obscured by soft tissues & osseous structures areas or obscured by soft tissues & osseous structures

3-D image 3-D image ≈≈ 10% of lesions seen only in lateral view 10% of lesions seen only in lateral view

APICOLORDOTICAPICOLORDOTIC VIEWVIEW

see apices obscured by see apices obscured by clavicle and first ribsclavicle and first ribs

ancillary viewancillary view

tube elevated& angled 45º

LATERAL DECUBITUSLATERAL DECUBITUS

outline fluid levels in outline fluid levels in cavities & free pleural fluidcavities & free pleural fluid

Normal Chest RadiographNormal Chest Radiograph Interpretation Interpretation

1st p.rib

9th p.rib

CTR = A B

< 0.52

A

B

L hilum/Left PA

3 cm

1.5 cm

Rt CPS

R hilumRt PA

Lt CPS

RA

Aorticknob

LVRV

LA

60º; <90º>100º LAE

sternalangle

T4

SuperiorMediast.

MiddleMediast.

Post.Mediast

AntMed.

Lateral view provide landmarks for mediastinal compartmentsLateral view provide landmarks for mediastinal compartments

LA

LV

RV

trachearetrosternal

space

retrocardiacspace

Rt. minor/horizontal

fissure

Rt majorfissure

Lt. majorfissure

pleural outline

FissuresFissures

Hilum to rib 6

rightmajor f

leftmajor f.

major fissuresT3 - -- T10

maybe thickened due to fluid, fat, air, tumor & reactive maybe thickened due to fluid, fat, air, tumor & reactive ’s ’s

Anatomic and Physiologic Basis of Anatomic and Physiologic Basis of Air-Space & Interstitial DiseasesAir-Space & Interstitial Diseases

AIRSPACE SPACE DISEASESAIRSPACE SPACE DISEASES “CONSOLIDATION” Air in alveoli replaced by:Fluid (Pulmonary Edema)Blood (Hemorrhage)Cells (Tumor)Inflammatory exudates ( Infections -bacteria & mycobacteria)Lipoprotein (Alveolar

proteinosis) X-ray: coalescing homogenous opacities “patchy” “segmental” “lobar” “ diffuse consolidations”

Air Space Air Aveologram Air Space Air Aveologram Nodules Nodules

lucencies/airincompletely

alveoli

poor margination4-10 mm

Air-Bronchogram SignAir-Bronchogram Sign

air-filled bronchus air-filled bronchus look like radiolucent look like radiolucent "tubes""tubes"

airways OK but airways OK but surrounding lung surrounding lung tissues airlesstissues airless

Air-bronchogramSign

Air-way Opacities DistributionAir-way Opacities Distribution Diffuse Segmental Diffuse Segmental

‘butterfly”medullarydistribut’n

•Time factor: rapidity of appearance & resolution of Time factor: rapidity of appearance & resolution of infiltrates infiltrates clue to etiology e.g. hem’ge vs. infxn vs. neoplasm •Alveolar + interstitial pattern co-exist

SEPTIC INFARCTSPULMONARY EDEMA

Silhouette SignSilhouette SignSilhouette Adjacent lobe/s

egment

Right Diaphragm

RLL/Basal segments

Right Heart margin

RML/Medial segment

Ascending Aorta

RUL/Anterior segment

Aortic knobLUL/Posterior

segemnt

Left Heart margin

Lingula/Inferior segment

Descending Aorta

LLL/Superior & medial segments

Left DiaphragmLLL/Basal

segments

* an intrathoracic lesion touching a border of the heart, aorta or diaphragm will obliterate that border in an x-ray

Consolidation of Lung SegmentsConsolidation of Lung Segments

LEFT UPPER LOBE LEFT LINGULALEFT LOWER LOBE RIGHT UPPER LOBE RIGHT MIDDLE LOBERIGHT LOWER LOBE

Atelectasis

INTERSTITIAL DISEASEINTERSTITIAL DISEASE Alveolar Walls: “ perihilar haze”

Axial : connective tissue support pulmo art& bronchi

“peribronchial thickening”

Interlobular septa: pulmo.veins & lymphatics “Kerley A,B,C lines”

Subpleural /Peripheral: “ thickening of interlobar

fissures”

Interstitium –Skeleton of Lungs* edema, tumor, infxn, fibrosis

“septal”

“nodular” “reticulo-nodular”

“reticular”

visceral pl

bronchusperivasc. sheath

parietal pl

vein

MEDIAST.LUNG

INTERSTITIAL EDEMA SEPTAL Kerley B-lines

Peribroncial CuffingPerhilar Haziness

Reticular /Reticular /Honeycomb NodularHoneycomb Nodular

honey-comb

thick interlobsepta

INTERSTITIAL FIBROSIS MILIARY TB

Interstitial Alveolar Disease

DAY 1 DAY 9PNEUMOCYSTIS CARNII

Peribronchialcuffing

perihilarhaze

ADULT RESPIRATION DISTRESS SYNDROME

PNEUMONIA“Radiology alone was unable distinguish bacterial from non-bacterial pneumonia”

Tew J, Calenoff L, Berlin B. : Bacterial or Non-bacterial pneumonia: Accuracy of Radiographic Diagnosis

Classification based on morphology: 1- lobar pneumonia

2- bronchopneumonia 3- acute interstitial pneumonia

Classification based on mechanism of origin: Community-Acquired Pneumonia (CAP) Nosocomial pneumonia (NP) Aspiration pneumonia (AP)

exudates spread adjacent lobules & segments

fluid serve as culture media for bacteria

& alveolar wall (+) PMN’s

infected mucoid particleslung periphery

spread via small airways &collaterals: pores of Kohn/

canals of Lambert

LOBAR PNEUMONIA:* confluent areas of air-space

disease limited to one segmentor lobe

tissue react– wateryedema fluid into alveoliAlveoliw/fluid

Round PneumoniaRound Pneumonia

non-segmental sublobar & well circumscribed non-segmental sublobar & well circumscribed due to uniform involvement of adjacent alveoli due to uniform involvement of adjacent alveoli

Lobar PneumoniaLobar Pneumonia

BRONCHOPNEUMONIA LOBULAR PNEUMONIA

*airway mucosa ulceration

fibrinopurulent exudates

bronchial walls spreadto peribronchial

alveoli filled w/ hem’gic fluid & neutrophils

may spread to lobes

basal

involvecentral airway

mix air-space & interstitial pattern; segmental atelectasis

Peribronchial thickeningmarkings – small

ill-defined nodularities

ACUTE INTERSTITIAL PNEUMONIA

* diffuse bilateral reticulo-nodular interstitial pattern* bronchitis - - peribronchial thickening

**Common etiologic agents:

Viral and Mycoplasma

MYCOPLASMA PNEUMONIA

Community Acquired PneumoniaCommunity Acquired Pneumonia

Most common Most common pathogenspathogens S. Pneumoniae S. Pneumoniae

(48%)(48%) Viruses (19%) Viruses (19%) H. Influenzae H. Influenzae

(20%)(20%) C. Pneumoniae C. Pneumoniae

(13%)(13%) M. Pneumoniae M. Pneumoniae

(3%)(3%)

limited bypleural sfc

peripheral loc. develop pl.effusion

NosocomialNosocomialPneumoniaPneumonia

*commonly bilateral with diffuse or multiple foci of consolidation not limited to one lobe * frequently associate pleural effusion

Aspiration Aspiration PneumoniaPneumonia

*air-space opacities*air-space opacities

*dependent portion of *dependent portion of lung : RML & RLL lung : RML & RLL

* maybe bilateral , * maybe bilateral , multicentric perihilar multicentric perihilar

and basal and basal distributiondistribution

Lung Abscess

Lung Abscess

Fungus Ball

Tuberculosis

Cavitary Tuberculosis

Tuberculosis

CAVITARY TB W/ MILIARY NODULES PRIOR TO TX S/P SIX MONTHS THERAPY

45 YEAR OLD FEMALE WITH WEIGHT LOSSLOW GRADE FEVER AND BODY WEAKNESS

Miliary nodules : 2- 3 mm Post-primary hematogenous spread

of TB w/ granulomatous responseDDx: varicella pneumonia & metastasis

PLEURAL DISEASE

100% 75% 50% 25%

Pneumothorax

PneumothoraxPneumothorax

CollapsedLung

TensionPneumothorax

re-expansionof lung

Pneumothorax Pneumothorax

Pleural Effusion

Loculated Pleural Effusion (Empyema thoracis)

Mesothelioma

AIRWAY DISEASESAIRWAY DISEASES

27 year old male w/ dyspnea, chronic

productive cough & hemoptysis

Bronchiectasis

“Monocle sign”- Normallythe bronchiole

& arteriole should bethe same size

“Signet Ring”signThickening& dilatationof bronchi

arteriole

bronchiole

Emphysema

Foreign Body causing Atelectasis

Atelectasis right lung

Lower lobe Middle lobe

Upper lobe

NEOPLASMSNEOPLASMS

Pancoast tumor

Bronchogenic Carcinoma

A- intrapulmonary mets B- main tumor C- lymph nodes D- aorta E- right mainstem bronchus

Metastasis

Lymphoma

Lymphoma

Aortic Aneurysm

GOOD DAY!