Chest Radiographs

Loyola University Stritch School of Medicine

Drs. Pierce and Demos

Loyola University Medical CenterDepartment of Radiology

Radiographs

• Free Intraperitoneal Gas

• Pneumothorax

• Pleural Effusion

• Pulmonary Edema

Free Intraperitoneal Gas

Free Air

Free Intraperitoneal Gas

FREE AIR SENSITIVITY OF IMAGING STUDIES

• COMPUTED TOMOGRAPHY 99%

• LATERAL UPRIGHT CHEST RADIOGRAPH 98%

• AP UPRIGHT CHEST RADIOGRAPH 80 - 90%

• LEFT DECUBITUS ABDOMEN RADIOGRAPH 80- 90%

• SUPINE ABDOMEN RADIOGRAPH ?

Upright chest

Left lateral decubitus abdomen

Free Intraperitoneal GasPatient Supine

FREE AIRCENTRAL TENDON

SUPINE

UPRIGHT

FREE AIRCENTRAL TENDON

SUPINE

LEFT DECUBITUS

Free Intraperitoneal Gas

Neonate with distended abdomen Supine

abdomen

58-year-old man with acute abdominal pain

Supine abdomen Free air under right hemidiaphragm

Upright abdomen

Free Air in Supine PatientRIGLER’S SIGN

BOTH SIDES OF BOWEL WALL VISIBLE

DOUBLE WALL SIGNIN THREE PATIENTS

1

23

Free Intraperitoneal Gas

• When diagnosis is uncertain- If the patient can stand

• Upright chest and abdomen

- If the patient can not stand• Left lateral decubitus abdomen radiograph

• Most sensitive - Computed tomography

Pneumothorax

Pneumothorax Displaced Visceral Pleura

Pneumothorax Displaced pleura (arrows)

Skin Fold

Look for displaced Visceral Pleura

Skin fold extends outside ribs

Tension Pneumothorax

TENSION PNEUMOTHORAX ** Examine patient

* Look for deviated heart and mediastinum, depressed hemidiaphragm

* Compare to previous radiographs

Supine Patient Medial Pneumothorax

Supine PatientDeep Sulcus Sign

Before….No pneumothorax After….Pneumothorax

Is there a pneumothorax or isn’t there?

• Order a Lateral Decubitus chest radiograph- With the side of the chest in question as the upside

• Possible left pneumothorax get right lateral decubitus chest

> Look for displaced visceral pleura along upside lateral chest wall

• Order Upright Expiratory chest radiograph- Look for pneumothorax at lung apex

Pleural Effusion

Pleural Effusion

Upright…Meniscus

Decubitus…Effusion layered on downside

Supine…Unilateral increased density

Pleural EffusionSupine patient

Pleural Effusion

Semiupright…..Lung base opacity fades superiorly

63-year-old man recovering from congestive heart failure…Effusion loculated in fissure

Massive Pleural Effusion or

Total Lung Atelectasis

Total Atelectasis Heart and mediastinum shifted toward whited out hemithorax

Massive pleural effusion Heart and mediastinum shifted away from whited out hemithorax

Pleural Effusion

• Most sensitive way to show pleural effusion- Decubitus chest radiograph

• Least sensitive way to show pleural effusion- Supine chest radiograph

Pulmonary Edema

Normal Chest PA and Lateral Radiographs

Pulmonary Edema

Normal pulmonary vessels

Interstitial pulmonary edema

Alveolar pulmonary edema

Septal (Kerley B) lines due to interstitial pulmonary edema are thickened interlobular septae

Pulmonary Edema

• Interstitial pulmonary edema- Poorly defined pulmonary vessels

- Visible lung fissures

- Septal lines

- Thick bronchial walls

• Alveolar pulmonary edema- Bilateral symmetric perihilar lung consolidation

• Enlarged heart, Pleural effusion

COMPARE TO PREVIOUS RADIOGRAPHS

Left Upper Lobe Pneumonia

27-year-old man with productive cough, dyspnea, and fever

Monty Python

Gumbies