copyright © 2006 by mosby, inc. slide 1 chapter 8 radiologic examination of the chest radiologic...

Copyright © 2006 by Mosby, Inc.Slide 1

Chapter 8Chapter 8

Radiologic Examination of the ChestRadiologic Examination of the Chest


Fundamentals Fundamentals of of

RadiographyRadiography


Standard Positions and Techniques Standard Positions and Techniques of Chest Radiographyof Chest Radiography

Posteroanterior radiographPosteroanterior radiograph

Anteroposterior radiographAnteroposterior radiograph

Lateral radiographLateral radiograph

Lateral decubitus radiographLateral decubitus radiograph


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


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


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


Figure 8-4. Figure 8-4. AP chest radiograph. The diaphragms are elevated, the lower lung 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 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. 2:1, and extraneous lines are apparent on the patient’s left side.


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


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


Inspecting the Inspecting the Chest RadiographChest Radiograph


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


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


Table 8-1 Table 8-1 Common Radiologic TermsCommon Radiologic Terms

Air cystAir cyst

BlebBleb

BullaBulla

BronchogramBronchogram

CavityCavity

ConsolidationConsolidation

Homogeneous densityHomogeneous density

HoneycombingHoneycombing

InfiltrateInfiltrate


Table 8-1 Table 8-1 Common Radiologic Terms, cont.Common Radiologic Terms, cont.

Interstitial densityInterstitial density

LesionLesion

OpacityOpacity

Pleural densityPleural density

Pulmonary massPulmonary mass

Pulmonary nodulePulmonary nodule

RadiodensityRadiodensity

RadiolucencyRadiolucency

TranslucentTranslucent


Selected Examples Selected Examples of Common of Common

Radiologic TermsRadiologic Terms


CavityCavityLung with TB cavitiesLung with TB cavities Radiograph of cavityRadiograph of cavity

Figure 17-1, C.Figure 17-1, C. Figure 17-2; Figure 17-2; FromFrom Armstrong P et al: Armstrong P et al: Imaging Imaging of diseases of the chest,of diseases of the chest, ed ed

2, St. Louis, 1995, Mosby.2, St. Louis, 1995, Mosby.


Consolidation or OpacityConsolidation or Opacity(Caused by a Right Lung Pneumonia)(Caused by a Right Lung Pneumonia)

PneumoniaPneumonia

Figure 15-5.Figure 15-5.



BronchogramBronchogram

Figure 15-6. Air bronchogram. Figure 15-6. Air bronchogram. (From Armstrong P et al: (From Armstrong P et al: Imaging of diseases of the chestImaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.), ed 2, St. Louis, 1995, Mosby.)


BronchogramBronchogramShown in chest CT ScanShown in chest CT Scan

Figure 15-7. Figure 15-7. (From Armstrong P et al: (From Armstrong P et al: Imaging of diseases of the chestImaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.), ed 2, St. Louis, 1995, Mosby.)


HoneycombingHoneycombing(as shown in interstitial pulmonary fibrosis) (as shown in interstitial pulmonary fibrosis)

Figure 28-4. Figure 28-4. (From Armstrong P et al: (From Armstrong P et al: Imaging of diseases of the chestImaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.), ed 2, St. Louis, 1995, Mosby.)


InfiltrateInfiltrate(As shown in patient with ARDS—general term)(As shown in patient with ARDS—general term)



Pleural DensityPleural Density

Figure 28-3.Figure 28-3. (From Armstrong P et al: (From Armstrong P et al: Imaging of diseases of the chestImaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.), ed 2, St. Louis, 1995, Mosby.)


Pulmonary Mass Pulmonary Mass

Figure 26-3.Figure 26-3. (From Rau JL, Pearce DJ: (From Rau JL, Pearce DJ: Understanding chest radiographsUnderstanding chest radiographs, Denver, 1984, Multi-Media Publishing.), Denver, 1984, Multi-Media Publishing.)


Radiodensity Radiodensity (Caused by a Right Lung Pneumonia)(Caused by a Right Lung Pneumonia)

PneumoniaPneumonia




Translucency or RadiolucencyTranslucency or Radiolucency(Caused by a Right Pneumothorax)(Caused by a Right Pneumothorax)

Right pneumothoraxRight pneumothoraxRight pneumothoraxRight pneumothorax

Figure 22-10, B.Figure 22-10, B.Figure 22-1.Figure 22-1.


Emphysema Emphysema Emphysema Emphysema

Translucency or RadiolucencyTranslucency or Radiolucency(Caused by a Chronic Emphysema)(Caused by a Chronic Emphysema)

Figure 12-3.Figure 12-3. Figure 12-2.Figure 12-2.


Technical Quality of the RadiographTechnical Quality of the Radiograph

Technical qualityTechnical quality

Exposure qualityExposure quality

Level of inspirationLevel of inspiration


FirstFirstTechnical QualityTechnical Quality

Was the patient in the correct position?Was the patient in the correct position? Check the medial ends of the clavicles to the Check the medial ends of the clavicles to the

vertebral columnvertebral column

Even a small degree of patient rotation can Even a small degree of patient rotation can create a false imagecreate a false image Erroneously suggesting tracheal deviation, cardiac Erroneously suggesting tracheal deviation, cardiac

displacement, or cardiac enlargementdisplacement, or cardiac enlargement


SecondSecondExposure QualityExposure Quality

Normal exposure is verified by determining Normal exposure is verified by determining whether the spinal processes of the vertebrae whether the spinal processes of the vertebrae are visible to the 5th or 6th thoracic levelare visible to the 5th or 6th thoracic level

Compare the relative densities of the heart Compare the relative densities of the heart and lungsand lungs Overexposure: heart and lungs more radiolucentOverexposure: heart and lungs more radiolucent

Underexposure: heart and lungs more dense or Underexposure: heart and lungs more dense or whiterwhiter


Third Level of Inspiration When Third Level of Inspiration When Radiograph Was TakenRadiograph Was Taken

At full inspiration, the diaphragmatic domes At full inspiration, the diaphragmatic domes should be at the level of the 9th to 11th ribs should be at the level of the 9th to 11th ribs posteriorlyposteriorly

At expiration, the lungs appear denser, the At expiration, the lungs appear denser, the diaphragm is elevated, and the heart appears diaphragm is elevated, and the heart appears wider and enlargedwider and enlarged


Sequence of ExaminationSequence of Examination

MediastinumMediastinum

TracheaTrachea

HeartHeart

Hilar regionHilar region

Lung tissueLung tissue

PleuraPleura

DiaphragmDiaphragm

Gastric air bubbleGastric air bubble

Bony thorax and soft tissuesBony thorax and soft tissues


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


StructureStructure

MediastinumMediastinum TracheaTrachea

CarinaCarina

HeartHeart

Major vesselsMajor vessels

Abnormal PositionAbnormal Position

Leftward shiftLeftward shift

Table 8-2.Table 8-2.Examples of Factors That Pull or Push Anatomic Structures Examples of Factors That Pull or Push Anatomic Structures

Out of Their Normal Position in the Chest Radiograph.Out of Their Normal Position in the Chest Radiograph.

CausesCauses Pulled left by upper lobe tuberculosis, atelectasis, or Pulled left by upper lobe tuberculosis, atelectasis, or

fibrosisfibrosis

Pushed left by right upper lobe emphysematous bulla, Pushed left by right upper lobe emphysematous bulla, fluid, gas, or tumorfluid, gas, or tumor


StructureStructure

Left diaphragmLeft diaphragm


Upward shiftUpward shift

Table 8-2.Table 8-2.Examples of Factors That Pull or Push Anatomic StructuresExamples of Factors That Pull or Push Anatomic StructuresOut of Their Normal Position in the Chest Radiograph, cont.Out of Their Normal Position in the Chest Radiograph, cont.

CausesCauses Pulled up by left lower lobe atelectasis or fibrosisPulled up by left lower lobe atelectasis or fibrosis

Pushed up by distended gastric air bubblePushed up by distended gastric air bubble


StructureStructure

Horizontal fissureHorizontal fissure Right lungRight lung

Right hilumRight hilum


DownDownward shiftward shift


CausesCauses Pulled down by right middle lobe or right lower lobe Pulled down by right middle lobe or right lower lobe

atelectasisatelectasis

Pushed down by right upper lobe neoplasmPushed down by right upper lobe neoplasm


StructureStructure

Left lungLeft lung


Rightward shiftRightward shift


CausesCauses Pulled right by right lung collapse, atelectasis, or fibrosisPulled right by right lung collapse, atelectasis, or fibrosis

Pushed right by left-sided tension pneumothorax or Pushed right by left-sided tension pneumothorax or hemothoraxhemothorax


Other Radiologic TechniquesOther Radiologic Techniques

Computed tomography (CT)Computed tomography (CT) CT scanCT scan

Position emission tomography (PET)Position emission tomography (PET) PET scanPET scan

Magnetic resonance imagingMagnetic resonance imaging Pulmonary angiographyPulmonary angiography Ventilation-perfusion scanVentilation-perfusion scan FluoroscopyFluoroscopy BronchographyBronchography


Normal CT Scan Lung Window Normal CT Scan Lung Window

Figure 8-9. Figure 8-9. Overview of normal lung window CT scan. The apex appears in the two 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 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.lungs appears in the lower right hand view.


Example of Several Normal Example of Several Normal CT Scan Lung Window SlicesCT Scan Lung Window Slices



Figure 8-9 B. The actual cross-Figure 8-9 B. The actual cross-sectional slice, or axial view of the sectional slice, or axial view of the chest.chest.

A B

Figure 8-10. Figure 8-10. Close-up of a normal lung Close-up of a normal lung window CT scan. A, The portion of the window CT scan. A, The portion of the chest the CT scan is taken. chest the CT scan is taken.


Figures 8-10, A, and 8-9, C.Figures 8-10, A, and 8-9, C.




Figures 8-10, A, and 8-9, D.Figures 8-10, A, and 8-9, D.



Figures 8-10, A, and 8-9, E.Figures 8-10, A, and 8-9, E.



Figures 8-10, A, and 8-9, F.Figures 8-10, A, and 8-9, F.



Figures 8-10, A, and 8-9, G.Figures 8-10, A, and 8-9, G.



Figures 8-10, A, and 8-9, H.Figures 8-10, A, and 8-9, H.



Figures 8-10, A, and 8-9, I.Figures 8-10, A, and 8-9, I.



Figures 8-10, A, and 8-9, J.Figures 8-10, A, and 8-9, J.



Figures 8-10, A, and 8-9, K.Figures 8-10, A, and 8-9, K.



Figures 8-10, A, and 8-9, L.Figures 8-10, A, and 8-9, L.


Example of Several Normal Example of Several Normal CT Scan Mediastinal WindowCT Scan Mediastinal Window


Normal CT Mediastinal Window Normal CT Mediastinal Window


Normal CT Mediastinal WindowNormal CT Mediastinal Window



Figures 8-11. Figures 8-11. Close up of normal CT mediastinal window. A, The portion of the 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 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 the chest. Note that the lungs are overexposed and appear mostly black. The bone and mediastinal organs appear mostly white.bone and mediastinal organs appear mostly white.


Positron Emission TomographyPositron Emission TomographyPET ScanPET Scan


AA

BB

Figure 8-12. Figure 8-12. Chest radiograph identifying two suspicious findings: in the right upper lobe (A) and in the Chest radiograph identifying two suspicious findings: in the right upper lobe (A) and in the

left lower lobe (B), just behind the heart (see left lower lobe (B), just behind the heart (see white arrowswhite arrows).).


A

B

CT scan, CT scan, upper right lobeupper right lobe

CT scan, CT scan, left lower lobeleft lower lobe

Chest radiographChest radiograph

Figure 8-13. Figure 8-13. Same chest radiograph as shown in Figure 8-12. Note the CT scanSame chest radiograph as shown in Figure 8-12. Note the CT scanalso identifies the suspicious nodules and their precise location.also identifies the suspicious nodules and their precise location.


Coronal ViewCoronal View

Figure 8-14. Figure 8-14. PET scan: coronal views. PET scan: coronal views.

The last three views show a “hot spot” in left lower lung lobe.The last three views show a “hot spot” in left lower lung lobe.


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

lobe.lobe.


Axial View

Figure 8-16.Figure 8-16.PET scan: axial view. A “hot spot” is further confirmed in left lower lung lobe.PET scan: axial view. A “hot spot” is further confirmed in left lower lung lobe.


No hot spot seen

Axial View

Figure 8-17.Figure 8-17.PET scan: axial view. This image confirms that the small nodule identified in the upper right 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).lobe in the chest radiograph and CT scan is benign (i.e., no “hot spot” is evident).


PET Scan PET Scan andand

CT ScanCT Scan


CT Scan PET ScanCT/PET Fusion

Axial ViewAxial View

CoronalView

CoronalView

Figure 8-18. CT/PET scan (center). CT scan, CT/PET fusion, and PET scan, all showing the Figure 8-18. CT/PET scan (center). CT scan, CT/PET fusion, and PET scan, all showing the same malignant nodule in right upper lobe (see same malignant nodule in right upper lobe (see white arrowwhite arrow). Note: The CT/PET fusion is ). Note: The CT/PET fusion is

normally presented in color (e.g., red, blue, yellow).normally presented in color (e.g., red, blue, yellow).


Magnetic Resonance ImagingMagnetic Resonance Imaging


Figure 8-19. Figure 8-19. Anatomy of mediastinum on MRI. A, Anatomy of mediastinum on MRI. A, LBCV,LBCV, Left brachiocephalic vein; Left brachiocephalic vein; RBCV,RBCV, right brachiocephalic vein; right brachiocephalic vein; Ao A,Ao A, aortic arch; aortic arch; T,T, trachea; trachea; Es,Es, esophagus. B, esophagus. B, RV, RV, Right Right ventricle; ventricle; LV,LV, left ventricle; left ventricle; RA,RA, right atrium; right atrium; LA,LA, left atrium; left atrium; D Ao,D Ao, descending aorta; descending aorta; Es,Es, esophagus; esophagus; Az V,Az V, azygos vein. (From Armstrong P, Wilson AG, Dee P: azygos vein. (From Armstrong P, Wilson AG, Dee P: Imaging of diseases Imaging of diseases of the chestof the chest, St. Louis, 1990, Mosby.), St. Louis, 1990, Mosby.)


Pulmonary AngiographyPulmonary Angiography


Figure 8-20. Figure 8-20. Abnormal pulmonary angiogram. Radiopaque material injected into the blood Abnormal pulmonary angiogram. Radiopaque material injected into the blood is prevented from flowing into the left lung past the pulmonary embolism is prevented from flowing into the left lung past the pulmonary embolism (arrow).(arrow). No No vascular structures are seen distal to the obstruction.vascular structures are seen distal to the obstruction.


BronchographyBronchography


Figure 8-21. Figure 8-21. Bronchogram obtained using contrast medium in a patient with a history of Bronchogram obtained using contrast medium in a patient with a history of bronchiectasis. bronchiectasis. ArrowsArrows indicate the carina and the bronchi leading to the posterior basilar indicate the carina and the bronchi leading to the posterior basilar segment of the left lower lobe. (From Rau JL, Jr, Pearce DJ: segment of the left lower lobe. (From Rau JL, Jr, Pearce DJ: Understanding chest Understanding chest radiographs,radiographs, Denver, 1984, Multi-Media Publishing.) Denver, 1984, Multi-Media Publishing.)

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