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1 Chest Radiography Interpretation Dr. Raghu Ram Uppalapati.

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1 1 Chest Radiography Interpretation Dr. Raghu Ram Uppalapati

2 Lung Anatomy Trachea Trachea Carina Carina Right and Left Pulmonary Bronchi Right and Left Pulmonary Bronchi Secondary Bronchi Secondary Bronchi Tertiary Bronchi Tertiary Bronchi Bronchioles Bronchioles Alveolar Duct Alveolar Duct Alveoli Alveoli

3 Lung Anatomy Right Lung Right Lung Superior lobe Superior lobe Middle lobe Middle lobe Inferior lobe Inferior lobe Left Lung Left Lung Superior lobe Superior lobe Inferior lobe Inferior lobe

4 Lung Anatomy on Chest X-ray PA View: PA View: Extensive overlap Extensive overlap Lower lobes extend high Lower lobes extend high Lateral View: Lateral View: Extent of lower lobes Extent of lower lobes

5 Lung Anatomy on Chest X-ray The right upper lobe (RUL) occupies the upper 1/3 of the right lung. The right upper lobe (RUL) occupies the upper 1/3 of the right lung. Posteriorly, the RUL is adjacent to the first three to five ribs. Posteriorly, the RUL is adjacent to the first three to five ribs. Anteriorly, the RUL extends inferiorly as far as the 4th right anterior rib Anteriorly, the RUL extends inferiorly as far as the 4th right anterior rib

6 Lung Anatomy on Chest X-ray The right middle lobe is typically the smallest of the three, and appears triangular in shape, being narrowest near the hilum The right middle lobe is typically the smallest of the three, and appears triangular in shape, being narrowest near the hilum

7 The right lower lobe is the largest of all three lobes, separated from the others by the major fissure. The right lower lobe is the largest of all three lobes, separated from the others by the major fissure. Posteriorly, the RLL extend as far superiorly as the 6th thoracic vertebral body, and extends inferiorly to the diaphragm. Posteriorly, the RLL extend as far superiorly as the 6th thoracic vertebral body, and extends inferiorly to the diaphragm. Review of the lateral plain film surprisingly shows the superior extent of the RLL. Review of the lateral plain film surprisingly shows the superior extent of the RLL.

8 Lung Anatomy on Chest X-ray These lobes can be separated from one another by two fissures. These lobes can be separated from one another by two fissures. The minor fissure separates the RUL from the RML, and thus represents the visceral pleural surfaces of both of these lobes. The minor fissure separates the RUL from the RML, and thus represents the visceral pleural surfaces of both of these lobes. Oriented obliquely, the major fissure extends posteriorly and superiorly approximately to the level of the fourth vertebral body. Oriented obliquely, the major fissure extends posteriorly and superiorly approximately to the level of the fourth vertebral body.

9 The lobar architecture of the left lung is slightly different than the right. The lobar architecture of the left lung is slightly different than the right. Because there is no defined left minor fissure, there are only two lobes on the left; the left upper Because there is no defined left minor fissure, there are only two lobes on the left; the left upper

10 Lt Lower Lobes Left lower lobes Left lower lobes

11 Lung Anatomy on Chest X-ray These two lobes are separated by a major fissure, identical to that seen on the right side, although often slightly more inferior in location. These two lobes are separated by a major fissure, identical to that seen on the right side, although often slightly more inferior in location. The portion of the left lung that corresponds anatomically to the right middle lobe is incorporated into the left upper lobe. The portion of the left lung that corresponds anatomically to the right middle lobe is incorporated into the left upper lobe.

12 RUL (Right Upper Lung)

13 RML (Right Middle Lung)

14 RLL (Right Lower Lung)

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16 LUL (Left Upper Lung)

17 LLL (Left Lower Lung)

18 Left Side Fissure LUL LLL

19 A structure is rendered visible on a radiograph by the juxtaposition of two different densities A structure is rendered visible on a radiograph by the juxtaposition of two different densities Chest Radiography: Basic Principles

20 Silhouette Sign Loss of the expected interface normally created by juxtaposition of two structures of different density Loss of the expected interface normally created by juxtaposition of two structures of different density No boundary can be seen between two structures of similar density No boundary can be seen between two structures of similar density

21 Right Lower Lobe Pneumonia

22 Differential X-Ray Absorption The absence of a normal interface may indicate disease; The absence of a normal interface may indicate disease; The presence of an unexpected interface may also indicate disease The presence of an unexpected interface may also indicate disease The presence of interfaces can be used to localize abnormalities The presence of interfaces can be used to localize abnormalities

23 Chest Radiographic Patterns of Disease Air space opacity Air space opacity Interstitial opacity Interstitial opacity Nodules and masses Nodules and masses Lymphadenopathy Lymphadenopathy Cysts and cavities Cysts and cavities Lung volumes Lung volumes Pleural diseases Pleural diseases

24 LUL Pneumonia

25 Air Space Opacity Components: Components: air bronchogram: air-filled bronchus surrounded by airless lung air bronchogram: air-filled bronchus surrounded by airless lung confluent opacity extending to pleural surfaces confluent opacity extending to pleural surfaces segmental distribution segmental distribution

26 Air Space Opacity: DDX Blood (hemorrhage) Blood (hemorrhage) Pus (pneumonia) Pus (pneumonia) Water (edema) Water (edema) hydrostatic or non-cardiogenic hydrostatic or non-cardiogenic Cells (tumor) Cells (tumor) Protein/fat: alveolar proteinosis and lipoid pneumonia Protein/fat: alveolar proteinosis and lipoid pneumonia

27 Interstitial Opacity: Small Nodules

28 Interstitial Opacity: Lines

29 Interstitial Opacity: Lines & Reticulation

30 Interstitial Opacity Hallmarks: Hallmarks: small, well-defined nodules small, well-defined nodules lines lines interlobular septal thickening interlobular septal thickening fibrosis fibrosis reticulation reticulation

31 Interstitial Opacity: DDX Idiopathic interstitial pneumonias Idiopathic interstitial pneumonias Infections (TB, viruses) Infections (TB, viruses) Edema Edema Hemorrhage Hemorrhage Non–infectious inflammatory lesions Non–infectious inflammatory lesions sarcoidosis sarcoidosis Tumor Tumor

32 Nodules and Masses Nodule: any pulmonary lesion represented in a radiograph by a sharply defined, discrete, nearly circular opacity 2-30 mm in diameter Nodule: any pulmonary lesion represented in a radiograph by a sharply defined, discrete, nearly circular opacity 2-30 mm in diameter Mass: larger than 3 cm Mass: larger than 3 cm

33 Nodules and Masses Qualifiers: Qualifiers: single or multiple single or multiple size size border definition border definition presence or absence of calcification presence or absence of calcification location location

34 Mass Calcification Well-Defined Ill-Defined

35 Lymphadenopathy Non-specific presentations: Non-specific presentations: mediastinal widening mediastinal widening hilar prominence hilar prominence Specific patterns: Specific patterns: particular station enlargement particular station enlargement

36 Right Paratracheal Lymphadenopathy

37 Right Hilar LAN

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39 Left Hilar LAN

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41 Subcarinal LAN *

42 AP Window LAN

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44 Cysts & Cavities Cyst: abnormal pulmonary parenchymal space, not containing lung but filled with air and/or fluid, congenital or acquired, with a wall thickness greater than 1 mm Cyst: abnormal pulmonary parenchymal space, not containing lung but filled with air and/or fluid, congenital or acquired, with a wall thickness greater than 1 mm epithelial lining often present epithelial lining often present

45 Cysts & Cavities Cavity : Abnormal pulmonary parenchymal space, not containing lung but filled with air and/or fluid, caused by tissue necrosis, with a definitive wall greater than 1 mm in thickness and comprised of inflammatory and/or neoplastic elements Cavity : Abnormal pulmonary parenchymal space, not containing lung but filled with air and/or fluid, caused by tissue necrosis, with a definitive wall greater than 1 mm in thickness and comprised of inflammatory and/or neoplastic elements

46 Cysts & Cavities Characterize: Characterize: wall thickness at thickest portion wall thickness at thickest portion inner lining inner lining presence/absence of air/fluid level presence/absence of air/fluid level number and location number and location

47 Benign Lung Cyst : PCP Pneumatocele Uniform wall thickness Uniform wall thickness 1 mm 1 mm Smooth inner lining Smooth inner lining

48 Benign Cavities : Cryptococcus max wall thickness  4 mm max wall thickness  4 mm minimally irregular inner lining minimally irregular inner lining

49 Indeterminate Cavities max wall thickness 5-15 mm max wall thickness 5-15 mm mildly irregular inner lining mildly irregular inner lining

50 Malignant Cavities: Squamous Cell Ca max wall thickness  16 mm max wall thickness  16 mm Irregular inner lining Irregular inner lining

51 Pleural Disease: Basic Patterns Effusion Effusion angle blunting to massive angle blunting to massive mobility mobility Thickening Thickening distortion, no mobility distortion, no mobility Mass Mass Air Air Calcification Calcification

52 Pleural Effusion

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54 Pleural Calcification

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56 SOME INTERESTING X-RAYS & DISCUSSIO N

57 Chest breast implants

58 Tip of ET Pneumomediastinum

59 wide mediastinum wide mediastinum obliteration of aortic knob obliteration of aortic knob Rt mainstem shift up and right Rt mainstem shift up and right NG deviate to right NG deviate to right pleural cap pleural cap Major Vessel Injury Potential X ray findings

60 Expiration reduces lung volume, making a small pneumo easier to see

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67 Irregular linear opacities are present in both lungs, especially in the periphery and the bases of the lungs. The heart is slightly enlarged, but this is not related to the pulmonary abnormalities in this case.

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70 Hodgkin’s Disease

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72 A single, 3cm relatively thin-walled cavity is noted in the left midlung. This finding is most typical of squamous cell carcinoma (SCC). One-third of SCC masses show cavitation

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74 LUL Atelectasis: Loss of heart borders/silhouetting. Notice over inflation on unaffected lung

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76 Right Middle and Left Upper Lobe Pneumonia

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78 Pseudotumor: fluid has filled the minor fissure creating a density that resembles a tumor (arrow). Recall that fluid and soft tissue are indistinguishable on plain film. Further analysis, however, reveals a classic pleural effusion in the right pleura. Note the right lateral gutter is blunted and the right diaphram is obscurred.

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80 Pneumonia:a large pneumonia consolidation in the right lower lobe. Knowledge of lobar and segmental anatomy is important in identifying the location of the infection

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83 24 hours after diuretic therapy

84 CHF:a great deal of accentuated interstitial markings, Curly lines, and an enlarged heart. Normally indistinct upper lobe vessels are prominent but are also masked by interstitial edema.

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