Teaching point #2
• Choose and utilize a standardized way to view
each radiograph
– Alphabet method
– BIO (Between, inside, outside the lungs)
– Top down
– Other
• My approach: Abnormalities, right lung, left lung, compare
the two lungs, trachea, mediastinum, heart, outside the
lungs (including abdomen) and bones
Now that you have a search pattern
• What structures should you normally see?
– Anatomy important for lines and tubes
•
•
•
•
•
Trachea and carina
Aortic arch
Cavoatrial junction
Subclavian vein/artery
Internal jugular vein
Trachea
Carina
Right main bronchus
Left main bronchus
SVC
Aortic arch
Aortopulmonary recess
Main Pulmonary Artery
Cavoatrial junction
Cavoatrial junction
• Our perspective on most central lines
– Is it central? Yes = good
– Is it flopping around hitting the AV Valve? Yes = bad
– Close to the CAJ is fine
– CAJ landmarks
• About 2 cm below the bulge of the right atrial appendage
• About 2 vertebral bodies below the carina (better for peds)
Appropriately placed IJ line?
Lobar anatomy
• Lesson for today – the upper lobes aren’t just
at the top of the CXR, and the lower lobes
aren’t just at the bottom.
Right Lung: Lobes and Fissures
Lobar Anatomy:
Right Upper & Right Middle Lobes
RUL
RUL
RML
RML
Lobar Anatomy:
Right Lower Lobe
RLL
RLL
Lobar Anatomy:
Left Upper Lobe
LUL
LUL
Lobar Anatomy:
Left Lower Lobe
LLL
LLL
Which lobe is collapsed?
Which lobe has a pneumonia?
Pattern and Distribution
• Abnormalities have
two important
imaging clues:
– Pattern of disease
– Distribution of disease
location, location,
location!
Patterns
•
•
•
•
Consolidation
Ground Glass
Lines (interstitial or septal thickening)
Reticulation
– Peripheral Lace-like opacities
• Cysts
• Nodules
– Tree-in-Bud or Budding Tree opacities
Patterns
• *Infiltrate is not one of these patterns*
•
•
•
•
•
•
Consolidation
Ground Glass
Lines (interstitial or septal thickening)
Reticulation
Cysts
Nodules
We can do better
• “Infiltrate”: A vague term at best, used to
describe any abnormality. Avoid it!
• Lung “fields”: Fields are for cows! They are
lungs or lobes
• “Poor inspiratory effort”: Low lung volumes
is at least more appropriate
• “Nonspecific”: Earn your paycheck
Fields are for cows

Patterns
• Consolidation
• Ground Glass
•
•
•
•
Lines (interstitial or septal thickening)
Reticulation
Cysts
Nodules
– Tree-in-Bud or Budding Tree opacities
Distribution of Disease
• Focal (or multifocal) versus diffuse
• Dependent distribution (varies with position!)
•
•
•
•
Upper lobe
Bronchovascular
Peripheral
Random
Normal versus consolidation
Acute Consolidation
Indeterminate White Blob (IWB)
• Infection
– Bacterial pneumonia
• Water
– Pulmonary edema
• Blood
– Pulmonary hemorrhage,
contusion
Acute?
Think Infection, Water, Blood
Normal
Ground Glass
Acute Ground Glass Opacity
Indeterminate White Blob (IWB)
• Infection
– PCP, viral pneumonia
• Water
– Pulmonary edema
• Blood
– Pulmonary hemorrhage
17 yo Male: Sudden Onset Dyspnea
Acute Ground Glass Opacity (2 Weeks of
symptoms) & Upper Lobe Distribution
Diffuse GGO versus focal consolidation
Questions?
Teaching points
1) Name the 5 densities that are seen on standard
radiographs
2) Choose and utilize a standardized way to view
each radiograph
3) Locate the following anatomic structures:
– Trachea, carina, subclavian artery and vein, SVC,
cavoatrial junction
4) Name the 6 patterns seen on chest imaging
Teaching points
• Name the 5 densities that are seen on standard
radiographs
Air
Fat
Densities Water/tissue
Bone
Metal
Teaching points
• Choose and utilize a standardized way to view
each radiograph
– Alphabet method (Airspaces, Bones, Cardiac, etc.)
– BIO (Between, inside, outside the lungs)
– Top down
– Other
Teaching points
• Locate important anatomic structures:
– SVC begins at approximately the 1st anterior rib
space
– Cavoatrial junction: 2 cm below the initial SVCright atrium bump, or about 2 vertebral bodies
below the carina
– Carina is the branch point of the trachea, it’s
usually directly identifiable
• If it’s not, it should be around T6
Teaching Points
• Consolidation
• Ground Glass
•
•
•
•
Lines (interstitial or septal thickening)
Reticulation
Cysts
Nodules
– Tree-in-Bud or Budding Tree opacities