RADIOLOGY IMAGING
OF THE CHEST
Part II
The respiratory system
Interstitial lung disease
• The pulmonary interstitium is the network
of connective tissue fibres that supports
the lung. It includes the alveolar walls,
interlobular septa, and the
peribronchovascular interstitium
• Although the majority of the disorders
also involve air spaces, the predominant
abnormality – thickening of the
interstitium
Interstitial lung disease
Basic radiographic signs and
interpretation
Septal pattern
• Interstitial pulmonary oedema
• Lymphatic spread of tumour
Reticular pattern
• Fibrosin alveolitis
• Sarcoidosis
• Chronic alergic alveolitis
• Langerhans cell histiocytosis
• Lymphangioleiomyomatosis
Nodular pattern
• Silicosis
• Coal workers` pneumoconiosis
• Sarcoidosis
• Tuberculosis
• Subacute alergic alveolitis
Reticulonodular pattern
• Langerhans cell histiocytosis
• Sarcoidosis
• Lymphatic spread of tumour
Ground-glass pattern
• Subacute alergic alveolitis
• Pneumocystis carini pneumonia
• Nonspecyfic interstitial
pneumonia (NSIP)
• Idiopathic pulmonary
haemorrhage
Interstitial lung disease
Basic radiographic signs and
interpretation
Septal pattern
Thickening of the interlobular
septa – Kerley B lines,
short (1-2 cm) lines
perpendicular to the
pleura, continuous with it
Reticular pattern
The result of summation of
smooth or irregular linear
opacities, cystic spaces, or
both – interlacing line
shadows suggesting the
mesh
Nodular pattern
The accumulation of small
lesions within the
pulmonary inetrstitium
well circumscribed, discrete
nodules 2mm or lessmiliary nodules
Reticulonodular pattern
Ground-glass pattern
A generalized hazy increase
in opacity which obscures
the underlying vascular
markings on chest
radiograph
Interstitial lung disease
differential diagnosis
1. The predominant pattern of abnormality
2. Its distribution within the lung
3. The presence of associated findings:
a.
hilar or mediastinal lymphadenopathy
b.
c.
d.
cardiomegaly
pleural thickening
effusion
Case 1002
A 28 year old Afro-Caribbean woman presented with a
persistent dry cough and progressive exertional dyspnoea over
three months. She was not wheezy and had not noticed any
diurnal variation in symptoms. She was otherwise well with no
known allergies or hayfever. Clinical examination revealed no
abnormalities and her chest sounded normal.
•
•
What is the likely clinical diagnosis?
Which investigations would you request?
sarcoidosis
Sarcoidosis
A multisystem granulomatous disorder of unknown
aetioloogy characterized by the presence of
noncaseating epihelioid cell granulomas in several
affected organs (the skin, eyes, peripheral lymph
nodes, spleen, cns, parotid glands, bones)
A disease of young adults – a peak incidence in the
third decade
Traditionally staged according to its appearance of
the chest radiograph
I
– lymphadeopathy
II – lymphadeopathy with parenchymal opacity
III - parenchymal opacity alone
Sarcoidosis
Radiographic features
Lymphadenopathy
• Enlargement of
bilateral, symmetrical
hilar and paratracheal
• Occasionally
asymmetrical – 1-5%
• In 90% disappears
within 6-2 months
• Lymph nodes can
calcify - eggshell
fashion (shared only
by silicosis) seen on
plain films in 5%, on
CT scans – 40%
• Parenchymal changes
• Rounded or irregular
nodules 2-4mm in
diameter, which
maybe poorly or
moderately well
defined
• Patchy airpace
consolidation,
sometimes contain air
bronchograms, with ill
defined margins,
commonly break up
into nodular pattern
Industrial lung diseases silicosis
Due to the inhalation of silica (SiO2)
Radiographic appearance
- Multiple, small nodules, predominantly in
the middle and upper zones
- Enlargement of the hilar lymph nodes- an
eggshell patern
- Calcification occasionally seen in the
mediastinal, cervical and intra-abdominal
nodes
Micronodular pneumoconiosis
Nodular pneumoconiosis
Tuberous pneumoconiosis
Pneumoconiosis
Massive
fibrosis in
silicosis
Industrial lung diseases asbestosis
The silicates: asbestos 90% of malignant
mesotheliomas are related to previous exposure
to asbestos
Pleural changes
the pleural plque – well defined, soft tissue sheets
originating on the parietal pleural , usually
bilateral, in the middle and lower zones and over
the diaphragm
• When calcified – a „holly leaf” pattern with sharp,
often angulated outlines, usually less than 1cm
thick
• Diffuse pleural thickening
• Pleural effusions – uncommon 3%
Pulmonary changes - fibrosing alveolitis peripherally
at the lung basas
Case13 History:
A 62 yo gentleman comes to his family practice physician
complaining of shortness of breath. The patient normally
avoids physicians because he doesn't have insurance and he
feels that they are all quacks anyway. However, he has been
having more and more difficulty keeping up with his work on
the assembly line at an automobile factory and he fears
getting fired. The patient has 70 pack-year history of
smoking Camel Studs. Otherwise, he is a fairly healthy
individual. On physical exam his breath sounds are
diminished diffusely. A subsequent chest x-ray is shown on
the left.
Questions:
What is the most likely diagnosis?
What part of the history is pertinent to this diagnosis?
Emphysema
Condition of the lung characterized by
permanent , abnormal enlargement of air
spaces distal to the terminal bronchiole,
accompanied by the destraction of their
walls without obvious fibrosis
Is thought to result from the distraction of
elastic fibres – inbalance between
proteases and protease inhibitors, the
mechanical stresses of ventilation and
caughing
Emphysema
Radiological findings
Overinflation
a.
b.
c.
d.
e.
f.
The height of of the right lung being greater
than 29.9cm
Location of the right diaphragm at or below the
anterior aspect of the 7-th rib
Flattering of the hemidiaphragm
Enlargement of the retrosternal space
Widening of the sternodiaphragmatic angle
Narrowing of the transverse cardiac diameter
Emphysema
Radiological findings
Alterations in lung vessels
a. Arterial depletion, whereas vessels of normal
calibre are present in unaffected areas
b. Absence or displacement of vessels caused by
bullae
c. Widened branching angles with loss of side
branches and vascular redistribution
With the development of cor pulmonale or left heart
failure – the radiolographics appearences will
alter
Emphysema
CT, particularly HRCT scans the most accurate
mean! (low window values -800 to -1000 HU)
specially for surgery treatment
Presence of areas of abnormally low attenuation
Focal areas of emphysema usually lack distinct walls
as opposed to lung cysts
Types
1. Centrilobular
2. Panlobular
3. Paraseptal
4. Irregular
Emphysema
Bullae
• generaly found in patients with centrilobular
and/or septal emphysema
• Avascular, low-attenuation areas that are larger
than 1cm and that can have a thin but perceptible
wall
Bullous ephysema
• Associated with large bullae, mainly in young men
• Large, progressive upper lobe bullae, often
asymmetrical
• Avascular, transradiant areas separated from the
lung parenchyma by a thin curvilinear wall
• Complications: pneumothorax, infection,
haemorrhage
Emphysema
Emphysema
Emphysema
Emphysema
Emphysema
Diseases of the pleura
•
•
•
•
•
•
Pleural effusion
Bronchopleural fistula
Hemothorax
Chylothorax
Pneumothorax
Pleural masses
Case7 History:
A 54 yo male with a history of Hodgkin's Lymphoma
presents to his primary care physician with a oneweek history of shortness of breath and pleuritic
chest pain. The patient has also noticed a nonproductive cough that has progressively worsened
over the past two days. Physical exam
demonstrates diminished breath sounds and
egophony on the left. The chest x-ray on the left
was taken shortly thereafter.
Questions:
What is the diagnosis?
What findings on the x-ray help distinguish this condition
from other opacifications?
Pleural effusion bil
Collapse segment
Heart failure
Encysted effusion
case 6
Pleural effusion
The most common clinical
manifestation of pleural pathology
A result of mismatch between the
rates of inflow and outflow of fluid in
the pleural space
Pleural effusion
Transudates; Result from:
• a decrease in the colloid
osmotic pressure –
hypoproteinemia
• increase in the
microvascular hydrostatic
osmotic pressure (the
systemic venous pressure)
Causes:
• congestive heart failure
• cirrhosis
• nephrotic syndrome
• nephrogenic effusion
• hypoalbuminemia
• constrictive pericarditis
• atelectasis
• pulmonary embolism
Exudates; Result from:
• alteration in the pleural
surface
• an increase in permeability
• decrease in the lymph flow
Causes:
• pleural malignancy
• pleural inflammation
Pleural effusion
More than 90% of cases
caused by
• Heart failure
• Cirrhosis
• Ascites
• Pleuropulmonary
infections
• Malignancy
• Pulmonary embolism
Diagnostic imaging
• Chest radiograph
• CT
• Ultrasound
Radiographic features
Depends on the patient`s position and the
mobility of the pleural fluid
On the PA radiograph
• blunting of the lateral costophrenic angles
- 200ml-up to 500ml of fluid
• The most sensitive projection – the lateral
decubitus chest radiograph – 5ml
Radiographic features
In the erect patient
• Initially collects in the
subpulmonic region
• Blunting of the lateral
costophrenic angles
• Elevated hemidiaphram
sign - the superior margin
of the fluid mimics the
contour of the diaphragm –
apparent elevation of the
hemidiaphragm with
flattening of its medial
portion
• Opacity as hazy meniscus
higher laterally than
medially
In the spine patient position
• Capping of the lung apex
with pleural fluid –early
sign
• Increased hazy opacity
with preserved vascular
markings
• Blunting of the
costophrenic angle
• Hazy diaphragm silhouette
• Thickening of the minor
fissure
• Widened paraspinal soft
tissues
• Elevated hemidiaphragm
sign
Hemothorax
Most commonly results from trauma
Less common reasons:
• Varicella infections
• Coagulopathies
• Vaascular abnormalities
Chest radiogrph: a pleural effusion without
any distinguishing factor to suggest blood
in the pleeural space
Non contrast CT- the characteristic
attenuation increase
Chylothorax
Discruption of the thoracic duct
• 50%- neoplastic in origin lymphoma (75%)
• 25% traumatic - surgery
• 10% miscellaneous
• 15% idiopathic
Usually cannot be differentiated from other
effusions based on chhest radiographs or
CT scans
Pleural effusion
Pleural effusion
Pleural effusion
Pleural effusion
Pleural effusion
Pleural effusion
The effusion in pleural
adhesions
The effusion in pleural
adhesions - inside fissures
Case8 History:
This chest x-ray is from a 54 yo female who presented two
weeks prior to the current visit for a productive cough and
shortness of breath. The patient was diagnosed with
community acquired pneumonia and sent home with
antibiotics. She returns now stating that her cough and
shortness of breath have resolved but now she is
experiencing chest pain on deep inspiration. Her physical
exam reveals diminished breath sounds and dullness to
percussion on the left lower lung. The x-ray on the left was
then ordered.
Questions:
What is the diagnosis?
Does the normal appearance of the pulmonary vasculature
help with the diagnosis?
Does the patient history help narrow the differential?
Pyothorax, thoracic
empyema
Pleural adhesions
Pleural adhesions
Pleural adhesions
Case4 History:
A 6'4", thin smoking 32 yo male presents to the ER with
shortness of breath and chest pain. The patient reports that
he was just going for a jog when he became severely short
of breath and began having chest pain that was retrosternal
and slightly to the left. The patient has not history of lung
disease but has been smoking about 1 ppd for over 10
years. Physical exam shows absent breath sounds on the
left and hyperresonance to percussion. The x-ray on the
left was taken in the ER.
Questions:
•What is the diagnosis?
•How does the pulmonary vasculature help you make your
diagnosis?
Case1 History:
A 26 yo male came to the ER complaining of shortness of
breath and some left-sided chest pain. The patient was
snowboarding at a local resort when he lost control going
off a jump. The patient reports landing directly on his left
side after falling approximately 10 feet . The symptoms
started immediately after the fall. On physical exam the
patient has decreased breath sounds on the upper left lung.
The patient was given an AP chest x-ray in the ER, which is
shown on the left.
Questions:
What is the diagnosis?
Is this a common location for this condition?
Case3 History:
A 54 yo alcoholic male presents to the ER following
an evening of heavy drinking with chest pain and
dyspea. The patient reports that he had multiple
episodes of violent vomiting and then passed out.
When he awoke, he was having chest pain that was
worse on inspiration and radiated to his neck with
each breath. Physical exam was normal and MI
work up came out negative. The x-ray on the left
was taken shortly after admission.
Questions:
What is the diagnosis?
What part of the patient's history is applicable to the diagnosis?
Asthma
Mediastinal air
Pneumothorax – gas or air in
the pleural space
Spontaneous
• Primary – no
identifiable cause,
often related to an
apical intrappleural
bleb rupture
• Secondary with
related undrelying
lung parenchymal
disease
Traumatic
• Blunt or penetrating
trauma
• Iatrogenic causes –
central venosus
catherization,
transbronchial or
transthoracic biopsy
Pneumothorax
• Chest radiograph
• Identification of a radiolucent air space
separating the visceral pleural line from
the parietal pleura
• Pulmonaryu vessels extend to the edge of
the visceral pleural line,nor beyond
• More sutable- on CT scans
Pneumothorax
Pneumothorax
Mediastinal emhysema,
pneumothorax with fluid
Bronchopleural fistula - fistulous
communication between the pleural
space and the bronchial tree
Causes – the most
common: necrotizing
pulmonary infections
and surgical lung
resections
• penetrating and blunt
lung injures
• pleural drains
• thoracentesis
• ventilator support
May be seen (x-rays, CT)
as
• hydropneumothorax,
an intrapleural airfluid collection
• extansion of the airfluid level to the
chest wall
• unequal linear
dimensions on
orthogonal views
Pneumothorax
Bronchopleural fistula : pneumothorax + pyothorax
Pleural masses
Benign
• Lipoma
• Fibroma
• Asbestos related
disease
• Rounded
atelectasis
Malignant
• Metastatic 95&
• Brest or lung
carcinoma,
• Thymma
• Lymphoma
• Diffuse malignant
mesothelioma
Diffuse malignant
mesothelioma
• rare and agressive 20003000 cases per year in
USA
• Men 2-6x more often than
women 50-70 y
• Symptoms: chest pain,
dyspnea, cough, weight loss
• The association with
asbestod strongly
established
Tumor may further extend to
the thoracic wall,
contralateral chest,
• abdomen
Chest radiograph
• Irregular, nodular,
peripheral pleural opacities
with associated pleural
effusion
• 40-86% extension to into
interlobar fissures
CT
• Wide spread of nodular
pleural thickening with
mediastinal surface
involvment
• Encasement of the lung
• Extension into the
interlobar fissures
Mesothelioma pleure
Mesothelioma
Mesothelioma pleure
The patient shown below
most likely has:
a.
b.
c.
d.
e.
Atelectasis of the left lung
A large left pleural effusion
A large right pneumothorax
Pneumonia in the left lung
Unilateral pulmonary edema
The patient shown
below most likely has:
a.
b.
c.
d.
e.
A large right pleural effusion
A large left pneumothorax
Atelectasis of the right lung
Pneumonia in the right lung
Unilateral pulmonary edema
The patient shown
below most likely has:
a.
b.
c.
d.
e.
A large left pleural effusion
A large right pneumothorax
Atelectasis of the left lung
Pneumonia in the left lung
Unilateral pulmonary edema
The patient shown
below most likely
has:
a. A large left pleural effusion
b. A large right pneumothorax
c. Atelectasis of the left lung
because of a mucus plug
d. Pneumonia in the left lung
e. Atelectasis of the left lung
because the ETT is too low
The patient shown
below most likely
has:
a. There is a large left pleural
effusion
b. There is a large right
pneumothorax
c. Atelectasis of the left lung
because of a mucus plug
d. Pneumonia in the left lung
e. The left lung has been surgically
removed