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Chest Imaging

• RADIOLOGY DEPARTMENT

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IMAGING MODALITIES

1. Plain chest Radiograph
2. Fluoroscopy
3. Computerized tomography
4. Radionuclide lung scan
5. MRI
6. Ultrasound
7. Pulmonary angiography

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Plain chest radiograph

• Diagnostic in 80 cases
• Standard views
• Postero-anterior(P/A)
• Lateral (right/left)
• Additional views
• Oblique view(ribs)
• Apical lordotic view
• Expiration view
• Decubitus view

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Computed Tomography

• Numerous protocols/techniques depending on
  clinical history
• Helical/spiral versus high resolution
• Contrast
• Renal failure
• Allergy

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Computed Tomography

• Role of CT
• Main further investigation for most CXR
  abnormality (eg nodule/mass) or to exclude
  disease with normal CXR
• Main investigation for certain scenarios (PE,
  dissection, trauma)

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MRI

• Multiple planes
• No radiation
• Common Indication
• Pancoast tumour
• Brachial plexus
• Cardiac
• Vascular (aorta)
• Usually targeted examination (unlike CT)

Coronal
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Nuclear Medicine

• Variety of tests functional rather than anatomic
• V/Q specific to chest imaging
• Others bone scan, gallium, WBC etc.

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Ultrasound

• Limited use in thorax (non cardiac) due to air in
  lungs
• Assess pleural effusions
• Mainly used for procedures

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Chest Radiographs

• PA (posterior to anterior) and Lateral (left)
• Minimizes magnification of heart (heart closest
  to film)
• Portable (nearly always AP)
• Supine or Erect
• Specialized Views
• Lordotic
• Lateral decubitus (for effusions, pneumothorax)

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Lordotic View
Better assess apices without bone overlap
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Postero-anterior view (PA)
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Check technique
1 Adequate penetration of the mediastinum-is the
thoracic spine seen?
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a
a
2 Has the patient taken a good inspiratory
effort? About 8-10 posterior thoracic ribs should
be seen through the lungs
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3 Is there any rotation of the chest?
Assessed by checking the upper thoracic spinous
process (oval) in relation to the medial ends of
the clavicles (lines a) - this CXR is rotated
to left
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Retro cardiac space
Retro sternal space
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Chest Radiograph Approach andNormal Anatomy

• THERE IS NO ONE APPROACH BE SYSTEMATIC
• Bone and Soft Tissue including abdomen
• Heart
• Mediastinum-aorta, trachea
• Hila
• Pulmonary Vasculature
• Lungs
• Pleura

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Sequence For X Ray Reading

• 5 Ds
• Detect
• Describe
• Differential Diagnosis
• Discuss
• Diagnosis

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CXR Superimposition
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CT Coronal Reconstruction
Right Brachiocephalic Vein
Left Brachiocephalic Vein
Superior Vena Cava
Right Atrium
Inferior Vena Cava
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Heart Size

• Normal is lt50 on PA upright radiograph

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Increased Cardiac Size
Normal for comparison
Cardiomegaly (Big heart)
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Aorta
MRI of Aorta
PA view
Aortic arch
Descending Aorta
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Aorta
CXR Lateral View
Ascending Aorta
Descending Aorta
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Case Aorta can be enlarged (aneurysm)
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Pulmonary Artery
Coronal Image
PA
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inspexp

• Spine Sign Lungs posteriorly should get darker
  as you go down more inferiorly

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Case (Look at the trachea)
Trachea is Deviated by large mass (goiter)
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Abnormal Cases

• Bone
• Cardiovascular
• Airspace Disease including Silhouette Sign
• Interstitial Disease and Pulmonary Edema
• Atelectasis
• Pulmonary Nodule
• Pleura and Diaphragm
• Mediastinal Mass

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Terminology used in the interpretation of CXR
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ACINAR PATTERN (CXR) Radiology Round or
elliptical ill-defined 4-8mm opacities in
lung Microscopic Portion of lung distal to
terminal bronchial (respiratory bronchial,
alveolar duct, alveolar sac and alveoli) is the
acinus
CXR close up of acinar pattern
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ACINAR PATTERN (CT SCAN) Round or elliptical
ill-defined 4-8mm opacities in lung
CT scan of right upper lobe showing typical
acinar pattern (arrow)
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AIR BRONCHOGRAM Air containing bronchus
peripheral to the hilum surrounded by airless
lung
CXR
CT Scan
Air Bronchogram
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NODULAR PATTERN Collection of innumerable small,
linear and nodular opacities together producing
a net with small superimposed nodules.
CT
CXR
Close up of nodular pattern
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EMPHYSEMA Abnormally expanded air spaces distal
to terminal bronchiole with destruction of walls
of involved air spaces..
BULLA Gas containing avascularity of lung
measuring 1cm or more in diameter, 1mm thickness
Bulla
CT of bulla
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Pneumonia (consolidation)

• Air bronchograms would confirm an alveolar
  process.
• The lung volume should not be lost (may even be
  increased).
• Usually all radiographic abnormalities should
  disappear after 6 weeks of appropriate antibiotic
  therapy.

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Pneumonia RML
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Right Upper Lobe Pneumonia
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Left Lingular Pneumonia
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Left Lower Lobe Pneumonia
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Pneumonia RLL
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Consolidation and follow-up X-rays

• Recommendations are, repeat film at 1, 3 and 7
  days to check for the development of
  complications.
• Resolution of the X-ray signs always lags behind
  the clinical findings
• The X-ray should therefore be repeated 4 weeks
  later to check for resolution.
• If there is persistent consolidation at this
  stage, further investigation is necessary to
  exclude an obstructive lesion.

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SIGNS OF COLLAPSE

• DIRECT SIGNS
• Displacement of fissures
• Loss of aeration
• Vascular bronchial signs
• INDIRECT SIGNS
• Mediastinal Hilar displacement
• Elevation of Hemidiphragm
• Compensatory hyperinflation

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Collapse RUL
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Collapse LUL
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Left lower lobe collapse

• Further investigations?

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Diagnosis LLL Collapse

• Collapse secondary to central obstructing tumour

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Pleural Effusion
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Small Pleural Effusion
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Small Pleural Effusion
Normal Sharp Angles
Blunted posterior costophrenic sulcus
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Pleural Effusion
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Tension Pneumothorax
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ptxinspexp
Expiration
Inspiration
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hugeptx
Collapsed Right Lung
What would you do with this patient?
Tension Pneumothorax Requires chest tube
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Causes of a pneumothorax

• Spontaneous
• Iatrogenic/trauma,
• Obstructive lung disease, e.g. asthma, COPD
• Infection, e.g. pneumonia, tuberculosis Cystic
  fibrosis
• Connective Tissue Disorders, e.g. Marfans,
  Ehlers-Danlos

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Pneumomed
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Diagnosis Pneumomediastinum
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Coin Lesion
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Causes of single coin lesions

• Benign tumor, e.g. hamartoma
• Malignant tumor, e.g. bronchial carcinoma, single
  secondary
• Infection, e.g. pneumonia, abscess, tuberculosis,
  hydatid cyst
• Infarction
• Rheumatoid nodule

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Solitary Pulmonary Nodule can be
Benign Densely calcified nodule
Malignant Adenocarcinoma
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Cavitating lung lesion
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Causes of cavitating lung lesions

• Abscess
• Neoplasm
• Cavitating pneumonia
• Cavitations in infarct
• Rheumatoid nodules (rare)

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Left Ventricular Failure
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CASE 1
1What is your diagnosis 2 Give differential
diagnosis for upper lobe fibrosis
History Young patient with cough and night sweats
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Normal
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Severe heart failure

• Severe pulmonary edema gives confluent alveolar
  shadowing which spreads out from the hilum giving
  a 'bat's wing' appearance.
• If this is the cause of generalized shadowing
  then upper lobe blood diversion and Kerley B
  lines should be present.
• In pulmonary edema hilum may appear distended and
  the vessels close to the hilum may be blurred.

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Severe heart failure vs. non-carcinogenic
pulmonary edema

• In non-cardiogenic pulmonary edema the heart size
  is likely to be normal and there will not
  necessarily be sparing of the peripheries.

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COPD
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Bronchiectasis
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Causes of Bronchiectasis

• Structural, e.g. Kartagener syndrome,
• obstruction (carcinoma, foreign body)
• Infection, e.g. childhood pertussis or measles,
  tuberculosis, pneumonia
• Immune, e.g. hypogammaglobulinaemia, allergic
  bronchopulmonary aspergillosis
• Metabolic, e.g. cystic fibrosis
• Idiopathic to stasis

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Unilateral Hilar enlargement
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Unilateral Hilar Enlargement

• Causes of hilar lymphadenopothy
• Neoplastic, e.g. spread from bronchial carcinoma,
  primary lymphoma
• Infective, e.g. tuberculosis
• Sarcoidosis (rarely unilateral)
• Causes of hilar vascular enlargement
• Pulmonary artery aneurysm
• Poststenotic dilatation of the pulmonary artery

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Bilateral Hilar Enlargement
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Bilateral Hilar Enlargement

• Causes of bilateral hilar lymphadenopathy
• Sarcoid
• Tumors, e.g. lymphoma, bronchial carcinoma,
  metastatic tumors
• Infection, e.g. tuberculosis, recurrent chest
  infections, AIDS
• Berylliosis
• Causes of pulmonary hypertension
• Obstructive lung disease, e.g. asthma, COPD
• Left heart disease, e.g. mitral stenosis, left
  ventricular failure
• Left to right shunts, e.g. ASD, VSD
• Recurrent pulmonary emboli
• Primary pulmonary hypertension

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NORMAL
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Sarcoidosis
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benignthymoma
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Lateral shows mass is anterior
NORMAL
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Computed Tomography
Thymoma
Do you know of any associated clinical syndrome?
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Presenting CXR
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MRI
Computed Tomography
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pulmedema
SOB
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Same Patient
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baseline
Same Patient Baseline
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Rul collapse
RUL Collapse
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Lul consolidation
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Diagnosis LUL Consolidation
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Paratracheal ln
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Right Paratracheal Lymphadenopathy
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Rml consolidation
RML Consolidation
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50 y.o female with progressive SOB. What can you
do to improve SOB?
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Volume loss with atelectasis
Mass effect with large effusion
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baseline
Mastectomy
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hh
Hiatus hernia
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Where is the Lymphadenopathy?
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Nipple Shadow