PULMONARY

RADIOLOGY
 Back to the Basics:
- Densities in Radiographs
- Common Radiographic Views
- Normal Chest Radiographic Interpretation
- Anatomic and Physiologic Basis of
Pulmonary Diseases
 Cases:

Radiographic presentation
Clinical Application
Densities in Radiographs
 AIR-FILLED FATTY VARIOUS
STRUCTURES TISSUE FLUIDS

BULLAE/ (N) BREAST CHYLO- PLEURAL PUS/

PNEUMOTHORAX TISSUE =MAMMO THORAX EFFUSION BLOOD

BLACK WHITE
( LUCENT ) ( DENSE )
 SOLID BONE/ CONTRAST METALS
TISSUES/ BARIUM & IODINE LEAD
MASSES
CALC’N

GRAY TO
WHITE WHITE
( DENSE ) ( DENSE )
Lead blocks passage of x-rays
& used for shielding
 DENSITIES
Air < Fat < Liver < Blood < Muscle < Bone < Barium < Lead

 Air —  density : allow x-ray beam to hit film  black

( lungs, gastric bubble, trachea, bifurcation of bronchi)
 Fat — breasts
 Fluid — most of what you see
( vessels, heart, diaphragm, soft tissues, mediastinum)
 Minerals — density (or radiopaque) of body structures;
(mostly Ca++; bones ,vascular calc’ns ,granulomas;
contrast , bullets, safety pins, etc. )

*Thickness & composition determine radiodensity

* Radiologic Image = sum and diffierences in densities
between x-ray beam source & film
Radiographic
Positions
 POSTERO-ANTERIOR VIEW
X-ray
tube

6 feet

Film

 upright position – better evaluation of vascular distribution

 deep inspiration – good aeration of lung  volume
  crowding of structures & magnification

 heart is closer to film, less magnification

  energy beam - better quality
 ANTERO-POSTERIOR VIEW

film

X-ray
tube

 heart magnified
 higher diaphragms
  lung volume (+) crowding
film under
patient  difficult to assess vascularity
 AP view:
light / lesion/heart
X-ray far from film

lesion/
heart

Film
PA view:
lesion/heart
near film

 heart & lesions should be near

the film  distortion &
magnification
 LEFT/RIGHT LATERAL (90°)
& OBLIQUE (45°) VIEWS

 evaluate “blind spots” –sternum /retro-sternal & retro-cardiac

areas or obscured by soft tissues & osseous structures
 3-D image ≈ 10% of lesions seen only in lateral view
 APICOLORDOTIC VIEW

tube elevated
& angled 45º

 see apices obscured by

clavicle and first ribs
 ancillary view
 LATERAL DECUBITUS

 outline fluid levels in

cavities & free pleural fluid
Normal Chest Radiograph
Interpretation
 1st p.rib
3 cm

Aortic
knob L hilum/
60º; <90º Left PA
R hilum >100º LAE
1.5 cm Rt PA LA
RA A
CTR = A
RV
LV B
B
< 0.52

9th p.rib
Lt CPS
Rt CPS
 Superior
Mediast.
sternal
T4
angle
Ant
Med. trachea
retrosternal
space
RV
LA
Middle
Mediast.
LV
Post. retrocardiac
Mediast space

 Lateral view provide landmarks for mediastinal compartments

 Fissures
Rt. minor/
horizontal
fissure

major fissures
T3 - -- T10

Hilum to rib 6

right
major f
left
majo
r f.
Rt major Lt. major
fissure pleural outline
fissure

 maybe thickened due to fluid, fat, air, tumor & reactive ’s
Anatomic and Physiologic Basis of
Air-Space & Interstitial Diseases
 AIRSPACE SPACE DISEASES
“CONSOLIDATION”
Air in alveoli replaced by:
Fluid (Pulmonary Edema)
Blood (Hemorrhage)
Cells (Tumor)
Inflammatory exudates
( Infections -bacteria &
mycobacteria)
Lipoprotein (Alveolar
proteinosis)
X-ray:
coalescing homogenous
opacities
“patchy”
“segmental”
“lobar”
“ diffuse consolidations”
Air Space Air Aveologram
Nodules

lucencies/air
incompletely
alveoli

poor margination
4-10 mm
 Air-Bronchogram Sign

Air-bronchogram
Sign
 air-filled bronchus
look like radiolucent
"tubes"
 airways OK but
surrounding lung
tissues airless
 Air-way Opacities Distribution
Diffuse Segmental

‘butterfly”
medullary
distribut’n

PULMONARY EDEMA SEPTIC INFARCTS

•Time factor: rapidity of appearance & resolution of infiltrates clue to
etiology e.g. hem’ge vs. infxn vs. neoplasm
•Alveolar + interstitial pattern co-exist
 Silhouette Sign Silhouette Adjacent lobe/s
egment
* an intrathoracic lesion Right RLL/Basal
touching a border of the heart, Diaphragm segments
aorta or diaphragm will Right Heart RML/Medial
obliterate that border in an x-ray margin segment

Ascending RUL/Anterior
Aorta segment

LUL/Posterior
Aortic knob
segemnt

Left Heart Lingula/Inferior

margin segment

LLL/Superior &
Descending
medial
Aorta
segments

LLL/Basal
Left Diaphragm
segments
Consolidation of Lung Segments

RIGHT
LEFT
LEFT
RIGHT
RIGHTLOWER
LEFTUPPER
UPPER
MIDDLE
LOWER LOBE
LOBE
LINGULA
LOBE
Atelectasis
 INTERSTITIAL DISEASE
visceral pl parietal pl  Alveolar Walls:
“ perihilar haze”
perivasc. sheath
bronchus
 Axial : connective tissue support
pulmo art& bronchi
“peribronchial thickening”

vein Interlobular septa:

pulmo.veins & lymphatics
“Kerley A,B,C lines”
LUNG MEDIAST.
 Subpleural /Peripheral:
Interstitium –Skeleton of Lungs “ thickening of interlobar fissures”
* edema, tumor, infxn, fibrosis
“reticular”
“septal”

“nodular” “reticulo-
nodular”
 SEPTAL
Peribroncial
INTERSTITIAL
Perhilar Cuffing
EDEMA
Haziness
Kerley B-lines
 Reticular /
Honeycomb Nodular

thick
interlob
honey-comb septa

INTERSTITIAL FIBROSIS MILIARY TB

 Interstitial Alveolar
Disease
Peribronchial
cuffing

perihilar
haze

DAY 1 PNEUMOCYSTIS CARNII DAY 9

 ADULT RESPIRATION
DISTRESS SYNDROME
 PNEUMONIA
“Radiology alone was unable distinguish
bacterial from non-bacterial pneumonia”
Tew J, Calenoff L, Berlin B. : Bacterial or
Non-bacterial pneumonia: Accuracy of Radiographic Diagnosis

Classification based on morphology:

1- lobar pneumonia
2- bronchopneumonia
3- acute interstitial pneumonia

Classification based on mechanism of origin:

Community-Acquired Pneumonia (CAP)
Nosocomial pneumonia (NP)
Aspiration pneumonia (AP)
LOBAR PNEUMONIA:
* confluent areas of air-space infected mucoid particles
disease limited to one segment lung periphery
or lobe
tissue react– watery
Al edema fluid into alveoli
v
w/ eoli
flu
id
spread via small airways &
collaterals: pores of Kohn/
canals of Lambert

exudates spread adjacent

lobules & segments

fluid serve as culture

media for bacteria
& alveolar wall (+) PMN’s
 Round Pneumonia

 non-segmental sublobar & well circumscribed

due to uniform involvement of adjacent alveoli
Lobar Pneumonia
 BRONCHOPNEUMONIA
LOBULAR PNEUMONIA
*airway mucosa
ulceration

fibrinopurulent exudates

bronchial walls spread involve

central
to peribronchial airway
alveoli filled w/ hem’gic
fluid & neutrophils
basal

may spread to lobes Peribronchial thickening

mix air-space & interstitial
markings – small
pattern; segmental
ill-defined atelectasis
nodularities
 ACUTE
INTERSTITIAL
PNEUMONIA
* diffuse bilateral
reticulo-nodular
interstitial pattern
* bronchitis - -
peribronchial thickening
**Common etiologic agents:
Viral and Mycoplasma

MYCOPLASMA PNEUMONIA
 Community Acquired Pneumonia

 Most common
pathogens
 S. Pneumoniae
limited by
(48%) pleural sfc
peripheral
loc. develop
 Viruses (19%)
pl.effusion
 H. Influenzae
(20%)
 C. Pneumoniae
(13%)
 M. Pneumoniae
(3%)
 Nosocomial
Pneumonia

*commonly bilateral with diffuse

or multiple foci of consolidation
not limited to one lobe
* frequently associate pleural
effusion
 Aspiration
Pneumonia
*air-space opacities

*dependent portion of lung :

RML & RLL

* maybe bilateral ,
multicentric perihilar and
basal distribution
Lung Abscess
Lung Abscess
Fungus Ball
Tuberculosis
Cavitary Tuberculosis
 Tuberculosis

CAVITARY TB W/ MILIARY NODULES

S/P SIX MONTHS
PRIOR TOTHERAPY
TX
45 YEAR OLD FEMALE WITH WEIGHT LOSS
LOW GRADE FEVER AND BODY WEAKNESS

Miliary nodules : 2- 3 mm
Post-primary hematogenous spread
of TB w/ granulomatous response
DDx: varicella pneumonia & metastasis
PLEURAL DISEASE
Pneumothorax

100% 75% 50% 25%

 Pneumothorax

Collapsed
Lung
re-expansion
of lung

Tension
Pneumothorax
Pneumothorax
Pleural Effusion
Loculated Pleural Effusion
(Empyema thoracis)
Mesothelioma
AIRWAY DISEASES
 Bronchiectasis

27 year old male w/ dyspnea, chronic

productive cough & hemoptysis

 “Monocle sign”- Normally
the bronchiole
& arteriole should be
the same size

arteriole

“Signet Ring”sign
Thickening
& dilatation
of bronchi

bronchiole
Emphysema
 Foreign Body
causing Atelectasis
Atelectasis
right lung
Upper lobe

Middle lobe Lower lobe

NEOPLASMS
Pancoast tumor
Bronchogenic Carcinoma

 A- intrapulmonary mets
 B- main tumor
 C- lymph nodes
 D- aorta
 E- right mainstem bronchus
Metastasis
Lymphoma
Lymphoma
Aortic Aneurysm
GOOD DAY!