Chest Imaging

Damascus University
Faculty of Medicine
5th Year
CHEST IMAGING / PART 3
Dr. Said Huwaijah
Assistant prof.
Head division of Radiology department
Al-Asad university Hospital
2013
Classifying Lung Disease

Diseases that affect the lung can be divided into
two main categories:
1- Airspace (alveolar) disease
2- Interstitial (infiltrative) disease
Characteristics of Airspace
Disease
1.
Produces opacities in the lung which can be
described as fluffy, cloudlike, or hazy
 These fluffy opacities tend to be confluent,
 The margins of airspace disease are indistinct,
2.
Airspace disease may be distributed throughout
the lungs, as in pulmonary edema, or it may appear
to be more localized as in a segmental or lobar
pneumonia
3.
Airspace disease may contain air bronchograms.
 An air bronchogram is a sign of airspace disease.
 What can fill the airspaces besides air?

Fluid, such as occurs in pulmonary edema

Blood, e.g., pulmonary hemorrhage

Gastric juices, e.g., aspiration

Inflammatory exudate, e.g., pneumonia

Water, e.g., near-drowning
Pulmonary
Alveolar Edema
bilateral , perihilar airspace
disease sometimes described as
having a bat-wing or angel-wing
configuration
 Edema may be asymmetrical but
is usually not unilateral .
 Pulmonary edema that is cardiac
in origin is frequently associated
with pleural effusions and fluid
that thickens the major and
minor fissures .

Characteristics of Interstitial
Disease

It having three patterns of presentation:
1)- Reticular interstitial disease appears as a network
of lines



Pulmonary interstitial edema
Idiopathic palmary fibrosis
Rheumatoid lung
2)- Nodular interstitial
assortment of dots .
o
o
disease
appears
as
an
Bronchogenic carcinoma
Metastases to the lung
3)- Reticulonodular interstitial disease contains both
lines and dots
o
Sarcoidosis
Linear Interstitial
Nodular Interstitial
Reticulonodular Interstitial
PULMONARY INTERSTITIAL EDEMA


Pulmonary interstitial edema can occur because of increased capillary
pressure (congestive heart failure) . increased capillary permeability
(allergic reactions) , or decreased fluid absorption (lymphangitic
blockade from metastatic disease)
Considered the precursor of alveolar edema , pulmonary interstitial
edema classically manifests four key radiologic findings : fluid in the
fissures (major and minor) , peribronchial cuffing (from fluid in the
walls of bronchioles) , pleural effusions , and kerley B lines.
IDIOPATHIC PULMONARY FIBROSIS

best demonstrated on high-resolution CT scans
There is marked
thickening of the
interstitium ,
bronchiectasis ,
and small cystic
apace in the lung
called
honeycombing .
Atelectasis
Atelectasis is a loss of volume in some or all of the lung, usually
leading to increased density of the lung involved.
Signs of Atelectasis
 1)-Displacement (shift) of the interlobar fissures (major and minor)
toward the area of atelectasis
 2)-Increase in the density of the affected lung
 3)-Displacement (shift) of the mobile structures of the thorax
-The mobile structures are those capable of movement due to
changes in lung volume:
 Trachea
 Heart
 Hemidiaphragm
4)- Overinflation of the unaffected ipsilateral lobes or the
contralateral lung
Types of Atelectasis

Subsegmental atelectasis (also called discoid atelectasis or plate-like
atelectasis)


Linear densities of varying thickness usually parallel to the
diaphragm
Most commonly seen at the lung bases
 Does not
produce a shift
of the mobile
thoracic
structures
 Postoperative
patients
Loss of volume due to passive compression of the lung
can be caused by a large pleural effusion, large
pneumothorax or a space-occupying lesion (such as a
large mass in the lung)

This form of compressive arelectasis is usually seen at the periphery of
the lung base and develops from a combination of prior pleural disease
(such as from asbestos exposure or tuberculosis) and the formation of a
pleural effusion that produced adjacent compressive arelectasis.
This produces a
masslike lesion that
can be confused with a
tumor.

Obstructive atelectasis = an
obstructing
lesion
of
the
bronchial tree + resorption
of air from the alveoli.

The affected segment, lobe
collapses
in
configuration.
a
fanlike
RIGHT UPPER LOBE ATELECTASIS
On the frontal radiograph

There is an upward shift of the minor fissure.

There is a rightward shift of the trachea.

If there is a mass in the right hilum producing right upper lobe
arelectasis, the combination of the hilar mass and the upward shift of
the minor fissure produces a characteristic appearance on the frontal
radiograph named the S sign of Golden
LEFT UPPER LOBE ATELECTASIS
On the frontal radiograph

There is a hazy area of increased density
around the left hilum.

There is a leftward shift of the trachea.

There may be elevation of the left
hemidiaphragm.
Lower lobe atelectasis
On the frontal radiograph
 Triangular density that extends from its
apex at the hilum to its base at the
medial portion of the affected
hemidiaphragm.
 There is elevation of the hemidiaphragm
on the affected side.
 The heart may shift toward the side of
the volume loss.
 On the right (only), there is a downward
shift of the minor fissure
RIGHT MIDDLE LOBE ATELECTASIS
On the frontal radiograph

There is a triangular density silhouetting the right heart border with
its base pointing toward the hilum.

The minor fissure is displaced downward .
ATELECTASIS
On the frontal radiograph

There is opacification of the
atelectatic lung due to loss of air.

There is a shift of all the mobile
structures of the thorax toward the
side of the atelectatic lung.
OF THE ENTIRE LUNG
RML&RLL
RUL&RLL
LLL
LLL&RLL
Lingula
LUL including Lingula
PNEUMONIA
 Pneumonia can be generally defined as
consolidation of lung produced by inflammatory
exudate, usually as a result of an infection agent.
CAUSES

Bacteria

Viruses

Fungi
CHEST X-RAY FINDINGS
 Area of increased opacity, sometimes described as “fluffy”

Fissures do not move

No shift in mediastinal structures

May see air bronchogram sign
CT FINDINGS
 Air bronchogram sign .
PATTERNS OF APPEARANCE OF
PNEUMONIANS
Pattern
Lobar
Characteristics
Homogeneous consolidation of affected lobe with air
bronchogram
Segmental
(bronchopneumonia)
Patchy airspace disease frequently involving several segments
simultaneously. No air bronchogram . Atelectasis may be
associated
Interstitial
Reticular interstitial disease usually diffusely spread throughout
lungs early in a disease process frequently progresses to
airspace disease
Round
Cavitary
Spherical pneumonia usually seen in the lower lobes of
children , may resemble a mass
Produced by numerous microorganisms . Chief among them
being Mycobacterium tuberculosis .
CXR demonstrating RLL pneumonia.
Note spine sign on the lateral view.
Pneumonia of an Entire Lung

Inflammatory exudate fills the airspaces,
causing consolidation and opacification of
the lung.

The hemithorax becomes opaque
because the lung no longer contains air.

There is no shift of the heart or trachea.

There may be air bronchograms present
LUNG ABSCESS
Opacified Hemithorax
There are three major causes of an
opacified hemithorax:

Atelectasis of the entire lung

A very large pleural effusion

Pneumonia of an entire lung

pneumonectomy-removal of an entire
lung
‫انخماص رئة كامالً ‪ /‬تسثة انسذادٌ‬
‫‪ .1‬ارتفاع قثة الحجاب‬
‫الُسري ‪.‬‬
‫‪ .2‬انسحاب المنصف إلً‬
‫جهة االنخماص‪.‬‬
‫‪ .3‬فرط التهىَة المعاوض‪.‬‬
‫‪ .4‬تكثف ناحٍ‪.‬‬