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Chest x rays made easy
In the fourth of a five part series, Elizabeth Dick compares collapse and consolidation of the lung and looks at pleural effusions
The basics of looking at a chest x ray (recap):
● First look at the mediastinal contours—run your eye down the left side of the patient and then up the right. ● The trachea should be central. The aortic arch is the first structure on the left, followed by the left pulmonary artery; notice how you can trace the pulmonary artery branches fanning out through the lung. ● Two thirds of the heart lies on the left side of the chest, with one third on the right. The heart should take up no more than half of the thoracic cavity. The left border of the heart is made up by the left atrium and left ventricle. ● The right border is made up by the right atrium alone. Above the right heart border lies the edge of the superior vena cava. ● The pulmonary arteries and main bronchi arise at the left and right hila. Enlarged lymph nodes can also occur here, as can primary tumours. ● Now look at the lungs. Apart from the pulmonary vessels (arteries and veins), they should be black (because they are full of air). Scan both lungs, starting at the apices and working down, comparing left with right at the same level, just as you would when listening to the chest with your stethoscope. The lungs extend behind the heart, so look here too. Force your eye to look at the periphery of the lungs—you should not see many lung markings here; if you do then there may be disease of the air spaces or interstitium. Don’t forget to look for a pneumothorax. ● Make sure you can see the surface of the hemidiaphragms curving downwards, and that the costophrenic and cardiophrenic angles are not blunted—suggesting an effusion. Check there is no free air under the hemidiaphragm. ● Lateral films: if the area anterior or superior to the heart is opacified, suspect disease in the anterior mediastinum or upper lobes respectively. If the area posterior to the heart is opacified suspect collapse or consolidation in the lower lobes.
Normal R Upper lobe Frontal view L Upper lobe Post Oblique fissure Vertebrae Ant Horizontal fissure Middle lobe Lower lobe R Lung Post Upper lobe Ant Oblique fissure Lower lobe L Lung Lateral view
Fig 1 Where the lobes of the lung normally lie
Abnormality: lobar collapse
Collapse of a lobe is caused by proximal obstruction—for example, by a neoplasm, mucus plug, such as in a postoperative patient, or foreign body, such as in a child. Always mention that you are looking for the cause of the collapse. When the lobe is not aerated it will lose much of its volume and collapse to a predictable location depending on whether it is an upper, middle, or lower lobe. Figure 1 shows the normal site of the lobes of the lung; figures 2 to 5 and their accompanying line diagrams show where the lobes collapse to. The collapsed lobe itself can be very difficult to see—there may simply be a little extra shadowing on the film. A collapsed lobe is a cause of volume loss; the other cause is a pneumothorax. The signs that should alert you to a collapse are due to the loss of lung volume: ● The mediastinum may be shifted towards the side of collapse ● The hilum is pulled up or down from where it normally lies ● The horizontal fissure will also be pulled up (in a right upper lobe collapse) or down (right lower lobe collapse) ● The remaining (non-collapsed) lung on the side of the collapse has to expand to fill the hemithorax, thus “spreading” its contained vessels; therefore the abnormal side will
Fig 2 Right upper lobe collapse. Increased shadowing in the right upper zone with a clear linear border of the horizontal fissure which has been pulled up (arrowhead). Note the remaining right lung is blacker than the opposite side. In addition the hilum is pulled up. There is a mass arising from the right hilum (arrow); this is the obstructing bronchial carcinoma which is causing the collapse
R Upper lobe collapse Collapsed R upper lobe Horizontal fissure pulled up Residual R middle and lower lobe expands to compensate so R side blacker than L side Look for proximal obstruction eg a carcinona
seem blacker with fewer lung markings than the opposite normal side ● The proximal obstruction may be
STUDENT BMJ VOLUME 8
Increased shadowing in the left upper and mid zone with a blurred lower border. they can coexist. The collapsed left lower lobe may form a “sail” shape behind the heart border on the Antero-posterior film (arrow) P A P A Fig 3b Lateral. Left upper lobe collapse. after a pneumonectomy the mediastinum shifts to the empty hemithorax and the residual pleural space fills with fluid and fibrotic material leaving the patient with a complete “white out” on the side that has been operated on ( fig 9 ) . The left heart border is also lost. or pus (fig 7). so the right heart outline is lost. The key features of an effusion are: ● If the patient is erect there should be a fluid level and meniscus visible ● If the effusion is large the mediastinum will be shifted to the opposite side. same patient. The right middle lobe collapses anteriorly in a wedge shape over the heart. and it can be difficult to distinguish between them—of course. blood.Education L L L Fig 4a Antero-posterior chest radiograph. The upper border of the wedge is the horizontal fissure (arrowhead). which could be serous fluid. material within the pleural space. the lower border is the oblique fissure (arrow) R Middle lobe collapse Frontal view Lateral view Fig 5b On the lateral film there is extra shadowing posteriorly over the vertebrae due to the collapsed lobe (arrow) L Lower lobe collapse Frontal view Horizontal fissure R Middle lobe R Middle lobe lies against heart border making it indistinct Oblique fissure L Lower lobe shadowing behind heart with loss of clarity of medial hemi-diaphragm L Lower lobe collapses posteriorly and inferiorly L Hilum pulled down Lateral view Hilum pulled up visible—for example. The right middle lobe lies adjacent to the right heart border. Left lower lobe collapse. Complete collapse of one lung with the mediastinum shifting over the the abnormal side can also cause a “white out” on the abnormal side (fig 8). Right middle lobe collapse. Finally. material within the air-spaces—see November studentBMJ ) and pleural effusion— that is. Fig 3a Antero-posterior chest radiograph. Abnormality: confluent opacification of the hemithorax There are four main causes of confluent opacification of a hemithorax—consolidation (fig 6) (that is. a large carcinoma arising from the right upper lobe.com 445 . Compare this with pure consolidation in which there is STUDENT BMJ VOLUME 8 DECEMBER 2000 studentbmj. On the lateral view the upper lobe can be seen to have collapsed anteriorly and lies anterior to the oblique fissure (arrow) L Upper lobe collapse Frontal view Lateral view Upper zone Upper lobe veil-like collapses shadowing anteriorly with no and clear superiorly lower border Oblique fissure Fig 4b Lateral. left upper lobe collapse P A Fig 5a Antero-posterior chest radiograph. because the lung collapses adjacent to it. Consolidation and pleural effusion are the two most common. The lower lobes collapse posteriorly and inferiorly so that the contour of the hemidiaphragm is lost.
The left lung contained a carcinoid tumour and was removed. and Dr Robert Dick for contributing some of the films which are illustrated. A proximal right main bronchus carcinoma has obstructed the distal right bronchus and caused complete collapse of the right lung with the trachea and mediastinum pulled to the right side by the loss of volume on the right. The residual space in the left hemithorax fills with fluid and fibrotic tissue a few weeks after pneumonectomy 446 STUDENT BMJ VOLUME 8 DECEMBER 2000 studentbmj. air bronchograms can be seen within the consolidation which occupies the posterior lower hemithorax—that is. There is opacification of the left lower zone with loss of the hemidiaphragm.com . However. There is one caveat to bear in mind. Fig 8 Complete collapse of the right lung. There is also a rightsided pleural effusion.Education L L Fig 7 Right pleural effusion. North Thames Deanery Fig 9 Left pneumonectomy. As we discussed in November the key feature of consolidation is an air bronchogram. which is that if Next month: we will look at lung nodules and masses. I would like to thank Dr Anju Sahdev. indicating the consolidation abuts the diaphragm—that is. A key feature is that there is no loss of volume. and the mediastinum is pushed to the left side L Fig 6a Left lower lobe consolidation. the loss of volume due to the right lung collapse is greater than the increase in rightsided volume due to the pleural effusion so that overall the mediastinum is pulled over to the right Fig 6b On the lateral film. In infective causes of consolidation the process may affect a lobe (lobar pneumonia in a distribution according the normal anatomy shown in fig 1) or spread in a more patchy distribution (bronchopneumonia). best seen superiorly. is within the lower lobe.com. There is no mediastinal shift and no fluid level P A collapse of the lung is accompanied by a pleural effusion the loss of volume (caused by the collapse) may be balanced out by the increase in volume of the hemithorax (caused by the effusion) and therefore it may seem as if the volume of the hemithorax overall is equivalent to the opposite side. Now test yourself with our web quiz at studentbmj. There is opacification of the lower right hemithorax with a fluid level. Dr Brian Holloway. Elizabeth Dick. There is left sided loss of volume with shift of the mediastinum and chest wall (ribs) and left hemidiaphragm towards the “empty” left hemithorax. specialist registrar in radiology. the normal anatomical site of the left lower lobe no change in volume of the hemithorax and therefore no mediastinal shift.