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Is air in the pleural space secondary to a) penetr8tion injuries (stab'\ lincs) or b) breeches of the
visccralllicura (spontal1eous rupture of subpleural bullae or nlcchanical ventilation at high
r,ressures.
Sign is the visceral pleural edge, and lateral to this edge 110 vascular or lung s11adows are
visible. Medial to the edge the sel11i-collapsed lUl1g can be of higher dellsity to the other lUllg.
tl1at in a supine CXR air will collect anteriorly alld you ll1ay not see the pleural
edge
If air the pleural space during illspiration but cannot leave on cxpiration (usually a
check-valve eflect), pressure increases rapidly al1d is life threatening -- a t,ension
r)ncunlothorax. Recognised by a shift oftlle nlediastilll1nl to the opposite side and
straightening of tIle ipsilateralHD.
!)[ellral EtfilSiol1
Pleural effusioll is defilled as an abnonllal acculTIulatiol1 of fluid in the pleural space. Pleural
effusion develops because of excessive filtratioll or defective absorption of aCCUll1ulated fluid.
rrhe presence of pleural ef1lJsion lllay be a prilllary nlanifestation or a secondary COll1plicatioll
of nlany disorders.
("xrz: Seen in upright filnls as the loss of the costophrenic angle. As fluid accull1ulates,
blunting bcconles lllore pronounced, and an up\\lardly concave nleniscus seenlS to ascend the
lateral chesl this is called the nlel1iscus sign. ("lues indicating pleural ef-fusion include
generalized honlogenous opacity and diffuse 11azil1ess as the 11uid (orl11s layers posteriorly
(ground-glass appearance), visibility ofpuln10nary vessels through the haziness, and an
,lbsence of air brol1cll0grall1. With illcreasing size, tIle HD is obscured and a nlass sllift nlay
begin \vith increasing fluid levels. If taken supille, you nlay see a nonspecific haze or 'veilillg'
over the affectedhelllitll0raX., as the fluid levels out in the posterior surface.
/tltDS
Progressive respiratory insufficiency follo\\ling a bodily insult and can be due to a
1111111bcr such as: increased pernleability of tile l)llinlonary capillaries and fornlation
01' platelet and fibrin lllicroell1boli.Results in alveolar oedellla and haenlorrhage., \vhicll can
effect thc \vhole lung. As a general rule synlptoll1S occur on rhe SCCOl1d day after injury but the
ren1ains Il0rnlal illitially.
("X:R: Interstitial oedenla (blurry vessels, perillilar 11aze and vague increased density over tIle
lo\ver zones) is the first radiograpllic abll011llality followed rapidly by patchy air-space
By 36-72 ll0urs diffuse global air space consolidation develops
Jill il/IOllar'v (Jettell1a
oedenla refers to extravasation of fluid lionl the pullllonary vasculature into the
intcrstitiull1 and alveoli of the lung. Most C0111n10n in cardiac but due to such
conditions asflllid overload., renal failure, heroin 00, inhalalion injuries and burns
(')(l{: is C01111l101l as well as pulnl011ary venous congestion \vith upper lobe
diversion, interstitial oedenla alld tIle so called "bat wing" appearance: superinlposed slladows
of innunlerable fluid-filled alveoli nlay cause disappearance orthe vessels of the l1ilul1l. S111all
pleural eifusiollS are typical
COl1solidatiol1
Air filled spaces replaced by products of the disease a patient has, eg: \vater, pus, blood
rZadiological SigllS are:
a) Air brollchograll1 - present \vhen the air\vays contain air and appear as radiolucellt or
blacl( bral1cllillg structures agaillst a I10W white background of airless lung
b) Silhouette Sign - border of a structure is lost as the l1orn1ally air filled lung outlinillg tIle
border is replaced by fluid. Significal1t in deternlinillg tIle exact area of the abllonnality
eg: (R) 11eart border is illdicative of (R) ML Consolidation
('auses: 1) Fluid (Puhnol1ary Oedelna)
2) Exudate (Illfectioll, pl1eulll0nia, TB, ARDS, Contusion)
3) Inhalation (Aspiratioll, Toxic funles)
4) Infiltration (Lynlpll0111a, Alveolar ('Iell
Collapse
()r atelectasis is tIle loss of aeration and, tllerefore, exposure in part or all of a lung. Collapse
of a lobe or entire 1Ul1g is usually secol1dary to el1dobronchial tunl0ur, foreign body or sputunl
plug.
rrhe 1110St reliable al1d frequellt1y presellt filldillg in lobar collapse is shift of fissures, w11ich
\vi 11 invariably occur to SOllle extent
Signs: 1) Increased del1sity of collapsed lobe
2) Shift of fissures
3) Si 1110uette sign
4) Hi lar or l11ediastil1al s11ift
5) Elevatiol1 ofilellli-diaphragnl (n10st COll1n10n inLL collapse, whereas peakillg of
the l11id part ill UL collapse secolldary to displacenlent of the oblique fissure)
6) Crowdillg of ribs., vessels or airways
Exal11ples
RUL: Elevation of transverse fissure (+/- hilulll)., illcreased density aIol1gside to tIle
superior ll1ediastinllnl
part of fissure 1110ves do\vn alld blurring of the (Iz) heart border (as per
consolidation)
Increased density overlying the ll1edial portion of the (R) 1-10 and hilunl displaced
do\vn. l---Ieart border is usually still defined secondary to aerated (R) ML
L.lUL: Main feature is a veil-like increase ill dellsity without a sllarp lllargill, spreadil1g
outwards al1d upwards fronl tIle 11ilul11. (L) 11eart features n1ay have ill defilled olltlil1es. As
VOlU111e decreases tIle collapsed lobe nloves closer to tIle nlidline and tIle IUllg apex l11ay
becolne lucellt secondary tohyperil1f1atioll of the apex of the LLL., a sharp border Inay
return to the aortic arch. \Vith 111arked collapse tllere is herniatioll of (R) IUllg across tIle
lllidlille lllal(il1g tIle ascending aorta alld arcll lucent agaill.
l-l lingltlar segnlellt: suspected when the (L) heart border is illdeiined
L./LL: nl0st COl1111lon ill patients follo\villg heart surgery or a thoracot0111y due to retelltion
of secretions. A trial1gular density behind tIle heart v'lith loss of the ll1edia] portioll of tIle
(1-1) HD
Cardiac Failure
As (L) atrial pressure increases, blood is shunted to the upper zones (difficult to tell in a
supine film secondary to blood redistribution), and interstitial oedema follO\vs due to leakage
from capillary vessels. As (L) ventricle pressure increases, multiple small, ill-defined
opacities occur in the lower half of the lungs, leading to lluid in the alveoli. Bilateral pleural
effusions are often present (? More common on the right)
/1 s/Jiration Pneumonia
An ETT or tracheostomy doesn't stop aspiration a lot of' the lime!
(,XI<.: Often patchy and ditfuse bilateral changes/consolidation in the first 24 hours - mostly at
the bases, (R) more than (L). But then there is often a nlpid progression aller that initial 24
hours - so don't be ['ooled by a relatively good eXR initially post a suspected aspiration
C>lL
Overinflation leading to flattening of the HD's and this results in an apparently small heart
;lI1d decreased cardio-thoracic ratio. Alteration in the appearance of pulmonary vessels and
presence ofbulJae
to remember
Usuall y eXR are PA, but the majority are done as AP
Sometimes the time reported on a CXR is wrong - cross check on the actual PACS system
1::levation of a HD may be because it is paralysed, pushed up (fat, abdomen contents) or
pulled up
.. The CXR of an ill (often critically) patient is usuaJJy ofa poor quality, ,md there Illay be
lots of lines or attachments obscuring views
.a eve ideally ends in the SVC
.. SGC' ideally located in the main or pulmonary artery
It is often good to check all the attachments when you first look at a CXR (especially if
the CXR is a 'post-insertion' XR ie cve or SGC or ICC: check for PTx). If a line is
inserted into the mediastinum, it can lead to bleeding and a wide mediastinum, ifinto the
pleural space then a P.Effusion or HTx is common
!ABP: From the femoral artery to the aortic arch
'" I:TT: mid trachea or a few cm above the carina. Jf it is in too it can cause collapse of
part or an entire lung.
Post-op collapse can become secondarily infected and consolidated ifnot treated
(Ippropriately