GAMBARAN RADIOLOGIS

PADA KEGAWATAN PARU

Farah Fatma Wati
 How to Read a Chest X-Ray
A Step by Step Approach

• The chest x-ray and computed tomography (CT) are part of

every physician’s practice.
• You should have a basic understanding of the anatomy and
pathologic findings visible on these images.
On all X-rays CHECK the following:

Patient details • First name, surname, date of birth

Orientation, position • Left, right, erect, ap, pa, supine, prone,

and side description inspiration, expiration

• measure the distance from the medial end of each

rotation clavicle to the spinous process of the vertebra at the
same level, which should be equal

adequacy of • Nine pairs of ribs should be seen posteriorly in order

to consider a chest x-ray adequate in terms of
inspiration inspiration
• should barely see the thoracic vertebrae behind the
Penetration and heart
exposure • needs to be able to identify both costophrenic angles
and lung apices

SSMJ Vol 1 Issue 2

Specific Radiological Checklist:

Airway

Bones

Cardiac

Diaphragm

Effusion

Fields of the lung

Gastric air bubble

Hilum

Instrumen

SSMJ Vol 1 Issue 2

Normal Chest X Ray
• The standard frontal view of the chest: the posteroanterior
(PA) radiograph, or the “PA chest.”
• The terms posterior and anterior refer to the direction of the
x-ray beam, which in this case traverses the patient from
back (posterior) to front (anterior).
• The routine frontal view is taken with the patient upright
and in full inspiration.
• The anteroposterior (AP) view is usually made with a
portable x-ray unit on very sick patients who are unable to
stand, and on infants. The patient is supine or sitting in bed.
• The PA upright is preferred to the AP supine view because
1. there is less magnification (the heart is an anterior
structure, so it would seem larger on a(n) AP image) ;
2. the image is sharper;
3. the erect patient inspires more deeply, showing more
lung;
4. pleural air and fluid shift with gravity and are easier to
detect on the erect film.
Figures 1-1A and 1-1B are two images of the same patient
Which one is the PA image? Figure 1-1A is the PA
How did you decide? Sharper edges, less magnification, deeper inspiration
It is often difficult to detect a lesion located behind the heart, near the
mediastinum, or near the diaphragm on the PA view.
The lateral view often shows such a lesion, so we use it routinely.
In Figure 1-4A, the patient is in the right anterior oblique position.
His right chest is against the cassette.
Oblique views can help us localize lesions and eliminate superimposed structures.
Figure 1-4B is a PA radiograph showing a calcified (white) mass over the upper
thorax on the patient’s left.
In Figure 1-4C, the right anterior oblique mass moves laterally relative to the thorax.
Pulmonary emergencies
1. Efusi pleura masif
2. Pneumotoraks
3. Benda asing di saluran napas
4. Inhalasi gas toksik
5. ARDS
6. Hemoptisis masif
7. Pneumonia berat
8. VCSS dan kegawatan onkologi lainnya
9. Asma dan PPOK eksaserbasi

ERS
 EFUSI PLEURA MASIF
Pleural Effusion:
Abnormal accumulation of fluid within pleural space
Caused by :
IMBALANCE between FORMATION and ABSORPTION of pleural fluid in various
states of disease

↑ Hydrostatic Pressure
↓ Oncotic Pressure
↑ Vascular Permeability
↓ Lymphatic Drainage

Thomas R, et al. Thoracic surgery clinics. 2013; Light RW. Pleural Diseases. 2013
 Massive Effusion
Congestive heart failure

Cirrhosis with ascites

Tuberculosis (TB)
Rupture of a liver abscess

Peritoneal dialysis (90% right sided)

Meigs syndrome

Uremic pleuritis
Diagnostic Approach: Chest radiography
Diagnostic Approach: CT Scan
PNEUMOTORAKS

Itard (1803) – Lannec (1819):

Presence of air in pleural cavity
(space between the parietal and
visceral pleura)
 Imaging
• Plain Radiographs
• Upright PA on inspiration
• Detect other pathologies: pneumonia,
cardiac, etc.
• Partially collapsed lung
• Tension Pneumothorax
• Trachea and mediastinum deviate
contralaterally
• Ipsilateral depressed hemi-diaphragm
• Chest CT
• Not routine
• Only to assess the need for surgery
(thoracotomy)
 Pneumothorax Size
Quantification

LIGHT’S CRITERIA
• The average diameter of collapsed
lung and the affected hemithorax :

[(HT3 – L3) / HT3} x 100%

MacDuff A, et al. Thorax. 2010; Light RW. Pleural Diseases. 2013

 Differential Diagnosis
• Local or generalisata emphysema
• Wide bleb emfisematous
• Wide lung cavity
• Cystic formations
• Hernia diafragmatika

19
ASPIRATION OF FOREIGN BODY

• When an asphyxiating foreign body aspiration is suspected

immediate airway control is needed. Pre-treatment diagnostics will
delay intervention and may worsen the outcome. Immediate rigid
bronchoscopy is the primary diagnostic and therapeutic choice.
• When suspecting a foreign body aspiration in the less acute
presentation, a conventional chest X-ray is the first imaging modality
of choice. A standard frontal view and lateral view has to be
obtained.
• an aspirated foreign body is often not visible on the X-ray (5-50%).
Organic materials in particular are either not or reduced radio-
opaque. Air trapping or atelectasis can then be suggestive of
aspiration.
• If a patient is suspected of having a foreign body aspiration and has a
negative chest X-ray, a thoracic CT is justifiable.
ARDS
 Radiologic manifestation

• Patchy, diffuse ground glass opacities

• Pattern of opacification does not
change with position change, as the
exudates are trapped in alveoli
• Septal lines, peribronchial cuffing, and
thick fissures are usually ABSENT
• In severe cases, air bronchograms can
be seen
HEMOPTISIS MASIF

• Hemoptisis  bleeding arising from the lower airways

• Mostly originate from one of two main sources : bronchial or pulmonary
arterial circulation.
• Hemoptisis massif  > 600 mL in 24 h or > 30 mL/h
• Bronchial arteries : 90% sources of massive hemoptysis
• Chronic inflammation disease / neoplasma  induce neovascularization
of bronchial arteries through anastomosis  easy to disrupt by systemic
pressure

Bidwell (2005), Lundgren et al (2010), Spinu et al (2013)

Etiology

The most causes of

massive hemoptysis :
1. Tuberculosis
2. Bronchiectasis
3. Lung abscess
 Hemoptysis in Tuberculosis
• Spontaneous rupture of Rasmussen’s aneurysm.
– involves the erosion of a small or medium-sized pulmonary arte
ry into an adjacent tuberculosis cavity.
– continuous necrotizing of pulmonary artery in TB cavity  layer
of vascular wall was replaced by granulation.

Ingbar (2005), Shetty et al

PNEUMONIA

• The primary role of imaging examinations is to confirm the diagnosis

of pneumonia
• If a patient has clinical symptoms suggestive of infection pneumonia,
such as fever, cough or sputum, and the imaging findings are
consistent with pneumonia, a definitive diagnosis of infectious
pneumonia can be made.
• Imaging examinations also play a complementary role for the
evaluation of treatment effects of antibiotics although treatment
effects may be determined based solely on clinical findings
• It is generally difficult to determine specific pathogens of infectious
pneumonia based only on the imaging findings. However, as
characteristic imaging findings of several pathogens have been
reported, they may help choose subsequent examinations or first
antibiotics. This is especially true for the exclusion of tuberculosis.
IMAGING FINDINGS OF CAP

• CAP has classically been divided into three distinctive patterns on

imaging examinations:
1. consolidation (alveolar/lobar pneumonia),
2. peribronchial nodules (bronchopneumonia)
3. ground-glass opacity (GGO)
The fourth, a unique uncommon pattern of CAP is random nodules,
suggestive of hematogenous pulmonary infection or granulomatous
infection
1. Consolidation predominant pattern
(alveolar/ lobar pneumonia)
2. Peribronchial nodules predominant pattern
(bronchopneumonia)
3. Ground-glass opacity (GGO)
VCSS

• Superior vena cava (SVC) obstruction can occur from extrinsic

compression, intrinsic stenosis or thrombosis.
• Malignancies are the main cause and are considered an oncologic
emergency.
• Clinical presentation depends on the speed, severity and location of
superior vena cava obstruction
• Collateral drainage may develop with slow obstruction and patients
may have no or only mild symptoms.
• With acute superior vena cava obstruction, symptoms include facial
and neck swelling, facial flushing, bilateral upper extremity swelling,
neurological signs, dyspnoea, headache and cough
Radiographic features
Plain radiograph
• Indirect signs on chest x-ray, such as superior mediastinal
widening and right hilar prominence that may indicate the
presence of mediastinal mass.
CT
• Is the imaging modality of choice. Enhanced CT shows the
location and severity of the SVC obstruction, superimposed
thrombosis, a mediastinal mass or lymphadenopathy,
collateral vessels and associated lung masses.
ASTHMA EXACERBATION

Plain radiograph
• Plain chest radiographs can be normal in up to 75% of patients with asthma.
• Possible findings are bronchial wall thickening and hyperinflation (although
marked hyperinflation is uncommon in patients who do not also have
emphysema)
• Chest x-rays at diagnosis should be reserved for children with severe disease
or in any patient with atypical features or clinical symptoms or signs
suggesting other conditions.

In acute asthma, a chest x-ray is only required if there is:

• suspected pneumomediastinum, pneumothorax or surgical emphysema
• suspected consolidation
• requirement for ventilation or life-threatening asthma
• failure to respond to treatment satisfactorily
COPD EXACERBATION

Radiologic feature
• Emphysema manifests as lung hyperinflation with flattened
hemidiaphragms, a small heart, and possible bullous
changes.
• On the lateral radiograph, a "barrel chest" with widened
anterior-posterior diameter may be visualized.
• The "saber-sheath trachea" sign refers to marked coronal
narrowing of the intrathoracic trachea (frontal view) with
concomitant sagittal widening (lateral view).
TERIMA KASIH