William Herring, M.D.

2002

The Fundamentals of
Chest Roentgenology

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 The Fundamentals of Chest
Roentgenology

l Fundamental Observations
n Silhouette sign
n Air bronchograms
n Solid spheres vs. hollow tubes
l Basic Disease Processes
n Alveolar vs. interstitial lung disease
n Opacified hemithorax
n Cavities
The Fundamentals of Chest
Roentgenology

Diseases
Congestive Heart Failure
Pneumothorax
 Silhouette Sign

l When two objects of the same

density touch each other, the
edge between them disappears

A B
 Using the Silhouette Sign

Right middle lobe silhouettes right

heart border
Lingula silhouettes left heart border
Right lower lobe silhouettes right
hemidiaphragm
Left lower lobe silhouettes left
hemidiaphragm
 Using the Silhouette Sign
The mass (red arrow)
silhouettes the right
heart border which is
to say there is no
longer an edge of the
right heart seen. That
means the mass is (a)
touching the right
heart border (the mass
is anterior) and (b) the
mass is the same
density as the heart
(fluid or soft tissue
density). The mass is a
thymoma.

Where in the chest is this mass?

 Air Bronchogram
l Bronchi are not visible since their walls are
thin, they contain air, are surrounded by air
l When something of fluid density fills alveoli,
air in bronchus becomes visible, e.g.
n Pulmonary edema fluid
n Blood
n Gastric aspirate
n Inflammatory exudate
 Air Bronchogram

The visibility of air in the bronchi because of

surrounding airspace disease is called an
air bronchogram
An air bronchogram is almost always a sign
of airspace disease
The black branching
structures are the
result of air in the
bronchi, now visible
because density
other than air
surrounds them (in
this case it is
inflammatory exudate
from a pneumonia).
Solid Spheres vs. Hollow Tubes

A. Solid spheres are homogeneous from one

side to other
Blood vessels and masses
B. Hollow tubes have a lower density in
center
Bronchi and cavities

A B
 There are multiple
nodules visible on
the CT scan of the
chest in this patient.
In most cases the
nodules are due to
metastases from a
primary malignancy
in an organ other
than the lung.
In this case the
metastases to the l
ung
were from a colon
cancer.
Solid spheres or hollow tubes?
Diseases with Multiple Lung Nodules

Metastases
Multiple AVMs
Rheumatoid nodules
Wegeners Granulomatosis
Disease with Multiple Cystic
Structures

Cystic fibrosis
Bronchiectasis
Tuberculosis

Parenchymal Lung Disease

Two Major Types

Alveolar (air space)
Interstitial
 Alveolar Lung Disease

Has air bronchograms

Fluffy and indistinct
Confluent and homogeneous
May have segmental or lobar distribution
 This disease is
fluffy and indistinct
in its margins, it is
confluent and
tends to be
homogeneous. In
both upper lobes,
you can see air
bronchograms.
This is an alveolar
(airspace) disease,
in this case
pulmonary edema o
n a non-
cardiogenic basis.

Pulmonary edema
Common Alveolar Lung Diseases

Pneumonia
Pulmonary edema
Pulmonary hemorrhage
Aspiration
 Airspace Disease

Aspiration pneumonia at both bases

Interstitial Lung Disease

Discrete
Inhomogeneous
No air bronchograms
Made up of lines (reticular) or dots
(nodular) or both (reticulonodular)
 Interstitial versus Airspace Disease

Interstitial disease discrete, Airspace disease fluffy,

inhomogeneous, no air indistinct, homogeneous,
bronchograms contains air bronchograms
Common Interstitial Lung Diseases

Cancer1 or 2
Sarcoidosis
Cystic fibrosis
Asbestosis
Cystic Fibrosis - interstitial
Opacified Hemithorax
Three Causes

Atelectasis
Pleural effusion
Pneumonia

Recognizing the Causes of an

Opacified Hemithorax
 Atelectasis

l Opacified hemithorax from volume loss

l Shift of heart and mediastinal structures
toward opacified hemithorax
Atelectasis of right lung shift of the mediastinal structures
TOWARD the side of opacification
 Pleural Effusion

Opacified hemithorax from large

effusion
Shift of heart and mediastinal
structures away from side of opacified
hemithorax
Large right pleural effusion - shift of the mediastinal structures
AWAY from the side of opacification
 Pneumonia

Opacified hemithorax
No shift
Air bronchograms
 Pneumonia of LUL no shift of the mediastinal
structures to either side; multiple air bronchograms
Congestive Heart Failure
Four Reliable Signs

l Kerley B lines
l Pleural effusions
l Fluid in the fissures
l Peribronchial cuffing
n Not cardiomegaly
n Not cephalization

Recognizing CHF
Four Reliable Signs of CHF

Short (1 -2 cm)
white lines at
the lung
bases,
perpendicular
to the pleural
surface
representing
distended
interlobular
septa

Kerley B Lines
Four Reliable Signs of CHF

Pleural Effusions
Four Reliable Signs of CHF

Fluid in the
minor fissure.
The fissures
may be seen
normally but
they should
be about as
thin as a line
drawn with a
sharpened
pencil.

Fluid in the fissures

Four Reliable Signs of CHF

Fluid in the
walls of the
bronchi make
them visible
and produce
numerous
doughnut
densities
throughout
the periphery
of the lung.

Peribronchial cuffing
 Pneumothorax

Must see visceral pleural white line

Absence of lung markings peripherally
Shift of mediastinal structures
None=simple pneumothorax
Away from pneumothorax=tension
pneumothorax
Never a shift toward side of pneumothorax
Recognizing
a Pneumothorax
Visceral pleural white line marks the edge of the lung
Cavitary Lung Lesions
Differentiation

Thickness of the wall
Inner margin of the cavity
Air-fluid level
Cavitary Lung Lesions
Three Causes

Carcinoma of the lung

TB
Abscess
 cavities

Thickness of
Inner Margin A|F Level
Wall

Carcinoma Thick Nodular +/-

TB Thin Smooth No

Abscess Thick Smooth Yes

Thick-walled with nodular inner margin
carcinoma of the left lower lobe
Thick-walled with smooth inner margin
RUL abscess
Thin-walled with smooth inner margins, RUL
Tuberculosis