Basic Chest Radiology for

Medical Students
Dr Joel Joseph
Georgetown Public Hospital Corporation
Dept. Of Medical Imaging
Texila American University School of Medicine-
Radiology
Overview
At the end of this presentation students should be able to

● Understand the indications for chest X-rays, CT and MRI.

● Examine Present chest x-ray images in a concise and logical way.

● Identify common pathology on chest X-ray and CT.
● List differential diagnosis for common imaging findings.
Comparative Radiation Dose In Chest Imaging
 Chest imaging indication
CXR CT MRI

● Trauma ● Trauma ● Workup of

● Primary and secondary ● Primary and secondary congenital lung
screening screening malformation
● Sepsis workup ● Malignancy ● Cardiac and
● Workup for shortness of ● Monitoring of ILD vascular anatomy
breath. ● Mediastinal mass
● Workup for congenital heart ● Cardiac and Vascular
disease anatomy
● Check device placement ● PE

American College of Radiology Appropriateness Criteria for any imaging test can be found via Google search.
https://www.acr.org/Clinical-Resources/ACR-Appropriateness-Criteria
CHEST X-RAY

Name the
structures!
Chest X-ray
1. first rib
2. upper portion of
manubrium
3. trachea
4. right main bronchus
5. left main bronchus
6. Main pulmonary artery
7. left pulmonary artery
8. right interlobar
pulmonary artery
9. right pulmonary vein
10. aortic arch
1. trachea
2. right upper lobe bronchus
3. left upper lobe bronchus
4. right pulmonary artery
5. left pulmonary artery
6. inferior vena cava
7. ascending aorta
8. descending aorta.
Approach to CXR

● A: airways

● B: breathing (the lungs and pleural spaces)

● C: circulation (cardiomediastinal contour, vascular markings)

● D: disability (bones - especially fractures)

● E: everything else, e.g. pneumoperitoneum

● https://radiopaedia.org/articles/chest-x-ray-abcde-summary?lang=us
Case 1
60 y/o htn pt with SOB worse at night
and when climbing stairs. Afebrile.

What is the most likely diagnosis

A. Pneumonia
B. Chronic obstructive pulmonary
disease.
C. Heart failure.
D. Pulmonary fibrosis
 Congestive heart failure
(CHF)

Insufficient cardiac output

because of

● decreased
contractility
● high resistance in the
circulation
● fluid overload.
Patient after treatment with diuretics
Case 2
Road traffic accident.

What is the most likely

diagnosis?

A. Right pneumothorax, left

contusion.
B. Left pneumothorax.
Pneumothorax
● collapsed lung.
● air leaks into the space between lung and chest wall.
● air pushes on the outside of your lung and makes it collapse.rib fracture
● May be evidence of emphysema/bullae if spontaneous.
● May be evidence of fractures, hemothorax or lung contusion if traumatic.
Case 3
Where is the pneumothorax?

a. Left
b. Right
c. Neither
Case 4
Where are the pleural effusions?
a. Left
b. Right
c. Bilateral
d. Neither
Pleural effusion
● A buildup of excess fluid between the layers of the pleura outside the lungs.

● Exudate vs transudate.
Pneumonia
● Inflammation in the alveoli.
● The alveoli fill with fluid or pus
Non-cardiogenic pulmonary edema
● Drowning
● Acute glomerulonephritis
● Fluid overload
● Aspiration
● Inhalation injury
● Neurogenic pulmonary edema
● Allergic reaction
● adult respiratory distress syndrome (ARDS).
Bronchoalveolar carcinoma

● Relatively rare adenocarcinoma that typically arises in the lung periphery and

grows along alveolar walls, without destroying the lung parenchyma.

● Often multicentric

● May arise from a previously stable scar

INCREASED INTERSTITIAL MARKINGS
● dDX
○ INTERSTITIAL LUNG DISEASES
○ HEART FAILURE
○ ALVEOLAR PROTEINOSIS
Pulmonary Fibrosis
● Interstitial lung disease
● reticular pattern particularly at the lung bases.
Atelectasis

● Collapse or closure of a lung

● Reduced or absent gas exchange.
● May affect part or all of a lung.
● Usually unilateral.
● Alveoli are deflated down to little or no volume
● Distinct from pulmonary consolidation where alveoli are filled with
liquid.
TUBERCULOSIS

● Primary TB is usually clinically silent.

● In 5% of infected individuals the immunity is inadequate and clinically active
disease develops, which is known as progressive primary disease.
● Postprimary TB is reactivation of the latent infection and occurs in 5% of
infected patients.
● On the CXR it is seen as consolidation with cavitation in the apical segments
of the upper and lower lobes.
PULMONARY MASS
In lesions that do not respond to antibiotics, probably the most important non-
invasive diagnostic tool is nowadays the PET-CT.
Lung Abscess
● a type of liquefactive necrosis of the lung tissue and formation of cavities
(more than 2 cm) containing necrotic debris or fluid caused by microbial
infection.
Chronic obstructive pulmonary disease
● a type of obstructive lung disease characterized by long-term breathing
problems and poor airflow.
● Tobacco smoking is the most common cause of COPD
● chronic cough and shortness of breath
Metastases

Metastases are the most common cause of multiple pulmonary masses.

Usually they vary in size and are well-defined.

MEDIASTINAL MASSES
Mediastinal Mass
● The ability to visualize pulmonary vessels through the mass implies that it is
located either anterior or posterior to the hilum, but not at the hilum.
● This is known as the hilum overlay sign.
● Middle mediastinal masses are convex and may obscures the vasculature
Pediatric Chest X-ray
Neonate
CONGENITAL HEART DISEASE
. Echocardiography is the diagnostic test of choice

. However, knowledge of X-ray findings are useful in narrowing the diagnostic

workup.
Tetralogy of Fallot
Transposition of Great Vessels
Croup
FOREIGN BODY
Image from pintrest.com
CHEST CT
● If in doubt NON CONTRAST CT is sensitive for most lung pathology.
○ Trauma
○ Primary and secondary screening
○ Rule out malignancy
○ Diagnosis and monitoring of ILD, COPD, ASTHMA.
○ Lung infection
○ Calcium scoring
● CONTRAST CT INDICATIONS
○ Suspected vascular malformation (a cause of dysphagia in children)
○ Suspected pulmonary embolism.
○ Mediastinal mass
○ Cardiac CT
MDCT
● 64 detectors is the most in a scanner in Guyana as of May 2019
○ High temporal and spatial resolution.
○ Minimum required for cardiac imaging and brain perfusion imaging.
● Default mode is continuous/helical acquisition.
● Detector width is as low as 1.5mm with slice thickness reconstruction as low
as 0.25mm with multiplanar reformat -MPR.
● Software helps optimise image quality with low as possible radiation.
Approach to chest CT
● A chest CT may be looked at like a 3D chest X ray.
○ Soft tissues
○ Bones
○ Visualised abdomen
○ Mediastinum
○ Lungs
○ Pleura
Normal CT
https://radiopaedia.org/articles/tuberculosis-summary?lang=us
Pneumonia
Atelectasis
Pleural effusion
COPD
EMPYEMA
TUBERCULOSIS
Interstitial Lung Disease
● Interstitial lung diseases classically produce the "3Cs": cough, clubbing of the
nails, and coarse crackles on auscultation
● Causes
○ granulomatous diseases
○ Neoplasia
○ Vasculitis
○ inherited diseases, e.g. neurofibromatosis
○ autoimmune and collagen vascular diseases
○ idiopathic pulmonary fibrosis
THANK YOU!!