RADIOLOGY IMAGING OF THE

CHEST

Part IIThe respiratory system

Interstitial lung disease

• The pulmonary interstitium is the network of connective tissue fibres that supports the lung. It includes the alveolar walls, interlobular septa, and the peribronchovascular interstitium

• Although the majority of the disorders also involve air spaces, the predominant abnormality – thickening of the interstitium

Interstitial lung diseaseBasic radiographic signs and

interpretationSeptal pattern• Interstitial pulmonary

oedema• Lymphatic spread of tumourReticular pattern• Fibrosin alveolitis• Sarcoidosis• Chronic alergic alveolitis• Langerhans cell

histiocytosis• LymphangioleiomyomatosisNodular pattern• Silicosis• Coal workers`

pneumoconiosis

• Sarcoidosis• Tuberculosis• Subacute alergic alveolitisReticulonodular pattern• Langerhans cell histiocytosis• Sarcoidosis• Lymphatic spread of tumourGround-glass pattern• Subacute alergic alveolitis• Pneumocystis carini

pneumonia• Nonspecyfic interstitial

pneumonia (NSIP)• Idiopathic pulmonary

haemorrhage

Interstitial lung diseaseBasic radiographic signs and

interpretation

Septal patternThickening of the

interlobular septa – Kerley B lines, short (1-2 cm) lines perpendicular to the pleura, continuous with it

Reticular patternThe result of summation of

smooth or irregular linear opacities, cystic spaces, or both – interlacing line shadows suggesting the mesh

Nodular patternThe accumulation of small

lesions within the pulmonary inetrstitium

well circumscribed, discrete nodules 2mm or less- miliary nodules

Reticulonodular patternGround-glass patternA generalized hazy increase

in opacity which obscures the underlying vascular markings on chest radiograph

Interstitial lung diseasedifferential diagnosis

1. The predominant pattern of abnormality

2. Its distribution within the lung3. The presence of associated findings:a. hilar or mediastinal lymphadenopathy

b. cardiomegalyc. pleural thickeningd. effusion

Case 1002A 28 year old Afro-Caribbean woman presented with a persistent dry cough and progressive exertional dyspnoea over three months. She was not wheezy and had not noticed any diurnal variation in symptoms. She was otherwise well with no known allergies or hayfever. Clinical examination revealed no abnormalities and her

chest sounded normal.

• What is the likely clinical diagnosis? • Which investigations would you request?

sarcoidosis

SarcoidosisA multisystem granulomatous disorder of

unknown aetioloogy characterized by the presence of noncaseating epihelioid cell granulomas in several affected organs (the skin, eyes, peripheral lymph nodes, spleen, cns, parotid glands, bones)

A disease of young adults – a peak incidence in the third decade

Traditionally staged according to its appearance of the chest radiograph

I – lymphadeopathyII – lymphadeopathy with parenchymal opacityIII - parenchymal opacity alone

Sarcoidosis Radiographic features

Lymphadenopathy• Enlargement of

bilateral, symmetrical hilar and paratracheal

• Occasionally asymmetrical – 1-5%

• In 90% disappears within 6-2 months

• Lymph nodes can calcify - eggshell fashion (shared only by silicosis) seen on plain films in 5%, on CT scans – 40%

• Parenchymal changes• Rounded or irregular

nodules 2-4mm in diameter, which maybe poorly or moderately well defined

• Patchy airpace consolidation, sometimes contain air bronchograms, with ill defined margins, commonly break up into nodular pattern

Industrial lung diseases -silicosis

Due to the inhalation of silica (SiO2)

Radiographic appearance- Multiple, small nodules, predominantly

in the middle and upper zones- Enlargement of the hilar lymph nodes-

an eggshell patern- Calcification occasionally seen in the

mediastinal, cervical and intra-abdominal nodes

Micronodular pneumoconiosis Nodular pneumoconiosis

Tuberous pneumoconiosis

Pneumoconiosis

Massive fibrosis in silicosis

Industrial lung diseases -asbestosis

The silicates: asbestos 90% of malignant mesotheliomas are related to previous exposure to asbestos

Pleural changes the pleural plque – well defined, soft tissue

sheets originating on the parietal pleural , usually bilateral, in the middle and lower zones and over the diaphragm

• When calcified – a „holly leaf” pattern with sharp, often angulated outlines, usually less than 1cm thick

• Diffuse pleural thickening• Pleural effusions – uncommon 3%Pulmonary changes - fibrosing alveolitis

peripherally at the lung basas

Case13 History: A 62 yo gentleman comes to his family practice physician

complaining of shortness of breath. The patient normally avoids physicians because he doesn't have insurance and he feels that they are all quacks anyway. However, he has been having more and more difficulty keeping up with his work on the assembly line at an automobile factory and he fears getting fired. The patient has 70 pack-year history of smoking Camel Studs. Otherwise, he is a fairly healthy individual. On physical exam his breath sounds are diminished diffusely. A subsequent chest x-ray is shown on the left.

Questions: What is the most likely diagnosis? What part of the history is pertinent to this diagnosis?

Emphysema

Condition of the lung characterized by permanent , abnormal enlargement of air spaces distal to the terminal bronchiole, accompanied by the destraction of their walls without obvious fibrosis

Is thought to result from the distraction of elastic fibres – inbalance between proteases and protease inhibitors, the mechanical stresses of ventilation and caughing

EmphysemaRadiological findingsOverinflation

a. The height of of the right lung being greater than 29.9cm

b. Location of the right diaphragm at or below the anterior aspect of the 7-th rib

c. Flattering of the hemidiaphragmd. Enlargement of the retrosternal spacee. Widening of the sternodiaphragmatic anglef. Narrowing of the transverse cardiac diameter

Emphysema

Radiological findingsAlterations in lung vessels

a. Arterial depletion, whereas vessels of normal calibre are present in unaffected areas

b. Absence or displacement of vessels caused by bullae

c. Widened branching angles with loss of side branches and vascular redistribution

With the development of cor pulmonale or left heart failure – the radiolographics appearences will alter

Emphysema

CT, particularly HRCT scans the most accurate mean! (low window values -800 to -1000 HU) specially for surgery treatment

Presence of areas of abnormally low attenuationFocal areas of emphysema usually lack distinct

walls as opposed to lung cystsTypes1. Centrilobular2. Panlobular3. Paraseptal4. Irregular

EmphysemaBullae• generaly found in patients with centrilobular

and/or septal emphysema• Avascular, low-attenuation areas that are

larger than 1cm and that can have a thin but perceptible wall

Bullous ephysema• Associated with large bullae, mainly in young

men• Large, progressive upper lobe bullae, often

asymmetrical• Avascular, transradiant areas separated from

the lung parenchyma by a thin curvilinear wall• Complications: pneumothorax, infection,

haemorrhage

Emphysema

Emphysema

Emphysema

Emphysema

Emphysema

Diseases of the pleura

• Pleural effusion• Bronchopleural fistula• Hemothorax• Chylothorax• Pneumothorax• Pleural masses

Case7 History: A 54 yo male with a history of Hodgkin's

Lymphoma presents to his primary care physician with a one-week history of shortness of breath and pleuritic chest pain. The patient has also noticed a non-productive cough that has progressively worsened over the past two days. Physical exam demonstrates diminished  breath sounds and egophony on the left. The chest x-ray on the left was taken shortly thereafter.

Questions: What is the diagnosis? What findings on the x-ray help distinguish this condition from other opacifications?

Pleural effusion bilCollapse segmentHeart failure

Encysted effusion case 6

Pleural effusion

The most common clinical manifestation of pleural pathology

A result of mismatch between the rates of inflow and outflow of fluid in the pleural space

Pleural effusionTransudates; Result from: • a decrease in the colloid

osmotic pressure – hypoproteinemia

• increase in the microvascular hydrostatic osmotic pressure (the systemic venous pressure)

Causes:• congestive heart failure• cirrhosis• nephrotic syndrome• nephrogenic effusion• hypoalbuminemia• constrictive pericarditis• atelectasis• pulmonary embolism

Exudates; Result from:• alteration in the pleural

surface• an increase in

permeability • decrease in the lymph

flow

Causes:• pleural malignancy• pleural inflammation

Pleural effusion

More than 90% of cases caused by

• Heart failure• Cirrhosis• Ascites• Pleuropulmonary

infections• Malignancy• Pulmonary embolism

Diagnostic imaging• Chest radiograph• CT• Ultrasound

Radiographic features

Depends on the patient`s position and the mobility of the pleural fluid

On the PA radiograph • blunting of the lateral costophrenic

angles - 200ml-up to 500ml of fluid• The most sensitive projection – the

lateral decubitus chest radiograph – 5ml

Radiographic features

In the erect patient• Initially collects in the

subpulmonic region• Blunting of the lateral

costophrenic angles• Elevated hemidiaphram

sign - the superior margin of the fluid mimics the contour of the diaphragm – apparent elevation of the hemidiaphragm with flattening of its medial portion

• Opacity as hazy meniscus higher laterally than medially

In the spine patient position• Capping of the lung apex

with pleural fluid –early sign

• Increased hazy opacity with preserved vascular markings

• Blunting of the costophrenic angle

• Hazy diaphragm silhouette

• Thickening of the minor fissure

• Widened paraspinal soft tissues

• Elevated hemidiaphragm sign

Hemothorax

Most commonly results from traumaLess common reasons:• Varicella infections• Coagulopathies• Vaascular abnormalitiesChest radiogrph: a pleural effusion

without any distinguishing factor to suggest blood in the pleeural space

Non contrast CT- the characteristic attenuation increase

Chylothorax

Discruption of the thoracic duct • 50%- neoplastic in origin lymphoma

(75%)• 25% traumatic - surgery• 10% miscellaneous• 15% idiopathicUsually cannot be differentiated from other

effusions based on chhest radiographs or CT scans

Pleural effusion

Pleural effusion

Pleural effusion

Pleural effusion

Pleural effusion

Pleural effusion

The effusion in pleural adhesions

The effusion in pleural adhesions - inside

fissures

Case8 History: This chest x-ray is from a 54 yo female who presented two

weeks prior to the current visit for a productive cough and shortness of breath. The patient was diagnosed with community acquired pneumonia and sent home with antibiotics. She returns now stating that her cough and shortness of breath have resolved but now she is experiencing chest pain on deep inspiration. Her physical exam reveals diminished breath sounds and dullness to percussion on the left lower lung. The x-ray on the left was then ordered.

Questions: What is the diagnosis? Does the normal appearance of the pulmonary vasculature help with the diagnosis? Does the patient history help narrow the differential?

Pyothorax, thoracic empyema

Pleural adhesions

Pleural adhesions

Pleural adhesions

Case4 History:

A 6'4", thin smoking 32 yo male presents to the ER with shortness of breath and chest pain. The patient reports that he was just going for a jog when he became severely short of breath and began having chest pain that was retrosternal and slightly to the left. The patient has not history of lung disease but has been smoking about 1 ppd for over 10 years. Physical exam shows absent breath sounds on the left and hyperresonance to percussion. The x-ray on the left was taken in the ER.

Questions: •What is the diagnosis? •How does the pulmonary vasculature help you make your diagnosis?

Case1 History: A 26 yo male came to the ER complaining of shortness of

breath and some left-sided chest pain. The patient was snowboarding at a local resort when he lost control going off a jump. The patient reports landing directly on his left side after falling approximately 10 feet . The symptoms started immediately after the fall. On physical exam the patient has decreased breath sounds on the upper left lung. The patient was given an AP chest x-ray in the ER, which is shown on the left.

Questions: What is the diagnosis? Is this a common location for this condition?

Case3 History: A 54 yo alcoholic male presents to the ER

following an evening of heavy drinking with chest pain and dyspea. The patient reports that he had multiple episodes of violent vomiting and then passed out. When he awoke, he was having chest pain that was worse on inspiration and radiated to his neck with each breath. Physical exam was normal and MI work up came out negative. The x-ray on the left was taken shortly after admission.

Questions: What is the diagnosis? What part of the patient's history is applicable to the diagnosis?

AsthmaMediastinal air

Pneumothorax – gas or air in the pleural space

Spontaneous• Primary – no

identifiable cause, often related to an apical intrappleural bleb rupture

• Secondary with related undrelying lung parenchymal disease

Traumatic• Blunt or penetrating

trauma• Iatrogenic causes –

central venosus catherization, transbronchial or transthoracic biopsy

Pneumothorax

• Chest radiograph• Identification of a radiolucent air space

separating the visceral pleural line from the parietal pleura

• Pulmonaryu vessels extend to the edge of the visceral pleural line,nor beyond

• More sutable- on CT scans

Pneumothorax

Pneumothorax

Mediastinal emhysema, pneumothorax with

fluid

Bronchopleural fistula - fistulous communication between the pleural

space and the bronchial tree

Causes – the most common: necrotizing pulmonary infections and surgical lung resections

• penetrating and blunt lung injures

• pleural drains• thoracentesis• ventilator support

May be seen (x-rays, CT) as

• hydropneumothorax, an intrapleural air-fluid collection

• extansion of the air-fluid level to the chest wall

• unequal linear dimensions on orthogonal views

Pneumothorax

Bronchopleural fistula : pneumothorax + pyothorax

Pleural massesBenign• Lipoma• Fibroma• Asbestos related

disease• Rounded

atelectasis

Malignant • Metastatic 95&• Brest or lung

carcinoma,• Thymma• Lymphoma• Diffuse malignant

mesothelioma

Diffuse malignant mesothelioma

• rare and agressive 2000-3000 cases per year in USA

• Men 2-6x more often than women 50-70 y

• Symptoms: chest pain, dyspnea, cough, weight loss

• The association with asbestod strongly established

Tumor may further extend to the thoracic wall, contralateral chest,

• abdomen

Chest radiograph • Irregular, nodular,

peripheral pleural opacities with associated pleural effusion

• 40-86% extension to into interlobar fissures

CT• Wide spread of nodular

pleural thickening with mediastinal surface involvment

• Encasement of the lung • Extension into the

interlobar fissures

Mesothelioma pleure

Mesothelioma

Mesothelioma pleure

a. Atelectasis of the left lungb. A large left pleural effusionc. A large right pneumothoraxd. Pneumonia in the left lunge. Unilateral pulmonary edema

The patient shown below most likely has:

The patient shown below most likely has:

a. A large right pleural effusionb. A large left pneumothoraxc. Atelectasis of the right lungd. Pneumonia in the right lunge. Unilateral pulmonary edema

The patient shown below most likely has:

a. A large left pleural effusionb. A large right pneumothoraxc. Atelectasis of the left lungd. Pneumonia in the left lunge. Unilateral pulmonary edema

The patient shown below most likely has:

a. A large left pleural effusionb. A large right pneumothoraxc. Atelectasis of the left lung

because of a mucus plugd. Pneumonia in the left lunge. Atelectasis of the left lung

because the ETT is too low

The patient shown below most likely has:

a. There is a large left pleural effusion

b. There is a large right pneumothorax

c. Atelectasis of the left lung because of a mucus plug

d. Pneumonia in the left lunge. The left lung has been

surgically removed