Radiographic features of

chest pathologies.

By: Dr. Elias K. (MD, Ass. Prof radiology)

Objectives.
 To be familiarize with radiographic anatomy of
chest .
 Detection and interpretation of common lung
pathologies on chest radiograph.
 Detection and interpretation of common mediastinal
pathologies on chest radiograph.
 To be familiarize with common pleural pathologies
on chest radiograph.
 Segmental Bronchial Anatomy
•Rt. Upper lobe:
1. Apical
2. Anterior
3. Posterior
•Rt. Middle lobe
4. Medial
5. Lateral
• Rt lower lobe
6. Superior
7. Medial basal
8. Anterior basal
9. Lateral basal
10.Posterior basal
 Con’t
 Lt. upper lobe
1&2. Apico-posterior
3. Anterior
4. superior lingula
5. inferior lingula
 Lt lower lobe
6. Superior
7&8.Anteromedial basal
9. Lateral basal
10.Posterior basal
 Pulmunary Acinus:

• The portion of lung distal to the terminal bronchiole

where gas exchange takes place.
• The basic anatomic and functional pulmonary unit
• It Contains:
(1)Respiratory bronchioles
(2) Alveolar ducts
(3) Alveolar sacs
(4) Alveoli
 Pulmonary lobule:
• The grouping of 3-5 acini

• It is a consistently recognizable structure

Anatomically and radiographically

• Diameter = l cm in an adult

• Each lobule is surrounded by its own

interlobular septa and interstitial structures .
Pulmonary lobule: diagram
 Microscopic communications

1. Canals of Lambert: from bronchiole to

alveoli
2. Pores of kohn: small openings in
alveolar wall the diameter
• 10-15 microns in diameter
• These permit ventilation by a process
known as Collateral air drift.
 The six basic lung pathologies:
These are abnormalities that may alter the
normal appearance of the lung.
Air- space disease: consolidation
Interestial lung diseases
Atelectasis
Pleural fluid
Masses
Emphysema
Schematic drawing of the four basic
pathology patterns affecting the lungs
 I. Air Apace pathology
(Consolidation)

 Definition: Displacement of air in distal air-

way and alveoli by fluid and rarely by tissues.
 Causes:
Fluid => inflammatory exudates &
transudates, and blood
Cells=> neoplastic cells
Radiographic appearance of consolidation:

There is increased density in the lungs. How

may the density appear?
Acinar nodules 4-10 mm in diameter
Ill-defined and fluffy margins
Coalescence
Segmental distribution
Air- bronchogram
consolidation
Homogeneous opacity of the Rt lung with air bronchogram
consolidation
consolidation
 II. Interestitial diseases:

Definition: Disease processes that primarily

affect tissues outside the acinar space i.e. the
interlobular connective tissue.
• The air-spaces may or may not be secondarily
involved.
 contd… Interstitial disease
Causes: It has multitude of causes some of these
are:
• CHF
• Lymphagitic spread of tumor
• Idiopathic pulmonary fibrosis
• Collagen vascular diseases
• Drugs
• Pneumoconiosis
• Viral pneumonia
 Radiographic appearance:
 Usually diffuse and are seen as linear, nodular,
combined linonodalar
 Occasionally they may be honeycombed

DDx: it is non-specific

 DDx depends on whether the interstitial

infiltrate is acute or chronic
 III. Collapse (Atelectasis )

Definition: A condition of volume loss of the lung

Causes:
(1) obstructive atelectasis: the most common
 Results when a bronchus is obstructed by a
neoplasm, foreign body, mucous plug, or
inflammatory debris.
 Quite often, there is associated pneumonia distal
to the site of obstruction.
(2) Compressive atelectasis:
The lung is compressed by a tumor,
emphysematous bullae, pleural effusion, or
enlarged heart.
 Contd…. Collapse:
• (3) Cicatrisation atelectasis: is produced by organizing
scar tissue. This occurs most often in healing tuberculosis and
other granulomatous diseases.
• (4) Adhesive atelectasis: is a unique type of volume
loss that occurs in the presence of patent air-ways. The
mechanism involved is believed to be the inactivation of
surfactant. Ex. HMD
• (5) Passive atelectasis: results from the normal
compliance of the lung in the presence of either
pneumothorax or hydrothorax. The air-ways remain patent.
 The radiographic signs of lobar and
segmental collapse
a. Direct signs:
1. Displacement or deviation of a fissure => most reliable.
2. Increased opacity
3. Crowding of vessels
4. Silhouette sign.
b. indirect signs:
1. Displacement of the hilar vessels => most reliable.
2. Shift of the mediastinum
3. Elevation of the hemidiaphragm
4. Compensatory emphysema
5. Herniation of the lung across the midline
6. Crowding or approximation of the ribs in long standing cases
 Collapse contd…
Direction of collapse:
• Rt upper lobe: upward, medially, and anteriorly Lt
upper lobe =>

• Middle lobe: downward and medially Lingula

=>

• Rt lower lobe: posteriorly, medially and downward Lt

lower lobe =>
 IV. Emphysema
Definition: distension of the air-spaces distal to
the terminal bronchiole with destruction of
alveolar septa.
 Better diagnosed by clinical findings
.
Radiographic findings of emphysema

Classic emphysema reflect overinflation, loss of

compliance and parenchymal destruction

 Decreased vascularity – most reliable.

 Hyperlucency
 Increased lung volume
 Flattening, depression of the diaphragms
 Presence of prominent pulmonary arteries and rapid tapering of
vessels
 Vertical cardiac configuration
 Bullae
 Prominent interstitial markings
 “Dirty lung” pattern in smokers
 V. Masses

• In general, a variety of clinical, historic and

radiological findings are used to predict the
nature of the lesion.
• Ultimately, the diagnosis rests in the hands of
the pathologist.
• Pulmonary nodules can be solitary or multiple
• The most common etiologies of the solitary
pulmonary nodule are either tumours or
granulomas.
Tumours: benign and malignant
 Contd… masses
• Some nodules may be cavitary
The most common lesions to undergo
cavitation are lung ca, granulomas and
metastatic lesions ( usually squamous cell
carcinoma )
• others: Abscesses, hematomas and
pneumatoceles
• Mediastinal masses are sometimes difficult to
separate from pulmonary parenchymal masses.
 Sharp margins, tapered borders, convexity
• Anterior mediastinum:- majority 4T’s
• Middle mediastinum- 1/3
– Arise from LNS: lymphoma, metastatic diseases,
sarcoidosis or in response to refection.
• Posterior mediastinum: Neurogenic tumours,
oesophageal &vascular lesions, LNs
•
 VI. Pleural pathologies

(1) Pleural fluid:

• It is a sign.
• Occurs in a variety of pathologies including infection, embolism, neoplasm,
CHF & trauma
• may be either free or loculated
Free:
• meniscus sign
• Increase in the over all opacity of one hemithorax on a recumbent film.
• Mediastinal shift in massive effusions
• an apparent elevation of the “diaphragm” on the upright film if it is
subpulmonic effusion
– May be demonstrated in decubitus film
Loculated:
• loculation in the fissures => Form
“pseudotumour” or phantom tumor
• has tapered margins => spindle shaped
• Other signs
– Widening of the pleural space
– Blunting of costophrenic angles
(2) Pneumothorax

Causes: Trauma
Iatrogenic
Spontaneous
Radiographic findings:
• Absence of pulmonary vessels extending to the chest
• Visceral pleura displaced
• Increased lucency of one hemithorax
• Tension pneumothorax-
• Air continually enters the pleural space
• It is an emergency condition
(3) Pleural masses:
• Benign: pleural fibroma, lipoma etc.
• Malignant: mesethelioma, metastasis
(4) Pleural thickening: following infection, trauma and
neoplastic diseases

(5) Pleural calcification: post-empyema and post-trauma