Imaging of the Respiratory

System

Imaging Modalities
1- Plain ( conventional ) X ray.
2- Computerized Tomography ( CT ).
3- Magnetic Resonance Imaging ( MRI ).
4- Angiography.
5- Biopsy.
6 - Radionuclide ( Isotope) scan.
7- Bronchography.
8- Tomography.
9- Ultrasonography.

Plain chest x ray

Standard views for chest radiography :
1- PA ( postero anterior ) view
- Patient chest placed against the film cassette .
- X rays enter the patient posteriorly and reaches
the film anteriorly .
2- Lateral view
- Patient placed with one side against the film.

Additional views
AP ( antero posterior ) view ;
- Patient unable to stand .
- Children .
Oblique view :
for pleural , chest wall & rib pathology.
Lat. Decubitus view:
small pleural effusion and sub pulmonary
effusion .
Lordotic view: to examine lung apex.

Viewing a chest film

Lung fields
Hilar shadows
Cardiac & other mediastinal shadows
Diaphragm and Costo-phrenic angles.
Ribs and soft tissues.

Lung Segments

Right Lung containing:

Upper Lobe: Apical Segment
Upper Lobe: Posterior Segment
Upper Lobe: Anterior Segment
Middle Lobe: Lateral Segment
Middle Lobe: Medial Segment
Lower Lobe: Anterior Basal
Segment
Left Lung containing:
Upper Lobe: Apical Posterior
Segment
Upper Lobe : Anterior Segment
Lingula Superior Segment
Lingula Inferior Segment
Lower Lobe: Anterior basal
Segment

 Left Lung containing:

Upper Lobe: Apical Posterior
Segment
Upper Lobe : Anterior Segment
Lingula Superior Segment
Lower Lobe: Superior Segment
Lower Lobe: Lateral Basal Segment
Lower Lobe: Posterior Basal
Segment
Right Lung containing:
Upper Lobe: Apical Segment
Upper Lobe: Posterior Segment
Upper Lobe: Anterior Segment
Middle Lobe: Lateral Segment
Lower Lobe: Superior Segment
Lower Lobe: Posterior Basal
Segment
Lower Lobe: Lateral Basal Segment

Different pathology patterns

Nodules: Single or multiple discrete opacity e.g.
T.B., benign or malignant tumors
Cavitary: Hollow opacity with wall e.g. abscess,
cancer
Diffuse: Most common is consolidation and ground
glass appearance.
Pleural: Homogenous opacity obliterating the
costophrenic angle e.g. Effusion, masses,
calcification.

Pleural effusion
Collection of fluid in space between parietal and visceral layers
of pleura .
Appearance :
Homogeneous opacity. Obliteration of the C/P angels.
No pulmonary or bronchial markings.
Upper border rising towards axilla .
There needs to be at least 75ml of pleural fluid in order to blunt
the costophrenic angle on the lateral chest radiograph, and
200ml on the posteroanterior view. On a lateral decubitus,
amounts as small as 5ml of fluid are possible.

Pneumothorax
Air in pleural cavity .
Appearance :
Area of increased translucency , no lung
markings .
Lung margins sometimes seen .
+/- Mediastinal shift .

Causes
Iatrogenic ; commonest ( biopsy , thoracic
surgery )
Spontaneous : tall thin young males due to
rupture of bleb .
Trauma ; stab wounds , rib fractures
Pre existing lung dis.; emphysema , cystic
fibrosis .

Pneumonia
Inflammatory condition of the lungs mainly
affecting the alveoli .
Replacement of air in alveoli by fluid and inflammatory
materials .
Patent bronchi and airways are often visible , when
surrounded by fluid filled alveoli it gives a characteristic
appearance ( Air bronchogram ) .

Radiological criteria to call a shadow

consolidation:
Lobar or Segmental Density: The density should
either correspond to the lobe or lung segment.
Air Bronchogram: Presence of air bronchogram
would confirm an alveolar process.
No Loss of Lung Volume: Lung volumes increase in
early stages of consolidation. In later stages there
can be some amount of loss of lung volume due to
secretions obstructing airways. As a general rule,
there is no significant loss of lung volume in
consolidation.


Silhouette sign
When two tissues of
same densities touch
each other and blur
the edges of each
other .

Bronchiectasis
Bronchiectasis is defined as localized, irreversible
dilatation of part of the bronchial tree

Radiologic findings include:

Normal appearing CXR in most cases

Tubular shadows
Tram line
Ring shadows with thickened bronchial walls
Air fluid levels
Diffuse lung fibrosis due to recurrent infections

Bronchography

Tuberculosis
Chronic infection caused by Mycobacterium
tuberculosis .
Appearances :
Peripheral pneumonic consolidation with enlarged
mediastinal lymph nodes ( primary complex )
usually heals by calcification.
Post primary : Patchy consolidation , pleural
effusion , empyema , thickening , miliary shadows
( 1-2mm ) , fibrosis , calcified foci .

Chronic Obstructive Pulmonary Disease

COPD
Chronic bronchitis and Emphysema
- can exist together and lead to
narrowing of airways .
- Persistent, largely irreversible
airway obstruction

X ray might be normal,

however;
1) Hyper inflated lungs
2) Flattened diaphragm
3) Widened intercostal
spaces
4) Tubular-shaped heart
5) Prominent pulmonary
vessels

Lung cancer

Primary : Originating in the lung.

Secondary (Metastatic) : When tumor cells

spread from other distant malignancy e.g. breast .
In children majority are metastatic.
X ray can miss small lesions, CT is the best
imaging modality.

Central ( hilar ) mass .

Peripheral mass .
Appearance :
Enlarged hilar shadow .
Lobulated or spiculated mass.
Collapse.
Cavitary lesion.

Pancoast Tumor

Apical density
Rib destruction

Mass density at left

upper lobe
Thick wall
Cavitation

Abscess

Lung Metastasis
From a primary tumor
elsewhere
e.g. Breast
UT
Testis
GIT
Thyroid .

Appearances
Single or Multiple variable sized rounded or
irregular opacities .
Cavitations occasionally present .
Pleural masses .
Lymph nodes .
Local invasion e.g. rib destruction .

Tomography

Pleural Effusion

Encysted effusion

Empyema

Pneumothorax

Pneumonia

Bronchiectasis

Bullae

Bronchogenic Carcinoma

CT guided biopsy

MRI

Pulmonary Angiography
Used for :
- Diagnosing pulmonary emboli .
- Demonstration of congenital
anomalies .

Pulmonary embolism
Very common in patients confined to bed .
Originating in leg and pelvic veins or
patients with heart disease .

Appearances
Usually no evident findings on plain films
however in some patients :
Infarct appears as an area of consolidation ,
pleural based , indistinguishable from
pneumonia .

Isotope scan
Two types :
- Perfusion scan : injected IV ,
particles trapped in pulmonary capillaries ,
when imaged by gamma camera it reflects
blood flow .
- Ventilation scan : patient inhales
radioactive gas and its distribution is
imaged by gamma camera .

Diagnosis
In perfusion scan : one or more defects as
the radionuclide particles do not reach the
under perfused portions .
In ventilation scan : normal distribution .

Normal

Pleural
effusion

Bronchogenic
carcinoma

pneumothorax

Pneumonia

Abscess

CT Pleural
effusion

emphysema

Thank You