Radiology Department of Hasan Sadikin Hospital

Medical Faculty of Padjadjaran University

IMAGING OF CHEST
DISEASES
CHEST DISEASES

o Lung
o Pleura
o Diaphragm
o Soft Tissue and Skeletal
o Kardiovaskular
o Mediastinum
 LUNG

INCREASE OPACITY INCREASE LUCENCY

o Pneumonia o Emphysema
o Atelectasis o Bullae & Bleb
o Pulmonary Contusion & o Cyst
Laceration o Tuberculous cavity
o Traumatic Wet Lung o Pulmonary abscess
o Pulmonary Edema o Malignant Cavity
o Pulmonary Mass o Bronchiectasis and
o Pulmonary Metastasis Bronchitis
PNEUMONIA
Inflammation of the
airspaces and/or interstitium
Etiology
Infective
Bacterial, Virus, Fungi, Parasites
Autoimmune
Chemical meconium
aspiration
Neoplasm
Idiopathic
PNEUMONIA
Early detection early
initiation of treatment
Role of imaging is
supporting the clinical
diagnosis as early as
possible
Should be suspected in
Elderly
Immunocompromised
Fever of unknown origin
 PNEUMONIA

Preferred imaging modality

Posteroanterior chest x ray
Lateral chest x ray
PNEUMONIA
Classification based on
radiology appearance
Lobar pneumonia
Lobularis pneumonia /
Bronchopneumonia
Interstitial pneumonia
Round pneumonia
Cavitary pneumonia
 Lobar Pneumonia
Affected the pulmonary lobes.
Spread through pore of Kohn from alveoli to
alveoli.
Homogenous opacification with air bronchogram.
Air bronchogram : a pattern of air-filled bronchi
on a background of opaque airless lung
Usually limited to fissures.
Silhouette sign depend on the affected lobe.
No volume changes
Lobar Pneumonia
Volume changes
Tracheal deviation.

Mediastinal shift.

Fissure traction.

Hilar traction.

Diaphragm elevation or flattening.

Intercostal space narrowing or

widening.
The film should be symmetrical to

get accurate assessment.

Lobar Pneumonia
Silhouette sign
Absence of depiction of an anatomic soft-
tissue border (not only in chest imaging)
Caused by consolidation and/or
atelectasis of adjacent lung, large mass,
or by pleural fluid.
Juxtaposition of structures of similar
radiographic attenuation which depend
on:
Level
Density
Contrast of the examination
Lobar Pneumonia
Lobar Pneumonia
Why do we still see the silhouette of
the right diaphragm on the PA-film
Lobar Pneumonia

Air bronchogram
Lobar Pneumonia

Air bronchogram
Lobar Pneumonia

RUL Pneumonia
Homogenous
opacification
Air bronchogram
Limited by the
minor fissure at
the inferior
Silhoutte to the
upper mediastinal
No volume changes
Lobar Pneumonia

RML Pneumonia
Homogenous
opacification
Air bronchogram
Limited by the minor
fissure at the
superior
Silhoutte to the right
heart border
No volume changes
Lobar Pneumonia

RML Pneumonia
Homogenous
opacification
Air bronchogram
Limited by the minor
fissure at the
superior
Limited by the major
fissure at the
posterior
No volume changes
Lobar Pneumonia

RLL Pneumonia
Homogenous
opacification
Air bronchogram
Silhoutte to the right
diaphragm
No volume changes
Lobar Pneumonia

RLL Pneumonia
Homogenous
opacification
Air bronchogram
Limited by the major
fissure at the anterior
Silhoutte to the right
diaphragm (only one
diaphragm that is
seen)
No volume changes
Lobar Pneumonia
LUL Pneumonia
Homogenous
opacification
Air bronchogram
Silhoutte to the
mediastinum and
left heart border.
The left diaphragm
can still be seen.
No volume changes
Lobar Pneumonia
LUL Pneumonia
Homogenous
opacification
Air bronchogram
Limited by the major
fissure at the
posterior
Both of the diaphragms
can still be seen.
No volume changes
Lobar Pneumonia
Lingular Pneumonia
Homogenous
opacification
Air bronchogram
Silhoutte to the left
heart border.
No volume changes
 Bronchopneumonia or
Lobular Pneumonia

Affected the pulmonary lobules.

Commences in the terminal and
respiratory bronchioles
Endobronchial spread.
Infiltrates or patchy consolidation
No air bronchogram
Bronchopneumonia

Patchy
consolidation
No air
bronchogram
 Interstitial Pneumonia
Lack of alveolar exudate
Inflammatory centered within alveolar wall &
interstitium
Interstitium consists of a continuum of connective
tissue throughout the lung comprising 3
subdivision:
The bronchovascular (axial) interstitium
Surrounding bronchi, arteries, & veins from hilum to
respiratory bronchiole
The parenchymal (acinar interstitium)
Between alveolar & capillary basement membranes
Subpleura connective tissue contiguous with the interlobular
septa
 Interstitial Pneumonia
Etiology :
Usually viral (late stage alveolar process)
Influenza virus types A and B
Respiratory syncytial virus
Adenovirus
Mycoplasma pneumonia
Linear opacification
Increased bronchovascular marking
No silhouette sign or air bronchogram.
Interstitial Pneumonia
 Round Pneumonia
Etiology:
Haemophilus influenzae
Streptococcus
Pneumococcus
Children are affected much more than adults.
Location usually lower lobe, most often posterior
May have slightly irregular border & air
bronchogram.
Differential diagnosis of mass.
Mechanism: immature development of the pores
of Kohn
Round Pneumonia
Round Pneumonia
 Cavitary Pneumonia
Complication from severe necrotising
pneumonia (Staphylococcus aureus)
Can also result from pulmonary tuberculosis.
Show subtle area of radiolucency
superimposed on a region of consolidation
Should be differentiate with abscess which
have thick wall > 2cm. CT scan examination
with contrast media will give enhancement of
its wall.
Cavitary Pneumonia
Cavitary Pneumonia
Cavitary Pneumonia vs Lung
Abscess
ATELECTASIS
Reduced inflation of all or
part of the lung
Synonim: collapse
Reduced lung volume
 ATELECTASIS
Classified based on etiology:
Compressive/relaxation/passive
Expansion is hampered by pneumothorax or pleural
effusion
Obstructive/absorption/resorption
Luminal occlusion with air absorption at the distal part
E/ mass,mucous plug,corpal,inflammation,lymph node
Adhesif
Surfactant deficiency
Cicatrical/contraction
Lung or pleural fibrosis that hampered the lung expansion
ATELECTASIS

3 direct sign (major)

Displacement of

interlobar fissures
Increased opacity

Increased

bronchovascular marking
ATELECTASIS
6 indirect signs (minor)
Diaphragm elevation

Mediastinal shift

Tracheal deviation

Hilar traction

Compensated hyperinflation

of normal lung
Intercostal space narrowing
ATELECTASIS
Other type of atelectasis
Subsegmental (discoid/plate-

like)
Compressive with

compensation no
mediastinal shift.
Round atelectasis

S golden sign RUL

atelectasis with perihilar mass.

RUL Atelectasis
RUL Atelectasis
RUL Atelectasis
RML Atelectasis
RML Atelectasis
RML Atelectasis
RLL Atelectasis
RLL Atelectasis
LUL Atelectasis
LUL Atelectasis
LUL Atelectasis
LLL Atelectasis
LLL Atelectasis
LLL Atelectasis
Subsegmental / Plate-like /
Discoid Atelectasis
Compressive with compensation
Round Atelectasis
Round Atelectasis
Gold S sign
PULMONARY CONTUSION AND
LACERATION
The most common complication
of blunt injury to the chest
Intra-alveolar and interstitial
haemorrhage at the impact
site.
Clinical history play an
important role
Resemble pneumonia,
aspiration
PULMONARY CONTUSION AND
LACERATION
Infiltrates at the peripheral
area (maximum impact point)
Usually no air bronchogram
6 hours after trauma and
disappear after 72 hours.
Persist >72 hours
pulmonary laceration or
pneumonia.
PULMONARY CONTUSION AND
LACERATION
Pulmonary laceration hard to be
diagnosed in first couple of days
covered by contusion
The findings of pulmonary
laceration:
Ovoid mass if it is filled
completely by blood.
Air fluid level if partially fill
with blood and air.
Cyst if filled with air.
PULMONARY CONTUSION AND
LACERATION
Need weeks or months for
the chest x ray to be seen
clearly again.
PULMONARY CONTUSION
PULMONARY CONTUSION
PULMONARY LACERATION
TRAUMATIC WET LUNG

Controversy
Synonim with pulmonary

contusion and laceration

Different:
Traumatic wet lung or Da Nang
Lung pulmonary edema that was
not directly caused by trauma at
the chest
 PULMONARY EDEMA

Classified into
Cardiogenic
Non-cardiogenic
Cardiogenic pulmonary edema heart failure
Heart failure
Left heart failure backward failure pulmonary
congestion pulmonary edema
Right heart failure backward failure systemic
congestion doesnt cause pulmonary edema
 PULMONARY EDEMA
Chest x ray screening tool
Left heart failure:
Heart enlargement with the apex downward to
the diaphragm
Depend on the severity
1. Cranialization / cephalization (PCWP 10-15
mmHg)
2. Interstitial pulmonary edema (PCWP 20-25
mmHg)
3. Alveolar pulmonary edema (PCWP >25 mmHg)
 PULMONARY EDEMA

Cranialization / cephalization
Pulmonary veins at the superior part of the lung >3-
5:1 than the pulmonary veins at the inferior part of
the lung.
Vascular marking at the superior part of the lung is
more crowded than the inferior part of the lung.
Measure at equidistant from the hilar point.
Mechanism:
Decreased vascular compliance at the lung base.
Hypoxic vasoconstriction phenomenon
PULMONARY EDEMA

Cranialization / Cephalization
 PULMONARY EDEMA

Interstitial pulmonary edema

Interlobular septa thickening
Kerley B lung base : thickness 1mm, length 1-2cm,
horizontal
Kerley A dilatation of channel that connect the peripheral
lymphatic channel to central lymphatic channel. Length up
to 6cm, oblique at the central part
Kerley C reticular at the lung base (en face Kerley B)
Peribronchial thickening at both hila
Fluid in fissures
Pleural effusion (Bilateral especially the right side)
PULMONARY EDEMA

Kerley B lines
PULMONARY EDEMA
 PULMONARY EDEMA

Peribronchial thickening and fluid in

PULMONARY EDEMA

Interstitial pulmonary edema

 PULMONARY EDEMA

Alveolar pulmonary edema

Infiltrates in the medial two third of the lung.
Bats wing appearance
Butterfly appearance
Usually no air bronchogram
PULMONARY EDEMA

Alveolar pulmonary edema

PULMONARY EDEMA

Alveolar pulmonary edema

 PULMONARY EDEMA

Non cardiogenic pulmonary edema

More peripherally
No cranialization/cephalization
Etiology:
Volume overload
ARDS
NSAID
Neurogenic pulmonary edema (intracranial
pressure>>)
Drowned
 PULMONARY EDEMA

Non cardiogenic pulmonary edema

 PULMONARY NEOPLASM

Primary lung cancer leading cause of

cancer deaths in both males and
females
Commonest cancer in males
Strong association with smoking,
exposure to asbestos
Age of onset > 40
 PULMONARY NEOPLASM

Subtypes:
Small cell carcinoma
Squamous cell carcinoma
Large cell carcinoma
Adenocarcinoma
Bronchioloalveolar carcinoma
 PULMONARY NEOPLASM

Clinical management depends on disease

extent (staging) role of imaging other
than detection.
Central :
Smallcell carcinoma
Squamous cell carcinoma
Peripheral
Largecell carcinoma
Adenocarcinoma
 PULMONARY NEOPLASM
Imaging finding spectrum

Mass >3cm
Nodule <3cm
Consolidation
Infiltrates
Smooth or irregular
Cavitation
Satellite nodules
Lymphadenopathy
Skeletal involvement
PULMONARY NEOPLASM
 PULMONARY METASTASIS

Types:
Milliary(<0.5cm)
Coin lesion / coarse nodular pattern (1-
2cm)
Golf ball / cannon ball patter (>2cm)
Lymphangitic spread
Pneumonic and peribronchial pattern
Pleural effusion
 PULMONARY METASTASIS
Milliary
Thyroid, lung, breast, bone sarcoma
Coin lesion
Oropharynx, gaster, thyroid, limfosarcoma, choriocarcinoma, ovarian,
uterine
Golf ball
Sarcoma, carcinoma, seminoma, renal cell ca
Lymphangitic spread
Breast,
pancreas, lung, lymphoma, leukemia, thyroid, larynx, stomach,
pancreas, cervix
Pneumonic & peribronchial pattern
Esophagus, lung, breast
Pleural effusion (not truly pulmonary metastasis)
Breast, gaster, adenocarcinoma
MILIARY PULMONARY METASTASIS
COIN LESION PULMONARY METASTASIS
GOLF BALL PULMONARY
METASTASIS
 LYMPHANGITIC SPREAD
PULMONARY METASTASIS
PNEUMONIC TYPE PULMONARY METASTASIS
PLEURAL EFFUSION METASTASIS
 ATYPICAL PULMONARY
METASTASIS
Mass with cavitation
Squamous cell ca of head & neck, adenocarcinoma of
the GI tract, breast, sarcoma
Mass with calcification
Osteosarcoma, chondrosarcoma (bone formation)
Papillary carcinoma of the thyroid, GCT, synovial
sarcoma (dystrophic calcification)
Mucinous adenocarcinoma of GI tract or breast
(mucoid calcification)
Spontaneous pneumothorax
Osteosarcoma, angiosarcoma
 ATYPICAL PULMONARY
METASTASIS
Ground-glass attenuation
Choriocarcinoma, angiosarcoma, adenoca of GI tract
Consolidation with or without ground-glass opacity
Adenoca of GI tract
Hepatoma, breast, renal, gastric, prostatic,
choriocarcinoma
Mass within pulmonary artery
Hepatoma, breast and renal carcinoma, gastric and
prostatic cancers, and choriocarcinoma
Atelectasis, endobronchial mass
Renal cell carcinoma, breast cancer, colorectal cancer
Mass with Cavitation
Mass with Calcification
Pneumothorax
Ground-glass Attenuation
Consolidation
Mass within Pulmonary Artery
Westermark sign
Hamptons hump sign
Endobronchial Mass with
Atelectation
 Emphysema

Emphysema is defined pathologically as

permanent enlargement of the airspaces
distal to the terminal bronchioles,
accompanied by destruction of their walls
Etiology :
Imbalance of elastase and antielastase
activity of elastase (smokers)
1-antiprotease
destruction of elastin alveolar wall
Proteolytic
destruction
 Emphysema
Finding:
Hyperaeration of the lung.
Decreased brochovascular marking (Increased if
accompanied by chronic bronchitis)
Widened intercostal space & horizontal ribs
Flattening of the diaphragm & blunted costophrenic angle
Barrel chest (Anteroposterior diameter >>).
> 7th rib anteriorly or >10 th rib posteriorly.
Tear drop heart.
Retrosternal space widening in lateral chest x ray
Respiratory excursion < 3cm.
Atypical appearance of pneumonia or pulmonary edema.
Emphysema
 Bullae & Bleb

Thin-walled-less than 1 mm
Air-filled space
Contained within the lung
Bleb diameter < 1cm,
subpleura
Giant bulla > 1/3 hemithorax
vanishing lung syndrome
Bullae & Bleb
 Cyst

1 3 mm wall
Air or fluid filled
Wall that contains respirator epithelium,
cartilage, smooth muscle and glands
Contained within the lung
Congenital or acquired
Pneumatocele cyst associatied with
pneumonia, frequently transient
Cyst
 Tuberculous Cavity

Result from process that

produces necrosis of the central
portion of the lesion
Wall thickness 3-5 mm
Contained within the lung
Tuberculous Cavity
 Abscess

Thick wall >5mm

Smooth inner margin
Background pneumonia (7-14
days)
Same length on both frontal and
lateral view (different with
empyema)
Abscess
 Malignant Cavity

Thick wall >5mm

Irregular inner margin
Mural nodule
Malignant Cavity
 Bronchiectasis

Abnormal dilatation of the bronchial

tree.
Irreversible localized or diffuse
bronchial dilatation, usually resulting
from chronic infection proximal
airway obstruction, or congenital.
Irreversible except some traction
bronchiectasis.
 Bronchiectasis

Causes:
Post Infective (most common)

Congenital

Obstruction

Loss of surrounding lung volume

(traction)
Bronchiectasis
 Bronchiectasis vs Bronchitis

Bronchiectasis Bronchitis
Ring shadow
Ring shadow
Tram-track or tram-line
Cuffing sign (en
Increased

bronchovascular
face)
marking Tram-track (en

Honeycomb appearance profile) or tram-line

(old terminology) Increased
Air-fluid level infected
bronchovascular
marking
Bronchitis
 Bronchiectasis
Congenital cystic bronchiectasis
Bronchiectasis
Bronchiectasis
Bronchiectasis
 Bronchiectasis

CT Findings:
Bronchial dilatation

Signet ring sign

Lack of tapering of bronchi

Identification of bronchi within 1

cm of the pleural surface

PLEURA

o Pleural Effusion
o Pleural
Thickening
o Hydropneumotho
rax
o Empyema
o Pneumothorax
 PLEURAL EFFUSION

o Fluidcollection in the pleural cavity

o Produced : parietal pleura capillaries
o Absorbed : visceral pleura and
lymphatic at the parietal pleural
 PLEURAL EFFUSION
Can be caused by
o Increased production
o hydrostatic pressure (left heart failure)
o oncotic pressure (hypoproteinemia)
o capillary permeability (pneumonia,
hypersensitivity)
o Decreased resorption
o lymphatic absorption (obstruction by
tumour)
o intrapleural cavity pressure (atelectasis)
 PLEURAL EFFUSION
o 300 mL Erect chest x ray
o 75 mL Lateral chest x ray
o 15-20 mL Lateral decubitus
o Lateral decubitus is also useful to see the
dynamicity of the fluid and to see the lung
area that was previously obscured by the
pleural effusion.
 PLEURAL EFFUSION
o Minimal pleural effusion
o Ultrasonography examination
o CT scan
o Aspiration guiding also with
ultrasonography.
 PLEURAL EFFUSION
Various appearance
o Subpulmonal effusion
o Costophrenic sinus blunting
o Meniscus sign
o Homogenous opacification
o Localized effusion
o Pseudotumor / vanishing tumor
o Laminar effusion
o Hydropneumothorax
PLEURAL EFFUSION

Subpulmonal
PLEURAL EFFUSION

Normal and blunting

PLEURAL EFFUSION

Meniscus sign
 PLEURAL EFFUSION

Homogenous opacification with

PLEURAL EFFUSION

Localized pleural effusion

 PLEURAL EFFUSION

Pseudotumor or vanishing tumor (lemon

PLEURAL EFFUSION

Laminar effusion
 HYDROPNEUMOTHORAX

Hydropneumothorax (horizontal air-fluid

 PLEURAL THICKENING
o Mimicking pleural effusion.
o The margin is not smooth
o Does not change with position
o Do not conform to the menicus sign
sky-slope
o If there is traction schwarte
o More opaque than the soft tissue
(subjective)
PLEURAL THICKENING
 EMPYEMA
o Distinction between a sterile pleural
effusion and an infected collection
(empyema) is often impossible.
o Clue : air fluid level that was localized.
o Without air fluid level it is hard to be
recognized.
o Lenticular
o The length of air fluid level in AP/PA view
is different with the air fluid level in lateral
view.
EMPYEMA
Lung Abscess Empyema
 PNEUMOTHORAX
o Air in the pleural cavity
o One of chest trauma complication
o Tension type : progressive accumulation
mediastinal shift cardiovascular
compromise
o Pleural line can be seen
o No bronchovascular marking beyond the
pleural line
o Expiration film
o Deep sulcus sign tension pneumothorax
PNEUMOTHORAX
PNEUMOTHORAX
PNEUMOTHORAX
DIAPHRAGM

o POSITION
o CONTOUR
o HERNIATION
 DIAPHRAGM

Position
o Right diaphragm is higher than the left
diaphragm.
o Normal : 2.5 cm
o > 3 cm: abnormal
 DIAPHRAGM

Etiology of right diaphram elevation

o Hepatomegaly
o Chilaiditi syndrome
o Paralysis n.phrenicus
o Eventratio
o Subpulmonal effusion
o Atelectasis
o Fibrosis
o Intraabdominal tumor
o Subphrenic abscess
DIAPHRAGM
 DIAPHRAGM
Etiology of left diaphram elevatio
o Paralysis n.phrenicus
o Eventratio
o Subpulmonal effusion
o Atelectasis
o Fibrosis
o Distended stomach or colon
o Intraabdominal tumor
o Subphrenic abscess
DIAPHRAGM
 DIAPHRAGM

Etiology of both diaphram

elevation
o Ascites
o Intraabdominal tumour
o Pregnancy
o Obesity
o Pneumoperitoneum
DIAPHRAGM
 DIAPHRAGM
Contour of diaphragm
o Tenting
o Normal variant
o Pulmonary / pleural fibrosis
o Atelectasis (caused by pulmonary ligament
traction)
o Scalloping / bulging
o Normal variant
o Eventratio
o Focal mass below the diaphragm or at
diaphragmatic pleura.
DIAPHRAGM

Scalloping
DIAPHRAGM

Tenting
 DIAPHRAGM

Diaphragmatic herniation
o Congenital
o Morgagni (anterior)
o Bochdalek (posterior)
o Acquired (Traumatic)
o Hiatal hernia
DIAPHRAGM
DIAPHRAGM
 DIAPHRAGM

Diaphragm rupture with herniation

SOFT TISSUE & SKELETAL

o RIBFRACTURE
o CLAVICLE FRACTURE
o SCAPULA FRACTURE
o SUBCUTIS
EMPHYSEMA
o CORPUS ALIENUM
RIB FRACTURE
CLAVICLE FRACTURE
SCAPULAR FRACTURE
SUBCUTIS EMPHYSEMA
CORPUS ALIENUM
Thank you
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