Chest Film Primer Images and Material courtesy of:

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Chest Film Primer Images and Material courtesy
of

• David S. Feigin, M.D.
• Colonel (Ret), USA, MC
• Professor of Radiology,
• Uniformed Services University of the Health
  Sciences
• A Systematic Approach To Abnormal Chest
  ImagesRadiographs And Computed Tomograms
• Updates and compilation
• Les Folio, DO, MPH
• Col, USAF, MC, SFS
• Associate Professor of Radiology,
• Uniformed Services University of the Health
  Sciences

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Main Menu
EXIT

• 5 PATTERNS OF PATHOLOGY
• Mass
• Consolidative
• Interstitial
• Linear
• Nodular
• Vascular
• Airway
• Wall-Thickened
• Obstructive

• NORMAL ANATOMY
• A-P Chest Radiograph
• Lateral Chest Radiograph

• THE SEARCH PATTERN
• A-P Chest Radiograph
• Lateral Chest Radiograph

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Normal Anatomy- AP
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1. Gross Specimen
2. The Respiratory System A. The Airway
B. The Lungs and Diaphragm

• Cardiovascular System
• A. The Cavals

B. The Heart
SVC Edge
Left paratracheal stripe
LUL
C. The Pulmonary Arteries
RUL, next to minor fissure
D. The Pulmonary Veins
E. Aorta
3. The Bones, Bowel Gas, Azygous, etc.
Right Atrium
Left Ventricle
RML, next to right heart border
RLL
LLL
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Normal Anatomy- Lateral
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1. Respiratory System A. The Airway
B. The Lungs and Diaphragm
RUL
Trachea
2. Cardiovascular System
Aorta
A. The Vessels
Right Pulmonary Artery
B. The Heart
Left Pulmonary Artery
Left main bronchus
RML, with minor fissure
3. The Bones (no link yet)
Right Ventricle
RLL, with major fissure
Left Ventricle
Inferior Vena Cava
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Quiz yourself Mediastinum Lines, Edges
Recommendation Test yourself before advancing
to the answers
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1

• SVC Edge
• Rt Paratracheal Line
• Lt Paratracheal Stripe
• (both red and black lines)
• Aortic Arch
• Descending Aorta
• (only left edge seen, and not always)
• Rt Atrium
• Azygoesophageal edge
• Lt Ventricle
• Main Pulmonary Artery
• AKA trunk, middle mogul

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4
9
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6
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Mediastinum
Mid
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Trachea
Lt MSB on end
Right Pulmonary Artery (red)
Left Pulmonary Artery (green)
Left Ventricle (curved line)
IVC (arrows)
Lateral
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Main Menu
EXIT

• The 5 PATTERNS OF PATHOLOGY
• Mass
• Consolidative
• Interstitial
• Linear
• Nodular
• Vascular
• Airway
• Wall-Thickened
• Obstructive

• NORMAL ANATOMY
• A-P Chest Radiograph
• Lateral Chest Radiograph

• THE SEARCH PATTERN
• A-P Chest Radiograph
• Lateral Chest Radiograph

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Search Pattern- AP
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• PRELIMINARIES
• Verify patient info, date, L and R
  markers
• Note technique deficiencies
• Quick look at both films for obvious
  abnormalities
• FRONTAL
• 1. LUNGS
• Up and down
• Side to side
• Volume and Symmetry
• 2. PERIPHERY
• Pneumothorax (air)
• Effusions (fluid)
• 3. MEDIASTINUM
• Contours
• Edges
• Shape
• 4. TRACHEA AND MAIN BRONCHI
• 5. HILA

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Search Pattern- Lateral
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• PRELIMINARIES
• Verify patient info, date, L and R
  markers
• Note technique deficiencies
• Quick look at both films for obvious
  abnormalities
• LATERAL
• 1. SIZE AND SHAPE OF LUNGS AND DIAPHRAGMS
• 2. AIRWAY
• Neck to Hilum
• Pulmonary Arteries
• 3. Back of heart and darkening downward
• 4. Up anterior mediastinum for darkening
• 5. Down spine for vertebral bodies and darkening
• 6. PERIPHERY
• Abdomen
• Anterior chest wall
• Posterior ribs
• Costophrenic angles

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Main Menu
EXIT

• 5 PATTERNS OF PATHOLOGY
• Mass
• Consolidative
• Interstitial
• Linear
• Nodular
• Vascular
• Airway
• Wall-Thickened
• Obstructive

• NORMAL ANATOMY
• A-P Chest Radiograph
• Lateral Chest Radiograph

• THE SEARCH PATTERN
• A-P Chest Radiograph
• Lateral Chest Radiograph

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1. Mass
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• Mechanism - Local destruction of lung
  parenchyma
• Radiological sign - Any localized opacity not
  completely bordered by fissures or pleura

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1. Mass
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• Differential Diagnosis
• Malignancy - Primary or secondary
• Granulomatous disease - Infectious or
  noninfectious, active or inactive
• Other inflammation, including pneumonia and
  abscess, Benign neoplasm, Congenital abnormality
• Crucial appearance characteristics for inactivity
• Calcification central, lamellar
• Evolution 2-year stability or regression

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2. Consolidative (Alveolar) Pattern
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• Mechanism
• Produced in pure form and by ALVEOLAR FILLING
• May be mimicked by alveolar collapse, as in
  airway obstruction
• Rarely, confluent interstitial thickening
• Radiological signs
• Fluffy, cloud-like, coalescent opacities
• Sharp edges when limited by fissures or pleura
• Complete air bronchograms through the clouds

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Fluffy and cloud-like appearance Air bronchograms
THROUGH clouds
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Air bronchogram
Normal lung
Consolidated lung, with air in bronchioles
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2. Consolidative (alveolar) Pattern
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• Differential Diagnosis (5 general)
• Hemorrhage - BLOOD - embolism, trauma
• Exudate - PUS - pneumonia, pneumonitis
• Transudate - WATER - congestion, ARDS
• Secretions - PROTEIN - Mucous plugging, Alveolar
  proteinosis
• Malignancy - CELLS - Alveolar cell carcinoma,
  Lymphoma

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3. Interstitial Pattern
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• Composition of pulmonary interstitium
• Alveolar walls, septi
• Connective tissue surrounding bronchi and
  vessels (peribronchial and perivascular
  spaces)
• Mechanism
• Thickening of lung interstices
• Architectural destruction of interstitium
  (honeycomb or end stage lung)

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3. Interstitial Pattern
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• Radiological Signs
• Linear form - reticulations (lines in all
  directions), septal lines (Kerley lines)
• Nodular form - small, sharp, numerous, evenly
  distributed, uniform (especially uniform in
  shape) nodules
• Destructive form - peripheral, irregular cyst
  formation

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3. Interstitial Pattern
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• Radiological Signs
• Linear form - reticulations (lines in all
  directions), septal lines (Kerley lines)
• Nodular form - small, sharp, numerous, evenly
  distributed, uniform (especially uniform in
  shape) nodules
• Destructive form - peripheral, irregular cyst
  formation

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Reticular form (Lines in all directions)
Kerley B lines (horizontal septal)
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3. Interstitial Pattern Linear Form
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• Differential Diagnosis The LIFE Lines
• Lymphangitic spread of malignancy
• Inflammation
• Fibrosis
• Edema

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3. Interstitial Pattern
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• Radiological Signs
• Linear form - reticulations (lines in all
  directions), septal lines (Kerley lines)
• Nodular form - small, sharp, numerous, evenly
  distributed, uniform (especially uniform in
  shape) nodules
• Destructive form - peripheral, irregular cyst
  formation

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Multiple small nodules, uniform in shape and
distribution
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3. Interstitial Pattern- Nodular Form
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Granulomatous Diseases Infectious Tuberculosis
Atypical mycobacterial diseases - especially
MAI Fungal diseases, especially Histoplasmosis
Coccidioidomycosis Blastomycosis (N. A. and
S. A.) Cryptococcosis Sporotrichosis Bacteria
l diseases, especially Nocardiosis Actinomyco
sis Non-infectious Sarcoidosis Hypersensitivity
Pneumonitis (HP) Vasculitis-granulomatosis
diseases Wegeners Lymphocytic Bronchocentri
c Allergic (Churg-Strauss) Langerhans
Granulomatosis (eosinophilic granuloma,
histiocytosis) (LCG)

• Differential Diagnosis

Pneumoconiousus Granulomatous Silicosis Beryllio
sis Benign Coal Workers Pneumoconiosis Sidero
sis Stannosis
1. Granulomas
2. Hematogenous Spread of Malignancy
3. Pneumoconiosus
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3. Interstitial Pattern
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• Radiological Signs
• Linear form - reticulations (lines in all
  directions), septal lines (Kerley lines)
• Nodular form - small, sharp, numerous, evenly
  distributed, uniform (especially uniform in
  shape) nodules
• Destructive form - peripheral, irregular cyst
  formation

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Early findings are non-specific. The peripheral
cyst formation (End-Stage Lung) is a late
finding.
Peripheral cyst formation, Honeycomb lung
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4. Vascular Patterns
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• Mechanism - increased, or decreasedperfusion,
  altering diameter of pulmonaryvessels
• Radiological signs - changes in diameterof
  specific vessels

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4. Vascular Patterns
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• Common examples
• Congestion - engorged veins, especially upper
  lungs
• Emphysema - diminished vessels
• Shunt vascularity - all vessels enlarged
• Lymphangitic carcinoma - irregular infiltration
  around vessels may resemble vessel enlargement
• Arterial hypertension - large central arteries
  with peripheral tapering
• Thromboembolism - locally diminished vessels with
  possible vessel mass centrally located
• Bronchial circulation - irregular vessels in
  unusual directions

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Engorged vessels, especially upper lungs
Congested vasculature
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Diminished vasculature
Emphysematous changes
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Enlarged pulmonary trunk (middle mogul)
Prominent left pulmonary artery
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5. Airway (Bronchial) Patterns
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• Mechanism
• Complete or partial obstruction of airways
• Thickening of airway walls
• Forms
• Complete airway obstruction - opacity and
  decreased volume
• Partial obstruction - lucency and increased
  volume
• Wall thickening - tram tracks, central cystic
  spaces or circles

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Flattened diaphragms on lateral
Bronchial wall thickening (circles and tram
tracks)
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5. Airway (Bronchial) Patterns
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• Differential diagnosis
• Opacities - endobronchial malignancies,
  granulomas, inflammatory, benign or congenital
  masses, mucous plugs, foreign bodies
• Lucencies - COPD, cysts, blebs, pneumatoceles
• Thickening - bronchiectasis, chronic bronchitis

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5. Airway (Bronchial) Patterns
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• Lobar atelectasis (collapse)
• Primary Signs
• Vessel number assymetry
• Fissure as edge
• Secondary signs
• Volume loss
• Elevation of diaphragm
• Shift of mediastinum and ribs

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Atelectasis Patterns
Right
Left
Upper
RUL
LUL
Lower
LLL
RLL
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Vessel Asymmetry
Left lower lung collapse