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Thoracic radiology Dr.Khaleel Ibraheem MBChB,DMRD,CABMS-rad Approach to chest x ray Chest consolidation Diffuse lung lesions Differentiating the Causes of an Opacified Hemithorax • • • • Atelectasis of an entire lung A large pleural effusion Pneumonia of an entire lung And a fourth cause: Post-pneumonectomy – removal of an entire lung Atelectasis of the Lung • There is a shift of heart and hemidiaphragm toward side of opacification (toward side of volume loss) Pleural Effusion • It acts like a mass • Pushing the heart and trachea away from the side of opacification pneumonia • The hemithorax is opaque and there isno shift of the heart or trachea • There may be an air bronchogram sign present postpnemonectomy • The hemithorax eventually fibroses and becomes opaque • Clues: There is frequently a resected fifth rib and/or surgical clips quiz Pleural effusion • Subpulmonary On the frontal film, the highest point of the apparent right hemi diaphragm is displaced laterally (it is usually in the center). Blunting of CP angle Normally there are 2-10cc of fluid in the pleural space When >75cc accumulate, the posterior costophrenic (CP) sulci, seen on the lateral film, become blunted When 200-300cc accumulate, the CP sulci on the frontal film become blunted Meniscus sign • Pleural fluid tends to rise higher along its edge producing a meniscus shape medially and laterally • Usually only lateral meniscus can be seen • The meniscus is a good indicator of the presence of a pleural effusion Loculated effusion • Occurs secondary to adhesions which form between visceral and parietal pleura • Adhesions more common with blood(hemothorax) and pus (empyema) • Loculated effusions have unusual shapes or positions in thorax hydropneumothorax • If both a pneumothorax and a pleural effusion occur together, it is called a hydropneumothorax • A hydropneumothorax is usually due to trauma, surgery, bronchopleural fistula • It is characterized by an air-fluid level in the hemithorax A straight edge,indicative of a fluid interface, in this case an air-fluid interface, is seen on the right. pneumothorax • When air enters the pleural space, the parietal and visceral pleura separate making the visceral pleura visible • The thin white line of the visceral pleura is called the visceral pleural white line • You must see the visceral pleural white line to make diagnosis of pneumothorax! Simple pneumothorax In a simple pneumothorax, there is no shift of the heart or mediastinal structures (trachea) Air in left hemithorax balances the air in the right hemithorax Tension pneumothorax • • • Progressive loss of air into pleural space causing a shift of the heart and mediastinal structures away from side of pneumothorax Opposite lung is compressed Respiratory function severely compromised