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Chapter 8
Radiologic Examination of the Chest
Slide 1
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Fundamentals
of
Radiography
Slide 2
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Standard Positions and Techniques
of Chest Radiography
Slide 3

Posteroanterior radiograph

Anteroposterior radiograph

Lateral radiograph

Lateral decubitus radiograph
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Figure 8-1. Standard PA chest radiograph with the patient’s lungs in full inspiration.
Slide 4
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Figure 8-2. A PA chest radiograph of the same patient shown in Figure 8-1 during expiration.
Slide 5
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Figure 8-3. Compared with the PA chest radiograph, the heart is significantly magnified in the AP
chest radiograph. In the PA radiograph the ratio of the width of the heart to the thorax is normally less
than 1:2.
Slide 6
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Figure 8-4. AP chest radiograph. The diaphragms are elevated, the lower lung lobes
appear hazy, the ratio of the width of the heart to the thorax is greater than 2:1, and
extraneous lines are apparent on the patient’s left side.
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Figure 8-5. Lateral radiograph.
Slide 8
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Figure 8-6. Subpulmonic pleural effusion. Right lateral decubitus view. Subdiaphragmatic
fluid has run up the lateral chest wall, producing a band of soft tissue density. The medial
curvilinear shadow (arrow) indicates fluid in the lips of the major fissure.
Slide 9
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Inspecting the
Chest Radiograph
Slide 10
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Figure 8-7. Normal PA chest radiograph. 1, Trachea (note vertebral column in middle of trachea);
2, carina; 3, right main stem bronchus; 4, left main stem bronchus; 5, right atrium; 6, left ventricle;
7, hilar vasculature; 8, aortic knob; 9, diaphragm; 10, costophrenic angles; 11, breast shadows;
12, gastric air bubble; 13, clavicle; 14, rib.
Slide 11
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Figure 8-8. Normal lateral chest radiograph. 1, Manubrium; 2, sternum; 3, cardiac shadow;
4, retrosternal air space in the lung; 5, trachea; 6, bronchus, on end; 7, aortic arch (ascending
and descending); 8, scapulae; 9, vertebral column; 10, diaphragm; 11, breast shadow.
Slide 12
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Table 8-1
Common Radiologic Terms
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
Air cyst

Bleb

Bulla

Bronchogram

Cavity

Consolidation

Homogeneous density

Honeycombing

Infiltrate
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Table 8-1
Common Radiologic Terms, cont.
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Interstitial density

Lesion

Opacity

Pleural density

Pulmonary mass

Pulmonary nodule

Radiodensity

Radiolucency

Translucent
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Selected Examples
of Common
Radiologic Terms
Slide 15
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Cavity
Lung with TB cavities
Figure 17-1, C.
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Radiograph of cavity
Figure 17-2; From Armstrong P et al:
Imaging of diseases of the chest, ed
2, St. Louis, 1995, Mosby.
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Consolidation or Opacity
(Caused by a Right Lung Pneumonia)
Pneumonia
Figure 15-1.
Figure 15-5.
Slide 17
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Bronchogram
Figure 15-6. Air bronchogram.
(From Armstrong P et al: Imaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.)
Slide 18
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Bronchogram
Shown in chest CT Scan
Figure 15-7.
(From Armstrong P et al: Imaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.)
Slide 19
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Honeycombing
(as shown in interstitial pulmonary fibrosis)
Figure 28-4.
(From Armstrong P et al: Imaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.)
Slide 20
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Infiltrate
(As shown in patient with ARDS—general term)
Figure 27-2.
Slide 21
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Pleural Density
Figure 28-3.
(From Armstrong P et al: Imaging of diseases of the chest, ed 2, St. Louis, 1995, Mosby.)
Slide 22
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Pulmonary Mass
Figure 26-3.
(From Rau JL, Pearce DJ: Understanding chest radiographs, Denver, 1984, Multi-Media Publishing.)
Slide 23
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Radiodensity
(Caused by a Right Lung Pneumonia)
Pneumonia
Figure 15-1.
Figure 15-5.
Slide 24
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Translucency or Radiolucency
(Caused by a Right Pneumothorax)
Right pneumothorax
Figure 22-1.
Slide 25
Figure 22-10, B.
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Translucency or Radiolucency
(Caused by a Chronic Emphysema)
Emphysema
Figure 12-3.
Slide 26
Figure 12-2.
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Technical Quality of the Radiograph
Slide 27

Technical quality

Exposure quality

Level of inspiration
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First
Technical Quality

Was the patient in the correct position?


Even a small degree of patient rotation can
create a false image

Slide 28
Check the medial ends of the clavicles to the
vertebral column
Erroneously suggesting tracheal deviation, cardiac
displacement, or cardiac enlargement
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Second
Exposure Quality
Slide 29

Normal exposure is verified by determining
whether the spinal processes of the vertebrae
are visible to the 5th or 6th thoracic level

Compare the relative densities of the heart
and lungs

Overexposure: heart and lungs more radiolucent

Underexposure: heart and lungs more dense or
whiter
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Third Level of Inspiration When
Radiograph Was Taken
Slide 30

At full inspiration, the diaphragmatic domes
should be at the level of the 9th to 11th ribs
posteriorly

At expiration, the lungs appear denser, the
diaphragm is elevated, and the heart appears
wider and enlarged
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Sequence of Examination
Slide 31

Mediastinum

Trachea

Heart

Hilar region

Lung tissue

Pleura

Diaphragm

Gastric air bubble

Bony thorax and soft tissues
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Figure 8-7. Normal PA chest radiograph. 1, Trachea (note vertebral column in middle of trachea);
2, carina; 3, right main stem bronchus; 4, left main stem bronchus; 5, right atrium; 6, left ventricle;
7, hilar vasculature; 8, aortic knob; 9, diaphragm; 10, costophrenic angles; 11, breast shadows;
12, gastric air bubble; 13, clavicle; 14, rib.
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Structure
Abnormal Position
Mediastinum
Leftward shift

Trachea

Carina

Heart

Major vessels
Causes

Pulled left by upper lobe tuberculosis, atelectasis, or
fibrosis

Pushed left by right upper lobe emphysematous bulla,
fluid, gas, or tumor
Table 8-2.
Examples of Factors That Pull or Push Anatomic Structures
Out of Their Normal Position in the Chest Radiograph.
Slide 33
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Structure
Abnormal Position
Left diaphragm
Upward shift
Causes

Pulled up by left lower lobe atelectasis or fibrosis

Pushed up by distended gastric air bubble
Table 8-2.
Examples of Factors That Pull or Push Anatomic Structures
Out of Their Normal Position in the Chest Radiograph, cont.
Slide 34
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Structure
Abnormal Position
Horizontal fissure
Downward shift

Right lung

Right hilum
Causes

Pulled down by right middle lobe or right lower lobe
atelectasis

Pushed down by right upper lobe neoplasm
Table 8-2.
Examples of Factors That Pull or Push Anatomic Structures
Out of Their Normal Position in the Chest Radiograph, cont.
Slide 35
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Structure
Abnormal Position
Left lung
Rightward shift
Causes

Pulled right by right lung collapse, atelectasis, or fibrosis

Pushed right by left-sided tension pneumothorax or
hemothorax
Table 8-2.
Examples of Factors That Pull or Push Anatomic Structures
Out of Their Normal Position in the Chest Radiograph, cont.
Slide 36
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Other Radiologic Techniques

Computed tomography (CT)


Position emission tomography (PET)

Slide 37
CT scan
PET scan

Magnetic resonance imaging

Pulmonary angiography

Ventilation-perfusion scan

Fluoroscopy

Bronchography
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Normal CT Scan Lung Window
Figure 8-9. Overview of normal lung window CT scan. The apex appears in the two
views in the upper right hand corner of this figure; the diaphragm at the base of the
lungs appears in the lower right hand view.
Slide 38
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Example of Several Normal
CT Scan Lung Window Slices
Slide 39
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Normal CT Scan Lung Window
A
Figure 8-10. Close-up of a normal lung
window CT scan. A, The portion of the
chest the CT scan is taken.
Slide 40
B
Figure 8-9 B. The actual crosssectional slice, or axial view of the
chest.
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Normal CT Scan Lung Window
Figures 8-10, A, and 8-9, C.
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Normal CT Scan Lung Window
Figures 8-10, A, and 8-9, D.
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Normal CT Scan Lung Window
Figures 8-10, A, and 8-9, E.
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Normal CT Scan Lung Window
Figures 8-10, A, and 8-9, F.
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Normal CT Scan Lung Window
Figures 8-10, A, and 8-9, G.
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Normal CT Scan Lung Window
Figures 8-10, A, and 8-9, H.
Slide 46
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Normal CT Scan Lung Window
Figures 8-10, A, and 8-9, I.
Slide 47
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Normal CT Scan Lung Window
Figures 8-10, A, and 8-9, J.
Slide 48
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Normal CT Scan Lung Window
Figures 8-10, A, and 8-9, K.
Slide 49
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Normal CT Scan Lung Window
Figures 8-10, A, and 8-9, L.
Slide 50
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Example of Several Normal
CT Scan Mediastinal Window
Slide 51
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Normal CT Mediastinal Window
Slide 52
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Normal CT Mediastinal Window
Slide 53
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Normal CT Mediastinal Window
Slide 54
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Normal CT Mediastinal Window
Slide 55
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Normal CT Mediastinal Window
Slide 56
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Normal CT Mediastinal Window
Figures 8-11. Close up of normal CT mediastinal window. A, The portion of the
chest the CT scan is taken. B, The actual cross-sectional slice, or axial view of
the chest. Note that the lungs are overexposed and appear mostly black. The
bone and mediastinal organs appear mostly white.
Slide 57
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Normal CT Mediastinal Window
Slide 58
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Normal CT Mediastinal Window
Slide 59
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Normal CT Mediastinal Window
Slide 60
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Normal CT Mediastinal Window
Slide 61
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Normal CT Mediastinal Window
Slide 62
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Positron Emission Tomography
PET Scan
Slide 63
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A
B
Figure 8-12.
Chest radiograph identifying two suspicious findings: in the right upper lobe (A) and in the
left lower lobe (B), just behind the heart (see white arrows).
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A
CT scan,
upper right lobe
B
Chest radiograph
CT scan,
left lower lobe
Figure 8-13.
Same chest radiograph as shown in Figure 8-12. Note the CT scan
also identifies the suspicious nodules and their precise location.
Slide 65
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Coronal View
Figure 8-14.
PET scan: coronal views.
The last three views show a “hot spot” in left lower lung lobe.
Slide 66
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Figure 8-15.
PET scan: sagittal views. The encircled images show a “hot spot” in the lower left lobe.
Slide 67
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Axial View
Figure 8-16.
PET scan: axial view. A “hot spot” is further confirmed in left lower lung lobe.
Slide 68
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Axial View
No hot spot seen
Figure 8-17.
PET scan: axial view. This image confirms that the small nodule identified in the upper right
lobe in the chest radiograph and CT scan is benign (i.e., no “hot spot” is evident).
Slide 69
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PET Scan
and
CT Scan
Slide 70
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CT Scan
CT/PET Fusion
PET Scan
Axial
View
Coronal
View
Figure 8-18. CT/PET scan (center). CT scan, CT/PET fusion, and PET scan, all showing the
same malignant nodule in right upper lobe (see white arrow). Note: The CT/PET fusion is
normally presented in color (e.g., red, blue, yellow).
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Magnetic Resonance Imaging
Slide 72
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Figure 8-19. Anatomy of mediastinum on MRI. A, LBCV, Left brachiocephalic vein; RBCV,
right brachiocephalic vein; Ao A, aortic arch; T, trachea; Es, esophagus. B, RV, Right
ventricle; LV, left ventricle; RA, right atrium; LA, left atrium; D Ao, descending aorta; Es,
esophagus; Az V, azygos vein. (From Armstrong P, Wilson AG, Dee P: Imaging of diseases
of the chest, St. Louis, 1990, Mosby.)
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Pulmonary Angiography
Slide 74
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Figure 8-20. Abnormal pulmonary angiogram. Radiopaque material injected into the blood
is prevented from flowing into the left lung past the pulmonary embolism (arrow). No
vascular structures are seen distal to the obstruction.
Slide 75
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Bronchography
Slide 76
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Figure 8-21. Bronchogram obtained using contrast medium in a patient with a history of
bronchiectasis. Arrows indicate the carina and the bronchi leading to the posterior basilar
segment of the left lower lobe. (From Rau JL, Jr, Pearce DJ: Understanding chest
radiographs, Denver, 1984, Multi-Media Publishing.)
Slide 77
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