RADIOLOGY

OF THE RESPIRATORY SYSTEM

ADNAN M
LUTHFY ATTAMIMI
DEPART. OF RADIOLOGY
MED. FAC. UNHAS

(= CHEST )
RADIOLOGY OF THE :

LUNG PARENCHYMA
PLEURA
DIAPHRAGMA
MEDIASTINUM (TUMORS)

LUNG PARENCHYMA
PULMONARY LOBULE

Small Bronchiole

5 7 Terminal Bronchiole

PULMONARY ACINUS

Single Terminal Bronchiole

Respiratory Bronchioles
( air sacs in the walls )
Aveolar ducts
ALVEOLI

ANATOMY

INDIKASI PEMERISAAN FOTO TORAKS

BILA ADA KELAINAN / PENY. TRAKTUS RESP ;
A. BAWAAN, RADANG, TUMOR, TRAUMA
B. BATUK, BATUK DARAH, SESAK,SAKIT DADA,
dll.

RADIOLOGICAL METHODS OF
INVESTIGATION
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

PLAIN FILM / CHEST X-RAYS

CT SCAN
MRI
ULTRASONOGRAPHY (USG)
NUCLEAR MEDICINE
ARTERIOGRAPHY
MCS ( = MASS CHEST SURVEY )
TOMOGRAPHY
FLUOROSCOPY
BRONCHOGRAPHY

Chest x-ray ;
is one of the most important diagnostic tools
in evaluating patients with pulmonary problems.
Physical examination of the chest has inherent
limitations.
Lesions located in the mediastinum, interstitium,
and in the center of the lung
are rarely picked up by physical exam.
Physical exam and chest x-ray compliment each other in providing
information and they are not mutually exclusive.
In general, physical exam is recommended for acute illness,
while chest x- ray is recommended for chronic illness.

 CHEST X-RAYS : VIEWS

POSTEROANTERIOR ( PA ) ROUTINE
LEFT / RIGHT LATERAL (LL/RL)
RIGHT / LEFT ANTERIOR OBLIQUES (RAO/LAO)
RIGHT / LEFT LATERAL DECUBITUS (RLD/LLD)
TOP LORDOTIK

 POSTERO-ANTERIOR (PA) VIEW

 RIGHT / LEFT LATERAL DECUBITUS

RLD

DBD/DHF

LLD

 TOP LORDOTIC VIEW

 MASS CHEST SURVEY (MCS)

SYARAT-SYARAT FOTO THORAX PA bila memungkinkan ;

1. INSPIRASI CUKUP
Diafragma kanan setinggi iga.9 posterior

2. POSISI SIMETRIS
Proyeksi tulang corp.vert. Th. terletak ditengah sendi sternoclav.
kanan & kiri

3. KONDISI SINAR-X SESUAI

mAs ( jumlah sinar ) cukup film diluar cav.thorax cukup kehitaman
kV

( kualitas sinar ) cukup vert.Th. Hanya terlihat s/ Th. 3 4.

4. FILM MELIPUTI SELURUH CAVUM THORAX

Puncak cavum thorax & sinus phrenico-costalis kanan kiri

ISTILAH DENSITAS
RADIOGRAFI:
1. AIR DENSITY = HIPERLUSEN
2. FAT DENSITY = RADIOLUSEN
3. WATER DENSITY = INTERMEDIATE
4. BONE DENSITY = RADIOPAK
5. METAL DENSITY = HIPERRADIOPAK

supine AP (anteriorposterior) position the x-ray tube is

40 inches from the patient.

PA ( POSTERO-ANTERIOR )

AP ( ANTERO-POSTERIOR )

his is a PA film on the left compared with a AP supine film on the right.

e AP shows magnification of the heart and widening of the mediastinum

henever possible the patient should be imaged in an upright PA position

AP views are less useful and should be reserved for very ill patients
who cannot stand erect.

Inspiration
The patient should be examined in full inspiration.
The diaphragm should be found at about the level
of the 8th - 10th posterior rib or 5th - 6th anterior rib on good inspiration.

A patient can appear to have a very abnormal chest if the film is taken
during expiration.
Look at the case - on the first film, the loss of the right heart border
silhouette would lead you to the diagnosis of a possible pneumonia.
However, the patient had taken a poor inspiration.

On repeat exam with improved inspiration, the right heart border is normal.

X-ray Penetration

normal PA film that is underpenetrated

overpenetrated PA film

Adequate penetration of the patient by radiation

is also required for a good film.

NORMAL CHEST
PARENCHYME : RADIOLUCENT
PLEURA : INVISIBLE
HILAR : LEFT < RIGHT
DIAPHRAGM : RIGHT > LEFT
SINUS PHRENICO COSTALIS <

The the shadows originate from the hila and branches

while spread to the lung fields are known as
lung markings.

Lung markings consist of

pulmonary arteries and veins
as well as branches of bronchi and lymph ducts
which are not seen in normal chest film.

 Lung fields appear dark because of air.

Ninety-nine percent of t he lung is air

The pulmonary vasculature , interstitium constitute 1%
and give the lacy lung pattern.
Heart, vessels, liver and diaphragm are liquid density.
Vertebrae, sternum and ribs obviously cast a bone density.
Most of the disease states replace air from alveoli with
a pathological process which usually is a liquid
density and appears white.
Having a proper understanding of each of the pathological
process is
essential.

NORMAL CHEST

NORMAL CHEST LAT. VIEW

Magnification of clavicular head and spinous process alignment

demonstrating a straight film.

This is a normal PA film without any rotation.

Lobes and Fissures

The left image shows the right minor fissure ( A ) and

the inferior borders ( B )of the major fissures bilaterally.
The right image shows the superior border
of the major fissures (B) bilaterally.

On the lateral view, both lungs are superimposed.

Think about them separately,
the left lung has only a major fissure as shown.
The right lung will have both the major and minor fissure.

NORMAL CHEST RADIOGRAPHY

EVALUATION :
SOFT TISSUE
LUNGS
HEART
SINUS
HILA
MEDIASTINUM
DIAFRAGMA & PLEURA
RIBS

N - INSPIRATION

ADULT

CHILD

N - EXPIRATION

NORMAL DD : EMPHYSEMA

THYMUS IN CHILD

 DISEASES OF THE LUNG PARENCHYME

1.
2.
3.
4.
5.
6.
7.
8.

INFLAMMATORY
LUNG ABSCESS
ATELECTASIS
LUNG EDEMA
EMPHYSEMA
CHRONIC BRONCHITIS
BRONCHIECTASIS
RESPIRATORY DISTRESS OF THE NEW BORN
(RDN)
9. PNEUMOCONIOSIS
10. LUNG TUMORS

INFLAMMATORY
TUBERCULOSIS (TBC)
A. PRIMARY TBC
B. POST PRIMARY TBC
NON TBC / NON SPESIFIC
C. PNEUMONIA
D. BRONCHOPNEUMONIA

PRIMARY PULMONARY TBC

PRIMARY COMPLEX OF RANKE
CHEST X-RAYS :

PRIMARY FOCUS ( = GHON )

LYMPHANGITIS
HILAR NODES >> OR CALCIFICATION

 PRIMARY PULMONARY TBC

PRIMARY TBC

 GHON FOCUS & RANKE COMPLEX

 PRIMARY TBC & PNEUMONIA

POST PRIMARY TBC

ACTIVE SIGNS:
CHEST X-RAYS :

PATCHIES
CONFLUENS OPACITIES
CLOUDY HAZINESS
CAVITY CAVITIES

POST PRIMARY TBC ( ADULT )

CAVITY

INHOMOGENEOUS OPACITY

TBC : CAVITY AT LUL

Tuberculosis

Left upper lobe cavity

Tuberculosis

Left upper lobe cavity

POST PRIMARY TBC

POST PRIMARY TBC

POST PRIMARY TBC : QUIESCENT

o FIBROSIS RETRACTION
o CALCIFICATIONS

INACTIVE (OLD) TBC:

FIBROSIS & CALCIFICATION

OLD / INACTIVE TBC

OLD / INACTIVE TBC

POST PRIMARY TBC

+ PNEUMONIA AT RUL

Pleural effusion
LUL cavity
Tuberculosis

TBC COMPLICATION : MILIAR TBC

Milary Tuberculosis

Interstitial nodules

o Uniform size
o Sharper edges

Milary Tuberculosis

TBC COMPLICATION :

Tuberculosis Spine

Loss of intervertebral space

Vertebral collapse

Cold abscess is not present in this case

PA view is not diagnostic.

SPONDYLITIS TBC
& PARA VERTEBRAL ABSCESS

TBC TULANG

CT SCAN : TBC

DESTROYED LUNG herniasi

PNEUMONIA ( NON TB )
RELATIVELY HOMOGENOUS CONSOLIDATION
CLOUDY , HAZINESS LOBAR / SEGMENTALS .
SHARP BORDER
AIR BRONCHOGRAM SIGN (ABS + / - )
SILHOUETE SIGN ( + / - )
TENDENCY TO THE LOWER / MIDDLE LOBES

CONSOLIDATION
Consolidation is defined as a process in which
air in the lung is replaced by products of disease.

On CXR it is manifested by a homogenous opacity

in the lung with little or no volume loss and loss of
vessel detail sometimes with airbronchogram.

CONSOLIDATION OF THE LUNG PARENCHYME

AIR BRONCHOGRAM SIGN ( ABS )

PNEUMONIA / HMD

LLL PNEUMONIA

SILHOUETTE SIGN

Lobar pneumonia

Primary involves alveoli / Spreads through pores of Kohn throughout

a segment or lobe, but not totally.
Bronchi are not primary affected air bronchograms

LLL PNEUMONIA

Haziness in the left lower lung field

Density in the projection of lingula in lateral view
Air bronchogram in lateral
No significant loss of lung volume

RUL PNEUMONIA

Right upper lobe consolidation

No significant loss of lung volume
Air bronchogram

Consolidation Right Upper Lobe

Density in right upper lung field

Lobar density
Loss of ascending aorta silhouette
No shift of mediastinum
Transverse fissure not significantly shifted
Air bronchogram

On right note the air from alveoli are replaced with inflammatory exudate
resulting in liquid density to RUL in CXR.

Round Pneumonia
Round density
Shorter doubling time
Air bronchogram

The most common causes :

1. Fungal
2. Tuberculosis

Round Pneumonia
This is a case of blastomycosis

PNEUMONIC ASPIRATION

RML PNEUMONIA

RIGHT PLEUROPNEUMONIA

PNEUMONIA

PLEURAL EFFUSION

BRONCHOPNEUMONIA
CHEST X-RAYS DENSITIES
PATCHIES
POORLY DEFINED
INHOMOGENOUS
IRREGULAR SCATTERED
TENDENCY TO THE LOWER LOBE

Bronchopneumonia
Primary affects the bronchi and adjacent alveoli
Bronchial spread results in multifocal patchy opacities.
Bronchi fill with exudate causing of volume loss.

BILATERAL BRONCHOPNEUMONIA
PATCHIES

IRREGULAR SCATTERED

BRONCHOPNEUMONIA

Comparison of bronchopneumonia vs. lobar pneumonia

Bronchopneumonia

Lobar Pneumonia

Location

1. often bilateral
2. basal (i.e. lower lobes)

large area, even whole lobe involvement

Route of infection

spreads from bronchioles to nearby

alveoli

both alveoli and bronchioles

Spread of
infection

consolidation is patchy

Whole lobe becomes consolidated

Susceptible group

infants, elderly

Adults especially alcoholics and vagrants.

Causing
Organism

Dependent on circumstances
predisposing to infection(i.e.
nosocomial or community acquired)

Often caused by Pneumococcus or

Klebsiella.

Recovery

If treated, recovery usually involves

focal organisation of lung by
fibrosis.

If treated promptly, many recover with

lungs returning to normal structure and
functioning by resolution. In other cases
the exudate in alveoli is organised, leading
to lung scarring and permanent lung
dysfunction.

Notes

Patients who are immobile develop

retention of secretions; thus, most
commonly involves the lower lobes.

Patient are severely ill and usually

associated bacteriemia.

LUNG ABSCESS
Lung abscesses are localized suppurative (pus forming)
infiltrations of lung that are usually caused by Staph,
anaerobes or mixed infections.
They can develop from any pneumonia.

CXR ;

CAVITY WITH ONE CHAMBER

OR NODUL WITH
FLUID LEVEL,
THICK WALL
IRREGULAR BORDER

Lung Abscess
Bilateral
Multiple
Fluid level

Lung Abscess
Thick wall
Fluid level

LUNG ABSCESS

THICK & IRREGULAR WALL

LUNG ABSCESS:

AIR FLUID LEVEL

LUL NODUL& ABSCESS

NODUL

3 DAYS LATER

DD : CARC .CAVITIES

PRIMARY SQUAMOUS CELLS CARC

ATELECTASIS
Atelectasis is collapse or incomplete expansion of the lung
or part of the lung.
The distribution can be lobar , segmental, subsegmental.
It is most often caused by an endobronchial lesion,
such as mucus plug or tumor.
It can also be caused by extrinsic compression centrally
by a mass such as lymph nodes or peripheral compression
by pleural effusion.

An unusual type of atelectasis is cicatricial and is secondary

to scarring, TB, or status post radiation.

ATELECTASIS ;
CAUSED BY :
MECHANISMS :

OBSTRUCTION / RESORPTION
COMPRESSION / PASSIVE / RELAXATION
CONSTRICTION / CICATRIZATION
ADHESIVE / MICROATELECTASIS

MECHANISME OF ATELECTASIS

DIRECT SIGN : ATELECTASIS

DISPLACED SEPTA
LOSS OF AERATION / RADIOPACITY
OR LOCAL INCREASE IN DENSITY
VASCULAR & BRONCHIAL SIGNS :
CROWDING BRONCHIAL OR
VASCULAR MARKING

INDIRECT SIGN : ATELECTASIS

HEMIDIAPHRAGM ELEVATION
MEDIASTINUM DISPLACEMENT
HILAR DISPLACEMENT
COMPENSATORY OVERAERATION
NARROWING OF THE RIB CAGE

Plate like atelectasis

Atelectasis Right Upper Lobe

RUL ATELECTASIS

Density in the right upper

lung field
Transverse fissure pulled up
Right hilum pulled up
Smaller right lung
Smaller right hemithorax

RUL ATELECTASIS

Atelectasis Right Upper Lobe

Homogenous density right upper lung field

Mediastinal shift to right
Loss of silhouette of ascending aorta

Movement of oblique
and transverse fissures

RML Atelectasis

Vague density in right lower lung field (almost a normal film).

Dramatic RML atelectasis in lateral view, not evident in PA view.
Movement of transverse fissure

Atelectasis Right Lower Lobe

Density in right lower lung field

Indistinct right diaphragm
Right heart silhouette retained
Transverse fissure moved down
Right hilum moved down

Atelectasis Left Lower Lobe

Double density over heart

Inhomogenous cardiac
density
Triangular retrocardiac
density
Left hilum pulled down

Other findings include :

Pneumomediastinum

LUL ATELECTASIS

Atelectasis Right Lung

Homogenous density
right hemithorax
Mediastinal
shift to right
Right hemithorax
smaller
Right heart and
diaph. silhouette
are not identifiable

LEFT MASSIVE ATELECTASIS

HERNIASI

LEFT MASSIVE ATELECTASIS

DD ; AGENESIS OF THE RIGHT & LEFT LUNG

LUNG EDEMA
CHEST X-RAYS :

1. INTERSTITIAL
KERLEYS A LINE
KERLEY B LINE
PERIHILAR HAZE

2. ALVEOLAR
BATWING APPEARANCE
BUTTERFLY APPEARANCE
HAZINESS

RAD. OF THE INTERSTITIAL EDEMA

KERLEY A LINE

KERLEYS B LINE

EDEMA PARU : RIGHT PERIHILAR HAZE

Diffuse alveolar infiltrates

Pulmonary edema

Pulmonary edema

RADIOLOGY OF EDEMA:
supine BUTTERFLY APPEARANCE

CARDIOGENIC
uremic lung

NON CARDIOGENIC

CHEST X-RAYS EDEMA : NODULES/HAZINESS

Butterfly Pattern
Indicative of bilateral diffuse alveolar disease
Also called medullary distribution
Also called Bat wing appearance

INFARK PARU

COR PULMONALE : VENOUS HYPERTENSION

( PULMONARY HT )

LUNG EMPHYSEMA
CXR ;
BONES : - ANTERIOR BOWING OF THE STERNUM
- PROMINENT KYPHOSIS OF THE THORACIC SPINE
- INCREASED SPACING OF THE RIBS
DIAPHR : - FLATTENING ( SIGN OF HYPERINFLATION)
LUNGS : OVERINFLATION , OLIGEMIA , BULLAE
HEART : TEAR DROP CONFIGURATION

COPD : LUNG EMPHYSEMA

NORMAL CHEST

COPD

NORMAL DD : EMPHYSEMA

Emphysema

Hyperlucent lung fields

Multiple blebs
Prominent pulmonary arteries

Emphysema

Hyperlucent lung fields

AP diameter increased
Flat diaphragms
Multiple blebs
Retrosternal and infracardiac air

LOCAL EMPHYSEMA
BULLAE : ALVEOLAR EMPHYSEMA

GIANT BULLAE PNEUMATOCELE

LOBAR EMPHYSEMA

PREOPERATIVE

POST OPERATIVE

CHRONIC BRONCHITIS
PROMINENT VASCULAR LUNGS MARKINGS

( dirty chest )

BRONCHIECTASIS
localized irreversible dilatation of bronchial tree

BROCHIECTASIS : HONEYCOMB APPEARANCE

Bronchiectasis

Multiple bilateral basal

air fluid levels

Bronchiectasis

Multiple bilateral basal air fluid levels

HONEYCOMB LUNGS

Bronchiectasis
Cystic fibrosis

Tram lines
Multiple cavities

CT SCAN : BRONCHIECTASIS

MILD DILATED BRONCHI

MULTIPLE AREAS of
CYSTIC DILATATION BRONCHI

RESPIRATORY DISTRESS OF THE NEW BORN (

RDN)

o HMD : HYALINE MEMBRANE DISEASES

o LACK OF SURFACTAN PRODUCTION
ALVEOLI COLLAPS
o PREMATURE HIPOXIA CAPILARY
BROKEN HB MEMBRANE HYALINE
MUCOSE OF TB DUCTUS ALVEOLAR

CHEST X-RAYS : HMD

ALVEOLI COLLAPS :
FINE GRANULAR
HIPOAERATION
HIPERAERATION TB DA :
AIR BRONCHOGRAM SIGN ( + )

RDN : HMD / IRDN

HIPOAERATION

FINE GRANULARS

CHEST X-RAYS : HMD

AIR BRONCHOGRAM SIGN( = ABS + )

HMD

TRANSTIENT RESPIRATORY DISTRESS

OF THE NEW BORN

TRDN
PROLONGED

IMPAIRED
DELAYED

FLUID CLEARANCE

EDEMA

CHEST X RAYS : TRDN

TRDN EDEMA
COARSEGRANULARNODULES
HYPOAERATION
PERIHILAR HAZE
PLEURAL EFFUSION

CHEST X RAYS : TRDN

TRDN
AGE :1 HOUR
ALVEOLAR FLUID
PNEUMONIA

12 HOURS LATER
CLEAR

PNEUMOCONIOSIS
SILICOSIS

EGGSHELLS
Appearance

SILICOSIS

SILICOSIS

CT SCAN : SILICOSIS