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Basic of Thorax

Imaging
Introduction

• Plain chest radiograph is one of the most


commonly performed imaging procedures
• Up to 50% of studies in radiology practices.
• Countless volumes of radiology textbooks
have been dedicated solely to thoracic
imaging.
Introduction

Indication :
• Screening.
• Preoperative  underlying pulmonary and cardiovascular
diseases.
• Febrile patient  pulmonary sources of fever
• Trauma patient.

Contraindication (relative):
• Pregnant women especially 1st & 2nd trimester.
• Neonates and children.
ANATOMY
Lung Anatomy
Lung Anatomy

Right Lung
o 3 lobes
• (divided by major fissure and minor
fissure)
o 10 segments
Left Lung :
o 2 lobes
• (divided by major fissure)
o 8 segments
o Lingula segments ~ medial lobe of
the right lung
Lung Anatomy

• Minor (horizontal )fissure divides the superior lobe


and the middle lobe of the right lung.
• There is no minor fissure in the left lung.
Lung Anatomy
• In the right lung, the major fissure (oblique) divides the inferior
lobe with the middle and superior lobes.
• In the left lung, the major fissure (oblique) divides the inferior
lobe with the superior lobe.
RIGHT LUNG SEGMENTATION

Superior Lobe Apical segment (1)


Posterior segment (2)
Anterior segment (3)
Middle Lobe Lateral segment (4)
Medial segment (5)
Inferior Lobe Apicobasal segment (6)
Mediobasal segment (7)
Anterobasal segment (8)
Laterobasal segment (9)
Posterobasal segment (10)
LEFT LUNG SEGMENTATION

Superior Lobe Apicoposterior segment (1)


Anterior segment (2)
Lingula segments Superior segment (3)
Inferior segment (4)
Inferior Lobe Apical segment (5)
Anteromedial basal segment (6)
Laterobasal segment (7)
Posterobasal segment (8)
RESPIRATORY TRACT ANATOMY

Trachea :
• Begins at the lower border of the cricroid
cartilage at the level of C6 vertebra.
• Extend to the carina at the level of the sternal
angle (T5 level)
• T4 level on expiration
• T6 level on inspiration
• The trachea is 15 cm and 2 cm in diameter.
RESPIRATORY TRACT ANATOMY

Trachea :
• The trachea in children is very pliable.
• It may be deviated to the right in normal expiratory
film.
• It only deviates to the left if the aortic arch is on the
right side.
RESPIRATORY TRACT ANATOMY
Primary lobule
• The smallest functional unit of the lung
• Comprises all the structures distal to a
respiratory bronchiole including 16-40 alveoli.
• Normal adult has approximately 23 million
primary lobules.
Acinus
• Consists of all structures distal to the terminal
bronchiole, including vessels, nerves, and
connective tissue.
• It has a diameter 4-8mm
• Contains approximately 10-20 primary lobules
Secondary Lobule
• The smallest structural unit of lung parenchyma
that is surrounded by a connective tissue
septum.
• Contains 3-12 acini and measures 1,0-2,5 cm in
diameter.
TRACHEOBRONCHIAL SYSTEM

19
Acinus

Lobulus primer

12/11/2018 www.brainybetty.com 20
Radioanatomi Posteroanterior Chest X Ray
CHEST X-RAY POSITION

POSTER0ANTERIOR
ANTEROPOSTERIOR
RIGHT/LEFT LATERAL
RIGHT ANTERIOR OBLIQUE
LEFT ANTERIOR OBLIQUE
RIGHT POSTERIOR OBLIQUE
LEFT POSTERIOR OBLIQUE
TOP LORDOTIC
RIGHT/LEFT LATERAL DECUBITUS
POSTEROANTERIOR

Indication:
Routine
Screening TB
Pre-operative
ANTEROPOSTERIOR

Indication:
(cannot be taken with PA )
• Severely ill patient
• Children
• Infant and neonates
• Obese
• Pregnant
• Ascites
• Intraabdominal tumor
Distortion in Anteroposterior chest x-ray

• Heart enlargement
• Mediastinal widening
• Crowded bronchovascular
marking at the basal zone.
How to differentiate PA & AP

PA AP
• V – shaped clavicles • Straight clavicles
• No lung superposition • Lung superposition with
with the scapula the scapula
• No mediastinal widening • Mediastinal widening
• Distinct anterior aspect • Distinct posterior aspect of
of the costa. the costa
• Less crowded
• Crowded bronchovascular
bronchovascular marking
marking especially at the
basal zone.
PA vs AP CXR
Lateral Chest X-Ray

Indication:
• Look at mediastinal
abnormalities.
• Look at anomalies that wasn’t
clear at posteroanterior
position.
• Heart assessment.
• To look for minimal fluid
collection in the pleural cavity
(75cc) that can not be seen in
the PA chest x-ray
R
L AORTIC ARCH
TRACHEA

OBLIQUE FISSURE

POSTERIOR RIBS
LT. HEMI
DIAPHRAGM

RT. HEMI DIAPHRAGM


COLON GAS
Thorax Lateral
Oblique Position

Indication:
 To look at anomalies that were not clear at PA and lateral position.

Type:
 Right anterior oblique (RAO)
 Left anterior oblique (LAO)
 Right posterior oblique (RPO)
 Left posterior oblique (LPO)

The side that is mentioned is the side that was close to the film
 RAO: The right side and the anterior side was close to the film
 LPO: The left side and the posterior side was close to the film.
RAO LAO
Lateral Decubitus

Indication:
• To look for minimal fluid collection
in the pleural cavity (15-20cc) that
can not be seen in the PA chest x-
ray
LLD/RLD
Top Lordotic

Indication:
• To look for
anomalies at the
apex of the lung.
Inspiration

Level inspirasimaksimal
Apex of the diaphragm at the level 5th-6th
anterior ribs.
9th – 10th posterior ribs at the level of right
cardiophrenic sulcus.
Example of poor inspiration

Spurious findings : cardiomegaly, mass at the aortic


arch, patchy opacification in both lower zones.
Magnification

• Influence the heart size assessment.


• Depend on the patient position toward the film.
• PA chest x-ray is more accurate in depicting the
heart size than AP chest x-ray.
• Reason:
• The distance between the heart and the film is
closer in PA chest x-ray.
• Not significant in patient < 4 years old.
Magnification

AP PA
Distortion in AP Chest X-Ray
Trachea
• Lucent structure  contain air.
• Centrally located.
• Normal diameter : 1,5 cm
• Look for deviation.
• Extend to the carina at the level of the sternal
angle (T5 level)
• T4 level on expiration
• T6 level on inspiration
• Tracheal bifurcation (carina) normal angle <900
• >900 in left atrial enlargement.
Sinuses or Sulci

Costophrenicus
Cardiophrenicus
Diaphragm

Right diaphragm is
higher than the left
diaphragm.
Normal : 2.5 cm
> 3 cm: abnormal
Shape :
Tenting
Scalloping
Lung

• Lungs contain air


that will give
negative contrast 
black (lucent)
• Compare the right
lung with the left
lung
Lung Zone

Apex
From the apex to the
clavicle
Upper lung field
From the clavicle to the
2nd anterior rib
Middle lung field
From the 2nd anterior rib
to the 4th anterior rib
Lower lung field
From the 4th anterior rib
to the diaphragm
Other Division of the Lung Zone

Divided by the upper and


lower border of the
hilum.
Upper zone
Above the upper border
of the hilum
Middle zone
From upper border of
the hilum to the lower
border of the hilum
Lower zone
Below the lower border
of the hilum
Hilum (plural: Hila)
Latin: Hilus (plural: hili)

• The area where the


vessels (artery and vein),
bronchus, and lymphatic
vessels come in to and
come out from the lung.
• Normal left hilum is
higher than the right
hilum (about 1 rib)
• The diameter is about 9-
16 mm or not bigger than
trachea
PULMONARY ARTERY
PULMONARY VEIN
Bronchovascular Marking

• Extend from the central to the peripheral area.


• Decreasing in quantity and calibre from the
central to the peripheral.
• Increased bronchovascular marking if > 2/3 of the
hemithorax.
• More crowded in the basal region.
Bronchovascular Marking

NORMAL Increased
LATERAL CHEST X RAY
How to read lateral chest x ray
• Quality
• Retrosternal space
• Retrocardiac space
• Posterior sinus
• Anterior sinus
• Diaphragm
• Hilar area
• Lung field
How to read lateral chest x ray

Quality
• From apex to the sinus.
• From sternum to the
posterior ribs.
• Chin and arms elevated
sufficiently
• No rotation
• No motion (sharp outlines)
• Visualize rib outlines and
lung marking through the
heart shadow
How to read lateral chest x ray

Retrosternal space
• Covered by heart
shadow < 1/3 bottom
• Abnormal > ½
Retrocardiac space
• Clear triangular shaped
How to read lateral chest x ray

Anterior sinus
• Sharp

• Sometimes covered by
mediastinal fat
• Depend on the
exposure of the film.
Posterior sinus
• Sharp
How to read lateral chest x ray

Lung field
• Clear lung at the
anterio and posterior
of the heart.
• Decrease density from
superio to inferior in
the posterior
mediastinum.
PATHOLOGIC FINDINGS IN CHEST X-RAY
Heart Failure and Pulmonary
Edema
Pleural Effusion
Pulmonary Contusion
Pulmonary Contusion with
Ribs Fracture
Atelectasis
Atelectasis
Tension Pneumothorax
Aspiration Pneumonia
Aspiration Pneumonia with
Thymic Shadow in an Infant
Thank You

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