1
Q
What is the appearance of cardiomegaly on CXR?
A
The heart is abnormally large. It takes up greater than 50% of the internal width of the thorax.
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2
Q
What are the causes of cardiomegaly?
A
1) Hypertrophy - caused by an increase in afterload on a particular chamber (e.g. aortic stenosis, hypertension)
2) Dilatation - secondary to toxic, metabolic or infectious agents causing myocardial damage
Hypertrophy of either ventricle does not usually enlarge the heart shadow unless there is synchronous dilatation. Cardiomegaly is usually abnormal, except in athletes, and is associated with other cardio vascular pathology.
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3
Q
How does pulmonary oedema appear on an X ray?
A
The heart border can be enlarged or normal. There is increased shadowing spreading out from the hilar (enhanced lung markings). Pulmonary oedema occurs when fluid leaks into the lung interstitium from the pulmonary vasculature, leading to impaired gas exchange. It is caused by either:
i) an increased vascular hydrostatic pressure (e.g. cardiogenic causes - LVF, mitral stenosis)
ii) decreased plasma oncotic pressure - liver failure, renal failure
iii) increase in pulmonary capillary membrane permeability - ARDS, aspiration, inhalation injury, multiple blood transfusions
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4
Q
What are the chest x ray features of non cardiac pulmonary oedema?
A
Normal heart size
Diffuse alveolar shadowing
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5
Q
What are the x ray features of cardiogenic pulmonary oedema?
A
ABCDE signs:Alveolar shadowing (bats wings)Kerley B lines Cardiomegaly Upper lobe DiversionEffusion
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6
Q
Why does upper lobe diversion occur in cardiogenic pulmonary oedema?
A
The upper lobe vessels are normally narrower than the lower lobe vessels. In cardiogenic pulmonary oedema, lower zone alveolar hypoxia causes arteriolar vasoconstriction, diverting blood to the upper lobes.
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7
Q
What are Kerley B lines?
A
These represent oedema of the interlobular septa and are characteristic of pulmonary oedema. They are 1cm long, thin, horizontal and parallel and seen peripherally above the costophrenic angle.
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8
Q
What are the features of pleural effusion on CXR?
A
Blunting of the costophrenic angles, meniscus and a “white out” (large effusions) are classic features.
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9
Q
What are the main types of pleural effusion?
A
Aspiration allows biochemical division into transudates (<30g/L of protein) and exudates (>30g/L). Transudates are caused by LV failure, pulmonary embolism and cirrhosis. Exudates are caused by infection, neoplasia and inflammatory conditions - e.g. rheumatoid arthritis or SLE. CXR may point to the cause - e.g. enlarged heart shadow, lung mass, parenchymal disease, apical fibrosis or bone metastases. Effusions collect in gravity dependent areas.
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10
Q
How can you tell from a chest X ray that a patient had cardiac surgery as an adult?
A
Adults have radio-opaque sternotomy clips, whereas children have ties that are not visible on X ray. Other signs include mechanical prosthetic heart valves which are more radio-opaque than biologic ones.
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11
Q
How do pleural plaques appear on chest X rays?
A
Pleural plaques are focal areas of pleural fibrosis caused by previous exposure to asbestos. Pleural calcification is a late sign, occurring in approximately half of those with asbestos related disease. It is most easily seen along the diaphragmatic pleura as a layering of dense material.
Classic X ray features include a widespread distribution of opacification, peripheral pleural thickening and pleural calcific deposits.
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12
Q
What are the features of lobar consolidation on chest X ray? What can cause it?
A
Consolidation is a pathological process caused by filling of the alveolar air spaces with fluid or debris, such as:
i) inflammatory exudate - e.g. pneumonia
ii) haemorrhage - e.g. trauma, vasculitis or PE
iii) transudates
iv) secretion - alveolar proteinosis and mucus
v) malignancy - carcinoma, lymphoma
Key features are “fluffy” airspace density, and air bronchograms. The fluffy air space opacification is not well demarcated unless bordered by a pleural margin, e.g. a fissure or lung edge.
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13
Q
What is atelectasis?
A
Atelectasis is the incomplete expansion of lung tissue affecting a section or whole of one lung. It is usually not life threatening as the normal lung can compensate for functional loss and the atelectatic area usually re expands once the cause is treated. CXR features can be difficult, there are focal light grey densities and volume loss.
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14
Q
What are the causes of atelectasis?
A
Obstructive - foreign body, tumour or mucous plug may obstruct a large or small bronchus, leading to lobar or lung collapse
Non obstructive - a reduction in surfactant production may be the cause of the atelectasis in ventilated patients or ARDS. Surfactant reduces alveolar surface tension and helps splint the alveoli open. Post-operative diaphragm dysfunction is a common cause of atelectasis of the lung bases. Other non obstructive causes include lung fibrosis and loss of contact between the parietal and visceral pleura - e.g. effusion or pneumothorax, compromising lung expansion
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15
Q
What are the chest x ray features of bronchiectasis?
A
Bronchiectasis is a difficult diagnosis to make with any great certainty on plain X ray imaging. The diagnosis is made accurately on high resolution CT. CXR does however demonstrate serious disease and therefore remains the first line investigation for suspicious symptoms such as persistent cough, profuse purulent sputum and recurrent infections.
Suggestive features include:
1) Ring opacities - end on bronchi with thickened walls appear as circular light grey densities with black centres, resembling rings
2) Tram tracks - side on dilated bronchi with thickened walls appear as light grey parallel lines
3) Cystic spaces - these occur in cystic bronchiectasis and appear as circular light grey densities looking like thin walled ring opacities - may contain air fluid level
4) Crowding of pulmonary vascular markings - mucous obstruction of peripheral bronchi can cause atelectasis. The loss in lung volume brings the vascular markings closer together
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16
Q
What are the chest x ray features of COPD?
A
1) Lung hyperinflation - dependable indicator of patients with a smoking history. Hemidiaphragms are flat and depressed so that 7 or more ribs are visible anteriorly. Anterior border of the heart can be lifted off the diaphragm in some cases
2) Narrow and elongated heart - hyperinflation may cause the heart to appear narrow, elongated and lifted off the diaphragm. If there is coexisting cardiac failure the heart may appear normal in size or enlarged
3) Bullae - parenchymal destruction leads to large black areas bordered by light grey hairline densities distorting the surrounding vasculature
4) Pulmonary vascular pruning - destruction of lung parenchyma leads to distorted vasculature and reduced lung markings. The central pulmonary arteries and right heart may also be enlarged secondary to pulmonary arterial hypertension
17
Q
What are the x ray features of lung fibrosis?
A
1) Reduced lung volume - pulmonary fibrosis is a chronic and progressive condition causing lung scarring, shrinkage and loss of elasticity
2) Mediastinal shift - volume loss causes the mediastinum to be pulled towards the fibrosis if unilateral
3) Reticular/ reticulonodular shadowing - the fibrotic tissue appears as either a light grey meshwork pattern (reticular) or with additional light grey nodular densities (reticulonodular). The distribution of shadowing in the lung varies with aetiology - e.g. ankylosing spondylitis in the upper zone and scleroderma in the lower zone
4) Ground glass appearance - in the early stages, a think “veil like” light grey shadow covers all or part of the lung
5) Honeycombing - in the advanced stages, a framework of multiple light grey ring like structures may be seen resembling a honeycomb
6) Blurring of the mediastinum and diaphragms - fibrotic tissue reduces contrast between the lung and its adjacent soft tissue structures
18
Q
What is a pneumothorax?
A
Pneumothorax is the presence of air in the pleural cavity. During normal ventilation, the thoracic volume increases to create relative negative intrathoracic pressure for lung inflation. However, in the presence of a pleural defect, air enters the potential pleural space and breaks this pressure potential, which affects lung inflation. This impairs gas exchange and causes breathlessness.
19
Q
What is the difference between a simple and a tension pneumothorax?
A
Simple pneumothorax is common and occurs in healthy chests, especially tall, slim young males. Secondary pneumothoraces can arise in individuals with underlying disease, e.g. COPD, asthma, barotrauma, penetrating chest injuries and pneumonia.
Tension pneumothorax is a medical emergency where air accumulates under pressure in the pleural space due to the formation of a one way valve at the point of injury, permitting air to enter but not to leave. It can develop from a simple pneumothorax, often following traumatic injury, and requires emergency decompression.
20
Q
What are the chest X ray features of pneumothorax?
A
Linear pleural shadow with absence of lung markings beyond in the peripheral thorax.
Air in the pleural cavity will rise to the apices in an upright CXR. It is therefore vital to review the apices.
In a tension pneumothorax, the trachea is deviated away from the side of increased pressure. The mediastinum can also be moved away to the contralateral side.
21
Q
Where should a chest drain be situated on X ray for decompression of a pneumothorax?
A
The tube should be placed so that its tip is pointing high up towards the apex of the hemithorax.
22
Q
What is a haemothorax?
A
A haemothorax is a pleural effusion due to the accumulation of blood within the pleural cavity. It most commonly arises from blunt or penetrating chest injuries. Non traumatic haemothorax is less common and can result from malignancy, blood dyscrasias, pulmonary infarction and TB.
23
Q
What are the features of haemothorax on chest x ray?
A
The typical appearance on an UPRIGHT x ray are identical to a pleural effusion (meniscus, blunting of the costophrenic angle, white out and/or mediastinal shift with a large haemothorax).
In the context of a traumatic pneumothorax, the presence of a pleural effusion is almost always due to the accumulation of blood in the pleural cavity (called a haemopneumothorax). There is NO meniscal sign due to the direct interface between pleural air and blood.
24
Q
What are the features of a right upper lobe collapse?
A
Collapse of a single lobe causes characteristic patterns on CXR. In a RUL collapse, the horizontal fissure is pulled up (superior displacement) and there is a soft tissue shadow in the right upper zone. The remainder of the lung expands to fill the void.
25
Q
What are the features of a right middle lobe collapse?
A
The horizontal and oblique fissures are pulled closer together and there is loss of interface between the right heart border and the lung (silhouette sign). The lateral CXR demonstrates a wedge shaped opacity stretching from the hilum anteroinferiorly.
26
Q
What are the features of a right lower lobe collapse?
A
There is a soft tissue shadow in the right lower zone and loss of interface between the right hemidiaphragm and lung (silhouette sign). The collapsed lobe appears as a triangular opacity behind the right heart border WITHOUT obscurring it. The trachea always moves towards the side of lower volume or away from the side of increased pressure. Hence the trachea is deviated towards the hemithorax with the lobe collapse.
27
Q
What are the features of a left upper lobe collapse?
A
There is veil like shadow cast over the entire left lung due to an anteriorly lying collapsed lobe. Interposition of the lower lobe between the collapsed lobe and aortic arch may be seen as a crescent of air known as Luftsichel sign.
28
Q
What are the features of a lingula collapse?
A
There is loss of interface between the left heart border and the lung (silhouette sign).
29
Q
What are the features of a left lower lobe collapse?
A
The collapsed lobe is displaced medially and lies behind the heart. A triangular opacity is seen through the heart shadow with a straight left lateral border (sail sign). There is also loss of interface between the medial part of the left hemi-diaphragm and lungs (silhouette sign).
30
Q
What are the chest x ray features of lung cancer?
A
Coin or cavitating lesions - the centre of the lesion should be closely inspected since some tumours are associated with central cavitation.
Multiple similar looking lesions suggest metastatic disease.
Indirect CXR features include: consolidation or collapse, pleural effusion, lymph node enlargement, bone metastases, malignant lung lesions are rarely calcified (presence of calcification suggests an alternative diagnosis)
31
Q
What is the difference between a coin and a cavitating lesion?
A
A discrete, approximately circular, area of whiteness seen within the lung field is termed a coin lesion. If the edge if spiculated, irregular or lobulated it is more suggestive of a malignant lesion. If the centre of the lesion is more lucent (i.e. darker) than the edge, this suggests a cavitating process. The differential for such lesions is diverse and includes: malignancy (e.g. squamous cell carcinoma), infection (e.g. strep pneumoniae, staph aureus, TB, Klebsiella) and other rarer causes (e.g. Wegener’s, hydatid cyst, rheumatoid nodule)
32
Q
What is the cause of mediastinal lymph node enlargement?
A
Mediastinal lymph nodes drain lymphatics from the lungs, heart, thymus and oesophagus. The causes of mediastinal lymph node enlargement include malignancy (e.g. bronchogenic carcinoma, lymphoma), infection (e.g. tuberculosis, pneumonia, HIV), and inflammatory conditions (e.g. sarcoidosis). Enlarged mediastinal lymph nodes may cause cough, dyspnoea, wheezing, dysphagia, haemoptysis, atelectasis, and obstruction of the great vessels e.g. SVC. There are many lymph node groups within the mediastinum but the hilar nodes are most commonly seen on CXR due to the interface between them and the aerated lung.
33
Q
What is the most common cause of bilateral hilar lymphadenopathy?
A
Sarcoidosis
34
Q
What are the chest x ray features of active TB?
A
Consolidation - can be dense or patchy and may have ill defined borders
Cavitating lesion - lucent areas in the upper segments of the lung lobes
Pleural effusion
Lymph node enlargement - hilar and/ or mediastinal nodes may be enlarged on one or occasionally both sides
Signs of miliary TB - there may be tiny nodules scattered throughout the lung parenchyma bilaterally
35
Q
What are the chest x ray features of inactive TB?
A
Primarily areas of fibrotic scarring, classically seen in the apex of one or both of the lungs. This is often accompanied by nodular calcification causing a fibrocalcific appearance. The fibrosis may be extensive enough to cause volume loss resulting in upward displacement of the hilum on the ipsilateral side.
36
Q
How does an aneurysm of the thoracic aorta appear on a chest x ray?
A
An aneurysm is a localised or diffuse dilatation of an artery due to an underlying weakness in the vessel wall. The CXR features of a thoracic aortic aneurysm include:
- greater convexivity of the right or left superior mediastinum - this is caused by the soft tissue density shadow of the thoracic aortic aneurysm
- aortic calcification - atherosclerosis frequently accompanies aneurysm formation and thus calcification is often seen outlining the borders of the aneurysms soft tissue shadow
