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Chest Radiographs
Loyola University Stritch School of Medicine
Drs. Pierce and Demos
Loyola University Medical CenterDepartment of Radiology
Radiographs
• Free Intraperitoneal Gas
• Pneumothorax
• Pleural Effusion
• Pulmonary Edema
Free Intraperitoneal Gas
Free Air
Free Intraperitoneal Gas
FREE AIR SENSITIVITY OF IMAGING STUDIES
• COMPUTED TOMOGRAPHY 99%
• LATERAL UPRIGHT CHEST RADIOGRAPH 98%
• AP UPRIGHT CHEST RADIOGRAPH 80 - 90%
• LEFT DECUBITUS ABDOMEN RADIOGRAPH 80- 90%
• SUPINE ABDOMEN RADIOGRAPH ?
Upright chest
Left lateral decubitus abdomen
Free Intraperitoneal GasPatient Supine
FREE AIRCENTRAL TENDON
SUPINE
UPRIGHT
FREE AIRCENTRAL TENDON
SUPINE
LEFT DECUBITUS
Free Intraperitoneal Gas
Neonate with distended abdomen Supine
abdomen
58-year-old man with acute abdominal pain
Supine abdomen Free air under right hemidiaphragm
Upright abdomen
Free Air in Supine PatientRIGLER’S SIGN
BOTH SIDES OF BOWEL WALL VISIBLE
DOUBLE WALL SIGNIN THREE PATIENTS
1
23
Free Intraperitoneal Gas
• When diagnosis is uncertain- If the patient can stand
• Upright chest and abdomen
- If the patient can not stand• Left lateral decubitus abdomen radiograph
• Most sensitive - Computed tomography
Pneumothorax
Pneumothorax Displaced Visceral Pleura
Pneumothorax Displaced pleura (arrows)
Skin Fold
Look for displaced Visceral Pleura
Skin fold extends outside ribs
Tension Pneumothorax
TENSION PNEUMOTHORAX ** Examine patient
* Look for deviated heart and mediastinum, depressed hemidiaphragm
* Compare to previous radiographs
Supine Patient Medial Pneumothorax
Supine PatientDeep Sulcus Sign
Before….No pneumothorax After….Pneumothorax
Is there a pneumothorax or isn’t there?
• Order a Lateral Decubitus chest radiograph- With the side of the chest in question as the upside
• Possible left pneumothorax get right lateral decubitus chest
> Look for displaced visceral pleura along upside lateral chest wall
• Order Upright Expiratory chest radiograph- Look for pneumothorax at lung apex
Pleural Effusion
Pleural Effusion
Upright…Meniscus
Decubitus…Effusion layered on downside
Supine…Unilateral increased density
Pleural EffusionSupine patient
Pleural Effusion
Semiupright…..Lung base opacity fades superiorly
63-year-old man recovering from congestive heart failure…Effusion loculated in fissure
Massive Pleural Effusion or
Total Lung Atelectasis
Total Atelectasis Heart and mediastinum shifted toward whited out hemithorax
Massive pleural effusion Heart and mediastinum shifted away from whited out hemithorax
Pleural Effusion
• Most sensitive way to show pleural effusion- Decubitus chest radiograph
• Least sensitive way to show pleural effusion- Supine chest radiograph
Pulmonary Edema
Normal Chest PA and Lateral Radiographs
Pulmonary Edema
Normal pulmonary vessels
Interstitial pulmonary edema
Alveolar pulmonary edema
Septal (Kerley B) lines due to interstitial pulmonary edema are thickened interlobular septae
Pulmonary Edema
• Interstitial pulmonary edema- Poorly defined pulmonary vessels
- Visible lung fissures
- Septal lines
- Thick bronchial walls
• Alveolar pulmonary edema- Bilateral symmetric perihilar lung consolidation
• Enlarged heart, Pleural effusion
COMPARE TO PREVIOUS RADIOGRAPHS
Left Upper Lobe Pneumonia
27-year-old man with productive cough, dyspnea, and fever
Monty Python
Gumbies