This chapter is designed to present the key elements associated with imaging of the chest, other than the thoracic spine as covered in Chapter 14. The clinician starting assessment of a patient typically first determines if the presentation is related to trauma versus nontraumatic patient presentation, which makes the process often pointed toward fracture identification versus unexpected changes seen in basic radiographic screening associated with disease.
The chest radiograph (chest film) remains the most used for the basic screening of all patients with chest complaints. This is a PA standing along with the requisite standing left lateral to give the 90° opposition views to enable discernment of overlap and better isolation of structures (Figure 6-1A, B). These views are done in full inspiration and positioned to have the heart and lungs closest to the receptor, thus minimizing magnification distortion. When viewing the PA image, the patient is “facing” the examiner. The initial screen is always to examine proper contours of the internal organ “outlines,” thus confirming expected positions of the cardiopulmonary structures and overall “normalcy.” There are expected colors to each area and expected shadow. There are numerous guides to reading the chest film that have evolved over the past decades. A very complete process is provided by the American College of Radiology.1 Often some level of a mnemonic is used to establish a pattern with nearly always the inclusion of A to D:
Airway: Lucency from the neck down toward the carina—positioned midline to its two bronchi splitting from it
Bones: Glenohumeral joint proper orientation/outline and rib contours to assess for fractures or other positional abnormalities
Cardiac: Assessment of the right and left heart borders—general heart position/contour
Diaphragm: Well-outlined margins—equal spaces
(A) Normal chest PA radiograph with features labeled. (B) Normal chest lateral radiograph with features labeled.
Multiple pulmonary diseases have relatively well-defined presentations including chronic obstructive pulmonary disease (COPD), tuberculosis, and pneumonia (Figures 6-2 to 6-4). In some cases, advanced imaging may be utilized to allow a more complete understanding of the patient. Each of these conditions is, thus, diagnosed through clinical examination and the correlating images.
Chest radiograph COPD emphysema. (A) PA and lateral views of the chest demonstrate hyperinflated lungs with flattening of the diaphragm. Shrapnel projects over the left lower chest. (B) Axial chest CT in lung windows through the upper lobes demonstrates severe centrilobular emphysema. (C) Severe but less advanced changes are seen in the lower lobes. (Reproduced, with permission, from Elsayes KM, Oldham SA, eds. Introduction to Diagnostic Radiology. New York, NY: McGraw-Hill Education; 2015.)
Miliary tuberculosis. (A) Frontal chest radiograph demonstrates innumerable tiny nodules distributed throughout both lungs. There is a hazy opacity ...