Chest Radiology in Intensive Care Medicine

Dr. Andrew Ferguson

MEd FRCA DIBICM FCCP
Assistant Professor, Medicine (Critical Care) & Anesthesia
Dalhousie University
 Overview
• Air bronchograms & silhouette sign
• Hilar enlargement
• Alveolar & interstitial infiltrates
• Effusions
• Pulmonary oedema
• Assessment of volume status using CXR
• Lobar anatomy & collapse
• Abnormal air collections
• Lines, tubes and drains
 Radiographic anatomy

NOTE
In spite of what you
May have heard…
The right heart border
Is formed by left atrium
AV
in up to 38% of patients Or
MV
LA
TV
 Air bronchograms
• Bronchi normally invisible as they are thin-walled,
filled with air, and surrounded by air
• Except when alveoli fill with substance with the
density of fluid e.g.
• Pulmonary oedema
• Blood
• Gastric aspirate
• Inflammatory exudate
• Bronchi visible when surrounded by diseased
lung = air bronchogram
 Silhouette Sign
• When an object is in contact with another of
different density the adjoining edge is visible e.g.
heart border against aerated lung
• When objects of the same density are in contact
the adjoining edge is invisible e.g. heart border
against consolidated lung
 Silhouette Sign

Lobe Silhouetted structure

Right middle lobe Right heart border

Left lingula Left heart border

Right lower lobe Right hemidiaphragm

Left lower lobe Left hemidiaphragm

Post apical segment left upper lobe Aortic knob
Ant segment right upper lobe Ascending aorta
 Hilar enlargement
Unilateral hilar adenopathy
 Neoplasm
 Primary Tuberculosis
 Sarcoidosis (3-8%)
 Primary pulmonary fungal infection

Bilateral hilar adenopathy

 Sarcoidosis
 may also see right paratracheal nodes
 Lymphoma
 False positive
Expiration film
Pulmonary Hypertension
 Alveolar infiltrates
• Air bronchograms
• “Fluffy” / indistinct appearance
• Segmental or lobar distribution
• Homogeneous & confluent

What can fill alveoli?

Water: pulmonary oedema
Protein: ARDS, alveolar proteinosis
Fibrous tissue: BOOP, radiation
Cells:
Neutrophils: pneumonia; pneumonitis
Eosinophils: eosinophilic pneumonia
RBCs: DAH, contusion, infarction, vasculitis
Neoplastic: carcinoma, lymphoma,
Lymphocytes: pneumonitis, sarcoidosis
 Rapid Clearance of Alveolar Infiltrate

• Pulmonary oedema
• Pulmonary haemorrhage
• Aspiration
• Pneumococcal pneumonia (possibly)
 Interstitial Infiltrates
• Inhomogeneous
• Discrete
• No bronchograms
• Reticular (lines) and/or
• Nodular (circles)

Fibrosis
Connective tissue disease
Sarcoidosis
Radiation fibrosis
Asbestosis
Lymphangitis carcinomatosis
Silicosis
TB
Pleural effusions
 Pleural Effusion Appearances
• Subpulmonic effusion
• Blunting of Costophrenic angle
• Meniscus sign
• Layering
• Loculated
• Laminar effusion
• Subpleural between lung & pleura

• Opacified hemithorax
• Air-fluid levels
 Subpulmonic Effusion
• Tented diaphragmatic dome or apex more lateral than
expected
• Costophrenic angle more shallow than expected
• Elevated diaphragm appears thicker and more separated from
gastric bubble
• Usually < 350 ml volume
Blunting of Costo-phrenic Angle
• 200-300 ml effusion required (AP film)
• 100-150 ml blunts posterior angle on lateral CXR
Pulmonary Oedema
 Pulmonary Oedema
• ? Upper lobe diversion (“cephalization”)
• Infiltrates
• Batswing
• Diffuse Interstitial Oedema
• Pleural effusions
• Septal lines e.g. Kerley B
• Basal, 1-2 cm long, straight, 90o to pleura
• Thickening of fissures
• Peribronchial cuffing
Left atrial pressure & CXR signs
< 10% of cases of pulmonary oedema, usually in rapid onset oedema e.g. acute MR
Kerley B lines
Peribronchial Cuffing

May be normal finding if right at hilum

Asymmetric pulmonary oedema
• Chronic lung disease altering vascular flow
• Acute MR - jet to right pulm vein often RUL
• Patient position (gravitational)
• Re-expansion
Vascular Pedicle Width in
Pulmonary Oedema
Landmarks for measurement of VPW and CTR on a routine CXR

Martin, G. S. et al. Chest 2002;122:2087-2095

 Vascular pedicle width and
fluid status in pulmonary oedema
Using Vascular Pedicle Width
 VPW/CTR as predictor of PCWP > 18

Criteria Sensitivity Specificity PPV NPV Odds ratio

VPW > 70 & CTR > 0.55 54% 83% 76% 65% 3.2

VPW > 70 69% 72% 70% 72% 2.5

CTR > 0.55 63% 50% 56% 57% 1.3

Lobar anatomy and collapse
Lobar anatomy & collapse
RUL collapse
RML collapse

Indistinct right heart border

 RLL collapse

Fissure may be visible Sail-like line behind right heart plus indistinct
diaphragm
 LUL Collapse

Lufsichel sign = Aerated superior segment of left lower lobe interposes between
collapsed upper lobe and mediastinum producing lucency around aorta
 LLL collapse

Sail-like line behind heart – occasionally seen as extremely straight heart border
Total collapse
 Abnormal Air Collections

• Subcutaneous emphysema
• Pneumomediastinum
• Pneumothorax
• Pulmonary interstitial emphysema
Pulmonary Interstitial Emphysema
• Much more common in neonates, rare in adults
• Alveolar rupture: air dissects into pulmonary interstitium
• Factors associated:
• Anything increasing intrapulmonary pressure
• Ventilation with peak airway pressures > 30 cm H20
• RDS or ARDS severity
• Associated pulmonary abnormalities

CXR features: subtle & often hidden by other pathology

• Multiple small and large parenchymal cysts
• Small, mottled or streaky lucencies extending from hilum
• Perivascular halos from air collections
• Intra-septal air
• Subpleural cysts
Pulmonary Interstitial Emphysema
 Pneumomediastinum
• Sources of air
– Intrathoracic
Trachea and major bronchi
Esophagus
Lung
Pleural space
– Extrathoracic
• Head and neck
• Intraperitoneum and retroperitoneum
CXR Signs of Pneumomediastinum
• Thymic sail sign (infants/young children)
• Tubular artery sign (AP film)
• “Ring around the artery” sign (lateral film)
• Double bronchial wall sign
• Continuous diaphragm sign
• Extrapleural air
• Naclerio’s V sign

• Linear density parallel to heart border

• Dissection of air into neck
• Dissection of air into chest wall
Continuous diaphragm sign
 Naclerio’s V sign

Lucent band of gas extending along descending aorta and

intersecting band of gas that extends along medial left hemi-
diaphragm, together forming “V’
Double bronchial wall sign

Air on both sides of bronchial wall makes full wall visible

“Ring around the artery” sign

Air around
pulmonary
artery
Tubular artery sign

Air outlining left

subclavian & left
carotid
 Thymic sail sign

Thymus outlined
by air

Also air tracking

up into neck
Extrapleural air

e.g. pleura peeled off diaphragm

Mediastinal air
Mediastinal
air running
parallel to
descending
aorta
Pneumomediastinum vs pneumothorax
Pneumomediastinum vs pneumocardium
Pneumopericardium
 Pitfalls – Mach band effect

“The Mach band effect is associated with convex surfaces, appearing as a region of lucency
adjacent to structures with convex borders. The absence of an (associated) opaque line, which
is typically seen in pneumomediastinum, can aid in differentiation”
Zylak C. Pneumomediastinum Revisited. Radiographics 2000; 20: 1043-1057.
 Pneumothorax
• Apicolateral visceral pleural line
• Generally requires erect/semi-erect film
• Skin fold may be mistaken for pleural line

• Lack of lung markings outside line

• Caution in COPD/bullous disease
• Bullae generally convex

• ICU CXR often supine/semi-erect

• Different criteria for diagnosis
• Often subtle
• WATCH OUT!
 “Occult” pneumothorax

Crisp cardiac silhouette with increased lucency

 Occult pneumothorax II

Cardiophrenic sulcus highly visible Crisp heart border

 Potential signs of pneumothorax
• Pleural line with absent markings
• Double diaphragm sign
• Visible anterior costophrenic recess interface

• Sharpened cardiac silhouette & apex

• Hyperlucent hemithorax
• Inferior edge of collapsed lung
• Deep sulcus sign
• Depressed diaphragm
• Apical pericardial fat
• Discrete lobulated densities (1-1 .5cm) adjacent to cardiac apex
 Tension pneumothorax

• Flattening of heart border

• Flattening of adjacent
vascular structures e.g. SVC
• Mediastinal shift - AWAY
• Diaphragmatic inversion
Double diaphragm sign
 Pneumothorax in Supine Patients
• Anteromedial - unusually sharp outline of:
• Mediastinal vascular structures
• Heart border
• Cardiophrenic sulcus

Posteromedial
• Lucent band outlining mediastinal surface of a collapsed lower lobe
• Increased visibility of paraspinous line & descending aorta
• Increased visibility of posterior costophrenic sulcus

Subpulmonic
• Hyperlucent upper abdominal quadrant
• Deep costophrenic sulcus (“deep sulcus” sign)
• Sharp hemidiaphragm despite opacification in lower lobe of lung (if consolidated)
• Visualisation of inferior surface of consolidated lung
Posteromedial Pneumothorax
Subpulmonic pneumothorax

Deep sulcus, lucent RUQ

Rankine, J. J et al. Postgrad Med J 2000;76:399-404

Anteromedial pneumothorax

Sharp outline of mediastinum and right heart border. Right hemithorax

has concurrent consolidation and effusion

Rankine, J. J et al. Postgrad Med J 2000;76:399-404

Mimics - Skin fold
Subcutaneous emphysema
Lines, tubes and drains
 Central line positioning - issues
• Right upper heart border is left atrium, not the right, in 38% of patients
• Radiographic SVC/RA junction:
• hard to see in 10%
• inaccurate: can be up to 2.8 cm higher than echocardiographic junction
• not all lines within heart shadow on xray are in the RA
• CVC tip should lie
• in SVC
• above pericardial reflection (but no radiographic marker of this structure)
• BUT is acceptable for dialysis line tip to lie at SVC/RA junction or in RA

• Line should lie parallel to vessel wall

• Line tip < 2.9 cm beyond take-off of right main bronchus is always in SVC
• Right tracheobronchial angle is always below junction of brachiocephalic veins
• Carina is mean of 1.3 cm below mid-point of the SVC and up to 0.7 cm below pericardial
reflection – is suitable location for line tip
British Journal of Anaesthesia 2006 96(3):335-340
Catheter tips abutting SVC wall – risk of perforation
Malposition – subclavian line into jugular vein
Images to review
Asthma + diversion + peribronchial cuffing
Right Haemothorax with bullet
LUL collapse + LLL collapse
Linear (plate) atelectasis
+ small bowel obstruction
Bilateral hilar enlargement - lymphoma
Bilateral cavitating lesions with fluid levels
- Staph abcess
 Chilaiditi's syndrome – colon
interspersed between liver/spleen
and diaphragm
Deep sulcus sign – left
pneumothorax
Diffuse alveolar
haemorrhage
Node in aortopulmonary
window
Fluid level behind heart –
hiatus hernia
Silicone breast implants
Pneumothorax - blocked
chest drain
Subcutaneous emphysema,
LIJ CVC tip position poor
 Residual haemothorax on left with chest tube and LLL
collapse/consolidation + air bronchogram: haemothorax
on right. Oesophagus displaced to left