Chest X-ray: Lung Pathology II

Let’s get through a couple more cases of fundamental pathology on chest X-ray. We touched on pneumonia last time utilizing opacities to help localize lobar anatomy on chest X-ray. Pneumonia can appear different on chest X-ray depending on the pathogen. Bacterial pneumonia often cause the consolidative opacities we discussed in the last article. A viral pneumonia may cause increased perihilar markings and bronchial wall thickening. It is wise to remember multiorganism pneumonia caused by aspiration/stuff going down the wrong pipe!

Remember how the lungs are NOT symmetric. It should come as no surprise then that the airways are not symmetric either. Check it out:

Anatomically, stuff is favored to go into the right lower lobe.

You see how the right mainstem bronchus has a more obtuse angle with the trachea relative to the left mainstem bronchus with the more acute angle. Obviously, if your poured water into the top of the tube more would go into the right than the left. Voila! Aspiration pneumonia favors the right lower lobe!

RLL mass
Right lower lobe opacity suggests the possibility of aspiration pneumonia.

This absolutely corresponds to the airways picture showing how an aspiration can have a relative straight shot into the right lower lobe. However,one tenet of pneumonia for radiologists is to suggest a follow up chest X-ray to resolution. Following antibiotic treatment and clinical improvement the opacity should resolve. Of course, there is a caveat! Chest X-ray often lags clinical findings, so a patient may be fairly sick and the chest X-ray only shows a small opacity that gets bigger over subsequent days. Conversely, the patient may be showing signs of clinical improvement, but an opacity persists on the chest X-ray. Now if the opacity fails to resolve despite several rounds of antibiotics, then a chest CT scan with IV contrast should be considered. For those that noticed the port catheter, you know where I’m going with this:

RLL mass on CT
Right lower lobe tumor

This patient in the above chest X-ray has a lung tumor and NOT an aspiration pneumonia. A pneumonia may take up to 8 weeks to resolve on chest X-ray, but most do so in 4-6 weeks.

Well I think we will keep this short and do one more article in our chest X-ray series for now, then I will be ready to move onto another topic. Fluoroscopy was promised, so we will touch on some of the standard outpatient procedures. If you haven’t seen my video in the About Me section, I hope you will spend the less then four minutes to learn about what it means to be a radiologist.



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I am an American Board of Radiology certified Diagnostic Radiologist with a certificate of additional qualification in Neuroradiology. I absolutely love my job. I have learned a tremendous amount about the human body, including its’ expected complications given our extraordinary complexity, and get to use that knowledge to help people. I personally have experienced emotional devastation and loss, which has made me compassionate and empathetic. I really care about people, and I hope I can use this site to help you. I graduated medical school in 2004 from New York Medical College. My wife and I had our first son in NY where we bought our 900 sf two bedroom one bath starter home. I stayed at Westchester Medical Center for radiology residency, where we had our second son. I obtained a neuroradiology fellowship position at Yale New Haven Medical Center commuting about an hour and a half each way for a year while we had our third boy. Upon graduation I was fortunate to return to Westchester Medical Center to work in Neuroradiology, Body Imaging, and Women’s Imaging departments, a rarity in academic medicine. Almost a decade later and I am living in a larger home in Reno working in a private practice community based outpatient radiology group which contracts with a rural hospital in Elko, Nevada. My wife and I now have four boys and gave up on the girl. We also have a male Bernese mountain Dog named Helmut and female Newfoundland named Lucy. Despite all its hardships and tremendous struggles, I have an absolutely amazing life, which is a gift I cherish. It’s down to my philosophy. I am a firm believer in teamwork. So much comes down to communication. When healthcare providers talk to each other one-on-one, the patient care is always improved, every time! We might not find an answer to your problem, but our collective knowledge sure can help improve your chances. At Yale the best conference I ever regularly attended was a head and neck tumor board. The head and neck surgeon (otolaryngologist = ENT) presented the patient’s clinical history, the radiologist showed the images, the oncologist discussed the tumor and chemotherapy options, and the patient came to the conference and we all did a physical exam looking into their mouth to directly visualize a tumor. It was incredible! Patients came from far and wide to see this highly trained, world-renowned, humble, Japanese, gentleman surgeon. It was also an epiphany. I found that when I see the patient, talk to them, listen to their story, examine them and discuss the patient with my colleagues, the patient felt better and I had a lot of fun. It’s weird but reminds me of seeing a comedy where it is always funnier in a packed theater with everyone laughing. Knowledge and compassion are both infectious and contagious. My greatest days are helping patients deal with some of their most difficult days, and I am good at it.

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