Chest imaging includes use of
There are no absolute contraindications to undergoing noninvasive imaging procedures except for MRI.
The presence of metallic objects in the patient's eye or brain precludes MRI. The presence of a permanent pacemaker or internal cardioverter-defibrillator is a relative contraindication (see MRI Safety). Additionally, gadolinium, when used as a contrast agent for MRI, increases risk of nephrogenic systemic fibrosis Contrast reactions Sagittal T1-weighted image of the brain shows normal midline structures. Sagittal proton density–weighted 3-tesla magnetic resonance image of the right knee shows meniscocapsular separation... read more in patients with stage 4 or 5 chronic kidney disease or those receiving dialysis. Gadolinium may be harmful to a fetus and is generally avoided in pregnancy.
(See also Principles of Radiologic Imaging Risks of Medical Radiation Ionizing radiation (see also Radiation Exposure and Contamination) includes High-energy electromagnetic waves (x-rays, gamma rays) Particles (alpha particles, beta particles, neutrons) Ionizing... read more .)
Conventional Chest X-Ray Techniques
Conventional x-ray techniques that are used to image the chest and surrounding structures include
Plain chest x-rays provide images of structures in and around the thorax and are most useful for identifying abnormalities in the heart, lung parenchyma, pleura, chest wall, diaphragm, mediastinum, and hilum. They are usually the initial test done to evaluate the lungs.
The standard chest x-ray is taken from back to front (posteroanterior view) to minimize x-ray scatter that could artifactually enlarge the cardiac silhouette and from the side of the thorax (lateral view).
Lordotic or oblique views can be obtained to evaluate pulmonary nodules or to clarify abnormalities that may be due to superimposed structures, although chest CT Chest Computed Tomography (CT) Chest imaging includes use of Conventional x-rays Computed tomography (CT) scanning Magnetic resonance imaging (MRI) Nuclear scanning, including positron emission tomography (PET) scanning read more provides more information and has largely superseded these views.
Lateral decubitus views may be used to distinguish free-flowing from loculated pleural effusion, but chest CT or ultrasonography Ultrasonography of the Chest Chest imaging includes use of Conventional x-rays Computed tomography (CT) scanning Magnetic resonance imaging (MRI) Nuclear scanning, including positron emission tomography (PET) scanning read more can provide more information.
End-expiratory views can be used to detect small pneumothoraces.
Chest x-rays taken with portable machines (usually anteroposterior views) are almost always suboptimal and should be used only when patients are too ill to be transported to the radiology department.
Screening chest x-rays are often done but are almost never indicated; one exception is in asymptomatic patients with positive tuberculin skin test results, in whom a single posteroanterior chest x-ray without a lateral view is used to make decisions regarding additional diagnostic studies and/or treatment for pulmonary tuberculosis Tuberculosis (TB) Tuberculosis is a chronic, progressive mycobacterial infection, often with an asymptomatic latent period following initial infection. Tuberculosis most commonly affects the lungs. Symptoms include... read more .
Chest fluoroscopy is the use of a continuous x-ray beam to image movement. It is useful for detecting unilateral diaphragmatic paralysis. During a sniff test, in which the patient is instructed to forcibly inhale through the nose (or sniff), a paralyzed hemidiaphragm moves cranially (paradoxically) while the unaffected hemidiaphragm moves caudally.
Several ancillary procedures such as bronchoscopy can be done with fluoroscopic guidance.
Chest Computed Tomography (CT)
CT defines intrathoracic structures and abnormalities more clearly than does a chest x-ray Chest x-ray Chest imaging includes use of Conventional x-rays Computed tomography (CT) scanning Magnetic resonance imaging (MRI) Nuclear scanning, including positron emission tomography (PET) scanning read more .
Chest CT is normally done at full inspiration. Aeration of the lungs during imaging provides the best views of the lung parenchyma, airways, and vasculature, and of abnormal findings such as masses, infiltrates, or fibrosis.
Images obtained with the patient in the prone position can help differentiate dependent atelectasis Atelectasis Atelectasis is collapse of lung tissue with loss of volume. Patients may have dyspnea or respiratory failure if atelectasis is extensive. They may also develop pneumonia. Atelectasis is usually... read more (which changes with changes in body position) from lung disorders that cause ground-glass attenuation in the dependent posterior parts of the lungs, which persists despite changes in patient position (eg, fibrosis due to idiopathic pulmonary fibrosis Idiopathic Pulmonary Fibrosis Idiopathic pulmonary fibrosis (IPF), the most common form of idiopathic interstitial pneumonia, causes progressive pulmonary fibrosis. Symptoms and signs develop over months to years and include... read more , asbestosis Asbestosis Asbestosis is a form of interstitial pulmonary fibrosis caused by asbestos exposure. Asbestosis can cause progressive dyspnea on exertion, nonproductive cough, and fatigue. Diagnosis is based... read more , or systemic sclerosis Systemic Sclerosis Systemic sclerosis is a rare chronic disease of unknown cause characterized by diffuse fibrosis and vascular abnormalities in the skin, joints, and internal organs (especially the esophagus... read more ).
CT angiography uses a bolus of an IV radiopaque contrast agent to highlight the pulmonary arteries, which is useful in diagnosis of pulmonary embolism Pulmonary Embolism (PE) Pulmonary embolism (PE) is the occlusion of pulmonary arteries by thrombi that originate elsewhere, typically in the large veins of the legs or pelvis. Risk factors for pulmonary embolism are... read more .
Contrast agent load is comparable to that with conventional angiography, but the test is quicker and less invasive. CT angiography provides sufficient accuracy for the detection of pulmonary emboli, so it has largely replaced conventional pulmonary angiography and, except in patients unable to tolerate contrast agents, ventilation/perfusion (V/Q) scanning.
Magnetic Resonance Imaging of the Chest
MRI has a relatively limited role in pulmonary imaging but is preferred over CT in specific circumstances, such as assessment of
Superior sulcus tumors
Lesions that abut the chest wall
MRI/MRA of the chest can also be used to diagnose aortic dissection Aortic Dissection Aortic dissection is the surging of blood through a tear in the aortic intima with separation of the intima and media and creation of a false lumen (channel). The intimal tear may be a primary... read more .
In patients with suspected pulmonary embolism Pulmonary Embolism (PE) Pulmonary embolism (PE) is the occlusion of pulmonary arteries by thrombi that originate elsewhere, typically in the large veins of the legs or pelvis. Risk factors for pulmonary embolism are... read more in whom IV contrast agents cannot be used, MRI can sometimes identify large proximal emboli but usually is limited in this disorder.
Advantages include absence of radiation exposure, excellent visualization of vascular structures, lack of artifact due to bone, and excellent soft-tissue contrast.
Disadvantages include respiratory and cardiac motion, the time it takes to do the procedure, the expense of MRI, and the occasional presence of contraindications, which include many implanted devices and certain metallic foreign bodies. Gadolinium contrast may be harmful to the fetus, so use of contrast is usually avoided in pregnancy.
Ultrasonography of the Chest
Ultrasonography is often used to facilitate procedures such as thoracentesis How To Do Thoracentesis Thoracentesis is needle aspiration of fluid from a pleural effusion. Thoracentesis may be done for diagnosis and/or therapy. Diagnostic thoracentesis Indicated for almost all patients who have... read more and central venous catheter insertion Central Venous Catheterization A number of procedures are used to gain vascular access. Most patients’ needs for IV fluid and drugs can be met with a percutaneous peripheral venous catheter. If blind percutaneous placement... read more .
Ultrasonography is also very useful for evaluating the presence and size of pleural effusions Pleural Effusion Pleural effusions are accumulations of fluid within the pleural space. They have multiple causes and are usually classified as transudates or exudates. Detection is by physical examination,... read more . It is commonly used at the bedside to guide thoracentesis. Bedside/point-of-care ultrasonography can be used to diagnose pneumothoraces and is becoming more widely used as an extension of the physical examination. Evidence suggests that lung ultrasonography is more sensitive and specific than plain chest x-ray for the diagnosis of pleural effusions, pneumonia Overview of Pneumonia Pneumonia is acute inflammation of the lungs caused by infection. Initial diagnosis is usually based on chest x-ray and clinical findings. Causes, symptoms, treatment, preventive measures, and... read more , and pneumothorax Pneumothorax Pneumothorax is air in the pleural space causing partial or complete lung collapse. Pneumothorax can occur spontaneously or result from trauma or medical procedures. Diagnosis is based on clinical... read more , and can be helpful in diagnosis of pulmonary edema Pulmonary Edema Pulmonary edema is acute, severe left ventricular failure with pulmonary venous hypertension and alveolar flooding. Findings are severe dyspnea, diaphoresis, wheezing, and sometimes blood-tinged... read more (1, 2, 3 Ultrasonography references Chest imaging includes use of Conventional x-rays Computed tomography (CT) scanning Magnetic resonance imaging (MRI) Nuclear scanning, including positron emission tomography (PET) scanning read more ).
Endobronchial ultrasonography (EBUS) is increasingly being used in conjunction with flexible fiberoptic bronchoscopy Bronchoscopy Bronchoscopy is the introduction of an endoscope into the airways. Flexible fiberoptic bronchoscopy (rather than rigid bronchoscopy) is used for virtually all diagnostic, and most therapeutic... read more to help localize masses and enlarged lymph nodes. Diagnostic yield of transbronchial lymph node aspiration is higher using EBUS than conventional unguided techniques.
1. Ebrahimi A, Yousefifard M, Mohammad Kazemi H, et al. Diagnostic Accuracy of Chest Ultrasonography versus Chest Radiography for Identification of Pneumothorax: A Systematic Review and Meta-Analysis. Tanaffos 2014;13(4):29-40.
2. Ye X, Xiao H, Chen B, Zhang S. Accuracy of Lung Ultrasonography versus Chest Radiography for the Diagnosis of Adult Community-Acquired Pneumonia: Review of the Literature and Meta-Analysis. PLoS One 2015;10(6):e0130066. doi:10.1371/journal.pone.0130066
3. Lichtenstein D, Goldstein I, Mourgeon E, Cluzel P, Grenier P, Rouby JJ. Comparative diagnostic performances of auscultation, chest radiography, and lung ultrasonography in acute respiratory distress syndrome. Anesthesiology 2004;100(1):9-15. doi:10.1097/00000542-200401000-00006
Nuclear Lung Scanning
Nuclear scanning techniques used to image the chest include
Ventilation/perfusion (V/Q) scanning
Positron emission tomography (PET)
V/Q scanning uses inhaled radionuclides to detect ventilation and IV radionuclides to detect perfusion. Areas of ventilation without perfusion, perfusion without ventilation, or matched increases and decreases in both can be detected with 6 to 8 views of the lungs.
V/Q scanning is most commonly used for diagnosing pulmonary embolism Pulmonary Embolism (PE) Pulmonary embolism (PE) is the occlusion of pulmonary arteries by thrombi that originate elsewhere, typically in the large veins of the legs or pelvis. Risk factors for pulmonary embolism are... read more , but it has largely been replaced by CT angiography CT angiography Chest imaging includes use of Conventional x-rays Computed tomography (CT) scanning Magnetic resonance imaging (MRI) Nuclear scanning, including positron emission tomography (PET) scanning read more . However, V/Q scanning is still indicated in the diagnostic evaluation for chronic thromboembolic pulmonary hypertension Pulmonary Hypertension Pulmonary hypertension is increased pressure in the pulmonary circulation. It has many secondary causes; some cases are idiopathic. In pulmonary hypertension, pulmonary vessels may become constricted... read more .
Split-function ventilation scanning, in which the degree of ventilation is quantified for each lobe, is used to predict the effect of placement of endobronchial valves and the effect of lobar or lung resection on pulmonary function.
Positron emission tomography (PET) of the lungs
PET uses radioactively labeled glucose (fluorodeoxyglucose) to measure metabolic activity in tissues. It is used in pulmonary disorders to determine
Whether lung nodules or mediastinal lymph nodes harbor tumor (metabolic staging)
Whether cancer is recurrent in previously irradiated, scarred areas of the lung
PET is superior to CT for mediastinal staging because PET can identify tumor in normal-sized lymph nodes and at extrathoracic sites, thereby decreasing the need for invasive procedures such as mediastinoscopy Mediastinoscopy and Mediastinotomy Mediastinoscopy is a procedure in which an endoscope is introduced through the suprasternal notch into the mediastinum to allow visualization of it. Mediastinotomy is surgical opening of the... read more and needle biopsy Transthoracic Needle Biopsy Transthoracic needle biopsy of thoracic or mediastinal structures uses a cutting needle to aspirate a core of tissue for histologic analysis. Transthoracic needle biopsy is done to evaluate... read more .
Current spatial resolution of PET is 7 to 8 mm; thus, the test is not useful for lesions < 1 cm.
PET reveals metastatic disease in up to 20% of patients in whom it would not otherwise be suspected (1 Nuclear lung scanning references Chest imaging includes use of Conventional x-rays Computed tomography (CT) scanning Magnetic resonance imaging (MRI) Nuclear scanning, including positron emission tomography (PET) scanning read more ). The sensitivity of PET (80 to 95%) is comparable to that of histologic tissue examination (2 Nuclear lung scanning references Chest imaging includes use of Conventional x-rays Computed tomography (CT) scanning Magnetic resonance imaging (MRI) Nuclear scanning, including positron emission tomography (PET) scanning read more ). False-positive results can occur with inflammatory lesions, such as granulomas. Slowly growing tumors (eg, bronchoalveolar carcinoma, carcinoid tumor, some metastatic cancers) may cause false-negative results.
Combined CT-PET scanners are commonly used for lung cancer Lung Carcinoma Lung carcinoma is the leading cause of cancer-related death in men and women worldwide. About 85% of cases are related to cigarette smoking. Symptoms can include cough, chest discomfort or pain... read more diagnosis and staging.
Nuclear lung scanning references
1. Prévost A, Papathanassiou D, Jovenin N, et al. Comparaison entre TEP(-FDG) et scanner dans le bilan d'extension du cancer bronchopulmonaire, conséquences pour l'opérabilité chez 94 patients [Comparison between PET(-FDG) and computed tomography in the staging of lung cancer. Consequences for operability in 94 patients]. Rev Pneumol Clin 2009;65(6):341-349. doi:10.1016/j.pneumo.2009.08.008
2. Gould MK, Kuschner WG, Rydzak CE, et al. Test performance of positron emission tomography and computed tomography for mediastinal staging in patients with non-small-cell lung cancer: a meta-analysis. Ann Intern Med 2003;139(11):879-892. doi:10.7326/0003-4819-139-11-200311180-00013