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Chest X-Ray
 
 

Pulmonary Consolidation

 
 
 
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Overview

  • Look For

  • Opacification obscuring pulmonary vessels
  • Silhouette signs - obliteration of normally clear outlines between lung fields and adjacent structures
  • Air bronchograms - tubular outlines of smaller airways
  • No loss of lung volume
  • Significance

  • Consolidation indicates filling of the alveoli and bronchioles in the lung with pus (pneumonia), fluid (pulmonary oedema), blood or neoplastic cells.
  • Causes of Pulmonary Consolidation

  • Pneumonia - lobar pneumonia, bronchopneumonia, fungal pneumonia, viral pneumonitis
  • Fluid - pulmonary oedema (cardiogenic / non-cardiogenic)
  • Neoplasm - primary lung cancer, metastases, lymphoma
  • Vascular - pulmonary haemorrhage, contusion or infarct; septic embolism
  • Inflammation - systemic lupus erythematosus, granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangitis, Goodpasture’s syndrome, Henoch-Schonlein purpura
  • Cryptogenic organising pneumonia
  • Eosinophilic pneumonia
  • Pulmonary alveolar proteinosis
  • Aspiration pneumonitis
  • Sarcoidosis

Lobar Consolidation

  • Look For

  • Consolidation of a single pulmonary lobe, without crossing any pleural lines.
  • Causes of Lobar consolidation

  • Lobar pneumonia
  • Neoplasm - lung cancer, lymphoma
  • Vascular - pulmonary haemorrhage, pulmonary infarction
  • Cryptogenic organising pneumonia
  • Eosinophilic pneumonia
  • Sarcoidosis
  • Example

  • Right middle lobe consolidation in a patient with lobar pneumonia - PA film
  • Right middle lobe consolidation in a patient with lobar pneumonia - PA film
     
  • Right middle lobe consolidation in a patient with lobar pneumonia - lateral film
  • Right middle lobe consolidation in a patient with lobar pneumonia - lateral film
     

Diffuse Consolidation

  • Look For

  • Consolidation affecting multiple pulmonary lobes.
  • Example

  • Diffuse consolidation in a patient with tuberculosis
  • Diffuse consolidation in a patient with tuberculosis
     
  • Causes of Multifocal Consolidation

  • Pulmonary oedema
  • Infection  - bronchopneumonia, fungal pneumonia, viral pneumonitis, tuberculosis
  • Vascular - septic embolism
  • Inflammation - systemic lupus erythematosus, granulomatosis with polyangiitis, Goodpasture’s syndrome, Henoch-Schonlein purpura
  • Tumour - primary lung cancer, lymphoma, metastases
  • Pulmonary alveolar proteinosis
  • Aspiration pneumonitis

Silhouette Signs

  • Look For

  • Obliteration of normally clear outlines between the lung fields and adjacent structures such as the heart, aorta or hemidiaphragm.
  • Significance

  • Loss of normal borders appears when the adjacent area of lung is consolidated or collapsed.
  • Interpretation

  • Upper right heart border / ascending aorta - anterior right upper lobe
  • Upper left heart border - anterior left upper lobe
  • Aortic knob / arch - apical left upper lobe
  • Right heart border - right middle lobe
  • Left heart border - lingular lobe
  • Anterior hemidiaphragms - lung bases / lower lobes
  • Examples

  • Obscuration of the right hemidiaphragm suggesting right lower lobe consolidation
  • Obscuration of the right hemidiaphragm suggesting right lower lobe consolidation
     
  • Obscuration of the left hemidiaphragm suggesting right lower lobe consolidation
  • Obscuration of the left hemidiaphragm suggesting right lower lobe consolidation
     
  • Obscuration of the ascending aorta, suggesting right upper lobe consolidation
  • Obscuration of the ascending aorta, suggesting right upper lobe consolidation
     

Air Bronchograms

  • Look For

  • Tubular outlines of the smaller airways.
  • Significance

  • Appear when the alveoli surrounding the airway collapse or are filled with fluid.
  • Causes of Air Bronchograms

  • Pneumonia
  • Atelectasis
  • Pulmonary oedema
  • Acute respiratory distress syndrome
  • Bronchoalveolar carcinoma

Bat-Wing Appearance

  • Look For

  • A central, peri-hilar distribution of consolidation on chest x-ray.
  • Significance

  • The bat-wing appearance is classically a sign of pulmonary oedema.
  • Example

  • Batwing opacities consistent with acute pulmonary oedema
  • Batwing opacities consistent with acute pulmonary oedema
     
  • Causes of Bat-Wing Appearance

  • Pulmonary oedema (cardiogenic / noncardiogenic)
  • Atypical infection - PJP, fungal pneumonia
  • Aspiration pneumonitis
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