Respiratory

CHEST ZHANG YAN( 张焱） 1st clinic teaching hospital of Zhengzhou University (Henan Medical University)

• RUL Br:right upper lobe bronchus; • LMBRr:left main bronchus; • AO:aorta

Lung fields 1.Upper, middle and lower zones: – Draw lines at the anterior lower level of 2nd and 4th ribs

2.Inner,middle and outer zones: – Divide into three zones longitudinally averagely

Examine the lungs

Hilar shadows in the inner zone between 2nd - 4th anterior intercostal space  Consist of the shadow of the pulmonery blood vessels(mainly), the large bronchi, lymph nodes and the pleural reflections  The left hilum is usually slightly higher in position than the right  Situatuated

18

Check

the position of the mediastinum :

 Look

at the mediastinum mainly on lateral view

1.Three zones by the levels of T4 and T8: • Upper zone • Middle zone • Lower zone 2.Three division: • Anterior:thymus,lymph nod,et al • Middle:heart,aorta,trachea,hilar • Poster:eso,nerves et al

• • • • • • • •

Subclavian artery Brachiocephalic vein(innominate vein) Brachiocephalic trunk (innominate artery) Common carotid artery Bronchi Bronchioles terminal Bronchioles Pectoralis major

• • • • • • • •

Subclavian artery Brachiocephalic vein(innominate vein) Brachiocephalic trunk (innominate artery) Common carotid artery Bronchi Bronchioles terminal Bronchioles Pectoralis major

• Radiological signs of lung disease

(1). Pulmonary consolidation : Consolidation of a whole lobe or the majority of a lobe is diagnostic of bacterial pneumonia. The diagnosis of lobar consolidation requires the radiological anatomy of the lobes (Fig.2.15) .

Patchy consolidation •

one or more patches have ill-defined shadowing (Fig.2.17), is usually due to: 1.pneumonia 2.infarction 3.immunological disorders.

(2). Pulmonary collapse (atelectasis) • The common causes of collapse (loss of volume of a lobe or bung) are: • ·bronchial obstruction; • ·pneumothorax or pleural effusion.

The signs of lobar collapse 1.displacement of structures; 2.the consolidation shadow of the collapsed lobe

The commoner causes of lobar collapse are: 1. bronchial wall lesions usually primary carcinoma; rarely, other bronchial tumours such as carcinoid( 类癌 ); rare , endobronchial tuberculoses.

2 .Intraluminal occlusion mucus plugging, particularly in postoperative or unconscious patients inhaled foreign body.

3.Invasion or compression adjacent mass malignant tumour; enlraged lymph nodes;

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右肺上叶不张

Spherical shadows : 1.lung mass, 2.lung nodule

• The diagnosis of a solitary spherical shadow in the lung (Fig. 2.29) is a common problem, The usual causes of a solitary pulmonary lesion:

1.bronchial carcinoma/bronchial carcinoid( 类 癌 );

2.benign tumour of the lung, hamartoma being the most common; 3.infective granuloma, tuberculoma being the most common in the UK; fungal granuloma being the most frequent in the USA; 4.metastasis; 5.Lung abscess;

(3). Calcification Calcification is higher density,and it is a common finding in hamartomas, tuberculomas and fungal granulomas. In hamartomas it is often of the ‘popcorn’ type (Fig.2.30).

CT is of great value in detecting calcification and can help to confirm the nature of the lesion. Some calcification can be difficult to recognize on plain chest radiography. With CT, however, calcification can be diagnosed easy (fig.2.31).

↗

左肺斑片状钙化

→

左肺爆玉米花样钙化

(4).Cavitation If the centre of the mass undergoes necrosis and is coughed up, air is seen within the mass.

An air-fluid level may be visible on erect films. These features, which may be difficult to appreciate on plain films, are particularly well seen at CT.

Cavitation thickness of the cavitation wall 1.Thick(exceed 3mm) ---acute lung abscess;Ca 2.Thin (1-2mm) ---tuberculosis;Ca 3.Very thin ----caseous pneumonia

Cavitation almost always indicates a significant lesion. It is very common in lung abscesses (Fig.2.34), active TB,relatively common in primary carcinomas (Fig.2.35) and occasionally seen with metastases. It does not occur in benign tumours or inactive tuberculomas.

The distinction between cavitating neoplasms and lung abscesses can be very difficult, a sometimes impossible, particular if the walls are smooth. If, however, either the inner or outer walls are irregular the diagnosis of carcinoma is highly likely.

Size A solitary mass over 4cm in diameter which does not contain calcium is nearly always either a primary carcinoma or a lung abscess. Lung abscesses of this size, however, always show cavitation in fact.

TB

• Air containing space

含气囊肿

(5).Mass • Homogeneous in density ; • Round oval or lobulated in shape; • Some primary carcinoma may show spiculation （毛刺） at the periphery, Represent the growth of the mass; • Multiple and widespread round opacities in the middle and lower lung fields is metastases

周 围 性 肺 癌

Multiple pulmonary nodules Multiple well-defined spherical shadows in the lungs are virtually diagnostic of metastases (p.97). Occasionally, this pattern is seen with abscesses or with granulomas( 肉芽肿 ).

(6).Free

pleural fluid

Plain radiographic findings (Fig.2.43). Free fluid is always fills in the costophrenic angles, in the upright position.

中量

Pleural calcification or thickening: 1.usually they are caused by old

tuberculous (Fig.2.52) or old haemothorax. 2.X-ray plain film can find them and CT can find them more clearly.

左侧胸膜肥厚钙化

Pneumothorax

(Fig.2.53)

The diagnosis of pneumothorax depends on : 1.The line of pleura forming the lung edge separated from the chest wall, mediastinum or diaphragm by air;

• 2.the absence of vessel shadows outside this line.

The end

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