RADIOLOGI THORAK

MODALITAS IMAGING THORAK

Chest radiography Computed tomography /HR CTUltrasound Magnetic resonance imaging Ventilationperfusion scintigraphy Positron emission tomography

RADIOGRAPHY KONVENSIONALKEUNTUNGAN :1. MURAH2. KWALITAS DAN RESOLOSI GAMBAR BAIKKERUGIAN :BANYK PENGULANGANDISPLAY IMAGE TIDAK BISA DI MANIPULASI

SISTEM X RAY DIGITAL COMPUTED RADOGARPHY : MENGGUNAKAN PLATE PHOSPOR PHOTOSTIMULATOR

2. DIRECT RADIOGRAPHY MENGGUNAKAN FLAT PANEL DETECTOR BASE ON CESIUM IODIDE

KEUNTUNGAN X RAY DIGITAL

EFFISIEN DISPLAY ,PENYIMPANAN DAN PENGIRIMAN GAMBAR CEPAT.KWALITAS GAMBAR EXCELLENTRADIASI MINIMAL

TEKNIS DAN POSISI PA FULL INSPIRASIPA FULL EXPIRASIRPA/LPAAP SUPINELATERAL DECUBITUS OVER PENETRATED ( BUCKY / 4-6 INCH)APICAL LORDOTIKMAGNIFIKASI

POSISI KHUSUS PADA FOTO THORAXLLD view. => IDENTIFIKASI PLEURAL EFFFUSION=> American Thoracic Society guidelines : => KETEBALAN EFFUSI Menilai apek paru

LATERAL VIEWMenentukan lokasi lesi lebih accuratAnalisis lesi MediastinalMenilai Sternum dan Substernal structurMenilai pembesaran kelenjar hilus

PA EXPIRASIPNEUMOTHORAK LEBIH JELASMENDORONG EFFUSI KE COSTOPHRENIC EVALUASI AIR TRAPPING DALAM LOBUS/ SEGMENT

LATERAL DECUBITUSMENUNJUKKAN CAIRAN BEBAS DI THORAKMENILAI STRUKTUR MOBIL DI CAV.THORAKFUNGUS BALLFIXASI PERGERAKAN MEDIASTINUMAIR TRAPPING OLEH CORPUS ALIENUM ENDOBRONCHIAL

(COMPUTED TOMOGRAPHY ) INDIKASI CT SCAN THORAXTrauma Thorak Evaluasi Syndroma acut aortic (dissection, transection) Identifikasi komplikasi post op. thorak ( haematomas, pleural effsusion)Evaluasi nodul/ mass mediastinumDigosa dan staging Tu paru Identifikasi bronchiectasis. Deteksi metastases di paru dari tempat lain

USG THORAKKEUNTUNGAN : Bisa dilakukan Bedside Bebas radiasi Guiding Aspirasi pleural Effusion dan tumor .TEHNIS Pobe Linier 5-7.5 Mhz utk dinding dada. Probe 3.5 MHz Pleura dan Pulmo .

USG Thorax.Dasar2 : USG Sumber energie : Suara dengan frequensi tinggi , tidak terdengar telinga tidak merambat di udara sehingga organ2 yang berisi udara tidak bisa diperiksa dengan baik . Suara yang dipantulkan ditangkap detector pada transducer : terlihat putih .

USG Thorax Dasar 2 USG: Benda padat semua suara dipantulkan => permukaan putih dibelakangnya echo free. Benda cair atau solid homogen ( jelly , kelenjar ) meneruskan suara : terlihat sonolucent dengan posterior echo enhancement Akurasi: hampir 100% cairan encer , menurun pada cairan kental yang mengandung debris protein lipid.

USG THORAXIndikasiBila X Ray ragu adanya cairan di cavum pleuraMembedakan cairan/ solid di dinding thoraxTuntunan punctie aspirasi/ drainage

The Normal Chest

Lungsairways The lungs beyond the hila The hila The mediastinum The diaphragm

MODUS OPERANDI MENILAI FOTO THORAK PASusun film secara kronologisPelajari Lateral film setelah menilai foto Paus taPastikan posisi dan kondisi foto baikMENILAI HASIL X RAY :

MENILAI HASIL X RAY :1. Costoprenic angle harus tajam 2.Nilai Hemidiapragma dan subdiapragma 3. Nilai Dinding dada dan komponennya 4.Nilai Tracheobronchial 5.Mediatinum ,Jantung dan p.d utama dan azygos 6. 3 zona paru : Zona 2 cmZona 5 mmzona 1 mm

Pembuatan Foto ThoraxSebaiknya pakai alat dg spesifikasi tehnik mA 300-500,Kv sekitar 125.Jarak fokus film 1.8-2 meter.Proyeksi PA/Lat dg Esophagus terisi kontras

Syarat foto thorak yg baik1. Posisi baik : Symetris => trahea ditengah. Scapula terbuka Fase inspirasi : ujung costa 6 depan atau ujung costa 10 belakang diatas diaphrgma. 2. Kondisi optimum (Kv dan mA ckp )Vertebrae th.4 terlihat Kontras antar jaringan jelas (batas jantung jelas )

The Chest Wall, Pleura, DiaphragmThe chest wall Soft tissues Bony structures The pleura Pleural effusion Pneumothorax Pleural thickening and fibrothorax Pleural calcification Pleural tumours The diaphragm

SOFT TISSUE BreastMuscleSoft tissue calsificatonSubcutaneus emphysemaSoft tissue Tu

BONY STRUCTURESRibSternumClavicleSpine

PLEURAL EFFUSIONPaling banyak Transudat, exudat, darah da chyle.Jika bilateral umumnya transudat. Jika jumlahnya minima tidak terihat pada foto Thorak PA berdiri Jika terlihat sinus kostoprenius tumpul jumlah cairan sekitar 200500 ml.

MEDIASTINUMPembagian :Mediastinum anteriorMediastinum mediusMediastinum posterior

Mediastinal masses are often incidentally detected on chest radiograph

BENIGN TERATOMA

Achalasia

PNEUMONIAPneumonia adlah infeksi yang mengenai parenchim paruPENYEBAB BERVARIASI BACTERI ,VIRUS JAMUR, PARASIT.FOTO THORAK BERVARIASI KADANG TERLIHAT NORMAL DI FOTO PADA CT BARU TERLIHAT.HASIL HARUS DIKOMBINASI DENGAN INFORMASI KLINIS DAN LABORATORIUM.

PNEUMONIA Lobar pneumonias Bronchopneumonia Anaerobic pneumonias Atypical pneumonia Pulmonary tuberculosis /Nontuberculous mycobacterial disease Fungal infections Protozoal and metazoal diseases Pulmonary complications of HIV infection and AIDS Infections Malignancies

RADIOLOGIS PNEUMONIAS

Streptococcus pneumoniaeUmumnya opasitas homogen periferal dengan atau tanpa air bronchogramUmumnya di basal and soliter.Klebsiella pneumoniae in the community or in hospital. X ray homogeneous opacity mirip to Strep. pneumoniae or may reveal scattered focal heterogeneous opacities

BRONCHOPNEUMONIA

X Ray :Opasitas heterogen tersebar multifocal dan bilateeal[Pleural effusion or empyema, and cavitation umum dijumpai.Air bronchograms tidak lazim

Gram-negative pneumonias

Etio : enterobacteria (Enterobacter sp., Serratia marcescens, Proteus sp, Escherichia coli, Pseudomonas aeruginosa and Haemophilus influenzaeLokasi :Lower lobes dominan rdiologis sama dg pada infeksi Staph. Aureus pada orang dewasa

Major differentiating factors between atelectasis and pneumonia

AtelectasisPneumonia Volume Loss Associated Ipsilateral Shift

Linear, Wedge-Shaped

Apex at Hilum Normal or Increased volumeNo Shift, or if Present Then ContralateralConsolidation, Air Space ProcessNot Centered at Hilum

PULMONARY TUBERCULOSIS

Primary tuberculosis

Menyebabkan pneumonia menyerupai acquired pneumonias , such as Strep. PneumoniaePembesaran kel biasanya ipsilateral, hilar dan atau mediastinalPleural effusion

Post-primary tuberculosis

Radiographically, 95% diawali fibroinfiltrat. Lokasi apicoposterior segments dari lob.atas dan atau superior segment dari lob.bawahCavitas terlihat pada 40-80 % kasus.Penyembuhan menghasilkan scar formation.

AIR BRONCHOGRAMAn air bronchogram is a tubular outline of an airway made visible by filling of the surrounding alveoli by fluid or inflammatory exudates. Six causes of air bronchograms are;1. lung consolidation, 2. pulmonary edema, 3. nonobstructive pulmonary atelectasis, 4. severe interstitial disease, 5. neoplasm, 6. and normal expiration.

FUNGAL INFECTIONS

Gambaran Radiologis

Mass paru biasanya single bisa multiple. Opasitas Homogen dg/ tanpa air bronchogram, cavitas dan lymphadenopathy Diffuse nodular, kadang miliary, or reticulonodular opacities. Masses bisanya batas tidak jelas bisa ukuran 5 mm sampai sangat besar.

Large Airway Disease and Chronic Airway Obstruction

Tracheal disorders Bronchiectasis Broncholithiasis Emphysema Chronic bronchitis Asthma Obliterative (constrictive) bronchiolitis

BRONCHIECTASIS

Penebaan dinding bronchus terlihat single thin lines or as parallel line opacities (tramlines).end-on, bronchiectatic airways appear as poorly defined ring or curvilinear opacitiesDilated bronchi filled with mucous or pus result in tubular or ovoid opacities of variable size. Cystic bronchiectasis manifests as multiple thin-walled ring shadows often containing airfluid levels

EMPHYSEMA

HyperaeratedTinggi paru kanan lebih dari 29.9 cm. Hemidiaphragm kanan pada atau dibawah costa 7 anterior Hemidiaphragma mendatar, Retrosternal space melebar.Pelebaran sternodiaphragmatic angle Penyempitan diameter transversal cardiac.

Perubahan p.darah paru include arterial depletion, whereas vessels of normal, or occasionally increased, calibre are present in unaffected areas of the lung, absence or displacement of vessels caused by bullae, widened branching angles with loss of side branches and vascular redistribution

CHRONIC BRONCHITISThe majority have a normal chest radiographhyperinflation, oligaemia, bronchial wall thickening and accentuation of linear lung markingsThickening of the bronchial walls leads to tubular and ring shadows. Increased lung markings cause the appearance of a dirty chest,

ASTHMAHyperinflation may be seen in both relapse and remissionChest radiography may depict complications including consolidation, atelectasis, mucoid impaction, pneumothorax and pneumomediastinum.Bronchial wall thickening is more frequent in children,

PENYEBAB OPASITAS HEMITHORAX

Pleural effusion Consolidation Collapse Massive tumour Fibrothorax Combination of above lesions Pneumonectomy Lung agenesis

PENYEBAB ELEVASI DIAPHRAGMA SYMETRIS BILATERALPosisi Supine Inspirasi kurang Obesitas HamilDistensi Abdominal (ascites, intestinal obstruction, abdominal mass)

UNILATERAL ELEVASI DIAPHRAGMA UNILATERAL

Posisi : lateral decubitus position Dilatasi gaster atau colon Dorsal scoliosis Pulmonary hypoplasia Pulmonary collapse Phrenic nerve palsySubphrenic infection Subphrenic mass

FOCAL ELEVATION DIAPHRAGM

Partial eventration Diaphragmatic herniaDiaphragmatic tumour Pleural tumour Pulmonary tumour Focal diaphragmatic dysfunctionFocal diaphragmatic adhesions

LOBAR COLLAPSincreased opacity of the affected lobe and volume lossDirect signs of volume loss refer to displacement of interlobar fissures, pulmonary vessels and bronchi,indirect signs include compensatory shifts of adjacent structures such as hyperinflation of other lobes

Pulmonary Neoplasms

BRONCHIAL CARCINOMA

Peripheral tumours Tumours at the lung apex (Pancoast's tumours, superior sulcus tumours) may resemble apical pleural thickeningKebanyakan bentuk spheris / oval . Bentu lain loblated , kadang dumb bell.

Central tumoursThe cardinal imaging signs of a central tumour are : collapse/consolidation of the lung beyond the tumour and the presence of hilar enlargement

BENIGN PULMONARY TUMOURS

Bronchial carcinoids

Lokasi central bisa dg calsifikasi dan kadang ossifikasiBisa menyebabkan obstruksi bronchus parsial / komplit mengakibatkan atelektasi dg / tanpa pneumonia.Lesi perifer (1020% of carcinoids) gambaran soliter spheris atau nodule lobulated 2-4 cm.batas tegas rata.

Pulmonary hamartoma

Bentuk spheris/ obulated, batas jelas kurang dari 4 cm .parenchim skitar normal. Calcificasi bercak, linier atau popo corn

METASTASESAsal Payudara, GIT, Ginjal, Testis, head and neck Tu, tulang dan soft tissue sarcomas.Tehnik HIGHT KV (PA/ LAT) dapat mendeteksi metastas paru diatas 1 cm dengan baikCavitas kadang terlihat pada metastase di paru umumnya karna of squamous cell Ca.Calcificasi sangat jarang kecuali pada osteosarcoma and chondrosarcoma

MACAM2 METASTASE TU PARUMiliary typeLymphangitic typeGof Ball typeCoarse Noduler typeSubpleural typePneumonic type