Upload
shanon-white
View
221
Download
0
Tags:
Embed Size (px)
Citation preview
RADIOLOGY IMAGING OF THE
CHEST
Part IIThe respiratory system
Interstitial lung disease
• The pulmonary interstitium is the network of connective tissue fibres that supports the lung. It includes the alveolar walls, interlobular septa, and the peribronchovascular interstitium
• Although the majority of the disorders also involve air spaces, the predominant abnormality – thickening of the interstitium
Interstitial lung diseaseBasic radiographic signs and
interpretationSeptal pattern• Interstitial pulmonary
oedema• Lymphatic spread of tumourReticular pattern• Fibrosin alveolitis• Sarcoidosis• Chronic alergic alveolitis• Langerhans cell
histiocytosis• LymphangioleiomyomatosisNodular pattern• Silicosis• Coal workers`
pneumoconiosis
• Sarcoidosis• Tuberculosis• Subacute alergic alveolitisReticulonodular pattern• Langerhans cell histiocytosis• Sarcoidosis• Lymphatic spread of tumourGround-glass pattern• Subacute alergic alveolitis• Pneumocystis carini
pneumonia• Nonspecyfic interstitial
pneumonia (NSIP)• Idiopathic pulmonary
haemorrhage
Interstitial lung diseaseBasic radiographic signs and
interpretation
Septal patternThickening of the
interlobular septa – Kerley B lines, short (1-2 cm) lines perpendicular to the pleura, continuous with it
Reticular patternThe result of summation of
smooth or irregular linear opacities, cystic spaces, or both – interlacing line shadows suggesting the mesh
Nodular patternThe accumulation of small
lesions within the pulmonary inetrstitium
well circumscribed, discrete nodules 2mm or less- miliary nodules
Reticulonodular patternGround-glass patternA generalized hazy increase
in opacity which obscures the underlying vascular markings on chest radiograph
Interstitial lung diseasedifferential diagnosis
1. The predominant pattern of abnormality
2. Its distribution within the lung3. The presence of associated findings:a. hilar or mediastinal lymphadenopathy
b. cardiomegalyc. pleural thickeningd. effusion
Case 1002A 28 year old Afro-Caribbean woman presented with a persistent dry cough and progressive exertional dyspnoea over three months. She was not wheezy and had not noticed any diurnal variation in symptoms. She was otherwise well with no known allergies or hayfever. Clinical examination revealed no abnormalities and her
chest sounded normal.
• What is the likely clinical diagnosis? • Which investigations would you request?
sarcoidosis
SarcoidosisA multisystem granulomatous disorder of
unknown aetioloogy characterized by the presence of noncaseating epihelioid cell granulomas in several affected organs (the skin, eyes, peripheral lymph nodes, spleen, cns, parotid glands, bones)
A disease of young adults – a peak incidence in the third decade
Traditionally staged according to its appearance of the chest radiograph
I – lymphadeopathyII – lymphadeopathy with parenchymal opacityIII - parenchymal opacity alone
Sarcoidosis Radiographic features
Lymphadenopathy• Enlargement of
bilateral, symmetrical hilar and paratracheal
• Occasionally asymmetrical – 1-5%
• In 90% disappears within 6-2 months
• Lymph nodes can calcify - eggshell fashion (shared only by silicosis) seen on plain films in 5%, on CT scans – 40%
• Parenchymal changes• Rounded or irregular
nodules 2-4mm in diameter, which maybe poorly or moderately well defined
• Patchy airpace consolidation, sometimes contain air bronchograms, with ill defined margins, commonly break up into nodular pattern
Industrial lung diseases -silicosis
Due to the inhalation of silica (SiO2)
Radiographic appearance- Multiple, small nodules, predominantly
in the middle and upper zones- Enlargement of the hilar lymph nodes-
an eggshell patern- Calcification occasionally seen in the
mediastinal, cervical and intra-abdominal nodes
Micronodular pneumoconiosis Nodular pneumoconiosis
Tuberous pneumoconiosis
Pneumoconiosis
Massive fibrosis in silicosis
Industrial lung diseases -asbestosis
The silicates: asbestos 90% of malignant mesotheliomas are related to previous exposure to asbestos
Pleural changes the pleural plque – well defined, soft tissue
sheets originating on the parietal pleural , usually bilateral, in the middle and lower zones and over the diaphragm
• When calcified – a „holly leaf” pattern with sharp, often angulated outlines, usually less than 1cm thick
• Diffuse pleural thickening• Pleural effusions – uncommon 3%Pulmonary changes - fibrosing alveolitis
peripherally at the lung basas
Case13 History: A 62 yo gentleman comes to his family practice physician
complaining of shortness of breath. The patient normally avoids physicians because he doesn't have insurance and he feels that they are all quacks anyway. However, he has been having more and more difficulty keeping up with his work on the assembly line at an automobile factory and he fears getting fired. The patient has 70 pack-year history of smoking Camel Studs. Otherwise, he is a fairly healthy individual. On physical exam his breath sounds are diminished diffusely. A subsequent chest x-ray is shown on the left.
Questions: What is the most likely diagnosis? What part of the history is pertinent to this diagnosis?
Emphysema
Condition of the lung characterized by permanent , abnormal enlargement of air spaces distal to the terminal bronchiole, accompanied by the destraction of their walls without obvious fibrosis
Is thought to result from the distraction of elastic fibres – inbalance between proteases and protease inhibitors, the mechanical stresses of ventilation and caughing
EmphysemaRadiological findingsOverinflation
a. The height of of the right lung being greater than 29.9cm
b. Location of the right diaphragm at or below the anterior aspect of the 7-th rib
c. Flattering of the hemidiaphragmd. Enlargement of the retrosternal spacee. Widening of the sternodiaphragmatic anglef. Narrowing of the transverse cardiac diameter
Emphysema
Radiological findingsAlterations in lung vessels
a. Arterial depletion, whereas vessels of normal calibre are present in unaffected areas
b. Absence or displacement of vessels caused by bullae
c. Widened branching angles with loss of side branches and vascular redistribution
With the development of cor pulmonale or left heart failure – the radiolographics appearences will alter
Emphysema
CT, particularly HRCT scans the most accurate mean! (low window values -800 to -1000 HU) specially for surgery treatment
Presence of areas of abnormally low attenuationFocal areas of emphysema usually lack distinct
walls as opposed to lung cystsTypes1. Centrilobular2. Panlobular3. Paraseptal4. Irregular
EmphysemaBullae• generaly found in patients with centrilobular
and/or septal emphysema• Avascular, low-attenuation areas that are
larger than 1cm and that can have a thin but perceptible wall
Bullous ephysema• Associated with large bullae, mainly in young
men• Large, progressive upper lobe bullae, often
asymmetrical• Avascular, transradiant areas separated from
the lung parenchyma by a thin curvilinear wall• Complications: pneumothorax, infection,
haemorrhage
Emphysema
Emphysema
Emphysema
Emphysema
Emphysema
Diseases of the pleura
• Pleural effusion• Bronchopleural fistula• Hemothorax• Chylothorax• Pneumothorax• Pleural masses
Case7 History: A 54 yo male with a history of Hodgkin's
Lymphoma presents to his primary care physician with a one-week history of shortness of breath and pleuritic chest pain. The patient has also noticed a non-productive cough that has progressively worsened over the past two days. Physical exam demonstrates diminished breath sounds and egophony on the left. The chest x-ray on the left was taken shortly thereafter.
Questions: What is the diagnosis? What findings on the x-ray help distinguish this condition from other opacifications?
Pleural effusion bilCollapse segmentHeart failure
Encysted effusion case 6
Pleural effusion
The most common clinical manifestation of pleural pathology
A result of mismatch between the rates of inflow and outflow of fluid in the pleural space
Pleural effusionTransudates; Result from: • a decrease in the colloid
osmotic pressure – hypoproteinemia
• increase in the microvascular hydrostatic osmotic pressure (the systemic venous pressure)
Causes:• congestive heart failure• cirrhosis• nephrotic syndrome• nephrogenic effusion• hypoalbuminemia• constrictive pericarditis• atelectasis• pulmonary embolism
Exudates; Result from:• alteration in the pleural
surface• an increase in
permeability • decrease in the lymph
flow
Causes:• pleural malignancy• pleural inflammation
Pleural effusion
More than 90% of cases caused by
• Heart failure• Cirrhosis• Ascites• Pleuropulmonary
infections• Malignancy• Pulmonary embolism
Diagnostic imaging• Chest radiograph• CT• Ultrasound
Radiographic features
Depends on the patient`s position and the mobility of the pleural fluid
On the PA radiograph • blunting of the lateral costophrenic
angles - 200ml-up to 500ml of fluid• The most sensitive projection – the
lateral decubitus chest radiograph – 5ml
Radiographic features
In the erect patient• Initially collects in the
subpulmonic region• Blunting of the lateral
costophrenic angles• Elevated hemidiaphram
sign - the superior margin of the fluid mimics the contour of the diaphragm – apparent elevation of the hemidiaphragm with flattening of its medial portion
• Opacity as hazy meniscus higher laterally than medially
In the spine patient position• Capping of the lung apex
with pleural fluid –early sign
• Increased hazy opacity with preserved vascular markings
• Blunting of the costophrenic angle
• Hazy diaphragm silhouette
• Thickening of the minor fissure
• Widened paraspinal soft tissues
• Elevated hemidiaphragm sign
Hemothorax
Most commonly results from traumaLess common reasons:• Varicella infections• Coagulopathies• Vaascular abnormalitiesChest radiogrph: a pleural effusion
without any distinguishing factor to suggest blood in the pleeural space
Non contrast CT- the characteristic attenuation increase
Chylothorax
Discruption of the thoracic duct • 50%- neoplastic in origin lymphoma
(75%)• 25% traumatic - surgery• 10% miscellaneous• 15% idiopathicUsually cannot be differentiated from other
effusions based on chhest radiographs or CT scans
Pleural effusion
Pleural effusion
Pleural effusion
Pleural effusion
Pleural effusion
Pleural effusion
The effusion in pleural adhesions
The effusion in pleural adhesions - inside
fissures
Case8 History: This chest x-ray is from a 54 yo female who presented two
weeks prior to the current visit for a productive cough and shortness of breath. The patient was diagnosed with community acquired pneumonia and sent home with antibiotics. She returns now stating that her cough and shortness of breath have resolved but now she is experiencing chest pain on deep inspiration. Her physical exam reveals diminished breath sounds and dullness to percussion on the left lower lung. The x-ray on the left was then ordered.
Questions: What is the diagnosis? Does the normal appearance of the pulmonary vasculature help with the diagnosis? Does the patient history help narrow the differential?
Pyothorax, thoracic empyema
Pleural adhesions
Pleural adhesions
Pleural adhesions
Case4 History:
A 6'4", thin smoking 32 yo male presents to the ER with shortness of breath and chest pain. The patient reports that he was just going for a jog when he became severely short of breath and began having chest pain that was retrosternal and slightly to the left. The patient has not history of lung disease but has been smoking about 1 ppd for over 10 years. Physical exam shows absent breath sounds on the left and hyperresonance to percussion. The x-ray on the left was taken in the ER.
Questions: •What is the diagnosis? •How does the pulmonary vasculature help you make your diagnosis?
Case1 History: A 26 yo male came to the ER complaining of shortness of
breath and some left-sided chest pain. The patient was snowboarding at a local resort when he lost control going off a jump. The patient reports landing directly on his left side after falling approximately 10 feet . The symptoms started immediately after the fall. On physical exam the patient has decreased breath sounds on the upper left lung. The patient was given an AP chest x-ray in the ER, which is shown on the left.
Questions: What is the diagnosis? Is this a common location for this condition?
Case3 History: A 54 yo alcoholic male presents to the ER
following an evening of heavy drinking with chest pain and dyspea. The patient reports that he had multiple episodes of violent vomiting and then passed out. When he awoke, he was having chest pain that was worse on inspiration and radiated to his neck with each breath. Physical exam was normal and MI work up came out negative. The x-ray on the left was taken shortly after admission.
Questions: What is the diagnosis? What part of the patient's history is applicable to the diagnosis?
AsthmaMediastinal air
Pneumothorax – gas or air in the pleural space
Spontaneous• Primary – no
identifiable cause, often related to an apical intrappleural bleb rupture
• Secondary with related undrelying lung parenchymal disease
Traumatic• Blunt or penetrating
trauma• Iatrogenic causes –
central venosus catherization, transbronchial or transthoracic biopsy
Pneumothorax
• Chest radiograph• Identification of a radiolucent air space
separating the visceral pleural line from the parietal pleura
• Pulmonaryu vessels extend to the edge of the visceral pleural line,nor beyond
• More sutable- on CT scans
Pneumothorax
Pneumothorax
Mediastinal emhysema, pneumothorax with
fluid
Bronchopleural fistula - fistulous communication between the pleural
space and the bronchial tree
Causes – the most common: necrotizing pulmonary infections and surgical lung resections
• penetrating and blunt lung injures
• pleural drains• thoracentesis• ventilator support
May be seen (x-rays, CT) as
• hydropneumothorax, an intrapleural air-fluid collection
• extansion of the air-fluid level to the chest wall
• unequal linear dimensions on orthogonal views
Pneumothorax
Bronchopleural fistula : pneumothorax + pyothorax
Pleural massesBenign• Lipoma• Fibroma• Asbestos related
disease• Rounded
atelectasis
Malignant • Metastatic 95&• Brest or lung
carcinoma,• Thymma• Lymphoma• Diffuse malignant
mesothelioma
Diffuse malignant mesothelioma
• rare and agressive 2000-3000 cases per year in USA
• Men 2-6x more often than women 50-70 y
• Symptoms: chest pain, dyspnea, cough, weight loss
• The association with asbestod strongly established
Tumor may further extend to the thoracic wall, contralateral chest,
• abdomen
Chest radiograph • Irregular, nodular,
peripheral pleural opacities with associated pleural effusion
• 40-86% extension to into interlobar fissures
CT• Wide spread of nodular
pleural thickening with mediastinal surface involvment
• Encasement of the lung • Extension into the
interlobar fissures
Mesothelioma pleure
Mesothelioma
Mesothelioma pleure
a. Atelectasis of the left lungb. A large left pleural effusionc. A large right pneumothoraxd. Pneumonia in the left lunge. Unilateral pulmonary edema
The patient shown below most likely has:
The patient shown below most likely has:
a. A large right pleural effusionb. A large left pneumothoraxc. Atelectasis of the right lungd. Pneumonia in the right lunge. Unilateral pulmonary edema
The patient shown below most likely has:
a. A large left pleural effusionb. A large right pneumothoraxc. Atelectasis of the left lungd. Pneumonia in the left lunge. Unilateral pulmonary edema
The patient shown below most likely has:
a. A large left pleural effusionb. A large right pneumothoraxc. Atelectasis of the left lung
because of a mucus plugd. Pneumonia in the left lunge. Atelectasis of the left lung
because the ETT is too low
The patient shown below most likely has:
a. There is a large left pleural effusion
b. There is a large right pneumothorax
c. Atelectasis of the left lung because of a mucus plug
d. Pneumonia in the left lunge. The left lung has been
surgically removed