Imaging of the respiratory system -EduPublish- kareem

IMAGING OF THE RESPIRATORY SYSTEM

Prof Madya Dr. Hj. M. Abdul Kareem ©

© MMA Kareem, USM, KB, Malaysia


RESPIRATORY SYSTEM Modalities:1. Plain Chest X ray, neck2. Fluoroscopy3. Bronchogram 4. CT scan, CT Fluoroscopy & CT Angiography5. MRI6. Ultrasound7. Pulmonary Angiography 8. Nuclear medicine V/Q scan Our Objectives:

Identification of normal structures Interpretation of normal Differentiate pathology


INDICATIONS FOR A CXR:

RME: employment, enrolment,emigration

Prior to any surgery (Pre-op check) Prolonged cough, fever,Chest Infections Chronic lung diseases/Pleural disease Chest Trauma Thrombo-embolic diseases Tumour Cardio-vascular diseases



PLAIN CXR VIEWS

* Routine Views: 1. PA – Posteroanterior view: Full inspiratory film,Erect-

2. AP – AnteroPosterior view ill patient or children)

3. Lateral

4. Both obliques

Special views: Apical / Lordotic (PTB, ML collapse) Expiratory film - suspected , air trapping or small pneumothorax.

Lateral Decubitus film • detection of small pleural effusion-5ml

Deep Penetrated grid film ( high KV ) Posterior lesions,

bronchiectasis


http://www.e-radiography.net/ibase5/Chest_Pulmonary/Chest_tb_apices_ap_lordotic.jpg

http://in.wrs.yahoo.com/_ylt=Aq4GTXLDLtHME4_AuTIysNO9HAx.;_ylu=X3oDMTBpdDZuNzZrBHBvcwM5BHNlYwNzcgR2dGlkAw--/SIG=1k01fi2iu/**http%3A/in.images.search.yahoo.com/search/images/view%3Fback=http%253A%252F%252Fin.images.search.yahoo.com%252Fsearch%252Fimages%253Fp%253Dchest%252Bx-ray%2526fr%253DFP-tab-%25255Bobject%252BObject%25255D-t909%2526toggle%253D1%2526cop%253D%2526ei%253DUTF-8%26w=226%26h=306%26imgurl=medicalimages.allrefer.com%252Flarge%252Flung-nodule-right-middle-lobe-chest-x-ray.jpg%26rurl=http%253A%252F%252Fhealth.allrefer.com%252Fhealth%252Fchest-x-ray-lung-nodule-right-middle-lobe-chest-x-ray.html%26size=6.4kB%26name=lung-nodule-right-middle-lobe-chest-x-ray.jpg%26p=chest%2Bx-ray%26type=jpeg%26no=9%26tt=8,360%26oid=53f5bd00e9769f1e%26ei=UTF-8


READ A CXR?

Identify the film: Name? Is side labelled?

dated? Institute, RN, ID PA or AP ? Centering, exposure PA film erect (common): heart is

not magnified, laminae slope of the cervicothoracic vertebrae are clearly seen, medial ends of clavicle –at lower level

Fundus gas AP film supine / sitting (ill,

bedridden, child): heart is magnified, vertebral end plates are clearly seen, clavicle medial ends are higher



READ A CXR? Upright? Air fluid level in

Fundus, bowel, abscess, hiatus hernia

Is it taken in good inspiration /At the end of full inspiration?

The anterior ends of the 5-6th rib or the posterior ends of the 9-10th rib will be visible crossing or just above the dome right hemidiaphragm



READ A CXR?

Is the film well centered? Any rotation or scoliosis? This causes diff. in densities

Medial end of clavicle should be of equal distance from the spinous process of the vertebrae

Is the film of correct exposure? Midthoracic vertebrae, disc spaces and bronchovascular marks should be just visible through heart



READ A CXR / Interpretation?

Center Peripheral How is the trachea? Trachea is central in the neck and

inclines slight to the Rt at level of aortic knuckle

Is the hilar region normal? Lt normally at a higher level. Look for any increase in densities or enlargement to suggest mass

Are the lung fields clear? Look for any abnormal opacities or

cavities



READ A CXR?

Are the lung markings visible peripherally?

Only 1-2cm from the periphery have no lung markings

If not think the possibility of pneumothorax

Is the soft tissue normal? Identify the breast shadows- sex,

mastectomy, Lateral wall thickness gas/air/calcification, neck LN

Is the Thoracic cage bone normal? Assoc # or metastatic deposits



READ A CXR?

Is the diaphragm normal? It has a smooth curved line which is

convex upwards and sharp costophrenic angles laterally against chestwall. Lt hemidiaphragm is lower than Rt due to position of cardiac apex

Rarely at same level



Lateral and oblique views

Separate the lesion from the bones and soft tissue of the chest wall. Better visible

Localisation of the lesion Segments of the lung can be located Retrocardiac area well visualised-left

lower lobe Retrosternal area Spines and paraspinal region



ACCEPTIBILITY CRITERIA FOR A CXR

1.Is it labelled as to the side, name, and date?

2. Is it a good inspiratory film? 3. Is it well centered?Any rotation/

scoliosis? 4. Is the film of correct penetration/

exposure? 5. Is the CXR well collimated? Are all the

lung fields, costophrenic angles completely visualised? CXR- sides (scapula and part of shoulder joint should be included) and below (just below hemidiaphragm)



CT SCAN


ROLE OF CT SCAN

CT is performed to further clarify and characterize the nature of abnormalities seen on plain film or us

Pre and post operative planning - to localise pathology and staging

As a guidance for fine needle aspiration or trucut biopsy



ROLE OF CT SCAN

CT scan - recognition of less dense and smaller lesions, 2-3 mm in any part of the lung.

The bronchial tree can be evaluated down to the segmental bronchi.

Abnormal lung vessel distributions can be recognised.

Evaluation of patients with suspected diffuse lung disease

Tissue characterization of pulmonary masses. (eg. fat, fluid, calcification)


© MMA Kareem, USM, KB, MalaysiaRADIONUCLIDE IMAGING


RADIONUCLIDE-VQ SCAN

Ventilation Studies. 99mTc-DTPA aerosol, (133 Xenon,

81Krypton) Shows area of low activity

representing poor ventilation. Persistent activity denotes air

trapping. eg emphysematous bulla.



RADIONUCLIDE-VQ SCAN

Perfusion Studies –99mTc macroaggregated albumin (MAA)

- mechanical obstruction of artery or alveolar hypoxia

- redistribution of blood flow -main indication-suspected

Pulmonary embolism



http://www.e-radiography.net/ibase5/Chest_Cardiac/Chest_ventilation-perfusion_scintigraphy_fig1b.jpg

http://www.e-radiography.net/ibase5/Chest_Cardiac/Chest_ventilation-perfusion_scintigraphy_fig1a.jpg


PULMONARY ANGIOGRAPHY

Indication :1. Suspected primary pulmonary

vasculature abnormalities - arterial aneurysm or arteriovenous fistulae or AVM

2. Diagnosis and management of subacute and chronic pulmonary thrombo-embolic disease

3. Diagnosis and assessment of operability of Bronchial Carcinoma. Involvement intrathoracic vessels. May indicate the extent and dissemination of the

tumour




http://www.e-radiography.net/ibase5/Chest_Cardiac/Chest_pulmonary_embolism_pe_fig2.jpg


RADIOLOGICAL ASSISTED LUNG BIOPSY USING CT- FLUOROSCOPY –US GUIDED

Indication:1.Primary mediastinal lesions such as

mediastinitis/ mediastinal abscess2.Biopsy of a lung mass-central or

peripheral lesion or a pleural based mass

3. US- for peripheral lung lesion or pleural based lesion (contact with the thoracic wall)


Technology

Imaging of the respiratory system -EduPublish- kareem