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1、Imaging diagnosis of respirotary diseasepart 1AiPing Chen,小儿胸腺,肺大泡,呼吸系统影像观察、分析和诊断,X线,投照条件是否正确投照位置是否正确两侧胸廓是否对称纵隔位置是否居中横膈高度是否正常,CT,上下层面结合分析肺窗与纵隔窗结合分析断面图像与三维重建图像结合分析平扫图像与增强扫描图像结合分析,观察、分析病灶,病变的部位，数目病变的形态与大小病变的密度与边缘病变对邻近结构的影响,不同成像技术的优选和综合应用,不同成像技术的价值和限度,X线：健康普查、胸部疾病的诊断和随访 限度：结构重叠，小病灶漏诊，如心影后方病灶或后肋膈角病灶；密度分
2、辨率低，对纵隔病变的诊断有限。CT：发现病变、定位和定性诊断。限度：定性缺乏特异性。MRI：定位和定性均有一定优势。限度：肺组织信号弱，对微细结构的显示效果不好,成像技术的优选原则,疾病发病阶段、发病部位及病变性质不同，不同成像技术在胸部应用的优势不同，需要多种成像技术综合应用。经济优先，简便优先，实用优先，安全优先原则,支气管病变,气管、支气管异物foreign body in the bronchus先天性支气管囊肿 congenital bronchial cysts气管肿瘤支扩,Clinical symptom:cough,Purulent foul-smelling sputum,e
3、mptysis,or haemoptysis.儿童，青年多见，多见于左下叶、右中叶及右下叶。咳嗽、咳痰、咯血,支气管扩张bronchiectasis,Bronchiectasis支扩,Bronchiectasis is defined as localized,irreversible dilatation of the bronchial tree.congenital or aquired-There are several causes of bronchiectasis,postinfectious causes;congenital defects of a structure na
4、ture;chronic granulomatous infection such as tuberculosis.,无异常发现支气管及肺间质慢性炎症引起肺纹理增多，增厚，紊乱。可呈管状、杵状、囊状蜂窝状影，或卷发状。继发感染：呈小斑片状模糊影，常不易治愈，或于同一地方反复发作。,X线表现,Bronchiectasis,PathologyDamage of bronchus wallPression of bronchus increaseCircumference tissue draught支气管壁破坏支气管内压增加周围组织牵拉（疤痕、肺不张等）,Bronchiectasis,Bronch
5、iectasis can be divided into three morphologic types:cylindrical,saccular,mixed type.柱状、囊状或静脉曲张型。Cylindrical bronchiectasis refers to a generalized more or less regular widening of the large bronchi.Saccular bronchietasis shows that the bronchi terminate in sac-like cavities.,Bronchiectasis,X-ray ma
6、nifestation:The plain film may be normal if only a small part is involved and there is no secondary infection.The most common appearance on plain film is increasing of lung markings.The bronchial walls may be visible either as single or parallel line opacities.There are paths of opacity when infecti
7、on occures.,Bronchiectasis:lung markings of the left low lobe increase,and small sac(sac-like cavities),Bronchiectasis:lung markings of the left low lobe increase,and small sac(sac-like cavities),Bronchiectasis,Bronchographic investigation is important and necessary to delineate the total extent of
8、the disease.In the bronchogram,the cylindric bronchiectasis may be show club-shaped dilatation of the bronchi,while the saccular bronchiectasis will show saccular or cystic dilation of the affected bronchi.,Bronchogram:saccular bronchictasis in the left lung,Bronchiectasis,CT is helpful especially i
9、n the more advanced forms of bronchiectasis,cylindrical bronchiectasis causes smooth dilatation of bronchi,recognizable as“tram line”when seen in the scan plane and as the signet-ring sign in cross-section.The signet ring sign refers to the thickened and dilated bronchus,saccular bronchiectasis can
10、be diagnosed most reliably by CT,sometime we can see air-fluid level in the dilated bronchus.,HRCT：支气管壁增厚，管腔增宽。呈“轨道征”或“印戒征”。柱状、囊状或静脉曲张型。,bronchictasistram line 轨道征 signet-ring sign 印戒征,air-fluid level in the sac.,支扩伴黏液栓形成,bronchictasistram line and the signet-ring sign in cross-section.,Question:whe
11、re is the bronchiectasis?,肺先天性疾病,肺发育异常肺隔离症(bronchopulmonary sequestration)intralobar extralobar肺动静脉瘘,肺AVM,Pneumonia,The causative organisms are variable:病原体多样感染：细菌、病毒、真菌、支原体、衣原体、立克次体、寄生虫理化性：类脂性、毒气、药物、放射线等免疫和变态反应,Pneumonia,Pneumonia can cause a wide variety of abnormal findings on the chest radiograp
12、h.Commonly,it presents as alveolar consolidation,which can be segmental or lobar,or may be patchy,fluffy,alveolar infiltrates-without any segmental distribution(bronchopneumonia pattern).Pneumonia also may present as diffuse alveolar disease or as diffuse interstitial disease.It also can present as
13、single or multiple nodules.The presence of pneumonia sometimes may be masked by an associated pleural effusion,congestive failure,or adult respiratory distress syndrome(ARDS).,Pneumonia,According to the radiologic appearance,pneumonia can be commonly divided into lobar pneumonia bronchopneumonia int
14、erstitial pneumonia,Lobar pneumonia,Lobar pneumonia most commonly is caused by S.pneumoniae肺炎链球菌,but it can also occur with other organisms.Lobar pneumonia represents a type of inflammation of the lung characterized by out-pouring of exudates into the alveoli with little change in the bronchi or int
15、erstitial tissue.The out-pouring of fluid is generally considered to result from a local sensitivity reaction to the polysaccharides in the capsule of the pneumococcus.The bacteria are rapidly carried by the edema fluid from alveolus to alveolus,Lobar pneumonia,Early stage:Inflammatory edemaConsolid
16、ation stage Resolution stage,Lobar pneumonia,Early stage:Inflammatory edema The infection and edema have usually spread throughout a segment of the lung.X-ray findings:The lung markings increase.It does not completely obscure the pulmonary vessels in the area because many of the alveoli are still ae
17、rated.,Lobar pneumonia,Consolidation stage The lung is characterized by a rather dense shadow of uniform opacity.If the bronchi remain patent,the air column within them stands out as dark.The presence of an air bronchogram within a shadow in the pulmonary field indicates that the density is due to c
18、onsolidation of lung.If adequate antibiotic treatment is given,no further spread takes place.,1.大叶性肺炎,病理过程充血期：12-24hr。毛细血管充血，少量浆液渗出，肺泡部分仍含气；实变期：2-5d，分红色和灰色肝硬变期，肺泡内充满炎性渗出物。消散期：1w后开始,2-3w消散。,线表现可无异常或肺纹理增粗。均匀实变影，与肺叶、段一致的高密度影，随各肺叶形态不同而不同。不均匀斑片状，逐渐吸收，胸膜侧最晚，可有胸膜增厚、纤维条索,lobar pneumonia,consolidation of rig
19、ht upper lung and“air bronchogram“,consolidation of right middle lober,consolidation of right upper lober,Lobar pneumonia,Resolution stageThe homogenicity if the shadow of consolidation is lost and it becomes mottled as the exudate in various portions of the affected lung is absorbed and alveoli her
20、e and there are filled with air.The pathologic consists of intermingled areas of consolidation of varying degree,aeration of the alveoli and areas of atelectasis.The latter are often represented on the film by streak-like shadow.These shadows disappear as the lung re-expands and resolution is comple
21、ted.,Resolution stage in the right upper lober,Streak like shadow,Resolution stage in the left lower lober,consolidation of left upper lober,双上叶见大片状致密影，可见支气管充气征,consolidation of right and left upper lober(air bronchogram),Bronchopneumonia(lobular pneumonia),It is commonly seen in infants and elderly
22、 patients by infection by Staphylococcus aureus,most gram-negative bacteria and some fungi.It begins as a bronchial infection and has a tendency to involve separate parts of the lung.The infection spreads along the bronchial walls and results in infiltration of the interstitial tissues with little i
23、nvolvement of the alveolar air space.In most cases,both consolidations of the alveolar air spaces and interstitial infiltration are present.,Bronchopneumonia(lobular pneumonia),The radiologic manifestations of bronchopneumonia depend on the severity of the disease.Mild bronchopneumonia results in pe
24、ribronchial thickening and poorly defined air-space opacities.More severe disease results in inhomogeneous,patchy areas of consolidation that usually involve several lobes.,Bronchopneumonia(lobular pneumonia),Consolidation involving the terminal and respiratory bronchioles and adjacent alveoli resul
25、ts in poorly defined centrilobular nodular opacities measuring 4 to 10 mm in diameter(air-space nodules);extension to involve the entire secondary lobule(lobular consolidation)may be seen.Bronchopneumonia frequently results in loss of volume of the affected segments or lobes.When confluent,bronchopn
26、eumonia may resemble lobar pneumonia.,小叶性肺炎影像学表现,病变部位：两肺中下野的内中带肺纹改变：增多、增粗、模糊X-ray:两肺中下野的内中带沿支气管分布，肺纹理增多、增粗、模糊，小叶渗出与实变表现为斑片状模糊致密影，有融合倾向CT表现：两中下肺支气管血管束增粗，有大小不同结节和片状阴影，12cm大小，边缘模糊。病变之间除正常含气肺组织外，还有12cm类圆型透亮阴影，代表小叶性过度充气,patchy areas of consolidation,Lung markings increase and patchy in the right lower lo
27、be,Lung markings increase and patchy in the right and left lung,Patchy shadow in both of the lung,Patchy shadow in both of the lung,机遇性感染opportunity infection,immune deficiency accompany with infection or tuberculosis and so on 免疫缺陷者伴随的感染或结核等Eg.HIV infection:细菌，真菌，病毒，TB，PCP（肺孢子虫肺炎）,HIV female 23 yea
28、rs olds,HIV,Patchy shadow in both of the lung,AIDS and Pneumocystis carinii pneumonia,AIDS patient with pulmonary cryptococcal infection.（新型隐球菌）,Lung abscess,Hematogenous abscess血源性的脓肿 is rather rare now.Abscesses occur most often as a complication of aspiration of food,vomitus,or foreign body;of ba
29、cterial pneumonia;or bronchial obstruction.Anaerobic bacteria厌氧菌are often the cause.Other relatively Common agents are S.aureus金黄色葡萄球菌and Pseudomonas aeruginosa绿脓杆菌/绿脓假单胞菌.Abscesses may also be secondary to septicemia败血病,and they occasionally develop in an infected pulmonary infarct.,Lung abscess,Sy
30、mptomatology resembles that of acute pnenmonia with fever,cough productive of purulent sputum脓痰,and leucocytosis白细胞增多.Diabetics,alcoholics,and immunocompromised,免疫受损的individuals are at increased risk of developing lung abscess.,Lung abscess,The abscess resulting from aspiration most frequently occur
31、s in the dependent segments of the lung-the posterior segments of the upper lobe and the superior segments of the lower lobe.The abscess first appears as a round but poorly defined area of segmental consolidation usually near the periphery of the lung.No fluid level is seen until bronchial communica
32、tion is established.,Lung abscess,As the abscess ruptures into the bronchus a translucent ring with a fluid level is seen in the middle of the opaque segment.The inner walls of the cavity are smooth.Adjacent parenchymal consolidation is also present.Multiple cavities may develop within consolidated
33、lung(necrotizing pneumonia).Conventional tomography may show gas bubbles within an abscess indicating either a bronchial communication or possible infection with gas-forming organisms.There is frequently an associated pleural effusion.,Lung abscess,CT allows earlier detection of abscess formationCT
34、is also superior in defining the relationship of the process to the pleural cavity,.Empyemas脓胸 tend to be lenticular凸出的 in shape,and their angle of interface with the chest wall is usually obtuse钝角.A lung abscess is usually spherical and produces an acute angle with the chest wall.,Lung abscess,Afte
35、r antibiotic treatment in favorable cases both the cavity and the surrounding consolidation gradually shrinks and disappears.The abscess heals completely and leaves no visible scar or sometimes a small area of fibrosis indicates the site.In some cases healing is slow and there is often a residual br
36、onchiectasis of fusiform type.,肺脓肿 lung abscess,急性化脓性肺炎期：大片炎性浸润脓肿形成期：出现含液平空洞慢性肺脓肿：周围炎症吸收，代之以纤维组织增生，表现为紊乱的条索影及斑片阴影血源性肺脓肿：两肺胸膜下多发性类圆性阴影，中间有小空洞形成，可有液平，常累及胸膜,Acute abscess:the cavity(fluid in cavity)and the surrounding consolidation,Acute abscess:the cavity(fluid in cavity)and the surrounding consolidat
37、ion,Acute abscess:the cavity(fluid in cavity)and the surrounding consolidation,Chronic abscess:the cavity and the surrounding consolidation,Chronic abscess:the cavity and the surrounding consolidation,Chronic abscess:the cavity and the surrounding consolidation,Tuberculosis of the lung,Tuberculosis
38、is an infectious disease that may affect any organ but shows a marked predilection for the lungs.Nowadays better standards of living and hygiene have sharply reduced the incidence of tuberculosis.Despite recent advances in therapy and careful public health measures,TB remains a problem in the large
39、reservoir of elderly patients who have previously been infected with tubercle bacilli and in the urban poor who continue to be exposed to tubercle bacilli.,Tuberculosis of the lung,The main factor determining whether tuberculosis infection progresses to disease is the immune competence of the indivi
40、dual.The disease is most commonly found in persons whose immune status is compromised by old age,alcohol abuse,diabetes,steroid therapy,or AIDS.,Tuberculosis of the lung,Tuberculosis is classically divided into()primary tuberculosis.()hematogenous tuberculosis.()postprimary tuberculosis.()tuberculou
41、s pleurisy.()extraplumonary tuberculosis.,primary tuberculosis,Most cases of primary tuberculosis due to inhale the tubercle bacilli.It is commonly seen in children or adolescents.The infection spreads from the initial focus in the lung to the regional and mediastinal lymph nodes by way of the lymph
42、atic channels.Inhaled tubercle bacilli initially evoke a focal,nonspecific subpleural alveolitis that converts to a tuberculosis-specific inflammatory focus(Ghon focus)in about 10 days.Spread of tubercle via the lumphatics leads to a specific hilar lymphadenitis.The combination of the primary pulmon
43、ary focus,lymphangitis and lymphadenitis is known as the primary complex.,primary tuberculosis,The Ghon focus is a circumscribed,small,peripheral consolidation.Hilar and mediastinal lymphadenitis presents as hilar enlargement and mediastinal widening.Occasionally,lymphangitic stranding connecting th
44、e primary focus with the hilar lymphadenitis forms a dumbbell-shaped opacity.Segmental opacity may be due to segmental atelectasis distal to bronchial compression by enlarged lymph nodes.,Right hilar enlargement and mediastinal widening,Left hilar enlargement,Left hilar enlargement and mediastinal w
45、idening,Right hilar enlargement and mediastinal widening,Lymph node enlargement in mediastinum,After treatment enlargement lymph node disappear,Hematogenous tuberculosis(Type),Mycobacteria entering the blood from the primary complex may become disseminated to numerous extrapulmonary sites.It may be
46、classified as acute,subacute or chronic hematogenous dissemination tuberculosis.,Miliary tuberculosis,Acute miliary tuberculosisMilitary tuberculosis exhibits a finely mottled nodular pattern resulting from summation of individual nodules.These may range in size from 1-4mm in diameter.They completel
47、y obscure the normal lung markings in acute hematogenous dissemination tuberculosis.Three homogeneous:distribute,size,density,Three homogeneous:distribute,size,density,Acute miliary tuberculosis,Three homogeneous:distribute,size,density,Acute miliary tuberculosis,Acute miliary tuberculosis,Acute mil
48、iary tuberculosis,Miliary tuberculosis,Subacute or chronic miliary tuberculosistiny opacities are chiefly distributed in both upper and middle lung fields,the density of the opacities is not uniform and the size and shape of the opacities are not the same.Three nonhomogeneous:distribute,size,density
49、,Subacute or chronic miliary tuberculosis,Three inhomogeneous:distribute,size,density,Three homogeneous:distribute,size,density,Subacute or chronic miliary tuberculosis,Subacute or chronic miliary tuberculosis,Postprimary tuberculosis(Adult tuberculosis),Postprimary tuberculosis is characterized by
50、cavitating lesions in the upper lobes or apical segments of the lower lobes.Rupture of a parenchymal focus into an adjacent airway and subsequent endobronchial spread may lead to extensive pulmonary involvement.,Postprimary tuberculosis(Adult tuberculosis),Postprimary tuberculosis produces a spectru
