医学精品课件：04-06.2017-respiratory system-杨海涛.ppt

1、重庆医科大学附属第一医院呼吸系统影像诊断学呼吸系统影像诊断学Radiology of Respiratory system重庆医科大学附属第一医院放射科重庆医科大学附属第一医院放射科杨海涛杨海涛重庆医科大学附属第一医院目目 的的 要要 求求n熟悉呼吸系统疾病的影像学检查方法。熟悉呼吸系统疾病的影像学检查方法。n掌握肺与纵隔的正常掌握肺与纵隔的正常X X线、线、CTCT表现。表现。n掌握肺、胸膜与纵隔基本病变的掌握肺、胸膜与纵隔基本病变的X X线、线、CTCT表现。表现。n掌握支气管扩张症、各型肺炎、肺脓肿、肺结核掌握支气管扩张症、各型肺炎、肺脓肿、肺结核、原发性肺癌的典型、原发性肺癌的典型X

2、X线及线及CTCT表现。表现。n了解纵隔肿瘤及肿瘤样病变的影像诊断原则及常了解纵隔肿瘤及肿瘤样病变的影像诊断原则及常见纵隔肿瘤的影像表现。见纵隔肿瘤的影像表现。重庆医科大学附属第一医院Part I Imaging methods and normal imaging anatomy 重庆医科大学附属第一医院 Section I Common imaging techniquesn 1.chest fluoroscopy(透视透视)Advantages:n real-time fast imagenlive moving pictures n cheap price Disadvantages:

3、n lower resolution and sensitivityncan not storedn not applied in lung but more in digestive tract,interventional radiology重庆医科大学附属第一医院Common imaging techniquesn2.chest radiography(摄片摄片)routine position：nposterior-anterior P,PAnlateral P(left/right P,pathological side close to film)Ad：pcheap pricepg

4、ood natural contrastpLow radiation Disad:p overlapping image重庆医科大学附属第一医院Common imaging techniquesn chest radiography重庆医科大学附属第一医院 3.DSA（Digital subtractive angiography）n Bronchial arteriography(支气管动脉造影支气管动脉造影)n Pulmonary artery angiography(肺动脉造影肺动脉造影)Angiography重庆医科大学附属第一医院nprecontrast CT and contras

5、t enhanced CT(平扫平扫+增强增强)nmediastinum window and lung window(纵隔窗纵隔窗+肺窗肺窗)4.Computer Tomography(CT)重庆医科大学附属第一医院Computer Tomography(CT)HRCT（High resolution computed tomography）l very thinning slice(1-2mm）+high resolution reconstruction image of lungl value：small nodule,diffuse interstitial lung disease

6、s(DILD,弥漫性肺间质病变弥漫性肺间质病变 )and bronchiectasis(支气管扩张支气管扩张)重庆医科大学附属第一医院Computer Tomography(CT)Multiple Slice Computer Tomography(MSCT)post-processing techniques-3D ReconstructionMultiple plane reconstruction（MPR）-coronal Minimal intensity projection(MinP)surface shaded displays(SSD)重庆医科大学附属第一医院Computer

7、Tomography(CT)Computed tomography angiography(CTA)Fusion CT images of bronchial arteriography and bronchography重庆医科大学附属第一医院Computer Tomography(CT)Computed tomographic virtual endoscopy（CTCT虚拟内窥镜检查虚拟内窥镜检查）重庆医科大学附属第一医院Computer Tomography(CT)Dual energy CT and spectral CT(能谱能谱CT)nHas been widely used i

8、n clinicnSpectral curve analysis-identifying benign and malignant lymph nodulesnIodine based imaging-find early abnormal blood perfusion caused by pulmonary embolism重庆医科大学附属第一医院spectral CT lung perfusion diagnose early pulmonary embolism Computer Tomography(CT)重庆医科大学附属第一医院5.Magnetic Resonance Imagin

9、g(MRI)p multiple plane and multiple sequence imagep rarely used in lung because long scan time and breathy artifactp useful to mediastinum mass重庆医科大学附属第一医院5.MRI Artwhat are these？重庆医科大学附属第一医院Section IIThe normal X-ray features重庆医科大学附属第一医院Comparison of normal chest anatomy and X-ray film重庆医科大学附属第一医院（

10、1）Thoracic cage(胸胸 廓廓)1.Soft tissue of chest walllUnable to differentiate soft tissue of chest wall,just totally overlapping image lpectoralis major(胸大肌胸大肌)lsternocleidomastoid muscle(胸锁乳突肌胸锁乳突肌)lsupraclavicular skin fold(锁骨上皮肤皱褶锁骨上皮肤皱褶)重庆医科大学附属第一医院1.Soft tissue of chest walln female breast shadows:

11、the lower lung fields increase the density and curve marginnNipple shadows（乳头影）（乳头影）:look like pulmonary nodules（1）Thoracic cage(胸胸 廓廓)重庆医科大学附属第一医院2.2.Skeleton l scapula；thoracic vertebrae；clavicle；sternum(胸骨胸骨)l ribs and costal cartilagel anterior rib and posterior rib（location marker）l calcificati

12、on of costal cartilage（1）Thoracic cage(胸胸 廓廓)重庆医科大学附属第一医院2.2.Congenital rib anomalies ncervical rib(颈肋颈肋)nbifid rib(叉状肋叉状肋)nfusion of rib(肋骨联合）肋骨联合）（1）Thoracic cage(胸胸 廓廓)重庆医科大学附属第一医院（2）Pleura(胸膜胸膜)npartial pleura（PP）and visceral pleura（VP）nPleural cavity：vacuum,negative pressurenoblique fissure and

13、 horizontal fissure:double layer of visceral pleura between lung lobesnNormally invisible on X-ray film,fissure can be showed linear white shadow重庆医科大学附属第一医院 （2）Pleura(胸膜胸膜)Interlobular fissures重庆医科大学附属第一医院 Interlobular fissures重庆医科大学附属第一医院（3）Lung(肺肺)ntrachea and bronchusnlung fieldsnlung hilarnlung

14、 markingsnlobe,segment,lobules,alveolus重庆医科大学附属第一医院trachea and bronchus(气管、支气管气管、支气管)nTrachea:in the midline up to the thoracic inletnTracheal bifurcation:T5-6 level,acute angle(60-80)nR/L main bronchi（3）Lung(肺肺)重庆医科大学附属第一医院nnormal lungs filling with air appear dark areas on PA X-ray film ndivided i

15、nto zones：inner,middle and the outer zone upper,middle and lower fields lung fields(肺野肺野)（3）Lung(肺肺)重庆医科大学附属第一医院l Consists of pulmonary arteries,veins and major bronchil The left hilar is usually slightly higher than the rightlung hilar (肺门肺门)（3）Lung(肺肺)重庆医科大学附属第一医院nComposition:Lung artery,vein,bron

16、chial walls,lymphatics and some fibrotic tissuenRadiated distribution from hilar to distal lung arealung markings(肺纹理肺纹理)（3）Lung(肺肺)重庆医科大学附属第一医院nRight Lung:three lobes-upper,middle,lower loben left lung:two lobes-upper,lower lobe Right lobe Left lobe Right lateral left lateral Pulmonary lobe (肺叶肺叶)（

17、3）Lung(肺肺)重庆医科大学附属第一医院Lobes of right lung重庆医科大学附属第一医院Lobes of left lung重庆医科大学附属第一医院nRight lung:upper(S1-3),middle(S4-5),lower lobe(S6-10)-10SnLeft lung:upper(S1+2,3,4,5),lower lobe(S6,7+8,9,10)-8Snunable to identify lung segment on X-ray film but CTPulmonary segment (肺段肺段)（3）Lung(肺肺)重庆医科大学附属第一医院nLun

18、g lobe lung segment lobules terminal bronchioles alveoli（3）Lung(肺肺)Normally invisible on image 重庆医科大学附属第一医院nsmallest fundamental unit of lung structuren measures between 1 and 2.5 cm across;polyhedral in shape bounded by interlobular septansupplied by a terminal bronchiole and a pulmonary artery bra

19、nch.Secondary pulmonary lobule（次级肺小叶（次级肺小叶）重庆医科大学附属第一医院nPulmonary parenchyma(肺实质肺实质):portion of the lung involved in gas transferthe alveoli,alveolar ducts and respiratory bronchiole.nPulmonary interstitium(肺间质肺间质):a collection of support tissues within the lung that incluces the alveolar epithelium

20、,pulmonary capillary endothelium,peri-vascular and peri-lymphatic tissues.（3）Lung(肺肺)重庆医科大学附属第一医院（4）Diaphragm(膈肌膈肌)nThe upper surfaces of the diaphragm should be clearly visiblenThe right side higher than left.nthe level of the right hemidiaphragm:the anterior end of the 6th rib or the posterior seg

21、ment of the 10th rib重庆医科大学附属第一医院nmade of the chest wall and the diaphragm nmust be sharpnthe lowest position in the chest cavity（4）Diaphragm(膈肌膈肌)Costophrenic Angles(肋膈角肋膈角)Cardiophrenic Angles(心膈角心膈角)重庆医科大学附属第一医院（5）Mediastinum(纵隔纵隔)nextends from the sternum anteriorly to the vertebral column poster

22、iorlyn The upper limit is formed by the thoracic inlet and the lower border is the diaphragm nDivide 6 zones:nUpper and lower M:the lower border of T4 vertebranAnterior,middle and posterior M:重庆医科大学附属第一医院CT cross-sectional anatomyHow to know lung structures on CT:nR/L hilarnInterlobular fissure:the

23、marker of identifying lung lobenLung segment:according to the positioning of bronchi and vessels for identification 重庆医科大学附属第一医院T：TracheaE：esophagusS1：apical segmentChest inlet plane重庆医科大学附属第一医院Tracheal bifurcation plane重庆医科大学附属第一医院重庆医科大学附属第一医院2023-1-16重庆医科大学附属第一医院重庆医科大学附属第一医院重庆医科大学附属第一医院重庆医科大学附属第一医

24、院2023-1-16重庆医科大学附属第一医院2023-1-16重庆医科大学附属第一医院Part IICommon abnormal imaging signs重庆医科大学附属第一医院nObstruction of the bronchus nConsolidation or exudative lesionnCavity and air containing spacenSingle or multiple nodules and massnReticulatar shadow,leptonema shadow and stripe-like opacitiesnCalcification L

25、ung basic pathologic changes重庆医科大学附属第一医院Obstruction of the bronchusnObstructive emphysemanObstructive atelectasis nObstructive pneumonia 重庆医科大学附属第一医院Obstructive emphysema阻塞性肺气肿阻塞性肺气肿 nDefinition:is referred to the increased expansion of the lungs with air,is characterized by permanent enlargement of

26、 alveoli and is companied by destruction of alveolar walls(肺内含气组肺内含气组织的扩张，伴有永久性肺泡扩大和肺泡的破坏织的扩张，伴有永久性肺泡扩大和肺泡的破坏)nIt may be diffuse or localized and bullous emphysema(分为弥漫分为弥漫性或局灶性性或局灶性)nCauses:chronic lung disease,such as chronic bronchiolitis,asthma and pneumonoconiosis(慢支炎、哮喘和尘肺慢支炎、哮喘和尘肺)重庆医科大学附属第一医

27、院55Obstructive emphysemaX-ray features:nIncreased translucency of the overinflation areas 肺野透光度升高肺野透光度升高nLung markings thinner,fine,straight 肺纹理稀疏、细、直肺纹理稀疏、细、直nbarrel-shaped thorax 桶状胸桶状胸nintercostal space is increasedndiaphragm is flattened膈肌低平膈肌低平nbulla(1cm)肺大泡肺大泡nheart shadow becomes long and nar

28、row心影狭长心影狭长重庆医科大学附属第一医院Pulmonary collapse/obstructive atelectasis (肺不张肺不张)nDefinition：Complete bronchial obstruction,the air is absorbed by the blood within 18-24 hr,lung lobe shows collapse(increased density in involved lung accompanying with the volume loss)Include:Complete collapse of a lung（一侧肺不

29、张）（一侧肺不张）Lobar collapse（肺叶性肺不张）（肺叶性肺不张）segmental atelectasis（肺段性肺不张）（肺段性肺不张）Lobular atelectasis(小叶肺不张小叶肺不张)重庆医科大学附属第一医院Radiological signs of a lung collapse（一侧肺不张）一侧肺不张）Xrays features:Loss of aeration:increased attenuation（肺内空气消失、密度升高）（肺内空气消失、密度升高）Vascular and bronchial signs-crowdedElevation of the

30、 diaphragmDisplacement of adjacent fissure Shift of trachea,hilus,mediastinumObstructive atelectasis 重庆医科大学附属第一医院58Complete collapse of left lung-Narrowing intercostal space 肋肋间隙间隙-Compensatory emphysema in the unaffected lung（健侧肺代偿（健侧肺代偿性气肿）性气肿）and may herniate(疝入疝入)across the midlineshrink/contrac

31、tionObstructive atelectasis 重庆医科大学附属第一医院Right upper lobe collapsenThe right upper lobe appears as a dense triangular shadownThe apex of the triangular shadow at the hilar and its base at the outsidenThe horizontal fissure(水平裂水平裂)shift to the upperObstructive atelectasis 重庆医科大学附属第一医院PALObstructive at

32、electasis Middle lobe collapse重庆医科大学附属第一医院Consolidation 肺肺 实实 变变 nDefinition:gas in the alveoli are replaced by pathological fluid or tissues.Acute inflammation called exudation 渗出）渗出）nCommon diseases:pneumonia,pulmonary tuberculosis,pulmonary edema,pulmonary hemorrhage of the lung 肺炎、肺结核、肺水肿、肺炎、肺结核

33、、肺水肿、肺出血肺出血重庆医科大学附属第一医院nIn the earliest form,small focal areas of exudative lesion may appear as ill-defined nodules 1cm in diameter.nThen high density of consolidations（高密度实变影）（高密度实变影）nfog-like opacity（云雾状）（云雾状）;opacities areas（不透光区）（不透光区）nill-defined border(reaching fissure-clear borderConsolidati

34、on 肺肺 实实 变变 重庆医科大学附属第一医院nAir bronchogram 含气支气管征：含气支气管征：the visualization of air-filled bronchi,can be seen on radiography or CT because surrounding lung hilar is of increased attenuation,but the remain gas in the bronchi is seen.Consolidation 肺肺 实实 变变 重庆医科大学附属第一医院Air bronchogramConsolidation 肺肺 实实 变

35、变 重庆医科大学附属第一医院Lobar consolidation肺肺 叶叶 的实的实 变变X-ray features:nLobar homogenous densitynAir bronchogram(支气管气像支气管气像)nwell-defined edge,No change of lobar shape，no fissures displacementConsolidation 肺肺 实实 变变 重庆医科大学附属第一医院cavity and air containing space空洞与空腔空洞与空腔Definition:nCavity:necrotic lung tissues a

36、re drained out through bronchi,leaving a chamber containing air or fluid air/gas-fluid levelnThe wall consists of necrosis,granulation tissue,fibrous tissue,tumor tissueCommon Diseases:lung abscess，tuberculosis,tumor重庆医科大学附属第一医院x-ray appearance:na radiolucent shadow with a definite thin or thick rin

37、g wallnThe inner part of the cavity may be smooth or irregularnThere may be an air-fluid level in the cavity cavity and air containing space空洞与空腔空洞与空腔重庆医科大学附属第一医院Important features of Cavity Thin wall(3mm thick)TBThick wallTumorabscessMoth eaten cavityTBAccording to the size and thickness of wall:Mo

38、uth-eating cavity虫蚀样空洞虫蚀样空洞 Thin-wall cavity薄壁空洞薄壁空洞 Thick-wall cavity 厚壁空洞厚壁空洞重庆医科大学附属第一医院nThin-wall cavity（薄壁空洞）（薄壁空洞）:thickness of the wall is less than 3mmnno air-fluid level in the cavity洞内无液洞内无液平平nNo consolidation around it 洞周无实变洞周无实变Cavity重庆医科大学附属第一医院nthick-wall cavity 厚壁空洞厚壁空洞:thickness of w

39、all is more than 3mmn ill-regular transparent area不规则不规则透光区透光区n inner wall may be ill-regular or smooth内壁不规则或光滑内壁不规则或光滑nCommon diseases:lung abscess and lung cancer(carcinoma cavity）Cavity重庆医科大学附属第一医院Thin walled cavityThick walled cavityCavity重庆医科大学附属第一医院Abscess cavity-lung abscessnThick wall 厚壁空洞厚壁

40、空洞nSurrounding consolidation 周围实变周围实变nBecome smooth and thinner when consolidation resolves and necrotic material is coughed up.抗抗炎治疗后壁变薄，周围实炎治疗后壁变薄，周围实变吸收好转变吸收好转重庆医科大学附属第一医院Cavity重庆医科大学附属第一医院Cavity重庆医科大学附属第一医院Intrapulmonary air containing space(空腔空腔)nDefinition:pathological distention of intrapulmo

41、nary space(肺内生理性腔隙出现肺内生理性腔隙出现病理性扩大病理性扩大)nAir space enlargementnPossessing an epithelialized wall(保留肺泡上皮壁保留肺泡上皮壁)重庆医科大学附属第一医院X-ray:nless than 3mm in wall thicknessnno air-fluid level nno consolidation around itnconcurrent infection may be seen the air-fluid level and consolidation around it Common di

42、seases:nbullae（wall is very thinner and uniformity）ncontain air lung cysts ncystic bronchiectasisIntrapulmonary air containing space(空腔空腔)重庆医科大学附属第一医院Bronchiectasis 支气管扩张支气管扩张Definition:nLocalized(局灶性局灶性)irreversible bronchial dilationnBronchial wall thickeningCauses:nChronic infectionnAirway obstru

43、ction:tumor,stricture(狭窄狭窄)nInherited abnormalitiesIntrapulmonary air containing space(空腔空腔)重庆医科大学附属第一医院Bronchiectasis Classification nCylindrical（柱状）（柱状）nVaricose（曲张型）（曲张型）nCystic（囊状）（囊状）Cylindrical(tubular)Saccular(cystic)VaricoseIntrapulmonary air containing space(空腔空腔)重庆医科大学附属第一医院Bronchiectasis支

44、气管扩张支气管扩张重庆医科大学附属第一医院 The internal diameter of bronchus is greater than that of accompanying arteryBronchiectasis支气管扩张支气管扩张重庆医科大学附属第一医院NoduleDefinition:A rounded opacity,at least moderately well defined,no more than()3 cm in diameter.Common diseases:lung cancer,tuberculoma,metastatic carcinoma of lu

45、ng,hamartoma,inflammatory pseudotumor(炎性假瘤炎性假瘤)Single or multiple nodules and mass 结节与肿块结节与肿块 重庆医科大学附属第一医院Alveolar nodular sign:proliferation lesion x-ray appearance:u Nodule about less than 10mm in diameter u well-defined borderu without fusionDiseases:tuberculosis,chronic inflammationSingle or mul

46、tiple nodules and mass 结节与肿块结节与肿块 重庆医科大学附属第一医院Miliary nodules 粟粒状结节粟粒状结节 X-ray appearances:nsize：less than 4mmnshowing as spots shadowsndiffuse distribution Common diseases:nMiliary tuberculosisnMiliary fungal真菌）真菌）infectionnHematogenous metastasisnPneumosilicosis（矽肺）（矽肺）Single or multiple nodules a

47、nd mass 结节与肿块结节与肿块 重庆医科大学附属第一医院Hematogenous miliary nodules:TB。Single or multiple nodules shadow and mass 重庆医科大学附属第一医院Mass：Definition：round or round-like shadow more than 3cm in diameterX-ray appearances：n benign mass -round or round-like opacity -clear and regular border -Diffuse or central calcifi

48、cation -Doubling time over 18 months -Complete encapsule Single or multiple nodules and mass 重庆医科大学附属第一医院Solitary pulmonary massSingle or multiple nodules and mass 重庆医科大学附属第一医院Female,43 years old,health exam:a mass in the right upper lobe Sclerosing hemangiomaSingle or multiple nodules and mass 重庆医科

49、大学附属第一医院Malignant massX-ray appearances：-Irregular or spiculated edge 棘状突起棘状突起 or lobular 分叶分叶-Notch sign 脐凹征脐凹征-Doubling time:16 months-Invasion of adjacent structures-Metastasis-Thick-wall cavitySingle or multiple nodules and mass 重庆医科大学附属第一医院Malignant mass重庆医科大学附属第一医院Solitary pulmonary mass重庆医科大学

50、附属第一医院Solitary pulmonary mass重庆医科大学附属第一医院Solitary pulmonary mass重庆医科大学附属第一医院Reticulate,leptonema,stripe-like opacities间质性改变间质性改变 Definition：pathological features of interstitial disease,including exudation,infiltration,fibrous connective tissue desmoplasia(adhesion粘连粘连),diffuse or localization.重庆医科大