1060818 胸部x光

Chest Roentgenology 高雄市立小港醫院 內科加護室 陳煌麒 2017/8/18

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Anatomy---PA view 1.

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Trachea Right main bronchus Left main bronchus Scapula Clavicle Manubrium sterni Ascending aorta Aortic arch Left pulmonary artery LA appendage LV RA Lower lobe pulmonary artery Costo-phrenic angle (CP angle) Breast shadow

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胸部X光片(1) • PA view X光片之判讀要點 1.使頸部，整個胸部及左右橫膈膜涵蓋進去 2.攝影時片子曝光的電壓(Kev)及時間要適當 -氣管及分歧部 carina (T5-6) 隱約可見 -下段胸椎在心臟後方 retrocardia 隱約可見 -心臟後方之肺紋 lung marking 隱約可見 -右橫膈上 1-2 cm 肺紋 lung marking 隱約可見 3.病人有充分的吸氣及閉氣(前7-8/後9-10肋骨) 2017/8/18

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胸部X光片(2) • PA view X光片之判讀要點 4.攝影時之姿勢要正確(standing view) -二側肩胛骨有充分張開 -胸椎之棘突必在二個鎖骨之中間 -左右二根鎖骨對稱，鎖骨上可見肺尖 -胃內氣泡位於左橫膈膜下(air-fluid level) • 判讀拍攝條件不良的胸部 X 光片時，應採取保 留態度，最好重新拍攝，以免誤判 • 判讀X光片時，必須先核對病人資料是否正確， 以免造成不必要之困擾 2017/8/18

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Anatomy---lateral view 1. Trachea 2. Pretracheal vascular bundle 3. Aortic arch 4. RUL bronchus 5. LUL bronchus 6. Left PA 7. Right PA 8. Axilla 9. Spine 10. Right CP angle 11. Left CP angle 12. Gastric bubble 13. Transverse colon 14.

Inferior vena cava 2017/8/18

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胸部X光片(3) • Lateral view X光片之判讀要點 1.二個較透亮的三角形部位 a.在心臟前上方和主動脈前 面 b.心臟後面脊椎的陰影越下方越黑 2. 氣管後緣與胸椎前緣之距離大約1-1.5指幅寬，若變寬 應注意是否有陰影，常由食道變寬所引起 3.氣管由前上方向後下方延伸，其前下方是右肺動脈， 後上方是左肺動脈，通常在主動脈弓下方 4.心臟陰影通常是均勻之軟組織陰影，若右橫膈稍高或 拍攝方向偏差，可使心臟與右橫膈重疊 5.左右橫膈通常可由胃部氣泡(air bubble)來判定，也可看 前半段不清楚者應是左邊(silhouette sign) 2017/8/18

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胸部X光片 (4) 1. From anterior view to posterior view 2. Supine position 3. In very sick patients, infants, or unable to stand and sit 4. Misdiagnosis: ---pleural effusion ---lung abscess ---pneumothorax (deep sulcus sign) 2017/8/18

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胸部X光片(5) • AP view X光片之判讀要點 1.由於拍攝距離較短，心臟陰影較大，且肩胛股無法分 開又橫膈在較高位使受到遮蓋的肺野較大 2.肺內血量較大，使得肺紋較明顯，肺間質病變或栗粒 性細點不亦發現，且水平面之病灶不亦看出 3.若有氣胸，空氣常聚集在前胸較不易發現肋膜線，只 是呈現局部較黑而已 (deep sulcus sign) 4.常因臥床而使姿勢不正，或是產生皮膚皺折，而且若 是加護病房病人，常有呼吸管路及其他管線，也會使X 光片變的較複雜而影響到判讀結果

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判讀胸部X光片 • 以系統性分析方式判讀胸部X光片 常認定是理想的胸部X光片，可依下列系 統性分析方式，分段觀察。依(1)胸廓軟 組織，(2)骨架、骨骼，(3)橫膈，(4)縱膈 及心臟，(5)肺門，(6)肺紋及肺野，進行 判讀，以求詳盡。 • • • • • •

A airway, adenopathy B bone, breast C cardiac silhouette D diaphragm E everything else F fields

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Tissue Density on CXR • Bone (metal) density • Soft tissue (water) density • Fat density • Air density

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Extrapulmonary content • Tube, line, foreign body…

• Chest wall, mediastinum and pleura – – – – – – – –

Chest wall lesion Pleural and subpleural masses Pleural effusion Pleural thickening and pleural calcification Elevated diaphragm Shift of the mediastinum Widening of the mediastinum Mediastinal mass – anterior, middle, posterior

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Soft tissue

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Bone island

Lordotic view 2017/8/18

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Cervical rib 2017/8/18

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Rib fracture

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Multiple myeloma with bone osteolytic change Left posterior back pain for 3 months

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Rib calcification for sex

Central, penis 2017/8/18

Peripheral, vagina 20

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Hodgkin’s disease

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Bronchogenic cyst

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Ganglioneuroblastoma

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肺門 (hilum)： 肺門附近有許多小淋巴腺，因 太小在X光片上顯現不出來， 在X光片能照出來的肺門陰影 是左右肺主動脈進入肺臟所形 成的陰影。右邊的肺主動脈順 著右主氣管前下方進入肺臟。 而左邊的肺主動脈攀登左主氣 管後上方進入肺臟。所以95% 以上的症例，左肺門比右肺門 高1~3公分。若是兩邊肺門高 低位置有所變化，應警覺是否 26 有病變。

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Pleural Effusion

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Meniscus sign28

Subpulmonary Effusion Right hemidiaphragm elevation

• Lung parenchyma • Subpulmonary effusion • Diaphragm -phrenic nerve paralysis -eventration -herniation • Abdomen lesion 2017/8/18

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Pneumothorax

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Deep sulcus sign

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肺葉與葉間裂

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Silhouette sign

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Radiologic signs of chest disease • Increased lung density – Predominantly air space disease – Predominantly interstitial lung disease • • • • •

Septal pattern Reticular pattern Nodular pattern Reticulonodular pattern Ground glass pattern

– Combined air space and interstitial disease

• Decreased lung density – Alteration in pulmonary volume – Alteration in pulmonary vasculature

• Atelectasis – Mechanism – Radiologic sign (direct and indirect) 2017/8/18

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~ Radiologic diagnosis of disease of the chest

(alveolar shadow)

(Cavity) 2017/8/18

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Air space disease

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Septal pattern • A septal pattern results from thickening of the interlobular septa (secondary pulmonary lobules) • Normally, no septal lines can be identified on CXR. • Kerley B : short (1-2cm), continuous with the pleura • Kerley A : Long (2-6cm) line oriented toward the hila • HRCT appearance for differential diagnosis • Usually in hydrostatic pulmonary edema or lymphangitis carcinomatosis

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Interstitial Pulmonary Edema

Hilar Haze

Kerley’s B Line

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Lymphangitis carcinomatosis

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Reticular pattern • A reticular pattern is characterized by innumerable, interlacing line shadows that suggest a mesh.

• On CXR, the pattern maybe the result of summation of smooth or irregular linear opacities, cystic or both.

• Acute: – hydrostatic pulmonary edema, mycoplasma pneumonia, virus pneumonia • Chronic: – idiopathic pulmonary fibrosis, collagen disease associated pulmonary fibrosis, chronic hypersensitivity pneumonitis, sarcoidosis 2017/8/18

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Interstitial lung disease

塵肺病 (Pneumoconiosis)

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Reticular pattern subgroup: Cystic pattern • Cystic air space • Enlarged foci of air-containing lung surrounded by a wall of variable thickness and composition.

• Idiopathic pulmonary fibrosis or collagen disease with lung involvement • Langerhans’ pulmonary histiocytosis (LCH), lymphangiomyomatosis (LAM), bronchiectasis..

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Cystic bronchiectasis

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Nodular pattern • A nodular pattern is produced when the parenchymal interstitial is expanded in roughly spherical fashion by a cellular infiltrate, fibrous tissue or both.

• In the setting of interstitial lung disease, nodules are defined as round opacity less than 1cm.

• The most common diseases in small nodular pattern: – Acute: miliary tuberculosis, endobronchial TB – Chronic: pneumoconiosis, metastatic carcinoma, sarcoidosis, hypersensitivity pneumonitis.

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Metastatic carcinoma

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Cannon Ball

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Reticulonodular pattern • Presence of nodules superimposed on a reticular pattern • Sarcoidosis, Langerhans’ cell histiocytosis, lymphangitis carcinomatosis, pneumoconiosis

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Silicosis with mediastinal calcified LN Egg shell

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Ground-glass pattern • A ground glass pattern is considered to be present when there is a hazy increase in opacity unassociated with obstruction of underlying vascular markings. • Common causes : PCP, Hypersensitivity pneumonia, idiopathic interstitial lung diseases, pulmonary hemorrhage.

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PCP in AIDS patients

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Limitations of the pattern approach • Modifying factors – The pattern can be modified by associated underlying parenchymal lung disease.

– Lobar pneumonia superimposed on emphysema may stimulate interstitial lung disease

• Nonspecific radiographic findings – In some cases, it is impossible to determine the main pattern.

• Comparison of chest radiography and HRCT 2017/8/18

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Decreased lung density • Alteration in pulmonary volume – General excess of air – Local excess of air – Bulla, bleb and pneumatocele

• Alteration in pulmonary vasculature – Vascular obstruction: pulmonary embolism – Peripheral vascular obliteration: emphysema – Others: congenital cardiac malformation, primary pulmonary hypertension.

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Pulmonary embolism

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Pulmonary Embolism CXR Findings • Normal • Westermark’s sign: oligemia of the lung beyond the occluded vessel • Hampton’s hump: pleural-based, wedge-shape air-space consolidation, caused by pulmonary hemorrhage or infarction.

• Signs of right heart failure: cardiomegaly, engorged PA • Pleural effusion: 50%, small amount, unilateral, transudate or exudate, bloody.

• All the signs of PE have poor sensitivity and specificity.

• The major role of CXR is to exclude other diagnoses.

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Westermark’s Sign

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• It takes several months to resolve • Frequently leaves permanent linear scar • Cavitation is rare • Edema, hemorrhage or infarction Hampton’s hump

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Bulla / Bleb

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Atelectasis / Collapse • • • • • •

Resorption atelectasis: endobronchial lesion Passive atelectasis: pneumothorax or effusion Compressive atelectasis: pulmonary mass or lymphadenopathy Adhesive atelectasis: deficiency of surfactant Cicatrization atelectasis: tuberculosis or pulmonary fibrosis Round atelectasis : folded lung with pleural thickening.

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Radiologic signs of atelectasis • Direct sign : – Displacement of interlobar fissure – Crowding of vessels and bronchi

• Indirect sign : – – – – – – – 2017/8/18

Local increase in opacity Elevation of hemidiaphragm Displacement of mediastinum Compensatory overinflation of remaining lung Displacement of hilum Absent of an air bronchogram (resorption atelectasis) Absent of visibility of the interlobar artery 61

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RUL collapse - Golden S sign (Reverse S sign)

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RML collapse

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LUL collapse

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LLL collapse

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Thanks for Your Attention !

Any Question ?

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