Post on 21-Dec-2014
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IMAGING OF THE RESPIRATORY SYSTEM
Prof Madya Dr. Hj. M. Abdul Kareem ©
© MMA Kareem, USM, KB, Malaysia
© 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
© MMA Kareem, USM, KB, Malaysia
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
© MMA Kareem, USM, KB, Malaysia
© MMA Kareem, USM, KB, Malaysia
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
© MMA Kareem, USM, KB, Malaysia
© MMA Kareem, USM, KB, Malaysia
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
© MMA Kareem, USM, KB, Malaysia
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
© MMA Kareem, USM, KB, Malaysia
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
© MMA Kareem, USM, KB, Malaysia
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
© MMA Kareem, USM, KB, Malaysia
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
© MMA Kareem, USM, KB, Malaysia
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
© MMA Kareem, USM, KB, Malaysia
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
© MMA Kareem, USM, KB, Malaysia
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)
© MMA Kareem, USM, KB, Malaysia
CT SCAN
© MMA Kareem, USM, KB, Malaysia
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
© MMA Kareem, USM, KB, Malaysia
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
© MMA Kareem, USM, KB, Malaysia
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.
© MMA Kareem, USM, KB, Malaysia
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
© MMA Kareem, USM, KB, Malaysia
© MMA Kareem, USM, KB, Malaysia
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
© MMA Kareem, USM, KB, Malaysia
© MMA Kareem, USM, KB, Malaysia
© MMA Kareem, USM, KB, Malaysia
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)