Imaging of the respiratory system -EduPublish-www.slidesharenet-mma 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, neck
2. Fluoroscopy
3. Bronchogram
4. CT scan, CT Fluoroscopy & CT Angiography
5. MRI
6. Ultrasound
7. 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


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


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)


RADIONUCLIDE 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


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


RADIOLOGICAL ASSISTED LUNG BIOPSY USING
CT- FLUOROSCOPY –US GUIDED

Indication:
1.Primary mediastinal lesions such as mediastinitis/
mediastinal abscess
2.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)


Imaging of the respiratory system -EduPublish-www.slidesharenet-mma kareem

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