Radiodignosis respiratory system. Radiological symptoms of the respiratory organs diseases

X-ray diagnosis.

Methods of X-ray diagnosis of respiratoty system are divided on: methods of X-ray diagnosis using contrast agents, methods of X-ray diagnosis without contrast agents and radiofunctional methods of X-ray diagnosis.

To the methods of X-ray diagnosis without contrast agents, there are: fluorography, X-radiography, photofluoroscopy, tomography, computer tomography, electro-sciagraphy

Methods of X-ray diagnosis using contrast agents, there are: bronchography, angiopulmonography, artificial pneumothorax, pleurography, pneumomediastinography, fistulography and others.

Functional methods of X-ray diagnosis, there are methods which use X-ray diagnosis in the different respiratory phase.

The fluorography (see fig 10.13) is applied for prophylactic examination of the population.

The roentgenoscopy is used for examination of respiratory organs in more cases(see fig 10.11).

Fig.14.1 Sciagrams of normal thorax are in anterior view and lateral projection

The linear tomography (see fig 10.14, 10.20 b) is used for examination of structure of the pathological formations into a trachea, a large bronches, a root of lung and mediastinum.

Computer tomography (see fig 10.20 c) is used for examination of structure of the pathological process and for estimation the condition of adjacent organs. It is possible to distinguish shades of the pulmonary vessels, the bronches and lymphatic nodes in thoracic cavity. The pulmonary tissue has -650 – -850 НU, mediastinal adipose tissue - 70 – - 120 НU.

Spiral CT-angiography – it’s method of the lungs vessels defeats diagnosis. It gives diagnostic information about cause of narrowing|nature|, morphology of atherosclerotic plaque and vascular wall, about pathological arteries’ deformation. The method allows to find the location of vessels thrombus.

The magnetical resonance imaging is used after computer tomography mainly for evaluation of condition of the mediastinum, because pulmonary tissue gives a weak signal.

The bronchography (see fig 15.2) was used for estimation the trachea and bronchi morphological changes, congenital abnormality, bronchoectasis, bronchial fistules and tumours with the contrast agents which were entered through a catheter.

Fig.15.2 a) normal bronchogram of the right lung, anterior view: b) lateral bronchogram of a patient with bronchoectatic disease.

The angiopulmonography (see fig 15.3) – lungs’ vessels contrast examination after catheterisation of the femoral vein (general angiopulmonography). For selective angiopulmonography catheter is entered trought subclavian vein to the necessary pulmonary, lobar or segmentar artery under X-ray control. Indication for angiopulmonography is a suspicion on thrombembolia of pulmonary artery and congenital abnormality of lungs vessels, such as arteriovenous fistulas and aneurysm.

Sometimes contrast agency is injected into the bronchial arteries for differential diagnosis between the lungs tumours|swelling| and the chronic inflammations of lung.

Fig.15.3 Angiopulmonograma

The ultrasound (see fig 15.4) is used for evaluation of condition of the: heart, mediastinum, pleura, diaphragm, superficial parts of lungs. Ultrasonography allowes to find of liquid into a pleural cavity and estimate integrity of ribs. Ultrasound does not penetrate into a deep pulmonary parenchym.

Fig.15.4 The malignant tumour in lungs: 1 liver: 2 diaphragma; 3 tumour; 6 diafragmal pleura

The needle biopsy (see fig 15.5)– it is excision of the lungs tissues under roentgencontrol with bronchoscope through nasal ways (aspirational bronchoscopy), transbronchial biopsy (puncture biopsy through a bronchial wall) or a puncture biopsy through a thoracic wall.

Fig.15.5 A transbronchial biopsy of the left lung upper lobar bronchus

The thoracic organs roentgenanatomy

On survey X-ray film (see fig 15.6) in the anterior view the 7 pair of ribs are visualized. Lower ribs are partly hidden by the diaphragmal shadow and organs of abdominal region. Cartilaginous parts of the ribs is invisible on a X-radiographies (sciagrams, X-ray). After 30 years calcination arises in costal cartilage of the 1^th ribs.

A shoulder-blade and clavicle is well noticeable at fluoroscopy and on the sciagram. At the patient correct position in the anterior view, the clavicle sternumends are disposed symmetric on identical distance from a vertebral column.The sternum in the anterior view is invisible. In a lateral projection the shade of sternum forms a contour of chest.

Fig.15.6 Sciagram of the thoracal|mew| organs (marked elements of anatomic formations|formations|):1-trachea; 2- cupulaes of diaphragm; 3-right and left main|head,leading| bronches; 4-arc of the right auricle; 5-descendence| part|portion| of aorta; 6-aortal arc; 7-projection of subclavial arteries; 8-left heart border|line,boundary| (from above to downof the| arc: ascending part|portion| of aorta, the cone of pulmonary artery, auricle of the left auricle and left ventricle); 9-azygos vein; 10-horizontal interlobar| fissura; 11-intermediate pulmonary artery; 12-left main|head,leading| pulmonary artery; 13-lungs roots; 14-segmentar arteries(sub-root| area|zone|); 15-vessels of a 2^nd intervertebral| interval|space| (in the norm|standard| 3 mm| in a diameter); 18-back bends of pleura;19-clavicules;

Diaphragm limits the thorax from the organs of abdominal region. Diaphragm together with the organs of abdominal region has intensive shade. Diaphragm consists from left and right cupulaes (domes). Under left cupula of diaphragm is radiolucent zone of air-filled gastric funduss. The right cupula of diaphragm takes a place at the level of anterior ends of 5-6th ribs, and left - on one rib below.

The costodiaphragmatic recess are noticeable in the lateral corners of cupulas of diaphragm, and in medial corners are costomediastinal recesses. In lateral projection anterior costodiaphragmatic recesses are placed higher then posterior costodiaphragmatic recess.

In the anterior view are defined such pulmonary fields: 1) apex of lung – there are areas of lungs above clavicles; 2) superior lung fields - there are areas of lungs between clavicles and anterior parts of the 2-nd ribs; 3) middle lung fields - there are areas of lungs between anterior parts of 2-nd and 4-th ribs; 4) inferior lung fields - there are areas of lungs between anterior parts of 4 rib and diaphragm.

In a lateral projection well is evidently the shade of sternum, blade-bone, from 6^th to 9^th thorasic vertebraes and shades of ribs. Narrower and more expressly are shades from the ribs near the X-ray film. Radiolucent area between a sternum and a heart is called retrosternal space, radiolucent area between the heart and vertebral column is called retrocardial space.

Shadow of lungs root are formed from pulmonary arteries, veins, bronches, lymphatic vessels and nodes. In the anterior view this shade is not homogeneous structure, located at the level of anterior ends from 2 to 4-th ribs, in a width about 2 cm, occupies the not more than quarter of transversal size of lung. A root of left lung places higher than right, and his lower part closes by cardiac shade. In a lateral projection roots of lungs are under the aortal arch.

Most thoracic lymphatic nodes (see fig 15.7) are in the lungs roots and mediastinum. In the case of inflammatory and tumour processes they are increased and shade of root becomes homogeneous and unstructured.

Fig.15.7 Intrathorasic lymphatic nodes

1– paratracheal; 2 – tracheobronchial; 3 – bifurcational; 4 – bronchopulmonary

Linear shades of pulmonary vessels which comes away from the roots of lungs to lungs parenchima are called lung pattern, interlacing, are formed ansiform structure. The caliber of these shades gradually diminishes in anterior alion from roots and on 2 sm does not reach to the thorasic wall.

Parietal pleura can be traced in the anterior view as the thin arched strip which stretches from the apex of lateral surface lungs. Interlobar pleura and clear border between pulmonary lobes in the anterior view is not traced. The anterior view of oblique fissura goes from the 3^rd thorasic vertebra obliquely downward to the lateral surface of 4th rib (at the posterior surface of a body) and farther obliquely downward to the diaphragm. A horizontal interlobar fissura (is in right lung) goes horizontally from the lateral surface of the 4^th rib to lungs root. In a lateral projection the pleura of oblique interlobar fissura forms thin ("hairy") shade, that going from the level of 4th thorasic vertebra obliquely downward and anterior to the diaphragm. A horizontal fissura in a lateral projection begins from oblique at the level of root lungs and goes ahead to the thorasic wall horizontally (see fig 15.8).

Fig.15.8 projection of lobes and interlobar fissuras is on a sciagram (chart)

a) right lateral projection; b) anterior view; c) left lateral projection.

1-superior lobes; 2-middle lobe; 3-inferior lobes; 4-horizontal fissura; 5-oblique fissura

Left lung consists from two lobes, right lung consists from three lobes. Lobes consist from segments, which have a wrong pyramids form. The apexes of segments are dicected to the root, the bases of segments - to the surface lungs (see fig 15.9 and Table 15.1).

Roentgenological border between segments of lung are not present; however for the defining localization of pathological process it is necessary to know the topographical structure of bronchial tree, lobes and segments. A right lung consists of 3 lobes 10 segments, left - from 2 lobes and 10 segments.

a b c

Fig.15.9 The schematic image of the lungs segments. Anterior view (a), right lateral (b), left lateral (c) projections

1 - apex, 2 - back, 3 - anterior , 4 - lateral (in left lungs - superior uvular), 5 - medial (in left lungs - lower uvular), 6 – superior lower lobe; 7 - cardial (in left lungs absents often), 8 – anterior bazal, 9 – lateral basal, 10 - back basal.

Table 15.1 Lungs segments

RIGHT LUNG	LEFT LUNG
Superior lobe:	Superior lobe:
Apex segment (D1)	Apex segment (S1)
Back segment (D2)	Back segment (S2)
Anterior segment (D3)	Anterior segment (S3)
Middle lobe:	Middle lobe:
Lateral segment (D4)	Superior uvular segment (S4)
Medial segment (D5)	Lower uvular segment (S5)
Lower lobe:	Lower lobe:
Apex basal segment (D6)	Apex basal segment (S6)
Medial (cardiac) basal (D7)
Anterior basal segment (D8)	Anterior basal segment (S8)
Lateral basal segment (D9)	Lateral basal segment (S9)
Back basal segment (D10)	Back basal segment (S10)

Roentgen-anatomy| features of the respiratory organs in children |kids|.

Thorax in newborn is short and wide. Intervertebral intervals|spaces| are wide. | The sternum consists of separate ossificated nucleus.

A diaphragm at children|kids| under one year age is located on either side at the level of anterior parts of the 5^th-6^th ribs.

In newborn trachea is short (4-5 sm|). At children|kids| under age 3-4 years on the mediastinum background |a trachea and main|head,leading| bronches are differentiated as lengthened brithness|.

Lungs The obiqua interlobal fissures in newborn are located highly, therefore inferior pulmonary lobes|bottom|lobes are greater than superior|upper,top|. Interlobar fissures do not extend to|by| the roots, in this connection an inflammatory|hot-tempered,ardent| process in sub-root areas|zones| can pass|turns| from one lobe|part,stake,portion,share| to other. In the bronches mucus shell lot of circulatory and lymphatic vessels are located, that is why|that is why| at inflammatory|hot-tempered,ardent| processes, communicating|passable| of bronches is often violated|excited| (hyperinflation, atelectasis |).

Lungs vessels. The pulmonary trunk|barrel| diameter at children|kids| is greater, than aortal one (to 10 years). The segmentar and sub-segmentar arteries at children|kids| under age 3 years relatively|in relation to| short, that is why|that is why| on the sciagram their transversal cuts are form the outlined focal| shades|shadows| of round and oval form|shape|.

The lungs roots at the children|kids| of early age are located at the same level, their structure is homogeneous.

The computer tomography anatomy of the thoracic cavity organs. It is accepted to execute|implements| computer tomography| at certain|definite| anatomic levels. In accordance with|according to| these levels is developed a computer roentgen-anatomy| | (fig.15.10, A|but|, B, C, D, E, F, and G).

I. An apex|top| level or level of the|upper,top| superior thoracal aperture (0 mm|) passes through incisura|cutting| and sterno-clavicular joints|halving,compounds,junctions,joints,coupling|, 7^th cervical or 1^st thoracic vertebra and 1^st or 2^nd ribs. Pulmonary parenchyma| conforms S₁|tops|. A trachea is visualizing in the| center, in front of the trachea is thyroid | gland |, |but|between the trachea and vertebra column – esophagus, |bacthe anterolateral from trachea the brachiocephalic veins and brachiocephalic arteries are located. The para-tracheal lumphatic nodes are visualized| round|about| the trachea (their diameter in a norm|standard| no more than 5 mm|). The vascular pattern at this level has the appearance of shallow|small| roundish or short line-like shades|shadows|.

II. The level of sternoclavicular joint (20 mm|) - along the clavicle inferior|bottom| surface, through|from,because of| the handle of sternum|, areas of superior|upper,top| ribs and 2^nd thoracic vertebra. Pulmonary parenchyma | is the lungs superior lobe apex|tops| segments|upper,top|. A vascular pattern has the appearance of roundish shades|shadows|. The brachiocephalic| veins are located at front trachea with diameter about 2 sm|. The common|common| carotid aryery is located between the left brachiocephalic| vein and anterior-left trachea | wall, behind from it - |left subclavian artery. Between a right brachiocephalic| vein and anterior trachea wall located right arterial brachiocephalic| trunkus|barrel| wider than the alongside located arteries. Between a trachea and the 2^nd thoracic vertebral body situated esophagus, sometimes there is air in it|what|. On either sides of the trachea there are peratracheal limphatic nodes with the diameter of 5 mm.

III. The level of aortal arc (60mm) – from breast bone|, separate ribs areas, 4^th thoracic vertebrae and the shoulder-blade superior|upper,top| third part. Pulmonary parenchyma| in anterior departments shows itself anterior segments, in middle are back segments of both superior|upper,top| lobes|parts,stakes,portions,shares|; in dorsal| departments are lungs inferior lobe apexes|tops| segments. The lungs vascular pattern nearer to|by| the roots has the appearance of the rounded and linear shades|shadows| which appear due to transversal and slanting to the cut of segmentar and subsegmentar vessels. Arteries and veins on lungs periphery| on this cut look like identical. Behind from the located ascending aorta that adjoins to|by| the anterior wall of trachea, and|but| on the right|it|--- is superior|upper,top| vena cava. Between it|it| and in anterior-right| trachea wall in cellulose there are limphatic nodes. The arc of aorta issituated from anterior |ahead|to back|backwards|, esophagus adjoins to|by| it|it|. The descending aorta is situated near the 4^th thoracic vertebra anterior-left| contour.

IV. Level of the trachea bifurcation (70mm). T|he superior|upper,top|lobe lobe anterior segment is adjoins to anterior thoracic wall by the wide basis|foundation|. In right lung it medialy adjoins to|by| the ascending aorta right auricle and superior|upper,top| vena cava, and|but| in left lungs — to|by| the pulmonary trunk|barrel| In the central areas of this cut there are the segments of middle lobe|part,stake,portion,share| of right lungs and uvular segments of superior|upper,top|lobe lobe of left lung; the apexes|tops| of these segments are directed to|by| the proper roots, their wide basis|foundation| adjoins to|by| the anterior-lateral thoracic wall surface. The back departments of this cut occupy|borrows| the superior|upper,top| segments of the lungs lower|bottom| lobes|parts,stakes,portions,shares|. The apexes|tops| of these segments are directed to|by| the roots. The transversal cuts of right and left main|head,leading| bronches visualised| between an ascending aorta and body of the 5^ththoracic vertebra. There is ascending aorta at the front of trachea bifurcation; the esophagus- behind and to the left of it|to the left fro.The superior|upper,top| vena cava is traced on the right side of the ascending aorta, on the left|on the left|-left pulmonary artery. The descending aorta is visualized between the left main|head,leading| bronchus back wall and body of the 5^th thoracic vertebra. At this level right lungs root superior-lobe| part|portion| (superior-lobe| | right pulmonary artery) is traced on the right|to the right|, and|but| to the left|on the left|- segmentar bronches of the apex|top|, back, anterior and uvular segments.

Fig.15.10 The computer tomography anatomy of the thoracic cavity organs is executed|done,implemented| in the mode|regime| of lungs (A|but|, B, C, D, E, F, G ). The lungs segments are marked by the proper numbers.

V. The level of pulmonary artery (100mm) - from the sternumbody, 7^th, 6^th, 5^th, ribs and 7^th thoracic vertebra. In the lungs - on the right|to the right| is front segment of the right lungs superior|upper,top| lobe|part,stake,portion,share|; dorsally -| middle lobe|part,stake,portion,share| and basis|foundation| of apex|top| segment of the inferior lobe|part,stake,portion,share|; to the left|on the left| - front segment of the superior|upper,top| lobe superior-lingualis| segment|part,stake,portion,share|, to the left|on the left| dorsally|- basis|foundation| of the inferior lobe apex|top| segment|b|part,stake,portion,share|.

At this level large|great,big| vessels are expressly traced: at the front-|ahead|ascending aorta, to the left -a pulmonary trunk|barrel| with its|its| branches.

Between a right pulmonary artery and bulb|onion| of aorta there is superior|upper,top| vena cava. Dorsally| from right and left pulmonary arteries there are main|head,leading| bronches. Length of right bronchus - 2,2 sm; width - 1,53 sm, left accordingly - 5 sm and - 1,3sm. Arterial vessels in lungs accompany bronches and have a general|common| topography.

VI. The heart basis level |foundation| (140 mm) – from its|its| basis|foundation|, 8^th, 9^th thoracic vertebrae, inferior |bottom| ribs. The front areas of the lungs: on the right|to the right| - the medial and lateral right lung segments of the middle lobe|part,stake,portion,share|, to the left|on the left| - the uvular left lung superior|upper,top| lobe segments |part,stake,portion,share|. The middle areas of both lungs are situated in the inferior lobes anterior basis segments|parts,stakes,portions,shares|. In the back departmentsof the lungs inferior |bottom| lobes lateral and posterior segments are situated|parts,stakes,portions,shares|.

The lung vessels on this level in most cases are oriented horizontally and are traced on the tomography cut from the lungs roots, gradually narrowing to|by| the periphery. The pulmonary veins on either side of the lungs are situated near|by| the left auricle.

VII .The diaphragmal level (160 mm) – from 9^th-10^th thoracic vertebrae, 7^th, 9^th, 10^th ribs, xiphoid process| or inferior |bottom| segment of the sternumbody and the heart inferior |bottom| departments.

Depending on a patient constitutional feature at this level in the center of the right lungs basis| department tthe right diaphragmal cupula of different|diverse| area is situated|. The parenchyma | of the both lungs is segments, what at previous|preliminary| level.

Between the sternum and the 9^th - 10^th thoracic vertebrae bodies the heart is situated.

The esophagus is situated at front of|in advance of| the 9^th - 10^th thoracic vertebrae bodies, more left from its - descending aorta; between the 9^th-10^th | thoracic vertebrae bodies and esophagus is azugos vein, and|but| between the 9^th-10^th thoracic vertebrae bodies and aorta is hemyazigos vein.

Scheme of lungs sciagram studing:

Anterior al sciagram: 1. Common view of sciagram (an estimation of quality, simmetry patient’s positioning, common orientation - is a size and form of thorax, topography of thorasic cavity organs. 2. Study of the walls of thorax (volume and structure of soft tissues, condition of bone skeleton - bladebones, ribs, clavicles and vertebrae column, position and form of cupules of diaphragm,condition of costodiaphragmatic recess. 3. Comparative estimation of lung field – it is estimating right lungs fields with the same left lungs fields (radiolucency, form and square of fields), detailed study of lung pattern and roots of lungs. 4. Studing of mediastinum - it is a position and form of heart, pulmonary arteria and aorta, trachea and other.

Lateral sciagram: on the lateral sciagrams the studies are conduct in the same order (it is necessary to draw lungs schematically, lobes, and segments, to show sines, root and other).

In order to learn how to find the signs of lungs diseases, it is necessary to know well a norm, have a concept about a lung pattern.