呼吸系統(tǒng)放射學(xué)診斷劉輝 1

RadiologyDiagnosisofRespiratorySystem

劉輝

DepartmentofRadiology,thesecondXiangyahospitalTheX-rayexaminationisappliedverycommonly

naturecontrastisthebestinbodyWhy?Containsofthechapter：TheX-rayexaminationmethodsNormalchestviewThebasicX-rayfeaturesX-raydemonstrationsincommondiseases胸部透視（Chestfluoroscopy）胸部攝影（chestfilm）CT（computedtomography）MRI（magneticresonanceimaging）DSA(digitalsubstrationangiography)TheX-rayexaminationmethodsX-rayexaminationmethods—Chestfluoroscopy

real-timeimagingtofreepositionobservationofmediastinummovementinferiorresolution

X-rayexaminationmethods——Chestfilm常用體位：commonviews

后前位postero—anteriorposition

側(cè)位lateralposition特殊體位;specialviews

前弓位apicalposition后前位postero—anteriorview側(cè)位：lateralviewKeypoints：患側(cè)靠膠片;用于全面觀察病變形態(tài)與病變定位Notice:betakenwhenthePAviewhasbeinspected

體層攝影Tomography高千伏攝影High-KilovoltageRadiography造影檢查contrastexaminationX-rayexaminationmethods

——specialexaminations造影檢查

contrastexaminationBronchographyAngiography

支氣管造影BronchographyTodefiniteadiagnosisofbronchiectasis(highresolutionCT)PulmonaryAngiographydemonstrationofpulmonaryembolidemonstrationofpulmonaryarteriovenousmalformationsCTscanmethodsUnenhancedCTscanEnhancedCTscanHRCT(highresolution)HelicesCTorspiralCTscanCT（computedtomography）密度分辨率高h(yuǎn)ighDensityresolution，量化measured，以CT值體現(xiàn)HounsfieldUnit（Hu）

空間分辨率Spatialresolution:無前后結(jié)構(gòu)重疊avoidingoverlappingstructures,可三維重建providedthree-dimensionevaluationCT（computedtomography）CTcanfindsmalllesionsjust0.3-0.5cmindiametershowthelesionsdetailoptimal病變的細(xì)節(jié)CT（computedtomography）縱隔腫瘤的定位和定性determiningtumorlocationandthenatureWithenhancedscan,CTcandisplaytherelationshipoftumorandgreatvesselsDistinguishvessels,lymphnodesandmass

MRI（magneticresonance）

主要對縱隔腫瘤的定位和定性(tumorlocationandthenature)較好對與心臟大血管的關(guān)系顯示好(therelationshipofthetumorandgreatvessels)二、正常胸部X線表現(xiàn)NormalChestView1.NormalChestView——chestcast

軟組織softtissue

胸鎖乳突?。╯terno-mastoidmuscle）鎖骨上皮膚皺褶（skinreflectionovertheclavicle）胸大?。╬ectoralmusclemajor）女性乳房及乳頭（femalebreastandnipple）

骨胳bonyskeleton

肋骨（ribs）肩胛骨（scapula）鎖骨（clavicle）胸骨(sternum)胸椎（thoracicspine）

NormalChestView——chestcast

softtissue

sterno-mastoidmuscleskinreflectionovertheclavicle

胸壁軟組織正常乳房和乳頭影NormalChestViewNormalChestView——chestcast

softtissue:pectoralmusclemajorfemalebreastandnipple2.NormalChestView——chestcast

bonyskeleton

肋骨ribs肩胛骨scapula胸骨sternum鎖骨clavicle胸椎thoracicspine

氣管、支氣管TracheaandBronchus氣管trachea起自環(huán)狀軟骨長11-13cm寬1.5-2cm胸5-6平面分叉分叉下壁形成氣管隆突分叉角60-85度支氣管bronchus分級grade：mainbronchus—lobebronchus—segmentbronchus—sub-segmentbro—……alveolus(主-葉-段-亞段-

多級分支-肺泡)支氣管分支名稱

右側(cè)———————————————————————上葉1尖支2后支3前支中間支氣管中葉4外支5內(nèi)支下葉6背支7內(nèi)基底支8前基底支9外基底支10后基底支

左側(cè)上葉

上部支氣管1＋2尖后支3前支

下部支氣管4上舌支

（舌部）5下舌支下葉6背支7＋8內(nèi)前基底支9外基底支10后基底支兩側(cè)支氣管分支及差異肺lung

肺野（lungfield）：Theareaintowhichthepulmonaryorganisprojectedontheradiography兩肺野透明度相同，吸氣時透明度增高

肺lung

肺野（lungfield）：dividedintozoneswhichdonotcorrespondtoactuallobes

三帶：內(nèi)、中、外帶

三野：上、中、下野肺門（hilum）肺門組成：主要為pulmonaryarteriesandveins肺門陰影（hilarshadow）：

肺動、靜脈、支氣管和淋巴組織等的復(fù)合投影X-rayfeatures：radiopaqueshadowoneachsideofmediastinumHilum：右肺門

呈“〉”形上部：由上肺動脈、靜脈、下肺動

脈干后回歸支組成下部：由右下肺動脈干（≦15mm）

組成，內(nèi)側(cè)

為中間段支

氣管肺門角：成鈍角，突出為異常左肺門

由左肺動脈弓與左下肺動脈及

分支構(gòu)成

左肺門較右肺門高1-2cmX-raymanifest肺門hilum：X線表現(xiàn)X-raymanifest肺門異常

hilumshadowabnormity肺門增大hilumshadowenlarged肺門縮小hilumshadowshrinked肺門移位hilumshadowshifted肺門密度增高h(yuǎn)ilumshadowdensitystronger肺門增大hilumshadowenlarged肺門縮小hilumshadowshrinked

肺門移位hilumshadowshifted肺紋理lungmarkingsX-raymanifest：Radiateoutwardfromthehilumandcontinuetospread下肺野紋理較上肺野粗肺紋理lungmarkings組成component:thesearemadeupalmostentirelyofvascularshadow,especiallypulmonaryarteriesX線特點(diǎn)Fromthicktothinbranchingastree樹枝狀分布；Lacklungmarkingsinperiphery外帶細(xì)少肺葉lobes肺葉（lobes）：threelobesintherightlungtwointheleftseparatedbyinterlobularsepta

葉間裂走向及X線表現(xiàn)interlobularseptacourseandX-raymanifests葉間裂是識別肺葉的標(biāo)志肺葉分布示意圖Theinterlobularseptaarenotvisibleorfinelinear葉間裂處表現(xiàn)為無或少血管結(jié)構(gòu)的透明帶肺段（segment）LobesareconsistedofsegmentsfromtwotofiveThenameofthesegmentiscorrespondedtobronchus肺段間有肺段靜脈和結(jié)締組織隔開

肺段(segment)正常時X線不能顯示肺段界限

becauseofoverlappingofsegments單獨(dú)某肺段病變時可見肺段輪廓Segmentoutlinemaybeshowedastapershapeandtopforwardhilum肺小葉（lobule）Eachsegmentisconsistedofmanylobules小葉支氣管bronchus及小葉動脈lobule

artery進(jìn)入小葉小葉之間為小葉間隔

lobulsseptaThediameterofalobuleis1-2.5cm腺泡acinusThebasicandfunctionalunitThediameterisabout6mm每支末梢細(xì)支氣管small

terminalbronchiols所支配的范圍為腺泡肺實質(zhì)與肺間質(zhì)

parenchymaandInterstitium肺實質(zhì):具氣體交換功能的肺泡、肺泡壁

肺間質(zhì)：由結(jié)締組織組成的支架與間隙frameandinterstitialstructure

縱隔mediastinumMediastinum－－Extensionandconstitutes

范圍

:Belowsternum,infrontofthethoracicspine,betweentwosideoflungs.

組成

心臟、大血管、氣管、支氣管、淋巴組織、胸腺、神經(jīng)、脂肪等

Constitutes:theheart,trachea,greatvessels,lymphnodesandfatetc.

范圍與組成

Extensionandconstitutes縱隔mediastinum體位、呼吸影響：Thenormalwidthofmediastinumisaffectedbybodyposture,ageandbreathing

縱隔分區(qū)

mediastinumsubarea

Mediastinumcanbedividedintodifferent分區(qū)的意義：在于判斷縱隔腫瘤的組織來源和性質(zhì)九分法六分法縱隔基本病變

mediastinumpathologicalpatterns

縱隔增寬:mediastinumwidening

縱隔移位:

mediastinumshift:bothsides

縱隔擺動:

mediastinumwiggling

縱隔氣腫:

mediastinumemphysema縱隔增寬mediastinumwidening

縱隔移位：mediastinumshift:向患側(cè)移位

Tolesionside縱隔移位：mediastinumshift:向健側(cè)移位Tonormalsidemediastinumwiggling

膈

diaphragmLocation:betweenthethoraxandtheabdominalcavityTherighthemi-diaphragmis1-2cmhigherthantheleft

膈diaphragm

Shape:smoothdome,sometimesaswave-likeshape.肋膈角

costophrenicangle

心膈角

cardiophrenicangle

活動度：1-3cm

movementlimit膈diaphragm

膈正常變異Thediaphragmvariation

膈基本病變

diaphragmbasicpathologicpatterns

膈位置升高（肺不張、肺纖維化、腹水）

diaphragmpromoted

upward

膈位置降低（肺氣腫、氣胸等）Diaphragmdepresseddownward

膈膨升（見于膈發(fā)育不全或膈神經(jīng)麻痹）Diaphragmbulged

膈破裂穿孔（自發(fā)性、外傷性）Diaphragmrupturedandperforated

膈矛盾運(yùn)動（見于膈膨升

膈神經(jīng)麻痹）diaphragmconflictingmotion

肺氣腫膈位置降低

Obstructiveemphysemaforceddiaphragmdownward

肺不張膈位置升高

atelectasispromoteddiaphragmupward

胸膜pleura

壁層

臟層viscerapleura

胸膜腔

pleuracavity

X線表現(xiàn)thepleuraisnotvisualizedwiththeexceptofthenormalhorizontalinterlobarfissure三、基本病變X線表現(xiàn)

Basicpathologic-roentgenpatternsCorrelatedwiththeirunderlyingpathology支氣管阻塞bronchialobstructionCauses:Massorforeignbodyinbronchialcavitycongenitalnarrowmucusblockage粘液嵌塞

externalpressure外壓性壓迫

TBetc

支氣管阻塞-X線表現(xiàn)

bronchialobstruction

直接征象：支氣管狹窄或完全阻斷，腔內(nèi)腫塊，管壁增厚。CTisveryclear

支氣管阻塞-X線表現(xiàn)

bronchialobstruction

Indirectnesssigns:Incompleteobstruction—obstructiveemphysema.Completeobstruction—obstructiveatelectasis

支氣管阻塞

bronchialobstruction

支氣管阻塞

bronchialobstruction

機(jī)理:支氣管部分obstruction—actionaspiston活塞作用，空氣能吸入而不能完全呼出—該支氣管所分布的肺泡過度充氣膨脹overinflation—肺氣腫obstructiveemphysema.

阻塞性肺氣腫(obstructiveemphysema）

阻塞性肺氣腫--分類

（obstructiveemphysema）按氣腫部位分為：泡性或小葉性肺氣腫lobularemphysema間質(zhì)性肺氣interstitialemphysema

按氣腫范圍分為

彌漫性肺氣腫與局限性肺氣腫

diffuseandlocalization

主要由肺內(nèi)氣體增多

,肺體積膨大形成

Thelungcontaintoomuchair,Itreflectstheoverinflation阻塞性肺氣腫obstructiveemphysema

Diffusepattern:1.Radiolucencyincreased2.Thechestcastistubbiness-like3.Thevascularmarkingsdecreased4.Increasedretrosternalspace5.Theheartshadowvertical6.Depressionofthediaphragm局限型：

局部肺透亮度增加

Localizationpattern:TheradiolucencyofaregionlungisincreasedThevascularmarkingsandvascularitydecreasedAtelectasis(incompleteexpansionofthelung):Increaseddensitysizeoflungshrunken肺體積縮小

Shiftremainderofthelungmaybecomeoverexpanded

阻塞性肺不張Obstructiveatelectasis肺葉不張Lobaratelectasis

肺葉縮小lobeshrinkage

葉間裂向心性移位displacementofinterlobularsepta

縱隔與肺門向患肺移位

患葉密度均勻增高Homogenousincreaseddensityofthediseasedlobe.

鄰近肺葉代償性氣腫Compensatoryhyperinflationinanadjacentlobe

右肺上葉不張

rightupperlobesatelectasis右肺上葉不張

rightupperlobesatelectasis右肺上葉不張

rightupperlobesatelectasis右肺中葉不張

rightmiddlelobeatelectasis右肺中葉不張

rightmiddlelobeatelectasis左肺上葉不張

leftupperlobeatelectasis下葉不張

rightlowerlobeateletasisrightlowerlobeateletasis

肺段不張

segmentateletasis

小葉性不張lobuleateletasis瘢痕性肺不張

肺部病變

滲出與實變exudationandconsolidation

增殖proliferation

纖維化fibrosis

鈣化calcification

腫塊mass

空洞與空腔cavityandaircontainingspace

肺間質(zhì)病變intersititialchangings

滲出與實變exudationandconsolidation滲出:肺泡內(nèi)氣體被由血管滲出的液體、蛋白及細(xì)胞所代替，形成滲出性實變。

usuallyseeninTB,pneumonia,lunghemorrhagandlungedema.

滲出與實變exudationandconsolidationX-rayexhibition

云絮狀致密影

Increasedpatchy,cloudydensity,邊緣模糊,中心密度較高較均勻小片狀、大片狀或呈肺葉肺段分布NOTanylossofvolumeorshrinkage

滲出與實變exudationandconsolidation支氣管氣像（airbronchogram）

Contrastisproducedbetweentheairwithinthebronchialtree實變影像中可見含氣的支氣管分支影.經(jīng)治療后多可在1-2周內(nèi)吸收

增殖性病變Proliferativelesion

肺慢性炎癥在肺內(nèi)形成肉芽組織granulomatoustissues，為增殖性病變usuallyseeninTB,chronicpneumoniaandgranulomatouspneumonia增殖Proliferativelesion

X線表現(xiàn)：呈結(jié)節(jié)狀致密影---腺泡結(jié)節(jié)樣nodular病變，呈梅花瓣狀密度較高、邊界較清楚sharplybound,沒有融合趨勢

增殖Proliferation纖維化fibrosis

Fibrosis:Itisfibrotictissuesconformedalesion,Thepathologicfeatureisfibrosiswithscarformation.纖維化彌漫性間質(zhì)纖維化

Diffuseinterstitialfibrosis常廣泛累及肺間質(zhì)，對肺功能影響較大多見于彌漫性間質(zhì)性肺炎diffuseinterstitialpneumonia、TB,塵肺、特發(fā)性肺間質(zhì)纖維化.彌漫性纖維化

X線表現(xiàn)：紊亂的索條狀strip網(wǎng)狀或蜂窩狀

honeycomb致密影網(wǎng)結(jié)影netting-nodules

纖維化與肺紋理的區(qū)別———————————————

纖維化索條狀、網(wǎng)狀、蜂窩狀走向僵直粗細(xì)不均密度高

肺紋理樹枝狀走向柔和肺門—肺野逐漸變細(xì)密度較低

多為肺急性或慢性炎癥的愈合表現(xiàn)

healedlungemergencies肺組織破壞后代之以纖維結(jié)締組織見于吸收不全的肺炎、肺膿腫、肺結(jié)核等局限性纖維化

localizationfibrosis

鈣化calcification

鈣化Calcification良性病變或

病變愈合healstage

見于肺結(jié)核或淋巴結(jié)干酪樣結(jié)核灶的愈合某些腫瘤或囊腫塵肺、肺胞漿菌病等

鈣化Calcification

X線表現(xiàn)：

高密度影

形狀不一uncertainshapes呈斑點(diǎn)狀miliaryspots、塊狀,爆玉米花狀pop-coin,蛋殼樣eggshell鈣化,邊界銳利肺門部鈣化灶與肺血管橫斷面鑒別

肺血管橫斷面

肺門部鈣化灶園形

不規(guī)則形邊緣光滑

邊緣銳利有環(huán)形支氣管斷面伴行

無伴行密度低于鈣化灶

密度更高腫塊mass腫塊mass多見于肺腫瘤，也可見于結(jié)核瘤、炎性假瘤BenignMalignantMetastasis:multipleroundmasswithdifferentsizeBenignsmoothregularinshapeandgrowslow.malignantabscessabscessMalignant惡性腫瘤X線表現(xiàn)邊緣毛糙或毛刺形成，分葉狀，生長快

胸膜凹陷征

癌性空洞，厚壁、偏心性、壁結(jié)節(jié)肺部基本病變

空洞與空腔cavityandaircontainingspace肺內(nèi)病變組織發(fā)生壞死，壞死組織經(jīng)引流支氣管排出而形成

Cavityisformedasaresultoftissuenecrosisandcommunicatedwiththebronchus.空洞cavity

蟲蝕樣空洞（無壁空洞）薄壁空洞Thin-walledcavity厚壁空洞thick-walledcavity

壁厚3mm以上，見于肺膿瘍、肺結(jié)核、肺癌等X線表現(xiàn)薄壁空洞Thin-walledcavity

洞壁厚3mm以下內(nèi)壁光滑境界清楚的園形透亮區(qū)，見于肺結(jié)核結(jié)核性空洞常無或僅少量液體多為薄壁TBcavitywithalittleornotfluidlevel

蟲蝕樣空洞（無壁空洞）實變肺野內(nèi)多發(fā)小的透亮區(qū)，蟲濁樣，見于干酪性肺炎癌性空洞內(nèi)壁多呈結(jié)節(jié)狀

Thick-walledcavityIrregularinnerling厚壁空洞thick-walledcavity

壁厚3mm以上，見于肺膿瘍、肺結(jié)核、肺癌等肺膿瘍空洞多有明顯液片多為厚壁

Thickwallcavitywithsurroundexudativelesionsassociatedwithafluidlevel

空腔

aircontainingspace

肺內(nèi)腔隙的病理性擴(kuò)大

肺大皰、肺氣囊、肺氣囊腫、囊狀支擴(kuò)空腔性病變右下肺囊腫肺部基本病變

肺間質(zhì)病變

interstitiallesion:發(fā)生在間質(zhì)的彌漫性病變:即病變主要分布在支氣管血管周圍、

小葉間隔、肺泡間隔.X線表現(xiàn)

肺紋理增粗、網(wǎng)狀strip紋理、蜂窩狀honeycomb

或伴廣泛小結(jié)節(jié)影netting-nodules（間質(zhì)結(jié)節(jié)）彌漫性肺間質(zhì)病變(diffuseinterstitialdisease)HRCT：

小葉內(nèi)間質(zhì)增粗—

小葉內(nèi)細(xì)支氣管血管周圍

和肺泡間隔的間質(zhì)增厚彌漫性肺間質(zhì)病變(diffuseinterstitialdisease)

—多發(fā)小結(jié)節(jié)及粟粒病變(multinodularandmiliarydiseases)彌漫性肺泡病變diffusealveolardis