Respiratory System
Pathology 91
Spring 2013
Respiratory System Anatomy
1. Divided into:
1.
2.
Upper respiratory tract
Lower respiratory tract
2. Thoracic cavity
1.
2.
3.
RT & LT pleural cavities
Mediastinum
Lined by parietal pleura
3. Visceral pleura adheres to the lung tissue
4. Bones of thorax assist in inspiration & expiration
5. Sinuses
1.
2.
are lined with respiratory epithelium
communicate with visceral cavities
2
Upper & Lower Respiratory Tracts
1. Upper
1.
2.
3.
4.
Nose
Mouth
Pharynx
Larynx
2. Lower
1.
2.
3.
4.
Trachea
Bronchi
Alveoli
Lungs
3
Mediastinum
1. Anterior
1. Thyroid & thymus
glands
2. Middle
1. Heart
2. Great vessels
3. Esophagus & trachea
3. Posterior
1. Descending aorta
4
Mediastinum Frontal Radiograph
1.
2.
3.
4.
5.
6.
Superior vena cava
RT atrium
Inferior vena cava
Arch of aorta
LT pulmonary trunk
LT pulmonary artery
shadow
7. Auricle of LT atrium
8. LT ventricle
9. LT cardiophrenic angle
5
Retrieved from :www.liv.ac.uk/.../mbchb/hrtatk/images/ha1.jpg
The Importance of CXR’s
1. It is the most common diagnostic exam
2. It becomes routine
3. Improper techniques
6
Poor Inspiration vs. Sufficient Inspiration
1. Sufficient inspiration
2. Average movement of lungs and diaphragm
between inspiration and expiration is 3 cm
7
Film Screen vs. CR / DR
and Technique Considerations
1. Manual techniques
1.
Consistent Techniques
1. Use PSP plates
2. Daily radiographs
1.
2.
Analyze changes in
pathology after treatment
Or the progression the
disease
1.
They offer a wider latitude
2. KVp is increased to
decrease PT dose
3. Must have optimal
kVp and mAs
8
Additive & Subtractive Pathologies
1. Additive1. harder than normal to
penetrate
2. Requires an increase in
exposure factors
3. These are pathologies
that add fluid or tissue
to normal aerated chest
1. EX: pneumonia
1. Subtractive1. easier than normal to
penetrate
2. These pathologies
increase aeration in the
chest
1. EX: emphysema
3. Reduces exposure
factors required
9
Additive and Subtractive Examples
10
Technique Adjustments for Different
Image Receptors
1. Film Screen
1. mAs adjustment
2. kVp adjustments changes contrast
2. With a digital system
1. kVp should be adjusted
2. To reduce PT dose
11
AEC Sensors and Pathologies
1. AEC requires careful thought in regards to where
pathology is in relation to sensors
2. Portable AEC
1. consistent exposure accuracy
2. less sensors
3. Sensors should be carefully selected
12
CXR Projections
PA: Upright vs. Recumbent
1. Upright:
2. Recumbent:
14
AP CXR’s
 Usually seen in Portable exams
 Best to be performed upright to demonstrate
air/fluid levels
 Maintain beam perpendicular to plane of IR
 To prevent foreshortening of the heart
 Use 72”
 To reduce heart magnification
 Longer SID reduces magnification
 Short OID reduces magnification (this is why PA is
preferred)
15
Lateral CXR
 Left lateral places heart
closer to IR
 Heart is on left
 72” SID for reduced
heart magnification
16
Lateral Decubitus CXR
For diagnosis of free air in the pleural space or pleural fluid 17
Lordotic Chest
 Useful in demonstrating
apical regions of the lung
 Apices are normally
obscured by bony
structures
 TB likes to reside in apices
18
Soft tissues
of chest
 Can see pectoral muscles
 Breast shadows
 Sometimes breasts obscure
costophrenic angles
 Nipple shadows
 Implants
19
Mediastinal Radiographs
and Pathologies
Sail Sign
1. Mediastinum appears
large
1. Thymus is large on
healthy infant
2. Radiographic
Appearance:
1. AP- thymus extends
beyond heart borders
2. Lateral- may fill
anterior portion of
mediastinum
21
Sail Sign
22
Mediastinal Emphysema
(Pneumomediastinum)
1. Sudden rise in
intraalveolar pressure that
causes alveolar rupture.
2. Can be spontaneous
1. Severe coughing, vomiting
or straining
3. Can result from
trauma
1. Endoscopy
2. Injury
23
Mediastinal Emphysema
(Pneumomediastinum)
24
Treatment of Mediastinal
Emphysema
 Other than
spontaneous:
 Spontaneous:
 If there is no
pneumothorax, no
treatment is necessary
 Usually resolves in a
few days without
complications
 Rupture in esophagus
(usually from vomiting)
 Major bronchus trauma
(trauma)
 Both need prompt
diagnosis & surgical
intervention
 Esophogram can verify a
leak has not occurred.
25
Subcutaneous
Emphysema
1. Can be caused by:
1. Severe
pneumomediastinum
2. Penetrating or blunt
injuries
2. Usually in chest
and/or neck
3. Crackling sound or
sensation
26
Subcutaneous Emphysema
27
Congenital and Hereditary
Diseases
Cystic Fibrosis
Hyaline Membrane Disease
Cystic Fibrosis
 Generalized disorder from a genetic defect that affects the
function of the exocrine glands
 Involves many organs & nearly all exocrine glands
 Other organs affected






Salivary glands
Small bowel
Pancreas
Biliary tract
Female cervix
Male genital organs
 Most lethal genetic disease of white children
29
Cystic
Fibrosis
 Diffuse Interstitial
disease
 Nodular densities with
mucoid impaction
30
Progression of Cystic Fibrosis
 At birth lungs are normal
 Progression:




Increased secretions from bronchial glands
Leads to obstruction of the bronchial glands
Obstruction leads to staph infections,
Followed by tissue damage:
 atelectasis,(collapsed lung) and emphysema
 Once progression is in motion it is hard to stop
31
Cystic
Fibrosis
 Role of Radiography:
 Symptoms
 Chronic couth
 With sputum, vomiting &
disturbed sleep
 Wheezing
 Recurrent Pulmonary
infections
 CXR aid in diagnosis
 Early: bronchial thickening
and hyperinflation
 Progression: brochiectasis,
cyst, atelectasis, scarring,
enlargement of pulmonary
artery and RT ventricle,
overflation of lungs and chest
wall
32
Cystic Fibrosis Sinuses
 Sinus x-rays & CT will demonstrate persistent
opacification of sinuses
33
Cystic Fibrosis
 Prognosis:
 Determined by degree of
respiratory involvement
 Respiratory failure is
inevitable
 Death 20-30 years of age
 Treatment:




Antimicrobial drugs
Bronchodilators
Respiratory P.T.
With pneumothoraxchest tube
 With hemoptysisembolizing involved
brachial arteries
 Psychotherapy
34
Cystic Fibrosis
35
Hyaline Membrane Disease
Respiratory Distress Syndrome (RDS)
 Affects
 Premature infants
 Caused by immature surfactant producing
system
 What is surfactant?
 consists of lipids, proteins, and carbohydrates that
creates a high surface tension requiring less force
to inflate and maintain alveoli. Made in alveolar
36
walls.
RDS : Signs and Symptoms
1. Signs:
1. Rapid & labored breathing
2. Respiratory distress
3. Atelectasis worsening
2. In severe cases acidosis occurs
3. What is acidosis?
1. there is too much carbon dioxide (an acid) in the body,
primarily caused by decreased breathing
37
RDS
1. Severe atelectasis with
a air-bronchogram
sign
1. Life threatening
2. Underaeration
3. Fine granular
appearance known
as “ground glass”
38
Hyaline Membrane Disease With
Air bronchogram sign
39
Treatment for RDS
1. Proper thermal environment
2. Satisfactory tissue oxygenation
1. Monitored by arterial blood gas
3. Artificial surfactant
40
Inflammatory Diseases
Pneumonia
1. 6th leading cause of death in U.S.
1. Most common lethal noscomial infection
2. Most frequent type of inflammation in the
lung compromising pulmonary function
3. Causes include:
1. Bacteria
2. Virus
3. mycoplasmas
42
Pneumonia: Age related
 Infants & children
 Most common caused
by viral pathogens
 In adolescents & young
adults
 Most common causes
 In adults
 Most common causes:






Streptococcus
Staphylococcus
Pneumococcus
Haemophilus influenza
Chlamydia pneumoniae
Legionella pneumophila
 Bacterial organisms
termed mycoplasma
pneumoniae
43
Pneumonia:
Classification by location
1. Lobar pneumonia
1. The inflammation effects entire lobe
2. Segmental pneumonia
1. A segment of the lung
3. Bronchopneumonia
1. Bronchi and alveoli
4. Interstitial pneumonia
1. Interstitial lung tissue
44
Lobar
Pneumonia
 Right sided lobar
pneumonia
45
Segmental pneumonia
46
Bronchopneumonia
47
Interstitial Pneumonia
48
CXR’s for Pneumonia
 Important in determining location of
pneumonia
 Appears as soft-patchy, ill defined alveolar
infiltrates and pulmonary densities
 Alveolar infiltration results when alveolar air
spaces are filled with fluid or cells
49
Generalized Symptoms
of Pneumonia
 Cough
 Fever
 Sputum production (develops over days)
 Tachypnea
 Crackles during clinical examination
50
Types of Bacterial Pneumonia
 Most common
 Pneumococcal (lobar) pneumonia
 Less common
 Staphylococcal
 Occurs sporadically with epidemics of influenza
 Streptpcoccal
 Less than 1% of bacterial pneumonias
 Legionnaires
 Occurs in late summer- early fall
 Severe bacterial pneumonia
 Occurs in LG buildings such as hotels and hospitals
51
Pneumococcal (lobar) Pneumonia
 Caused by a bacteria present in healthy
throats
 Making it most common bacterial pneumonia
 When immune system weak bacteria multiplies
and spreads to lung, causing inflammation to
alveoli
 Usually in lobular without affecting bronchus
themselves
52
Pneumococcal (lobar) Pneumonia
 Demonstrates a collection of fluid on one or more less
 Lateral view serving to identify segmental involvement
 In a LLD pleural fluid is evident
53
Pneumococcal Pneumonia
54
Air- Bronchogram sign
55
Treatment of
Pneumococcal (lobar) Pneumonia
 Bed rest
 Antibiotics
 Based on lab results
 Age
 Usually resolves in 1 week
56
Aspiration Pneumonia
 Caused by acid vomitus aspirated by lower
respiratory tract
 May follow
 anesthesia
 alcoholic intoxication
 stroke
57
Aspiration
Pneumonia
 Reveals edema
produced by irritation
of air passages
 Appears as densities
radiating to one or
both hilia
58
Treatment of
Aspiration Pneumonia
 Strictly supportive
 Control of hypoxia and secretions
 Replacement of fluids (speech therapist)
 Antimicrobial drugs if infection has occurred
 Based on lab results
59
Viral (interstitial) Pneumonia
 Can be caused by various viruses
 Mostly influenza A & B
 Spreads by infected person spreading virus to
a non-immune person
 Most cases are mild and x-ray findings are
minimal
 Diagnosis is based on clinical findings and
serologic tests
60
Viral (interstitial) Pneumonia
 Symptoms:
 Dry cough
 Fever
 Complications:
 Secondary to bacterial infections as a result of low
resistance
 Brought on by inflammatory process to the virus
 Treatment:
 Relief of symptoms
 Does not respond to antibiotics
61
Interstitial Pneumonia
62
Interstitial Pneumonia
63
Bronchiectasis
 Permanent dilatation of 1 or more of the large
bronchi
 A result of destruction of the elastic & muscular
components of the bronchial wall
 Can be congenital or acquired
 Typically following and inflammation of the bronchial
walls due to bacterial or viral infections
64
Progression of Bronchiectasis
1. Early stages:
1. Chronic cough
2. Can be asymptomatic
2. Progresses:
1. Into a productive cough as bronchial a weakened a
dilated
2. Forms a sac-like structure which is a haven for infections
3. Later:
1. Infection grow and bronchial walls destroyed,
2. Results in an abscess
3. Pt’s may complain of pain, recurrent fevers and SOB
65
Bronchiectasis
 Demonstrated increased bronchovascular markings and parallel lines
outlining the bronchi (Tram lines)
66
 Occasionally honeycombing and cystic areas are present
Bronchiectasis
1. Bronchograms has been
replaced by high resolution
CT
2. Clearly demonstrates:
1.
2.
3.
4.
Dilated airways
Destruction of lung
parenchyma
Thickening of bronchial walls
Obstruction by mucus or air
67
CT and Bronchiectasis
 CT has replaced Bronchography
 High resolution CT
 With 1-2 mm slices
 With or without contrast
 Clearly demonstrates dilated airways of 1.5 times larger
than adjacent vessels
 Thickening of bronchial walls & obstruction of airways by
mucous or air
 Helical or spiral CT
 Can offer additional information regarding the extent of
disease & its distribution within the segment of the lung
68
Pulmonary TB
 Is an infection caused by inhalation of myobacterium
tuberculosis
 Generally virus affects lungs but can affect other areas of
the body
 PT’s contagious through sputum & air droplets
 Respiratory isolation indicated
 More prevalent in blacks than whites
 Increase in black & hispanic IV drug users
 Approximately 8 in 100,000 people in the U.S.
developed TB in late 1990’s
 1.7 million people worldwide and 10 million in U.S.
69
Progression of TB
 Early stages are asymptomatic (90-95%).
Only identified in mantoux skin test
 Primary means of diagnosis but if positive other
tests are performed because of false positives
 Lung lesions begin to appear (apices)
 Lordotic views of chest for diagnosis
70
TB
71
TB
Symptoms
 Most common- morning
productive cough
producing minimal mucous
 As disease progresses
cough becomes more
productive
 Pts complain of dyspnea,
spontaneous
pneumothorax, and pleural
effusion
Treatment
 Chemotherapeutic
agents
 Must be treated with 2
antituberculosis drugs
 In extreme cases where
TB is resistant to drug
therapy, surgical
resection of may be
performed
72
Miliary TB
1. Initially miliary TB is not identifiable on films
2. Immunosuppressed PT’s infection is much more
aggressive
1. Overwhelms immune system & spreads through lungs
causing pneumonia
2. Spreads through blood
3. Grows very rapidly
1. Without treatment TB pneumonia with result in death
in a few months
2. If resistant to drug therapy 50% will die in 60 days
73
74
Miliary TB
75
COPD- Chronic Obstructive
Pulmonary Disorder
1. Group of disorder that case chronic airway
obstruction
1. 2 most common are bronchitis & emphysema
2. Others are asthma & brochiectasis
2. It is irreversible & results in limited air flow
3. Mortality rate has increased in the past 20 years
due to cigarette smoking.
1. It is the top five most common causes of death in U.S.
2. # of people diagnosed has increased 60% since the 80’s
76
Chronic Bronchitis
 Often associated with long term smoking and
exposure to high levels of industrial air
pollution
 Chronic exposure leads to hyperplasia of
mucous glands, hypertrophy of smooth
muscle & thickening of the bronchial wall
 CXR demonstrates hyperinflation of lungs
77
Chronic Bronchitis
 Disease progresses slowly over months and
years
 Symptoms:
 Persistent cough & exportation of phlegm &
mucous
 Wheezing, SOB, & arterial hypoxia
 Lungs become hyperinflated and more air is
inhaled than exhaled
78
Chronic Bronchitis
Treatment
1. Stop smoking
2. Antibiotics if infection
has occurred
3. Bronchodilators
79
Bronchitis
80
Tram lines
81
Emphysema
1. Lung’s alveoli lose elasticity
2. Interference with expiration
3. Increase in air spaces distal to the terminal bronchioles
4. Destruction of the alveolar walls
5. Symptoms include dyspnea (most common).
82
Emphysema
1. Appears as depressed or
flattened diaphragm
2. Radiolucent lungs
3. Barrel shaped chest
4. CXR helps differentiate
this disease from others
that have similar
symptoms
83
Emphysema
84
Emphysema
85
Asthma
1. Widespread narrowing of airways develop
1. Due to increased responsiveness to various
allergens
2. Allergens include:
1. House dust, pollen, molds, animal dander, foods
fabrics (extrinsic asthma)
2. Exercise, cold, heat, and emotional upset (intrinsic
asthma)
86
Asthma
87
Asthma
88
Lung Cancer
89
Calcified Nodes
90
Croup
 Primarily a viral infection of
young children
 Produces inflammatory
swelling at the subglottic
portion of the trachea
 Causes a stricture that
causes a barking cough
91
Croup
92
Lung Abscess
 Localized area of dead lung tissue surrounded
by inflammatory debris
 May result from periodontal disease,
neoplasms, pneumonia, or other organisms that
invade lung
 More common in RT lung
93
Lung Abscess
 Appears as lobar or segmental consolidations that
becomes globular in shape as pus accumulates
 Also may appear as a round thick walled capsule
containing air and fluid
94
Lung Collapse (Pneumothorax)
95
Atelectasis
96
Foreign Body
97
Pulmonary Edema
98
Pleural Effusion
 Results when excess fluid collects on pleural
cavity
 Frequent manifestation of serious thoracic
disease
 Usually pulmonary or cardiac
 It is a sign on an underlying condition
99
Pleural Effusion
 CXR’s commonly used to diagnose
 Radiographically demonstrated as blunting of
costophrenic angles
 It occurs as part of the healing process and fibrous changes in
lung tissue may remain after it is resolved.
100
Pneumoconiosis
1. Occupational diseases in which inhalation of dust
in work environment causes pulmonary fibrosis
2. Exposure to substance must be in sufficient
duration & host must be susceptible
3. 3 types of pneumoconiosis:
1. Silicosis
2. Anthracosis
3. Asbestosis
101
Pneumoconiosis
 X-ray assists in diagnosis and follow up
 Lesions include nodules, cavitation & pleural thickening
102
Asbestos Plaques
103
Congestive Heart Failure (CHF)
104
CT
 Spiral CT has the advantage of imaging the entire
chest with one breath hold
 Allows for better evaluation of the chest including
emboli detection.
 Advances it CT allow high resolution, thin slices (11.5 mm), faster scan times in combination with
dynamic scanning.
 Needle aspirations is commonly performed under
CT guidance.
105
Nuclear Medicine
 Perfusion and ventilation scans are useful in
evaluating chest disease in the case of obstructive
disease and pulmonary emboli
 PET captures info regarding metabolic activity
 Because of cost constraints, PET is not currently
consistently used in the staging of early ling cancers
 Promising modality for the future especially when
combined with CT
106