Imagingdiagnosisofrespirotarydisease

part1

支氣管病變氣管、支氣管異物

foreignbodyinthebronchus先天性支氣管囊腫

congenitalbronchialcysts氣管腫瘤支擴(kuò)Clinicalsymptom:cough,Purulentfoul-smellingsputum,emptysis,orhaemoptysis.兒童，青年多見，多見于左下葉、右中葉及右下葉。咳嗽、咳痰、咯血支氣管擴(kuò)張bronchiectasisBronchiectasis支擴(kuò)Bronchiectasisisdefinedaslocalized,irreversibledilatationofthebronchialtree.congenitaloraquired---Thereareseveralcausesofbronchiectasis,postinfectiouscauses;congenitaldefectsofastructurenature;chronicgranulomatousinfectionsuchastuberculosis.BronchiectasisPathologyDamageofbronchuswallPressionofbronchusincreaseCircumferencetissuedraught支氣管壁破壞支氣管內(nèi)壓增加周圍組織牽拉（疤痕、肺不張等）BronchiectasisBronchiectasiscanbedividedintothreemorphologictypes:cylindrical,saccular,mixedtype.柱狀、囊狀或靜脈曲張型。Cylindricalbronchiectasisreferstoageneralizedmoreorlessregularwideningofthelargebronchi.Saccularbronchietasisshowsthatthebronchiterminateinsac-likecavities.BronchiectasisX-raymanifestation:Theplainfilmmaybenormalifonlyasmallpartisinvolvedandthereisnosecondaryinfection.Themostcommonappearanceonplainfilmisincreasingoflungmarkings.Thebronchialwallsmaybevisibleeitherassingleorparallellineopacities.Therearepathsofopacitywheninfectionoccures.

無異常發(fā)現(xiàn)支氣管及肺間質(zhì)慢性炎癥引起肺紋理增多，增厚，紊亂?？沙使軤?、杵狀、囊狀蜂窩狀影，或卷發(fā)狀。繼發(fā)感染：呈小斑片狀模糊影，常不易治愈，或于同一地方反復(fù)發(fā)作。X-raymanifestationBronchiectasis:lungmarkingsoftheleftlowlobeincrease,andsmallsac(sac-likecavities)Bronchiectasis:lungmarkingsoftheleftlowlobeincrease,andsmallsac(sac-likecavities)BronchiectasisBronchographicinvestigationisimportantandnecessarytodelineatethetotalextentofthedisease.Inthebronchogram,thecylindricbronchiectasismaybeshowclub-shapeddilatationofthebronchi,whilethesaccularbronchiectasiswillshowsaccularorcysticdilationoftheaffectedbronchi.Bronchogram:saccularbronchictasisintheleftlungBronchiectasisCTishelpfulespeciallyinthemoreadvancedformsofbronchiectasis,cylindricalbronchiectasiscausessmoothdilatationofbronchi,recognizableas“tramline”whenseeninthescanplaneandasthesignet-ringsignincross-section.Thesignetringsignreferstothethickenedanddilatedbronchus,saccularbronchiectasiscanbediagnosedmostreliablybyCT,sometimewecanseeair-fluidlevelinthedilatedbronchus.HRCT：支氣管壁增厚，管腔增寬。

呈“軌道征”或“印戒征”。柱狀、囊狀或靜脈曲張型。bronchictasistramline軌道征

signet-ringsign印戒征air-fluidlevelinthesac.支擴(kuò)伴黏液栓形成bronchictasistramlineandthesignet-ringsignincross-section.Question:whereisthebronchiectasis?肺先天性疾病※肺發(fā)育異?！胃綦x癥(bronchopulmonarysequestration)intralobarextralobar※肺動靜脈瘺肺AVMPneumoniaThecausativeorganismsarevariable:病原體多樣感染：細(xì)菌、病毒、真菌、支原體、衣原體、立克次體、寄生蟲理化性：類脂性、毒氣、藥物、放射線等免疫和變態(tài)反應(yīng)PneumoniaPneumoniacancauseawidevarietyofabnormalfindingsonthechestradiograph.Commonly,itpresentsasalveolarconsolidation,whichcanbesegmentalorlobar,ormaybepatchy,fluffy,alveolarinfiltrates-withoutanysegmentaldistribution(bronchopneumoniapattern)..Pneumoniaalsomaypresentasdiffusealveolardiseaseorasdiffuseinterstitialdisease.Italsocanpresentassingleormultiplenodules.Thepresenceofpneumoniasometimesmaybemaskedbyanassociatedpleuraleffusion,congestivefailure,oradultrespiratorydistresssyndrome(ARDS).PneumoniaAccordingtotheradiologicappearance,pneumoniacanbecommonlydividedinto

lobarpneumoniabronchopneumoniainterstitialpneumoniaLobarpneumoniaLobarpneumoniamostcommonlyiscausedbyS.pneumoniae肺炎鏈球菌,butitcanalsooccurwithotherorganisms.Lobarpneumoniarepresentsatypeofinflammationofthelungcharacterizedbyout-pouringofexudatesintothealveoliwithlittlechangeinthebronchiorinterstitialtissue.Theout-pouringoffluidisgenerallyconsideredtoresultfromalocalsensitivityreactiontothepolysaccharidesinthecapsuleofthepneumococcus.ThebacteriaarerapidlycarriedbytheedemafluidfromalveolustoalveolusLobarpneumoniaEarlystage:InflammatoryedemaConsolidationstageResolutionstageLobarpneumoniaEarlystage:InflammatoryedemaTheinfectionandedemahaveusuallyspreadthroughoutasegmentofthelung.X-rayfindings:Thelungmarkingsincrease.Itdoesnotcompletelyobscurethepulmonaryvesselsintheareabecausemanyofthealveoliarestillaerated.LobarpneumoniaConsolidationstageThelungischaracterizedbyaratherdenseshadowofuniformopacity.Ifthebronchiremainpatent,theaircolumnwithinthemstandsoutasdark.Thepresenceofanairbronchogramwithinashadowinthepulmonaryfieldindicatesthatthedensityisduetoconsolidationoflung.Ifadequateantibiotictreatmentisgiven,nofurtherspreadtakesplace.1.大葉性肺炎

病理過程①充血期：12-24hr。毛細(xì)血管充血，少量漿液滲出，肺泡部分仍含氣；②實(shí)變期：2-5d，分紅色和灰色肝硬變期，肺泡內(nèi)充滿炎性滲出物。③消散期：1w后開始,2-3w消散。

Ｘ線表現(xiàn)可無異?；蚍渭y理增粗。均勻?qū)嵶冇?，與肺葉、段一致的高密度影，隨各肺葉形態(tài)不同而不同。不均勻斑片狀，逐漸吸收，胸膜側(cè)最晚，可有胸膜增厚、纖維條索lobarpneumoniaconsolidationofrightmiddlelober

consolidationofrightupperloberLobarpneumoniaResolutionstageThehomogenicityiftheshadowofconsolidationislostanditbecomesmottledastheexudateinvariousportionsoftheaffectedlungisabsorbedandalveolihereandtherearefilledwithair.Thepathologicconsistsofintermingledareasofconsolidationofvaryingdegree,aerationofthealveoliandareasofatelectasis.Thelatterareoftenrepresentedonthefilmbystreak-likeshadow.Theseshadowsdisappearasthelungre-expandsandresolutioniscompleted.ResolutionstageintherightupperloberStreaklikeshadowResolutionstageintheleftlowerloberconsolidationofleftupperlober

雙上葉見大片狀致密影，可見支氣管充氣征consolidationofrightandleftupperlober(airbronchogram)Bronchopneumonia(lobularpneumonia)

ItiscommonlyseenininfantsandelderlypatientsbyinfectionbyStaphylococcusaureus金葡菌,mostgram-negativebacteriaandsomefungi.Itbeginsasabronchialinfectionandhasatendencytoinvolveseparatepartsofthelung.Theinfectionspreadsalongthebronchialwallsandresultsininfiltrationoftheinterstitialtissueswithlittleinvolvementofthealveolarairspace.Inmostcases,bothconsolidationsofthealveolarairspacesandinterstitialinfiltrationarepresent.Bronchopneumonia(lobularpneumonia)Theradiologicmanifestationsdependontheseverityofthedisease.Mildbronchopneumoniaresultsinperibronchialthickeningandpoorlydefinedair-spaceopacities.Moreseverediseaseresultsininhomogeneous,patchyareasofconsolidationthatusuallyinvolveseverallobes.Bronchopneumonia(lobularpneumonia)Consolidationinvolvingtheterminalandrespiratorybronchiolesandadjacentalveoliresultsinpoorlydefinedcentrilobularnodularopacitiesmeasuring4to10mmindiameter(air-spacenodules);extensiontoinvolvetheentiresecondarylobule(lobularconsolidation)maybeseen.Bronchopneumoniafrequentlyresultsinlossofvolumeoftheaffectedsegmentsorlobes.Whenconfluent,bronchopneumoniamayresemblelobarpneumonia.小葉性肺炎影像學(xué)表現(xiàn)病變部位：兩肺中下野的內(nèi)中帶肺紋改變：增多、增粗、模糊X-ray:兩肺中下野的內(nèi)中帶沿支氣管分布，肺紋理增多、增粗、模糊，小葉滲出與實(shí)變表現(xiàn)為斑片狀模糊致密影，有融合傾向CT表現(xiàn)：兩中下肺支氣管血管束增粗，有大小不同結(jié)節(jié)和片狀陰影，1~2cm大小，邊緣模糊。病變之間除正常含氣肺組織外，還有1~2cm類圓型透亮陰影，代表小葉性過度充氣patchyareasofconsolidationLungmarkingsincreaseandpatchyintherightlowerlobeLungmarkingsincreaseandpatchyintherightandleftlungPatchyshadowinbothofthelungPatchyshadowinbothofthelung一周后復(fù)查，有吸收機(jī)遇性感染opportunityinfection

immunedeficiencyaccompanywithinfectionortuberculosisandsoon免疫缺陷者伴隨的感染或結(jié)核等Eg.HIVinfection:細(xì)菌，真菌，病毒，TB，PCP（肺孢子蟲肺炎）……男，35歲

咳嗽、胸悶氣急半月HIV抗體陽性AIDSpatientwithpulmonarycryptococcalinfection.（新型隱球菌）LungabscessHematogenousabscess血源性的膿腫isratherrarenow.Abscessesoccurmostoftenasacomplicationofaspirationoffood,vomitus,orforeignbody;ofbacterialpneumonia;orbronchialobstruction.Anaerobicbacteria厭氧菌areoftenthecause.OtherrelativelyCommonagentsareS.aureus金黃色葡萄球菌andPseudomonasaeruginosa綠膿桿菌/綠膿假單胞菌.Abscessesmayalsobesecondarytosepticemia敗血病,andtheyoccasionallydevelopinaninfectedpulmonaryinfarct.LungabscessSymptomatologyresemblesthatofacutepnenmoniawithfever,coughproductiveofpurulentsputum膿痰,andleucocytosis白細(xì)胞增多.Diabetics,alcoholics,andimmunocompromised,免疫受損的individualsareatincreasedriskofdevelopinglungabscess.LungabscessTheabscessresultingfromaspirationmostfrequentlyoccursinthedependentsegmentsofthelung---theposteriorsegmentsoftheupperlobeandthesuperiorsegmentsofthelowerlobe.Theabscessfirstappearsasaroundbutpoorlydefinedareaofsegmentalconsolidationusuallyneartheperipheryofthelung.Nofluidlevelisseenuntilbronchialcommunicationisestablished.LungabscessAstheabscessrupturesintothebronchusatranslucentringwithafluidlevelisseeninthemiddleoftheopaquesegment.Theinnerwallsofthecavityaresmooth.Adjacentparenchymalconsolidationisalsopresent.Multiplecavitiesmaydevelopwithinconsolidatedlung(necrotizingpneumonia).Conventionaltomographymayshowgasbubbleswithinanabscessindicatingeitherabronchialcommunicationorpossibleinfectionwithgas-formingorganisms.Thereisfrequentlyanassociatedpleuraleffusion.LungabscessCTallowsearlierdetectionofabscessformationCTisalsosuperiorindefiningtherelationshipoftheprocesstothepleuralcavity,.Empyemas膿胸tendtobelenticular凸出的inshape,andtheirangleofinterfacewiththechestwallisusuallyobtuse鈍角.Alungabscessisusuallysphericalandproducesanacuteanglewiththechestwall.LungabscessAfterantibiotictreatmentinfavorablecasesboththecavityandthesurroundingconsolidationgraduallyshrinksanddisappears.Theabscesshealscompletelyandleavesnovisiblescarorsometimesasmallareaoffibrosisindicatesthesite.Insomecaseshealingisslowandthereisoftenaresidualbronchiectasisoffusiformtype.肺膿腫lungabscess急性化膿性肺炎期：大片炎性浸潤膿腫形成期：出現(xiàn)含液平空洞慢性肺膿腫：周圍炎癥吸收，代之以纖維組織增生，表現(xiàn)為紊亂的條索影及斑片陰影血源性肺膿腫：兩肺胸膜下多發(fā)性類圓性陰影，中間有小空洞形成，可有液平，常累及胸膜Acuteabscess:thecavity(fluidincavity)andthesurroundingconsolidationChronicabscess肺膿腫治療后周圍炎癥吸收膿腫，液平面肺膿腫引流后TuberculosisofthelungTuberculosisisaninfectiousdiseasethatmayaffectanyorganbutshowsamarkedpredilectionforthelungs.Nowadaysbetterstandardsoflivingandhygienehavesharplyreducedtheincidenceoftuberculosis.Despiterecentadvancesintherapyandcarefulpublichealthmeasures,TBremainsaprobleminthelargereservoirofelderlypatientswhohavepreviouslybeeninfectedwithtuberclebacilliandintheurbanpoorwhocontinuetobeexposedtotuberclebacilli.TuberculosisofthelungThemainfactordeterminingwhethertuberculosisinfectionprogressestodiseaseistheimmunecompetenceoftheindividual.Thediseaseismostcommonlyfoundinpersonswhoseimmunestatusiscompromisedbyoldage,alcoholabuse,diabetes,steroidtherapy,orAIDS.TuberculosisofthelungTuberculosisisclassicallydividedinto(Ⅰ)primarytuberculosis.(Ⅱ)hematogenoustuberculosis.(Ⅲ)postprimarytuberculosis.(Ⅳ)tuberculouspleurisy.(Ⅴ)extraplumonarytuberculosis.primarytuberculosisMostcasesofprimarytuberculosisduetoinhalethetuberclebacilli.Itiscommonlyseeninchildrenoradolescents.Theinfectionspreadsfromtheinitialfocusinthelungtotheregionalandmediastinallymphnodesbywayofthelymphaticchannels.Inhaledtuberclebacilliinitiallyevokeafocal,nonspecificsubpleuralalveolitisthatconvertstoatuberculosis-specificinflammatoryfocus(Ghonfocus)inabout10days.Spreadoftubercleviathelumphaticsleadstoaspecifichilarlymphadenitis.Thecombinationoftheprimarypulmonaryfocus,lymphangitisandlymphadenitisisknownastheprimarycomplex.primarytuberculosisTheGhonfocusisacircumscribed,small,peripheralconsolidation.Hilarandmediastinallymphadenitispresentsashilarenlargementandmediastinalwidening.Occasionally,lymphangiticstrandingconnectingtheprimaryfocuswiththehilarlymphadenitisformsadumbbell-shapedopacity.Segmentalopacitymaybeduetosegmentalatelectasisdistaltobronchialcompressionbyenlargedlymphnodes.RighthilarenlargementandmediastinalwideningLefthilarenlargementLefthilarenlargementandmediastinalwideningRighthilarenlargementandmediastinalwideningCentralcaseousnecrosisHematogenoustuberculosis(TypeⅡ)Mycobacteriaenteringthebloodfromtheprimarycomplexmaybecomedisseminatedtonumerousextrapulmonarysites.Itmaybeclassifiedasacute,subacuteorchronichematogenousdisseminationtuberculosis.MiliarytuberculosisAcutemiliarytuberculosisMilitarytuberculosisexhibitsafinelymottlednodularpatternresultingfromsummationofindividualnodules.Thesemayrangeinsizefrom1-4mmindiameter.Theycompletelyobscurethenormallungmarkingsinacutehematogenousdisseminationtuberculosis.Threehomogeneous:distribute,size,densityThreehomogeneous:distribute,size,densityAcutemiliarytuberculosisThreehomogeneous:distribute,size,densityAcutemiliarytuberculosis

MiliarytuberculosisSubacuteorchronicmiliarytuberculosistinyopacitiesarechieflydistributedinbothupperandmiddlelungfields,thedensityoftheopacitiesisnotuniformandthesizeandshapeoftheopacitiesarenotthesame.Threenonhomogeneous:distribute,size,densitySubacuteorchronicmiliarytuberculosisThreeinhomogeneous:distribute,size,densityThreehomogeneous:distribute,size,densitySubacuteorchronicmiliarytuberculosisSubacuteorchronicmiliarytuberculosisPostprimarytuberculosis(Adulttuberculosis)Postprimarytuberculosisischaracterizedbycavitatinglesionsintheupperlobesorapicalsegmentsofthelowerlobes.Ruptureofaparenchymalfocusintoanadjacentairwayandsubsequentendobronchialspreadmayleadtoextensivepulmonaryinvolvement..Postprimarytuberculosis(Adulttuberculosis)Postprimarytuberculosisproducesaspectrumofradiographicmanifestations;exudative,productive,cavitatory,andfibroticchangesfrequentlyoccursimultaneously.Becauseofthepredilectionfortheapicalandposteriorsegmentsoftheupperlobeandtheapicalsegmentofthelowerlobe,parenchymalchangesintheseregionsshouldarousesuspicionoftuberculosisPostprimarytuberculosisPostprimarytuberculosisPostprimarytuberculosisPostprimarytuberculosis(Adulttuberculosis)Exudativetuberculosisischaracterizedbyalobular,caseouspneumoniawithrelativefewepithelioidcells.Coalescencemayoccurtoformlargerfociofcaseouspneumonia.Exudativetuberculosismanifestsasconfluentmottledopacitieswithindistinctcontours.Theygraduallyalterinappearanceoveraperiodofweeksincontrasttononspecificpneumonia,whichmaychangewithindays.caseouspneumonia.Postprimarytuberculosis(Adulttuberculosis)Productivetuberculosisischaracterizedbywell-definedsolidnodules,1-2mmindiameterandrichinepithelioidcells;Productivetuberculosisproducessharplydefined,irregular,polygonalopacitiesadmixedwithcalcifiedgranulomata.ProductivetuberculosisPostprimarytuberculosis(Adulttuberculosis)Tuberculomasmeasure1-3cmindiameterandcompriseacaseouscoresurroundedbyamantleofgranulationtissue.Theyhavesmoothmarginsandpredilectionfortheupperzones.In80%ofcases,conventionalorcomputedtomographywillshowsmallsatellitelesionsandcalcifications.TuberculomasTuberculomasTuberculomasPostprimarytuberculosis(Adulttuberculosis)Cavitatingtuberculosis

isactivetuberculosis,thewallofthecavitycontainsinfectiouscaseousmaterial.Eventually,thecavitybecomesfibrosedandmayevenacquireanepitheliallining.30Y，糖尿病患者，典型薄壁空洞，衛(wèi)星灶Postprimarytuberculosis(Adulttuberculosis)Thetuberculousprocesshealsbyfibrosis,isassociated