GAMBARAN RADIOLOGIS

PADA KEGAWATAN PARU

Farah Fatma Wati
 Pemeriksaan
Klinis Penunjang
• Anamnesis • Imaging Diagnosis
• Pemeriksaan Fisik • Lab
• PA
• Mikrobiologi
Pemeriksaan imaging diagnostik yang sering digunakan :

• Radiografi konvensional (Thorax PA/AP-Lat)

• CT (Computed Tomography)
• Ekokardiografi
• Angiografi
• MRI
Wilhelm Conrad Roentgen (1895)
Bayangan
Luscent

Opaque
Luscent

Opaque
Anatomi Toraks, PA
Anatomi Toraks, Lateral kiri
POSISI

• The standard frontal view of the chest: posteroanterior (PA)

 the direction of the x-ray beam traverses the patient from
back (posterior) to front (anterior).
 the patient upright and in full inspiration.
 The x-ray beam is horizontal and the x-ray tube is 6 feet
(1,8 m) from the film

• The anteroposterior (AP) view is usually made with a

portable x-ray unit on very sick patients who are unable to
stand, and on infants. The patient is supine or sitting in bed.

Felson, 2015
PA
AP
• The PA upright is preferred to the AP supine view because
1. there is less magnification (the heart is an anterior
structure, so it would seem larger on a(n) AP image) ;
2. the image is sharper;
3. the erect patient inspires more deeply, showing more
lung;
4. pleural air and fluid shift with gravity and are easier to
detect on the erect film.

Felson, 2015
Figures 1-1A and 1-1B are two images of the same patient
Which one is the PA image?
How did you decide?

Figure A is the PA
Sharper edges, less magnification, deeper inspiration

Felson, 2015
Lateral
It is often difficult to detect a lesion located behind the heart, near the
mediastinum, or near the diaphragm on the PA view.
 lateral view, routinely taken with the left side against the cassette

Felson, 2015
 In the erect patient
intrapleural fluid falls with gravity >< Intrapleural air rises
 Lateral Decubitus View
Free fluid in the pleural
cavity is affected by gravity.
• Fluid gravitates toward the
diaphragm when the
patient is erect
• It flows toward the back
when the patient is supine
• It moves toward the lateral
aspect of the dependent
thorax when the patient is
on the side, in the lateral
decubitus position.

Felson, 2015
 Lateral Decubitus View
The ideal position to
diagnose a pneumothorax
(intrapleural air) is erect
• If you suspect a left
pneumothorax in a patient
who can’t stand or sit, have
the patient lie with the
right side down.
• The air will rise to the left
chest wall.

Felson, 2015
Apical Lordotik View
 the right anterior
oblique position

Oblique views can help us localize lesions and eliminate superimposed

structures

Felson, 2015
Faktor teknis yang mempengaruhi kualitas

• the distance from the medial end of each

Rotation clavicle to the spinous process of the vertebra
at the same level, should be equal

• Nine pairs of ribs should be seen posteriorly in

Inspiration order to consider a chest x-ray adequate

• should barely see the thoracic vertebrae

Penetration behind the heart and identify both
costophrenic angles and lung apices

Magnification • AP films magnify the heart slightly

• Clavicle normally has S shape, and medial

Angulation end superimposes onto the 3th or 4th rib
Rotasi
Inspirasi
Magnifikasi
 The normal chest image is always done on inspiration

Radiographs of the same patient at the same time.

An expiratory image and an AP
supine image make the heart and PA inspiratory image
vessels appear larger and the lungs
whiter Felson, 2015
Expiratory films If you hear a unilateral wheeze,
order an expiratory image to look for air trapping
can be used to detect focal air trapping from asymmetrical emphysema or a
partial bronchial obstruction
An expiratory image.

the right lung is slightly blacker The left deflates normally and gets whiter.
than the left lung The right remains inflated and black as the
result of air trapping behind an aspirated
foreign body. Felson, 2015
 Silhouette sign

• Two substances of the same density, in direct contact, cannot be

differentiated from each other on an x-ray.

The left heart border is not visible.

Felson, 2015
The Air Bronchogram Sign Alveolar consolidation

Visualization of air in the intrapulmonary bronchi on a chest x-ray

• On the normal chest x-ray, we see air in the trachea and proximal
bronchi because they are surrounded by the soft tissue (water
density) of the mediastinum.
• In the lungs, however, the bronchi are not visible. The only branching
structures visible in the lungs are the pulmonary vessels (water density)
surrounded by air.

• We can see normal bronchi on a chest x-ray when the lung is

consolidated and the bronchi contain air
Felson 2015
a radiograph of a patient with bilateral consolidation.

Felson, 2015
Fluoroscopy

• a realtime x-ray captured on a detector and viewed as a cine or video

on a monitor, provides information about moving organs.
descent of the diaphragm or chest wall during inspiration
 left ventricular contraction during systole.
• During fluoroscopy, the patient can be turned obliquely, to eliminate
overlapping structures

Felson, 2015
 CT scan
• CT has better contrast discrimination than conventional x-rays
and more easily distinguishes between muscle, fluid (e.g.,
blood, bile, effusion), and fat.

• CT density is expressed in Hounsfield units (HU).

• pure air (–)1000 HU
• lung = (–)800
• fat = (–)120
• fluid = 0
• muscle = 40
• bone = 350

Felson, 2015
 A. Axial

C. Coronal B. Sagital
Felson, 2015
mediastinal or soft tissue windows Lung window

Felson, 2015
USG

• In US or sonography, a transducer directs high-frequency sound waves into

the body
• The transducer detects the reflected sound waves and synthesizes them
into diagnostic images.
• Fluid causes minimal reflection, so it appears as a homogeneous low-signal
area (low echogenicity).
• Soft tissue absorbs, reflects, and deflects the signal, causing a
heterogeneous (echogenic) area.
• Sound waves travel poorly in air and bone  difficult to evaluate with US.
• US is relatively inexpensive, portable, and especially suited for imaging
pleural or pericardial fluid and cardiovascular structures.

Felson, 2015
US of the pleural space in two patients.
The diaphragm (arrow) separates the liver (L) from the pleural space.
Note the signal difference between the clear transudate (T) and the noisy
empyema (E).
US is also valuable for evaluating the diaphragmatic motion.
Felson, 2015
How to Read a Chest X-Ray
A Step by Step Approach
On all X-rays CHECK the following:

Patient details • First name, surname, date of birth

Orientation,
• Left, right, erect, ap, pa, supine, prone,
position and side inspiration, expiration
description

Faktor tehnik yang

mempengaruhi • R-I-P-M-A
kualitas

SSMJ Vol 1 Issue 2

Specific Radiological Checklist:

Airway

Bones

Cardiac

Diaphragm

Effusion

Fields of the lung

Gastric air bubble

Hilum

Instrumen

SSMJ Vol 1 Issue 2

• The lungs are so important so the lungs are examined last and we search
them twice.
• Start in the right costophrenic angle, examining the right and then left lung.
• The second look involves a side-by-side comparison of the lungs

We should look at old films when available.

They help to detect new disease and evaluate for change in preexisting disease.
Felson, 2015
 EFUSI PLEURA MASIF

Pleural effusion:
Abnormal accumulation of fluid within pleural space

Caused by :
IMBALANCE between FORMATION and ABSORPTION of
pleural fluid in various states of disease

Thomas R, et al. Thoracic surgery clinics. 2013; Light RW. Pleural Diseases. 2013
Chest radiography of pleural effusion
CT Scan of pleural effusion
PNEUMOTORAKS

Itard (1803) – Lannec (1819):

Presence of air in pleural cavity
(space between the parietal and
visceral pleura)
 Imaging
• Plain Radiographs
• Upright PA on inspiration
• Partially collapsed lung
• Tension Pneumothorax
• Trachea and mediastinum deviate
contralaterally
• Ipsilateral depressed hemi-diaphragm

• Chest CT
• Not routine
• Only to assess the need for surgery
(thoracotomy)
 Pneumothorax Size
Quantification

LIGHT’S CRITERIA
• The average diameter of collapsed
lung and the affected hemithorax :

[(HT3 – L3) / HT3} x 100%

MacDuff A, et al. Thorax. 2010; Light RW. Pleural Diseases. 2013

 Differential Diagnosis
• Local or generalisata emphysema
• Wide bleb emfisematous
• Wide lung cavity
• Cystic formations
• Hernia diafragmatika

50
 ASPIRATION OF FOREIGN BODY

• Immediate airway control is needed Pre-treatment diagnostics will delay

intervention and may worsen the outcome.
• Immediate rigid bronchoscopy is the primary diagnostic and therapeutic choice.
• If the airway is obstructed, air distal to the obstruction is resorbed and that
portion of the lung collapses (becomes atelectatic)
• an aspirated foreign body is often not visible on the X-ray (5-50%). Organic
materials in particular are either not or reduced radio-opaque  Air trapping or
atelectasis can then be suggestive of aspiration.
• If a patient is suspected of having a foreign body aspiration and has a negative
chest X-ray, a thoracic CT is justifiable.

De Kruif, 2013
• Direct signs of lobar collapse:
1. Fissure movement,
2. crowded markings, or
3. moving marker structures

• The indirect signs of volume loss rely on shift of structures toward

the collapsed lung
1. tracheal shift
2. cardiac shift
3. diaphragm elevation

Felson, 2015
It shows collapse of two lobes on the right. The minor fissure is elevated.
There is a silhouette sign of the upper mediastinum.
The trachea has shifted to the right because of right upper lobe collapse.
There is a silhouette sign of the right diaphragm.
The heart has moved to the right, indicating right lower lobe collapse.
The right middle lobe remains aerated.
We see the undersurface of the minor fissure and the right heart border because
the right middle lobe is aerated
Felson, 2015
An x-ray of a patient from the intensivecare unit.
Silhouette sign(s) indicate right lower lobe and left lower lobe are involved.
Air bronchograms are absent.
Likely cause of collapse is mucous plug.

Felson, 2015
An unlucky seamstress gasped at the wrong moment.
She aspirated a pin.
It is located in right lower lobe.

Felson, 2015
ARDS
 Radiologic manifestation

• Patchy, diffuse ground glass opacities

• Pattern of opacification does not
change with position change, as the
exudates are trapped in alveoli
• Septal lines, peribronchial cuffing, and
thick fissures are usually ABSENT
• In severe cases, air bronchograms can
be seen

Alveolar are filled with fluid, making the lung appear airless (radiodense, opaque,
consolidated).
The alveolar pattern may be relatively homogeneous (a lobe or segment) or patchy
and scattered throughout the lung
HEMOPTISIS MASIF

• Hemoptisis  bleeding arising from the lower airways

• Mostly originate from one of two main sources : bronchial or pulmonary
arterial circulation.
• Hemoptisis massif  > 600 mL in 24 h or > 30 mL/h
• Bronchial arteries : 90% sources of massive hemoptysis
• Chronic inflammation disease / neoplasma  induce neovascularization
of bronchial arteries through anastomosis  easy to disrupt by systemic
pressure

Bidw ell (2005), Lundgren et al (2010), Spinu et al (2013)

Etiology

The most causes of

massive hemoptysis :
1. Tuberculosis
2. Bronchiectasis
3. Lung abscess
 Hemoptysis in Tuberculosis
• Spontaneous rupture of Rasmussen’s aneurysm.
– involves the erosion of a small or medium-sized pulmonary
artery into an adjacent tuberculosis cavity.
– continuous necrotizing of pulmonary artery in TB cavity  layer
of vascular wall was replaced by granulation.

Ingbar (2005), Shetty et al

PNEUMONIA

• The primary role of imaging examinations is to confirm the diagnosis

of pneumonia
• Imaging examinations also play a complementary role for the
evaluation of treatment effects of antibiotics although treatment
effects may be determined based solely on clinical findings
• It is generally difficult to determine specific pathogens of infectious
pneumonia based only on the imaging findings. However, as
characteristic imaging findings of several pathogens have been
reported, they may help choose subsequent examinations or first
antibiotics. This is especially true for the exclusion of tuberculosis.

Nambu et al, 2014

IMAGING FINDINGS OF CAP

• CAP has classically been divided into three distinctive patterns on

imaging examinations:
1. consolidation (alveolar/lobar pneumonia),
2. peribronchial nodules (bronchopneumonia)
3. ground-glass opacity (GGO)
The fourth, a unique uncommon pattern of CAP is random nodules,
suggestive of hematogenous pulmonary infection or granulomatous
infection

Nambu et al, 2014

• A silhouette sign helps localize disease, sometimes it actually helps
detect disease.
The patient has pneumococcal
pneumonia.
The consolidated lobes are
- right middle lobe
- right lower lobe
- lingula

Felson, 2015
a scout view of 2 patients with left lower lobe pneumonia and right middle lobe
pneumonia .
The CT scan shows a right middle lobe air bronchogram. Interstitial thickening
elsewhere in the right lung does not give an air bronchogram

In pneumonia, if the bronchi are filled with secretions, there would not be an air
bronchogram within the lesion. An air bronchogram indicates open airways.
Felson, 2015
1. Consolidation predominant pattern
(alveolar/ lobar pneumonia)

Nambu et al, 2014

It is alveolar consolidation, in the right middle lobe.
The superior margin of the right middle lobe is the minor fissure
(arrowhead) and the posterior margin is the major fissure (arrow).

CLINICAL PEARL: Dense alveolar consolidation is often due to infection.

Lobar pneumonia is usually bacterial in origin, caused by Streptococcus
pneumoniae or Klebsiella. Mycoplasma and Legionella infections also may
cause lobar consolidation
Felson, 2015
Nambu et al, 2014
2. Peribronchial nodules predominant pattern
(bronchopneumonia)

Nambu et al, 2014

3. Ground-glass opacity (GGO)

Nambu et al, 2014

Nambu et al, 2014
VCSS

• Superior vena cava (SVC) obstruction can occur from extrinsic

compression, intrinsic stenosis or thrombosis.
• Malignancies are the main cause and are considered an oncologic
emergency.
• Symptoms: facial and neck swelling, facial flushing, bilateral upper
extremity swelling, neurological signs, dyspnoea, headache and
cough
Radiographic features
Plain radiograph
• Indirect signs on chest x-ray, such as superior mediastinal
widening and right hilar prominence that may indicate the
presence of mediastinal mass.
CT
• the imaging modality of choice. Enhanced CT shows the
location and severity of the SVC obstruction, superimposed
thrombosis, a mediastinal mass or lymphadenopathy,
collateral vessels and associated lung masses.
COPD EXACERBATION

Radiologic feature
• Emphysema manifests as lung hyperinflation with flattened
hemidiaphragms, a small heart, and possible bullous
changes  hyperluscent, diaphragms are flat and low
(depressed)
• On the lateral radiograph, a "barrel chest" with widened
anterior-posterior diameter may be visualized.
• The "saber-sheath trachea" sign refers to marked coronal
narrowing of the intrathoracic trachea (frontal view) with
concomitant sagittal widening (lateral view).
• If the interstitium is destroyed (e.g., bulla formation), the lung becomes
more hyperlucent because there is less tissue to absorb radiation.
• Bullae or sparse markings replace normal branching vessels.
• Cavities and air cysts cause focal hyperlucencies.
• The combination of hyperinflation and bullae indicates emphysema
ASTHMA EXACERBATION

Plain radiograph
• Plain chest radiographs can be normal in up to 75% of patients with
asthma.
• Possible findings are bronchial wall thickening and hyperinflation, but
there are no bulla present.

In acute asthma, a chest x-ray is only required if there is:

• suspected pneumomediastinum, pneumothorax or surgical
emphysema
• suspected consolidation
• requirement for ventilation or life-threatening asthma
• failure to respond to treatment satisfactorily
TERIMA KASIH