RESPIRATORY

TRACT

BANGUN NUSANTORO, DR. ,SP.RAD

 Radiology
Medical imaging

techniques and processes used to

create images of the human body
RADIOGRAPHY
Radiographs / Roentgenographs
named after the discoverer of X-rays

8 November 1895

Wilhelm Conrad Röntgen (1845–

1923)

often used for evaluation of bony

Figure 1. Diagram of a standard x-ray tube
Taking an X-ray image with early Crookes tube
apparatus, late 1800s.
Wilhelm Conrad Röntgen (1845–1923)
X-ray equipmentS
X-ray equipments
 X- RAYS DEFINITION

 A relatively high-energy photon having a

wavelength in the approximate range from 0.01
to 10 nanometers.
 A stream of such photons, used for their
penetrating power in radiography, radiology,
radiotherapy, and scientific research. Often used
in the plural. Also called roentgen ray.
 A photograph taken with x-rays.
 These previously unknown rays (hence the X) were
found to
be a type of electromagnetic radiation.

Fluoroscopy,
computed tomography
(1970s), mammography,
ultrasound (1970s), and
magnetic resonance imaging
(1980s).
 Sources
X-ray photons

Sealed X-ray tubes Betatrons, Linear accelerators

(linacs)

Gamma rays Gamma rays, Radioactive sources such as Ir -192

have been used.
 GRADAtion DENSITy of X-RAY
FILM

Very Moderately Intermediate Moderately Very

Radiolucent radiolucent Radiopaqe Radiopaqe
Gas Fatty Tissue Connective Bones Heavy metals
tissue Calsium salt
Muscle tissue
Cartilago
Epithelium
Cholesterol
stones
Uric Acid
stones
CONTRAST AGENTS
Three type of contrast agents :

 Positive contrast agents : Barium sulphate,

Organic Iodine.

 Negative contrast agenst : Oxigen, Air, Helium

 Double contrast
 BIOLOGICAL EFFECTS OF X-
RAY EXPOSURE
 Early effects : Chemical changes
structure or function of constituent cells.
 Delayed effects, such as cancer, may also
occur ultimately as a result of DNA damage
produced by the radiation in surviving cells.
 Earliest visual indications of a high radiation
dose
erythema or skin reddening
 BIOLOGICAL EFFECTS OF X-
RAY EXPOSURE
 The threshold dose 300 rads (3.0 Gray)
 The effect erythema occurs within a day of the exposure and then
disappears.
 The effect may recur 8-14 days later pain in the affected tissue.
 After a few days, the skin may return to its normal appearance but
remain highly sensitive.
 For doses in excess of 5000 rads (50 Gray) blood flow problems
atrophy and ulcerations.
 may eventually require the amputation of fingers or major portions
of the hand.
 Occupational Dose Limits for

External Exposures to Ionizing Radiation.

Quarterly Annual

Whole body; head and trunk; lens of eye; 1.25 rems 5 rems
gonads

Hands and forearms; feet and ankles 18.75 rems 18.75 rems

Skin of the whole body 7.5 rems 30 rems

 RADIATION PROTECTION
Time

 Three factors Distance

Shielding

ALARA : "As Low As Reasonably

Achievable".
 CHEST X-RAY
Mammography equipment
CT Scan machine
MRI Machine
Ultrasonography GE Logic-E9
HRCT CHEST CORONAL
CT Scan Thorax Axial
Coronal T 1-weighted
Coronal gadolinium-enhanced T 1-
weighted
Respiratory Tract
 Imaging in Paranasal
Sinus
 Conventional x-rays (radiographs) can be
taken from four angles or views, known as :
 Caldwell's projection: posterior anterior (PA)
projection provides good visualization of the
frontal sinus and ethmoid air cells.
 Lateral projection: for the sphenoid,
maxillary sinuses, frontal and ethmoid
sinuses.
 Water's projection: for the maxillary sinuses.
 Submentovertical projection: for the
 RESPIRATORY TRACT

Upper Respiratory Tract

Cavum Nasi Nasopharynx

Larynx

Water’s position
Lateral Skull Photo
IMAGING : Cervical photo AP and
Lateral
CAVUM NASI
SINUS PARANASALIS
CALDWELL POSITION
Adult Skull - Lateral View
LEVORT FRACTURE
 The radiologic characteristics of sinusitis are
demonstrated in the images below.

Air-fluid level Right-sided Bilateral ethmoid

(arrow) in the sphenoethmoidal sinusitis on an MRI.
maxillary sinus pattern of sinusitis.
suggests
sinusitis
 ADVANTAGES OF CT OVER MRI ADVANTAGES OF MRI OVER CT

BONY DETAIL: CT identifies bony SUPERIOR SOFT TISSUE

details such as the extent of DISCRIMINATION: This permits
pneumatization of the ethmoid air cells, better assessment of the interface
the location of the natural maxillary between a pathological mass and
ostium, septations of the sphenoid sinus surrounding normal structures
and the position of the internal carotid
artery.
MUTLIPLANAR: Any anatomical
COST: Presently, CT is significantly plain must be viewed without a patient
less expensive than MRI. It is also having to take up several uncomfortable
more readily available. positions. The coronal plane is mostly
used in the study of the head and neck.
EXAMINATION TIME: CT takes only VASCULAR ANATOMY: Vascular
seconds to take sliced images. MRI structures are readily seen without
requires several minutes per slice. contrast material

PATIENT COMFORT: MRI scanners ARTIFACTS: Dental artifacts are not

are noisier and more confining than CT seen on MRI, but are seen on CT scans.
VALUE OF CT SCAN PARANASAL
SINUS
Allergic fungal sinusitis -
unenhanced CT
Lymphoma of sphenoid sinus and skull
base
Bilateral mucoceles
Normal anatomy larynx
 LARYNX

Lateral radiograph of the neck showing the

different structures of the larynx: a,
vallecula; b, hyoid bone; c, epiglottis; d,
pre-epiglottic space; e, ventricle (air-space
between false and true cords); f, arytenoid;
g, cricoid; and h, thyroid cartilage.
Epiglottitis in an adult
 EPIGLOSITIS AND CROUP

Epiglottitis (Supraglottitis) Croup. Lateral film shows dilatation of the

pyriform sinuses (P) and the valleculae (V),
with narrowing between the arrowheads of
the subglottic larynx.
 TUMOR LARYNX

CT scan shows tumoral CT scan shows a subglottic cancer

involvement of the right vocal along
cord. the cricoid cartilage
TUMOR LARYNX

Axial view on CT scan of an advanced right

laryngeal tumor invading through the
thyroid cartilage.
 TUMOR LARYNX

Dedifferentiated chondrosarcoma arising

in the thyroid cartilage. Axial CT bone
window shows the chondrosarcoma
expanding (arrowheads) the ala of the
thyroid cartilage. Note the ringlet organified
matrix (arrow) within the lesion.
 TUMOR LARYNX

Dedifferentiated chondrosarcoma arising in

the thyroid cartilage. The mass enlarged
rapidly. Axial CT with contrast shows a
large soft-tissue component (arrowheads)
extending anteriorly and laterally. Histology
of the soft-tissue component was
consistent with fibrous histiocytoma.
THORAX EXAMINATION

1. RO :
 FLUOROSCOPY
 RADIOGRAPHY
 P.A. INS. / EXP.
 A.P
 LAT.R / L
 RAO / RPO / LAO / LPO
 LAT. DECUBITUS R / L
 TANGENSIAL
 TOMOGRAPHY
 BRONCHOGHRAPHY
 ARTERIOGRAPHY
2. CT – SCAN
3. USG
4. MRI
5. RADIO ISOTOP SCANNING
 Reading the CXR
1. Dim room lighting
2. Check patient information - name, age, sex, date of radiograph and if multiple
images arrange them in chronological order
3. Identify radiographic technique - AP/PA film, exposure, rotation, patient position
(supine, sitting or erect)
4. Soft tissues – thickness, contours, presence of gas, masses
5. Bones – density, lesions or fractures
6. Identify and check position of lines, tubes and other invasive devices
7. Lungs - look for abnormal densities (opacity or lucency) or pneumothorax
8. Pleura - thickening, calcification, effusion or pneumothorax
9. Trachea - midline or deviated, wall, lumen diameter
10. Mediastinum - width and contour, discreet masses
11. Heart - size and shape
12. Pulmonary vessels - artery or vein enlargement
13. Hila - position, masses or lymphadenopathy
14. Check review areas - apices, especially right upper lobe, retrocardiac area, the
peripheral lung margins, posterior costophrenic sulci, and the diaphragm.
How do you look at
a

chest x-ray ?

or

Avoid tunnel
vision !
The Lateral Chest
Film
“Ring ar ound the bronchus”
 Technical
Factors

Positioning

straight vs
oblique
Effect of obliquity on heart size
 Tuberculosis Overview
Tuberculosis (TB) is an infectious disease

Two organisms cause tuberculosis

since the Neolithic times.

Mycobacterium tuberculosis Mycobacterium

bovis.
 Once infectious particles reach the alveoli
(small saclike structures in the air spaces in the
lungs),
another cell, called the macrophage,
engulfs the TB bacteria.

lymphatic system
bloodstream

spread to other organs

 CLINICAL CLASSIFICATION OF THE TBC BY
THE AMERICAN THORACIC SOCIETY

1. CLASSIFIED BY EXTENT ONLY

a. Minimal lesion
b. Moderately advanced lesion
c. Far advanced lesion

2. CLASSIFIED BY THE DYNAMIC OR APPARENT ACTIVITY

a. In active
b. Active
c. Quiescent
d. Chronic fibroid tbc
Tuberculous cavities in the right
upper lobe are shown here.
Tubercle bacilli in the lung tissue

Kinyoun stain
mycobacteria in sputum
sample.
cavity-like lesion in right upper lobe of her
lung.

One month later,

with three medications for TB
LUL cavity and RUL infiltrate bilateral upper
lobe disease
Tuberculosis LUL cavity RUL
infiltrate
Tuberculosis LUL cavity right pleural
effusion
Tuberculosis LUL cavity
Tuberculosis upper lobe disease
Miliere Tuberculosis
Miliary Tuberculosis
Miliere Tuberculosis
High Resolution CT Scan
Thorax
Pleurisy Tuberculosis
Tuberculosis Spine
 ACUTE BRONCHITIS

Definition

Acute bronchitis is an inflammation of the main

airways to the lungs (the bronchi) that usually lasts for
a brief period of time.

It is not the same as chronic bronchitis, which often

persists for a longer period of time.
 What is Bronchiolitis ?

Viral lower respiratory infection affects children up

to the age of 12 months

Respiratory Syncytial Virus (RSV) is the most

common cause,
however other viruses can also cause
bronchiolitis.

The illness usually peaks on the second or third

day with gradual resolution over 7-10 days.

The cough may persist for several weeks

 Chest X-rays:

CXR in bronchiolitis will show signs of hyperinflation,

peribronchial thickening, and often patchy areas of
consolidation and collapse.

This may lead to some confusion with pneumonia, however

if hyperinflation and wheeze are present the diagnosis
should be regarded as bronchiolitis.

The aetiology of pneumonia in this age group is

predominantly viral.

• A CXR should be done if complications are suspected

e.g. Pleural effusion or extraneous air.

• A CXR is indicated in severe cases or where diagnosis

Bronchioliti
s
Chest Xrays:
AP and Lateral
Bronchial Asthma
Bronchial Asthma
Chest X-Ray in Bronchial Asthma

Normal Chest X-Ray

Emphysema is a lung disease that involves
damage to the air sacs (alveoli) in the
lungs.
Chronic Obstructive Pulmonary
Diseas
Emphysematous Lung ( COPD )
 Atelectasis is loss of air in the
 Types of Atelectasis: alveoli
 Resorptive Atelectasis
 When airways are obstructed there is no further ventilation to the lungs and
beyond. In the early stages, blood flow continues and gradually the oxygen and
nitrogen get absorbed, resulting in atelectasis.
 Relaxation Atelectasis
 The lung is held close to the chest wall because of the negative pressure in the
pleural space. Once the negative pressure is lost the lung tends to recoil due to
elastic properties and becomes atelectatic. This occurs in patients with
pneumothorax and pleural effusion. In this instance, the loss of negative pressure
in the pleura permits the lung to relax, due to elastic recoil. There is common
misconception that atelectasis is due to compression.
 Adhesive Atelectasis
 Surfactant reduces surface tension and keeps the alveoli open. In conditions
where there is loss of surfactant, the alveoli collapse and become atelectatic. In
ARDS this occurs diffusely to both lungs. In pulmonary embolism due to loss of
blood flow and lack of CO2, the integrity of surfactant gets impaired.
 Cicatricial Atelectasis
 Alveoli gets trapped in scar and becomes atelectatic in fibrotic disorders.
 Round Atelectasis
 An instance where the lung gets trapped by pleural disease and is devoid of air.
Classically encountered in asbestosis.
Right Lung Atelectasis
Left Lung Atelectasis
Relaxation atelectasis
RML Lateral Segment Atelectasis
Round Atelectasis
 Bronchiectasis
Radiologic findings include:
 Normal appearing CXR in most
 Tubular shadows
 Tram line
 Gloved fingers
 Mucocele
 Ring shadows with thickened bronchial walls
 Air fluid levels
 Watch for dextrocardia
 Immotile cilia syndrome
 Diffuse lung fibrosis
 Due to recurrent infections
Sacular bronchiectasis
Cystic Fibrosis - Bronchiectasis

Bilateral diffuse
Multiple cavities / Bronchiectasis
Peribronchial fibrosis
Prominent hilum
Hyperinflated
 Bronchiectasis
Multiple bilateral basal air fluid
levels
 Bronchiectasis
Multiple bilateral basal air fluid
levels
Saccular Bronchiectasis
Adult Respiratory Distress Syndrome

Non-cardiogenic pulmonary edema

Distinguishing characteristics:
Normal size heart
No pleural effusion
 Pneumonia
The radiological pattern of pneumonia helps in suspecting the
etiology.
The most common causes for each radiological presentation is as
follows.:
Lobar Pneumonia Bronchopneumonia
1.Pneumococcus 1Streptococcus
2.Mycoplasma 2.Viral
3.Gram negative organisms 3.Staph
4.Legionella
Necrotizing Pneumonia Segmental Pneumonia
1.Staphylococcal 1.Post obstructive
2.Anaerobic infection 2.Aspiration
3.Gram negative organisms
Round Pneumonia Diffuse Alveolar
1.Fungal Pneumonia 1.Pneumocystis
2.Tuberculous 2.Cytomegalovirus
Diffuse Interstitial Radiation port
Pneumonia 1.Viral 1.Radiation pneumonia
2.Chickenpox
 Pneumonia

Consolidation Right Upper Lobe

Air Bronchogram
Diffuse Alveolar Pneumonia
Radiation Pneumonia
 Aspiration
Foreign body / Peanut / Coin
Partial obstruction
Complete obstruction / Atelectasis

Mineral oil
Lipoid pneumonia
Middle , lingula and lower lobes

Oropharyngeal bacteria
Gravity dependant segment
Superior segment of RLL and LLL
Axillary sub-segment of RUL anterior and
posterior segments
Lung abscess

Gastric acid
ARDS
Segmental Pneumonia
Aspiration Pneumonia
Coin in left main bronchus
 Aspirated Tooth

Partial obstruction
Right lung smaller than left
Tooth in right bronchial tree
 Aspirated Tooth

Note tooth in right bronchial

tree
Pneumothorax is air in
the pleural space.
Radiological criteria:
No lung markings in pleural space.
Recognition of atelectatic lung (lung
margin).

Shift of mediastinum to the opposite

side.

Larger hemithorax.

Opposite lung gets the entire cardiac

output and the vascular markings
become prominent.
 PNEUMO THORAX

Spontaneus pneumo thorax

 Traumatic pneumo thorax
 Artificial pneumo thorax
 Tension pneumo thorax
Loculated/encysted pneumo thorax

Complication
Haemo pneumo thorax
Pyo pneumo thorax
Hydro pneumo thorax
 Tension Pneumothorax

No vascular markings on right

Shift of mediastinum to left
Deep sulcus
Atelectatic right lung
Increased haziness on left:
Diversion of entire cardiac output
Pneumothorax
Tension Pneumothorax
Pneumothorax
Chest Tube
Pneumothorax Post Chest Tube
 LUNG CANCER
 Classification
 1.1 Non-small cell lung carcinoma (
NSCLC )
 1.2 Small cell lung carcinoma ( SCLC )
 1.3 Others
 1.4 Secondary cancers
 1.5 Staging
 LUNG CANCER

Cross section of a human lung.

The white area in the upper lobe
is cancer; the black areas are
discoloration due to smoking.
 LUNG CANCER

Micrograph of squamous
carcinoma, a type of non-small
cell carcinoma.
FNA specimen.
 LUNG CANCER

Chest radiograph
showing a CT scan
cancerous tumor
in the left lung.
 LUNG CANCER

Chest radiograph showing lung cancer.

 LUNG CANCER

Chest radiograph showing a Pancoast

tumor (labeled as P, non-small cell
lung carcinoma, right lung),
LUNG CANCER

Pancoast Tumor
 LUNG CANCER

Solitary pulmonary nodule

as carcinoma on chest
radiograph.
 LUNG CANCER

Bronchioloalveolar cell carcinoma.

Posteroanterior chest radiograph shows
patchy areas of consolidation in the right
lung, confluent consolidation in the left
lower lobe, and bilateral poorly defined
 LUNG CANCER

Bronchioloalveolar carcinoma. High-

resolution CT image shows extensive
consolidation and mild volume loss in the
right middle lobe and patchy consolidation,
ground-glass opacities and small nodular
opacities in the lower lobes
 LUNG CANCER

True positive integrated

PET/CT in a 70-year-old
man with adenocarcinoma
of lung.
LUNG CANCER

True positive integrated

PET/CT in a 70-year-old
man with adenocarcinoma
LUNG CANCER

Bubble-like lucencies
in adenocarcinoma.
 LUNG CANCER

Lung, carcinoid. Chest radiograph CT scan of the same

patient obtained with soft-
tissue window settings
 LUNG CANCER

Lung, carcinoid.
CT scan obtained with lung Standard posteroanterior (PA)
window settings confirms a
mass lesion in the left lower
lobe.
LUNG CANCER

Pneumonectomy specimen
containing a squamous cell
carcinoma, seen as a white
BE SMART