Medical science

1. Visual diagnostics
of the
respiratory system

2. Methods of studying the respiratory system:
• Fluorography
• Radioscopy
• Radiography
• Tomography
• Bronchography
• Angiopulmonography
• Ultrasound diagnostics
• Computed tomography
• Magnetic resonance imaging
• Radionuclide diagnostics
• PET/CT

3. Direct projection Lateral projection
Chest X-ray

4. Anterior
posterior
projection
Chest X-ray

5. Right lateral projection.

6. Right lateral projection: the contour of
the right dome of the diaphragm is
higher than the left, no breaks of the
shadow
Left lateral projection: The contours of
the right and left dome of the
diaphragm are at the same level, with
break due to the heart shadow

7. Evaluation of the quality of the X-ray image
1. Rigidity of the image:
Soft – less than 3 thoracic vertebrae
Medium – 3 thoracic vertebrae
Rigid – more than 3 thoracic vertebrae
2. Symmetry
The distance from the spinous process to the medial end of the clavicles
should be the same
3. Sinuses visible or not
4. Apexes visible or not
5. Are the shoulder blades spread

9. Pulmonary fields

10. retrosternal space
retrocardium space

11. Sternum
is clearly detected only on the lateral projection, it is the
criterion for the correctness of the patient's installation. On
the radiograph in the anterior projection, the manubrium of
the sternum can sometimes be determined, the outline of
which can imitate pulmonary pathology.
Synostosis of the sternum in the lower part of its body
occurs at the age of 15-16 years, in the upper part - at 25
years.

12. Sternum

13. The skin fold above the clavicle is displayed as a low-intensity, but
clearly defined second contour of the clavicle. On the internal parts of
the upper extremities of the lungs, the sternocleidomastoid muscles
(GCSM) are projected as low intensity shadow, which is not always
symmetrical.
At the level of II-IV intercostals, an image of the large and small pectoral
muscles is detected in the form of a slight decrease in transparency, the
intensity of which increases slightly to the peripheral parts of the lungs.
The lower contour of the muscles is determined outside the pulmonary
fields.

14. Trachea
is defined in the anterior projection in the median plane against the
background of the spinal column in the form of a band of enlightenment
with clear, even contours. Normally, the cartilage of the trachea is not
determined, but when calcified, it becomes visible on the image. The
bifurcation of the trachea is located at level Th V vertebra, which
corresponds to the level of the I-II ribs on the anterior chest wall. The
angle of bifurcation is 90 ° or less.
Main bronchi
diverge to the hilus pulmonic at straight angle. The right main bronchus
is straight, short, wide, looks like an extension of the trachea, in the right
tracheobronchial corner an unpaired vein is determined. The left main
bronchus is longer, about 1.5 times narrower than the right and moves
away from the trachea at a large angle.

15. trachea
Trachea
bifurcation
Main
bronchi

16. On the radiograph in the lateral projection, the trachea is
defined as a band of enlightenment; the place where the
shape changes in the distal region is the place of transition
of the trachea to the main bronchi.
On plain radiographs, lobar and segmental bronchi can be
detected. Tomography helps to visualize them up to
subsegmental parts.
On x-rays, the bronchi in the hilus regions and medial-basal
parts of the lungs are usually seen as light bands surrounded
by parallel lines of shadows from the bronchi's walls. The
bronchi are cut in a way that is either straight across or at an
angle. This makes ring-shaped or oval lumens.

17. Main bronchi
trachea

18. Diaphragm
-In the anterior projection of the x-ray, the right dome is at the same level
as the front segment of the VI rib, while the left dome is one rib lower. In
the lateral projection, you can see both domes of the diaphragm at the
same time. X-ray schialogy explains why the dome of the diaphragm next
to the film is always higher than the rest of the dome.
-In the anterior and lateral projections6, between the diaphragm and the
chest wall, sinuses are determined: in lateral projections - anterior and
posterior pleural sinuses (deeper); in the anterior projection - lateral
pleural sinuses. Between the diaphragm and the heart, right and left
cardiodiaphragmatic angles (sinuses) are distinguished, the parameters
of which depend on the state of the left ventricle and right atrium

20. Roots of the lungs
Located on the medial surface of the lungs in the area of the hilus. The
definition "root" includes the lobular, zonal and intermediate bronchi, the
pulmonary arteries of their lobe and zonal branches, the same veins, lymph
nodes, connective tissue and fatty tissue. On radiographs - in the anterior
projection, the roots are located between the anterior segments of the II and
IV ribs, the upper border of the root of the left lung is located approximately
one intercostal above the upper border of the root of the right lung.
An adult's lung root is between 2 and 3 cm wide. It is made up of three
parts: the head (the arch of the pulmonary artery and the vessels that
branch off of it), the body (the trunk of the pulmonary artery), and the tail
(the last branches of the pulmonary arteries). At body level, the root
shouldn't be wider than 1.5 cm. It is measured from where the median
shadow ends to where the pulmonary artery curves outward. Most of
the time, the root is structural, and the clear, outer contour on the right is
straight or concave. On the left may be variable

21. roots of the lungs
II-IV ribs

22. Pulmonary pattern (vascularity)
This term refers to a group of normal body parts that show up on x-rays as
pulmonary fields. In young and middle-aged people, these structures are the
vessels of the arterial and venous systems and the third- and fourth-level
bronchi.
At age 50, interstitial connective tissue starts to form in the structure of the
pulmonary pattern. This causes the pattern’s vision to change it’s
representation as cellular, mostly in the lower parts of the lungs.

23. Costa diaphragmatic sinuses
Pulmonary pattern
cardiodiaphragmatic sinuses
Costa diaphragmatic sinuses

24. Linear Tomography

25. Mediastinal lymph nodes
paratracheal lymph nodes
tracheobronchial lymph nodes
bifurcation lymph nodes
bronchopulmonary lymph nodes

26. Plain chest Xray in anterior posterior view
1 — front end of the ribs 2 — trachea and main bronchi; 3 —ribs;
4 —right side low lobe artery; 5 — diaphragm 6 — back end of the ribs
7 — root of the left lung; 8 — contour of the right breast, 9- root of the right lung
1
2
9 7
5
8
3
4
6
Xray anatomy of the chest

27. Perfusion scintigraphy of the lungs
 It is based on temporary vascular embolization.
 Indications:
-Thromboembolism of the branches of the pulmonary artery
- Lung infarction
- Chronic obstructive pulmonary diseases
- Regional ventilation disorders
- Emphysema
- Evaluation of pulmonary blood flow before and after radical
reconstructive and palliative surgery and endovascular surgery on
the pulmonary artery and its branches

28.  Human serum albumin microspheres labeled with 99mTc are given through an
IV.
 The more capillaries are blocked, the higher the contrast of the image and vice
versa (with thromboembolism, microspheres cannot penetrate the capillary of
the embolized area).

 The amount of injected albumin particles is from 60 thousand to 300 thousand
(optimal for an adult - 100 -200 thousand).
 Contraindications for the introduction of more than 100 thousand albumin
particles: children under 15 years of age, high pressure in the pulmonary
circulation, the presence of heart disease - blood discharge from right to left.
 The test is done right away or between 5 and 10 minutes after the drug is given.
The detectors are put on the front and back of the chest in an angled way. The
study is polypositional!
 Each lung should be divided into three zones: front (100%) and back (100%) - a
total of 100%.
 The rate of the most accumulation in the back of the basal parts.

30. Ventilation scintigraphy of the lungs
 Indication: obstruction of the bronchial tree.
 Inhalation of finely dispersed aerosols labeled with xenon 133, 127
(more expensive and longer half-life).
 The duration of inhalation is 5-10 minutes.
 The method is highly sensitive to tobacco smoke, so the patient is
advised to stop smoking three days before the procedure.
 The patient can swallow saliva, and sputum spits into a napkin, with its
further placement in the storage of radioactive waste.
 The study is polypositional!

32. Imaging of pneumonia
Main
1) Radiography
* in 2 projections
* in the phase of deep breathing with
breath holding
* if possible in an standing position
Additional
1) ULTRASOUND
* pleura , pericarditis
* subdiaphragmatic
space
2) Computed tomography
* changes in the lungs not visible on
Xray (ground glass, milliary foci)

33. Indications for Radiography
- Confirmation / exclusion of the disease;
- Localization and prevalence;
- Complications (pleurisy, abscess, pneumothorax);
- Detection of another pathology (cancer, abscess, etc.);
- Evaluation of dynamics during/after treatment

34. Indications for ultrasound
- Method for detecting pleural effusions
- To replace fluoroscopy and laterography
- Differential diagnosis of consolidation in the lung and
pleural effusion
- Ultrasound usually does not reveal interlobular pleurisy
- for puncture and drainage under the control of ultrasound

35. Indications for CT
 Controversial radiography data
 Radiography data and the clinical picture of the disease don't
match up
 Differential diagnosis (abscess, pulmonary edema, acute
tuberculosis, etc.)
 Complications (pneumothorax, encapsulated pleurisy, atelectasis,
bleeding, etc.)
 Prolonged pneumonia
 Recurrent pneumonia

36. Pneumonia:
1. Primary
• Bacterial
• Viral
• rickettsial
• Parasitic
• Fungal
2. Secondary
• with disorders in the pulmonary circulation (congestive, hypostatic,
infarction, pulmonary edema)
3. With changes in the bronchi
4. Aspiration
5. In various diseases (septic, metastatic, infectious diseases, allergies)

37. Pneumonia
Acute Chronic

38. X-ray classification
Focal: local damage to the segment or lobe, or local pulmonary pattern
enhancement with peribronchial and perivascular infiltration (previously,
such pneumonias were interpreted as bronchopneumonia - now this
terminology is not used)
Polysegmental means that two or more segments of the lung have been
massively infiltrated (previously, such pneumonias were treated by
radiologists as croupous - now this interpretation is not used in radiology)
Interstitial: сhanges on x-rays are caused by the interstitial tissue. Usually,
changes are on both sides

39. position
number
form
size
intensity
pattern
contours
structure
Changes in the lungs are described according to the following
scheme:

40. Stages of pneumonia
Congestion stage
1. Strengthening and enrichment of the
pulmonary pattern due to hyperemia
2. Transparency is normal or slightly
reduced
3. The root of the lung on the side of the
lesion expands somewhat, its shadow
becomes less distinct - homogenized
When localizing the process in the lower
lobe, fluoroscopy reveals decreasing in
excursions of the corresponding dome of
the diaphragm.

41. Hepatization stage
1. Intensive decrease in the
transparency of lung tissue,
within the anatomical
boundaries, corresponding to
the affected area
2. The size of the affected area
(within the anatomical
boundaries) is normal or slightly
enlarged (in contrast to
atelectasis)
3. Some of the shadows get
darker as they move toward the
edges.

42. 4. In the medial parts of the lesion, "streaks of enlightenment" are
differentiated - the free lumen of large and medium bronchi (better
detected on tomograms)
5. The root of the lung, on the side of the lesion is expanded, its shadow
is homogenized
6. Contoguos pleura is thick
7. A certain amount of fluid can be found in the pleural sinuses (better
determined in lateral laying position)

43. Resolution stage
1. Reducing the intensity of the
shadow of the affected area
2. Fragmenting the shadow, and
reducing it in size
3. Root shadow extended, non-
structural, homogenized
4. Pulmonary pattern enhanced,
enriched

44. Residual changes that are
determined within 4 weeks after
"clinical recovery"
1. Enhanced, enriched pulmonary
pattern.
2. Extended and partially
homogenized shadow of the lung root

45. Focal pneumonia
The inflammatory focus is usually limited to a single lobule. Multiple foci appears at
different time
1. Characterized by the presence of 1–1.5 cm focal shadows on both sides, which
are the same size as the pulmonary lobules.
2. The number of foci increases in the direction downwards.
3. The outlines of the foci are fuzzy, the intensity of the shadow is low.
4. The apexes in most cases are not affected.
5. The pulmonary pattern is enhanced throughout the pulmonary fields due to
hyperemia.
6. The shadows of the roots of the lungs are expanded, their structure is
homogeneous.
7. The reaction of the pleura is noted.
8. Diaphragm mobility is limited in most cases.

48. - occurs with acute inflammation of the alveolar tissue of the lung, which
develops as complication of bronchitis or bronchiolitis

49. Segmental pneumonia
 Extends to one or more segments of the lung
 Fuzzy contours of the affected area
 Symptom of "air bronchogram" in the compacted are

50. Symptom of air bronchogram
 (Left) An X-ray of the chest of a patient with right-sided upper lobe pneumonia shows a
large consolidation with an internal air bronchogram. This shows that the patient does not
have a central obstructive lesion. But consolidation should be observed until it is
completely gone so that the underlying cancer can be ruled out
 (Right) coronary CT scan of a patient with pneumonia reveals a large consolidatation of
the upper lobe of the right lung with an air bronchogram

51. Segmental pneumonia

52. Segmental pneumonia

53. Polysegmental bronchopneumonia, the right lung, in the middle and
lower part of the pulmonary field, heterogeneous focal-confluent
infiltration and strengthening of the pattern are determined

54. Interstitial pneumonia
 - Inflammatory interstitium infiltration
 - edema and lymphocytic infiltration of the walls of the bronchi, bronchioles
 - Distribution along the interlobular septa
 - lymphocytic infiltration of peribronchial alveoli

 X-ray semiotics
 - Diffuse enhancement of the interstitial component of the pulmonary
pattern
 - thickening of the pulmonary pattern
 - loss of clarity of the elements of the pulmonary pattern
 - expansion of the roots of the lungs
 - The process is usually affects both lungs
 - reticular changes in the pulmonary pattern with predominant central
distribution
 - there may be focal shadows melting with each other
 - ”ground glass" symptom

55. -the pathological process is localized in the interstitial
tissue of the lung, mainly in the walls of the alveoli
- A decisive role in the detection of interstitial pneumonia
belongs to MSCT

58. Most of the time, heart
defects (most often stenosis
of the left atrium-ventricular
foramen), damage to the
heart muscle, and problems
with the heart's rhythm are
what cause blood to get
trapped in the pulmonary
circulation and cause
inflammation.
Congestive pneumonia

59. 1. The transparency of the pulmonary fields decreases due to a decrease
in the airiness of the lungs.
2. With less transparency, you can see darker spots that range in size from 2-3
mm to 2-3 cm and more.
3. At the intersection of linear shadows of enhanced pulmonary pattern, a large
number of small-diameter nodular shadows can be seen. They are most
noticeable in the root area.The number and size of these shadows decreases
toward the periphery of the lungs.
4. When stagnation persists for an extended period of time, nodules of
hemosiderosis form. Hemosiderosis nodules are also more widespread in the
center of the lungs, especially in the root parts.
6. The roots of the lungs expand and become homogeneous (expansion of
large vessels and their fullness, hyperplasia and swelling of the lymph
nodes of bronchopulmonary groups, lymphostasis and infiltration of the
fiber of the lung root area). At the same time, the shadows of the roots
become branchy, and their external contours are fuzzy.

60. 7. In the pleural cavities, fluid is often found - transudate or exudate.
8. Sometimes effusion can be detected in the pericardium.
9. The configuration of the heart is often mitral.
10. Single or few well-defined shadows – Kerley lines or lines B.

61. Hypostatic pneumonia is a type of congestive pneumonia that happens when
blood and fluid accumulate in the bottom parts of the lungs due to gravity. It
happens to old or sick people who have to lie down for a long time because
they can't move. This makes it easier for inflammatory changes to happen.
X-ray semiotics is characterized by a number of additional symptoms that
characterize congestive pneumonia, these are:
1. Reduced transparency of the basal parts of the lungs on one or both sides.
The upper boundary is fuzzy, the lower one merges with the diaphragm.
2. Costo-diaphragmatic sinuses are poorly differentiated or do not differentiate
at all.
3. Fluid (transudate, exudate) accumulates in the pleural sinuses.
Hypostatic pneumonia.

62. Pneumonia in immunodeficiency patients
 Pneumonia in immunodeficiency patients has great clinical importance, as it is
the leading cause of their death.
 Infectious agents: protozoa (Pneumocystis carinii), pathogenic fungi (Aspergil,
Histoplasma capsulatum, Coccidiodis immitis), bacteria (Streptococcus
pneumonia, Haemophilus influenza), Viruses (Cytomegalovirus).
 The etiology of the inflammatory process significantly depends on the nature
and duration of the main disease: neutropenia - bacterial and fungal infection;
lymphopenia is a viral and protozoal infection.
 In performing an X-ray assessment, the clinical picture of the disease is taken
into account. The study starts with a radiographic study of the lungs from two
different projections.
 X-rays may not show any changes in 10–15% of patients. In these situations,
you should get a CT scan.

63. Pneumocystis pneumonia
 • Ground glass
 • «crazy pavement»
 • Predominant central localization
 • Upper lobes
 • Pulmonary cysts

64. Aspiration pneumonia
• most often in the lower lobes
• ”ground glass" • and/or consolidation
• bronchiolitis
• centrilobular foci
• "tree in buds"

65. Periscissuritis
– inflammatory process localized along the periphery of the lobe and
adjacent to the interlobular pleura

66. Complications of pneumonia
1. ABSCESS
2. EXUDATIVE PLEURISY
3. ACUTE RESPIRATORY FAILURE
4. ADULT RESPIRATORY DISTRESS SYNDROME
5. PULMONARY EDEMA

67. Complications of pneumonia
Right-sided paracostal encapsulated pleurisy
The paracostal darkening has a wide base and is close
to the costal pleura. The convex contour confronts the
lung tissue.
Right-sided pyopneumothorax (pleural empyema)
On the right, the cavity of an empyema with a horizontal
level is found paracostally.

68. Radiological signs: an increase in the intensity of the shadow of the infiltrate,
the disappearance of the air lumens of the bronchi in it; an increase in the
volume of the affected part of the lung; the appearance of destruction.
Abscessed pneumonia