呼吸系統(tǒng)影像診斷課件

呼吸系統(tǒng)影像診斷BronchialObstruction局部支氣管狹窄stenosis支氣管閉塞Obstruction腫塊massinbronchialcavity管壁增厚thickenedofbronchialwalldirectnesssigns重點(diǎn)復(fù)習(xí)

Indirectnesssigns：阻塞性肺氣腫：部分阻塞

Incompleteobstruction—obstructiveemphysema阻塞性肺不張：完全阻塞.Completeobstruction—obstructiveatelectasis.

centrilobularemphysema肺體積膨大Overinflation密度減低Densityreducepanlobularemphysema肺體積縮小Incompleteexpansionofthelung,Thesizeoflungshrunken密度增高

Increaseddensity

obstructiveatelectasis.

obstructiveemphysema

纖維化fibrosis局部病灶纖維化Localfibrosis彌漫性間質(zhì)纖維化

DiffuseinterstitialfibrosisCalcificationnoduleandmassBenignMalignantlobulationspiculation血管集束征病灶胸膜側(cè)小片狀浸潤支氣管充氣征空氣半月征

Aircrescentsign曲菌球

支氣管血管束增粗peribronchovascularburdleinterstitialthickingSignet-ringsign印戒征小葉間隔增厚Interlobularseptalthicking

小葉核增大Lobularcorethicking樹芽征（tree-buddedsign）肺間質(zhì)病變interstitialnodulesmultinodularandmiliarydiseasesair-spacenodule

胸腔積液

（pleuraleffusion）

游離性胸腔積液freepleuraleffusion

少量積液中量積液：大量積液：

局限性胸腔積液localizedpleuraleffusion包裹性積液葉間積液肺底積液胸膜凹陷征胸膜凹陷征pleuralindentationsign支氣管擴(kuò)張bronchiectasis肺炎pneumonia

大葉性肺炎小葉性肺炎間質(zhì)性肺炎支原體肺炎肺結(jié)核Pulmonarytuberculosis肺癌Lungcancer縱隔腫瘤mediastinaltumor本節(jié)課內(nèi)容bronchiectasis臨床表現(xiàn)：咳嗽、咳血、咳痰Continuouscough,purulentsputum,recurrenthaemoptysis分型：柱狀型(Cylindricalbronchiectasis)、囊狀型(Cysticbronchiectasis)、曲張型(Varicosebronchiectasis)病理：pathologicchangings支氣管壁組織破壞（慢性感染）管內(nèi)壓增高（分泌物淤積、長期劇烈咳嗽）外在性牽拉（肺不張、纖維化等）bronchiectasis平片：plainchestradiographicfindingsoftennonspecific肺紋理增粗紊亂，囊狀透亮影，anincreaseoflungmarkings

Surroundinginfiltrateorfibrosis合并感染時有液平及囊壁增厚。dilatedbronchi,sometimeswithair-fluidlevelsbronchiectasis曲張型擴(kuò)張TubularandCystic

bronchialdilatation念珠狀粗細(xì)不均囊柱狀bronchiectasis平片價值有限,支氣管造影病人痛苦主要依靠CT診斷

HRCT(

highresolutionCT)bronchiectasis軌道征軌道征Tram-tracksign囊柱狀粗細(xì)不均念珠狀柱狀型

曲張型bronchiectasis葡萄串征clustersofgrapessign囊狀型葡萄串征clustersofgrapessign液平air-fluidlevels囊壁增厚囊狀型bronchiectasisDilatationofthebronchus,BronchialwallthickeningSometimesair-fluidlevels肺炎(pneumonia)ClassficationofpneumoniaAccordingtotheanatomicpositionofthelesion:

Lobarpneumonia

BronchopneumoniaorLobularpneumonia

InterstitialpneumoniaAccordingtotheetiologyofthepneumonia按病變分布分為：

大葉性肺炎Lobarpneumonia

炎癥累及肺葉或肺段支氣管肺炎(小葉性肺炎)

bronchopneumoniaorLobularpneumonia

炎癥累及多個肺小葉為主間質(zhì)性肺炎Interstitialpneumonia

炎癥累及肺間質(zhì)為主Lobarpneumonia—大葉性肺炎臨床Causedbypneumococcus肺炎鏈球菌致病Onsetsuddenly,rapiddevelopmentofhighpyrexia,pleuriticpaincoughAcharacteristicrustycolorsputum鐵銹色痰pathologicchangings

of

Lobarpneumonia

Thebasicpathologiclesion:Acuteinflammatoryexudationofthepulmonaryparenchyma

病理分四期：充血期Thecongestivestage:

毛細(xì)血管充血為主Inflammatoryedema紅色肝樣變期Theredconsolidationstage

:

肺泡內(nèi)充滿滲出液,有較多紅細(xì)胞,肺組織切面呈紅色灰色肝樣變期Thegrayconsolidationstage

:

肺泡內(nèi)有較多白細(xì)胞,肺組織切面呈灰色消散期Resolutionstage:

肺泡內(nèi)滲出物溶解,吸收X線表現(xiàn)

X-rayfeatures影像學(xué)表現(xiàn)與病理改變密切相關(guān),是病理改變在影像學(xué)上的反映

充血期Thecongestivestage可無陽性發(fā)現(xiàn),臨床癥狀出現(xiàn)3--12小時后才出現(xiàn)X線征象

NoX-raychanges病變區(qū)肺紋理增多，透亮度減低

anincreaseoflungmarkingLobarpneumonia實(shí)變期（紅色或灰色肝樣變期）Theconsolidationstage密度均勻的致密影alargehomogeneousradiopaqueshadowinthelungfieldNovolumelossAirbronchogramiscommon累及肺葉：以葉間裂為界的大片致密影,但體積不縮小,無葉間裂的移位右中葉肺炎LobarpneumoniaLobarpneumoniaTheX-rayfeatureisalargehomogenousradiopaqueshadowthereisnovolumelossairbronchogramiscommonBordersoftheshadowappearasasharplydefinedmargin實(shí)變期（紅色或灰色肝樣變期）密度均勻的致密影homogeneousradiopaqueshadow累及肺段：片狀或三角形,尖端指向肺門下葉節(jié)段性肺炎LobarpneumoniaLobarpneumonia實(shí)變期（紅色或灰色肝樣變期）支氣管氣像Airbronchogram

致密陰影內(nèi),可見透亮支氣管影Lobarpneumonia消散期X線改變

Resolutionstage病變密度逐漸減低，呈大小不等、分布不規(guī)則的斑片狀陰影Theshadowofconsolidationbecomesscatter可完全吸收或遺留少量索條影起病1周后病變開始吸收，多在2周內(nèi)完全吸收，少數(shù)可延遲吸收或演變?yōu)闄C(jī)化性肺炎發(fā)病10后LobarpneumoniaCT表現(xiàn)CTmanifestations一般平片就可診斷,不需要CTCT優(yōu)勢是:充血期可發(fā)現(xiàn)磨玻璃樣改變ground-glassopacity,GGO更容易發(fā)現(xiàn)支氣管氣像Airbronchogram如消散緩慢,反復(fù)發(fā)作,年齡較大的患者,與阻塞性肺炎鑒別大葉性肺炎CT表現(xiàn)

支氣管氣象Airbronchogramrightlowerlobepulmonaryconsolidationwithairbronchograms.支氣管肺炎

（bronchopneumonia）又稱小葉性肺炎(lobularpneumonia)致病菌為鏈球菌、葡萄球菌、肺炎雙球菌streptococcus,staphylococcus,pneumococcus多見于嬰幼兒、老年及極度衰弱患者，或手術(shù)后bronchopneumonia臨床表現(xiàn)Symptoms:起病急，高熱寒戰(zhàn)highpyrexia咳嗽、咳泡沫粘液膿性痰、胸痛cough,purulent

sputum,pleuriticpain呼吸困難甚至紫紺

shortnessofbreath

pathologicchangings病理變化肺小葉滲出與實(shí)變

lobularconsolidation小支氣管壁充血水腫、間質(zhì)內(nèi)炎性浸潤

Smallbronchuswallcongestandswelling,interstitialinflammationimmersing小支氣管壁充血水腫--不同程度阻塞--

小葉性肺氣腫、小葉性肺不張

lobularemphysemaorlobularatelectasisX線表現(xiàn)

X-rayfeaturesbronchopneumonia肺紋理增多、增粗、模糊Intensificationoflungmarkings病變多在兩肺中下野的內(nèi)中帶,沿肺紋理分布的斑片狀影，密度不均，邊緣模糊，密集的病變可融合成較大的片狀

Smallpatchyopaqueshadowsinthemiddleandlowerlungfields,Confluenceofthesepatchyopacities

Intensificationoflungmarkings

Smallpatchyopaqueshadowsinthemiddleandlowerlungfields,

Confluenceofthesepatchyopacities

Emphysemaofthebothlungsisusuallyvisible金黃色葡萄球菌支氣管肺炎Intensificationoflungmarkings

Smallpatchyopaqueshadowsinbothlungfields,

Pneumatoceles(肺氣囊)支氣管肺炎CT表現(xiàn)(CTfeatures)支氣管血管束增粗peribronchovascularburdlethicking小片狀影(小葉性實(shí)變或小葉性不張)Smallpatchyopaque大片狀影(小片狀影融合)Confluenceofthesepatchyopacities1-2CM小圓形透亮影(小葉性肺氣腫)centrilobularemphysemaLobularpneumonia.CTdemonstratesmultifocalareasofconsolidationandairbronchograms.間質(zhì)性肺炎

（interstitialpneumonia）累及肺間質(zhì)為主的炎癥，包括支氣管壁及周圍間質(zhì)和肺泡壁

Interstitialpneumoniainvolvesmainlytheinterstitialtissueoflungs,includingthebronchovascularbundlesandinterlobularandintralobularsepta可由細(xì)菌或病毒引起viralorlacterialinfection多見于小兒，常繼發(fā)于麻疹、百日咳、流行性感冒等急性傳染病原發(fā)傳染病癥狀+咳嗽、氣急、紫紺shortnessofbreath,cough,cyanosis癥狀重，體征少、wbc不高病理

pathology

小支氣管壁及肺間質(zhì)炎性細(xì)胞浸潤Interstitialinflammationimmersing炎癥沿淋巴管擴(kuò)展引起淋巴管炎和淋巴結(jié)炎

Lymphatitis,lymphadenitis小支氣管的炎癥－阻塞－小葉性肺氣腫肺不張

Smallbronchusinflammation---obstructemphysemaandatelectasis

肺泡內(nèi)可有輕度炎性浸潤interstitialpneumonia病變廣泛，累及兩肺尤中下肺肺紋理增粗、模糊，Intensificationoflungmarkings網(wǎng)狀紋理finestreak-like,net-like,nodularornod-reticularshadows肺門密度增高，模糊，肺門增大enlargementofthehilarshadow小葉性肺氣腫、肺不張，嬰幼兒彌漫性肺氣腫empyhsemaofthebothlungs磨玻璃影、小斑片狀影GGO,Smallpatchyopaqueshadows

interstitialpneumoniaX-rayfeaturesinterstitialpneumoniaCTandHRCT廣泛的支氣管血管束增粗Intensificationofbronchovascularbundles小葉間隔增厚interlobularandintralobularseptathickening胸模下線Subpleuralline磨玻璃影、小片狀影GGO,Smallpatchyopaqueshadows

肺門、縱膈淋巴結(jié)可增大廣泛的支氣管血管束增粗

Intensificationofbronchovascularbundles

小葉間隔增厚

Interlobularandintralobularseptathickening

胸模下線SubpleurallineGround-glassopacity,GGO

間質(zhì)性肺炎與支氣管肺炎鑒別支氣管肺炎:以小片狀影為主,累及中下肺野為主間質(zhì)性肺炎:以肺紋理增粗模糊為主,病變更廣泛,累及兩肺interstitialpneumonia支原體肺炎

Mycoplasmapneumonia好發(fā)于青少年臨床癥狀輕,常表現(xiàn)發(fā)熱,咳嗽.白細(xì)胞總數(shù)正?；蛏缘吞礬鼻\喉拭子培養(yǎng)可獲支原體血清學(xué)檢查:紅細(xì)胞冷凝集試驗(yàn)大于1:32,補(bǔ)體結(jié)合試驗(yàn)大于1:16,間接凝血試驗(yàn)大于1:32,間接熒光試驗(yàn)大于1:16病理pathology

急性間質(zhì)性肺炎及支氣管炎1-2周吸收病變自限性影像學(xué)表現(xiàn)Imagingmanifestations早期病變:肺紋理增粗、模糊

Intensificationoflungmarkings網(wǎng)狀紋理finestreak-like,ornod-reticularshadows病變發(fā)展后:Smallorlargepatchyopaque胸腔積液,肺門縱隔淋巴結(jié)腫大少見.肺膿腫(lungabscess)由化膿性細(xì)菌引起,早期為化膿性肺炎,壞死液化,形成膿腫Purulencebacteria---inflammationfocus-Necrosisandfluidify---abscessinfectapproach：inhale

hematogenousdirectspreedStage：acuteandchronic

stagelungabscess

臨床

急性期Acutestage：有急性化膿性肺炎的表現(xiàn)，高熱寒戰(zhàn)、咳嗽咳痰、胸痛、咳大量膿臭痰白細(xì)胞及中性粒細(xì)胞明顯增高

慢性期Chronicstage：

After3monthstheabscesswasconsideredtobechronic

經(jīng)?？人?、咳膿痰和血痰，不規(guī)則發(fā)熱及貧血消瘦等lungabscess

病理

化膿性肺炎（滲出和實(shí)變）—細(xì)支氣管阻塞、小血管炎性栓塞—壞死液化—形成空洞(膿腔)

膿液破潰到胸腔—膿氣胸、支氣管胸膜瘺

持續(xù)不愈超過3個月轉(zhuǎn)為慢性，膿腔周圍炎性浸潤減少但纖維組織增生lungabscess急性期Acutestage排膿之前：化膿性肺炎團(tuán)狀致密影,邊緣模糊X線表現(xiàn)

lungabscess急性期排膿以后邊界模糊的團(tuán)狀陰影內(nèi)有透亮的空洞影，空洞壁較厚，內(nèi)壁較光整，常伴有液平面Cavitythickwallwithair-fluidlevelsurroundedbyexudati