4呼吸病诊断课件

Respiratorydisease

放射学院刘林祥6222136lxliu@1特发性肺间质纤维化原因不明的弥漫性纤维性肺泡炎又称Hamman-Rich综合征为肺泡壁损伤所引起的非感染性炎性反应近认为系免疫性疾病，可能与遗传有关2病理急性期：肺泡内皮细胞和基底膜受损，肺泡和间质内蛋白样物质渗出，伴透明膜形成，继而淋巴细胞和单核细胞渗出。肺泡内皮细胞再生覆盖在渗出物表面并使其整合入肺间质，肺泡壁增厚，胶原纤维扭曲、紊乱而机化。病变发展，间质纤维化加重晚期：肺泡壁、小叶间隔及胸膜下广泛纤维化，肺体积缩小变硬，毛细血管网和气道的终末部分被破坏。在范围较大的纤维化区域，可有终末气道的代偿性扩张，形成直径数mm至2cm的囊样含气腔隙3胸部X线平片早期两肺中下野细小网织阴影病变发展，不对称性、弥漫性网状、条索状及结节状阴影，可扩展至上肺野晚期，结节影增大，伴广泛厚壁囊状阴影，蜂窝肺并阻塞性肺气肿时，肺野透亮度增强囊肿破裂可发生自发性气胸肺纤维化严重时可发生肺动脉高压和肺心病5Idiopathicpulmonaryfibrosis磨玻璃样影及实变影，内见含气支气管影，支气管血管数增粗Ground-glassattenuation与胸膜面垂直的细线形影，长1-2cm，宽约1mm，多见于两肺下叶两肺中内带小叶间隔增厚，分支状细线形影，Reticularattenuationwithinterlobularseptalthickening胸膜下0.5cm内与胸壁内面弧度一致的弧线状影，长5-10cm，边缘较清或略模糊，见于两下肺后外部6Idiopathicpulmonaryfibrosis蜂窝状影，数mm至2cm不等的圆形或椭圆形含气囊腔，壁薄而清楚，与正常肺交界面清楚。分布于两肺基底部胸膜下区.Ahoneycombpattern,predominantlybasalandperipheralindistribution小结节影，边缘较清楚，纤维条索在横断面的表现，或相互交织而成小叶中心性肺气肿：散在、2-4mm，肺外围部，病变发展可渐见于肺中央部。胸膜下见1-2cm类圆形肺气囊中小支气管扩张，柱状，伴支气管扭曲、并拢Architecturaldistortionwithassociatedtractionbronchiectasisandbronchiolectasis7IdiopathicpulmonaryfibrosisF47peripheralGGOInterlobularseptalthickeningIrregularityofthefissuresBronchiectasisEarlyinterstitialpneumonia22mlater,progressionofinterstitialpneumoniaDiffuseGGO,interlobularseptalthickeningAhoneycombpattern8结节病（Sarcoidosis）AsystemicdisorderofunknowncauseNoncaseatinggranulomaswithproliferationofepithelioidcells,多系统肉芽肿性疾病，良性经过，可累及淋巴结、肺、胸膜、皮肤、骨、眼、脾、肝、腮腺及扁桃体等病理特征为非干酪性肉芽肿淋巴结大，但不融合。肺门LN易受累，次为气管旁和AA旁肺内病变沿支气管血管周围结缔组织鞘及小叶间隔发展蔓延，肺内肉芽肿主要分布在间质，小，直径在0.4mm以下，胸膜下肺间质内肉芽肿更密集。小肉芽肿可融合成大结节急性发病者肉芽肿大多经治疗消退或自行消退。慢性发病者常导致进行性肺纤维化10LaboratoryAngiotensinconvertingenzyme(ACE)levelelevatedandmaycorrelatewithactivityCD4:CD8ratioiscommonlydecreasedHypercalcemiaduetoincreasedintestinalabsorptionofcalcium,resultingfromactivationofvitaminDbymacrophagesinsarcoidgranulomas12Sarcoidosis肺部病变多发生在淋巴结病变之后两肺弥漫性网状结节影，但肺尖或肺底少或无。结节大小不一，多为1-3mm大小，轮廓尚清楚肺内圆形病变，直径约1.0-1.5cm，密度均匀，边缘较清楚，单发者类似肺内良性病变或周围型肺癌，多发者酷似肺转移瘤节段性或小叶性浸润，类似肺部炎性病变，一般伴或不伴胸腔内淋巴结病变少数为单纯粟粒状，似急性粟粒型结核14Sarcoidosis以纤维性病变为主者，不易与其他原因所致的肺纤维化区别，且可引起多种继发性改变胸膜渗液可能为胸膜脏、壁层广泛受累所致。肥厚的胸膜为非干酪性肉芽肿骨病变约占10%。损害一般限于手、足的短管状骨，显示小囊状骨质缺损并伴有末节指（趾）的骨质吸收，变细、变短15CT纵隔、肺门淋巴结肿大，密度均匀，边缘清楚，周围脂肪界面存在。增强扫描呈均匀强化肺内可见大小结节影或块状影晚期支气管血管束扭曲、聚拢或变形，叶间裂、血管支气管移位，支气管扩张和不同程度肺气肿支气管血管束增厚，边缘不规则或结节状，周围可有大小不等的结节状影；小叶间隔增厚和细小蜂窝影，见于胸膜下区胸膜初期为胸腔积液，可自然吸收，少数可发展为胸膜肥厚16鉴别诊断肺门结核：年轻，有轻度中毒症状。气管旁、支气管旁淋巴结肿大，可有钙化。结素反应阳性，痰中找到结核杆菌霍奇金病：常先有颈部、锁骨上淋巴结肿大，然后出现不对称性双侧或单侧纵隔淋巴结肿大，前纵隔较后纵隔多见。纵隔淋巴结肿大的程度常较肺门淋巴结肿大显著非霍奇金淋巴瘤：多为单侧纵隔淋巴结肿大，即使双侧纵隔淋巴结肿大亦不对称。后纵隔多于前纵隔淋巴结肿大，晚期才有肺门淋巴结肿大。纵隔淋巴结多大于肺门淋巴结未分化型小细胞肺癌：多为单侧纵隔或（和）肺门分叶状淋巴结肿大，双侧纵隔淋巴结肿大较少见。部分伴有不同程度的阻塞性肺炎或肺不张。病程发展迅速间质性病变：当病变发展至纤维化期则需与癌性淋巴管炎、间质性肺炎、嗜酸性肉芽肿等鉴别17SarcoidosisSymptomsandsignsarenonspecific,halfasymptomaticFatigue,weightloss,generalmalaise,feverBilateralhilarlymphadenopathyiscommonfindingOftenwithassociatedpulmonaryinfiltratesSkinandocularlesions,theliver,spleen,lymphnodes,parotidglands,CNS,genitourinarysystem,muscles,andbonesmaybeinvolved18HilaradenopathyM27ChestradiographTypicalbilateralhilaradenopathyAdenopathyintherightparatrachealandleftaortic-pulmonarywindownodesisalsoidentified20HilaradenopathyE+CTclearlydepictsthebilateralhilaradenopathy21MediastinaladenopathyM26SeverebackpainEnlargedrightparatrachealnodesLeftaortic-pulmonarywindownodeswithassociatedminimalhilarinvolvementarealsoseen23MediastinaladenopathyMediastinaladenopathy,60MCalcificationintheaffectedhilarnodes,hugesubcarinallymphnodesAnunusualfindinginothergranulomatousdiseasessuchastuberculosis24PulmonarysarcoidosisStageIVdiseasemaymanifestasconglomeratedmasseswithmarkedtractionbronchiectasisUsuallypredominantlyinthecentralandupperlung.thisdistributionistypicalofsarcoidosisbutcanalsobeseenintuberculosisandsilicosisExtensivecalcificationmaybeencounteredwithinfibroticgranulomasCavitationorcystformationmayalsobeseen26PulmonarysarcoidosisM37Smallnoduleswithaperivasculardistributionandirregularthickeningofbronchovascularbundlesandinterlobularsepta27PulmonarysarcoidosisM24HRCTMultiplemiliarynodulesanddiffusethickeningofthebronchialwallSimultaneouspresenceofsmallnoduleswithaperivasculardistributionandalongtheinterlobularpleura28PulmonarysarcoidosisHRCTWidespreadgroundglassattenuationReticulonodularMildbronchiectasisperipherally30PulmonarysarcoidosisF26MultiplenodulesbilaterallyMinimalhilaradenopathySimulatemetastates31PulmonarysarcoidosisAnodularconsolidationwithill-definedbordersAirbronchogramwithinthenodules32StageIVpulmonarysarcoidosisM60,ExtensivefibroticchangeandcavitarylesionswithacentraldistributiondistortinglungparenchymaIrregularthickeningofpleuraandoverinflationofperipherallungparenchyma33PrimaryBronchogenicCancerMacro-pathologyCentraltype：主支气管、肺叶支气管及肺段支气管的肺癌Peripheraltype：肺段以下支气管直到细支气管以上的肺癌Alveolartype：发生于细支气管或肺泡上皮的肺癌34Histologicaltypesoflungcancer来自支气管表面上皮的癌鳞状上皮癌Squamouscellcarcinoma腺癌Adenocarcinoma腺鳞癌大细胞癌Largecellcarcinoma来自神经内分泌细胞的癌高分化：类癌carcinoid中分化：不典型类癌atypicalcarcinoid低分化：小细胞癌Smallcellcarcinoma来自细支气管Clara细胞和Ⅱ型肺细胞的癌细支气管肺泡癌bronchialalveolarcarcinoma35中心型肺癌临床表现：刺激性干咳、痰中带血，胸痛、发热直接征象：肺门肿块，支气管狭窄与阻塞间接征象：支气管阻塞或狭窄后引起的阻塞性肺炎、肺不张、肺气肿转移征象36右肺上叶中心型肺癌37右肺上叶中心型肺癌38右肺上叶中心型肺癌39中心型

肺癌纵隔增宽、肺门增大，为肺癌的淋巴结转移40中心型肺癌：右肺门及右上纵隔不规则肿块，中上肺野片絮状密度增高影。断层示上叶支气管鼠尾状狭窄41中心型肺癌左肺肺癌，右肺代偿性肺气肿42Centraltype--CTfindings管壁型：管壁增厚，管腔不规则狭窄管内型：腔内软组织肿块，偏心性狭窄或闭塞，杯口状截断管外型：管壁环形增厚，腔外软组织肿块管腔狭窄或闭塞，继发远端肺炎症、不张或气肿肺门纵隔淋巴结转移，呈软组织样等密度，单个或多个融合成分叶状，增强扫描无强化肺内，胸膜及远处转移43中心型肺癌44Centraltype--CTfindings45Centraltype--CTfindings46Centraltype47Squamouscellcarcinoma48Squamouscellcarcinoma49Squamouscellcarcinoma50Lungcancer--peripheraltype临床表现：可无症状或胸痛、咳嗽直接征象：肺内结节和肿块边缘分叶，脐样切迹，毛刺小于2cm的孤立结节，内部密度不均匀。大于3cm时，密度较均匀厚壁空洞间接征象：小叶范围的阻塞性肺炎、肺不张，彗尾征。胸膜凹陷转移征象51右肺见结节性病灶，CT示分叶与毛刺52厚壁空洞，体层示空洞内壁凹凸不平53周围型肺癌--癌性空洞54Peripheraltype肺内肿块，下缘与胸膜间有牵拽，箭头所指为慧尾征55Peripheraltype—CTfindings肺内结节，肿块软组织密度，均匀或不均匀，空泡征，钙化少肺窗：边缘毛刺，胸膜凹陷征，血管集束征纵隔窗：深分叶，偏心空洞，小棘状突起，脐征肺门纵隔淋巴结转移远处转移56周围型肺癌57Peripheralcarcinoma58Peripheralcarcinomaground-glassopacity59PeripheralcarcinomaSofttissuemassSpicula60Peripheralcarcinoma61Peripheralcarcinoma62Peripheralcarcinoma--lobulation63Hilarmetastases64Peripheralcarcinoma65Peripheralcarcinoma66Peripheralcarcinoma67Peripheralcarcinoma68Peripheralcarcinoma-cavity69PancoasttumorsArisefromlungapexInvadecostovertebralgrooveinsuperiorsulcusInvadeparietalpleura,causingnonspecificshoulderpainradiatingdownmedialaspectofscapulaInvolveT1nerveroot,causingpainradiatingalongmedialaspectofarmandforearmasfaraswristInvadestellateganglion,causingHornersyndrome,includeptosis(narrowingofthepalpebralfissure),miosis(pupillaryconstriction),andanhidrosis(absenceofsweatingononesideoftheface)70PancoasttumorsInvadefirst,second,andthirdribsposteriorlySuperiorextensionencasingC8nerveroot,withresultantpaininmedialtwodigitsofhandandatrophyofintrinsicmusclesofhandAnteriorextensionintotracheoesophagealgrooveresultinvagalorrecurrentlaryngealnervepalsySuperomedialextensionmayresultininvolvementofvertebralartery,vertebralbodies,neurovertebralforamina,andspinalcanal,withaconsequentriskofparaplegia71右肺上沟癌右肺上野片状阴影，第一、二肋骨溶骨性破坏72Pancoasttumor73M48，leftinterscapularchestwallpain

suggesteT1nerverootinvasion74SuperiorsulcustumorM48w/oneurologicsignsinleftupperextremitybutwithleftinterscapularchestwallpainsuggestiveofT1nerverootinvasionM48，leftinterscapularchestwallpain

suggesteT1nerverootinvasion75Alveolarcancinoma双肺布满结节性病灶病理证实为肺泡癌76肺泡癌77Alveolarcancinoma78Alveolarcancinoma79Alveolarcancinoma80Bronchioloalveolar

carcinoma

A

53-year-oldmanInitial(1mm)CTatthelevelofthebronchusintermediusasmallnodularareaofground-glassattenuationintherightupperlobeFollow-upCT(5mm)48monthslaterincreasednodulesize.81肺转移瘤宫颈癌术后，肺内数个转移病灶82Lungmetastases83Lungmetastases,rectalcancer84Lungmetastases85食道癌肺转移86Lungmetastases,coloncancer87错构瘤(hamartoma)非真性肿瘤，内胚层与间胚层发育异常形成根据部位，分为周围型和中央型局限于某一肺叶或肺段的反复发作感染肺内球形软组织肿块，见爆米花样钙化CT扫描：钙化、钙化、脂肪88错构瘤左肺门外上肿块内可见爆米花样钙化89Hamartoma90错构瘤91Hamartoma92肺栓塞(pulmonaryemboli)肺动脉分支被栓子堵塞引起的肺供血障碍常见栓子是深静脉脱落的血栓久病卧床、妊娠、大手术后和心功能不全可发生深静脉血栓风心病，原发于肺动脉的血栓进入血循环的脂肪、肿瘤栓子和气体93PulmonaryembolismThethirdmostcommonacutecardiovasculardiseaseaftermyocardialinfarctionandstrokeResultsinthousandsofdeathseachyearbecauseitoftengoesundetectedCTAhassensitivitiesof53%–100%andspecificitiesof83%–100%Pulmonaryangiography,thediagnosticstandardofreferenceforconfirmingorrefutingdiagnosis94病理双重供血，正常时两组有丰富的吻合支当肺动脉的某一分支栓塞后，肺组织因支气管动脉的侧枝供血而不发生异常，栓子较小未能完全堵塞肺动脉分支时也不易发生供血障碍多数小栓子进入肺循环可引起肺动脉小分支多发性栓塞95临床表现多无明显症状，或有轻微不适可为突发的呼吸困难和胸痛肺动脉大分支或主干栓塞或广泛的肺动脉小分支栓塞可出现严重的呼吸困难、发绀、休克或死亡较大的栓子堵塞肺动脉大分支或主干可引起急性右心衰竭或心肌梗死而致死亡96X线表现肺动脉较大分支栓塞或多发性小分支栓塞X线平片可出现异常阴影，较小分支栓塞即使出现症状并经血管造影证实，X线仍可正常肺缺血又称Westermark征，当肺叶或肺段动脉栓塞时，相应区域内肺血管纹理减少或消失，透亮度增加多发性肺小动脉栓塞引起广泛性肺缺血，显示肺纹理普遍减少和肺野透亮度增加，但无肺体积膨胀现象97X线表现嵌塞在肺动脉内的血栓使相应部位血管阴影增宽，阻塞远端致血流减少而变细多发于下叶且以右下叶多见，下叶体积缩小，膈肌升高，叶间裂下移。并盘状肺不张较大肺动脉栓塞或多发性小动脉栓塞可引起心影增大，主要是右心室增大，同时有肺动脉高压右心功能不全时心影增大更为显著，奇静脉和上腔静脉增粗98X线血管造影肺动脉分支内充盈缺损或截断局限性血管减少或无血管区，血灌流缓慢小分支多发性栓塞引起肺动脉外围分支迂曲，突然变细，呈剪枝样细小分支的栓塞血管造影不能显示血栓24hs后开始溶解，故48hs后造影可正常继发肺动脉高压和肺心病时，肺动脉干和大分支扩张，周围分支变细99CT平扫：较大肺动脉栓塞见血管内高密度或低密度病灶。高密度为新鲜血栓，低密度为陈旧性血栓增强：血栓为长条状及不规则形充盈缺损栓塞的肺动脉可有不同程度的扩张较大肺血管栓塞可见相应区域肺血管分布减少100Acute

pulmonaryembolismArterialocclusionwithfailuretoenhancetheentirelumenduetoalargefillingdefectArterymayenlargedvs.adjacentpatentvesselsApartialfillingdefectsurroundedbycontrastmaterial,"polomint"sign,"railwaytrack"signPeripheralwedgeshapedareasofhyperattenuationrepresentinfarcts,alongwithlinearbandsaresignificantancillaryfindings101AcuteocclusivepulmonaryembolismF32ChestpainApulmonaryemboluswithinposterobasalsegmentofrightlowerlobearteryArteryenlargevs.adjacentpatentvessels102AcutepulmonaryembolismF45chestpainApulmonaryembolusaffectsthesegmentalarteryofthelaterobasalsegmentofrightlowerlobePartialfillingdefectsurroundedbycontrastmaterialproducesthepolomintsign103AcutepulmonaryembolismM66ChestpainanddyspneaAcutepulmonaryemboluscausesapartialfillingdefectsurroundedbycontrastmaterialAnotheracutepulmonaryembolusaffectstheleftmainpulmonaryartery104AcutepulmonaryembolismF58ChestpainanddyspneaApulmonaryembolusresultsinaneccentricallypositionedpartialfillingdefectSurroundedbycontrastmaterialandformsacuteangleswiththearterialwall105AcutepulmonaryembolismF58chestpainanddyspneaAncillaryfindingsofaperipheralwedge-shapedareaofhyperattenuation106AcutepulmonaryembolismMorphologicabnormalitiessuggestrightventricularfailurecanbequantifiedwithCTpulmonaryangiographyRVdilatation(RVcavityiswiderthanLVcavityintheshortaxis),w/ocontrastmaterialrefluxintohepaticveinsDeviationofinterventricularseptumtowardLVApulmonaryembolismindexgreaterthan60%107AcutepulmonaryembolismM42chestpainandseveredyspneashortaxisofRViswiderthanthatofLV,causedbyacutepulmonaryembolismandcreatedRVstrain108AcutecentralpulmonaryembolismF87asymptomaticSubtleregionsofhyperattenuationCTA:acutepulmonaryembolismwithintherightmainandleftinterlobarpulmonaryarteries109ChronicPulmonaryEmbolism

DiagnosticcriteriaCompleteoccludedvesselissmallerthanadjacentpatentvesselsAperipheral,crescentshapedintraluminaldefectformsobtuseangleswithvesselwallContrastmaterialflowingthroughthickened,oftensmallerarteriesduetorecanalizationAweborflapwithinacontrastfilledarterySecondarysignsExtensivebronchialcollateralvesselsAnaccompanyingmosaicperfusionpatternCalcificationwithineccentricvesselthickening110Chronicpulmonaryembolism27MdyspneaCompleteoccludedvesselsinleftlungaresmallerthanadjacentpatentvesselsCollateralbloodsupplyfromabranchofrighthemidiaphragmaticartery111ChronicpulmonaryembolismM62DyspneaAneccentricallylocatedthrombusformsobtuseangleswithvesselwallDilatedcollateralbronchialartery112ChronicpulmonaryembolismAsmall,recanalizedpulmonaryarterywithcontrastmaterialinthecentrallumen113ChronicpulmonaryembolismM56dyspneaAflapwithinasmallrightinterlobarpulmonaryarteryCollateralbronchialarterydilatationisalsonoted114ChronicpulmonaryembolismAlargechronicpulmonaryembolusinthemainandleftmainpulmonaryarteriesArrowsindicatecollateralbronchialarteries115ChronicpulmonaryembolismF60,dyspnea.Amosaicperfusionpattern:Darkregionsofunderperfusedlungcontainvesselsthataresmallerthanadjacentpatentvesselsinnormallyperfusedlung116ChronicpulmonaryembolismM62DyspneaPulmonaryarterialwallcalcificationAsecondarysignofchronicpulmonaryembolism117PulmonaryarterialhypertensionsecondarytochronicpulmonaryembolismAncillaryfindingspulmonaryarterydiameter＞33mmpericardialfluidPulmonaryarterymeasures41mmindiameterindicateshypertension118ChronicpulmonaryembolismPericardialfluidassociatedwithpulmonaryarterialhypertensionSecondarytochronicpulmonaryembolism119尘肺Pneumocomosis肺通过气道与外界相通，吸入在空气中悬浮的无机和有机尘粒，这些尘粒部分可致病正常肺有很强的能力来清除这些尘粒但过多的生产性粉尘则可引起气道和肺泡的损伤，导致肺部弥漫性纤维化，称为尘肺120国家现行规定的12种尘肺矽肺silicosis煤工尘肺coalworkerpneumoconiosis石墨尘肺graphitepneumoconiosis炭黑尘肺anthracosis石棉肺abestosis滑石尘肺talcpneumoconiosis水泥尘肺cementpneumoconiosis云母尘肺micapneumoconiosis陶工尘肺kaolinpneumoconiosis铝尘肺aluminumpneumoconiosis电焊工尘肺electricandwelderpneumoconiosis铸工尘肺foundryworkerpneumoconiosis121尘肺的诊断原则①根据目前我国现行政策的规定：尘肺的诊断必须是由国家卫生行政部门指定的尘肺诊断小组来进行，任何个人作出的诊断都是无效的②许多疾病可形成类似尘肺的肺部弥漫性改变，因此作为影像专业医师，应对引起尘肺的病因学、生产现场的流行病学调查及其临床病理资料有所了解③尘肺诊断的前提是病人必须有明确的生产性粉尘接触史，并且有同行业人发病年龄作为参考资料122基本影像学表现类圆形小阴影：最常见和最重要表现，见于矽肺不规则形小阴影：网状，有时呈蜂窝状大阴影：指直径超过10mm的阴影，边界清楚，周围有明显的肺气肿；多出现于两肺上、中区，常对称出现；大阴影的长轴常与后肋垂直，不受叶间裂的限制。“八字形”或长条形大阴影常见于典型矽肺胸膜斑：不同程度的胸膜肥厚、粘连及钙化等改变，局限性胸膜斑则是石棉肺的主要表现之一。局限胸膜增厚的厚度大于3mm时称为胸膜斑，多见于侧胸壁，亦见于部分心缘和膈面，可发生钙化123基本影像学表现肺门改变：早期肺门阴影增大增浓，有时见肿大淋巴结影。淋巴结蛋壳样钙化多于两侧肺门对称出现，也可见于一侧，呈圆形、椭圆形或不整形，常数个同时出现；壳壁可呈断续的残缺状肺纹理改变：早期有肺纹理增强、变粗等改变。肺间质纤维化的进一步发展，使肺纹理变形。随着小阴影出现和逐渐增多，特别是不规则小阴影的增多，肺纹理则逐渐变成模糊、减少或消失124矽肺Silicosis

二氧化硅粉尘引起的肺部弥漫性纤维化尘肺中最多见且危害最大的一种，多见于采矿、玻璃、陶瓷、耐火材料、石英制粉、机械制造业工人基本改变是慢性进行性肺间质纤维化及矽结节形成多个小结节可相互融合形成大结节或融合团块，周围有肺气肿，是矽肺晚期常见改变125Silicosis粉尘中游离二氧化硅含量越高，肺内改变越以结节为主，矽结节越致密清楚。游离二氧化硅含量越低，间质性纤维改变越明显，矽结节淡而轮廓模糊早期可无症状晚期则可有呼吸困难，甚至发绀、咯血合并结核及慢性炎症者症状更为严重最后因肺源性心脏病而致心肺功能衰竭126X线表现肺纹理增强并伸展至肺外带，细网状纹理，在网格交叉处见有极小颗粒，肺野透亮度减低呈磨玻璃样矽结节：诊断矽肺和混合性矽肺的主要依据。多在两侧中、下肺野内中带区域开始出现典型表现为直径约3mm左右，轮廓清楚，致密孤立的结节阴影，多与肺纹理分离病变发展，矽结节渐增大增多，融合成致密而均匀的团块，即大结节影，常见于两上肺野外带，轮廓清楚。典型大结节阴影在两肺分布对称，呈翼状127X线表现肺门影增大，密度增高。晚期可见肺门上提或外移。肺门呈残根样。肺门淋巴结蛋壳样钙化肺纹理增多增粗，延长到肺野外带。病程进展，肺纹理发生扭曲变形、紊乱及中断现象。晚期由于矽结节增多，肺气肿加剧，肺纹理减少肺气肿可为弥漫性或局限性或灶性肺气肿胸膜改变：早期以肋膈角变钝或消失最多见，随病变进展，肺底胸膜肥厚，表现膈面毛糙，或膈胸膜粘连所形成幕顶样改变，纵隔胸膜增厚粘连表现为纵隔阴影增宽，边缘平直或呈不规则状。128矽肺合并结核早期矽肺或混合矽肺并发的结核病灶大都趋向于一侧或两侧肺尖或锁骨上下区晚期，各肺野包括肺尖区都已散布有明显矽结节时，并发一侧或两侧结核病灶与矽结节早期融合鉴别较为困难，伴有空洞者支持结核的诊断129Simplesilicosis59M,workedinhard-rockminingfor10yearsdiffusenodularopacities,relativesparingofbasallungzones130Simplesilicosisnumerousmicronodulesinbothupperlungswithposteriorzonalpredominance.multiplesubpleuralnodulesandpseudoplaques131尘肺的胸部X线片表现分期无尘肺（0）0：X线胸片无尘肺表现0＋

：胸片表现尚不够诊断为Ⅰ者一期尘肺（Ⅰ）Ⅰ：有总体密集度1级的小阴影，分布范围至少达到两个肺区Ⅰ＋：有总体密集度1级的小阴影，分布范围超过4个肺区或有总体密集度2级的小阴影，分布范围达到4个肺区二期尘肺（Ⅱ）Ⅱ：有总体密集度2级的小阴影，分布范围超过4个肺区；或有总体密集度3级的小阴影，分布范围达到4个肺区Ⅱ＋：有总体密集度3级的小阴影，分布范围超过4个肺区；或有小阴影聚集；或有大阴影，但尚不够诊断为Ⅲ者Ⅲ：有大阴影出现，其长径不小于20mm，短径不小于10mmⅢ＋：单个大阴影的面积或多个大阴影面积的总和超过右上肺区面积者132矽肺0-I期双肺门扩大增浓，肺门角隆起双肺纹理增多，隐约可见小粟状结节133矽肺Ⅱ期两肺门散在大小不等，互相重叠的圆形、卵圆形钙化影，上纵隔增宽，中上野有片状影134矽肺Ⅱ-Ⅲ期两肺野散在大小不等致密影，两肺门区有大小不等的蛋壳样淋巴结钙化135煤工尘肺Coalworkerpneumoconiosis煤矿工人长期吸入生产环境中的粉尘引起的尘肺岩石掘进工作面工人接触游离二氧化硅含量较高的硅尘，所患尘肺有典型矽结节，为矽肺。采煤工作面工人，主要接触煤尘，游离二氧化硅含量不足5%，所患尘肺有典型的煤尘灶，为煤尘肺煤尘肺在肺内只引起弥漫的间质性纤维改变，可见到数量不等，直径大小不一的煤斑，并伴有散在的局限性肺气肿改变，即单纯煤尘肺，通常不形成矽结节病变或大块纤维病灶。合并结核则可见进行性大块纤维改变136Coalworkerpneumoconiosis早期无症状。劳动时气急、吐痰、咳嗽和胸痛是最常见的主诉。无阳性体征胸片可见两肺有广泛的肺纹理改变和纤维条纹以及网织阴影，肺野透亮度减低呈磨玻璃样混合矽结节的直径比较小，形态不规则，密度较低，边缘不如典型矽结节那样锐利肺内有散在局灶性肺气肿透亮区域存在大阴影仅见煤矽肺137CoalworkerpneumoconiosisHRCT以间质性肺纤维化为主，小结节影不如矽肺明显两肺广泛不规则线条状阴影或网状影，肺血管纹理扭曲、紊乱晚期随肺气肿的发展，肺纹理减少小结节影以两肺中、下野分布为主。混合矽结节的直径较小，形态不规则，密度低，边缘不如矽结节锐利，一般不融合。可见局限性肺气肿胸膜改变不如矽肺明显138CWP,48M,HRCT,numeroussmallnodulesthatarelesswelldefinedthanthoseseeninsilicosis139ComplicatedCWP:57MAconglomerationofsmallnoduleswithsparingofthebibasilarareaandegg-shellcalcificationsinbothhila140ComplicatedCWPHRCTConglomeratemasses(progressivemassivefibrosis)andadjacentsmallnodulesAthoracostomytubewasplacedinthelefthemithoraxforapneumothorax.141CalcifiedprogressivemassivefibrosisM60,retiredcoalworkerAdenselycalcifiedrightparahilarmass142Complicatedsilicosis,58MAcavitaryconglomeratemassintheleftupperlobetheparacicatricialemphysemaAlthoughtuberculosismaycomplicatesilicosisorCWP,progressivemassivefibrosissometimesdemonstratescavitationduetoischemicnecrosis143SilicoproteinosisM52,quarryworkerHRCTPatchyareasofground-glassattenuationwithfineintralobularreticulationBiopsyconfirmedthealveolarproteinosisandsilicaparticles144ArcwelderpneumoconiosisM46,nonsmokerwitha15yearsofashipyardwelderNumeroussmallnodulesandbranchingareasofhyperattenuationarepoorlydefinedandcentrilobularSiderosiswasprovedattransbronchiallungbiopsy145ArcwelderpneumoconiosisM57,formersmoker13yearsworkinshipyardsasymptomatic,pulmonaryfunctiontestswerenormalGGOisdiffuseandmainlycentrilobularFollow-upHRCT1yearlatershowednochangeintheparenchymaldisease146Carbonpneumoconiosis49man10-yearhistoryofacarbonblackfactoryAfinereticulonodularpatternwithlowerzonalpredominance147CarbonpneumoconiosisDiffuseareasofGGoandnumeroussmallcentrilobularnodules148Giantcellinterstitialpneumonia52mpatchyareasofGGOandfinereticulationinbothlowerlungzones149GiantcellinterstitialpneumoniaBilateralareasofsmallcysts,GGO,finereticularhyperattenuation,andtractionbronchiectasis,sugestfibrosis150Giantcellinterstitialpneumonia45ySawmanufacturingplantpatchyareasof