呼吸系统放射学诊断刘辉 1

RadiologyDiagnosisofRespiratorySystem

刘辉

DepartmentofRadiology,thesecondXiangyahospitalTheX-rayexaminationisappliedverycommonly

naturecontrastisthebestinbodyWhy?Containsofthechapter：TheX-rayexaminationmethodsNormalchestviewThebasicX-rayfeaturesX-raydemonstrationsincommondiseases胸部透视（Chestfluoroscopy）胸部摄影（chestfilm）CT（computedtomography）MRI（magneticresonanceimaging）DSA(digitalsubstrationangiography)TheX-rayexaminationmethodsX-rayexaminationmethods—Chestfluoroscopy

real-timeimagingtofreepositionobservationofmediastinummovementinferiorresolution

X-rayexaminationmethods——Chestfilm常用体位：commonviews

后前位postero—anteriorposition

侧位lateralposition特殊体位;specialviews

前弓位apicalposition后前位postero—anteriorview侧位：lateralviewKeypoints：患侧靠胶片;用于全面观察病变形态与病变定位Notice:betakenwhenthePAviewhasbeinspected

体层摄影Tomography高千伏摄影High-KilovoltageRadiography造影检查contrastexaminationX-rayexaminationmethods

——specialexaminations造影检查

contrastexaminationBronchographyAngiography

支气管造影BronchographyTodefiniteadiagnosisofbronchiectasis(highresolutionCT)PulmonaryAngiographydemonstrationofpulmonaryembolidemonstrationofpulmonaryarteriovenousmalformationsCTscanmethodsUnenhancedCTscanEnhancedCTscanHRCT(highresolution)HelicesCTorspiralCTscanCT（computedtomography）密度分辨率高highDensityresolution，量化measured，以CT值体现HounsfieldUnit（Hu）

空间分辨率Spatialresolution:无前后结构重叠avoidingoverlappingstructures,可三维重建providedthree-dimensionevaluationCT（computedtomography）CTcanfindsmalllesionsjust0.3-0.5cmindiametershowthelesionsdetailoptimal病变的细节CT（computedtomography）纵隔肿瘤的定位和定性determiningtumorlocationandthenatureWithenhancedscan,CTcandisplaytherelationshipoftumorandgreatvesselsDistinguishvessels,lymphnodesandmass

MRI（magneticresonance）

主要对纵隔肿瘤的定位和定性(tumorlocationandthenature)较好对与心脏大血管的关系显示好(therelationshipofthetumorandgreatvessels)二、正常胸部X线表现NormalChestView1.NormalChestView——chestcast

软组织softtissue

胸锁乳突肌（sterno-mastoidmuscle）锁骨上皮肤皱褶（skinreflectionovertheclavicle）胸大肌（pectoralmusclemajor）女性乳房及乳头（femalebreastandnipple）

骨胳bonyskeleton

肋骨（ribs）肩胛骨（scapula）锁骨（clavicle）胸骨(sternum)胸椎（thoracicspine）

NormalChestView——chestcast

softtissue

sterno-mastoidmuscleskinreflectionovertheclavicle

胸壁软组织正常乳房和乳头影NormalChestViewNormalChestView——chestcast

softtissue:pectoralmusclemajorfemalebreastandnipple2.NormalChestView——chestcast

bonyskeleton

肋骨ribs肩胛骨scapula胸骨sternum锁骨clavicle胸椎thoracicspine

气管、支气管TracheaandBronchus气管trachea起自环状软骨长11-13cm宽1.5-2cm胸5-6平面分叉分叉下壁形成气管隆突分叉角60-85度支气管bronchus分级grade：mainbronchus—lobebronchus—segmentbronchus—sub-segmentbro—……alveolus(主-叶-段-亚段-

多级分支-肺泡)支气管分支名称

右侧———————————————————————上叶1尖支2后支3前支中间支气管中叶4外支5内支下叶6背支7内基底支8前基底支9外基底支10后基底支

左侧上叶

上部支气管1＋2尖后支3前支

下部支气管4上舌支

（舌部）5下舌支下叶6背支7＋8内前基底支9外基底支10后基底支两侧支气管分支及差异肺lung

肺野（lungfield）：Theareaintowhichthepulmonaryorganisprojectedontheradiography两肺野透明度相同，吸气时透明度增高

肺lung

肺野（lungfield）：dividedintozoneswhichdonotcorrespondtoactuallobes

三带：内、中、外带

三野：上、中、下野肺门（hilum）肺门组成：主要为pulmonaryarteriesandveins肺门阴影（hilarshadow）：

肺动、静脉、支气管和淋巴组织等的复合投影X-rayfeatures：radiopaqueshadowoneachsideofmediastinumHilum：右肺门

呈“〉”形上部：由上肺动脉、静脉、下肺动

脉干后回归支组成下部：由右下肺动脉干（≦15mm）

组成，内侧

为中间段支

气管肺门角：成钝角，突出为异常左肺门

由左肺动脉弓与左下肺动脉及

分支构成

左肺门较右肺门高1-2cmX-raymanifest肺门hilum：X线表现X-raymanifest肺门异常

hilumshadowabnormity肺门增大hilumshadowenlarged肺门缩小hilumshadowshrinked肺门移位hilumshadowshifted肺门密度增高hilumshadowdensitystronger肺门增大hilumshadowenlarged肺门缩小hilumshadowshrinked

肺门移位hilumshadowshifted肺纹理lungmarkingsX-raymanifest：Radiateoutwardfromthehilumandcontinuetospread下肺野纹理较上肺野粗肺纹理lungmarkings组成component:thesearemadeupalmostentirelyofvascularshadow,especiallypulmonaryarteriesX线特点Fromthicktothinbranchingastree树枝状分布；Lacklungmarkingsinperiphery外带细少肺叶lobes肺叶（lobes）：threelobesintherightlungtwointheleftseparatedbyinterlobularsepta

叶间裂走向及X线表现interlobularseptacourseandX-raymanifests叶间裂是识别肺叶的标志肺叶分布示意图Theinterlobularseptaarenotvisibleorfinelinear叶间裂处表现为无或少血管结构的透明带肺段（segment）LobesareconsistedofsegmentsfromtwotofiveThenameofthesegmentiscorrespondedtobronchus肺段间有肺段静脉和结缔组织隔开

肺段(segment)正常时X线不能显示肺段界限

becauseofoverlappingofsegments单独某肺段病变时可见肺段轮廓Segmentoutlinemaybeshowedastapershapeandtopforwardhilum肺小叶（lobule）Eachsegmentisconsistedofmanylobules小叶支气管bronchus及小叶动脉lobule

artery进入小叶小叶之间为小叶间隔

lobulsseptaThediameterofalobuleis1-2.5cm腺泡acinusThebasicandfunctionalunitThediameterisabout6mm每支末梢细支气管small

terminalbronchiols所支配的范围为腺泡肺实质与肺间质

parenchymaandInterstitium肺实质:具气体交换功能的肺泡、肺泡壁

肺间质：由结缔组织组成的支架与间隙frameandinterstitialstructure

纵隔mediastinumMediastinum－－Extensionandconstitutes

范围

:Belowsternum,infrontofthethoracicspine,betweentwosideoflungs.

组成

心脏、大血管、气管、支气管、淋巴组织、胸腺、神经、脂肪等

Constitutes:theheart,trachea,greatvessels,lymphnodesandfatetc.

范围与组成

Extensionandconstitutes纵隔mediastinum体位、呼吸影响：Thenormalwidthofmediastinumisaffectedbybodyposture,ageandbreathing

纵隔分区

mediastinumsubarea

Mediastinumcanbedividedintodifferent分区的意义：在于判断纵隔肿瘤的组织来源和性质九分法六分法纵隔基本病变

mediastinumpathologicalpatterns

纵隔增宽:mediastinumwidening

纵隔移位:

mediastinumshift:bothsides

纵隔摆动:

mediastinumwiggling

纵隔气肿:

mediastinumemphysema纵隔增宽mediastinumwidening

纵隔移位：mediastinumshift:向患侧移位

Tolesionside纵隔移位：mediastinumshift:向健侧移位Tonormalsidemediastinumwiggling

膈

diaphragmLocation:betweenthethoraxandtheabdominalcavityTherighthemi-diaphragmis1-2cmhigherthantheleft

膈diaphragm

Shape:smoothdome,sometimesaswave-likeshape.肋膈角

costophrenicangle

心膈角

cardiophrenicangle

活动度：1-3cm

movementlimit膈diaphragm

膈正常变异Thediaphragmvariation

膈基本病变

diaphragmbasicpathologicpatterns

膈位置升高（肺不张、肺纤维化、腹水）

diaphragmpromoted

upward

膈位置降低（肺气肿、气胸等）Diaphragmdepresseddownward

膈膨升（见于膈发育不全或膈神经麻痹）Diaphragmbulged

膈破裂穿孔（自发性、外伤性）Diaphragmrupturedandperforated

膈矛盾运动（见于膈膨升

膈神经麻痹）diaphragmconflictingmotion

肺气肿膈位置降低

Obstructiveemphysemaforceddiaphragmdownward

肺不张膈位置升高

atelectasispromoteddiaphragmupward

胸膜pleura

壁层

脏层viscerapleura

胸膜腔

pleuracavity

X线表现thepleuraisnotvisualizedwiththeexceptofthenormalhorizontalinterlobarfissure三、基本病变X线表现

Basicpathologic-roentgenpatternsCorrelatedwiththeirunderlyingpathology支气管阻塞bronchialobstructionCauses:Massorforeignbodyinbronchialcavitycongenitalnarrowmucusblockage粘液嵌塞

externalpressure外压性压迫

TBetc

支气管阻塞-X线表现

bronchialobstruction

直接征象：支气管狭窄或完全阻断，腔内肿块，管壁增厚。CTisveryclear

支气管阻塞-X线表现

bronchialobstruction

Indirectnesssigns:Incompleteobstruction—obstructiveemphysema.Completeobstruction—obstructiveatelectasis

支气管阻塞

bronchialobstruction

支气管阻塞

bronchialobstruction

机理:支气管部分obstruction—actionaspiston活塞作用，空气能吸入而不能完全呼出—该支气管所分布的肺泡过度充气膨胀overinflation—肺气肿obstructiveemphysema.

阻塞性肺气肿(obstructiveemphysema）

阻塞性肺气肿--分类

（obstructiveemphysema）按气肿部位分为：泡性或小叶性肺气肿lobularemphysema间质性肺气interstitialemphysema

按气肿范围分为

弥漫性肺气肿与局限性肺气肿

diffuseandlocalization

主要由肺内气体增多

,肺体积膨大形成

Thelungcontaintoomuchair,Itreflectstheoverinflation阻塞性肺气肿obstructiveemphysema

Diffusepattern:1.Radiolucencyincreased2.Thechestcastistubbiness-like3.Thevascularmarkingsdecreased4.Increasedretrosternalspace5.Theheartshadowvertical6.Depressionofthediaphragm局限型：

局部肺透亮度增加

Localizationpattern:TheradiolucencyofaregionlungisincreasedThevascularmarkingsandvascularitydecreasedAtelectasis(incompleteexpansionofthelung):Increaseddensitysizeoflungshrunken肺体积缩小

Shiftremainderofthelungmaybecomeoverexpanded

阻塞性肺不张Obstructiveatelectasis肺叶不张Lobaratelectasis

肺叶缩小lobeshrinkage

叶间裂向心性移位displacementofinterlobularsepta

纵隔与肺门向患肺移位

患叶密度均匀增高Homogenousincreaseddensityofthediseasedlobe.

邻近肺叶代偿性气肿Compensatoryhyperinflationinanadjacentlobe

右肺上叶不张

rightupperlobesatelectasis右肺上叶不张

rightupperlobesatelectasis右肺上叶不张

rightupperlobesatelectasis右肺中叶不张

rightmiddlelobeatelectasis右肺中叶不张

rightmiddlelobeatelectasis左肺上叶不张

leftupperlobeatelectasis下叶不张

rightlowerlobeateletasisrightlowerlobeateletasis

肺段不张

segmentateletasis

小叶性不张lobuleateletasis瘢痕性肺不张

肺部病变

渗出与实变exudationandconsolidation

增殖proliferation

纤维化fibrosis

钙化calcification

肿块mass

空洞与空腔cavityandaircontainingspace

肺间质病变intersititialchangings

渗出与实变exudationandconsolidation渗出:肺泡内气体被由血管渗出的液体、蛋白及细胞所代替，形成渗出性实变。

usuallyseeninTB,pneumonia,lunghemorrhagandlungedema.

渗出与实变exudationandconsolidationX-rayexhibition

云絮状致密影

Increasedpatchy,cloudydensity,边缘模糊,中心密度较高较均匀小片状、大片状或呈肺叶肺段分布NOTanylossofvolumeorshrinkage

渗出与实变exudationandconsolidation支气管气像（airbronchogram）

Contrastisproducedbetweentheairwithinthebronchialtree实变影像中可见含气的支气管分支影.经治疗后多可在1-2周内吸收

增殖性病变Proliferativelesion

肺慢性炎症在肺内形成肉芽组织granulomatoustissues，为增殖性病变usuallyseeninTB,chronicpneumoniaandgranulomatouspneumonia增殖Proliferativelesion

X线表现：呈结节状致密影---腺泡结节样nodular病变，呈梅花瓣状密度较高、边界较清楚sharplybound,没有融合趋势

增殖Proliferation纤维化fibrosis

Fibrosis:Itisfibrotictissuesconformedalesion,Thepathologicfeatureisfibrosiswithscarformation.纤维化弥漫性间质纤维化

Diffuseinterstitialfibrosis常广泛累及肺间质，对肺功能影响较大多见于弥漫性间质性肺炎diffuseinterstitialpneumonia、TB,尘肺、特发性肺间质纤维化.弥漫性纤维化

X线表现：紊乱的索条状strip网状或蜂窝状

honeycomb致密影网结影netting-nodules

纤维化与肺纹理的区别———————————————

纤维化索条状、网状、蜂窝状走向僵直粗细不均密度高

肺纹理树枝状走向柔和肺门—肺野逐渐变细密度较低

多为肺急性或慢性炎症的愈合表现

healedlungemergencies肺组织破坏后代之以纤维结缔组织见于吸收不全的肺炎、肺脓肿、肺结核等局限性纤维化

localizationfibrosis

钙化calcification

钙化Calcification良性病变或

病变愈合healstage

见于肺结核或淋巴结干酪样结核灶的愈合某些肿瘤或囊肿尘肺、肺胞浆菌病等

钙化Calcification

X线表现：

高密度影

形状不一uncertainshapes呈斑点状miliaryspots、块状,爆玉米花状pop-coin,蛋壳样eggshell钙化,边界锐利肺门部钙化灶与肺血管横断面鉴别

肺血管横断面

肺门部钙化灶园形

不规则形边缘光滑

边缘锐利有环形支气管断面伴行

无伴行密度低于钙化灶

密度更高肿块mass肿块mass多见于肺肿瘤，也可见于结核瘤、炎性假瘤BenignMalignantMetastasis:multipleroundmasswithdifferentsizeBenignsmoothregularinshapeandgrowslow.malignantabscessabscessMalignant恶性肿瘤X线表现边缘毛糙或毛刺形成，分叶状，生长快

胸膜凹陷征

癌性空洞，厚壁、偏心性、壁结节肺部基本病变

空洞与空腔cavityandaircontainingspace肺内病变组织发生坏死，坏死组织经引流支气管排出而形成

Cavityisformedasaresultoftissuenecrosisandcommunicatedwiththebronchus.空洞cavity

虫蚀样空洞（无壁空洞）薄壁空洞Thin-walledcavity厚壁空洞thick-walledcavity

壁厚3mm以上，见于肺脓疡、肺结核、肺癌等X线表现薄壁空洞Thin-walledcavity

洞壁厚3mm以下内壁光滑境界清楚的园形透亮区，见于肺结核结核性空洞常无或仅少量液体多为薄壁TBcavitywithalittleornotfluidlevel

虫蚀样空洞（无壁空洞）实变肺野内多发小的透亮区，虫浊样，见于干酪性肺炎癌性空洞内壁多呈结节状

Thick-walledcavityIrregularinnerling厚壁空洞thick-walledcavity

壁厚3mm以上，见于肺脓疡、肺结核、肺癌等肺脓疡空洞多有明显液片多为厚壁

Thickwallcavitywithsurroundexudativelesionsassociatedwithafluidlevel

空腔

aircontainingspace

肺内腔隙的病理性扩大

肺大疱、肺气囊、肺气囊肿、囊状支扩空腔性病变右下肺囊肿肺部基本病变

肺间质病变

interstitiallesion:发生在间质的弥漫性病变:即病变主要分布在支气管血管周围、

小叶间隔、肺泡间隔.X线表现

肺纹理增粗、网状strip纹理、蜂窝状honeycomb

或伴广泛小结节影netting-nodules（间质结节）弥漫性肺间质病变(diffuseinterstitialdisease)HRCT：

小叶内间质增粗—

小叶内细支气管血管周围

和肺泡间隔的间质增厚弥漫性肺间质病变(diffuseinterstitialdisease)

—多发小结节及粟粒病变(multinodularandmiliarydiseases)弥漫性肺泡病变diffusealveolardis