呼吸系统影像诊断课件

呼吸系统影像诊断BronchialObstruction局部支气管狭窄stenosis支气管闭塞Obstruction肿块massinbronchialcavity管壁增厚thickenedofbronchialwalldirectnesssigns重点复习

Indirectnesssigns：阻塞性肺气肿：部分阻塞

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

centrilobularemphysema肺体积膨大Overinflation密度减低Densityreducepanlobularemphysema肺体积缩小Incompleteexpansionofthelung,Thesizeoflungshrunken密度增高

Increaseddensity

obstructiveatelectasis.

obstructiveemphysema

纤维化fibrosis局部病灶纤维化Localfibrosis弥漫性间质纤维化

DiffuseinterstitialfibrosisCalcificationnoduleandmassBenignMalignantlobulationspiculation血管集束征病灶胸膜侧小片状浸润支气管充气征空气半月征

Aircrescentsign曲菌球

支气管血管束增粗peribronchovascularburdleinterstitialthickingSignet-ringsign印戒征小叶间隔增厚Interlobularseptalthicking

小叶核增大Lobularcorethicking树芽征（tree-buddedsign）肺间质病变interstitialnodulesmultinodularandmiliarydiseasesair-spacenodule

胸腔积液

（pleuraleffusion）

游离性胸腔积液freepleuraleffusion

少量积液中量积液：大量积液：

局限性胸腔积液localizedpleuraleffusion包裹性积液叶间积液肺底积液胸膜凹陷征胸膜凹陷征pleuralindentationsign支气管扩张bronchiectasis肺炎pneumonia

大叶性肺炎小叶性肺炎间质性肺炎支原体肺炎肺结核Pulmonarytuberculosis肺癌Lungcancer纵隔肿瘤mediastinaltumor本节课内容bronchiectasis临床表现：咳嗽、咳血、咳痰Continuouscough,purulentsputum,recurrenthaemoptysis分型：柱状型(Cylindricalbronchiectasis)、囊状型(Cysticbronchiectasis)、曲张型(Varicosebronchiectasis)病理：pathologicchangings支气管壁组织破坏（慢性感染）管内压增高（分泌物淤积、长期剧烈咳嗽）外在性牵拉（肺不张、纤维化等）bronchiectasis平片：plainchestradiographicfindingsoftennonspecific肺纹理增粗紊乱，囊状透亮影，anincreaseoflungmarkings

Surroundinginfiltrateorfibrosis合并感染时有液平及囊壁增厚。dilatedbronchi,sometimeswithair-fluidlevelsbronchiectasis曲张型扩张TubularandCystic

bronchialdilatation念珠状粗细不均囊柱状bronchiectasis平片价值有限,支气管造影病人痛苦主要依靠CT诊断

HRCT(

highresolutionCT)bronchiectasis轨道征轨道征Tram-tracksign囊柱状粗细不均念珠状柱状型

曲张型bronchiectasis葡萄串征clustersofgrapessign囊状型葡萄串征clustersofgrapessign液平air-fluidlevels囊壁增厚囊状型bronchiectasisDilatationofthebronchus,BronchialwallthickeningSometimesair-fluidlevels肺炎(pneumonia)ClassficationofpneumoniaAccordingtotheanatomicpositionofthelesion:

Lobarpneumonia

BronchopneumoniaorLobularpneumonia

InterstitialpneumoniaAccordingtotheetiologyofthepneumonia按病变分布分为：

大叶性肺炎Lobarpneumonia

炎症累及肺叶或肺段支气管肺炎(小叶性肺炎)

bronchopneumoniaorLobularpneumonia

炎症累及多个肺小叶为主间质性肺炎Interstitialpneumonia

炎症累及肺间质为主Lobarpneumonia—大叶性肺炎临床Causedbypneumococcus肺炎链球菌致病Onsetsuddenly,rapiddevelopmentofhighpyrexia,pleuriticpaincoughAcharacteristicrustycolorsputum铁锈色痰pathologicchangings

of

Lobarpneumonia

Thebasicpathologiclesion:Acuteinflammatoryexudationofthepulmonaryparenchyma

病理分四期：充血期Thecongestivestage:

毛细血管充血为主Inflammatoryedema红色肝样变期Theredconsolidationstage

:

肺泡内充满渗出液,有较多红细胞,肺组织切面呈红色灰色肝样变期Thegrayconsolidationstage

:

肺泡内有较多白细胞,肺组织切面呈灰色消散期Resolutionstage:

肺泡内渗出物溶解,吸收X线表现

X-rayfeatures影像学表现与病理改变密切相关,是病理改变在影像学上的反映

充血期Thecongestivestage可无阳性发现,临床症状出现3--12小时后才出现X线征象

NoX-raychanges病变区肺纹理增多，透亮度减低

anincreaseoflungmarkingLobarpneumonia实变期（红色或灰色肝样变期）Theconsolidationstage密度均匀的致密影alargehomogeneousradiopaqueshadowinthelungfieldNovolumelossAirbronchogramiscommon累及肺叶：以叶间裂为界的大片致密影,但体积不缩小,无叶间裂的移位右中叶肺炎LobarpneumoniaLobarpneumoniaTheX-rayfeatureisalargehomogenousradiopaqueshadowthereisnovolumelossairbronchogramiscommonBordersoftheshadowappearasasharplydefinedmargin实变期（红色或灰色肝样变期）密度均匀的致密影homogeneousradiopaqueshadow累及肺段：片状或三角形,尖端指向肺门下叶节段性肺炎LobarpneumoniaLobarpneumonia实变期（红色或灰色肝样变期）支气管气像Airbronchogram

致密阴影内,可见透亮支气管影Lobarpneumonia消散期X线改变

Resolutionstage病变密度逐渐减低，呈大小不等、分布不规则的斑片状阴影Theshadowofconsolidationbecomesscatter可完全吸收或遗留少量索条影起病1周后病变开始吸收，多在2周内完全吸收，少数可延迟吸收或演变为机化性肺炎发病10后LobarpneumoniaCT表现CTmanifestations一般平片就可诊断,不需要CTCT优势是:充血期可发现磨玻璃样改变ground-glassopacity,GGO更容易发现支气管气像Airbronchogram如消散缓慢,反复发作,年龄较大的患者,与阻塞性肺炎鉴别大叶性肺炎CT表现

支气管气象Airbronchogramrightlowerlobepulmonaryconsolidationwithairbronchograms.支气管肺炎

（bronchopneumonia）又称小叶性肺炎(lobularpneumonia)致病菌为链球菌、葡萄球菌、肺炎双球菌streptococcus,staphylococcus,pneumococcus多见于婴幼儿、老年及极度衰弱患者，或手术后bronchopneumonia临床表现Symptoms:起病急，高热寒战highpyrexia咳嗽、咳泡沫粘液脓性痰、胸痛cough,purulent

sputum,pleuriticpain呼吸困难甚至紫绀

shortnessofbreath

pathologicchangings病理变化肺小叶渗出与实变

lobularconsolidation小支气管壁充血水肿、间质内炎性浸润

Smallbronchuswallcongestandswelling,interstitialinflammationimmersing小支气管壁充血水肿--不同程度阻塞--

小叶性肺气肿、小叶性肺不张

lobularemphysemaorlobularatelectasisX线表现

X-rayfeaturesbronchopneumonia肺纹理增多、增粗、模糊Intensificationoflungmarkings病变多在两肺中下野的内中带,沿肺纹理分布的斑片状影，密度不均，边缘模糊，密集的病变可融合成较大的片状

Smallpatchyopaqueshadowsinthemiddleandlowerlungfields,Confluenceofthesepatchyopacities

Intensificationoflungmarkings

Smallpatchyopaqueshadowsinthemiddleandlowerlungfields,

Confluenceofthesepatchyopacities

Emphysemaofthebothlungsisusuallyvisible金黄色葡萄球菌支气管肺炎Intensificationoflungmarkings

Smallpatchyopaqueshadowsinbothlungfields,

Pneumatoceles(肺气囊)支气管肺炎CT表现(CTfeatures)支气管血管束增粗peribronchovascularburdlethicking小片状影(小叶性实变或小叶性不张)Smallpatchyopaque大片状影(小片状影融合)Confluenceofthesepatchyopacities1-2CM小圆形透亮影(小叶性肺气肿)centrilobularemphysemaLobularpneumonia.CTdemonstratesmultifocalareasofconsolidationandairbronchograms.间质性肺炎

（interstitialpneumonia）累及肺间质为主的炎症，包括支气管壁及周围间质和肺泡壁

Interstitialpneumoniainvolvesmainlytheinterstitialtissueoflungs,includingthebronchovascularbundlesandinterlobularandintralobularsepta可由细菌或病毒引起viralorlacterialinfection多见于小儿，常继发于麻疹、百日咳、流行性感冒等急性传染病原发传染病症状+咳嗽、气急、紫绀shortnessofbreath,cough,cyanosis症状重，体征少、wbc不高病理

pathology

小支气管壁及肺间质炎性细胞浸润Interstitialinflammationimmersing炎症沿淋巴管扩展引起淋巴管炎和淋巴结炎

Lymphatitis,lymphadenitis小支气管的炎症－阻塞－小叶性肺气肿肺不张

Smallbronchusinflammation---obstructemphysemaandatelectasis

肺泡内可有轻度炎性浸润interstitialpneumonia病变广泛，累及两肺尤中下肺肺纹理增粗、模糊，Intensificationoflungmarkings网状纹理finestreak-like,net-like,nodularornod-reticularshadows肺门密度增高，模糊，肺门增大enlargementofthehilarshadow小叶性肺气肿、肺不张，婴幼儿弥漫性肺气肿empyhsemaofthebothlungs磨玻璃影、小斑片状影GGO,Smallpatchyopaqueshadows

interstitialpneumoniaX-rayfeaturesinterstitialpneumoniaCTandHRCT广泛的支气管血管束增粗Intensificationofbronchovascularbundles小叶间隔增厚interlobularandintralobularseptathickening胸模下线Subpleuralline磨玻璃影、小片状影GGO,Smallpatchyopaqueshadows

肺门、纵膈淋巴结可增大广泛的支气管血管束增粗

Intensificationofbronchovascularbundles

小叶间隔增厚

Interlobularandintralobularseptathickening

胸模下线SubpleurallineGround-glassopacity,GGO

间质性肺炎与支气管肺炎鉴别支气管肺炎:以小片状影为主,累及中下肺野为主间质性肺炎:以肺纹理增粗模糊为主,病变更广泛,累及两肺interstitialpneumonia支原体肺炎

Mycoplasmapneumonia好发于青少年临床症状轻,常表现发热,咳嗽.白细胞总数正常或稍低痰\鼻\喉拭子培养可获支原体血清学检查:红细胞冷凝集试验大于1:32,补体结合试验大于1:16,间接凝血试验大于1:32,间接荧光试验大于1:16病理pathology

急性间质性肺炎及支气管炎1-2周吸收病变自限性影像学表现Imagingmanifestations早期病变:肺纹理增粗、模糊

Intensificationoflungmarkings网状纹理finestreak-like,ornod-reticularshadows病变发展后:Smallorlargepatchyopaque胸腔积液,肺门纵隔淋巴结肿大少见.肺脓肿(lungabscess)由化脓性细菌引起,早期为化脓性肺炎,坏死液化,形成脓肿Purulencebacteria---inflammationfocus-Necrosisandfluidify---abscessinfectapproach：inhale

hematogenousdirectspreedStage：acuteandchronic

stagelungabscess

临床

急性期Acutestage：有急性化脓性肺炎的表现，高热寒战、咳嗽咳痰、胸痛、咳大量脓臭痰白细胞及中性粒细胞明显增高

慢性期Chronicstage：

After3monthstheabscesswasconsideredtobechronic

经常咳嗽、咳脓痰和血痰，不规则发热及贫血消瘦等lungabscess

病理

化脓性肺炎（渗出和实变）—细支气管阻塞、小血管炎性栓塞—坏死液化—形成空洞(脓腔)

脓液破溃到胸腔—脓气胸、支气管胸膜瘘

持续不愈超过3个月转为慢性，脓腔周围炎性浸润减少但纤维组织增生lungabscess急性期Acutestage排脓之前：化脓性肺炎团状致密影,边缘模糊X线表现

lungabscess急性期排脓以后边界模糊的团状阴影内有透亮的空洞影，空洞壁较厚，内壁较光整，常伴有液平面Cavitythickwallwithair-fluidlevelsurroundedbyexudati