1. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 3 The Respiratory System

2. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Objectives Identify anatomic structures on both diagrams and radiographs of the respiratory system Describe the physiology of the respiratory system Explain how pathologies of the respiratory system affect the patient throughout the life Describe the various pathologic condition affecting the respiratory system and the radiographic manifestations Explain how a specific pathologic process will affect the technical factors that the technologist must consider

3. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Objectives—(cont.) Explain how various imaging modalities used in the diagnosis of pathology of the respiratory system helps in diagnosis

4. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy Review Trachea: anterior to esophagus; divides into right and left main bronchi at the carina Bronchi: right is shorter; wider more vertical (a cause of pathology occurring in the right more often) Hilum: right should be lower because of the heart

5. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy Review—(cont.) Alveoli: functioning unit of the lung found at the end of each bronchiole Fissures: two on the right and one on the left. Divide the lungs into lobes Pleural cavity: visceral pleura is lung covering and parietal pleura lines thoracic cavity. Space between is cavity. Important for pathology

6. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Physiology Purpose: take in oxygen for the body and to rid the body of carbon dioxide Ventilation: air moving from atmosphere to alveoli Perfusion: gas exchange of oxygen to blood and CO 2 from the blood

7. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Pathology—Congenital Cystic fibrosis RDS

8. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Congenital Diseases Cystic fibrosis: inherited; exocrine glands; thick mucus; frequent and progressive infections; survival 40 years Respiratory distress syndrome: AKA hyaline membrane disease; premature infants; “ground glass” appearance; “air bronchogram” sign

9. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cystic Fibrosis RDS

10. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Pathology—Inflammatory Processes Lung abscess Adult respiratory distress Asthma Atelectasis Bronchitis COPD Croup

11. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins More Inflammatory Processes Pleural effusion Pneumonia Respiratory syncytial virus Pneumoconiosis Pneumothorax Pulmonary edema Pulmonary emboli TB

12. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Inflammatory Processes Lung abscesses: embolic-infected blood clot; pneumonic complications of pneumonia; inhalation-inhalation of infected material; air-fluid levels; cavity from sputum Adult respiratory distress syndrome: sudden respiratory failure; acute alveolar injury; appearance similar to pulmonary edema

13. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Lung Abscess

14. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Asthma Types: extrinsic allergies; intrinsic stress or anxiety Symptoms: wheezing; coughing; chest tightening Radiographic appearance: normal; trapped air; opacity

15. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Atelectasis Definition: collapse of lung/lobe Types: obstructive; compressive; passive; adhesive; cicatrizing Causes: depends on the type; iatrogenic, ET tube placement Radiographic appearance: different, depends on cause; opaque area; lung edge

16. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Atelectasis due to Obstruction (Cancer)

17. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Atelectasis due to Obstruction (ET Tube)

18. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Bronchitis Definition: inflammation of bronchioles Causes: tobacco smoke; industrial air pollution Chronic bronchitis: repeated bouts over 2 years; sputum production Related to COPD

19. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Bronchiectasis Irreversible dilation Cystic fibrosis is congenital bronchiectasis Acquired from pulmonary infection Need bronchoscopy to diagnose

20. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins COPD Definition: pulmonary process caused by the obstruction of air Two processes: chronic bronchitis and emphysema Over 10,000,000 people in the United States suffer

21. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Emphysema Compensatory: lung increases to compensate for decrease elsewhere Three types of centrilobular: centriacinar (blue bloater); panacinar (pink puffer); paraseptal –These have trapped air Cause of above: smoking

22. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Emphysema—(cont.) Radiographic appearance: hyperlucency; flat diaphragm; elongated heart shadow, barrel chest; tenting indicates long term Technical caveats: costophrenic angles; over-exposure

23. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Emphysema—(cont.)

24. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Emphysema—(cont.)

25. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Emphysema—(cont.)

26. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Croup Definition: viral infection; young children; bark cough Why soft tissue neck radiograph: r/o epiglottitis; AP to make diagnosis Radiographic appearance: steeple sign

27. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Croup—(cont.)

28. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Pleural Effusion Definition: fluid in pleural cavity Causes: CHF; infection; trauma Radiographic features: opacity at angles; meniscus sign Radiographic positions: upright; lateral decubitus side down

29. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Pleural Effusion—(cont.)

30. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Pleural Effusion—(cont.)

31. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Pneumonia Definition: inflammation of the lungs Types and related causes: bronchopneumonia— Streptococcus or Staphylococcus bacteria; aspiration— inhaled foreign object; viral—virus; lobar—Streptococcus bacteria Radiographic features: opacity of segment or lobe of lung; overall opacity depending on the type

32. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Pneumonia—(cont.)

33. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins RSV Definition: pneumonia caused by virus Characteristics: only in children under the age of 3 Radiographic findings: normal; “dirty” lungs in the parahilar region

34. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Pneumoconiosis Types and causes: silicosis—silica dust; asbestosis— asbestos rock or insulation; CWP—anthracite, 50% Radiographic appearance: all are similar; fibrous “eggshell” pattern; diagnosis made by clinical history

35. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Pneumothorax Definition: air in the pleural cavity Images to take and why: upright inspiration/expiration; lateral decubitus affected side up –Air rises; expiration allows the pleural cavity to expand Important radiographic finding: compromise of opposite lung; mediastinal shift

36. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Pneumothorax—(cont.)

37. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Pneumothorax—(cont.)

38. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Pulmonary Edema Definition: backup of blood in the pulmonary vessels Causes: pulmonary circulation obstruction; CAD; renal failure Symptoms: dyspnea; SOB; rapid pulse Radiographic features: “Kerley B” lines; diffuse increased density Requires immediate treatment

39. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Pulmonary Emboli Definition: embolus in the lung Risk factors: immobility for 72 hours; DVT Sequence for diagnosis: chest radiograph; CT; nuclear medicine PE are fatal in over 50% of cases

40. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Tuberculosis Cause and spread: Mycobacterium tuberculosis; inhalation of particles from infected individual Two types: primary and secondary Risk factors: homeless; alcoholic, immigrants; AIDS; prisoners Radiographic features: primary, lower lobes’ small focal spots; secondary, apices, cavities; healing, streaks

41. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Tuberculosis—(cont.)

42. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins TB—(cont.)

43. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins TB with Cavity

44. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Lung Cavitation

45. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Pathology Neoplasms Benign: hamartoma Malignant –Adenocarcinoma –Squamous cell –Small cell –Metastatic

46. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Neoplasms Benign: hamartoma Best seen by: HRCT shows a fat-filled lesion Radiographic features: “popcorn” calcifications in the lesion Calcification usually means benign

47. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Hamartoma

48. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Bronchogenic Carcinoma Adenocarcinoma Definition: 40% of bronchogenic carcinoma; comes from major bronchus Characteristics: obstruction of bronchus; atelectasis; slow growing; abscess formation

49. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Bronchogenic Carcinoma Squamous Cell Carcinoma Definition: lesion derives from stratified squamous epithelium Characteristics: most favorable prognosis; smoking Radiographic features: cavity; atelectasis of lobe

50. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Bronchogenic Carcinoma Small Cell Carcinoma—(cont.) Definition: short, spindle-shaped cells that are found in bronchogenic carcinoma; oat cell Characteristics: comprise 15% of all bronchogenic carcinoma; little cytoplasm in these cells; metastasize to brain; very aggressive; poor prognosis Radiographic features: coin lesion; single tumor; no calcification

51. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Bronchogenic Carcinoma

52. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Metastatic Carcinoma Types: depends on primary; source determined by appearance Characteristics: both lungs, primary stomach; unilateral, breast primary Radiographic appearance: lymphangitic, diffuse streaks; pneumonic, pneumonia appearance; nodular, cotton ball

53. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Pneumonic Metastatic Carcinoma

54. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Nodular Metastatic Carcinoma

55. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Imaging Strategies Chest: see next slide Computed tomography (CT): differentiate tumors from solid versus cystic; shows fat; evaluates mediastinum Magnetic resonance imaging (MRI): distinguish between tumors and other lesions and normal tissue; valuable to see heart and blood vessels Nuclear medicine: very important for ventilation and perfusion; most important for PE

56. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chest Images