INFEKSI DAN KEGANASAN PADA THORAX

PA vs. AP
PA

Less stressful, better for heart Diaphragm rounded Caudal pulmonary vessels better visualized Better to see small amount of pleural air
Better for lungs Hear appears elongated Flat diaphragm Mickey Mouse ears Better to see small amount of pleural fluid

AP

PA vs AP

Right vs. Left Lateral

Right Lateral
Better cardiac detail R crus forward See Cava go into it

Left Lateral
Heart appears round L crus forward See Cava go past

Anesthesia Breed Differences

Lateral View
Make a Plus sign Bermuda triangle Left atrium Left Ventricle Right Ventricle

Thoracic and Pulmonary Vessels

Aorta Caudal Vena Cava Cranial pulmonary vessels

Proximal third rib

Caudal pulmonary vessels

9th rib where crosses

Veins are ventral and central

The most common abnormalitie in the thoracic cavity are:

Pneumothorax (Air) Hydrothorax (Fluid) Hemothorax (Blood) Chylothorax (Chyle) Pyothorax (Pus)

pneumothorax
Pneumothorax refers to the loss of negative pressure in the thoracic cavity when air gains entrance to the thorax. Most common causes: Fractured Ribs Gunshot Wounds (See Photo) Iatrogenic-thoracocenthesis-biopsy Ruptured Lung Ruptured Emphysematous Bulla Ruptured Parasitic Nodule Ruptured Esophagus or Diaphragm.

PNEUMOTHORAX

PNEUMOPERITONEUM DUE TO PERFORATED PEPTIC ULCER The CXR shows free air under the right hemidiaphragm, in addition to features of hyperinflation. The possibilities include perforated peptic ulcer or GI malignancy, recent laparoscopy/laparotomy, and peritoneal dialysis. It is important to do an erect CXR for the free air to rise to the top of the abdomen. For patients with a nasogastric tube in place, instillation of 200 ml of free air before the CXR may aid the diagnosis

MEDIASTINAL EMPHYSEMA (PNEUMOMEDIASTINUM) The CXR shows free air in the mediastinum and subcutaneous tissues of the neck (Fig. 16.2). The mediastinal air could have come from disruption of the integrity of the lung, major airways, or the esophagus. A history of trauma (e.g. motor vehicle accident with blunt injury to the anterior chest wall by the steering wheel) or iatrogenic instrumentation (e.g. recent endoscopy) is important. Descending infections by gas-producing organisms from the oral cavity and neck can cause severe mediastinitis and result in a similar appearance.

KELAINAN PLEURA
1. Penebalan pleura : e.c peradangan pleuritis r.o : garis opaq linier 2. Schwarte : - penebalan pleura yg tdk teratur + perlekatan - kalsifikasi pleura r.o : opaq kehitaman

3. Efusi pleura Sedikit : +/- 100 cc sudut costophrenicus tumpul (normal lancip) Banyak : Posisi PA berdiri : tampak kesuraman homogen makin banyak membentuk garis lengkung lateral lebih tinggi. Masif : seluruh hemithorax opaq homogen Posisi AP bagian bawah dekat diafragma lebih suram

4. Tumor pleura :

Jinak : fibroma (batas jelas, costae intack) / lipoma

Ganas : mesothelioma

Pleuritis
Pleuritis can occur alone or in combination with pneumonia. According to exudate: Fibrinous Purulent (suppurative) Empyema Granulomatous Chronic pleuritis typically results in pleural adhesions. Etiology: Most cases are infectious, although isolation is not always possible. Fibrinous pleuritis characterized by extensive deposition of fibrin on pleural membrane

Opacified Hemithorax
Three Causes

Atelectasis Pleural effusion

Pneumonia

Recognizing the Causes of an Opacified Hemithorax

Atelectasis

Opacified hemithorax from volume loss

Shift of heart and mediastinal structures toward opacified hemithorax

Normally there are 2-10 cc of fluid in the pleural space

Atelectasis of right lung shift of the mediastinal structures TOWARD the side of opacification

Pleural Effusion

Opacified hemithorax from large effusion Shift of heart and mediastinal structures away from side of opacified hemithorax

Large right pleural effusion - shift of the mediastinal structures AWAY from the side of opacification

Four Reliable Signs of CHF

Pleural Effusions

Pneumonia

Opacified hemithorax No shift

Air bronchograms

The CXR shows opacities with air bronchograms involving both lung fields. This is typical of severe pneumonia as evidenced by multilobar involvement. Typical organisms include Streptococcus pneumoniae, Legionella, and gram negatives like Klebsiella and Pseudomonas aeroginosa

Pneumonia of LUL no shift of the mediastinal structures to either side; multiple air bronchograms

The black branching structures are the result of air in the bronchi, now visible because density other than air surrounds them (in this case it is inflammatory exudate from a pneumonia).

Common Alveolar Lung Diseases

Pneumonia Pulmonary edema Pulmonary hemorrhage Aspiration

This disease is fluffy and indistinct in its margins, it is confluent and tends to be homogeneous. In both upper lobes, you can see air bronchograms. This is an alveolar (airspace) disease, in this case pulmonary edema on a noncardiogenic basis. Pulmonary edema

Airspace Disease

Aspiration pneumonia at both bases

Cavitary Lung Lesions

Three Causes

Carcinoma of the lung TB

Abscess

The CXR shows bilateral upper lobe infiltrates with cavities, suggestive of active pulmonary tuberculosis. In general, thinwalled cavities (5 mm) tend to be infective and

PPOK
Ringan normal Lanjut diafragma datar, vol. paru ber(+) / hiperinflasi, hiperaerated, tear drop heart, retrosternalspace melebar, BVP meningkat (bronkitis kronis)

The CXR of COPD typically demonstrates evidence of air trapping. The signs are horizontality of the ribs, hyperinflated lungs (normally the right sixth rib bisects the right hemidiaphragm), hyperlucent lung fields, bilateral symmetrical attenuated pulmonary vasculature, long tubular heart, scalloping and flattening o f t h e d i a p h r a g m

DIAGNOSA BANDING PPOK

Asma Bronkiale Gagal jantung kronis Bronkiektasis Sindroma obstruksi pasca TB

Infected BE

TB

Fibrosis & kalsifikasi

BULA PARU

The CXR shows bilateral infiltrates and air bronchograms with a perihilar distribution. The heart size is normal. There are no Kerley B lines or evidence of upper lobe venous diversion. All these are typical features of PCP. PCP is the most common life-threatening opportunistic infection in HIV disease.

There is a homogeneous density in the right upper zone and elevation of the transverse fissure. Instead of the transverse fissure being straight, there is a bulge at the medial end (Fig. 30.2), giving it an inverted S shape.

KEGANASAN
Categorization Parenchymal cancers Leiomyomas, fibromas, chondromas Bronchogenic lung cancer Squamous cell (epidermoid) Adenocarcinoma Large cell carcinoma Small (oat) cell

Nodule (benign vs malignant)

Age (malignancy increases with patient age) Increases with malignancy Size (size increases with malignancy) 85% of lesions > 3 cm are malignant Calcification (lung cancer rarely calcify) Benign pattern of ca++ rules out malignancy Growth rate (stability of size over 2 year period reliably excludes malignancy)

MEDIASTINUM COMPARTEMEN
Anterior: posterior to sternum anterior cardiac and tracheal borders Posterior: posterior to a line 1cm dorsal to anterior edge of vertebral bodies Middle: between the two

Anterior mediastinum
Thymic masses Lymphoma Germ cell tumors Thyroid masses Ectopic parathyroid masses Tumors of vessels, fat, mesenchymal Tu

Diseases with Multiple Lung Nodules

Metastases Multiple AVMs Rheumatoid nodules Wegeners Granulomatosis

Disease with Multiple Cystic Structures

Cystic fibrosis Bronchiectasis Tuberculosis

Cystic Fibrosis - interstitial

Middle mediastinum
Metastases to middle mediastinal nodes Most metastases arise from intrathoracic tumors, primarily lung Extrathoracic- include genitourinary,melanoma, head and neck

Posterior mediastinum
Neurogenic tumors Tumors of esophagus Primary and secondary tumors of the spine

Myasthenia gravis
Myasthenia gravis is associated with thymoma

Thymoma
Older patients Rarely before 20 y 20-50% asymptomatic Symptoms: cough, dyspnea, hoarseness, chest pain Myasthenia gravis SVC syndrome A thymic mass Homogeneous soft-tissue density Oval, round, lobulated Sharply demarcated Rarely cystic Enhances homogeneously May contain calcium

Using the Silhouette Sign The mass (red arrow) silhouettes the right heart border which is to say there is no longer an edge of the right heart seen. That means the mass is (a) touching the right heart border (the mass is anterior) and (b) the mass is the same density as the heart (fluid or soft tissue density). The mass is a thymoma.

Where in the chest is this mass?

Thymic masses: differential diagnosis

Lymphoma Neuroendocrine tumors (carcinoid) Lymphangioma Hemangioma Thymolipoma

Lymphoma - CT
Nodes greater than 1cm in diameter - enlarged on CT , MRI Multiple nodes smaller than 1cm suspicious Enlarged nodes- discrete or fuse to form a single larger mass Minor enhancement Low density areas Calcifications prior to therapy rare commoner in more aggressive subtypes seen occasionally following therapy

Carcinoma mass above right hilum

Enlarged hilum (bronchogenic carcinoma)

Pancoast (superior sulcus) tumor

Bronchogenic tumor in the lung apex Usually squamous cell type Presents with: Apical radiodensity Horners syndrome Thoracic outlet syndrome Rib or vertebral destruction

Pancoast tumor

Tumor paru

Tb paru lama & massa mediastnum

metastase
Milier Coin lesion Coarse nodular Golf ball Lymphangitic spread Pleural effusion / ateletase

Coin lesion

Multiple pulmonary nodules and masses. You should think of pulmonary metastasis when you see this presentation; although this case was due to a less likely possibility, sarcoidosis

multiple malignant masses

Pulmonary metastase

Pulmonary metastase

Pleural Mesothelioma
Benign localized form Malignant diffuse form Related to asbestos exposure Rarely calcified DDx from mets and lymphoma Pleural is more commonly involved with mets

Four Reliable Signs of CHF

Fluid in the walls of the bronchi make them visible and produce numerous doughnut densities throughout the periphery of the lung.

Peribronchial cuffing