Pathology Of The Respiratory System

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Pathology Of The Respiratory System

• DMI 56
• Marilyn Rose

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The Respiratory System

• Function
• Distributes air for gas exchange with circulatory
  system
• Anatomy
• Upper respiratory tract
• Nose, mouth, pharynx, larynx
• Lower respiratory tract
• Trachea, bronchi, alveoli, lungs

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The Thoracic Cavity

• Right and left pleural cavities
• Mediastinum
• Parietal pleura
• Lines the thoracic cavity
• Visceral pleura
• Adheres to the lung tissue
• Bony thoracic structures/Intercostal muscles
• Assists with respiration
• Ribs, sternum, thoracic vertebrae

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Paranasal Sinuses

• Lined with respiratory epithelium
• Communicate with nasal cavities
• Maxillary and ethmoid sinuses are the only
  sinuses present at birth
• Frontal sinuses-fully developed by age 10
• Sphenoid sinuses begin to develop around age 2
  3 and are fully developed by late adolescence

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Imaging Considerations

• Chest x-ray
• Routinely performed in the erect position using
  high kVp and a 72 inch distance to minimize
  magnification
• The most frequently performed examination
• Provides important information about the soft
  tissues of the chest
• Bone
• Pleura
• Mediastinal structures
• Lung tissues
• 10 ribs should be seen on a CXR to determine that
  inspiration is adequate
• The mediastinum should be sufficiently penetrated
  so that the thoracic spine is visualized
• 50 sensitive to chest disease
• Typically display advanced pathology

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PA Chest
http//medinfo.ufl.edu/year1/rad6190/planes_sectio
n.shtml
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Exposure Factors

• Correct exposure factors are critical
• Incorrect exposure factors can create or hide
  pathology
• Consistent exposures are very critical for
  portable examinations
• These patients usually have a condition that
  requires serial radiographs to follow it

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Other Radiographic Chest Studies

• Oblique projections
• Useful to separate superimposed structures
• Lordotic
• Useful in demonstrating apical structures
• Fluoroscopy
• Assess diaphragmatic movement
• Assist with biopsies
• Tomography
• Useful in evaluating cavities and calcifications
  in the chest

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Apical Lordotic
Auntminnie.com
Oblique CXR
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Specialized Chest Studies

• Computed tomography
• Very useful in demonstrating nodules, masses
• The method of choice for demonstrating pulmonary
  adenopathy
• MRI
• Useful in demonstrating the mediastinum
• Nuclear medicine
• Ventilation/perfusion scan very useful in
  demonstrating obstructive disease and pulmonary
  emboli

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CT Chest
http//www.radpod.org/2007/01/03/tuberculous-cervi
cal-lymphadenopathy/
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MRI
revealed an anterior mediastinal mass compressing
the trachea. Its radiographic density was
consistent with hematoma
http//www.salemradiology.com/about.htm
http//www.ispub.com/ostia/index.php?xmlFilePathj
ournals/ijtcvs/vol8n2/mediastinal.xml
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PET Fusion
http//www.tricitypetct.com/physician.html
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Chest tubes, Vascular access lines, catheters

• Endotracheal tube
• Central venous pressure lines
• Pulmonary artery catheter
• Hickman catheter
• Intra-aortic balloon pump
• Ventricular pacing electrodes

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Endotracheal Tube(ETT)

• Usually inserted through the nose or mouth into
  the trachea
• Helps to manage the airway, allows for
  suctioning, and mechanical ventilation
• Should be positioned below the vocal cords and
  above the carina
• Extreme care should be taken not to dislodge the
  tube when moving or handling the patient

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ET tubes
http//hsc.unm.edu/EMERMED/Resident_Case_Presentat
ions/Case_2.shtml
Kinked endotracheal tube in endoscopy (The
endotracheal tube was obviously kinked in the
larynx. This problem was only realized during
endoscopy)
http//www.uam.es/departamentos/medicina/anesnet/j
ournals/ija/vol3n3/answer1.htm
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Chest Tube(CT)

• A large plastic tube inserted through the chest
  wall between the ribs
• Allows for drainage of air or fluid
• The collection device must be kept below the
  level of the chest

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Inflation of the left lung after chest tube
thoracostomy (blue arrow). The unusual appearance
of the gastric bubble (green arrow) resolved on
subsequent images and was not due to free
intraperitoneal air
http//www.saddleback.edu/alfa/N176/maintainChestT
ube.aspx
http//health.allrefer.com/health/pneumothorax-che
st-tube-insertion-series-3.html
http//www.ispub.com/journal/the_internet_journal_
of_family_practice/volume_1_number_2_18/article_pr
intable/a_postpneumonectomy_patient_with_iatrogeni
c_pneumothorax_4.html
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Central Venous Pressure LineCVP Line

• Inserted into subclavian or jugular vein
• The tip distal superior cava
• Allows for an alternative injection site and high
  volume infusion
• Allows for measurement of central venous pressure
• Indicates patients fluid status and information
  about the hearts right side

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Venous Pressure Line
http//www.nursinghomesabuseblog.com/articles/negl
ect-1
http//depts.washington.edu/asaccp/ASA/Newsletters
/asa60_6_22_25.shtml
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Pulmonary Artery Catheter(Swan-Ganz Catheter)

• Usually inserted via the subclavian vein
• Evaluates cardiac function, left atrial pressure
• A balloon is at the catheters distal end
  allowing it to float into a pulmonary artery
  capillary
• Usually used after an MI or cardiogenic shock
  episode

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Hickman CatheterPICC Line

• Inserted via the subclavian vein
• The tip will lie in the SVC
• Usually used to administer chemotherapy
• Patients with this type of catheter usually have
  poor access to other injection sites
• PICC lines are inserted via a brachial vein

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http//uwmedicine.washington.edu/PatientCare/Medic
alSpecialties/SpecialtyCare/UWMEDICALCENTER/Radiol
ogy/vascularaccess.htm
http//mikehamel.wordpress.com/2009/03/22/chemo-pr
ep/
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Intra-aortic Ballon Pump

• This catheter has a balloon at its distal end
• Allows inflation and deflation of a pump to
  provide mechanical support of the left ventricle
  and systemic circulation
• Proper placement is below the subclavian and
  above the renal arteries
• Extreme care must be taken when moving these
  patients as the balloon could float downward
  causing possible blockage of the lower circulation

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Ventricular Pacing Electrode

• Either temporary or permanent
• They provide electrical pacing in patients with
  bradycardia
• Permanent pacing electrodes will be powered by a
  generator inserted under the skin below the right
  clavicle

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Congenital and Hereditary Diseases

• Cystic Fibrosis
• Hyaline membrane disease

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Cystic fibrosis

• A generalized disorder resulting from a genetic
  defect
• The basic cause is unknown
• Multisystemic
• Hypertrophy of the bronchial glands lead to
  increasing secretions and obstruction
• This promotes staph infection, tissue damage,
  possible atelectasis, and emphysema
• Most common lethal genetic disease
• Radiographs demonstrate increased lung volumes,
  pneumonia, and scarring
• Patients may be treated with antibiotics,
  bronchodilator drugs, and respiratory therapy

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CF
http//www.kinderradiologie-online.de/radiology/20
021127102045.shtml
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Hyaline Membrane Disease

• Also called respiratory distress syndrome
• Common to premature infants
• Incomplete maturation causes unstable alveoli due
  to increased surface tension from lack of a
  surfactant
• Patients experience alveolar collapse with
  widespread atelectasis
• Chest radiographs will demonstrate an
  air-bronchogram sign
• Treatment includes maintaining a proper thermal
  environment and tissue oxygenation

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HMD or RDS
Diffuse ground-glass appearance to both lungs
with a left-sidedtension pneumothorax and
pneumomediastinum(orogastric tube is in distal
esophagus)
http//www.scielo.br/scielo.php?pidS0482-50042009
000400012scriptsci_arttexttlngen
http//www.learningradiology.com/toc/tocsubsection
/tocarchives2004.htm
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Inflammatory Diseases

• Pneumonia
• Bronchiectasis
• Tuberculosis
• COPD
• Pneumoconioses
• Pleural effusion
• Sinusitis

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Pneumonia

• An inflammation of the lung caused by bacteria,
  viruses, or mycoplasms
• Radiographs reveal patchy alveolar infiltrates,
  or pulmonary densities
• The alveolar air spaces are filled with fluid or
  cells
• If the infection is bacterial, treatment includes
  antiobiotics

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Pneumonia
http//greggman.com/edit/editheadlines/2003-09-01.
htm7Clangjapanese7C?q
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Bronchiectasis

• A permanent, abnormal dilation of the bronchi
• Results from destruction of the elastic and
  muscular components of the bronchial wall
• Can be congenital or acquired
• The dilation forms a pocket allowing a pocket to
  harbor infection
• As the infection increases, the bronchial wall is
  destroyed, resulting in an abcess

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Tuberculosis

• An infection caused by mycobacterium tuberculosis
• Can affect other parts of the body
• On the increase in the US about 10 million
• Early tuberculosis is asymptomatic
• Lesions are most commonly seen in the lung apices
• The patient may either heal with scarring,
  develop fibrocaseous tuberculosis, or acute
  tuberculosis pneumonia
• If the bloodstream picks it up, large numbers of
  bacteria are carried throughout the body
  resulting in miliary tuberculosis
• Tuberculosis can be treated with chemotherapeutic
  agents

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Early Treatments for Tuberculosis
http//commons.wikimedia.org/wiki/FileTB_CXR.jpg
Cavitatory Pulmonary TB
http//www.orchd.com/TB/WhatTB.asp
http//sandnsurf.medbrains.net/2008/10/radiology-o
ddity-4/
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Chronic Obstructive Pulmonary Disease

• A group of disorders that cause chronic airway
  obstruction
• Bronchitis
• Asthma
• Emphysema

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Bronchitis

• Results from long term heavy smoking, or
  prolonged exposure to high levels of pollution
• A persistent productive caugh results
• Eventually the lungs remain in a hyperinflated
  state
• Treatment includes omission of the causative
  agent, antiobiotic therapy, and bronchodilators

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COPD- Bronchitis
http//www.medtogo.com/bronchitis-pneumonia.html
http//www.nzymes.com/articles/kennel_cough_pneumo
nia_and_respiratory_in_dogs_and_cats.htm
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Asthma

• Usually not visualized on a CXR except with
  patients with chronic conditions
• A response to allergens create a widespread
  narrowing of the airways
• Breathing becomes very difficult and patients
  will usually make a wheezing sound
• Usually treated with bronchodilators

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Emphysema

• A degenerative, debilitating condition
• Obstructive and destructive changes in airways
  create drastic increases in lung volumes
• Emphysema is closely associated with smoking
• Smoking and other pollutants destroy the cilia of
  the respiratory mucosa causing inflammation and
  secretion of excess mucous

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• Chest x-rays on emphysema patients are very
  distinctive
• The destruction caused by this disease is
  irreversible
• It is often necessary to decrease exposure
  factors to obtain a diagnostic CXR

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http//priory.com/cmol/diagnosi.htm
Classic barrel chest appearance with flattened
diaphragm
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Pneumoconioses

• Occupational diseases in which foreign substances
  are inhaled causing pulmonary fibrosis
• Silicosis
• Asbestosis
• Anthracosis

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Silicosis

• Comes from inhaling silica dust
• The most widespread and serious of the
  pneumoconiosis disorders
• Radiographs will display multiple small, rounded,
  opaque nodules throughout the lungs
• There is no treatment for silicosis
• Prevention is the key

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Anthracosis

• Black lung disease
• Inhalation of coal dust
• Small deposits develop around the bronchioles,
  causing dilations
• This dilation does not affect the alveoli or
  airflow

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Asbestosis

• Results from inhaling asbestos dust
• The lungs develop pleural calcifications and
  thickening
• Patients with asbestosis show an increase in the
  chance of developing mesothelioma, a rare
  malignant neoplasm of the pleura

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(1) Coal
(3) Asbestos
http//www.learningradiology.com/notes/chestnotes/
silicosispage.htm
(2) Silica
http//www.nytimes.com/imagepages/2007/08/01/healt
h/adam/1604Coalworkerspneumoconiosiscomplicated2.h
tml
http//images.google.com/imgres?imgurlhttp//www.
sw.edu/sarc/files/RTH_112/X-rays/asbest.jpgimgref
urlhttp//www.sw.edu/sarc/course_files.htmusg__
QI46NiW0cAXdO-vbSJbug5xWxcMh434w425sz16hl
enstart15um1tbnid5Icq_bUUWXAjHMtbnh126tb
nw123prev/images3Fq3Dasbestosis2Bx2Bray2Bi
mages26hl3Den26rlz3D1T4GGLF_enUS223US22326sa
3DX26um3D1
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Pleural Effusion

• Results from excess fluid collecting in the
  pleural cavity
• Usually results from pulmonary or cardiac disease
• It is not a disease entity itself, but the result
  of another serious disorder

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• The costophrenic angles will be blunted
• This disorder is best demonstrated by erect and
  lateral decubitus chest films
• Excess fluid is usually removed by thoracentesis,
  sometimes developing in a pneumothorax

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Pleural Effusion
Pleural effusion Chest x-ray of a pleural
effusion. The arrow A shows fluid layering in the
right pleural cavity. The B arrow shows the
normal width of the lung in the cavity
Massive left-sided pleural effusion (whiteness)
in a patient presenting with lung cancer.
http//en.wikipedia.org/wiki/Pleural_effusion
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Sinusitus

• An infection of the sinuses
• Ethmoid sinuses are most commonly affected due to
  their proximity of the nasal passages
• Upright sinus radiographs along with CT are
  helpful for diagnosis

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• Chronic sinusitis can lead to polyps
• Treatment involves antiobiotics, and analgesics
• Severe cases may involve the surgical drainage
  and/or polyp removal

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http//www.powerpak.com/index.asp?showlessonpage
courses/10132/lesson.htmlsn_id10132
http//www.dochazenfield.com/sinus_surgery.htm
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Pulmonary Embolism

• A potentially fatal condition
• The most common pathologic disorder involving the
  lungs of hospital patients
• Asymptomatic in about 80 of patients
• Most result from thrombi from the lower
  extremities

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• Usually not visualized on a CXR unless there is
  an infarct
• The radionuclide perfusion scan is the exam of
  choice
• Patients are advised to rest, limit activity, and
  are treated with blood thinning medications

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Atelectasis

• An incomplete expansion of the lung due to
  partial or total collapse
• May occur from pleural effusion, hemo or
  pneumothoraces
• A sign of an abnormal process rather than a
  disease itself

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• Chest radiographs reveal the airless area of the
  lung
• Treatment involves respiratory therapy, or
  bronchoscopy to suction secretions

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Chest X-ray shows persisting total atelectasis of
the right lung. Note the marked loss of volume on
the right, pronounced shift of the mediastinum to
the right, and compensatory overexpansion of the
left lung
http//www.biomedcentral.com/1471-2431/5/39/figure
/F1
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Pneumothorax

• Occurs when free air is trapped in the pleural
  space and compresses the lung tissue
• Air can enter from perforation from trauma, or by
  generation of gas forming bacteria
• A pathologic process can result in a spontaneous
  pneumothorax
• A radiograph will reveal a strip of radiolucency
  devoid of any lung markings
• It is best demonstrated by an expiration CXR
• A tension pneumothorax occurs when air enters the
  pleural space but cannot leave it
• This type of pneumothorax is life-threatening and
  requires immediate treatment
• Treatment may include rest for a small pneumo, or
  insertion of a chest tube

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http//www.blebinfo.co.uk/phpBB2/viewtopic.php?t6
0
http//www.ispub.com/journal/the_internet_journal_
of_thoracic_and_cardiovascular_surgery/volume_13_n
umber_1_2/article_printable/spontaneous_esophageal
_perforation_presenting_as_pneumothorax_a_case_rep
ort.html
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Diaphragmatic Paralysis

• A disorder caused by any process that interferes
  with the normal function of the phrenic nerve
• Best demonstrated by fluoroscopy of the diaphragm
  while having the patient sniff
• A paralyzed diaphragm will rise with
• inspiration due to increased intra-abdominal
  pressure

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Neoplastic Disorders

• Bronchial adenoma
• Bronchogenic carcinoma
• Pulmonary metastases

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Bronchial Adenoma

• Usually considered benign
• Sometimes they invade local tissues and
  metastasize
• Bronchial obstruction is a common presentation on
  CXRs
• Radiographs may show an opacity, bronchial
  narrowing, and local collapse

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Bronchogenic Carcinoma

• The most common primary malignancy in the US
• Tumors arise near the hilar area and metastasize
  via lymph nodes, or the bloodstream, or both
• Radiographs will present airway obstruction

68

• The prognosis is very poor 5 year survival rate
  of 12 14
• Cigarette smoking is the most important etiologic
  factor
• May be treated with surgery, chemotherapy, or
  radiation therapy

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http//www.tobacco-facts.info/images_html/lung_can
cer_x-ray-1.htm
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Pulmonary Metastases

• Much more common than primary lung neoplasms
• Usually detectable on a radiograph
• Common primary sites are the breast, GI tract,
  female reproductive system, and kidneys

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• Radiographs demonstrate multiple opacities
  throughout the lungs
• CT is much more sensitive in detecting small
  metastatic lesions

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http//www.allposters.com/-sp/XRay-Lung-Metastatic
-Sarcoma-to-Lungs-Posters_i4257226_.htm
http//radiology.casereports.net/index.php/rcr/art
icle/viewArticle/152/559
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The End