ANATOMIA

RADIOLOGICA A
APARATULUI
RESPIRATOR
Dr. Medar Cosmin

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 OBIECTIVE

Aspectul structurilor anatomice ale

toracelui pe radiografia toracica
standard:
ortostatism - incidenta postero-anterioara si
profil, inspir profund
decubit dorsal (pacienti imobilizati la pat)
radiografia efectuata in expir

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 Incidenta PA in
ortostatism
Pacientul sta cu fata
spre film
Tubul de raze X este
pozitionat in spatele
pacientului la cca. 1,8
m
Fasciculul de raze X
este diafragmat
aprox. la marimea
segmetului
radiografiat
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Incidenta PA in
ortostatism

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 DE CE EFECTUAM
RADIOGRAFIA IN
ORTOSTATISM
Dimensiuni reale ale cordului
Omoplatii sunt proiectati in
afara plamanilori
SI PA ?
De ce nu in decubit?
Mediastinul si marile vase
pot crea false imagini sau
pot masca o patologie
existenta
Acumularile gazoase la
nivelul cavitatilor se dispun
antigravitational: diagnostic
facil al pneumotoraxului sau
pneumoperitoneului
Acumularile fluide se dispun
gravitational: diagnostic
facila al pleureziilor
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Incidenta de profil
(stang)

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 DE CE SI CAND EFECTUAM O
INCIDENTA DE PROFIL

Regiuni ale plamanilor ascunse pe

radiografia de fata:
segmentele posterioare ale lobilor inferiori, ariile pulmonare din
spatele hilurilor sau a cordului

Configuratia cordului (contururi)

Localizarea anatomica a leziunilor
diagnosticarea pleureziilor in cantitati f.
mici
Vizualizarea coloanei vertebrale toracice
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CONSIDERENTE TEHNICE
Pentru a considera o radiografie bine
executata trebuie sa luam in
considerare urmatoarele:
raza centrala linia mediana a
pacientului
planul frontal al pacientului paralel
cu filmul
inspir profund
parametrii electrici adecvati
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 CENTRAREA
Vizibile:
apexurile
pulmonare
sinusurile costo-
diafragmatice

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 Rotatia
Capetele mediale ale claviculelor la o
distanta egala de linia ce uneste
apofizele spinoase ale coloanei
vertebrale toracale

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 GRADUL DE INSPIR
Hemidiafragmul
drept trebuie sa fie
cel putin in dreptul
arcurilor costale
anterioare 5/6 sau
posterioare 9/10
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7

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 PARAMETRII ELECTRICI
Vizibile doar
primele 3-4
vertebre toracale
superioare
Vasele pulmonare
al lobului inferior
stang vizibile prin
opacitatea
cordului
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ANATOMIE RADIOLOGICA
INCIDENTA PA

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ANATOMIE RADIOLOGICA
INCIDENTA PA

Bronhia principala
dreapta este mai
scurta si mai verticala
decat bronhia dreapta

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 Marginea dreapta a
mediastinului
Doua arcuri

Vena cava superioara o linie dreapta ce se continua

inferior cu marginea dreapta a cordului

Marginea dreapta a cordului linie curba, usor convexa

spre dreapta, este data de atriul drept

Hilul pulmonar drept situat aprox. la jumatatea

distantei dintre apex si diafragm
este format din bronsia si artera pulmonara dreapta,
precum si diviziuniule lobare ale acestora

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ANATOMIE RADIOLOGICA
INCIDENTA PA

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Marginea stanga a
mediastinului
Trei arcuri:
Butonul aortic (crosa aortei)
Trunchiul de artera
pulmonara
Marginea stanga a cordului
(ventriculul stang)
Hilul pulmonar stang
situat mai cranial decat
cel drept sau cel mult la
acelasi nivel

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 ANATOMIE RADIOLOGICA
INCIDENTA DE PROFIL (stang)

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ANATOMIE RADIOLOGICA
INCIDENTA DE PROFIL
(stang)
Capetele humerale sunt
vizibile ca doua opacitati
rotunde ce se suprapun
varfurilor pulmonare.
Omoplatii se proiecteaza in
posterior, pe coloana
vertebrala
Nu trebuie confundate cu
opacitati patologice

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20
 PLAMANII

Plamanii pot fi impartiti in doua

compartimente:
Alveole (spatii aerate)
Interstitiu (tesutul conjunctiv de
impachetare si suport ce
inconjoara spatiile aerate)

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 SEGMENTATIA
ARBORELUI BRONSIC

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 PATTERN-UL VASCULAR
PULMONAR
Vasele sangvine intrapulmonare au
urmatoarele caracteristici:
Arterele se bifurca in Y si au o dispozitie
mai verticala.
Venele se bifurca in unghi drept si au o
dispozitie mai orizontala (nu se vad in mod
normal pe o radiografie).
Arterele pulmonare din campurile
pulmonare superioare cu un calibru
mai mic decat cele inferioare.
Vasele se vad cu dificultate in 1/3 periferica
a campurilor pulmonare. 23
 SEGMENTATIA
PLAMANILOR
Trei lobi pe dreapta (superior, mijlociu si inferior)
si doi pe stanga (superior si inferior).

La nivelul ambilor plamani lobii superiori si

inferiori sunt separati de scizurile oblice.

Pe partea dreapta lobul mijlociu este delimitat de

lobul superior prin scizura orizontala si de lobul
inferior prin scizura oblica (segmentul caudal).

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 SEGMENTATIA
PLAMANILOR
Pe radiografia in incidenta de fata scizurile oblice nu
sunt vizibile iar scizura orizontala este vizibila doar
cand planul ei este paralel cu fasciculul de raze o
linie subtire, orizontala, ce uneste hilul pulmonar cu
peretele lateral toracic.

Pe radiografia in incidenta de profil se pot vedea

ambele scizuri:
scizura oblica cu un traiect cranio-caudal si postero-anterior;
scizura orizontala uneste mijlocul scizurii oblice cu peretele
anterior toracic.

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SEGMENTATIA
PLAMANILOR

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SEGMENTATIA
PLAMANILOR

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SEGMENTATIA
PLAMANILOR

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SEGMENTATIA
PLAMANILOR

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ASPECTE NORMALE

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The large right-sided
pleural effusion
silhouette sign

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erect / supine ?
well positioned ?
You can see the aeric
contents of the stomach.

The spinous processes of C7

and T1 are marked as
posterior point of reference,
the medial borders of the
clavicles as anterior point of
reference.

This patient is well

positioned!

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 The mediastinum
For descriptive purposes, the mediastinum is divided into several
compartments.
The superior mediastinum is considered to lie above a horizontal
line drawn from the lower border of the manubrium, the sternal angle
or angle of Louis, to the lower border of T4 and below the thoracic inlet.
The inferior compartment, lying below this imaginary line (and above
the hemidiaphragm) is further subdivided:
the anterior mediastinum lies in front of the pericardium and
root of the aorta
the middle medistinum comprises the heart and pericardium
together with hilar structures
the posterior mediastinum lies between the posterior aspect of
the pericardium and the spine.
This helps us to make a differential diagnosis of mediastinal masses
considering the localization of a mass in a particulary mediastinal
compartment.

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The mediastinum
Lateral radiograph
demonstrating the
anterior (A), middle
(M), posterior (P) and
superior (S)
mediastinal
compartments.

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 The hilum
The hilum can be considered to be the region at which
pulmonary vessels and airways enter or exit the lungs.

The main components of each hilum are the pulmonary

artery, bronchus, veins, and lymph nodes.

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 Pulmonary arteries
the right pulmonary artery passes in
front of the right main bronchus

the left main pulmonary artery

passes anterior, over and posterior
from the left main bronchus.

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Analyze the hila lateral
view

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 The heart
the ratio of the
transverse diameter of
the heart to the
maximal transverse
diameter of the thorax
(also called the
cardiothoracic ratio)
is less than 50%.

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The aorta

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The thoracic cage
The thorax is
cylindrical in shape
and delimitated by
the ribs, thoracic
vertebrae, and the
sternum.

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 The thoracic cage - Ribs
All 12 pairs of ribs are
attached posteriorly to their
respective vertebral bodies.
In addition, the upper seven
pairs attach anteriorly to
the sternum via individual
costal cartilages.
The eighth, ninth and tenth
ribs effectively are attached
to each other and also the
seventh rib by means of a
common costal cartilage.

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 The thoracic cage -
Sternum
The manubrium is the
uppermost and widest
portion, which
articulates laterally
with the clavicles and
also the first and
upper part of the
second costal
cartilages; inferiorly,
the manubrium
articulates with the
body of the sternum.
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 The thoracic cage -
Sternum
On a conventional
frontal chest
radiograph, the bulk of
the manubrium is
generally not visible.

The articulation of the

manubrium with the
clavicles (the
manubrio-clavicular
joint) can be seen.

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 The thoracic cage -
Sternum
On a lateral
radiograph the
manubrium can be
clearly identified.

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 The thoracic cage -
Vertebrae
The thoracic vertebrae
provide structural support to
the thorax in the axial plane.

A typical vertebra consists of

two essential parts:
Vertebral body
Vertebral arch vertebral
foramina
Two transverse processes
and one spinous processes
Four articular processes
Lamina of vertebral arch
Pedicle of vertebral arch

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 The thoracic cage -
Vertebrae
Intervertebral
foramina
Sup/inf fovea
costal

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Costovertebral
articulations

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The thoracic cage -
Vertebrae

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Right costophrenic
recess

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 CXR
A systematic approach to analysis of
the CXR should include identification
and assessment of the following:

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 PA film
Heart
Position.
Size.
Configuration.
Mediastinum
Trachea.
Aorta.
Pulmonary arteries.
Superior vena cava (SVC).
Azygos vein.

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 PA film
Lungs. Divide each lung into
thirds, first from top to bottom,
then from the hilum to the
periphery. Look at top, middle
and lower thirds, followed by
medial, central and lateral thirds.
Assess the vascular pattern:
compare upper lobe vessels to
lower lobe vessels. Look
particularly at difficult areas
where lesions are easily missed:
Behind the heart.
Behind each hilum.
Behind the diaphragms
Lung apices.
Check the lung contours for signs
of blurring or loss of definition:
Cardiac borders.
Mediastinal margins.
Diaphragms.
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 PA film
Bones
Ribs.
Clavicles
Scapulae/humerus
Sternum on the lateral film.
Thoracic vertebral bodies.
Other. In female patients,
check the breast shadows for
evidence of previous
mastectomy. Check betow the
diaphragm for free gas and to
ensure that the stomach
bubble is in correct position.
Check the axillae and lower
neck for masses.

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 Lateral film
Heart
Size.
Configuration.
Mediastinum
Trachea.
Right and left
pulmonary arteries.

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 Lateral film
Lungs
Retrosternal airspace.
Retrocardiac airspace.
Identify both
hemidiaphragms.
Posterior costophrenic
angles: very small pleura
effusions are seen with
greater sensitivity
Bones
Sternum and thoracic
spine

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 I See an Abnormality
What Do I Do Now?
If the abnormality concerns the lung parenchyma,
the following questions need to be answered:
Is it an opacity or an abnormal radiolucency?
Is it a rather circumscribed or a diffuse process?
Are we dealing with a solitary lesion or are
multiple lesions present?
Is the lesion homogeneous or heterogeneous?
Does the diffuse process have a patchy (acinar)
or fine linear (reticular) or diffusely nodular
pattern of appearance?

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