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RADIOLOGY IMAGING
IN PULMONARY
EMERGENCY
Widiastuti
Radiology Department of Dr. Moewardi Public Hospital /
Medical Faculty of Universitas Sebelas Maret
September 12nd, 2019
Chest Imaging
Chest Imaging includes imaging and diagnosis of the lung parenchyma, pleura, mediastinum and the hila.
Cardiovascular Imaging
Cardiac CTA can be used to evaluate ventricular function - anatomy, aortic valve function - anatomy, aneurysms, pseudoaneurysms and myocardial infarcts.
North Broward Radiologist, 2012
• Pulmonary emergencies are life-threatening conditions that occur when a person has difficulty breathing normally.
• A broad range of different respiratory emergencies is covered, from pneumothorax, pulmonary embolism, right heart failure and haematothorax to acute exacerbations of diseases such as asthma and chronic obstructive pulmonary disease.
• Radiologic imaging:
conventional radiography, multidetector computed tomography (CT).
1. GUNSHOT WOUND 8. PNEUMOTHORAX
2. COPD 9. RIB/STERNAL FRACTURE
3. DIAPHRAGMATIC RUPTURE/HERNIA 10. PNEUMOMEDIASTINUM
4. FLAIL CHEST 11. PULMONAY CONTUSION
5. FOREIGN BODY – INGESTED FOREIGN BODIES 12. PNEUMOCARDIUM
6. OESOPHAGEAL PERFORATION/RUPTURE 13. CARDIAC TAMPONADE
7. PNEUMONIA 14. AORTIC RUPTURE
Radiology Case Reports | radiology.casereports.net, 2012
M, 24 Yo: A gunshot wound to the right mid-abdomen of hemodynamic instability with marked hypotension and tachycardia
Characteristic Radiological features
A spectrum of conditions including chronic bronchitis and emphysema
CXR : are only moderately sensitive (40–60%), but highly specific in appearance.
expiratory airflow, infection, mucosal oedema, bronchospasm and bronchoconstriction due to reduced lung elasticity
hyper-expanded lungs with associated flattening of both hemidiaphragms, pruning of pulmonary vasculature, barrel-shaped chest’ and lung bullae
Causative factors include smoking, chronic asthma, and chronic infection.
A to Z of Emergency Radiology. Cambridge,2004
The lucency of the lung fields, flattening of the hemidiaphragms, narrowed cardiac silhouette and reduced of peripheral vascular markings.
Med Clin North Am. Author manuscript; 2014 April 29
CXR: Left diafragmatica herniation MSCT Thorax: Herniation Of The
Stomach
DIAPHRAGMATIC RUPTURE/HERNIA
Radiographics 2002 Oct; 22 Spec No: S103-16
A Newborn with A Congenital Diapragmatic Hernia
Herniation of the stomach in the left hemithorax Pediatric surgery
Pediatric surgery
• Multiple rib fractures (black arrows) with some ribs fractured in two or more places
• Pulmonary contusion (red arrow) and subcutaneous emphysema (white arrow)
Learningradiology, 2015
RSDM, Feb 2017
RSDM, Feb 2017
(a,b) Typical chest radiograph findings of intrapleural oesophageal perforation.
Oesophageal emergencies, 2015
CT appearances of spontaneous oesophageal perforation. (a) Left pleural hydropneumothorax. (b) Left basal intercostal chest drain in.
Oesophageal emergencies, 2015
Contrast swallow demonstrating free extravasation of contrast media after oesophageal perforation during balloon dilatation of achalasia.
Oesophageal emergencies, 2015
M, 80 Yo
a nonsegmental consolidation
in the right middle lung field.
A
IMAGING FINDINGS OF CAP Streptococcus pneumoniae Mycoplasma pneumoniae
ill-defined consolidation in the right lower lung field
F, 30 Yo
B
Nambu A et al . Imaging of CAP, Oct 28, 2014,Vol.6
Streptococcus pneumoniae Mycoplasma pneumoniae
a nonsegmental consolidation with air bronchograms suggestive of
alveolar pneumonia
Non-segmental consolidation with air bronchograms at the dorsal aspect of the right lower lobe.
Nambu A et al . Imaging of CAP, Oct 28, 2014,Vol.6
• Iatrogenic tension pneumothorax.
• This is secondary to the high intrathoracic pressures generated during ventilation resulting in rupture of a pleural bleb.
• There is progressive mediastinal shift to the right.
A to Z of Emergency Radiology. Cambridge,2004
Extensive pulmonary fibrosis and left pneumothorax
• Axial CT shows that drain (arrow) has transversed lung parenchyma.
CT: showing subcutaneous emphysema and pneumomediastinum
PNEUMOMEDIASTINUM
Annals of Nigerian Medicine / Jan-Jun 2015 / Vol 9 | Issue 1
M, 11 Yo: cough for 2 days, breathing difficulty, complained of swelling and pain over his neck, chest, abdomen, and upper limbs
F, 37 Yo: PULMONARY CONTUSION
Involved in a motor vehicle collision
a) Patchy air space disease representing pulmonary contusions b) Demonstrates a nonsegmental air space consolidation and a diffuse "ground
glass" appearance of the surrounding parenchyma due to blood filling the alveolar spaces. Note the associated left pneumothorax (star). European Society of Radiology, 2014
M, 39 Yo: After a motor vehicle accident
(a) Left sided pneumothorax and pneumopericardium (star) with a left dislocation of the heart b) Most likely air enter the pericardial space from the pleural space through
a tear in the pericardium ESR, 2014
RSNA, 2007
a) significant enlargement of the cardiac silhouette with the characteristic “water bottle” appearance/ shaped heart
b) a large pericardial effusion flattening the anterior cardiac contour
RSNA,2007
A. Cardiac tamponade in a newborn with respiratory distress syndrome who developed pneumopericardium associated with barotrauma from mechanical ventilation.
B. Pneumopericardium with cardiac tamponade in an adult patient with blunt thoracic trauma. The small heart sign suggests the presence of tension pneumopericardium.
A B
RSNA,2007
(a) Intrapericardial herniation of the colon (arrows), which produces
tamponade.
(b) The pericardial defect (white arrowheads) and the herniating bowel
loop with air (white arrow) compressing the anterior aspect of the
heart (black arrowheads). RSNA, 2007
F, 63 Yo: Pericardial tamponade with a delayed post traumatic diaphragmatic hernia.
Characteristic Chest radiograph CT Toraks
80-90 %t of patients die before reaching hospital
Widened mediastinum (8 cm on AP CXR) Vessel wall disruption or extra-luminal blood seen in contiguity with the aorta is indicative of rupture.
deceleration injuries, a fall from a height or in road traffic accidents > 40 mph
Blurred aortic outline with loss of aortic knuckle
The aorta usually ruptures 88–95%, just distal to the origin of the left subclavian artery
Left apical pleural cap
Left sided haemothorax
Depressed left/raised right main stem bronchus
Tracheal displacement to the right
Oesophageal NG tube displacement to the right
A to Z of Emergency Radiology. Cambridge,2004
Traumatic aortic rupture
http://torontonotes.ca/category/medical-imaging/chest/cardiovascular/2017
The markedly widened mediastinum in the AP , which is suggestive of aortic aneurysmal/dissection disease.
Show the “snowman” sign depicting the aneurysm, filling defects, and extravasation.
• Acute Type A ascending aortic dissection in an already aneurysmal aorta.
• The false lumen has partial thrombosis (the straight arrow) and there is a haemopericardium which compresses the left atrial appendage (curved arrow).
The British Journal of Radiology, 2011
• Pulmonary emergencies are life-threatening conditions that occur when a person has difficulty breathing normally.
• A broad range of different respiratory emergencies is covered, from pneumothorax, pulmonary embolism, right heart failure and haematothorax to acute exacerbations of diseases such as asthma and chronic obstructive pulmonary disease.
• Radiologic imaging: conventional radiography, multidetector computed tomography (CT).
Pulmonary Embolism Acute exacerbations of interstitial lung disease
Pneumothorax Haemoptysis
Right heart failure Foreign body aspiration and inhalation injury
Acute exacerbations of COPD Haematothorax
Acute exacerbations of asthma Severe community-acquired pneumonia
Pulmonary Embolism
• Acute PE is a common cause of acute onset chest pain presenting in the emergency room with as many as 1–2 per 1,000 patients potentially affected by VTE.
M, 55 Yo
A. CXR: shows a wedge-shaped opacity in the periphery of the right lateral lung (red arrows) concerning for infarction, dubbed a “Hampton hump”;
B. Coronal CTPA: shows a filling defect within an enlarged right lower lobe lateral segmental pulmonary artery consistent with occlusive thrombus (black arrow) and a wedge-shaped peripheral opacity consistent with infarct, correlating with abnormality on radiograph (red arrow).
Cardiovasc Diagn Ther 2018
A. a central filling defect surrounded by a ring of contrast exhibiting the “polo mint” sign of acute PE (black arrow).
B. a central filling defect surrounded by parallel lines of contrast consistent with the “railway sign” of acute PE (white arrows)
C. Extensive burden of large pulmonary emboli manifested by occlusive and mural filling defects whose edges form acute angles with the vessel walls (white arrows)
D. a large conglomeration of low density embolus is draped over the bifurcation of the pulmonary artery, exhibiting a “saddle embolus” configuration (black arrows).
E. a dilated right lower lobe posterior basal sub-segmental pulmonary artery with an occlusive filling defect consistent with acute PE (black arrow)
A. a round opacity in the left lower lobe posterior segment that exhibits a ground glass center (red arrow) surrounded by a rim of consolidation (black arrows).
B. indicative of right heart strain. Extensive embolic burden in the dilated segmental and lobar pulmonary arteries (curved white arrows)
Axial T1-weighted fat saturated MR angiographic sequence with digital subtraction show low signal filling defects within the right pulmonary artery and left common basal pulmonary artery consistent with acute PE (white arrows). There is also a small right pleural effusion (black arrow) which is often seen with acute PE and a metastasis from colorectal cancer in the posterior left lung (red arrow)
Pneumothorax
• CXR shows unremarkable appearance ofintercostal drain (arrow)
• Axial CT shows drain (arrow) is located insubcutaneous tissues.
Right pneumothorax with a pigtail chest tube in place, diffuse reticular interstitial opacities.
Extensive centrilobular emphysema, moderate right pneumothorax with pigtail chest drain on the right, subpleural reticular opacities with peripheral and basilar preponderance suggesting interstitial fibrotic lung disease, and diffuse lung cysts
Southwest J Pulm Crit Care. 2017
Pneumothorax
Extensive pulmonary fibrosis and left pneumothorax
• Axial CT shows that drain (arrow) has traversed lungparenchyma.
Right heart failure classification
Class I No limitation is experienced in any activities; there are no symptoms from ordinary activities
Class II Slight, mild limitation of activity; the patient is comfortable at rest or with mild exertion
Class III Marked limitation of any activity; the patient is comfortable only at rest
Class IV Any physical activity brings on discomfort and symptoms occur at rest
Functional NYHA Classification
ACA/AHA Classification
Stage A Patients at high risk for developing HF in the future but no functional or structural heart disorder
Stage B A structural heart disorder but no symptoms at any stage
Stage C Previous or current symptoms of heart failure in the context of an underlying structural heart problem, but managed with medical treatment
Stage D Advanced disease requiring hospital-based support, a heart transplant or palliative care
a) Preoperative CT-scan shows the dissection membrane in the ascending aorta (arrow).
b) Preoperative angiography with proximal closure of the right coronary artery (double arrow).
• CT angiogram verifying the presence of a mass insidethe right atrium occupying almost the whole cavity.
Journal of Cardiothoracic Surgery,2011
Acute exacerbations of COPD
• COPD patient with extensiveareas of centrilobular emphysema predominantly in the superior lung fields.
CLINICS 2012;67(11):1335-1343
• Axial (A,B), Coronal (C): demonstrating varicose bronchiectasis (arrow), large bronchoceles and very little panlobular emphysema (circle).
Chronic Obstr Pulm Dis. 2016; 3(2): 601-604
Axial (A,B), Sagittal (C): reveal very mild bronchiectasis (arrow) and larger areas of panlobular emphysema (circles).
Chronic Obstr Pulm Dis. 2016; 3(2): 601-604
F, 44 Yo: Acute exacerbation of asthma and was diagnosed with allergic bronchopulmonary
aspergillosis
Dilated and mucus-filled bronchi in the right lung appearing as finger in glove (white arrow) producing the radiologic sign, finger-in-glove sign.
ResearchGate 2019
Right infiltrates and patchy ground-glass opacity with bronchial wall thickening
Respirology case reports 2017
Acute exacerbations of interstitial lung disease
Smoking-related interstitial lung diseases a) Pulmonary Langerhans cell histiocytosis b) Respiratory bronchiolitis-associated ILD c) Combined pulmonary fibrosisand emphysema d) Desquamative interstitial pneumonia
Eur Respir Rev 2015; 24: 428–435
66 Yo: patient with idiopathic pulmonary fibrosis. • Peripheral reticular abnormality with traction bronchiectasis and subpleural
honeycombing. • Extensive ground-glass abnormality superimposed on the background of
pulmonary fibrosis can also be seen.
Pulmonary medicine 2017
Hemoptysis
M, 52 Yo with cough and hemoptysis. The ill-defined mass in the right lower lobe was found to be squamous cell carcinoma
Cystic dilatation of the bronchi bilat-erally, consistent with cystic bronchiectasis.
• M, 44 yo with hemoptysis.
• The solid mass on the left is a mycetoma within a thin-walled cavity in the left upper lobe.