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X-RAYS and Contrast

Just as visual images require color differences to identify objects X-rays require contrast differences to outline structure X-ray absorption is proportional to density It is the low density air content of the alveoli that outlines the normal and abnormal structure of the chest.

The Elements of a chest x-ray (CXR)

The Bronchovascular markings in the lung The borders of the heart The contours of the mediastinum and pleural space The ribs and spine

This diagram shows the appearance of a bronchogram ( X-ray dye in the bronchi) and a schematic identifying the bronchial segments. Note that on the frontal view there is considerable overlap of segments.

This is the corresponding lateral view: Note that the segments that overlap on frontal view are separated clearly on lateral view, at the expense of overlapping structure from right and left sides (which is not a problem on the frontal view). Since the frontal and lateral view resolve different segments, they are complimentary views allowing localization of problems in three dimensions.

Diaphragmatic and Mediastinal Contours

The margins of the diaphragm and mediastinum are seen due to air-contrast from the adjacent lung. If the lung is consolidated (fluid filled) as in pneumonia, contrast is lost and the contour disappears. The normal structures that account for the mediastinal contours seen on chest X-ray

Infiltrate in the lungs When fluid accumulates in lung, it may predominate in the alveolar (airspace) compartment or the interstitial compartment Typical bacterial pneumonia is an accumulation of exudative material in the alveolar spaces In addition to increasing the lung density, the infiltrate cancels the contrast between vessels and lung boundaries, and these structures disappear Air filled bronchi, normally invisible, will be contrasted by infiltrate creating air bronchograms.

Alveolar (Airspace) Consolidation

The unit of alveolar consolidation is served by a single terminal bronchiole and represents a fluffy 3-5 mm nodule. In most alveolar consolidations, these fluffy alveolar nodules coalesce into dense consolidation. Communication between alveolar spaces mean that disease tends to spread freely until the pleura is reached. This results in the typical "lobar" distribution of pneumonia

Silhouette Sign When alveolar infiltrate develops, air is replaced by fluid. Fluid does not create contrast with vessels and boundaries to the lung hence they are obscured The particular structure that is obscured indicates which portion of lung is involved. The disappearance of a normal lung border (ie. mediastinum or diaphragm) is called the silhouette sign. This is seen most often in pneumonia.

Differential Diagnosis of Alveolar Consolidation

Bronchial obstruction by tumor or foreign body Pulmonary hemorrhage Severe pulmonary edema Focal ARDS

Hyperinflation - Obstructive Airway disease

Hyperinflation most commonly results from "flap-valve" air trapping in diseases like Asthma, Emphysema and Chronic Bronchitis Air trapping results in small increases in lung volume which are difficult to see on X-ray. Air trapping results in decreased minute ventilation and reflex vasoconstriction

Definisi : terisinya rongga pleura oleh udara Etiologi : * Spontan bula pecah * Didapat trauma Bila terjadi mekanisme flap valve pelebaran yang progresif rongga pleura akibatnya jantung dan saluran pernafasan (tension pneumotoraks)

Definisi : ekstravasasi cairan dari vaskuler paru ke dalam interstitial dan alveoar paru Etiologi : 1. Imbalance Starling force - Peningkatan tekanan kapiler pulmonar - Penurunan tekanan plasma onkotik - Peningkatan tekanan negatif intertitial - Peningkatan permeabilitas kapiler 2. Kerusakan barier Alveoral- capiler 3. Obstruksi Limfatik 4. Idiopatik

Tahap Edema Paru : 1. Fase awal 2. Edema intertitial 3. Edema alveolar

Edema Paru

Edema Paru

Edema Paru

Edema Paru

Definisi : abnormal/ distorsi permanen dinding bronkus/ saluran nafas seringnya karena infeksi sekunder Etiologi - Kongenital : bronkopulmonary sequstration, Williams-Campbell syndrom, Swyer-James syndrom, Mounier-Kuhn syndrom - Didapat infeksi kronis/ infeksi rekurent