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Chest radiology 2009 traducao

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Chest radiology 2009 traducao

  1. 1. Radiologia de Tórax Básica para Clínicos na Tuberculose Jorge Eduardo Pio Secretaria Municipal de Saúde e Defesa Civil Gerencia de Pneumologia Sanitária Date
  2. 2. Basic Radiology for the TB Clinician Objetivos: Ao final desta apresentação os participantes devem ser capazes de:  Analizar a qualidade de uma radiografia usando critérios simples;  Identificar anatomia básica normal de uma radiografia nas incidencias PA e Perfil;  Reconhecer os padrões radiológicos de doença e descreve- los usando a terminologia apropriada;  Descrever os padrões típicos e atípicos da apresentação radiológica da tuberculose pulmonar.
  3. 3. Resumo:  Aspectos técnicos da radiografia de tórax  Abordagem sistematizada da “leitura” da radiografia  Anatomia radiológica básica  Padrões de doença  Manifestações radiológicas de tuberculose Basic Radiology for the TB Clinician
  4. 4. Chest Radiography: Basic Principles O mais Negro ar gordura tecido mole cálcio osso contraste radiológico metal O mais Claro Transmissão Máxima do Raio- X (tecido menos denso) Absorção Máxima do Raio - X (tecido mais denso)  Foton de Raio-X: Transmitido / absorvido / refletido  Absorçã de Raio-X depende de: • Fluxo de energia (constante) • Densidade do tecido
  5. 5. Porque nós vemos o que vemos:  Estruturas são visíveis em uma radiografia devido a justaposição de duas estruturas de diferentes densidades.  criando uma interface  Sinal da Silueta Perda de uma interface esperada  Nenhuma borda entre duas estruturas pode ser vista quando a densidade destas são similares Differential X-Ray Absorption
  6. 6. Silhouette Sign: RLL PneumoniaSinal da Silueta : Pneumonia LID
  7. 7. Assess CXR Technical Quality  Esforço inspiratório • 9 – 10 costelas posteriores  Penetração • Espaço do disco intervertebral torácico apenas visível  Posicionamento / rotação • Extremidade medial das clavículas equidistantes ao processo espinhoso
  8. 8. 10 1 2 3 4 5 6 7 8 9
  9. 9. Inspiratory Effort Baixos Volumes Pulmonares Inspiração completa
  10. 10. Superexposição Exposição adequada Exposure
  11. 11. Superexposição Exposição adequada
  12. 12. Rodado (Oblíquo)
  13. 13. Basic Radiology for the TB Clinician Resumo:  Aspectos técnicos da radiografia de tórax  Abordagem sistematizada da “leitura” da radiografia  Anatomia radiológica básica  Padrões de doença  Manifestações radiológicas de tuberculose
  14. 14. Approach to Reading a CXR  Seja Sistemático  Pulmões  Superficies pleurais  Contorno do mediastino e coração  Ossos e tecidos moles  Abdômen
  15. 15. Faça uma segunda olhada  Ápices  Áreas retrocardiaca (esquerda e direita)  Regiões hilares  Região abaixo do diafragma
  16. 16. TB Apical
  17. 17. TB Apical
  18. 18. Opacidade Retrocardiaca Esquerda
  19. 19. Nódulo Atrás do Diafragma
  20. 20. Basic Radiology for the TB Clinician Resumo:  Aspectos técnicos da radiografia de tórax  Abordagem sistematizada da “leitura” da radiografia  Anatomia radiológica básica  Padrões de doença  Manifestações radiológicas de tuberculose
  21. 21. Basic CXR Anatomy Incidência em PA e Perfil  Coração  Aorta  Artérias pulmonares  Vias aéreas
  22. 22.  Arco aórtico  Artéria pulmonar direita  Artéria pulmonar esquerda  Traquéia & brônquios
  23. 23. Basic Radiology for the TB Clinician Resumo:  Aspectos técnicos da radiografia de tórax  Abordagem sistematizada da “leitura” da radiografia  Anatomia radiológica básica  Padrões de doença  Manifestações radiogáficas de TB
  24. 24. Chest Radiographic Patterns of Disease  Consolidação / opacidade do espaço aereo  Opacidade intersticial  Nódulos e massas  Lifodenopatia  Cistos e cavidades  Anormalidades pleurais
  25. 25.  Causado por preenchimento do álveolo com líquido, pus, sangue, células (tumor), etc.  Pode ser difuso, ou isolado a segmentos ou lobos pulmonares  Pode estar associado a broncograma aéreo (brônquios cheios de ar em meio a um pulmão opacificado) Consolidação /Opacidade de Espaço Aéreo
  26. 26. LUL Pneumonia
  27. 27. Opacidade Intersticial  Doença localizada no interstício pulmonar, i.e., o septo alveolar e tecido conjuntivo que apoiam os alvéolos  Sinais cardinais: • Linhas e/ou reticulação • Pequenos nódulos bem definidos  Padrão miliar  DDX: Edema pulmonar, doenças pulmonares intersticial (ex. fibrose pulmonar idiopática), sarcoidose, infecção, tumor (linfangite carcinomatosa), etc.
  28. 28. Interstitial Opacity: Lines
  29. 29. Interstitial Opacity: Lines & Reticulation
  30. 30.  Nódulo: discreta lesão pulmonar, bem definida, opacidade quase circular 0.2 - 3 cm  Massa: maior que 3 cm  Procure descrevar as quesitos: • Solitário ou múltiplo • Tamanho • Características da borda • Presença or ausencia de calcificação • Localização Nódulos e Massas
  31. 31. Bem-Definida Calcificação Mal-Definida Massa
  32. 32. Linfadenopatia (LAN)  Termos Especificos : • Alargamento Mediastinal • Alargamento Hilar  Evite usar termos como: • Hilo proeminente É importante conhecer o aspecto “normal” para reconhecer o que for “ anormal”
  33. 33.  Janela hilar inferior (hilar direita e/ou subcarinal)  Hilar esquerda  Subcarinal Linfoadenopatia
  34. 34. Paratraqueal direita & Bilateral LAN
  35. 35. Hilar Direita LAN
  36. 36. Hilar Direita LAN
  37. 37. * Subcarinal LAN
  38. 38. Janela Aortico Pulmonar LAN
  39. 39. Cistos & Cavidades  Espaços Anormais no parênquima pulmonar (“buracos”), preenchidos com ar e/ou líquido, com uma parede apenas definivel (>1 mm) • Cistos: congenitos ou adquiridos • Cavidades: causadas por necrose tissular, (inflamatorio e/ou neoplasico)  Caracterize: • Espessura da parede na porção mais fina • Superfície interna • Presença / absence de nivel hidroaéreo • Número e localização
  40. 40. TB or Not TB? Cistos and Cavidades A “Homem ,45 anos com tosse e perda de peso”. Existem achados radiográficos sugestivos de doença benigna ou maligna? C D B
  41. 41. TB or Not TB? Cysts and Cavities Existem achados radiograficos que sugerem diagnósticos de doença benigna ou maligna?  Cistos benignos : parede com espessura uniforme , 1mm, superfície interna lisa (ex. PCP)  Cavidades Benignas : espessura máxima da parede  4 mm superfície interna pouco irregular(ex TB)  CavIdades Malignas: espessura máxima da parede 16 mm superfície interna Irregular
  42. 42.  Derrame • De apagamento de seio costofrênico a massivo  Espessamento  Massa  Ar  Calcificação Pleural Disease: Basic Patterns
  43. 43. Pleural Effusion
  44. 44. Post TB Pleural Calcification
  45. 45. Plombage with Lucite balls
  46. 46. Basic Radiology for the TB Clinician Overview:  Technical aspects of chest radiography  Systematic approach to reading CXR  Basic CXR anatomy  Patterns of disease  Radiographic manifestations of TB
  47. 47. “Typical Pattern”: Post-primary TB  Distribution • Apical / posterior segments of upper lobes • Superior segments of lower lobes • Isolated anterior segment involvement unusual for M.tb (think M. avium complex) Can this be TB?
  48. 48. “Padrão típico”: TB Pós-Primaria Padrões de doença • Consolidação de espaço aéreo • Cavitação, nódulo cavitado • Diseminação brônquica • Miliar • Broncostenose • Tuberculoma • Derrame Pleural (empiema mais provavel em doença pós-primaria)
  49. 49. “Atypical pattern”: Primary TB  Distribution : any lobe involved (slight lower lobe predominance)  Air-space consolidation  Cavitation is uncommon (<10%)  Adenopathy is common (esp. children and HIV), predilection for right side  Miliary pattern  Pleural effusions Can this be TB?
  50. 50. Can this be TB? Miliary TB
  51. 51. TB Pattern “Typical” (Post-Primary) “Atypical” (Primary) Infiltrate 85% upper Upper : Lower 60 : 40 Usually upper in children Cavitation Common Uncommon Adenopathy Uncommon Children common Adults ~30% Unilateral > bilateral Effusion May be present May be present Radiographic Patterns: Pulmonary TB
  52. 52. Early HIV (CD4>200) Advanced HIV (CD4<200) Pattern “Typical” (Post-primary) “Atypical” (Primary) Infiltrate Upper lobes Lower lobes, multiple sites, or miliary Cavitation Common Uncommon Adenopathy Uncommon Common Effusion Uncommon More common CXR Pattern: Early vs. Advanced HIV
  53. 53. “Old / healed” TB  Ca++ granuloma - Ghon lesion  Ca++ granuloma and hilar node calcification - Ranke complex  Apical pleural thickening  Fibrosis and volume loss Can this be TB?
  54. 54. Basic Radiology for the TB Clinician Summary:  Remember: Technical quality can significantly impact your CXR interpretation  Develop a systematic approach (use every time!)  Practice identifying normal CXR anatomy  Important to characterize and describe lesions—this can help with your differential diagnosis  Whether typical or atypical  TB can always fool you!

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