Round shadow in the lung on a chest x-ray. Technique for reading radiographs

The pathology of the lungs on the X-ray is determined not only by abnormal enlightenments and darkenings. Before proceeding with the formation of an x-ray protocol, the radiologist examines other tissues so that not a single smallest detail is missed on the x-ray.

What does lung disease look like on x-ray?

The pathology of the lungs on the radiograph is described by the following radiological syndromes:

1. Total blackout.
2. Limited dimming.
3. Round shadow.
4. Single shadow.
5. Ring shadow.
6. Subsegmental shading.
7. Enlightenment.

There are other x-ray syndromes, but they are less common on chest x-rays.

In addition to the formations described above, the doctor also pays attention to the roots of the lungs, the pulmonary pattern, and the state of the mediastinum.

X-ray signs of pulmonary embolism (M. Hofer scheme)

What is the root of the lung on x-ray

On x-rays of the organs, the roots of the lungs can be traced on both sides of the median shadow in the medial parts of the lung fields. They are formed by a combination of arterial and venous vessels, a group of lymph nodes and nerve trunks. The main role in the formation of their image in the picture is played by veins and arteries.

When reading a radiograph, the doctor classifies the roots into 3 component parts:

• head - formed by shadows of large vessels, branches of the pulmonary artery;
• body - formed by branches of the pulmonary artery and other vessels;
• tail - formed by veins that have a horizontal direction.

According to the structure, the roots are divided into:

• trunk;
• crumbly.

With the main type, the root head is represented by a massive formation, which is mostly represented by the pulmonary artery. The crumbly structure is characterized by pronounced heaviness, most of which is made up of branches from arteries and veins.

On an x-ray with a scopic examination (transmission), you can see an accumulation of enlarged lymph nodes against the background of roots with viral or bacterial infections. These formations do not belong to the functional structures in the norm, but appear with inflammation of the lymphatic vessels.

Pathological roots in the picture are manifested by several morphological options:

• little structure;
• increase;
• projection overlay;
• offset;
• amplification;
• vascular type deformity;
• fibrous seal.

If the radiologist in the description protocol indicates that the roots are poorly structured, this may mean the growth of fibrous tissue in them (after inflammation or in old age), which makes it difficult to visualize in the picture.

Tyazhist roots of the vascular type occur in diseases of the heart and high blood pressure, when congestive changes in the pulmonary circulation are observed.

Deformation of the roots according to the vascular type occurs in chronic lung diseases with the formation of bronchiectasis (cavities in the wall of the bronchi).

The displacement of the median structures is observed with atelectasis of the lung segments, tumors, accumulation of fluid in the pleural cavity.

What is total blackout

On X-ray, total blackout on the lateral and direct x-ray of the lungs is characterized by a white shadow that occupies most of the lung field. It happens unilateral and bilateral. The causes of the syndrome are toxic pulmonary edema or heart disease, which are accompanied by severe hemothorax.

X-ray limited shadow syndrome is accompanied by a white spot that does not extend beyond the lung lobe or segment. There is a pathology in cancer, tuberculosis, lobar pneumonia. If there is a syndrome on the radiologist, it is necessary to establish the exact localization of the blackout in segments. Often, simultaneously with this pathology, the roots of the lung are deformed due to inflammatory changes.

Subsegmental darkening occupies some part of the lung segment, but does not completely cover it.

How dangerous is a round and single shadow in the picture of the lungs

The round shadow on the x-ray has a limited localization with round or oval contours more than 1.5 cm in diameter. In the presence of this syndrome, it is necessary to establish the localization of the pathological process. It may be located intra- or extrapulmonary. Causes may include pleural mesothelioma, diaphragmatic hernia, and rib tumors.

What formations of the chest organs give a round shadow:

• tuberculoma;
• tumor;
• abscess;
• arteriovenous aneurysms;
• cysts.

If there are several round shadows on the x-ray of the lungs, these are most likely cancerous metastases.

How does a lung cyst appear on an x-ray

The cyst of the lung on the radiograph is manifested by an annular shadow. It was decided to describe this X-ray syndrome separately because the pathology in the picture is rarely observed, so radiologists forget its specific manifestations. The disease is skipped when deciphering lung images if the doctor does not prescribe a lateral projection. If the cyst has thin walls, it is not clearly visualized on a direct radiograph. Only when it is increased in size or liquid contents accumulate inside it, it is possible to consider the formation in the picture, if it is small in size.

A cyst is a lung cavity that has a fibrous outer shell. Inside, it may be lined with bronchial epithelium. The clear, straw-coloured liquid inside is due to glandular secretions.

Obviously, the pathology on the X-ray of the lungs is determined by the combination of many shadows. They form the doctor's view of the state of the chest organs in humans. Only by studying radiological syndromes, one can read radiographs.

X-ray of the lungs is applicable as part of the primary diagnosis of the conditions of paired organs and the respiratory system. This is a publicly available, simple and accurate method of examination, which can now be carried out even at home.

About 80% of all bronchopulmonary ailments are detected on the radiograph. The specialist has the ability to analyze the picture, which defines minor manifestations of the disease.

What does a lung x-ray show a doctor? Why is it needed?

A projection study makes it possible to determine the pathological processes affecting the respiratory system. The specialist analyzes the intensity of shadows, coverage and outlines.

Among the likely diagnoses based on the information received:

• inflammation of the bronchi, pleura, lung tissue;
• emphysema;
• tuberculosis;
• malignant education;
• swelling of the respiratory system;
• rib fracture;
• pneumothorax, etc.

In addition to helping in making a diagnosis, a lung x-ray provides control over the treatment of all pathological processes of the respiratory system.

The effect of radiation on the patient

The examination is carried out by means of radiation. According to sanitary rules and regulations, the allowable annual rate of human exposure should not exceed 5 mSV. In the case of using outdated equipment, the fraction of single radiation exposure is 0.3 mSV.

With the passage of digital X-ray diagnostics, this figure decreases by 10 times. Therefore, if it is necessary to conduct repeated X-rays, the diagnosis will not cause the development of pathological processes in the body.

Indications

Possible patient complaints include:

• prolonged cough;
• progressive shortness of breath;
• increase in body temperature;
• active sweat production;
• pain syndrome in the chest;
• wheezing;
• coughing up blood or sputum;
• prostration.

In addition, patients with suspected tuberculosis, pleurisy, pneumonia, heart disease, injuries of paired organs and bone tissue are examined.

For the purpose of prevention, they are made to persons working in production with harmful conditions. For example, miners, masons, staff of tuberculosis dispensaries, etc.

Preparatory stage and examination

No special preparation is required before an X-ray. The patient's actions during the examination are as follows:

1. Undresses above the waist and removes metal objects (watches, glasses, jewelry, etc.).
2. Removes hair from the area being examined.
3. Attaches to equipment.
4. He takes a deep breath and holds his breath, listening to the doctor's command.
5. Restores breathing after the procedure is completed.

During the examination, the patient is required to remain still. For these purposes, during the diagnosis of children, fixing products and stands are used.

The duration of the procedure is a few seconds. Usually they resort to an overview x-ray of the lungs, taking a picture in a direct projection. The patient is directed by the front of the chest to the matrix. Sometimes the patient needs to stand sideways, in which case the x-ray is done in two projections.

X-ray results

The radiologist begins to decipher the image. (Take advantage from our doctors). The specialist performs a series of sequential actions:

1. Evaluates the outlines of the roots of the lungs, the heart.
2. Analyzes the shadow of the mediastinum and bones.
3. Examines the lung tissue and sinuses.

The radiograph of the lungs is described using a couple of concepts:

• shadow (displays compacted areas);
• enlightenment (indicates places of increased airiness).

What do shadows in the picture mean?

Visualized enlightenment (darkening in the organs on an X-ray, since the picture is a negative), its shape, color intensity, contours help the specialist to assess the condition of the lungs and draw a conclusion.

When deciphering the image, it is mandatory to indicate in which projection the examination was performed (plain radiography in direct projection, in two planes or display in three projections).

The table below shows a list of diagnoses with an X-ray pattern corresponding to each of them:

Separately, it is worth touching on the topic of X-ray diagnostics of pneumonia and assessing the feasibility of X-rays in case of suspected pneumonia.

Does x-ray show inflammation of the lungs

In the process of x-ray examination, obvious symptoms can be detected, which will indicate the development of pneumonia. In particular:

• darkening with fuzzy contours;
• growth of the lung on the side of the development of pathology;
• deformed, enhanced vascular pattern in the affected area.

The croupous form of inflammation appears on the X-ray as a slight increase in the intensity of blackouts, a slight expansion of the lung root, thickening of the pleural sheets and a decrease in the transparency of the lung field. These signs may be missed by specialists or be mistaken for manifestations of bronchitis.

As an alternative method for diagnosing pneumonia, fluorography can also be performed. However, more often this technique is applicable only for preventive purposes. When comparing the two images, the difference is obvious: on the x-ray, well-distinguishable blackouts during inflammation are visualized, in the second case, clear signs will not be observed.

In clinical cases, they resort to a decisive diagnostic method - fluoroscopy. This procedure differs from the other two because fluoroscopy helps to observe the respiratory organs in real time. The image in this case is displayed on the monitor.

Fluoroscopy

Smoker radiograph

Healthy organs are distinguished by a clear contour line and a good natural shape. When a person smokes, the lungs look like they have been smoked.

The appearance of the respiratory organs gradually changes, even if a person rarely smokes, prefers exclusively expensive cigarettes, or only inhales cigarette smoke (smokes passively).

Experts compare an x-ray of a smoker's lungs with a sieve or a doormat. A similar picture is caused by the formation of multiple pores in the field of organs caused by developing inflammatory processes and defects in the bronchi.

As a person continues to smoke, non-functional connective tissue is formed in the lungs (just in those places where the cell of the respiratory tree dies poisoned by nicotine). Against the background of this process, there is a malfunction in the alveoli, which are designed to bind oxygen from the external environment and deliver it to the tissues. The result - the smoker is diagnosed with respiratory failure. At this stage, the picture shows enlightenment in the lung field. In the lower third of the organs - increased airiness. Over time, enlightenment moves upward.

The chest of a smoker with experience on the radiograph is visualized in tandem with additional shadows that can be formed by a number of diseases: tuberculosis, bronchitis, bronchial asthma, diaphragmatic hernia, etc.

It is applicable in medical practice to detect local diseases and control the dynamics of the ongoing treatment course. Indications for the appointment of the procedure can be both painful manifestations (cough, sputum production, high body temperature, chest pain, shortness of breath, etc.), and a certain type of patient's activity.

For diagnostic purposes, they often resort to survey radiography, less often, images in two or three projections are required. The procedure does not require preparation, takes a few seconds, the patient receives the results immediately after the examination.

When deciphering an x-ray, the specialist operates with the concepts of darkening and enlightenment, gives an assessment of the contour line, the shape of the lungs. Among the probable diagnoses made after the examination: tuberculosis, pneumonia, lung cancer, peritonitis, etc.

Video

The anatomical structure of the lungs, their ability to fill with air, which freely transmits x-ray radiation, makes it possible to obtain, during fluoroscopy, a picture that reflects in detail all the structural elements of the lungs. However, darkening in the lungs on an x-ray does not always reflect changes in the tissues of the lung itself, since other organs of the chest are located at the level of the lungs and, therefore, the radiation beam, passing through the body, projects on the film a superimposed image of all organs and tissues. falling within its range.

In this regard, if any darkened formation is found on the image, before answering the question of what it might be, it is necessary to clearly differentiate the localization of the pathological focus (in the tissues of the chest, diaphragm, pleural cavity or, directly, in the lungs).

The main syndromes on the radiograph

On a radiographic image taken in the anterior projection, the contours of the lungs form pulmonary fields, over the entire area, intersected by symmetrical shadows of the ribs. A large shadow between the lung fields is formed by the combined imposition of the projection of the heart and the main arteries. Within the contour of the lung fields, one can see the roots of the lungs located at the same level with the anterior ends of the 2nd and 4th ribs and a slight darkening of the area caused by the rich vascular network located in the lung tissue.

All pathological changes reflected on x-rays can be divided into three groups.

Blackouts

Appear in the picture, in cases where the healthy part of the lung is replaced by a pathological formation or substance, causing the air part to be replaced by denser masses. As a rule, it is observed in the following diseases:

• bronchial obstruction (atelectasis);
• accumulation of inflammatory fluid (pneumonia);
• benign or malignant degeneration of tissues (tumor process).

Change in lung pattern

• total (complete) or subtotal (almost complete) blackout;
• limited dimming;
• round (spherical) shadow;
• ring shadow;
• focal shading.

Enlightenment

Enlightenment in the picture reflects a decrease in the density and volume of soft tissues. As a rule, a similar phenomenon occurs when an air cavity forms in the lung (pneumothorax). Due to the specific reflection of X-ray results on photographic paper, areas that easily transmit radiation are reflected in a darker color due to the more intense effect of X-rays on silver ions contained in photographic paper, areas of a denser structure are light in color. The wording "darkening" in the picture is actually reflected in the form of a light area or focus.

On an x-ray, a pulmonary pattern of healthy lungs

blackout syndrome

Total obscuration of the lung on an x-ray is a complete or partial obscuration (at least 2/3 of the lung field). In this case, gaps are possible in the upper or lower part of the lung. The main physiological reasons for the manifestation of such a syndrome are the absence of air in the lung cavity, an increase in tissue density of the entire surface of the lung, the content of fluid or any pathological contents in the pleural cavity.

Diseases that can cause a similar syndrome include:

• atelectasis;
• cirrhosis;
• exudative pleurisy;
• pneumonia.

To carry out the differential diagnosis of diseases, it is necessary to rely on two main signs. The first sign is to assess the location of the mediastinal organs. It can be correct or offset, usually in the direction opposite to the center of blackout. The main reference point in identifying the displacement axis is the shadow of the heart, which is mostly to the left of the midline of the chest, and less to the right, and the stomach, the most informative part of which is the air bladder, which is always clearly visible on the pictures.

The second sign that allows you to identify a pathological condition is an assessment of the uniformity of darkening. So, with uniform darkening, with a high degree of probability, atelectasis can be diagnosed, and with heterogeneous - cirrhosis. The interpretation of the results obtained using the radiographic method consists in a comprehensive assessment of all visually detected pathological elements in comparison with the anatomical features of each individual patient.

Limited Shading Syndrome

To identify the causes of the appearance of a limited darkening of the lung field, it is necessary to take a picture in two directions - in frontal projection and lateral. Based on the results of the obtained images, it is important to assess what is the localization of the blackout focus. If the shadow on all images is inside the lung field, and converges in size with its contours or has a smaller volume, it is logical to assume lung damage.

With a darkening adjacent to the diaphragm or mediastinal organs with a wide base, extrapulmonary pathologies (fluid inclusions in the pleural cavity) can be diagnosed. Another criterion for evaluating limited blackouts is size. In this case, two options should be considered:

• The size of the darkening clearly follows the contours of the affected part of the lung, which may indicate an inflammatory process;
• The size of the darkening is less than the normal size of the affected segment of the lung, which indicates cirrhosis of the lung tissue or blockage of the bronchus.

Of particular note are cases in which there is a blackout of normal size, in the structure of which light foci (cavities) are traced. First of all, in this case, it is necessary to clarify whether the cavity contains liquid. To do this, a series of images is taken in various positions of the patient (standing, lying or tilting) and assessing changes in the level of the supposed upper limit of the liquid content. If fluid is present, a lung abscess is diagnosed, and if it is not, then the likely diagnosis is tuberculosis.

Important! The detection of several cavities with limited darkening of the lung is characteristic of pneumonia caused by staphylococcus aureus. Such a lesion has a poor prognosis, and often treatment is possible only with the help of surgery.

On the x-ray, limited darkening of the lungs in two projections

round shadow syndrome

I state the syndrome of a round shadow when the spot on the lungs has a round or oval shape in two pictures taken perpendicular to each other, that is, in front and on the side. To decipher the results of radiography when a round shadow is detected, they rely on 4 signs:

• form of dimming;
• localization of darkening relative to nearby organs;
• clarity and thickness of its contours;
• the structure of the inner shadow field.

Since the shadow reflected on the picture within the lung field may actually be outside it, an assessment of the shape of the blackout can greatly facilitate diagnosis. So, a rounded shape is characteristic of intrapulmonary formations (tumor, cyst, infiltrate filled with inflammatory contents). An oval shadow in most cases is the result of compression of a round formation by the walls of the lung.

The structure of the inner shadow field also has a high information content. If, when analyzing the results, the heterogeneity of the shadow is obvious, for example, lighter foci, then with a high degree of probability, it is possible to diagnose the decay of necrotic tissue (with decaying cancer or the decay of tuberculous infiltrate) or the formation of a cavity. Darker areas may indicate partial calcification of the tuberculoma.

A clear and dense contour indicates the presence of a fibrous capsule, characteristic of an echinococcal cyst. Round shadow syndrome includes only those shadows that are more than 1 cm in diameter, shadows of a smaller diameter are considered foci.

ring shadow syndrome

An annular spot on the lung on an x-ray is the simplest syndrome to perform analysis. As a rule, an annular shadow appears on the x-ray as a result of the formation of an air-filled cavity. An obligatory condition under which the detected darkening is referred to as an annular shadow syndrome is the preservation of a closed ring when taking pictures in all projections and in various positions of the patient's body. If the ring does not have a closed structure in at least one of the series of images, the shadow can be considered an optical illusion.

If a cavity is found in the lung, the uniformity and thickness of its walls should be assessed. So, with a large and uniform thickness of the contour, one can assume an inflammatory origin of the cavity, for example, a tuberculous cavity. A similar picture is observed with an abscess, when purulent fusion of tissues occurs with the removal of contents through the bronchi. However, with an abscess, the remnants of pus, most often, continue to be in the cavity and their complete removal is quite rare, so usually such a cavity is a tuberculous cavity.

Unevenly wide walls of the ring indicate the process of decay of lung cancer. Necrotic processes in the tumor tissue can cause the formation of a cavity, but since necrosis develops unevenly, tumor masses remain on the inner walls of the cavity, creating the effect of an “irregularity” of the ring.

Important! The main difficulty in assessing the annular shadow is determining the localization of the formation, since in most cases a similar syndrome is observed in extrapulmonary processes (deformation of the ribs, gases in the intestines, gases in the pleural cavity).

In the picture, an annular shadow is determined in the lower lobe of the right lung.

Focal dimming syndrome

Spots on the lungs larger than 1 mm and less than 1 cm are considered foci. On an x-ray, you can see from 1 to several foci located at a considerable distance from each other or in a group. If the area of ​​distribution of foci does not exceed 2 intercostal spaces, the lesion (dissemination) is considered limited, and when the foci are distributed over a larger area, it is diffuse.

The main criteria for evaluating focal opacities are:

• area of ​​distribution and location of foci;
• shading contours;
• darkness intensity.

With the location of one or more blackouts in the upper sections of the lung - a clear sign of tuberculosis. Many foci with limited distribution is a sign of focal pneumonia or the result of the collapse of a tuberculous cavity, which is usually located slightly higher than the detected foci. In the latter case, a round or annular shadow may also be observed in the image.

As a reason for the appearance of a single darkening in any part of the lung, first of all, consider the likelihood of developing cancer or tumor metastasis. This is also evidenced by the clear contours of the shadow. Fuzzy contours indicate an inflammatory origin of blackouts.

To assess the intensity of darkening, they are compared with the image of the vessels visualized in the image. If the severity of the focus is inferior to the shadow of the vessel, this is a low-intensity darkening, characteristic of focal pneumonia or infiltrated tuberculosis. With medium and strong darkening of the focus, when the severity is equal to or darker than the vascular pattern, one can judge the attenuation of the tuberculous process.

Since extensive dissemination of lesions may indicate more than 100 diseases, the size of the opacities should be assessed to distinguish between causes. So, the smallest foci covering the entire area of ​​\u200b\u200bthe lung can mean pneumoconiosis, miliary tuberculosis, or focal pneumonia.

In the picture, small-focal shading

Important! Regardless of what changes are observed on an x-ray of the lungs, the presence of a normal lung pattern, which is characterized by the presence of shadows of the vascular system, should be taken into account when analyzing the results.

In the vast majority of cases, on the basis of lung radiography, it is impossible to make a final diagnosis, since the analysis of the resulting image can only reveal a syndrome characteristic of a particular disease. If the x-ray showed a darkening of any area, then in order to clarify the diagnosis and assess the dynamics of the development of the disease, it is necessary to conduct a complex of laboratory studies and additional diagnostics using MSCT, bronchography, biopsy, etc.

X-ray manifestations of pathological processes in the lungs are very diverse, but they are based on only 4 phenomena: shading of the lung fields, enlightenment of the lung fields, changes in the lung pattern, changes in the roots of the lungs.

Shading of the lungs is most often due to the accumulation of inflammatory exudate or edematous fluid in the alveoli, a decrease in the airiness of the lungs due to impaired bronchial patency or due to compression of the lungs, replacement of the lung parenchyma with pathological tissues. It should be borne in mind that extrapulmonary processes can also give this phenomenon: neoplasms of the chest wall, diaphragm and mediastinum, protruding into the pulmonary fields; accumulation of fluid in the pleural cavities.

Enlightenment is due to a decrease in the mass of tissues per unit volume of the lung. This occurs with an increase in the airiness of the entire lung or part of it, or with the formation of air cavities in the lung parenchyma. In addition, the enlightenment of the lung field may be due to the accumulation of gas in the pleural cavity.

A change in the lung pattern occurs in connection with either the interstitial component, or with a violation of the blood and lymph flow in the lungs.

The change in the x-ray picture of the roots of the lungs is due to the defeat of their structural elements: blood vessels, bronchi, fiber, lymph nodes.

These skiological phenomena can be detailed depending on their length, shape, structure, outlines. There are 9 x-ray syndromes that reflect almost all the diverse pathology of the lungs (Fig. 8.7).

Analysis of the x-ray picture of the lungs should begin with a distinction between "normal" and "pathology". In the presence of pathological changes, it is necessary to determine what x-ray syndrome they manifest themselves in, which will immediately significantly narrow the range of probable diseases and facilitate differential diagnosis. The next step is intra-syndrome

Rice. 8.7. Schemes of radiological syndromes of lung diseases. 1. Extensive shading of the lung field. 2. Limited shading. 3. Round shadow. 4. Foci and limited focal dissemination. 5. Extensive focal dissemination. 6. Extensive enlightenment. 7. Limited enlightenment. 8. Change in lung pattern. 9. Changing the roots of the lungs

Roma diagnostics with the definition of the general nature of the pathological process and the specific nosological form of the disease.

Syndrome of extensive shading of the lung field. The pathological process displayed by this syndrome is determined by the position of the mediastinum and the nature of the shading (see Fig. 8.8 - 8.10). The position of the mediastinum and the nature of shading in various diseases are shown in Table. 8.2.

limited shading can give both changes in the lungs and extrapulmonary processes. Starting to decipher this syndrome, first of all, it is necessary to establish the anatomical localization of the pathological process: chest wall, diaphragm, mediastinum, lungs. In most cases, this can be achieved in the simplest way - with the help of a multiprojection x-ray examination.

dovaniya. The processes emanating from the chest wall are widely adjacent to it and are displaced during breathing in the same direction as the ribs. The processes emanating from the diaphragm are, of course, closely connected with it. Mediastinal neoplasms protruding into the lung fields are mostly located in the median shadow, do not move during breathing, push back and squeeze certain anatomical structures of the mediastinum.

The unconditionally intrapulmonary localization of the pathological process is evidenced by its location inside the pulmonary field in all projections (the only exception is fluid in the interlobar fissure) and the displacement of the pathologically altered area during breathing and coughing, along with elements

Table 8.2. The position of the mediastinum and the nature of shading in various diseases

lung. Most often, such a syndrome displays inflammatory infiltrations of the lung tissue of various etiologies, segmental atelectases, local pneumosclerosis (see Fig. 8.11, 8.12).

round shadow syndrome- limited shading, in all projections retaining the shape of a circle, semicircle, oval more than 12 mm. In this case, it is also first of all necessary to establish the localization of the pathological process: it is located extra or intrapulmonary. From intrapulmonary processes most often give a round shadow of a tumor, cysts, tuberculosis (infiltrative, tuberculoma), vascular aneurysms, lung sequestration. Carrying out the differentiation of these processes, it is necessary to pay attention to the number of shadows, their contours and structure, the dynamics of the x-ray picture. Despite the differences in the skiological representation of spherical pathological processes, their differentiation remains a difficult task. Nevertheless, sometimes it is possible with a high degree of probability to assume a morphological substrate of a round shadow: a single formation and an increase in the lymph nodes of the lung root - peripheral cancer; multiple formations - metastases; a single formation with massive chaotic or mottled calcification - hamartoma; formation with independent pulsation - vascular aneurysm (Fig. 8.13).

Foci and limited focal dissemination- rounded, polygonal or irregularly shaped shadows up to 12 mm in size, the anatomical basis of which is a lung lobule. Several foci located side by side are designated as a group of foci. Limited dissemination is defined on the x-ray multiple foci, localized within no more than two segments. Most often, this syndrome displays focal tuberculosis, peripheral cancer, metastases, lobular atelectasis, aspiration pneumonia (Fig. 8.14).

Syndrome of extensive focal dissemination- lesions of the lungs, the length of which exceeds two segments (common dissemination), and lesions of both lungs (diffuse dissemination). According to the size of the foci, 4 types of rashes are distinguished: miliary (focal sizes - up to 2 mm), small-focal (3-4 mm), medium-focal (5-8 mm), large-focal (9-12 mm). The most common syndrome of extensive focal dissemination is disseminated tuberculosis, sarcoidosis, carcinomatosis, pneumoconiosis, alveolar pulmonary edema (Fig. 8.15).

Syndrome of extensive enlightenment of the pulmonary field. Of the extrapulmonary pathological processes, this syndrome displays total pneumothorax (Fig. 8.16).

With intrasyndromic differentiation of intrapulmonary pathological processes, one should first of all assess their prevalence. There are 3 options for extensive enlightenment: total bilateral, total one-sided, subtotal one-sided.

Total bilateral enlightenment is most often given by pulmonary emphysema and hypovolemia of the pulmonary circulation in some congenital heart defects (tetralogy of Fallot, isolated pulmonary artery stenosis).

Total unilateral enlightenment most often displays valvular obstruction of the main bronchus, compensatory hyper-

Rice. 8.8. Total homogeneous shading of the left hemithorax with mediastinal shift towards shading (atelectasis of the left lung)

Rice. 8.9. Total non-uniform shading of the left hemithorax with mediastinal shift towards shading (cirrhosis of the left lung)

Rice. 8.10. Total homogeneous shading of the left hemithorax with mediastinal displacement in the opposite direction (left-sided total hydrothorax)

Rice. 8.11. Limited shadowing of the right lung - upper lobe atelectasis

Rice. 8.12. Limited shading of the right lung - segmental pneumonia

Rice. 8.13. Round Shadow Syndrome - Gamartoma

Rice. 8.14. Limited focal dissemination in the upper lobe of the right lung (focal tuberculosis)

Rice. 8.15. Diffuse bilateral miliary dissemination of the lungs

Rice. 8.16. Total one-sided enlightenment

Rice. 8.17. Limited enlightenment of the left lung field (limited pneumothorax)

pneumatosis of one lung with atelectasis or absence of the other lung, thromboembolism and agenesis of one of the main branches of the pulmonary artery.

Subtotal unilateral enlightenment is observed with valvular obstruction of the patency of the lobar bronchus due to its partial mechanical obstruction by a tumor or foreign body; with compensatory hyperpneumatosis of a part of the lung due to atelectasis or removal of another lobe of the same lung; with thromboembolism of the lobar branch of the pulmonary artery; with congenital lobar emphysema.

Syndrome of limited enlightenment represents a local increase in the transparency of the lung field, which may have an annular or irregular shape. The most frequent intrapulmonary processes displayed by such a picture are true and false cysts, cystic hypoplasia, emphysematous bullae, abscesses, destructive forms of tuberculosis.

lesa, cavitary form of peripheral cancer. Of the extrapulmonary processes, this syndrome most often manifests itself as limited pneumothorax, diaphragmatic hernia, conditions after plastic surgery of the esophagus with the stomach or intestine (Fig. 8.17). Syndrome of limited enlightenment of the lungs can imitate a variety of pathological changes in the ribs: congenital deformities, fusion of neighboring ribs, tumors, inflammatory processes (osteomyelitis, tuberculosis).

Syndrome of changing lung pattern- all deviations from the x-ray picture of the normal pulmonary pattern, which are manifested by amplification, depletion or deformation.

Strengthening the lung pattern - an increase in the number and caliber of its elements per unit area of ​​the lung field. This is due to either plethora of the lungs with some congenital and acquired heart defects, or excessive development of connective tissue.

The impoverishment of the lung pattern, on the contrary, is manifested by a decrease in the number and caliber of its elements per unit area of ​​the lung field. This is observed with hypovolemia of the pulmonary circulation in congenital heart defects with pulmonary stenosis; swelling of the lung tissue with valvular stenosis of the bronchus and with hyperpneumatosis; with emphysema.

Deformation is a change in the normal course, shape and unevenness of the contours of the elements of the lung pattern, as well as a change that causes its mesh, taut appearance. A similar picture is often observed in chronic bronchitis, pneumoconiosis, pneumosclerosis (see Fig. 8.18).

Syndrome of changes in the roots of the lungs manifested by a change in their size and shape, deterioration in the structure of the image, unevenness and fuzziness of the contours. To establish the nature of the pathological process, along with the features of the skiological picture, it is necessary to take into account whether these changes are unilateral or bilateral (Fig. 8.19). Changes in the roots of the lungs in various diseases are shown in Table. 8.3.

Rice. 8.18. Diffuse amplification and de- Rice. 8.19. Chest tomogram in direct projection

formation of lung pattern, naibotion. Bilateral expansion of the roots of the leg

more pronounced in the basal compartments, due to an increase in lymphatic

lakh lung ic nodes

Table 8.3. Changes in the roots of the lungs in various diseases

The syndromic approach to X-ray diagnostics of respiratory diseases is quite fruitful. A detailed analysis of the features of the x-ray picture in many cases provides a correct determination of the nature of bronchopulmonary pathology. The data obtained during X-ray examination also serve as the basis for a rational further examination of patients using other radiation imaging methods: X-ray CT, MRI, ultrasound and radionuclide methods.

X-ray signs lung pathology enough. Among them, three main syndromes are distinguished: darkening of the lung field or part of it, enlightenment of the lung field or part of it, and changes in the lung and root pattern.

Figure 1 - The main options for darkening the lung field,

a - extensive or total blackout;

b - limited dimming;

c - round shadow;

g - ring-shaped shadow;

d - focal shadows;

e - dispersion (dissemination) of foci in the lungs.

Darkening of the lung field or part of it. Most lung diseases are accompanied by compaction of the lung tissue, i.e., a decrease or absence of its airiness. The denser tissue absorbs X-rays more strongly. Against the background of a light lung field, a shadow (or darkening) appears. The position, size and shape of the darkening depend on the volume of the lesion. There are several typical dimming options: extensive shadowing, limited shadowing, round shadow in the lung field, annular shadow in the lung field and focal shadow.

Figure 2 - Limited darkening of the right lung field with damage to the upper lobe.

Extensive blackout observed if the pathological process captured the entire lung. In this case, the entire lung field is darkened to one degree or another on the radiograph, and then they speak of extensive darkening. Darkening of the entire lung field is most often caused by blockage of the main bronchus and atelectasis (falling) of the corresponding lung. Such a light is airless, therefore its shadow is completely uniform. In addition, it is reduced, due to which the mediastinal organs are displaced towards darkening. These two signs are enough to recognize lung atelectasis.

A picture similar to atelectasis of the lung can give a condition after removal of the lung ( pneumonectomy).

Extensive darkening of the lung field can be observed with inflammatory infiltration (for example, with pneumonia), however, the mediastinal organs remain in place during pneumonia, and against the background of darkening, you can catch the gaps of the bronchi filled with air.

Darkening of the lung field can also be caused not only by compaction of the lung tissue, but also by fluid accumulated in the pleural cavity. With a large effusion, the darkening becomes extensive and uniform, as in atelectasis, but the mediastinal organs are displaced in the opposite direction. From the above information, it can be seen that such a syndrome as an extensive darkening of the pulmonary field has its own morphological interpretation.

If the pathological process does not affect the entire lung, but some part of it (a lobe or segment), and a shadow is found on the radiographs that matches in position, size and shape with this altered part, then in this case they speak of a limited darkening of the lung field . Most often, a limited darkening of the lung field can be observed with pneumonic and tuberculous infiltrations, as well as a tumor process. In the first case, focal blackouts have blurred outlines, and in the presence of a tumor, the shape of the shadow, as a rule, has uneven, well-demarcated contours.

Syndrome round shadow in the lung field implies such a darkening of the lung field, in which the shadow of the pathological formation in all projections of the study has the shape of a circle, semicircle or oval with a diameter of more than 1 cm. , lung infarction, closed cyst (bronchial, echinococcal), benign or malignant tumors, as well as many other pathological conditions.

Figure 3 - X-ray picture of diseases that cause round shadow syndrome in the lung field,

a - closed cyst;

in - tuberculous cavity; G - peripheral lung cancer with decay.

Fresh tuberculous cavern has the appearance of an annular shadow, and its dimensions range from a few millimeters to several centimeters. Peripheral lung cancer can also give a symptom of the cavity, however, the outer contours of the cavity are uneven and relatively sharply demarcated from the surrounding lung tissue.

Focal shadow - these are rounded or irregularly shaped shadow formations, the sizes of which vary from 0.5 mm to 1 cm. It should be noted that focal shadow is the most common type of blackout. Foci up to 2 mm are called miliary, from 2 to 4 mm - small, from 4 to 8 mm - medium, from 8 to 12 mm - large.

Figure 5 - X-ray of the upper parts of the lungs and a diagram for it.

In the tops and outer parts of the first intercostal spaces, multiple foci of different density are visible, merging in places. Focal tuberculosis in the phase of infiltration.

The number of focal shadows is very different. If they cover a fairly large area (for example, the apex of the lung), then they talk about limited dissemination, but if they cover a large area, then they talk about widespread dissemination.

For the differential diagnosis, the location of the focal shadows is primarily important (for example, their presence in the tops and outer parts of the subclavian zone in most cases indicates the tuberculous nature of the disease). The presence of foci in the middle and lower parts of the lungs is characteristic of focal pneumonia. Unsharp outlines of foci, enhanced pattern in the same area and their tendency to merge are a sign of an active inflammatory process, while clearly defined foci are evidence of a subsided inflammatory lesion.

Enlightenment of the lung field or part of it. An increase in the transparency of the lung field or part of it is also a manifestation of a number of pathological conditions of the lungs. They can be caused both by the presence of air in the pleural cavity (pneumothorax), and a decrease in the amount of soft tissues, mediated by an increase in the amount of air in the lung due to swelling of the lung tissue (emphysema), or a decrease in blood flow to the lung (which occurs in some congenital heart defects).

It is quite easy to differentiate such states. So, with pneumothorax, against the background of enlightenment, there is no pulmonary pattern and the edge of a collapsed lung is visible, while with pulmonary anemia, the pattern is depleted, and with emphysema, the pulmonary pattern is enhanced. Moreover, with pulmonary emphysema, a bilateral diffuse increase in the transparency of the lung fields is more often observed, their sizes are increased, and the inactive diaphragm is simplified and low located.

Changes in the lung and root pattern. Changes in the lung pattern is one of the key syndromes observed in a number of lung diseases, since, being formed primarily by arteries emanating from the root, it is involved in a pathological process that affects both the lung parenchyma and its root.

Figure 6 - X-ray image of the root of the lung (scheme),

a is a normal root; b - root fiber infiltration;

c - enlargement of the root lymph nodes; d - fibrous deformity of the root.

Normally, one can distinguish some general indicators of a normal lung and root pattern. So, in a healthy person, the pattern is clearly visible in both lung fields. It is composed of straight or arcuate branching strips, circles and ovals, representing a shadow display of arteries and veins passing in the lungs at different angles to the direction of the x-ray beam. The largest vessels are located in the root zone, so the pattern is richer here, and its elements are larger. Towards the periphery, the caliber of the vessels decreases, and only very small vessels are visible in the outer zone of the lung fields. For a normal pattern, correct branching is always typical, i.e., a fan-shaped departure of pattern elements from the root to the periphery, a continuous decrease in the size of these elements from the root to the outer zone, sharp contours and the absence of cellularity.

In the image of the root of the lung, shadows of arteries and light stripes of large bronchi can be distinguished. In the case of plethora of lungs and stagnation of blood in them, the caliber of the vessels in the roots increases. At fiber fibrosis at the gates of the lung, the shadow of the root becomes poorly differentiated - it is no longer possible to trace the outlines of individual anatomical elements in it. The outer contour of the root becomes uneven, sometimes convex, towards the pulmonary field. With an increase in bronchopulmonary lymph nodes, rounded formations with external arcuate contours appear at the root.

Among the various options for changing the lung pattern, two play a special role: pattern reinforcement and picture deformation.

Under pattern enhancement understand an increase in the number of elements per unit area of ​​the lung field and an increase in the volume of the elements themselves (a classic example is congestive plethora of the lungs with mitral heart disease). In this case, the changes are bilateral and capture both lung fields throughout: in the roots there are dilated branches of the pulmonary artery, which can be traced to the periphery of the lung fields.

Under pattern deformation understand the change in the normal position of the elements of the picture and their shape; at the same time, the direction of the shadow of the vessels changes, and their outlines become uneven and expand towards the periphery.

Such changes can affect both limited areas, which is the result of inflammation, and extensive, which occurs with diffuse (or disseminated) changes in the lungs.

middle lobe syndrome

In case of cirrhosis and pneumosclerosis the average share is significantly reduced in volume; its shadow is heterogeneous. Bronchography: the bronchi are deformed, drawn together, sometimes moderately dilated. With X-ray longitudinal tomography, the belonging of changes to the middle lobe is more clearly defined (by the localization of the process and the change in the position of the vascular and bronchial branches in neighboring areas), a decrease in its volume, bronchial gaps against the background of a shadow.

Fibroatelectasis of the middle lobe

Pneumonia- a rapidly developing inflammatory process in the tissues of the lung with a primary lesion of the alveoli, interstitial tissue or the vascular system. Distinguish between primary and secondary pneumonia. The latter develop against the background of chronic diseases of the respiratory system, cardiovascular system with stagnation in the pulmonary circulation, kidneys, hematopoietic system, etc.

According to clinical and morphological features, acute pneumonia is divided into croupous (lobar or segmental), focal and interstitial. Lobar pneumonia is characterized by localization in the upper and middle lobes, for focal - in the lower.

Depending on the affected area distinguish apical, central (basal), paravertebral and total pneumonia (Fig. 3). If the inflammatory process is localized around the bronchi and occurs due to the spread of inflammation from them to the lung tissue, then such pneumonia is called peribronchial. The interstitial course of the process is evidenced by the compaction of the interalveolar septa. The inflammatory process can affect only the alveoli (alveolar pneumonia), a group of alveoli that form an acinus (acenosis pneumonia), individual acini and groups of acini (acinous-nodular pneumonia), a lung lobule (lobular pneumonia), a segment of the lung (segmental pneumonia), a lobe of the lung ( lobar pneumonia) and the whole lung (total pneumonia).

Depending on the nature of the lesion of the lung tissue, multiple small, 1-2 mm in diameter, inflammatory foci (miliary pneumonia), small-focal shadows occupying the acinus or lobule (small-focal pneumonia), focal infiltration of limited areas of the lung tissue (focal pneumonia) and the fusion of individual small inflammatory foci into larger ones (confluent pneumonia). With X-ray longitudinal tomography, pneumonic infiltration is most often found in the bases of the segment, and its intensity decreases towards the root of the lung.

Lung root due to spread of the inflammatory process, its constituent elements are often expanded, poorly structured, its contours are fuzzy, enlarged bronchopulmonary lymph nodes are determined. The resorption of infiltration usually goes in the opposite direction - from the root of the lung to the periphery. In the process of resorption, the intensity of infiltration decreases, an image of the vessels appears, the lumen of the bronchi is more clearly defined, there may be areas of bullous swelling of the lung tissue. In adjacent areas, hyperventilation, discoid atelectasis are often observed.

Diagnosis of acute pneumonia is based on the totality of the clinical picture, x-ray data and the results of a blood and sputum study.

X-ray examination (Fig. 4): radiographic signs are detected later than clinical symptoms, and in some cases may not be detected at all. X-ray longitudinal tomography allows to detect foci of infiltration of the lung parenchyma, which were not determined by conventional X-ray examination. Often, pneumonic infiltration can be first detected in areas of the lungs that do not receive their image on the radiograph, in particular, behind the domes of the diaphragm, against the backdrop of the spinal column, in the medial sections of the lungs.

X-ray computed tomography has limited application. According to most authors, the indications for X-ray computed tomography are: 1) the presence of X-ray negative, but obvious clinical manifestations of the disease; 2) the need for differential diagnosis (for example, hilar pneumonia and obstructive pneumonitis due to central cancer); 3) the need for a control study of patients with a torpid, poorly treatable course of the inflammatory process; 4) control of the cure of patients with recurrent and chronic processes.

Figure 4 - Schemes of the shadow picture in croupous pneumonia of various localization

In accordance with the division of pneumonia according to the etiological principle accepted in the domestic literature, special attention is paid to clinical symptoms and laboratory parameters, which make it possible to make a presumptive and then a final etiological diagnosis. For the final diagnostic conclusion, both the nature of lung shadow formation and the features of the clinical manifestations of the disease are taken into account approximately equally.

staphylococcal pneumonia develops in individuals with foci of staphylococcal infection, or against the background of an upper respiratory tract infection. Children of the first year of life and the elderly are more often ill.

Depending on the severity of the disease, either focal or homogeneous lesions of the segments are possible. A rapid change of x-ray symptoms within 1-2 weeks of the disease is characteristic. Typical accession of exudative pleurisy. On one radiograph of the lungs, all stages of the development of the disease can be detected, which gives the x-ray picture a peculiar motley appearance: the presence of infiltrates, thin-walled cavities, and exudative pleurisy (Shints triad).

Pneumonia non-resolving- prolonged acute pneumonia, in which the inflammatory process is not resolved within a month. Elucidation of the etiology of these pneumonias is a difficult diagnostic problem. Non-resolving lobar and segmental pneumonia especially often have to be distinguished from infiltrative-pneumonic forms of pulmonary tuberculosis, from bronchial tumors, alveolar lung cancer, pulmonary form of lymphogranulomatosis. Focal pneumonia is differentiated from thromboembolism in the pulmonary artery system, focal pulmonary tuberculosis, alveolar cancer, pulmonary tuberculoma, lymphogranulomatosis and lung sarcoma. Diffuse miliary intractable pneumonia often simulate hematogenous disseminated forms of pulmonary tuberculosis, miliary carcinomatosis, sarcoidosis, pneumoconiosis, alveolitis and other pathological processes.

Radical intractable pneumonia is very difficult to distinguish from central cancer and tuberculous bronchodenitis. The greatest difficulties arise when distinguishing between hilar pneumonia and central lung tumors, when the picture of obstructive pneumonitis is so similar to banal inflammation that only a bronchological examination can remove diagnostic doubts. If X-ray computed tomography reveals gaps in the air bronchi (symptom of the air bronchi) in the compacted lung tissue, then one should think about the inflammatory process. The presence of a stump or narrowing of the bronchus, thickening of its walls, enlarged lymph nodes indicate cancer. Experience shows that intractable hilar pneumonia in middle-aged and elderly people is often in fact complicated by central lung cancer.

Bronchopneumonia- focal, lobular pneumonia. This is the most common pneumonia in children and adults during the cold season.

Reliable X-ray sign of bronchopneumonia are separate infiltrative shadows of medium and low intensity, more often in the lower parts of the lungs, 0.3-1.5 cm in size. The vascular pattern in the zone of foci is enriched. In young children, bronchopneumonia is initially predominantly unilateral and focal shadows are located within the same segment. With an increase in the inflammatory process, they can spread to neighboring segments. It is also possible the appearance of foci in the opposite lung. Interstitial tissue is involved in the process and lymphostasis takes place.

middle lobe syndrome- reduction and compaction of the x-ray shadow of the middle lobe of the right lung; the term is used when forming a preliminary x-ray conclusion in cases requiring further clarification. The causes of the syndrome of the middle lobe may be narrowing of the middle lobe bronchus due to its disease or compression by enlarged lymph nodes, both of a nonspecific nature and of a tuberculous one.

According to the nature of the changes, all chronic non-specific inflammatory lesions of the middle lobe are divided into 5 groups: bronchiectasis, cirrhosis and pneumosclerosis, obstructive pneumonitis, fibroatelectasis and purulent-destructive processes.

When bronchiectasis on survey radiographs, strengthening and deformation of the pulmonary pattern and cystic bronchiectasis are determined, the tomogram is an inhomogeneous darkening of the middle lobe, a slight decrease in its volume, bronchography reveals in most cases mixed, less often cystic bronchiectasis.

In the case of cirrhosis and pneumosclerosis, the average proportion is significantly reduced in volume; its shadow is heterogeneous. Bronchography: the bronchi are deformed, drawn together, sometimes moderately dilated. With X-ray longitudinal tomography, the belonging of changes to the middle lobe is more clearly defined (by the localization of the process and the change in the position of the vascular and bronchial branches in neighboring areas), a decrease in its volume, bronchial gaps against the background of a shadow.

Obstructive pneumonitis develops as a result of broncholithiasis or inflammatory stenosis of the bronchus and is manifested radiographically by a uniform darkening of the middle lobe, sharply reduced in volume. Bronchography or bronchoscopy determines the true "stump" of the middle lobe bronchus.

Fibroatelectasis of the middle lobe is a rather rare occurrence. Homogeneous shading is revealed, which on the lateral radiographs has a ribbon-like appearance. On bronchograms, a complete amputation of the middle lobe bronchus is found. With the help of X-ray computed tomography, a volumetric decrease in the lobe along the periphery of the bronchus axis is detected while maintaining the topography of the lobe. In contrast, with tumor atelectasis, there is a volumetric decrease in the lobe along the periphery of the bronchus axis with a tendency for it to fit closely to the mediastinum.

Purulent-destructive processes are manifested by heterogeneous darkening of the lobe, one or multiple cavities, which are contrasted with dilated and deformed bronchi during bronchography.

In the syndrome of the middle lobe and reed segments, the contours of the shadow of the heart merge with pathological changes in the lungs.