CHAPTER 12

PULMONARY IMAGING
Pulmonary Imaging
The lung examination is performed to determine
 the distribution of the air space (ventilation) and
 the distribution of blood flow (perfusion–sometimes
abbreviated as Q) in the lungs.
the ventilation and perfusion scans (sometime
called V/Q scans) are frequently used to diagnose
pulmonary emboli.
PART I. PERFUSION IMAGING
1 Radiopharmaceuticals
 The distribution of pulmonary arterial blood

flow is usually demonstrated by the

intravenous injection of
radioactive particle, 99mTc-MAA
 which measure 30 to 40μm(microns) in

diameter.
1 Radiopharmaceuticals
 After intravenous injection the particle, which pass
through the right atrium and right ventricle, where
they are well mixed with blood, and then into the
pulmonary artery.
 They pass out into the blood vessels of the lung
until they become impacted in the terminal
arteriales and capillaries because they are too
large to pass through them. 30 to 40μm
 Diameter of capillary is about 8~9 μm.
Safe?

Yes!
1 Radiopharmaceuticals
 SAFE
 With the usual dose of particulate material of the appropriate
size, fewer than 1 in 1000 pulmonary arterioles are
blocked.
 Special care should be taken in patients known to have
 severe pulmonary hypertension
 because their available vascular bed is reduced.
 right to left shunts
 because the particles will pass through to the systemic circulation
and embolize to the brain, kidneys, heart, and other organs.
 Pneumonectomy
 Pediatric patients
 Pregnancy
2 Method of injection
 There is a difference in the patterns of perfusion
depending on whether the particles are injected with
the patient in the upright or supine position.
 As gravity plays an important role in the pressure
relationships with the lungs.
 Patients injected upright will tend to have a larger
proportion of the particles distributed toward the bases.
 Patients injected supine demonstrate a more homogeneous
distribution of particles from the bases to the apices.
3 Positioning
Standard perfusion imaging includes six
basic views:
posterior (POST),
Anterior (ANT),
right and left laterals (RL,LL), and
right and left posterior obliques
(RPO,LPO).
Presently, tomography of lung has been
widely performed in this study.
PART II. VENTILATION IMAGING
The body maintains a precise regulation of the distribution of
perfusion based upon a continuous sampling of the level of
oxygen in the alveoli.
When the partial pressure of oxygen in a segment of lung is
low, pulmonary blood flow is directed away from that area.
If an imaging of the regional distribution of perfusion is
recorded without any knowledge of the regional distribution of
ventilation, it is difficult to determine if the blood flow was
directed away from that area because of
decreased local oxygen content or
secondary to a mechanical (embolic) obstruction.
PART II. VENTILATION IMAGING
 133
Xe
 133
Xenon
 The xenon exam consists of 3 phases:
1. Single breath
2. Equilibrium
3. Washout
Xenon-133
1. Single breath
 The patient takes a single deep inspiration and
holds it for as long as possible.
 This view reflects regional ventilation and can
detect approximately 66% of ventilation defects
associated with obstructive airway disease.
Xenon-133
2. Equilibrium
 During this phase, the patient performs normal tidal
respirations for at least 3 minutes, and 5 minutes if
possible, while rebreathing a mixture of 133Xe and
oxygen.
 This view demonstrates the overall lung volume as
tracer equilibrates between all aerated portions of the
lungs.
 It is the least sensitive for detecting obstructive airway
abnormalities. However, adequate duration of
rebreathing ensures diagnostic quality washout phase.
Xenon-133
3. Washout
 Inhalation of 133Xe is discontinued and the patient
breaths room air or oxygen while exhaling the
xenon into a charcoal trap.
 133
Xe should clear from the lungs normally in 2-3
minutes.
 Retention of tracer activity beyond 3 minutes is
observed in areas of air trapping (obstructive
airway disease).
Xenon-133

 The washout phase of the exam will detect

about 90% of abnormalities associated with
obstructive airway disease.
 It is therefore more sensitive than the single
breath view in this regard.
The other radiopharmaceuticals

 Tc-99m DTPA Aerosol,

 Xenon-127 ,
 Tc-99m Technegas,
 Krypton-81m .
Characteristic Patterns:
 By combining studies of ventilation and
perfusion one can determine whether
defects in blood flow are associated with
defects in ventilation.
 The pulmonary diseases commonly met with
in clinical nuclear medicine tend to fall into
two categories:
 V/Q mismatch

 V/Q match
Characteristic Patterns:
(1) V/Q mismatch
 With abnormal regional pulmonary blood flow, but normal
(or almost normal) regional ventilation.
 Pulmonary embolism is by far the most important one of
these, but early heart failure, interstitial lung disease, some
lung cancers and other abnormalities of the pulmonary
vasculature may show this pattern.
(2) V/Q match
 with abnormal ventilation and abnormal blood flow.
 Here the most common conditions are chronic
bronchitis, emphysema, and asthma, with cystic fibrosis
and bronchial tumors, or foreign bodies obstructing a
bronchus can all produce localized abnormalities of
ventilation and blood flow.
CLINICAL APPLICATIONS
1. Pulmonary Embolism
A pulmonary embolus occurs when a thrombus
forms the wall of the vein, and circulates through
the heart to enter the lung.
These events are more likely to occur in
bedridden or sedentary people that in active,
healthy individuals.
Clinical Findings
 No single, or combination of, clinical findings is either specific or
sensitive enough to diagnose or exclude PE.
 Symptoms of pulmonary embolism include tachypnea (most common),
tachycardia, hypoxia, pleuritic chest pain, hemoptysis, and atrial
fibrillation.
 Massive PE may be associated with cor pulmonale and the ECG may
show right axis deviation, P-pulmonale, RBBB, or other evidence of
right heart strain.
 A normal arterial blood gas does not exclude the presence of a PE.
 Although PE occurs most commonly from deep venous thrombosis in
the lower extremity, about 10% arise from clot in the upper extremity
primarily associated with an indwelling catheter.
Risk Factors
 In the PIOPED (Prospective Investigation of Pulmonary
Embolism Diagnosis) study, 92% of the patients with
pulmonary embolism had at least one of the following
risk factors:
 immobilization,
 recent surgery,
 underlying malignancy,
 history of deep venous thrombosis or pulmonary
embolism, estrogen use,
 pre-existing cardiac disease.
 In patients without prior cardiac or pulmonary disease
only immobilization and surgery are significant
discriminating predisposing factors.
CLINICAL APPLICATIONS
 On V/Q scanning, a pulmonary embolism is
characterized by a ventilation-perfusion
mismatch:
 An area of normal ventilation corresponding

to a segmental wedge-shaped area of

decreased or absent perfusion which
extends to the surface of the lung.
CLINICAL APPLICATIONS
2 Chronic Obstructive Airway Disease
 chronic bronchitis, emphysema, and
asthma, with cystic fibrosis and
bronchial tumors, or foreign bodies
obstructing a bronchus can all produce
localized abnormalities of ventilation and
blood flow.
 with abnormal ventilation and abnormal
blood flow------ V/Q match.
1. Interpret the EF, PER, PFR, the
amplitude image and the phase image.
2. What are the clinical application of
equilibrium multiple-gated blood pool
imaging.
3. What are the clinical application of
ventilation-perfusion studies.
4. What is the characterized of pulmonary
embolism on V/Q scanning?