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RADIOLOGI THORAX

Sumarsono
Lateral decubitus position:
It is helpful to assess the volume of pleural
effusion and demonstrate whether a pleural
effusion is mobile or loculated.

Lateral decubitus position film showing mobile pleural effusion (arrows)


Dasar Citra/Gambar
Sinar-X :

Jaringan Densitas Jaringan Gambaran


Logam Metal Desity Hyper radiopak
Tulang Bone Density Radioopak
Cairan Water Density Intermediate
Lemak Fat Density Radiolusen
Udara/Gas Air Density Hyper Radiolusen
Five Radiographic Opacities

Air Fat Soft tissue Bone Metal

least opaque to most opaque


most lucent to least lucent
Black to White
Tujuan pemeriksan foto toraks
Menilai jantung, misalnya : kelainan letak
jantung, pembesaran atrium atau ventrikel,
pelebaran dan penyempitan
aorta.
Menilai kelainan paru, misalnya
edema paru, emfisema paru, tuberkulosis paru.
Menilai adanya perubahan pada struktur
ekstrakardiak.
Gangguan pada dinding toraks Fraktur
iga Fraktur sternum
Gangguan rongga pleura Pneumotoraks
Hematotoraks Efusi pleura
Gangguan pada diafragma Paralisis saraf
frenikus
Menilai letak alat-alat yang dimasukkan ke
dalam organ di rongga toraks misalnya: EET,
CVP, NGT dll
Normal Anatomy
SYARAT FOTO THORAX YANG BAIK

1. FULL INSPIRASI
2. TIDAK ADA TUMPANG TINDIH
3. SIMETRIS
4. KONDISI FOTO BAIK
5. REPRESENTATIF
Thorax Normal
Chest breast implants
Quality Control

Penetration

Should see ribs


through the heart

Barely see the spine


through the heart

Should see pulmonary


vessels nearly to the
edges of the lungs
PENETRATION
Quality Control
1
6. Inspiration 2

Should be able to 4

count 9-10 posterior 5


ribs 6

7
Heart shadow should
not be hidden by the 8

diaphragm 9
10
Poor inspiration
can crowd lung
markings
producing pseudo-
8
airspace disease

About 8 posterior ribs are showing

With better inspiration, the


disease process at the lung
bases has cleared
9

9-10 posterior ribs are showing


Quality Control

7. Rotation

Medial ends of
bilateral clavicles are
equidistant from the
midline or vertebral
bodies
If spinous process appears closer to the right clavicle (red arrow), the
patient is rotated toward their own left side

If spinous process appears closer to the left clavicle (red arrow),


the patient is rotated toward their own right side
Quality Control
8. Angulation 1
2

Clavicle should lay


3

over 3rd rib


AP versus PA
The Effect of Magnification

AP portable film makes the On this PA film done on the same


heart look larger than it does patient an hour later
BAGAIMANA
membedakan sisi kiri dan kanan
Now for the Cases

PENTING .!!!!!
MEMBACA FOTO THORAX
HARUS DISERTAI INFORMASI
KLINIS
Viewing PA radiograph of the chest

Bones and soft tissue:


Ribs (anterior and posterior)
Clavicles
Vertebrae
Shoulder joints
Look carefully at the soft
tissues for asymmetry (i.e.
mastectomy)

Ribs
PENGETAHUAN DASAR MEMBACA
KASUS KARDIOVASCULAR PADA
FOTO THORAX
Mampu mengenal / Membaca

Pembacaan dasar
Silhouette sign
Air bronchogram sign (ABS)
CTR / Sisi Pembesaran Jantung
Corakan Vascular
Diafragma
Efusi Pleura
Garis Kirley
Pola pola khusus (elemeyer glass, sepatu
boot, butterfly dan bat wing)
Aorta yang menonjol / prominen
(ielongatio aorta) juga sering
ditemukan kalsifikasi aorta. biasanya
pada pasien hipertensi kronik
Conus pulmonalis merupakan gambaran
dari main arteri pulmonal yang jika
menonjol bisa jadi terdapat hipertensi
arteri pulmonal seperti pada pasien mitral
stenosis, Atrial Septal Defect (ASD) dan
Primary Pulmonal Hypertension (PPH).
0 mm 15 mm
Ao
Ao

Main
Pulmonary
Artery
Main
Pulmonary
Artery

LV

LV
Main pulmonary
artery ranges from
0 mm15mm
from tangent line
SILHOUETTE SIGN
Silhouette Sign

Hilangnya the lung/soft tissue interface


disebabkan adanya cairan dalam paru yang
normalnya adalah udara
If an intrathoracic opacity is in anatomic
contact with a border, then the opacity will
obscure that border
Sering terlihat dengan perbatasan jantung ,
aorta , dinding dada , dan diafragma
Lung Fields: Using
Structures / Silhouettes
Upper right heart
border / ascending Aortic knob
aorta (Apical portion
(anterior RUL) of LUL )

Upper left
Right heart border heart border
(medial RML) (anterior
LUL)

Left heart
border
Anterior (lingula;
hemidiaphragms anterior)
(anterior
lower lobes)
SILHOUETTE SIGN
Air Bronchogram Sign (ABS)

Sebuah garis tubular dari saluran napas dibuat


terlihat karena pengisian alveoli sekitarnya dengan
eksudat cairan atau inflamasi

Terlihat pada :
Lung consolidation
Pulmonary edema
Non-obstructive pulmonary atelectasis
Interstitial disease
Neoplasm
Normal expiration
AIR BRONCHOGRAM
AIR BRONCHOGRAM
AIR BRONCHOGRAM
CORAKAN BRONKHOVASKULER

CARA PENILAIAN
BAGI PARU DARI TEPI MENJADI 3, LIHAT BAGIAN 1/3 LATERAL

NORMAL :
Kanan: </= 2/3 medial paru (tarik 2 garis khayal vertikal
yang membagi paru menjadi 3) (1/3 LATERAL
TAMPAK BERSIH)

Kiri: </= 1/3 medial paru

INTERPRETASI:
NORMAL /MENINGKAT
CORAKAN BRONKHOVASKULER

NORMAL
Normal Distribution of Flow
Upper Versus Lower Lobes

In erect position,
blood flow to
bases > than flow
to apices
Size of
vessels at
bases is
normally
> than size
of vessels
at apex You cant measure size of
vessels at the left base
because the heart obscures
them
Right Descending Pulmonary Artery

Right
Descending
Pulmonary
Artery

Serves right
middle and
lower lobes
1. Right Descending Pulmonary Artery
Diameter can
be measured
(before
bifurcation)

RDPA Normally, the


< 17 mm right
descending
pulmonary
artery should
not be more
than 17mm in
diameter
Normal Vasculature - review

RDPA 2
< 17 mm in
diameter Gradual
tapering of
1 vessels
from central
to
peripheral

3
Lower lobe
vessels
larger than
2 upper lobe
vessels
Venous Hypertension
RDPA usually
> 17 mm

Upper lobe
vessels equal
to or larger
than size of
lower lobe
vessels =
Cephalization
Pulmonary Arterial Hypertension

Main
Pulmonary
Artery
RDPA usually projects
> 17 mm beyond
tangent line
Increased Flow

RDPA usually
> 17 mm

All of blood vessels everywhere in


lung are bigger than normal
Increased Flow

Distribution of
flow is
maintained as
in normal

Gradual
tapering from
central to
peripheral

Lower lobe
vessels bigger
than upper
lobe
Normal Increased Flow
Decreased Flow

Unrecognizable
most of the
time

Small hila

Fewer than
normal blood
vessels
SINUS COSTOPHRENICUS

INTERPRETASI
LANCIP ATAU TUMPUL
NORMAL : LANCIP
BILA TUMPUL PASTIKAN ADA KELAINAN
ATAU TERPOTONG
SINUS COSTOPHRENICUS

TERPOTONG EFUSI PLEURA


Normal R costophrenic angle Blunted L costophrenic angle

When 200-300cc of fluid accumulate in pleural space, the usually acute


costophrenic angle (sulcus), as seen on the right in this person, becomes
blunted (as seen on the left in this person)
DIAFRAGMA

NORMAL :
Kanan lebih tinggi dari kiri (jantung menekan)
Selisih <3 cm)/ atau sebagai patokan tidak lebih
dari 2 vertebra
Licin
Viewing PA radiograph of the chest

Pleura and Diaphragm:


The highest point of the right diaphragm is usually 11.5 cm
higher than that of the left.
Each costophrenic angle should be sharply outlined.
Viewing PA radiograph of the chest

Pleura and Diaphragm:


Assessment of diaphragmatic flattening
The highest point of a hemidiaphragm should be at least 1.5
cm above a line drawn from the cardiophrenic to the
costophrenic angle.
JANTUNG

Size
Shape
Silhouette-margins should be sharp
Diameter (>1/2 thoracic diameter is enlarged
heart)

Remember: AP views make heart appear larger than it


actually is.
Cardio-thoracic ratio
seen on postero-anterior (PA)
CTR = B/A x 100% view only
>50% is considered abnormal
in an adult; more than 66% in
a neonate.
Possible causes of a ratio
greater than 50% include:
cardiac failure
pericardial effusion
left or right ventricular
hypertrophy

*AP views make heart appear larger than it actually is.*


Sometimes, CTR is more than 50%
But Heart is Normal

Extra-cardiac causes of cardiac


enlargement
Portable AP films
Obesity Flat / elevated
diaphragm
Pregnancy
Ascites
Straight back syndrome
Pectus excavatum
Sometimes, CTR is less than 50%
But Heart is Abnormal

Obstruction to outflow of the ventricles


Ventricular hypertrophy

Must look at cardiac contours


Sometimes, CTR is more than 50%
But Heart is Normal

Extra-cardiac causes of cardiac


enlargement
Portable AP films
Obesity
Flat / elevated
Pregnancy diaphragm

Ascites
Straight back syndrome
Pectus excavatum
>50%

Here is a heart that is larger than 50% of the cardiothoracic ratio, but it is still a normal heart. This is
because there is an extracardiac cause for the apparent cardiomegaly. On the lateral film, the arrows
point to the inward displacement of the lower sternum in a pectus excavatum deformity.
MENGENAL SISI YANG MEMBESAR
Pembesaran atrium kiri

tampak gambaran double contour yang terlihat


di batas jantung kanan
bronkus utama kiri terangkat
aurikula atrium kiri menonjol.
Sudut Carina membesar
Normal Left atrial
enlargement
Pembesaran Ventrikel Kiri

Jantung membesar ke kiri dengan apeks


menekan/tertanam di diafragma
segmen pulmonal tidak menonjol.
Pembesaran atrium kanan

batas kanan jantung menoniol melebihi


sepertiga diafragma
Pembesaran Ventrikel Kanan

jantung membesar ke kiri dengan apeks


terangkat (di atas diafragma) dan segmen
pulmonal ( arteri dan vena pulmonalis)
menonjol.
The term air Bronchogram is used for signifies alveolar disease.
Note the branching radiolucent columns of air corresponding to the
bronchi, in Right Upper Lobe consolidation in the adjacent CXR.

AIR BRONCHOGRAM SIGN (ABS)


Mitral Stenosis

LA membesar :
1. Double
countour
apendiks
atrium kiri
yang menonjol
disebabkan
oleh kelebihan
tekanan
atrium kiri .
ARCUS AORTA
Aortic Knob
The first bump on Aortic knob
the left-side is the should
aortic arch. We can measure
measure the knob < 35mm
from the lateral
border of air in the
trachea to the
edge of the aortic
knob.
Aortic Knob
42mm
Enlarged with:
Increased pressure
Increased flow
Changes in aortic wall
MAIN PULMONARY ARTERY
Main
Pulmonary
Artery

Important

The next bump down is the


main pulmonary artery and is
the keystone of this system.
Finding the
Main
Pulmonary
Artery
Finding the
Main
Pulmonary
Artery

Adjacent to left
pulmonary artery

We can measure the main pulmonary artery . . .


If we draw a The distance
tangent line between the
from the apex tangent and
of the left the main
ventricle to the pulmonary
aortic knob artery (between
(red line) and two small
measure along green arrows)
a falls in a range
perpendicular between 0 mm
to that tangent (touching the
line (yellow tangent line) to
line) as much as 15
mm away from
the tangent line
0 mm 15 mm
Ao
Ao

Main
Pulmonary
Artery
Main
Pulmonary
Artery

LV

LV
Main pulmonary
artery ranges from
0 mm15mm
from tangent line
Two Major Classifications

The main pulmonary artery (MPA)


projects beyond the tangent line
The main pulmonary artery is more
than 15 mm away from the tangent
line
Because the MPA is small or absent
Because the tangent line is being pushed away
from the MPA
Main
pulmonary
artery
projects
beyond
tangent

Increased
pressure
Increased flow
Main pulmonary
artery is more
than 15 mm
from tangent

Small pulmonary
artery
Truncus arteriosus
Tetralogy of Fallot
Main pulmonary
artery is more
than 15 mm
from tangent

Left ventricle
and/or aortic
knob push the
tangent away
Common
To
recapitulate: 0 - 15 mm
Left atrial enlargement
Concavity where L
atrium will appear on
left side when
enlarged
Left atrial enlargement

Straightening of the
left heart border

Left atrium
may enlarge
without
producing
double
density
In the example on the Main
right, not only is the Pulmonary
left atrium enlarged, Artery
but the left atrial
Left
appendage is too. So Atrial
there is a convexity Appendage
outward where there
is normally a
concavity inward.
ODEMA PARU

edema paru interstitial


edema paru alveolar.
Edema interstitial
edema ini menunjukkan septal line yang dikenal sebagai
Kerleys line
Garis kerley A : garis linear panjang yang membentang
dari perifer menuju hilus yang disebabkan oleh distensi
saluran anastomose antara limfatik perifer dengan
sentral.
Garis kerley B terlihat sebagai garis pendek dengan arah
horizontal 1-2 cm yang terletak dekat sudut kostofrenikus
yang menggambarkan adanya edema septum
interlobular.
Garis kerley C berupa garis pendek, bercabang pada lobus
inferior
Garis kerley A tidak pernah terlihat tanpa
adanya Garis kerley B dan C A

B C
B
Edema alveolar

terjadi pengurangan lusensi paru yang difus


mulai dari hilus sampai ke perifer bagian atas
dan bawah. Gambaran ini dinamakan
butterfly appearance/ butterfly patterns atau
bats wing pattern. Batas kedua hilus menjadi
kabur (Malueka, 2008).
Bat wing / Butterfly
appearance
Odema Paru
NO. Gambaran Edema Edema Non
Radiologi Kardiogenik Kardiogenik
1 Ukuran Jantung Normal atau Biasanya Normal
membesar
2 Lebar pedikel Normal atau Biasanya normal
Vaskuler melebar
3 Distribusi Seimbang Normal/seimbang
Vaskuler
4 Distribusi Edema rata / Sentral setengah atau
perifer
5 Efusi pleura Ada Biasanya tidak
ada
6 Penebalan Ada Biasanya tidak
Peribronkial ada
7 Garis septal Ada Biasanya tidak
ada
8 Air bronchogram Tidak selalu ada Selalu ada
Mitral Stenosis

Pelebaran vena pulmonalis


Pembesaran atrium kiri
Pertambahan aliran pada pembuluh darah di
lapangan atas (Kranialisasi/cefalisasi)
Carina terbentang
Penyakit jantung Kongesti
CHF
Congestive Heart Failure Alveolar edema
(Bats wings)
Kerley B lines
(Interstitial edema)
Cardiomegaly
Penebalan hilus
Peningkatan
corankan
brnchovascular
Kadang kadang
Pleural effusion
PERICARDIAL EFFUSION
jantung membesar
berbentuk globuler
(water bottle
SIGN)/tabung
elenmeyer
baru tampak jika
cairan lebih dari
250ml
Coba sebut kasus apakah ini
pericardial + pleural effusion

after pericardiocentesis dan


thoracentesis
DEXTRA CARDIA
Congenital cardiovascular
anomalies
dextrocardia with complete situs inversus
ToF

tampak apeks jantung terangkat dan MPA


menjauh lebih dari 15 mm dari garis tangesial
sehingga seperti sepatu boot (boot shape).
15 mm
ASD = gambaran pembesaran atrium kanan
dan ventrikel kanan, Corakan vaskuler
bertambah
VSD = gambaran pembesaran atrium kiri dan
ventrikel kiri (defek kecil), ditambah
gambaran pembesaran ventrikel kanan
(defek besar).
PDA
gambaran pembesaran atrium kiri, ventrikel
kiri, ventrikel kanan, serta hilus lebar.
PEDOMAN UMUM
CTR (%) Kesan Diagnosis Banding
Jantung terkompensasi (Cor
< 50 Normal
compensated)

Jantung terkompensasi
Dekompensasi jantung kanan
Dekompensasi jantung kiri
50 Kardiomegali Gagal jantung kongestif (CHF)
Kardiomiopati terdilatasi (Dilated
cardiomyopathy)
Kardiomiopati peripartum[
Sudut Diagnosis
Apeks Kesan
kardiofrenikus Diferensial

Jantung
terkompensasi
Terbenam / Left ventricle
Dekompensasi
tenggelam 90 enlargement
kordis sinistra
(grounded) (LVE)
Gagal jantung
kongestif (CHF)[1]
Jantung
Right terkompensasi
Terangkat ventricle Dekompensasi
< 90
(rounded) enlargement kordis dekstra
(RVE) Gagal jantung
kongestif (CHF)[1]
Sudut Sudut
Diagnosis
kostofrenikus kostofrenikus Kesan
Diferensial
kanan kiri
Tak ada
Tajam
kelainan

Tumpul atau
Efusi pleura
tertutup Tajam
dekstra
perselubungan

Tumpul atau
Efusi pleura
Tajam tertutup
sinistra
perselubungan

Tumpul atau tertutup Efusi pleura Gagal jantung


perselubungan bilateral kongestif (CHF)
Gambaran Kesan
Fibroinfiltrat di hemithorax kanan
hemithorax kiri Bronkopneumonia
kedua lapang paru

Perselubungan homogen di hemithorax dextra


Atelektasis dextra
Penarikan cor dan mediastinum ke dextra

Daerah avaskuler di paru kanan Pneumothorax dextra


paru kiri sinistra
Air fluid level Efusi pleura
Daerah avaskuler
Fluidopneumothorax
Air fluid level
Gambaran sarang tawon (honeycomb appearance) di
Bronkhiektasis dextra
hemithorax dextra
sinistra
hemithorax sinistra
Gambaran sayap kelelawar/kupu-kupu (bat/butterfly's
Udema paru (alveuolar)
wing appearance)
Letak cor terbalik Dextroversi
The ABCs A
If yes, Look at the
Pulmonary
Normal

Pulmonary
venous
Mitral
regurg

Mitral
Stenosis
Is the Left then L Myxoma
Vasculature hypertension
Atrium
If no, VSD, PDA
Enlarged?
Increased
then

Plum.
If yes, stenosis
Normal
B
then Look at the
Is the Main ASD
Pulmonary
Pulmonary Increased (VSD)
Artery Big If no, Vasculature
or then Pulmonary Idiopathic
(1)
Bulbous? hypertension

If yes, Normal Cardiomyopathy


C Don't Look at
Is the Main then Pulmonary Ascending Ao
Vasculature.
Pulmonary dilated Stenosis
Artery Look at Aorta
If no, Whole Ao Ao regurg
Segment
then HBP
Concave? Dilated

D
Is the Cardiomyopathy
Heart If yes,
Pericardial
Dilated or
Delta- then Effusion

Shaped? Molt. valve dz


The System

Those were all of the answers


Now here are the questions
The system is successful only if you
ask the questions in this order
The answers are the fundamental
observations you make on the frontal
film alone
A
Is The Left Atrium
Enlarged ?
To answer that question

A Straight or
Double convex at
density at site of
site of normal normal
indentation concavity
A
If Answer To Question A Is YES
Look At Pulmonary Vasculature
To answer that question

A
A
If Answer To Question A Is NO
Then...
B
Is The Main Pulmonary
Artery Big ?
To answer that question

B Main
pulmonary
artery projects
beyond
tangent line
B
If Answer To Question B Is YES
Look At Pulmonary Vasculature
B
If Answer To Question B Is NO
Then...
C
Is The Main Pulmonary
Artery Concave ?
C To answer that question
Main
pulmonary
artery is >
15mm
away from
tangent
line
C
If Answer To Question C Is YES
Look At Configuration of Aorta
C
If Answer To Question C Is NO
Then...
D
Is The Heart a Dilated Or
Delta-Shaped Heart ?
D 1. Pericardial effusion
2. Cardiomyopathy

Cardio-thoracic ratio > 65%


Mitral
Normal regurgitation

Look at the Pulmonary


If yes, Mitral
A venous Stenosis
Pulmonary
then L Myxoma
Is the Left hypertension
Atrium Vasculature
If no, VSD, PDA
Enlarged? Increased
then

B
Pulmonic
Is the Main stenosis
If yes, Normal
Pulmonary
then Look at the
Artery Big ASD
Pulmonary
or Increased (VSD)
If no, Vasculature
Bulbous? Pulmonary
then arterial Idiopathic
hypertension 2 to lung dz
C
Is the Main
If yes, Normal Cardiomyopathy
Pulmonary Don't Look at
then Pulmonary Ascending
Artery Vasculature. Aortic
Segment
Look at Aorta dilated
If no, Stenosis
Concave? then Whole Aorta Aortic
regurgitation
D Dilated
Is the HBP
Heart
Cardiomyopathy
Dilated or If yes, Pericardial
Delta- Effusion
then
Shaped? Multiple valve dz
THANK YOU FOR YOUR ATTENTION
LATIHAN
Double countour LA Enlargement
Enlarged or not?

Yes
Enlarged or not?

Yes
Enlarged or not?

No