KELAINAN THORAX

Visceral organ can be detected by X ray

are ;

1. Lungs

2. Hilus

3. Mediastinum

4. Heart

5. Diafragma

6. Skeleton thorax

Systematic of the chest examination :

• Lungs Field, Upperlobe, middle lobe ,

lower lobe

• Hilus

• Mediastinum : upper, middle , lower,

anterior, superior

• Heart : Size, Configuration,

Enlargemnet

Vasular marking of Lungs, Pulmonary

Oedema, Aortic calcification

* Diaphargm

Yg dpt diamati pada x ray

1. Parenchym paru ( Jaringan ikat

fibroelastis )

2. Vascular marking paru ( Arteria, Vena )

3. Limphonodi yang membesar di Hilus

Yang tidak dapat dilihat pada thorax foto,

kecuali Keadaan pathologis :

1. Bronchus ( kecuali ada calsifikasi

cartilago bronchus ) yang dapat dilihat

adalah udara didalam bronchus

2. Bronchioli

3. Alveoli

KELAINAN KELAINAN PATHOLOGIS PULMO

YANG DAPAT DIDETEKSI PADA THORAX FOTO

1. INFILTRAT ( Proses radang paru )

2. OEDEMA PULMONUM ( PADA Decomp )

3. FIBROSIS PARU ( KP lama )

4. CAVERNA ( KP ACTIF )

5. KALSIFIKASI PARU

6. ABSCES PARU

7. MASSA TUMOR

8. EFFUSI PLEURA ( PLEURITIS EXUDATIVA ,

DECOMP CORDIS, OEDEMA ANASARCA

,metastasis paru)

ANALISA FOTO RONTGEN THORAX

APEKS PARU

CORAKAN BRONKHOVASKULER

PARENKIM PARU

HILUS DAN MEDIASTINUM PARU

SINUS COSTOPHRENICUS

DIAFRAGMA

JANTUNG

SISTEMA TULANG & JARINGAN LUNAK

6/19/2015 6

6/19/2015 7

6/19/2015 8

KEDUA APEKS PARU

PENILAIAN :

TENTUKAN LOKASI APEKS PARU

GAMBARAN APEKS

INTERPRETASI

APEKS TENANG/ BERSIH

APEKS TERDAPAT

INFILTRAT/FIBROSIS/KALSIFIKASI UKURAN,

BENTUK, BATAS DENSITAS

6/19/2015 9

CARA PENILAIAN CORAKAN

BRONCHOVASKULER

BAGI PARU DARI LATERAL KE MEDIAL MENJADI 3, LIHAT BAGIAN 1/3 LATERAL

BAGI PARU DARI SUPERIOR KE INFERIOR MENJADI 3, LIHAT BAGIAN 1/3 SUPERIOR

NORMAL :

TIDAK MELEBIHI 2/3 MEDIAL (1/3 LATERAL TAMPAK BERSIH)

TIDAK MELEBIHI 2/3 BASAL ( 1/3 SUPERIOR TAMPAK BERSIH)

INTERPRETASI:

NORMAL /MENINGKAT

6/19/2015 10

12

Gb. 2.35 Post primer TB dgn. reaktivas

Pasien 68 th. penurunana BB 5 kg

Lepas follow up selama 3 bl.

(a) Cavitas kecil, nodul batas tegas

(b) Konsolidasi dgn. Loss of vol. paru

ka.

(2) Trachea tertarik ke kiri

(3) Elevasi diaphragma kanan

(4) Penebalan pleura kanan

13

Gb. 2.40 Cavitas TBC

Laki-laki 66 th. dgn. batuk lama

(1) Bronchus (2) tuberculoma (3) acinar nodul

Gb. 2.41 Cavitas TBC pneumonia

Konsolidasi lobus sup. kanan

Cavitas dgn air bronchogram

14

Gb. 2.42 Fibrosis TBC paru

Pr. 88 th. Diterapi TBC pd. masa muda &

sekarang asymptomatik

Scar, bulla dikedua lobus sup., hilus ter-

tarik ke atas, scar pleura basal kanan &

hiperexpansi bibasilar compensasi

Gb. 2.43 Kalsifikasi pleura kanan dgn. scoliosis

Pasien 52 th. stl terapi pneumothorax dgn.

Cavitas TBC dan sekarang asymptomatik

Calsifikasi pleura dgn. tebal 5 cm,

tracheomegali yg. tertarik & trachea deviasi

(1) Udara yg. mengisi esophagus

Gb. 2.3 Pneumonia dgn. parapnemonic effusion

Pr. 40 th. Tiba-tiba menggigil, batuk, dahak purulent

mengandung Aerobacter.

\tx. 10 hari bersih

(1) Sulcus costophrenic kanan tumpul

(2) Konsolidasi melalui fissura mayor

(3) Konsolidasi melalui fissura minor

(4) Air bronchogram

(5) A. interlobaris

(6) V. pulmonalis lobus inferior

(7) Azygoosephageal recess

(8) Bronchus intermedius

(c) Pandangan lateral

15

Gb. 2.10 Bronchopneumonia

Laki-laki, 29 th. Febris acut, respon cepat dgn antibiotik

Patchy konsolidasi paru bawah kanan (a,b), hilangnya batas jantung kanan dan a. pulmonalis lobus bawah kanan

Pneumonia pd. segmen medial lobus tengah dan bawah

Bersih pada follow up (c,d)

16

17

Gb. 2.31 TBC miliar

Pr. 43 th. dgn. keluhan BB turun &

keringat malam

Nodul miliar tersebar dikedua

paru

Relatif bersih stl. chemo Tx.1 bl.

dan bersih total stl. 7 bulan

terapi

Pneumonia

Clinical features

● Productive cough, dyspnoea, pleuritic chest pain, myalgia and haemoptysis may occur.

● In the immuno-suppressed patient Pneumocystis may present with profound hypoxia and little else on examination.

● The young patient may present with vague symptoms, such as headache, abdominal pain or even diarrhoea. Confusion may be the only sign in the elderly.

● Examination may reveal coarse inspiratory crepitations. Bronchial breathing with a dull percussion note is present in 25%.

Pneumothorax

Clinical features

● Chest pain and shortness of breath are common.

● Variable spectrum ranging from acutely unwell, with cyanosis and tachypnoea, to the relatively asymptomatic patient.

● Signs and symptoms do not necessarily correlate well with the degree of associated lung collapse.

■ Signs of a tension pneumothorax include:

– Tachycardia

– Jugulo-venous distension

– Absent breaths sounds

– Hyper-resonance to percussion

– Tracheal and cardiac impulse displacement away from the affected side

– The patient may be acutely unwell with signs of cardio-respiratory distress.

Radiological features

● Simple:Visceral pleural edge visible. Loss

of volume on the affected side

(e.g. raised hemidiaphragm).A small pneumothorax may not be visualised

on a standard inspiratory film.A expiratory film may be of benefit.

● Tension: THIS IS A CLINICAL AND NOT A RADIOLOGICAL DIAGNOSIS!

Associated mediastinal shift to the opposite side is seen.

Chronic obstructive pulmonary

disease Clinical features

● Exacerbations commonly precipitated by infection.

● Cough, wheeze and exertional dyspnoea.

● Tachypnoea, wheeze, lip pursing (a form of positive end expiratory pressure(PEEP)) and use of accessory muscles.

● Cyanosis, plethora and signs of heart failure suggest severe disease.

● Signs of hypercarbia include coarse tremor, bounding pulse, peripheral vasodilatation, drowsiness, confusion or an obtunded patient.

Radiological features

- CXRs are only moderately sensitive (40–60%), but

highly specific in appearance.

– Easily accessible method of assessing the extent and degree of structural parenchymal damage.

– In the emergency setting, useful for assessing complications, such as pneumonia, heart failure, lobar collapse/atelectasis, pneumothorax or rib fractures.

– Radiographic features include hyper-expanded lungs with associated flattening of both hemidiaphragms, pruning of pulmonary vasculature,„barrel-shaped chest‟ and lung bullae.

Flail chest

Clinical features

● Dyspnoea

● Tachycardia

● Cyanosis

● Tachypnoea

● Hypotension

● Chest wall bruising palpable abnormal movement or rib crepitus

● The degree of hypoxia often depends on the severity of the underlying pulmonary contusion.

Radiological features

● Multiple rib fractures.

● Costochondral separation may not be

evident.

● Air space shadowing may be seen

with pulmonary contusions (often absent

on initial films).

Foreign body – Inhaled foreign

bodies

Clinical features

● Spectrum from complete upper airway obstruction (distressed, agitated and choking child leading to unresponsiveness with associated pre-morbidity) to an asymptomatic child, or a child with a persistent cough.

● Auscultation of the chest may be normal. Monophonic wheeze is characteristic of large airway obstruction. Beware the localised absence of breath sounds.

Radiological features

● A radio-opaque foreign body may or

may not be seen.

● Look for secondary signs, such as

loss of volume, segmental collapse,

consolidation or hyperinflation, as the

foreign body acts as a ball valve.

Rib/sternal fracture

Clinical features

● Pain with limitation of inspiration.

● Often related to complications from

any associated injury, e.g. cardiac

dysrhythmias or splenic rupture.

Radiological features

● A CXR/lateral sternal view are

performed to assess for both

complications

and to identify any underlying fracture.

● Signs of secondary complications may

be evident – pneumothorax,

haemothorax, pulmonary contusion, etc.

EDEMA PARU

Pengabutan paru

Kanan dan kiri

Batas jantung paru

menghilang

PNEUMOTHORAX DEXTRA

Corakan paru kanan

lateral relatif kosong

dan paru kolaps ke

medial

PLEURAL EFFUSION SINISTRA MASIF

PERSELUBUNGAN

MASIF PARU KIRI

DAN SIFTED KE

KANAN

TB PARU ANAK

Primary TB :

Primary Pulmonary TB & Complications

Endobronchial TB & Complications

Progressive Primary TB :

Milliary TB

Post Primary TB

Extrathoracic TB :

Lymphnodes TB

Progressive Primary TB

The primary disease

passes into

the postprimary form

WITHOUT a break.

“Wallgreen Timetable”

Miller FJW. Tuberculosis in children, 1982

A minority of children

experience :

1. Febrile illness

2. Erythema Nodosum

3. Phlyctenular Conjunctivitis

EVOLUTION AND TIMETABLE OF

UNTREATED PRIMARY TUBERCULOSIS

IN CHILDREN

Complications of focus

1. Effusion

2. Cavitation

3. Coin shadow

Complications of nodes

1. Extension into bronchus

2. Consolidation

3. Hyperinflation

MENINGITIS OR MILIARY

in 4% of children infected

under 5 years of age LATE COMPLICATIONS

Renal & Skin

Most after 5 years

1 2 3 4 5 6

BONE LESION Most within

3 years

24 months

Resistance reduced :

1. Early infection

(esp. in first year)

2. Malnutrition

3. Repeated infections :

measles, whooping cough

streptococcal infections

4. Steroid therapy

infection

BRONCHIAL EROSION

Most children

become tuberculin

sensitive

12 months

DIMINISHING RISK

But still possible

90% in first 2 years GREATEST RISK OF LOCAL & DISEMINATED LESIONS

Development

Of Complex

4-8 weeks 3-4 weeks fever of onset

PRIMARY COMPLEX

Progressive Healing

Most cases

Uncommon under 5 years of age

25% of cases within 3 months

75% of cases within 6 months

3-9 months Incidence decreases

As age increased

Milliary TB

Hematogenous Spreading

Post Primary TB

Like the adult type

44

Gb.2.27 Primer comlex pd. Anak

dgn. tanpa gejala.

Opacitas, batas tak jelas pd. lob.

sup. kanan dgn. pembesaran

limphonodi hilar &

paratracheal kanan

Gb. 2.28 Kalsifikasi primer

complex

(1) Kalsifikasi granuloma perifer

(2) Kalsifikasi limphonodi hilus

Extrathoracic TB

Axillar

Lymphnodes

Calcifications

HYALINE MEMBRANE DISEASE

(HMD)

Terjadi bayi baru lahir (BBL)

APGAR scrore rendah

½ mati dalam 24 jam

Ett : Kekurangan surfactan paru tak

mengembang baik

TX : O2 tekanan tinbggi fibrosis,

displasia bronchopulmoner

GAMBARAN RADIOLOGI

GRADE I : Perselubungan opq tipis pd

kedua paru.

GRADE II : Bercak tersebar seperti

infiltrat (granuler)

GRADE III : Kekabutan total (white lung)

TRANSIENT TACHYPNOE OF THE

NEW BORN (TTN/WET LUNG)

Sejumlah cairan di paru pada BBL

Pre disposisi : Prematur, Ibu DM, Op

Caesar.

Membaik dalam 2-3 hari

Oedema pulmonum

atelektasis

Simple nodule

Wassalamu‟alaikum wr wb