第四章 呼吸系统
一、目的与要求
1．了解呼吸系统的各种影像检查方法。
2．熟悉胸部正常的X线、CT和MRI表现以及正常变异。
3．掌握呼吸系统各种基本病变的X线表现和CT表现。
4．掌握支气管扩张、肺部炎症、肺脓肿、肺结核和原发性肺癌的X线和CT表现。
5．熟悉常见的纵隔原发肿瘤的影像学表现。
二、教学内容
第一节 检查方法
1．X线检查：平片、透视、体层摄影、支气管造影。
2．CT检查：CT平扫、高分辨CT、螺旋CT、CT增强扫描。
3．MRI检查：应用于呼吸系统的检查序列。
第二节 正常影像解剖
一、正常X线表现
1．胸廓的影像表现：软组织与骨骼。
2．气管和支气管：左右支气管的分支名称及不同点。
3．肺：肺野概念及划分，肺叶和肺段。
4．肺门：构成及正侧位表现，胸膜及叶间裂。
5．纵隔与横膈：位置、分区及正常表现。
二、正常CT表现
胸壁、胸膜、支气管、肺动静脉、肺门及膈肌，重点纵隔各层面的表现。
三、正常MRI表现
第三节 基本病变的影像表现
一、X线表现
1．支气管阻塞改变：阻塞性肺气肿（局限性和广泛性）、阻塞性肺不张。
2．肺部病变：渗出性病变、增殖性病变、纤维化、钙化、空洞性病变、空腔、结节和肿块。
3．肺门的改变：肺门增大或缩小，肺门移位。
4．胸膜病变：胸腔积液（游离性、限局性），气胸与液气胸，胸膜肥厚、粘连及钙化，胸膜肿瘤。
5．纵隔的改变：形态的改变（注意纵隔肿瘤），位置的改变（纵隔摆动）。
6．膈的改变：形态、位置与运动的改变（矛盾运动）。
二、CT表现
1．气管和支气管病变：管腔内肿物、管腔狭窄和梗阻、管壁增厚和管腔增宽。
2．肺部病变：结节及肿块，空洞和空腔病变，肺叶、肺段病变（肺实变及肺不张），弥漫性肺间质纤维化，弥漫性肺泡病变，多发性小结节及粟粒病变、肺气肿，肺门肿块，胸膜病变及膈病变。
第四节 支气管疾病
一、支气管扩张症
介绍病理、分型及临床表现，重点为X线和CT表现。
二、气管、支气管异物
气管、支气管异物引起的病理改变及X线、CT表现。
第五节 肺部疾病
一、肺部炎症
1．大叶性肺炎：病理分期、临床表现，各期的X线与CT表现（含气支气管影）。
2．支气管肺炎：病理改变、临床表现，重点为X线表现。
3．病毒性肺炎：病因、病理及临床表现，主要的X表现。
4．支原体肺炎：病理及临床，X线表现及诊断要点。
5．过敏性肺炎：病因及临床特点，X线与CT表现特点。
6．肺脓肿：感染途径、病理改变及临床表现，X线与CT表现（空洞特点与鉴别）。
二、肺结核
肺结核的基本病理改变与转归、临床表现，肺结核的分期，肺结核新旧分类法的区别；着重讲述原发型肺结核、血行播散型肺结核、浸润型肺结核、慢性纤维空洞型肺结核以及结核性胸膜炎的X线、CT表现；并强调对结核球与周围性肺癌、结核性空洞与癌性空洞的鉴别诊断与分析。
三、肺部肿瘤
1．良性肿瘤：重点讲述肺错构瘤的概念、病理、分型，以及其X线和CT表现。
2．支气管肺癌：病理组织学类型、大体病理形态的分型及其生长方式特点，早
期肺癌的标准，肺癌的临床表现。着重中心型肺癌和周围型肺癌的X线与CT表现及鉴别；适当介绍MRI表现及弥漫型肺癌影像表现。
3．肺转移瘤：发生途径与机理，X线与CT表现特点。
四、支气管及肺部外伤
1．气管及支气管外伤
2．肺部外伤：肺挫伤、肺撕裂伤和肺血肿
第六节 胸膜病变
一、胸膜肿瘤
胸膜间皮瘤的分型、病理改变及X线与CT表现。
二、胸膜损伤
第七节 纵隔疾病
一、纵隔气肿与血肿
二、纵隔肿瘤、囊肿和肿瘤样病变
1．胸内甲状腺肿：X线与CT表现特点。
2．胸腺瘤：病理分型及X线与CT表现，注意鉴别诊断。
3．畸胎类肿瘤：囊性和实性畸胎瘤的X线与CT表现特点。
4．淋巴瘤：中纵隔最常见恶性肿瘤，分两种类型，其X线与CT表现及鉴别。
5．神经源性肿瘤：后纵隔最常见肿瘤，其X线与CT表现，MRI检查的价值。
6．纵隔囊肿：淋巴管囊肿、支气管囊肿、心包囊肿等主要特点及影像学表现。
三、实验内容与要求
1．通过典型X线和CT示教片及必要的解剖模型辨认和熟悉胸廓的软组织与骨骼，支气管与肺野，肺门与纵隔等的X线与CT正常的表现。
2．通过示教展示和讲解大量典型的肺部X线与CT教学片，并适当配合CAI课件，着重学习和掌握：支气管阻塞的改变（阻塞性肺气肿、肺不张）；肺部的基本病变（渗出性病变、增殖性病变、纤维化、钙化、空洞性病变、空腔、结节 和肿块、弥漫性肺间质纤维化）、胸膜病变（胸腔积液、气胸与液气胸，胸膜肥厚、粘连及钙化，胸膜肿瘤）等的基本征象，并要求懂得其征象的病理基础。
3．通过X线和CT教学片学习支气管扩张症、大叶性肺炎、支气管肺炎、过敏性肺炎、肺脓肿和各种肺结核病的影像学表现与诊断，注重培养同学独立认征和分析诊断的能力，适当以一些典型病例组织讨论和讲评；注意结核球与周围性肺癌，结核性空洞、肺脓肿与癌性空洞等的鉴别诊断。
4．以各种类型丰富的教学片介绍肺良性肿瘤中肺错构瘤和肺恶性肿瘤支气管肺癌的X线和胸膜间皮瘤的CT表现，要求熟练掌握其影像诊断与鉴别，并对弥漫型肺癌、肺转移瘤和的X线与CT表现有所了解。
5．通过教学片（CT为主、X线为辅）学习和掌握常见的纵隔肿瘤如胸腺瘤、畸胎类肿瘤、淋巴瘤、神经源性肿瘤以及淋巴管囊肿和支气管囊肿、心包囊肿的影像学表现。
四、教学时数分配
（一）理论课学时分配
|
章 节 |
理 论 课 内 容 |
学 时 |
|
第四章 第一节 |
检查方法：介绍常规X线、CT及MRI检查技术与应用 |
0.5 |
|
第四章 第二节 |
胸部主要结构的X线表现、CT表现，适当介绍MRI表现 |
1.5 |
|
第四章 第三节 |
重点讲解支气管、肺脏和胸膜基本病变的X线、CT表现，适当介绍MRI表现。 |
2 |
|
第四章 第四～五节 |
适当介绍支气管扩张影像学表现，重点介绍主要肺部炎症、肺结核及肺良、恶性肿瘤的影像学表现（以X线、CT为主） |
3 |
|
第四章 第六～七节 |
适当介绍胸膜的病变影像学表现，重点讲解纵隔内常见肿瘤的影像学表现与诊断。简单总结 |
2 |
|
总 学 时 |
9 |
（二）实验课学时分配
|
序 号 |
实 习 课 内 容 |
实 验 类 型 |
学 时 |
|
1 |
影像检查方法；胸部主要结构正常X线与CT表现；支气管、肺与胸膜的X线与CT基本征象；支气管扩张及常见肺炎的X线、CT诊断 |
演示性实验 |
2 |
|
2 |
肺结核、肺肿瘤、胸膜常见病变及常见纵隔肿瘤的X线与CT诊断 |
演示性或设计性实验 |
2 |
|
总 学 时 |
4 |
思考题
1．各种影像学技术方法在胸部的应用价值
2．X线与CT检查在胸部正常结构的显示中的优缺点
3．支气管阻塞的后果及病理机制
4．肺脏常见的基本病变的病理改变及相应的X线与CT表现特点
5．常见肺炎的X线与CT诊断
6．各型肺结核的特点及影像学表现
7．肺错构瘤与各型肺癌的影像学表现与鉴别诊断
8．常见纵隔肿瘤及囊性病变的X线与CT诊断
Chapter 4 Respiratory system
一、Objective and requirement
1. Comprehend the imaging examination methods of respiratory system.
2. Familiar with the normal appearance of thorax and its normal variation in X-ray, CT and MRI.
3. Master the X-ray and CT manifestation of basic pathological changes in respiratory system.
4. Master the X-ray and CT manifestation of bronchiectasis, pneumonia, lung abscess, pulmonary tuberculosis and primary bronchogenic carcinoma.
5. Familiar with the imaging manifestation of common primary mediastinal tumors.
二、Content of courses
Section 1 Examination methods
1. X-ray: radiography, fluoroscopy, tomography, bronchography.
2. CT: plain scan, high resolution CT, spiral CT scan, contrast enhancement scan.
3. MRI: sequences applied to respiratory system
Section 2 Normal imaging anatomy
1. Normal X-ray manifestation
a.thorax: soft tissue and skeleton
b.trachea and bronchus: branches of dexter bronchus and sinister bronchus and their difference
c.lung: concept and division of lung field, lobes and segments of lung.
d.hilar shadow: component and appearance in the anterioposterior and lateral film, pleura and fissura.
e.mediastinum and diaphragm: location, zonation and normal appearance.
2. Normal CT manifestation
chest wall, pleura, bronchus, pulmonary artery and vein, hilus and diaphragm, lay stress on the normal appearance of mediastinum in each slice.
3. Normal MRI manifestation
Section 3 Imaging manifestation of basic pathological changes
1. X-ray manifestation
a.changes of bronchial obstruction: obstructive emphysema (limited and extensive), obstructive atelectasis.
b.pulmonary lesions: exudation, proliferation, fibrosis, calcification, cavity, air containing space, node and mass.
c.hilar changes: hilar enlargement and shrinkage, shift of hilus.
d.pleural lesions: pleural effusion(localized and free), pneumothorax and hydropneumothorax, pleural thickening, adhesion and calcification, pleural tumor.
e.mediastinal changes: shape of mediastinum(pay attention to mediastinal tumor), location of mediastinum (pendular movement of mediastinum).
f.diaphragm changes: shape, location and movement(paradoxical movement).
2. CT manifestation
a.changes of trachea and bronchus: mass in the lumen, stenosis and obstruction of lumen, thickening of the wall, broadening of the lumen
b.pulmonary lesions: node and mass, cavity and air containing space, diseases of lobe and segment(consolidation and atelectasis), diffuse pulmonary interstitial fibrosis, extensive vesicular lesions, multiple nodular and miliary diseases, emphysema, mass of hilus, pleural changes and diaphragm changes.
Section 4 Bronchial diseases
1. bronchiectasis: provide information of pathology, typing and clinical appearance, lay stress on the appearance in X-ray and CT.
2. foreign bodies in trachea and bronchus: pathological changes and appearance in X-ray and CT
Section 5 Pulmonary diseases
1. Pneumonia
a.lobar pneumonia: pathological stage, clinical appearance, the X-ray and CT appearance(air bronchogram) of different stages.
b.bronchopneumonia: pathological changes, clinical appearance, put emphasis on the X-ray appearance.
c.viral pneumonia: pathogeny, pathology and clinical changes, major appearance in X-ray.
d.mycoplasmal pneumonia: pathology, the clinical and X-ray appearance, main points of diagnosis.
e.allergic pneumonia: pathogeny, clinical features, characteristics of X-ray and CT appearance.
f.lung abscess: infection ways, pathological changes, clinical appearance, appearance in X-ray and CT(characteristics and differentiations of cavity).
2. Pulmonary tuberculosis: the basic pathological lesions and changes , clinical appearance and staging of pulmonary tuberculosis, the difference between new classification and old one; emphatically explain the X-ray and CT appearance of primary tuberculosis, hematogonous pulmonary tuberculosis, infiltrative pulmonary tuberculosis, chronic fibro-cavitativer pulmonary tuberculosis and tuberculosis pleuritis; emphasize differentiation between tuberculoma and peripheral pulmonary carcinoma, tuberculosis cavity and carcinoma cavity.
3. Pulmonary tumors
a.benign tumors: lay stress on the hamartoma, including its conception, pathology, typing and appearance in X-ray and CT.
b.bronchogenic carcinoma: pathohistological type, typing of macropathologic shape and characteristics of growth style, standard of early-stage carcinoma, clinical appearance; put emphasis on the X-ray and CT appearance and differentiation between central carcinoma and peripheral carcinoma; provide information of MRI appearance and the imaging manifestation of diffuse pulmonary carcinoma.
c.metastasis: mechanism of occurence, the characteristics of X-ray and CT appearance.
4. Injury of bronchus and lung
a.injury of trachea and bronchus
b.injury of lung: contusion of lung, laceration and hematoma of lung.
Section 6 Pleural diseases
a.pleural tumors: the typing, pathological changes, X-ray and CT appearance of mesothelioma of pleura.
b.injury of pleura
Section 7 Mediastinal diseases
1. Pneumomediastinum and mediastinal hematoma
2. Mediastinal tumors, cysts and tumor-like lesions
a.intrathoracic goiter: the X-ray and CT characteristics
b.thymoma: pathological typing and appearance in X-ray and CT, give attention to differentiation diagnosis.
c.dermoid cyst and teratoma: the X-ray and CT characteristics of cystic and solid teratoma
d.lymphoma: the commonest malignant tumor in the middle medistinum, include two types, the X-ray and CT appearance and differentiation.
e.neurogenic neoplasms: commonest in the posterior medistinum, the X-ray and CT appearance, value of MRI examination.
f.mediastinal cysts: the main characteristics and imaging manifestation of lymphangial cyst, bronchogenic cyst, pericardial cyst
三、Experiment content and requirement
1. By demonstration with typical X-ray, CT films and necessary anatomic model, discern and have an intimate knowledge of the normal X-ray and CT appearance of thoracic soft tissue and skeleton, bronchus and lung field, hilus and mediastinus.
2. By demonstration and explanation with lots of X-ray, CT films, cooperating with proper CAI coursewares, emphatically learn and master: changes of bronchial obstruction(obstructive emphysema and atelectasis); basic changes of lung(exudation, proliferation, fibrosis, calcification, cavity, air containing space, node and mass, extensive pulmonary interstitial fibrosis); pleural diseases(pleural effusion, pneumothorax and hydropneumothorax, pleural thickening, adhesion and calcification, pleural tumors); and comprehend the pathologic basis of these signs.
3. By learning the imaging manifestation and diagnosis of bronchiectasis, lobar pneumonia, bronchopneumonia, allergic pneumonia, lung abscess and pulmonary tuberculosis with X-ray and CT films, emphatically cultivate students’ capability of self-authentication; conduct discussion and comment of some typical cases; take note of the differentiation of tuberculome from peripheral pulmonary carcinoma, tuberculosis cavity from lung abscess and carcinoma cavity.
4.By demonstration with example films, provide information of the X-ray appearance of hamartoma and bronchogenic carcinoma and the CT appearance of mesothelioma of pleura, master the imaging diagnosis and differentiation of the diseases above and comprehend the X-ray and CT appearance of extensive pulmonary carcinoma, pulmonary metatesis.
5. By demonstration with example films(put CT films first and X-ray films secondary), learn and master the imaging manifestation of common medistinal tumors, such as thymoma, dermoid and solid teratoma, lymphoma, neurogenic neoplasms, lymphangial cyst, bronchogenic cyst and pericardial cyst.
四、Distribution of class hours
1. Distribution of class hours in theory lessons
Chapters and sectionsContent of theory lessonsClass hour
Chapter4 section1Examination methods: provide information of conventional X-ray, CT, MRI techniques and their application0.5
Chapter4 section2The X-ray and CT appearance of major thoracic structure, give right information of MRI appearance.1.5
Chapter4 section3Emphatically explain the X-ray and CT appearance of basic bronchial, pulmonary and pleural diseases, give right information of MRI appearance.2
Chapter4 section4-5Give information of imaging manifestation of bronchiectasis, emphasize the imaging manifestation of pneumonia, tuberculosis, benign and malignant pulmonary tumors(mainly include X-ray and CT appearance).3
Chapter4 section6-7Give briefs of imaging manifestation of pleural diseases, lay stress on the imaging manifestation and diagnosis of common mediastinal tumors; make a brief summary of respiratory system.2
Total class hours9
2. Distribution of class hours in experimental lessons
Serial numberContent of experimental lessonsExperimental typeClass hour
1Examination methods: normal X-ray and CT appearance of major thoracic structure; the basic X-ray and CT signs of bronchus, lung and pleura; the X-ray and CT diagnosis of bronchiectasis and common pneumonia.Demonstration1
2The X-ray and CT diagnosis of pulmonary tuberculosis, pulmonary tumors and common pleural diseasesDemonstration or design2
Total class hours3
Questions:
1.the application values of varieties of imaging techniques in thorax examination
2.the advantage and shortage of X-ray and CT in display of normal thoracic structure
3.the consequence and pathological mechanism of obstruction of bronchus
4.the pathological changes and X-ray , CT characteristics of common pulmonary diseases
5.the X-ray and CT diagnosis of common pneumonia
6.the characteristics and imaging manifestation of different types of pulmonary tuberculosis
7.the imaging manifestation and differentiation diagnosis of hamartoma and bronchogenic carcinoma
8.the X-ray and CT diagnosis of common mediastinal tumors and cystic diesases