alveolar / airspace lung disease acute,chronic and ground glass consolidation / opacification...
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Alveolar / Alveolar / Airspace lung Airspace lung
diseasedisease
Acute,chronic and ground Acute,chronic and ground glass consolidation / glass consolidation /
opacificationopacificationJacques le RouxJacques le Roux
03/02/201203/02/2012
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Definition (air space Definition (air space disease)disease)
Disease process (fluid or cells) that Disease process (fluid or cells) that replaces the normal air spaces in the replaces the normal air spaces in the lunglung
Homogeneous opacity characterised Homogeneous opacity characterised by little or no volume loss, by little or no volume loss,
Effacement of pulmonary vessels Effacement of pulmonary vessels unlike ground glass opacitiesunlike ground glass opacities
And if airways remain air filled you And if airways remain air filled you see air bronchogramssee air bronchograms
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AIR SPACE DISEASE (ALVEOLAR LUNG DISEASE)
•Acute and chronic consolidation
•Ground glass opacity
•Anatomy (HRCT)
•Pathology and complications
•Approach •Diseases (acute and chronic) consolidation•Clinical• Lab• Options: diseases on CXR •Ground glass opacity - Approach - HRCT (expiration and inspiration)
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ANATOMY ON HRCT
AIRSPACE (ALVEOLI)Distal to term bronchioli are the sec. pulm. lobule (best seen on CT in lung periphery)contains:
•Acini –with the alveoli and respiratory bronchioli •Pores of Kohn connect the alveoli•Channels of Lambert connect alveoli with the bronchi
Acini not seen on CT
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ALVEOLAR INTERSTITIUM•Peribroncho vasc. interstitium runs from hilum to periphery of lung•It becomes the centrilobular interst in the lobule and contains the art. and bronchioli•At the periphery is the interlob. septa with vein and lymphatics
On CT you see:- arteries and veins but not centrilob. bronchioli and lymphatics
Normal HRCT lobular anatomy
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PATHOLOGY
Air space disease can be:1 Alveolar2 Interstitial3 Mixed (overflow of disease from interstitium)
NB - ALVEOLI CAN BE FILLED WITH: (The consolidation)
•Serous fluid: cardiogenic and non cardiogenic edema•Blood: pulm. hemorrhage: - vascilitis (eg Wegener’s) - PE•Pus: pneumonia•Proteins: alveolar proteinosis•Malignant cells - BAC - Lymphoma•Calcium: alveolar microlithiasis
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COMPLICATIONS
ACUTE•Pleural effusion•Empyema with or without BR. pleural fistel•Lung abcess•Atelectasis (Broncho PN)
GROUND GLASS OPACITY (Mainly a HRCT term)
•Sign of acute disease•Can Δ early changes before consolidation is present•Means: -hazy increase in lung density (high att)
-CAN SEE VESSELS THROUGH THE HAZE
If reticulations are superimposed, use term ‘crazy paving’or honey combing
CHRONIC•PAH•Bronchiectasis (traction)•Emphysema (irregular) - in area of fibrosis
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Acute and chronic air space Acute and chronic air space consolidationconsolidation
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AIRSPACE DISEASE (CONSOLIDATION)ACUTE1. Pneumonia (bact, viral, PCP, mycoplasma)2. ARDS, AIP (Ideopatic ARDS – Hamman Rich)3. Hemorrhage (PE)4. Aspiration5. Acute eosin. PN (Löffler)6. Radiation
CHRONIC1. Tumors - BAC - Lymphoma 2. Inflam - TB, Fungi - COP (BOOP) - with eosinophilia:
- chronic eosinophilic PN - ABPA (aspergillosis) - Drugs (penicillin) - Churg-Strauss (asthma + granulomas)
3. Vascular - pulm renal syndromes eg. Good Pasture, H-S Purpura, Wegener4. Other
• Alveolar sarcoidosis• Interst. Pneumonias (UIP, DIP, NSIP)• Chronic hypersensit PN (Farmer Lung)• Lipoid PN (laxatives, eye drops)
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CLINICAL (IMPORTANT)
ACUTE•Dyspnea•Purulent sputum•Fever•Bronchial breathing
LAB:•Immunocompromised patient eg AIDS•Sputum•Lung func tests•Sarcoid (↑ ACE and calcium)•Wegener (ANCA)•Good pasture (Anti-GBM)•Other: - Bronchoscopy – lavage, biopsy
CHRONIC•Dyspnea•Dry cough•Finger clubbing•Dry crepitations
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A. NON SPECIFIC – Does not tell cause SIGNS OF CONSOLIDATION (HRCT can’t tell you more than CXR)•Opacities - fluffy hazy - margin indistinct (except if process is against a fissure) - tend to merge into one another•Air bronchogram – there is air in bronchi and exudate around them (black branching tubular structures)•Silhouette sign (2 objects in contact with each other and must have same density) - margin will be obscure•No blood vessels in opacity•No volume loss – structures don’t move eg fissures, diaph, mediastinum•Spine sign (lat film)
CXRTHE APPROACH
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USING SILHOUETTE SIGN ON FRONTAL CXR
Structure That Is No Longer Visible Disease LocationAscending aorta Right upper lobeRight heart border Right middle lobeRight hemidiaphragm Right lower lobeDescending aorta Left upper or lower lobeLeft heart border Lingula of left upper lobeLeft hemidiaphragm Left lower lobe
On a Normal CXR: - You see no bronchi – walls too thin and air on both sides - What you see are blood vessels
* Consolidation, example ARDS ,pulm oedema will clear quickly within hoursBacterial PN will clear within 10 daysSo important do a follow-up CXR
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B. MORE SPECIFIC (MIGHT LIMIT THE ΔΔ)
CONSOLIDATION (CXR)
DIFFUSE•PN /oedema•ARDS(Bat-wing)•Hemorrhage
LOBAR•PN (Strep) - Air bronchogram - No vessels
RETICULAR/NOD•Viral•Mycoplasma•PCP
PATCHY•Broncho PN (Staph+ Mycopl) - No bronchogram - Collapse (vol. loss) (bronchi blocked)
OTHER1. Bulging fissures – Klebsiella2. Round PN (H.Influenza) – Child (no pores of Kohn, canals of Lambert)3. Cavity with mass – Aspergilloma4. Mass with finger shadows – Acute bronchopulmonary aspergillosis (ABPA)5. Solitary nodule – Criptococcus (AIDS)6. Multiple nodules – Histoplasmosis7. Cavities – Post prim TB / pseudomonas8. Pneumotocele – Staph, PCP9. Aspiration – Lower lobes (bacteroides)10. Mycoplasma – Signs of both bact and virus (patchy Bronch PN and reticular)
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ExamplesExamples
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DIFFUSECARDIOGENIC PULM EDEMA•Bilat perihilum airspace disease (bat-wing)•↑Heart•Cardiogenic pulm edema due to eg CHF•Usually pleural effusions•Kerley lines•Peribronch cuffing
NON CARDIOGENIC EDEMA (ARDS)•Bilat perihilum airspace disease (bat-wing)•Normal heart•Non cardiac. pulm edema due to eg septic shock•Usually no pleura eff. or Kerley lines
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OTHER SIGNS OF CARDIOG. PULM EDEMA
Kerley B - Interlob septa - Near pleura - Short (1-2cm)
Kerley A - Broncho art. bundle - Near hilum - Long 6cm
Peribronch. cuffing - Fluid aroud bronchi - walls look thicker
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LOBAR – STREPTOC. PNEUMONIA
RML PNEUMONIACXR (PA) - Homogeneous consolidation - Silhouette sign Lat - Major, minor fissures clearly seen
CT - Air bronchogram (better seen centrally)
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LOBAR PN
RUL PN•Homogeneous consolidation•Air bronchogram centrally•Minor fissure – demarcate lesion (Fissures bound lobar PN)
LINGULAR PN (LUL)•Air bronchogram•Silhouette sign (left heart border)
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BRONCHO PN - STAPH
•Patchy consolidation, moving centrifugally•Lung segments are not bound by fissures (only lobes)
•No air bronchogram because exudate fills bronchi as well as airspaces
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INTERST PN– RETICULAR PATTERN
PCP IN PATIENT WITH AIDS•Disease starts as an interst (reticular) disease, perihilum and spreads to airspace•No effusion, or adenopathy•Δ sputum methanamine silver staining
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ROUND PNEUMONIA – H. INFLUENZA
•Child with fever and a mass
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TB
PRIMARY
CHILD - Usually ipsilat adenopathy - If consolidation – upper lobe
ADULTS - Large unilat effusion
POST PRIM•Cavitation common•Classic bilat upper lobes
- upper lobe (apical, post segments)- or lower lobes (sup segments)
•Transbronchial spread eg upper lobe to opposite lower lobe is common•Healing causes fibrosis, traction bronchiectasis
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ASPIRATION PN – Anaerobic organisms (Bacteroides)
Lower lobes – R more affected(R bronchus short,straight, wide)
•ACUTE aspiration gives airspace disease – in stroke patient
•CHRONIC aspiration cavitation
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THE SPINE SIGN – RLL PN
CXR (PA)•R LL PN – Not so obvious, but hemidiaphragm not clearly definedCXR (LAT)•Normal vertebrae bodies get darker as you go down (less tissue for beam to penetrate)•Lower throracic vertebrae whiter – the spine sign for R LL PN
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Broncho PN – STAPH•Patchy consolidation L and R•Abcess and cavity formation
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PN - Pseudomonas - L Apical-Cavity - Bronchoscopy revealed org
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PN – Mycoplasma (sputum Δ)•Diffuse reticular interst markings•Bilat lower lung zone airspace disease
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PRIM TB•RUL consolidation•Hilum and right paratracheal nodes
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ASPERGILLOMA•History of TB•Mass with crescent of air (Monod sign) and pleural thickening – RUL
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Bulging of minor fissure - Klebsiella
CMV - patchy consolidation - nodules in interstitium
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BAC (chronic)BAC (chronic)
Consolidation and ground-glass present
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? Sign? Sign
CT angiogram sign CT angiogram sign
? 3 Associations ? 3 Associations
1) BAC1) BAC
2) lymphoma2) lymphoma
3) infective PN3) infective PN
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GROUND-GLASS OPACITY
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LUNG OPACITY ( ↑ LUNG ATTENUATION ON HRCT )
CONSOLIDATION
• BRONGOGRAM• NO VESSELS
GROUND GLASS OPACITY (HAZY LUNG - ↑ ATT, SEE BLOOD VESSELS)
NO RETICULATIONS(ACTIVE DISEASE 80%)WITH RETICULATION
SUBPLEURALPOST LOWER LOBES
•IPF(60%)•ASBESTOSIS
HONEYCOMBING
FIBROSIS LIKELY(95%)
CRAZY PAVING
ACTIVE DISEASE LIKELY
•ALVEOLAR PROTEINOSIS•ARDS•PULM. HEMORRHAGEUPPER LOBE
•SARCOIDOSIS
DIFFUSE
•INTERST.PN (UIP, DIP, AIP)•PCP•CMV•HEMORRHAGE•OEDEMA
NODULAR - centrilobularPERIPHERAL PATCHY
•EOSINPHELIC PN
NB NB Mosaic attenuation – areas of ↓ att vs MOSAIC PERFUSION• Sign of vascular obstruction or airway obstruction (usually)• ↓att on inspiratory scan – call it mosaic perfusion – vessels appear smaller (difficult to see)• ↓att on expiratory scan – call it air trapping
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NODULES [will be done at later stage]
•Micronodule < 3 mm•Small < 1 cm•Large 1-3 cm•Mass > 3 cm
•Centrilobular interst contains- bronchioli – don’t see normally on HRCT- artery – you see
•Nodules can be 1. Alveolar (centrilobular) – air space disease 2. Interstitial
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HRCT OF CENTRILOB NODULES (AIR SPACE)
Centrilobular interstitum•Art and bronchioli are enlarged but smooth- usually due to fluid•Art and bronchioli show a nodular pattern due to other causes ,infection
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SMALL NODULE DISTRUBUTION
( HEMATOGENEOUS DISEASE)• MILIARY TB, FUNGI, METS• SARCOID
RANDOM
PERILYMPHATIC
(NEAR PLEURA AND FISSURES)• PN CONIOSIS• SARCOID• LYMPHANGITIS• LYMPHOMA• LIP
NO TREE IN BUD
( SIGN OF BRONCHI AND VASC. DISEASE- BRONCHI AND ART SMOOTH DILATED)
• FLUID -PUM EDEMA - HIPERSENS PN - BOOP
****CENTRILOBULAR NODULES5 – 10 mm from pleura
TREE IN BUD
(SIGN OF BRONCHIOLAR DISEASE - CENTRAL BRONCHI DILATED AND BRANCHING)
• USUALLY BY PUS (INFECTION) - TB(ACTIVE) - Broncho PN - MYCOPLASMA
• MUCUS - ASTHMA
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ExamplesExamples
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PULM. HEMORRHAGE
Combination of
•Consolidation- no vessels- air bronchograms
•Ground-glass opacity vessels - Sign of acute disease - Lung hazy (↑ att) - See vessels
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BRONCHOPNEUMONIAHRCT (Signs)
A.Centrilobular nodules
B. Tree-in-bud - dilated centrilobular bronchioli - can be filled with pus, fluid or mucus - there are peribronchiolar inflam. (walls appears thick) - bronchiectasis (signet ring)
C. Pathology slice
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PCP (PNEUMOCYSTIS CARINII PNEUMONIA) - JIROVECI
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TB
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ACUTE INTERSTITIAL PNEUMONIA (HAMMAN RICH)(IDEOPATHIC ARDS)
CXR and HRCT•Peripheral ground-glass and consolidation opacities like ARDS•But more lower lobe disease
•Fulminant lung disease (> 50% fatal)•Occurs in previously healthy people (> 40 years)•Present with signs of ARDS with rapid deterioration suggesting PN-like disease
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SIMPLE EOSINOPHILIC PNEUMONIA (LÖFFLER)
•Usually patient with asthma and peripheral eosinophilia (blood)
CXR - Bilat. peripheral airspace disease
HRCT - Periph. ground-glass opacity with reticulation – upper lobes
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PULM. ALVEOLAR PROTEINOSIS
•Rare (males 20-40 years)•Ass. with silica dust (sandblasters) and ↓ immune patient•↑ surfactant (lipoprotein material) accumulate in airspaces
CXR - Bilat. airspace opacities
HRCT - Crazy paving (classic) - is a combination of ground-glass opacity and interlobular thickening
- also seen in ARDS and pulm. hemorrhage
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BOOP (COP)
Inflam. of respiratory bronchioli with obstruction by plugs of granulation tissue(bronchiolitis obliterans) with organizing pneumonia
CAUSE: - unknown - possible : - radiation - amiodarone - auto immune diseasesHRCT:
•Peripheral triangular patchy areas of consolidation (typical)•Classic – ATOLL sign
- is an area of ground-glass surrounded by a ring of ↑ density (consolidation)
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HIPERSENSITIVITY PNEUMONITIS (EXTRINSIC ALLERGIC ALVEOLITIS)eg FARMERS LUNG (ORGANIC DUST – HAY)
HEADCHEESE SIGN (Typical) – looks like a type of sausage• A type of mosaic attenuation manifested by a combination of:1. Patchy ground-glass opacity – you see bloodvessels2. Patchy consolidation – no bloodvessels, air bronchograms possible3. Mosaic attenuation – areas of ↓ att
• Sign of vascular obstruction or airway obstruction (usually)• ↓att on inspiratory scan – call it mosaic perfusion – vessels appear smaller (difficult to see)• ↓att on expiratory scan – call it air trapping
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Difficult to ΔΔ between pulmonary edema(cardiogenic or non cardiogenic (ARDS) on HRCT)Both give pulm. alveolar edema(ground-glass opacity)
• Cardiogenic - more smooth septal thickening (Kerley lines) - perihilar ground-glass opacity - ↑ heart
• Non cardiogenic - more peripheral ground-glass opacity - normal heart
PULMONARY EDEMA
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PAH (complication)
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SUMMARY
• CXR will tell you there is a consolidation (airspace disease) but not the cause, (no blood vessels ,air bronchograms, silhouette sign)
• If you were given one investigation to detect the cause for ground-glass opacity- Non invasive : HRCT- Invasive : Lung biopsy
*NB! NB! Ground-glass = area of increased density , see vessels, acute changes
Mosaic attentuation = areas of decreased density / attentuation sign of vascular obstruction or airway obstruction
On expiratory scan decreased att = air trapping
Mosaic perfusion = area of decreased attentuation on inspiratory scan vessels appear smaller, difficult to see thinking chronic PE
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References
1. Herring W. Learning Radiology, Mosby, 20072. Webb WR. HRCT Of The Lung 4th ed. Lippincott, 20093. Brant W. Helms G. Fundamental Of Diagnostic Radiology, Lippincott. 20074. Mayberry JP. Thoracic Manifestations Of Auto Immune Diseases : Radiographic And HRCT Findings, Radiographic 2000, 20: 1623-16355. AL-Tubaikh J. Internal Medicine, An Illustrated Radiological Guide, Springer, 20106. Gurney. Diagnostic Imaging, Chest, 2007.