Pulmonary Radiology John Yasmer, DO

CYSTIC FIBROSIS CT findings Bronchiectasis (worst in upper lobes) Hyperinflation Obstruction of small to medium airways Air trapping Mucous plugging Tree in bud opacities Atelectasis

18 y/o male with chronic cough Single non- contrast axial CT image through the upper lobes demonstrates areas of bronchiectasis and peri-bronchial thickening. There is cylindric bronchiectasis with both a signet ring and tram track appearance.

*Cystic fibrosis* Abnormal thick secretions lead to decreased mucociliary clearance

18 y/o male with chronic cough Single frontal radiograph of the chest demonstrates peribronchial thickening and bronchiectasis, with an upper lobe predominance. Consistant with ________ _________

ARDS Interstital edema progressing to patchy airspace opacities and then to widespread pulmonary opacification Low lung volumes Heart size is usually normal Usually no pleural effusion Diffuse alveolar damage Shock Massive trauma Burns Aspiration Near drowning Severe pneumonia Marked dyspnea and profound hypoxia

22 y/o male near drowning Portable AP radiograph of the chest in a profoundly hypoxic patient demonstrates low lung volumes with bilateral patchy airspace opacities, consistent with __________

Asthma Single frontal radiograph of the chest demonstrates mild hyperinflation and increased bronchial markings, consistent with ______.

23 year old female with difficulty breathing

Fungal pneumonia PA radiograph of the chest demonstrates a 1 cm cavitary lesion in the left upper lobe. The patient was PPD and AFB negative. Diagnosis of coccidiomycosis confirmed by sputum. Appearance is variable and depends on the organism Acute phase is usually consolidation (but may be nodular) with mediastinal or hilar adenopathy Chronic phase is nodules which may calcify Cavitation may also be seen

26 y/o female from Arizona with cough

Pulmonary edema Presence of excess extravascular fluid within the interstitial and alveolar compartments of the lung Cardiac: Elevated pulmonary microvascular pressure Non-cardiac: Increased capillary membrane permeability Kerley lines (linear opacities) Kerley A radiate from hila Kerley B are seen in the periphery

26 y/o male with cough and shortness of breath "Kerley B lines"

Primary tuberculosis PA radiograph demonstrates a *right lower lobe opacity and right hilar adenopathy.* This was determined to be primary tuberculosis by AFB staining. Consolidation (often basilar) Cavitation is rare Mediastinal and hilar adenopathy Ghon lesion Host defense shrinks to consolidation to a nodule Eventually becomes a small calcified nodule Ranke complex is a Ghon lesion plus calcified adenopathy

3 y/o female with exposure to TB

Pulmonary malignancy Benign pulmonary neoplasms PA radiograph of the chest demonstrates a right lower lobe nodule. Hamartoma Usually an incidental finding Focal fat helps to make diagnosis When calcium is present, it has a characteristic "popcorn" appearance PA radiograph of the chest demonstrates a right lower lobe nodule.

33 y/o female with cough PA radiograph of the chest demonstrates a right lower lobe nodule.

Hypersensitivity pneumonitis PA radiograph of the chest demonstrates *increased interstitial markings* (pt top left) and hazy opacities (pt bottom rt) predominantly in the lung bases. Lung biopsy showed acute hypersensitivity pneumonitis.

34 y/o male with cough and dyspnea

Pleural effusion PA radiograph of the chest demonstrates mild blunting of the left costophrenic angle, consistent with a small pleural effusion A large effusion can completely opacify a hemithorax Mediastinal shift may occur Fluid may loculate

35 y/o male with shortness of breath

Pleural effusion Lateral radiograph of the chest demonstrates blunting of the costophrenic angles posteriorly, consistent with pleural effusion

35 y/o male with shortness of breath Posterior CVA blunting

Pneumocystis pneumonia Non-contrast axial CT of the chest at the level of the lower lobes in an HIV positive patient demonstrates bilateral ground glass opacities with interstitial thickening. Pneumocystis pneumonia was diagnosed by lung biopsy.

39 y/o male with AIDS and dyspnea *GROUND GLASS OPACITIES*

Pneumocystis pneumonia PA radiograph of the chest in an HIV positive patient demonstrates reticulonodular interstitial thickening, predominantly in the lung bases. Pneumocystis pneumonia was diagnosed by lung biopsy. Seen in immunocompromised hosts Initial presentation is an interstitial pattern *May have ground glass opacities* TQTQTQTQ Over time, this progresses to consolidation CT shows these findings better than radiographs

39 y/o male with AIDS and dyspnea GROUND GLASS OPACITIES

Wegener granulomatosis Non-contrast axial CT of the chest demonstrates bilateral pulmonary opacities. Autoimmune disorder Causes a necrotizing vasculitis Granulomatous involvement of small and medium pulmonary vessels

40 y/o female with cough Opacity/ nodular opacity consolidation

Acute interstitial pneumonia PA radiograph of the chest demonstrates increased interstitial markings. This finding can be seen in viral pneumonia. Often viral Bronchial thickening early on Becomes a reticular pattern which radiates from the hila

48 y/o female with cough

Vascular lesions Pulmonary embolism tqtq) on hamptons hump! Often there are no radiographic findings Diminished vascularity (Westermark's sign) Infarction can cause peripheral wedge shaped opacity (Hampton's hump) Still get a radiograph to look for other causes of chest pain (pneumothorax) and if you are getting a V/Q scan

50 year old male with shortness of breath and chest pain "Hamptons hump" top right

Atelectasis PA radiograph of the chest demonstrates low lung volumes on the right. There are horizontal linear opacities in the RML and RLL, consistent with atelectasis. Image courtesy of Dr. Moser.

59 y/o male with shortness of breath

Reactivation tuberculosis PA radiograph of the chest demonstrates a cavitary right upper lobe opacity. AFB staining confirmed tuberculosis infection. Often in upper lobes/superior segments of lower lobes Chronic patchy consolidation Cavitation is a hallmark May get endobronchial spread

62 y/o male with chest pain

Emphysema *TQTQ* Lateral radiograph of the chest demonstrates hyperinflation of the lungs, *large retrostenal space* (TOP LEFT) and increased interstitial markings, predominantly in the upper lobes.

65 y/o male smoker

Single post-contrast coronal CT image demonstrates areas of increased lucency of the lungs (parenchymal destruction), without walls in a centrilobular distribution. The upper lobes are affected more than the lower lobes. This is consistent with centrilobular emphysematous change

65 y/o male smoker

PA radiograph of the chest demonstrates hyperinflation of the lungs and increased interstitial markings, predominantly in the upper lobes

65 y/o male smoker .

Bronchopneumonia PA radiograph of the chest demonstrates multiple patchy airspace opacities in the right upper and right lower lobes, consistent with bronchopneumonia. Starts in the airway and spreads to alveoli Multiple ill defined patchy nodular opacities May become confluent and look similar to a lobar pneumonia

65 y/o male with cough

Bronchiectasis Often normal Bronchial wall thickening Air-filled cysts *Lumen of bronchus is larger than adjacent pulmonary artery* Abnormal dilation of bronchi Many causes The most common is infection Deficient host defense Abnormal cartilage Abnormal mucous production Abnormal ciliary clearance

77 y/o male smoker with worsening DOE PA radiograph of the chest demonstrates bronchial wall thickening. History is key to making diagnosis

Post contrast axial CT of the chest demonstrates a cavitary right lower lobe nodule. This was determined to be non-small cell carcinoma of the lung, in this case, squamous cell carcinoma by biopsy

78 y/o male with abnormal CXR

Malignant pulmonary neoplasms PA radiograph of the chest demonstrates a left lower lobe mass. This was diagnosed as small cell lung cancer Broadly divided into small cell vs non-small cell Different histology and treatment Radiographically both types are seen as a nodule or mass May be parenchymal or endobronchial May be solid or ground glass

82 y/o female with cough

Hypersensitivity pneumonitis Exposure to inhaled organic dust or other antigens Phases Acute 4-6 hours after exposure Subacute after resolution of acute symptoms Chronic development of fibrosis

Imaging findings in hypersensitivity pneumonitis: Acute Airspace consolidation which rapidly clears Subacute: Upper lobe predominant nodules Ground glass opacities on CT Chronic: Upper lobe predominant linear opacities and honeycombing

Pneumonia Confluent opacification with air bronchograms Affects a segment/segments or an entire lobe May cause expansion of a lobe from edema May cause necrosis and cavitation PA radiograph of the chest demonstrates an *airspace opacity in the right upper lobe.* Given the patient's elevated WBC count, this is consistent with a lobar pneumonia.

PA radiograph of the chest demonstrates an *airspace opacity in the right upper lobe.*

Emphysema *Centrilobular* Respiratory bronchioles predominantly affected *Paraseptal* Alveolar ducts and sacs predominantly affected *Panlobular* Respiratory bronchioles and alveoli affected

Radiographic features of emphysema Normal when disease is mild Hyperinflation Wide retrosternal space Rapid tapering and attenuation of pulmonary vessels with associated lucencies Bullae (well defined lucency >1 cm)