Patterns of Lung Disease - Written and Practical Extensive Overview

Miliary TB

May be from lung or from other part of the body that has spread to the interstitium of the lung via the blood stream. More common in immunocompromised patients. A serious infection that gets into the blood and spreads throughout the body and stars growing in one or several other organs.

1) Cervical area due to fistula or trauma 2) Perforations of the trachea, esophagus, or primary bronchus 3) By dissection along retroperitoneal spaces

Mediastinal emphysema occurs when there is free air in the mediastinum that may come from:

Klebsiella (aka Friedlander)

This type of pneumonia results aggressive and necrotizing (death/distruction of lung tissue). Patients with chronic alcoholism, diabetes, or COPD are at increased risk.

True

True or false? Most people that have COPD have both emphysema and COB.

Viral pneumonia

Type of pneumonia that is extensive and severe cased, may present in a perihilar location. Frequently bilateral in distribution. Frequently associated with pleural effusion.

1) Low flat diaphragm (below right 10.5th rib posteriorly, 7th rib anteriorly, with blunting of the costophrenic angels) 2) Diminished diaphragmatic excursion 3) Abnormally large retrosternal space 4) Irregular hyperlucency of the lungs 5) Narrow, vertically oriented heart with large pulmonary artery 6) Diminished size of peripheral vessels 7) An increase in vascular and interstitial markings and a large pulmonary artery sector.

What are the possibly/likely radiographic signs of COPD?

bloody or rust-colored sputum

What color sputum might pneumococci pneumonia produce?

green sputum

What color sputum might pseudomonas, haemophilus, and pneumococcal species pneumonias produce?

A gas filled space within pulmonary consolidation, a mass, or a nodue.

What is a cavity?

CHF, cancer, pneumonia, and pulmonary embolism.

What is the most common cause of pleural effusion?

foul smelling psutum

What kind of sputum might anaerobic infections produce?

sputum resembling currant jelly (due to necrosis, inflammation, and hemorrhage)

What kind of sputum might klebsiella and type 3 pneumococci produce?

Senescent or postural emphysema

What type of emphysema is this? Altered size and shape of the thorax due to formation of a kyphosis.

Pulmonary Miliary Tuberculosis (primary tuberculosis may be in lung or outside lung, and spread hematogenously resulting in miliary TB)

What type of tuberculosis is consequence of hematogenous spread of organisms to the pulmonary parenchyma (interstitial disease). Can be recognized by circumscribed nodules less than 1-2mm in diameter located diffusely throughout both lungs/body.

Reactive Tuberculosis

What type of tuberculosis is patchy and has confluent air space apacities that involve the apical and posterior segments of the upper lobes and the superior segments of the lower lobes.

air bronchogram sign (as long as there is air in the bronchi, there will be an air bronchogram sign)

When bronchi are surrounded by diseased fluid filled alveoli, the dense water density of the fluid surrounding the bronchi results in what radiographic sign?

RUL

Which lobe consolidation will cause silhouette sign of the upper right heart border and the right tracheal lung interface?

lower lobe or RML

Which lobe is most commonly affected by lobar pneumonia?

LUL (it may also obscure the proximal descending aorta)

Which lobe will obliterate the left atrium, the aortic knob, and the anterior and middle mediastinum?

Upper lobes

Which lobes are usually affected by Klebsiella (Friedlander's) pneumonia?

Lordotic view

Which radiographic view is helpful in diagnosing RML syndrome?

Because, lymphadenopathy is conspicuously absent in postprimary tuberculosis.

Why might the presence of hilar and mediastinal lymphadenopathy distinguish primary from postprimary tuberculosis?

No

Will asthma cause an air bronchogram sign?

No

Will interstitial edema cause an air bronchogram sign?

No

Will patchy peripheral lung consolidation or interstitial disease cause an air bronchogram sign?

Pulmonary edema

Refers to extravasation of fluid from the pulmonary vasculature into the interstitium and alveoli of the lung.

Recurrent pneumonia to RML due to present or previous obstruction of the bronchus to the RML. Hilar lymphadenopathy obstructing bronchus to RML. Downward displacement of interlobular fissure, blurring of right heart border.

Right middle lobe syndrome

Miliary pattern

Small, widespread, poorly defined nodules diffusely scattered throughout the lungs. Nodules may coalesce to form larger nodules.

LLL pneumonia

Sputum Gram stain showed gram-positive diplococci

Chronic obstructive bronchitis

The lining of the airways is constantly irritated and inflamed. This causes the lining to thicken. Thick mucus forms in the airways, rendering it difficult to breathe.

consolidation

The loss of airspace and its replacement with fluid is called:

Ghan lesions

The lung opacity tends to become rounded with healing, and it continues to shrink until only a small nodule remains. Subsequently, the nodule may become calcified or ossified, resulting in a calcified granuloma...these are known as

tape measurement of the chest on inspiration and expiration (min of 2 on expasion)

The most simple test leading to a suspicion of emphysema is the

anterior

The upper right heart border and ascending aorta are __________ structures on the right.

emphysema

The walls between many of the airsacs (alveoli) are damaged, they become weak and rupture, causing them to lose their shape and become floppy. This damage leads to fewer and larger airsacs (alveoli) instead of many tiny ones.

Lung abscess in the posterior segment of the right upper lobe

42-year-old man developed fever and production of foulsmelling sputum • He had a history of heavy alcohol use, and poor dentition was obvious on physical examination

Gas/air, fat, water (water, blood, muscle), bone, metal (implants, wires, clips, prostheses)

5 basic radiographic densities

Lung abscess in the left lower lobe, superior segment

54 - year -old patient developed cough with foul -smelling sputum production

bronchiectasis

A condition that occurs when the tubes (airways) that carry air in and out of your lungs get damaged, causing them to widen and become loose and scarred. A chronic, destructive process of brocnhi and bronchioles that results in loss of structural integrity and permanent abnormal dilation of airways.

Bullous emphysema

A large air sac formed by massive alveolar wall breakdown. From 1-2cm to an entire lobe in size. If they rupture, may cause a pneumothorax.

Alpha-1 antitrypsin

A protein made in the liver to help protect the lungs. If your body does not make enough of this protein your lungs can be more easily damaged from smoking, pollution, or dust from the environment. This can lead to COPD. It also protects the lungs from the neutrophil elastase enzyme, which can disrupt connective tissue.

achlasia

A rare disorder that makes it difficult for food and liquid to pass from the swallowing tube connecting your mouth and stomach (esophagus) into your stomach. This typically occurs when nerves in esophagus have been damaged.

RLL disease

A right lung base pneumonia fails to obliterate the heart:

PPD

A tuberculin skin test

Fistula

Abnormal connection between two body parts

Alveolar (lobar) Pneumonia

Acute exudative inflammation of the entire lobe. Uniform consolidation with a complete or near complete consolidation of a lobe of a lung. Majority of cases caused by streptococcus (pneumococcus) pneumonia. This pneumonia is a form of pneumonia characterized by inflammation exudate within the intra-alveolar space resulting in consolidation that affects a large and continuous area of the lobe of a lung. May cross segmental lines, may not be confined to a lobe, alveolar exudate which spreads towards hilum.

Non pulmonary emphysema

Air in the tissues OUTSIDE of the lungs - interstitial emphysema. Can occur from any penetrating wound to the lungs or bowels and does occur in some types of bacterial infection of the lungs/tissues.

cirrhosis and liver failure (*it is the leading cause of liver transplants in newborns)

Alpha-1 antitrypsin deficiency also causes imparired liver function and may lead to

liver disease

Alpha-1 antitrypsin deficiency is associated with emphysema in a small percentage of people due to

That the lung disease is not due to an obstructing tumor. (If a tumor obstructs a bronchus, the air in the obstructed lobe will be resorbed and may be replaced by secretions or pneumonia and air bronchograms will not be visible.)

An air bronchogram sign indicates open airways, which is strong evidence of what?

Mycetoma - aspergillus (fungal) infection

An air crescent is a collection of air in a crescent shape that separates the wall of a cavity from an inner mass.

Pulmonary emphysema

An anatomic alteration of the lungs characterized by an abnormal enlargement of the airspace distal to the terminal nonrespiratory bronchiole, accompanied by destructive changes in the alveolar walls. Airway obstruction and elastolysis (breakdown of fibers) chronic broncial infection is often seen.

LLL disease

An infiltrate obscures the descending thoracic aorta:

the lungs in patches around the tubes (bronchi or bronchioles)

Bronchial pneumonia affects

S. aureus infection, anaerobic infections, gram-negative infections, tuberculosis.

Cavitation and associated pleural effusions are observed in cases of:

with loss of lung tissue in the center of lung lobules accompanied by extensive deposition of black and anthrocotic pigment. Most common cause is smoking! Damage is cumulative and permanent.

Centrilobular pattern of emphysema

Klebsiella (Friedlander's) pneumonia

Confluent alveolar pneumonia, affects elderly and debilitated patients. Initially looks like bronchopneumonia -> must differentiate from TB of lung. Patchy areas, pulmonary cavitation increased volume of lobe -> convexity of fissures. Extensive tissues destruction, abscess formation, extensive necrosis, pleural effusion followed by emphysema (collection of pus in cavity). May result in lung fibrosis and contraction.

Nutmeg liver

Deposition of fat, RBCs, etc, in lever due to damage from sluggish blood flow.

Primary abscess

Develops as a result of a primary infection of the lung. These most commonly arise from aspiration, necrotizing pneumonia, or chronic pneumonia.

Secondary abscess

Develops as a result of another condition. -bronchial obstruction: bronchogenic carcinoma, inhaled foreign body. -hematogenous spread: bacterial endocarditis, IV drug users, direct extension from adjacent infection.

No

Do you see vascular markings in bullas?

Cystic bronchiectasis

Extensive varicose bronchiectasis; the term varicose denotes dilation as seen in venous varices. When greater dilation occurs, it is referred to descriptively as:

transient pulmonary aterial hypertension and mucus plugging with and without atelectasis.

Features of bronchial asthma can include a mild prominence of the hilar vasculature that results from

CD4 counts (T Lymphocytes) below 200/mm, small pneumatocoeles, sub pleural blebs, a fine reticular interstitial pulmonary pattern, and there is often a perihilar distribution.

Features which are highly suggestive of PCP (Pneumocystis (carinii) jiroveci pneumonia) are

Backup of blood due to liver, and portal vein congestion.

GI congestions in COPD

• Bronchial wall thickening • Bronchial dilation • Cylindrical and varicose bronchiectasis • Reduced airway luminal area • Mucoid impaction of the bronchi • Centrilobular opacities, or bronchiolar impaction • Linear opacities • Air trapping, as demonstrated or exacerbated with expiration • Mosaic lung attenuation, or focal and regional areas of decreased perfusions

HRCT findings of bronchial asthma

cardiac cirrhosis

If chronic hepatic passive congestion continues for a long time, this condition may develop in which there is fibrosis bridging between central zonal regions, so that the portal tracts appear to be in the center of the reorganized lobule.

LUL, apical posterior segment disease

If lung consolidation obliterates the aortic knob:

Lingula, inferior segment disease

If lung consolidation obliterates the left heart border:

left lower lobe, posterior pleural cavity, adjacent posterior mediastinum

If the lower descending thoracic aorta is not visible, the lesion causing this could lie in the:

-flattening of the hemidiaphragm -increased retrosternal airspace -relatively minor differences in diaphragmatic positions between inspiration and expiration.

In most patients with uncomplicated asthma, radiographic findings are NORMAL. In patients with more advanced cases, varying stages of hyperinflation are reflected on chest x-rays:

Progressive primary tuberculosis

In some immunocompromised patients, primary infection may lead to fulminant pulmonary infection, with pulmonary necrosis leading to death.

Pneumococcal/Streptococcus pneumoniae

Infection in the lungs caused by Streptococcus pneumoniae (pneumococcus)

Tuberculosis

Infections caused by mycobacterium tuberculosis and mycobacterium bovis, etc. Involves multiple organs - lung, liver, spleen, kidney, brain, and bone.

the areas in between the alveoli (most common cause is mycoplasma pneumonia - bacterial)

Interstitial pneumonia involves

No. But it is diagnosed by seeing vertical streaks of air along the pericardium and/or extending up into the cervical area paraspinally.

Is mediastinal emphysema common?

A buildup of fluid between the layers of tissue that line the lung and chest cavity. Due to a poor pumping of the heart or by inflammation.

Left pleural effusion causes:

one or more sections (lobes) of the lungs

Lobar pneumonia affects

space between the air sacs and the small blood vessels that surround the air sacs

Lung interstitium is the

right sided heart failure

Nutmeg liver is caused by chronic passive congestion of the liver secondary to what conditon?

Centrilobular emphysema

Only the central and proximal portions of the respiratory lobule (respiratory bronchi) is involved. Most common! Associated with smoking and coal dust.

Canals of Lambert

Openings in the walls of terminal bronchioles or respiratory bronchioles, which communicate with alveoli • Provide an alternative route for entry or escape of air and probably play an important role when parts of the lungs become fibrotic • Provide an avenue through which macrophages can pass from the alveolus to respiratory and terminal bronchioles where ciliated cells can remove or clear them from the lungs

Bacteremia or tricuspid valve endocarditis, caused by septic emboli to the lung.

Other mechanisms for lung abscess formation include:

Systemic capillaries, pulmonary capillaries, holes in diaphragm.

Pleural fluid comes from 3 main sources:

Because the left lower lobe is posterior to the heart

Pneumonia in the lingula obscures the left heart border. However consolidation in the left lower lobe obscures nothing. Why is this?

an increased filtration throughout the loose junctions of the pulmonary capillaries as the intracapillary pressure increases. Normally impermeable junctions between the alveolar cells open, permitting alveolar flooding to occur.

Pulmonary edema begins with

Pneumonia. Problems with the heart valves due to 1) rheumatic heart disease 2) congenital defects 3) bacterial endocarditis 4) calcium deposits. High BP, heart muscle damage after a heart attack, coronary heart disease. Cardiomyopathy (weakened, damaged heart muscle) due to infection, alcohol abuse, genetic defects.

Pulmonary edema can occur because of

increased radiolucency (air trapping)

Radiographic findings of COPD often correlate poorly with the symptoms and pulmonary function. Hyperinflation of the lungs resulting in a radiographic finding of ______________ is a primary change that is seen.

-homogeneous density representing consolidation in a segment(s) or a lobe. -looks like pneumococcal lobar pneumonia.

Segmental and lobar pneumonia types

Alveolar Pores (Pores of Kohn)

Small apertures which occur in the alveolar wall and usually vary in number. Permit air to pass between alveoli and thus prevent collapse (atelectasis) of the alveoli in case of airway obstruction. Permit the spread of bacteria and exudate to adjacent alveoli.

• Lateral chest radiograph of a patient with LLL pneumonia

Sputum Gram stain showed gram-positive diplococci

minor fissure

The RUL occupies the anterior and mid thorax above which lung fissure?

posterior

The descending aorta is _________ on the left.

Areas of normal lung, areas of inflammation, areas of end-stage, scarred, and non-functioning cystic lung with the appearance of a honeycomb.

The microscopic findings of UIP show three findings in the lung tissue:

two structures of the SAME DENSITY are in DIRECT contact with each other

The silhouette sign applies whenever

mid thorax

The trachea and the aortic knob are located in the

Panacinar (panlobular) emphysema

There is involvement of the complete respiratory lobule (all alveoli are involved of a respiratory lobule). Typically involves the lower zones and anterior margins of the lung. Associated with A1AD and cigarette smoking.

Bronchopneumonia (lobular pneumonia) (bronchial pneumonia)

This type of pneumonia affects patches throughout both lungs. A descending infection starting around bronchi and bronchioles, which then spreads locally into the lungs. Lower lobes are usually involved. Patchy areas of consolidation which represents neutrophil collection in the alveoli and bronchi. There are multiple foci of isolated, acute consolidation affecting one or more pulmonary lobes. Densities of varying sizes that are poorly defined small and mottled. Densities could coalesce. Affects very young or very old. Straphylococcal infection, bacterial origin.

aspiration pneumonia

This type of pneumonia occurs when food or liquid is breached into the airways or lungs, instead of being swallowed. From mixed bacterial infection, fistula, post surgical vomitus, achalasia.

True

True or false? Atelectasis may occur often as a consequence of tuberculosis airway involvement. Parenchymal consolidation may be observed.

True

True or false? Cancer of the lung may develop adjacent to bullous emphysema. Cancer may also develop in areas of heavy pulmonary fibrosis.

True

True or false? Mediastinum shifts away from obstructive lung and controlateral hemidiaphragm elevates and ipsilateral hemidiaphragm remains low.

True

True or false? Cavitary lesions and bulging lung fissures may be observed with Klebsiella pneumoniae infection.

True

True or false? Sometimes air bronchograms seen through the cardiac shadow is the most definitive sign of LLL consolidation.

1) Peribronchial type (interstitial disease) -streaky densities extending from hilum along vascular markings. -scattered alveolar patchy densities, may have widespread reticular pattern 2) Bronchopneumonic type -poorly defined scattered radiopacities

Types of primary atypical pneumonia (mycoplasma aka walking pneumonia)

Usual Interstitial Pneumonia: (UIP)

Variation from relatively normal to fibrotic to end-stage honeycombing of the lung.

They are air-filled cavitary lesions usually seen in lung after infection, trauma, or as a part of more extensive cystic disease of the lung. Develops within the lung parenchyma (alveoli). (Most often, they occur as a sequela to acute pneumonia, commonly caused by staph aureus.)

What are pneumatoceles?

A pulmonary lesion is present and excludes (rules out) a pleural or mediastinal lesion.

What does an air bronchogram sign indicate?

Bulging fissure sign - bulging of usually minor fissue from heavy exudative pneumonia like klebsiella

What is the arrow pointing to?

1) segmental or lobular air space consolidation 2) ipsilateral hilar and mediastinal lymphadenopathy 3) pleural effusion

What radiographic findings are found/likely seen in primary pulmonary tuberculosis?

Compensatory emphysema

What type of emphysema is this? A lobe is removed for some reason. There will be alveolar expansion in the remaining lobe so that the space is filled.

Acute obstructive emphysema (If obstruction is complete, atelectasis results as air is absorbed.)

What type of emphysema is this? Usually temporary, usually in children, obstruction caused by foreign body. Air into lungs but NOT OUT. Hyperinflation of lung shifts mediastinum.

Staphylococcus aureus

What type of pneumonia is observed in intravenous drug abusers and other individuals with debilitations?

Unlike pulmonary edema in which fluid collects inside your lungs, pleural effusion is when it builds up in the layers of tissue that line the outside of your lungs and inside your chest.

Whats the difference between pulmonary edema and effusion?

RLL and RML

Which lobes are most commonly affected by aspiration pneumonia?

Pneumococcal/Streptococcus pneumoniae

Which pneumonia begins peripherally and spreads centrally with homogeneous involvement, may cross fissures and therefore is not due to bronchial obstruction?

Because they are filled with air, and are surrounded by air in alveoli. (In lungs, we see the blood vessels since they are surrounded by air.)

Why are bronchi not normally visible on x-ray?

No

Will there be an air bronchogram sign if the a bronchus is obstructed or filled with secretions, pus, TB, bacterial pneumonia, or is congenitally stenotic?

cough with purulent, necrotic, and sometimes bloody sputum, fever, and dysphea.

With bronchiectasis the cartilage, elastic connective tissue, and muscle in the walls of bronchi are destroyed and as a result bronchial walls become weak, "flabby", and unable to maintain their normal diameter and round shape. They dilate and acquire bizarre fusiform and saccular configurations. Bronchioles may be obliterated and the ones that remain are weak, mis-shapen, and larger than normal diameter. These weakened breathing tubes are prone to collapse during the expiratory phase of airflow and cause obstructive lung disease for pts. Because of the presence of chronic bacterial infections (pneumonia or cystic fibrosis) within bronchiectatic lesions, pts can have the following symptoms:

centrilobular, panlobular

________ emphysema appeared to be mainly a disease of the upper lobe and the apices within the upper and lower lobes. In contrast, _______ emphysema was a more or less diffuse process within lobes and lungs with mild preferential involvement of lower lobes.

emphysema and chronic obstructive bronchitis

COPD includes what two main conditions?

Lung abscess

Foul smelling sputum, necrotizing anaerobic pneumonia. Circumscribed collections of pus within the lungs.

Pneumonic consolidation, pulmonary edema, hyaline membrane disease.

Common causes of air bronchogram sign?