19- COAD/ COPD: Emphysema Flashcards
What is emphysema?
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Disease characterised by abnormal permanent expansion of air spaces distal to the terminal bronchioles with loss of alveolar walls and supporting elastic fiber network. Four categories are recognised–> centrilobular, panacinar, cicatricial and paraseptal
A. Lung Overinflation (panlobular)
– indiscriminate destruction of the acinar walls leading to air trapping
– vascular obstruction peripherally, may lead to pulmonary hypertension – little or no fibrosis
– bleb
• small, usually peripheral, interstitial collection of air – bulla
• large parenchymal collection of air
B. Increased Markings (Centrilobular)
– “dirty lungs” due to increased yet hazy vascular markings – hilar pulmonary arteries enlarged
– may see right ventricular enlargement from cor pulmonale – overinflation of lungs is not a characteristic finding
These two forms of emphysema may occur in combination, or may be associated with chronic bronchitis. Chronic bronchitis and asthma are primarily clinical diagnoses, and there are little or no distinct x-ray findings to confirm their diagnosis.
PHEUMONIA what is it? Causes? Radiographic findings? 1778
Its inflammation within lung tissue within the lung tissue beyond the airways, involving the respiratory bronchioles, alveoli
- consolidation of lung tissue
- can occur secondary to bacteria, viruses, fungi, parasites and chemical irritants
Findings:
- hazy ill defined opacities
- complete consolidation with air-bronchogram
- may be unilateral or bilateral
- usually respect pleural boundaries
Note: for findings of pulmonary consolidation, think about the following etiologic categories:
– Blood (can be focal or diffuse pattern)
o post-trauma or hemorrhagic disorders: eg, hematoma, Goodpastures
– Water (diffuse pattern)
o edema: eg, CHF, acute inhalation diseases
– Pus (focal or diffuse pattern)
o infection: eg, pneumococcal pneumonia, pneumocystis carinii
– Protein (diffuse pattern)
o rare: eg, avelolar proteinosis
– Cells (focal or diffuse pattern)
o (tumors, eg, alveolar cell carcinoma).
TUBERCULOSIS
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- is a chronic bacterial infection caused by mycobacterium tuberculosis
- chronic caseating granulomatous disease
Chronic caseating granulomatous disease cause by Mycobacterium tuberculosis
B. Radiographicfindings-primary
– right side more commonly involved – hilar lymphadenopathy is common – Ghon tubercle
IV.
• parenchymal granuloma associated with TB – Ranke complex
• a Ghon tubercle and hilar lymph node calcification
C. Radiographic findings - reactivation
– progressive infection
– poorly defined, incomplete consolidations which coalesce into radiopacities
– interstitial disease, fibrosis, and calcification (pulmonary, pleural) can be seen late
stage
SOLITARY PULMONARY NODULE/ MASS
A. Round to oval pulmonary radiopacities
SOLITARY PULMONARY NODULE/ MASS
a) Granuloma
b) Mass lesion
GRANULOMA
1. Well-defined calcified lesion, under 6cm in diameter
– May be classified as a nodule or mass, depending on size.
– Calcification can be central, peripheral rim, or solid (3 patterns that suggest
the lesion is benign)
2. Usually associated with slow growing infections (tuberculosis is the most
common)
3. Size of lesion remains stable for a long period of time (doubling time > 2 years)
MASS LESION
1. Pulmonary radiopacity greater than 3cm 2. Bronchogenic carcinoma (m.c.)
– may have fuzzy or lobulated border
– may have peripheral (but eccentric) calcification
– cell types: small cell and non-small cell (squamous cell, adenocarcinoma)
– Pancoast tumor: squamous cell carcinoma affecting the lung apex. May be
associated with Horner’s syndrome. Look for thick, apical cap, convex / irregular inferior border, adjacent bone destruction.
3. Some other causes of solitary pulmonary masses
– abscess, arteriovenous malformation, bronchial carcinoid tumors,
4.
bronchogenic cyst, chest wall lesion, granuloma, hamartoma, hematoma, intralobar sequestration…
Multiple nodules or masses
– metastasis and TB are most common
– other infectious and non-infectious, granulomatous conditions (eg, fungal infections, sarcoidosis, Wegener’s granulomatosis)
– other causes occur, but are uncommon
PNEUMOCONIOSES – ASBESTOSIS AND ASBESTOS-RELATED DISEASE
-due to inhalation of inorganic dust particles resulting in irreversible damage to lungs (pulomary fibrosis, carcinoma) and pleura (calcification, firbosis, malignant mesothelioma).
Radiographic features:
-manifestations depends on type of asbestos inhaled, how much exposure and lifestyle (smoker etc)
- Pulmonary Disease:
a) interstitial fibrosis–> diffuse white lines predominately effecting the lower lung zones until later in the disease
- shaggy heart boarder
b) Bronchogenic carcinoma–> ife xposed 60 x more likely to develop - Pleural Disease
- pleural plaques, diffuse pleural thickening, pleural calcification- seen along the rib contours and over the domes of the diaphragm and/or small pleural effusion
- malignant mesothelioma–> large pleural effusion, diffuse pleural thickening, pleural calcifications
- pleural and pericardial mass or masses, frequently encasing the lower lung
- one side involved, often with normal opposite lung field.
ATELECTASIS defined by: 4 types radiographic signs Linear/ subsegmental atelactasis 39
defined by: loss of volume of some portion of a lung
4 Types:
- Resorptive (obstructive)-due to obstruction of an airway from mass, mucous, foreign body, edema
- loss of volume, consolidation with no air-bronchogram - Passive (large area); compressive (focal area) opneumothorax, hemothorax (passive) oany focal lesion (compressive)
- Adhesive
odue to inactivation of surfactant, which allows walls to stick when alveoli expel
air - Cicatrization
oscarring/fibrosis of any portion of the lung, commonly seen with TB
C. Radiographic signs of volume loss
1. Direct:
o most reliable finding: displaced interlobar fissure
2. Indirect
o local increase in density
o crowding of pulmonary vessels
o elevation of hemidiaphragm on affected side
o mediastinal shift towards the affected side
o hilar shift towards the affected region
o compensatory over-inflation of the normal portion of the affected lung or
herniation of opposite lung across midline o crowding of the ribs (long term)
- Linear / subsegmental atelectasis
o a focal, linear area of partial volume loss, usually found in the lower lobes
o may be from primary pulmonary disease (eg, fibrosis), or secondary to abdominal
disease (eg, diaphragmatic splinting from liver abscess)
PLEURAL EFFUSION what is it? Radiographic findings some underlying causes? 40
A. Large collection of transudate, exudate, blood or chyle – non-specific sign of underlying pathology
B. Radiographic findings can range from:
– mild costophrenic blunting with meniscus sign to; – near complete hemithorax opacification
C. Someunderlyingcauses
– abdominal disease, chylothorax, collagen diseases, CHF, empyema, malignancies,
pneumonia, pulmonary infarct, renal disease, trauma, tuberculosis
PNEUMOTHORAX what is it? Types? Radiographic Findings? 40
A. Collection of air in the pleural space
B. Traumatic
C. Spontaneous – primary • rupture of bleb – secondary • chest disease with associated cysts or cavities
D. Radiographic findings
– crescent-shaped radiolucent shadow between the lung and chest wall – absence of lung markings
– thin pleural line
– best seen on full expiration, standing chest x-ray
CONGESTIVE HEART FAILURE Cardiac factors? right sided heart failure? Left sided heart failure? Radiographic Findings?
A. Cardiac factors
– preload, after load, myocardium contractility, heart rate
– disturbance of one or more can lead to an inability to circulate an adequate blood supply
B. Right-sided failure
– blood backs up systemically
– cor pulmonale
C. Left-sided failure
– Transudative fluids congest the pulmonary tissues and collect in the interstitial tissues and pleural space
D. Radiographic findings
– enlarged heart shadow
• single or multiple chamber enlargement
• shape of the heart depends on chambers involved – cephalization of blood flow
• increased vascular markings in upper lung fields compared to lower – pleural effusion
– pulmonary edema (peri-hilar opacification: butterfly/bat wing pattern) – Kerley A and B lines (edema of intralobular septa)
AORTIC UNCOILING AND ATHEROSCELROSIS
A. Usually older individuals with hypertension
B. Uncoiling = Aortic shadow “pulled away” from the midline
C. Atherosclerosis = Damage to the intima causes a collection of reparative
tissue, eventually calcifying and narrowing the lumen
– thin linear calcification along the lining of the aorta
– may appear ring-like on the PA view in the arch (knob)
HIATAL HERNIA
A. A portion of the proximal stomach (cardia, fundus) protrudes through the diaphragm into the chest cavity
B. Types
– sliding (m.c.)
– paraesophageal
C. Radiographic findings
– air-filled “mass”, which may demonstrate an air-fluid level
– mass lies midline over heart shadow on PA, behind heart on lateral – May need UGI contrast study to DDx from cavitating mass in chest
