Chest Flashcards
By convention, lateral X-rays are taken in which position?
Left lateral
normal thickness pst wall bronchus intermedius
<3mm
the black hole
left upper lobe bronchus
what runs through the black hole?
bronchus intermedius
how much higher is left hilum point/angle vs right?
1cm
Hilar point/angle
crossing of RUL pulm v and RLL pulm a
inferior hilar window
btw RUL bronchus and bronchus intermedius
retrotracheal/raider triangle obliterated in what testable setting?
aberrant right subclavian artery
pointy parts mechanical valves point in which direction?
toward direction of BF
PM lead through which valve?
TV
bigger: MV vs AV?
MV
azygos lobe fissure-how many layers of pleura?
azygos v displaced laterally
-covered by 4 layers pleura
how many segments R vs L
R-10
L-8
pig/tracheal bronchus
RUL bronchus off trachea
-asyx, air trapping, recurrent inf
cardiac bronchus-where does it come off, syx’s
supernumerary BLIND ENDING bronchus off bronchus intermedius
-asyx, recurr infs
superior mediastinum
thoracic inlet–>sterno-manubrial junction
contents pst mediastinum
es, thoracic duct, desc aorta
MC pulmonary v anatomic variation
v drains right middle lobe
-matters to electrophysiologist in setting of ablation
Proximal interruption of pulmonary artery
- Congenital absence of R > L PA w/ more distal pulmonary vasculature –> hemithorax volume loss
- opposite side of AA
- ass: PDA. Left PA: TOF, Truncus
- recurrent infections (lack of bs)
patterns of atelectasis
- obstructive/absorptive
- compressive/relaxation/passive
- fibrotic/cicatrization
- adhesive
superior triangle sign
RUL (RLL?) atelectasis –> mediastinal vess pulled R –> trianglular opacity R of trachea
right middle lobe syndrome
chronic RML atelectasis via MAI
S Sign of Golden
RUL central obstr
luftsichel sign
LUL central obstr
non visualization aortic knob
LUL atelectasis
peaking of diaphragm
-volume loss –> pulmonary ligament
flat waste sign
flattened hilum & heart border in LLL atelectasis
cervicothoracic sign
obliteration pst junction line (above clavicles) –> pst mediastinal mass
pulmonary vs mediastinal origin angles w/ lung
acute=pulm
obtuse=mediastinal
lobar PNA-types
- SP
- legionella
- klebsiella
- proteus
- morganella
BW: bulging fissure
klebsiella
-exuberant inflamm
Staph Aureus PNA appearance
bronchopulmonary- BL, patchy opacities, abscess
-MRSA-no classic findings
anthrax classic app
- hemorrhagic lymphadenitis, mediastinitis, hemothorax
- med widening
klebsiella vs conventional PNA
+inflamm, PE, empyema, cavity
- EtOH, nursing home
- “current jelly” sputum
H influenza PNA-app, who
bronchitis +/- BL LL bronchopneumonia
-COPD, ø spleen
pseudomonas-app, who
- icu on vent. CF/1˚ ciliary dyskinesia
- patchy opacities, abs, Pl Eff common (small)
areas of ground-glass attenuation - tends to involve multiple lobes and may demonstrate an upper zonal predilection 4
bronchial wall thickening
peribronchial infiltration and areas of consolidation.
legionella-who, appearance
-COPD, crappy air conditioners
-per sublobar opacities surr by GG
+cavitation in immunosuppressed
*xray lag behind resolution of symptoms
xray lag behind resolution of symptoms
legionella
mcc pulmonary cavitation/abscess
aspiration PNA
aspiration PNA-where, img, compl
- R side. Supine: pst lobes. Upright: basal lower lobes
- MCC pulmonary cavitation, abs
- mc compl=empyema –> bronchopleural fistula
mc complication of aspiration PNA
empyema –> bronchopleural fistula
actinomycosis-how, img
- dental procedure –> mandible osteoporosis –> aspiration
- per lower lobes
- aggressive + rib OM, cw invasion
mycoplasma pulmonary findings
reticular + TIB
nocardia PNA
- 50% immcompr, common s/p cardiac transplant. AIDS < 50
- consolidation/mass, nod w/ surr reticulation +/- cav
- PlEff
- +/- inv pleura, cw, mediastinum
- necrotizing in imm compr
pulmonary considerations s/p bone marrow tx
- infection (50%, MCC death)
- Graft vs Host
- PTLD
Pulmonary graft vs host-phases
- Acute (20-100d)- GI, skin, liver.
- Chronic (>100 d)-lymphocytic infiltration of aw & obliterative bronchiolitis
Bmarrow Tx pulmonary findings time divisions
- early neutropenic (0-30d)
- early (30-90d)
- late (>90d)
Early neutropenic s/p bmarrow tx-time frame & pulm findings
- <30 d
- pulm edema, hemorrhage, drug induced lung injury
- fungal PNA (invasive aspergillosis)
Early pulm findings s/p bmarrow tx-time frame & pulm findings
- 30-90 d
- PCP, CMV
Late pulm findings s/p bmarrow tx-time frame & pulm findings
- > 90
- bronchiolitis obliterates, cryptogenic orgz pna
CD4 >200
- bacterial
- Tb
CD4 <200
PCP, atypical mycobacterium
CD4 <100
CMV, disseminated fungal, mycobacterial
PCP classic findings
- central/perihilar UL gg opacities
- +/- thin walled cystic in gg opacities (30%)
AIDS + gg
PCP
aids + opacity
strep pna=MC
- CD4 low-Tb
- chronic-lymphoma or capos
aids + persistent opacities
lymphoma
aids + flame shaped perihilar opacity
kaposi sarcoma
aids + lung cysts
lip (pediatric)
Aids + lung cysts + gg + PTX
PCP
aids + hyper vascular LNs
castleman or kaposi
aids + MF airspace opacities
bacterial or fungal
aids + gg
PCP
-<100 and PCP as answer choice not provided: CMV
4 phases of Tb
- 1˚
- 1˚ disseminated
- latent
- 2˚/post 1˚/reactivation
immune reconstitution inflammatory syndrome
- worsening of syx’s in AIDS + Tb once started on HAART
- rx: steroids
1˚ Tb MOA:
inhalation –> necrosis –> immune mediated attack –> granuloma (ghon focus) –> nodal expansion –> Ca (ranke complex) –> atelectasis (obstr)
- -> rupture: endobronchial (aw) or hematog (bv) spread =1˚ progressive spread
- pleural effusions
- cav uncommon
Tb LAD in kids
-bulky
what determines MOA of TB 1˚ progressive spread?
if node ruptured into aw (endobronchial spread) or bv (hematog spread)
RFs for 1˚ progressive spread in Tb
- HIV (MC)
- other imm suppr: tx, steroids
- jejunoileal bypass, subtotal gastrectomy, silicosis
Latent Tb
- (+) PPD, (-) CXR, ø syx’s
- vaccination
- PPD conversion = 9 mo INH
Tb post primary/reactivation
- progression MC
- UL/sup LL cavitation + nodular opac (endobronchial spread)
- Hematog spread –> miliary pattern
- Rasmussen aneurysm-pulm a’s near cavity
AIDS + Tb
- CD4 >200-reactivation (cavitation)
- CD4 <200- 1˚ progressive (adenopathy, consolidation, biliary)
- NOT lobar
non-TB mycobacterium to know-orgm names
- M avium-intracellulare complex
- M Kansasii
- M absessus
cavity/classic type non-tb myco
old white male smoker. looks like reactivation Tb
non-classic/bronchiectatis type non-tb myco
RML & lingular TIB + cylindrical bronchiectasis
HIV type non-tb myco
CD4 <100
GI –> blood –> mediastinal LAD (MC)
+other pulm findings bc often mixed with other inf
+SMG, HMG
Hypersensitivty type non-tb myco
CL gg opacities
3 types of aspergillus
1) normal immune-aspergilloma
2) suppressed immune- invasive, “air crescent sign”, halo sgx
3) hyperimmune-bronchiectasis + finger in glove
aspergilloma
aspergillum ball in EXISTING cavity
*moves w/ positional change
invasive aspergilloma-who, classic sgx’s
- AIDS, tx
- peripheral wedge shaped infarcts +
- air crescent sign-healing 2-3 wk s/p rx
- halo sign
Allergic broncho pulmonary aspergillosis-ing features and dx criteria
UL, central bronchiectasis saccular bronchiectasis + finger in glove
-diagnosis requires:
1) serum IgE (+) OR (+) Asp hypersensitivity skin test
+
2) total IgE >1000,
mucormycosis
- invasive fungus
- impaired immunity (DM, steroids, aids)
- face + lungs + medisatinal, pleural, cw invasion
CMV PNA who
- reactivation s/p bmarr tx
- infusion of CMV positive marrow/other blood products
cmv PNA img
mult nodules, gg or consolidation
measles pna
Mult gg opacities + smaller nodules
- bf or after skin
- compl + in pregnant or immunocompromised
influenza PNA
coalescent LL opacities, Pl Eff rare
-ie: think covid 19 vibe
varicella-appearance
mult peripheral nodular opacities
-Ca when healed
varicella peds vs adults
- peds: chickenpox
- adults (immcompr)=pna
EBV ass
-ass w/ PTLD (pst transplant lymphoproliferative disorders) and ARL
EBV pna
LAD + SMG. lungs uncommonly affected.
MC radiographic abN of EBV
SMG
COVID-19 acute vs chronic
- Acute (<14 d): BL per GGO, bronchovascular thickening. Crazy paving & reverse halo
- chronic (>14d): fibrous stripes
CAVITY
Cancer (SCC) AutoImmune (granulomatosis w/ polyangiits, RA, Caplan) Vascular (SE, bland emb) Inf (Tb, SA, aspiration) Trauma-pneumatoceles Young (CCAM, sequestration)
Lung cancer RFs
- age (v rare <40yo)
- smoking (90% of lung cancer cases)
- copd (even if you didn’t smoke)
- exposure-arsenic, nicke, uranium, asbestos, chromium, beryllium, radon
- family hx
- fibrosis-10x the risk
who gets screened for lung cancer?
-55-80 yo + 30 pack yr hx (currently or quit in last 15 yrs
CT dose recommendation for lung cancer screening
CTDI vol < 3mGy
what’s considered “growth” for lung nodule?
1.5 mm in 1 yr
What scoring system is used in lung cancer screening?
LUNG RADS
how do you score findings in lung cancer screening?
One nodule (most suspicious)
Can you be enrolled in lung cancer screening with a history of lung cancer?
Treated, remote (>5 yrs) and must fall into normal inclusion criteria (55-80 yo + 30 pack yr)
Fleischer Society Overview
- incidental SOLID nodule
- > 35 yo w/o known or suspected malignancy, imm compromise
- risk stratification (mild, intermediate, high)-RFs & nodule characteristics
- f/u based on arbitrary guess of cancer risk >1%
- thin slice CT (<1.5mm)
how to measure nodule for FS?
avg diam (short + long/2)
Fleichner Society RFs to consider
smoking, cancer hx, family hx, age, exposures
what to do with perifissural nodules re: FS
nothing
how are nodules stratified re: FS
number & risk
-risk= nodule char + pt RFs
likely of malignancy re: nodule density
- mixed > gg > solid
- solitary > mult
SPN benign morph Ca
1) solid/diffuse
2) laminated
3) central
4) popcorn
SPN malignant morph Ca
- eccentric
- popcorn + GI
- solid + osteosarcoma
What makes you think benign SPN?
- fat
- rapid doubling (<1 mo)
- slow doubling (>16 mo, 2 yrs=B9)
what makes you think cancer in setting of SPN?
- spiculated (“corona radiata sgx”)
- air bronchogram (5x MC in malignant SPN, 50% adenoCa)
- mixed density
when do you use PET for SPN? What SUV is considered HOT? when do you think cancer vs B9?
- > 1 cm
- SUV > 2.5
- solid: hot=CA, cold-not
- gg: hot=inf, cold=CA
Lung CA MC loc?
- UL (70%)-exc LL fibr
- R (1.5x)
SPN in setting hot h/n CA?
-1˚ > met (sim RFs)
nodule decreasing in size: mal or b9?
either! (mal if increasing density)
Paraneoplastic syndromes of lung cancer
- nonSC: parathyroid
- SC: SIADH, ACTH, Lambert eaton (often bf dx)
Lambert eaton
proximal weakness from abN release acetylcholine at NMJ
TTF-1 (thyroid transcription factor 1) and lung CA
-not expressed in non-small cell squamous
MC lung CA subtype to present as SPN
Adeno
MC and least common lung CA subtypes
- MC= AdenoCa (35%)
- LC= non-SC large (15%)
Lung AdenoCA loc and known ass
- Upper lobe, per
- pulm fibrosis
LA is on the Coast
Large & Adeno favor peripheral locs
lung CA loc based on syx
central=hemoptysis
-per=pleuritic cp
MC 1˚ lung CA to cause SVC obstr & PNS?
small cell
Small cell lung CA img
central LAD
spectrum of adenocarcinoma
- pre-invasive
- AAH: atypical adenomatous HP of lung
- ACIS (Adeno In Situ)
- minimally invasive adenoCA (MIA)
- Invasive mucinous adenoCA
Atypical adenomatous HP of lung (AAH) vs Adeno In Situ (ACIS) vs minimally invasive (MIA)
- AAH: <5mm, mild, gg
- ACIS: <3cm, mixed
- MIA: <3 + stromal invasion (<5mm) (>5mm=lepidic)
superior sulcus/pancoast tumor-cause, pres, img modality used to stage, ci to sx
- non-SC
- shoulder pain
- staging: MRI (brachial plexus)
- CI to surgery:
- 50% VB
- spinal canal
- upper brachial plexus (C8+)
- diaph paralysis (C3-5)
- distal mets
measuring a nodule for lung CA staging
- solid=max diam
- mixed- solid part
staging multiple lesions in lung CA
- synchronus-others=mets, changes stage
- metachronous- stage individually
important nodal stage for lobectomy/resection
Stage 3B=N3 or T4, surgically unresectable
level 1 vs 2 nodes in lung CA
- border: lower level of clavicles/upper border of manubrium
- level 1= above, N3
- level 2= below, N2
who gets wedge resection in lung Ca
stage 1A/B, per & <2cm
wedge resection vs lobectomy
wedge = better pulm reserve
bronchopleural fistula s/p pneumonectomy
-post op space progressively filling w/ air rather than fluid
compensatory emphysema (post pneumonectomy syndrome)
-hyperexpansion of lung to compensate fo absence of other
pulmonary radiation changes
- immediate-bubbles
- early (1-3mo)-homogenous patchy ggo.
- late-dense consol, traction bronchiectasis, volume loss
- linear
- rib fx
lung CA recurrence
High (2yrs)
- loc: per of radiation bed, regional LNs, bronchial stump
- app: enhancing, enlarging round lesion along resection line/bronchial stump. New LNs (>1cm), new persistent PlEff
mc benign lung mass
hamartoma
pulmonary hamartoma classic app
- fat (60%) & popcorn Ca
- hot on PET
- uncommonly endobronchial
MC lung tumor in AIDs
- Kaposi sarcoma (requires CD4 <200)- MC
- lymphoma-2nd MC
MC liver neoplasm in AIDS
Kaposi sarcoma
kaposi sarcoma pulmonary img, consistency of pl eff
- slow growing flame shaped opacities in asyx pts
- bloody Pl Eff (50%)
- thall+, gall (-)
MC pulm mets via dir invasion
- es
- lymphoma
- malignant GC
GEL
order of commonness: pulm met, pleural met, mesothelioma pulm met
-in that order
mc img hematogenous mets to lungs
-mult round, smooth-bordered, randomly distr LL nodules
cannonball mets-which cancers?
RCC, chorioCA (testicle)
lymphangitic carcinomatosis causes
- bronchogenic CA=MC
- breast, stomach, pancreas, prostate (paint brush paint brush serosa)
lymphangitic carcinomatosis vs fibrosis
LC does not distort lobule
pulmonary lymphoma 4 flavors
- 1˚
- 2˚,
- AIDS
- PTLD
1˚ pulmonary lymphoma-time frame to qualify, type
- > 3 mo’s w/o extrathoracic involvement
- rare, NHL (MALToma)
2˚ pulmonary lymphoma-HL vs NHL lung parenchyma involvement and percent cases Intrathoracic at time of presentation
- pulm inv of systemic lymphoma
- NHL>HL
- HL = LN + parenchyma (40%), 85% Intrathoracic at pres
- NHL-parenchyma (25%), 45% Intrathoracic at pres
pulm PTLD-what, when, img
-bcell lymphoma ass w/ EB virus s/p solid or stem cell tx
-~1 yr (later=more aggressive)
-well-defined nods/mass, patchy as consol, halo, interlobular thick
+/- nodal dx
AIDS related pulmonary lymphoma (ARPL)-ass, CD4 county, img, other findings
- high grade NHL, EBV ass
- CD4<100
- MC img: mult per nods (1-5cm), PlEff, LAD
- extranodal common: CNS, bmarr, lung, liver, bowel
thallium vs gallium in kaposi vs lymphoma vs toxo
- Kaposi: Thall+, Gall (-)
- lymphoma: Thall + , Gall +, PET+
- toxo: thall -, gall +
Poland syndrome
UL abscent pectoral major & minor +/- weird limbs
bronchial atresia
- in utero vascular insult –> SHORT SEGM lobar, segm, subsegmental bronchus
- LUL apical pst segm
- MC= hyperinflated lobe (via collateral flow through pores of Kohn and canals of Lambert)
- decreased pulm vasc
- hilar nodule (branching, finger in glove)
- asyx, recurr pna
ddx mucous plug in bronchial atresia
endobronchial tumor.
- mucoid impaction= <25 HU
- bronch for indeterminate lesions
avm- moa, where, img, rx
- sporadic (MC), hereditary (HHT/Osler Weber Rendu)
- LL (bf)
- compl: R–> L shunt, stroke,
- rx- afferent vessel >3mm+
MC congenital venous anomaly of chest
persistent left SVC –> coronary sinus
-problem if –> LA (R–>L shunt)
Swyer James
post vial obliterative bronchiolitis (via contributive bronchiolitis –> small lung –> compensatory BL UL lucent lung
Horse-shoe lung-where, ass
- fusion of LL pst basilar segms behind heart
- scimitar syndrome
Spares costophrenic angles
LCH
HSP
Asbestos pleural plaque
Birt Hogg Dupe
- LL pulm cysts (favor paramediastinal region) (closer to kidneys)
- BL oncocytomas
- chromophobic RCCs
lymphangiomyomatosis (LAM) ass
Tuberous sclerosis
tuberous sclerosis triad
- seizure
- MR
- adenoma sebaceum
- Seizure, Sebaceum, Stupid
Lymphocytic interstitial PNA ass
- adult: Sjogren (MC), SLE, RA)
- kids: HIV
vanishing lung syndrome
idiopathic necrosis of lung parenchyma & hyperinflation –> BL UL bullous disease occupying at least 1/3 hemithorax
- young men
- 20˚ alpha 1 antitrypsin deficiency
- compl: tension ptx
vanishing lung RFs
- smoking, marijuana
- alpha-1 antitrypsin deficiency
- male
saber sheath trachea
coronal narrowing of trachea <2/3 sag diam, sparing extrathoracic portion
***COPD
central dot sign
vessel w/i secondary pulm lobule in centrilobular emphysema
what to think if you see cavitation in setting of silicosis?
Tb
who gets progressive massive fibrosis (PMF)
silicosis, coal workers pneumoconiosis
ship yard
asbestosis
miners, quarry workers
silicosis
Quarry workers use powerful machinery to dig and drill rock, sand, slate, gravel, and minerals from quarries and mines. They crush, transport, and process these aggregates for use, often on construction sites.
washed coal
coal workers pneumoconiosis
aircraft/space industries
berylliosis
Nitrogen dioxide
silo fillers disease
Silo-filler’s disease. “Silo-filler’s disease”—a syndrome caused by nitrogen dioxide. Silage gas poisoning: nitrogen dioxide pneumonia, a new disease in agricultural workers. NO2 is derived from the nitrates in corn or hay that are converted to nitrites and oxygen by anaerobic fermentation, which eventually yield NO2.
filler tablets
talcosis
cancer vs PMF
cancer=T2 bright
PMF=T2 dark
2 types of NSIP
cellular, fibrotic
lung fibrosis & cancer
- progressive wall thickening or developing nodule w/I cyst
- favors interface btw fibrotic cyst and N lung
- NELSON trial-we miss them
“heterogenous histology”
UIP
Sarcoid CXR staging
0-N 1-nodes 2-nodes + lung 3-lungs 4-end-stage (fibrosis)
Lofgren Syndrome
LAD
nOdosum
Feet
“Acute sarcoid”
1) BL hilar LN enlargement
2) arthritis (ankles) (male)
3) erythema nodosum (female)
stages of CHF
1) “redistribution”-wedge P 13-18 mmHg
2) interstitial-18-25
3) alveolar-25+
sarcoid labs
ACE+
Ca+
pulmonary alveolar proteinosis (PAP)-ass, risk of infection, fibrosis risk, rx
- ass: smoking (in peds: alymphoplasia)
- inf: nocardia 2/ brain abscesses
- 30% risk fibrosis
- rx-bronchoalveolar lavage
types of lipoid PNA
- exogenous
- endogenous-MC. Post obstructive process (CA)–> lipid laden MP
acute exogenous lipoid PNA
- childen who accidentally poison themselves w/ hydrocarbons
- fire eating/flame blowing
orgz/cryptogenic PNA-MOA, causes, rx
- granulation tissue depo in alveoli –> fibroblast proliferation, ie: not an active inf (abx don’t help)
- cryptogenic=not known
- other causes
- inf
- amiodarone
- collagen vasc disease
- fumes
- rx-steroids
Upper lobe disease distribution
- CF
- APBP
- Chronic Eusinophilic PNA
- hypersensitivity PNA
- pneumoniosis
- pulmonary lagerhans cell histiocytosis
- RB-ILD
- Sarcoid
- 1˚ Tb
- PCP
- ankylosing spondylitis
halo sign
solid surr by gg (hemorrhage/invasion into surr ties)
- invasive aspergillosis (classic)
- other fungus
- hem mets
- adeno in Situ
- wegeners
reverse halo
central gg w/ rim of consolidation
- COP (classic)
- tb
- pulm infarct
- covid
- invasive fungal & wegeners (also halo)
“headcheese”
hypersensitivity pneumonitis (mix of everything)
AW/bronchial disease that spare pst membrane
relapsing polychondritis
-tracheobronchopathia osteochondroplastica (TBO)
AW/bronchial disease that don’t spare pst membrane
- amyloid
- post-intubation
- wegeners
tracheal thickening relapsing polychondritis
- smooth, diffuse antlat thickening. + Ca if chronic
- recurr episodes cartilage inflamm, recurr PNA
post intubation tracheal thickening
subglottic circumferential stenosis, hrglass configuration
tracheobronchopathia osteochrondroplastia (TBO)
anterolateral cartilaginous/osseous nodules in submucosa of tracheal & bronchial walls
amyloid tracheal thickening
circumferential irregular, focal/short segment thickening
-+Ca
Wegener’s tracheal thickening
- subglottic circumferential, focal or long segment
- no Ca
tracheal/bronchial tumors
- SCC-MC
- adenoid cystic -2nd MC
- carcinoid
- mets
- squamous call papilloma
primary ciliary dyskinesia ass
Kartagener’s syndrome )50%)
William campbell syndrome
congenital cartilagenous deficiency of 4th-6th order bronchi –> cystic bronchiectasis
mounier-kuhn (tracheobronchomegaly)
tracheal dil >3cm
follicular bronchiolitis
- inflamm process rel to lymphoid HP
- RA, Sjogrens
- CL gg nodules, scattered bronchial dilation
constrictive bronchiolitis
inflamm post virus, tx, drug, inhalation, DIPNECH
- 2/2 mononuclear cells –> granulation tissue –> plug aw
- air trapping
- process seen in Sawyer James
Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) is an extremely rare pulmonary disorder at the benign end of the neuroendocrine cells proliferation spectrum. It is mainly seen in non-smoker middle-age females with a history of chronic cough or asthma.
small aw disease
- infectious bronchiolitis-TIB
- RB-ILD-CL gg nodules. Smokers
- sub acute hypersensitivity pneumonitis-CL gg nodules. Inhal organic
- follicular bronchiolitis-CL gg nods. RA, Sjogrens
- constrictive bronchiolitis-air trapping. viral, rx, drug, inhalation, DIPNECH
mc complication aspiration pna
empyema
mendelson’s syndrome
aspiration gastric acid–> as opacity, massive pulm edema
aspiration of water or neutralized gastric contents
“fleeting opacity”, resolves in hours
aspiration of germs (often mouth bugs)
PNA
aspiration of oil (often mineral oil)
lipoid PNA
aspiration patterns/syndromes
- gastric acid-opacity, pulm edema
- water/neutralized gastric content-opacity resolves hrs
- bugs (From mouth)-pna, cavitation, abscess, empyema
- oil-lipoid pna
ankylosing spondylitis
Upper lobe fibrobullous disease (UL –> BL)
shrinking lung
progressive volume loss in pts w/ SLE (SL=SL)
what makes breathing worse inhepatopulmonary syndrome vs CHF
HPS: worse sitting up
CHF: worse laying down
mc orgn involved with granulomatosis w/ polyangiitis
lung (95%)
-randomly distr nodules +/- cavitation, gg (hem), pl eff (15%)
goodpasture syndrome
- BL coalescent AS opacities (hemorrhage), resolve ~ 2wks
- recurr–> fibrosis
- pulm hemosiderosis-small ill defined nodules
Caplan syndrome
RA + silicosis/CWP
-UL predominance lung nodules +/- cav, pl eff
how much pleural fluid to diagnose a pleural effusion on AP film?
175 cc
how much pleural fluid to diagnose a pleural effusion on lateral film?
50cc
time lag s/p asbestos exposure: pl effusion, plaques, mesothelioma
- pl eff: 5 yrs
- plaques 20-30 yrs (Ca 40yrs)
- lung Ca-~20 yrs
- mesothelioma-30-40 yrs
pleural rind along medial surface
mesothelioma
Pleural Ca
- asbestosis
- old hemothorax
- old inf
- Tb
- extraskel osteosarcoma
*fibrothorax
solitary fibrous tumor of pleura (SFTP)-what, ass
solitary tumor arising from visceral pleura
-Doege-potter syndrome (hypoglycemia via insulin-like GF) 5%
pleural mets-MC CA
- lung (adenoCA)
- breast, lymphoma
pleural mets- MC manifestation
pleural effusion
most common benign pleural ST tumor
lipoma
subpulmonic effusion
pleural effusion accumulates btw lung base and diaphgram
- R > L
- ski sloping of diaph peak
encysted pleural effusion
round shape via collection btw pleural layers
empyema vs pulm abscess
- empyema=lentiform, split pleura sign, ct
- abscess= round, claw sign, abx
split pleural sign
- thickening/separation of visceral & parietal pleura
- empyema
why don’t you treat pulm abscess w/ chest tube?
risk of bronchopleural fistula
who gets empyemas
mc in AIDS
emphysematous necessitans-causes
- Tb (70%)
- actinomyces
diaphragmatic paralysis causes
idiopathic 70%
-lung cancer (phrenic n compression)
thymus pathology
- rebound
- cyts
- thymoma
- thymic carcinoma
- thymolipoma
thymus rebound vs lymphoma
- Lymphoma hotter on pet
- thymic rebound drops out on MRI in phase img
thymus cyst etiology
- cong
- acquired (thoracotomy, crx, HIV)
thymus cyst img
- UL or ML
- T2 bright
thymoma spectrum. Differentiation.
- non-invasive thymoma –> invasive (30%) –> CA (distal met)
- Ca, invasion mediastinal fat/adj structures=aggressive
- invasive drop met–> pleura, pericardium, RP (img abd!)
thymoma ass
- MG
- pure red cell aplasia
- hypogammaglobinemia
thymolipoma
fatty mass in thymic ST
MC thoracic GCT, ass
- teratoma (75%)
- klinefelter syndrome
- cystic (90%), fat, teeth
- small risk malignancy
ant mediastinal masses
- lymphoma
- thymic lesions (Rebound, cyst, thymoma spectrum, thymolipoma)
- GCT
- pericardial cyst
- thyroid lesions
fibrosing/sclerotic mediastinitis-types
- granulomatous (MC)-histo, tb, sarcoid
- non granulomatous/idiopathic-AI (SLE, RA, behcet, etc), radiation, methysergide (headache mx). NG ass w/ RP fibrosis
granulomatous vs non-gran fibrosing/sclerotic mediastinitis
- granulomatous-ST mass + Ca
- non-gran-infiltrative, lack Ca, enh+
compl of fibrosing/sclerotic mediastinitis
SVC syndrome
mc loc bronchogenic cyst
subcarinal (obliterate azygoesophageal line) –> pulm
mediastinal lipomatosis-what, ass
excess unencapsulated fat w/ steroids, Cushing, obesity
middle mediastinal masses
- lymphoma, LAD
- fibrosing mediastinitis
- bronchogenic cyst
- mediastinal lipomatosis
pst mediastinal masses
- neurogenic=mc (schwannoma=mc, neurofibroma, malignant peripheral n sheath tumors). SNS ganglion tumors MC in peds/young adults (ganglioneuroma, NB, GNB)
- extramedullary hematopoiesis
- hiatal hernia
- desc thoracic aortic aneurysm
- lateral meningocele (ass w/ NF)
- esophageal neoplasm
- foregut dupicliation cyst
- paraspinal abscess
who gets extramedullary hematopoiesis
- response to bmarrow failing to respond to EPO
- CML, PCV, myelofibrosis, SCD, thalassemia
pulmonary artery aneurysm/pseudoaneurysm
1) iatrogenic 2/2 SG cath=MC
2) behcets, giant cell vasc
3) chronic PE
syndromes ass w/ pulmonary aneursym/pseudoaneurysm
- hughes-stovin syndrome
- rasmussen aneurysm
- tetrology of fallot repair
hughes stovin syndrome
- recurrent thrombophlebitis
- pulm artery aneurysm and rupture
Pulm hypertension
> 25 mmHg
img pulp htn
- 29+ mmHg
- PA > aorta, segmental a’s > bronchus
- eisenmenger phenomenon-mural Ca of central pulm a’s
banana and egg
visualization of main pulm artery (egg) at level of aortic arch (banana) in setting of PHtn
carina crossover
right PA crosses carina midline anteriorly rather than more caudal location in setting of PHtn
westermark sgx
regional oligemia
focal area of increased translucency due to oligaemia is caused by impaired vascularisation of the lung due to primary mechanical obstruction or reflex vasoconstriction.
fleischner sgx
enlarged pulmonary artery
hampton’s hump
peripheral wedge shaped opacity
mc radiographic abN in PE
pleural effectivement (30%)
PAH + normal wedge
pulmonary veno-occlusive dx
diaphragmatic injury
- L > R (liver=buffer), pstlat
- radial orientation, >10 cm
- “collar/hour glass” and “dependent viscera” sgx’s
collar/hour glass sign
waist-like appearance of herniated orgn thru injured diaphysis
dependent viscera sgx
abscent interposition of lungs btw cw and upper abd organs (liver on right, stomach on left)
pulmonary trauma
- diaph injury
- tracheo-bronchial injury
- macklin effect
- boerhaave syndrome
- flail chest
- PTX
- Hemothorax
- extrapleural hematoma
- pulmonary contusion/laceration
- malpositioned chest tube
- aortic rupture
- blunt cardiac injury
- fat embo
- barotrauma
trachea-bronchial injury-where
- w/i 2 cm of carina
- close to carina –> PMX (vs PTX)
- pstlat trachea
Macklin effect
- blunt trauma –> alveolar rupture –> air dissection along bronchovascular sheaths–> PMX
- MCC PMX in trauma
flail chest
- 3+ segmental rib fx (more than 1 fx in a rib) OR 5+ adj rib fractures
- paradoxical motion w/ breathing
“inversion/flattening of diaphragm”
tension PTX
hemothorax density
35-70 HU
when does malpositioned chest tube occ?
background lung disease or pleural adhesions
“blood around chest tube”
malpositioned
complication malpositioned chest tube
bronchopleural fistula
“persistent fluid collection after pleural drain/tube placement”
extra pleural hematoma
BW: “displaced extra pleural fat”
extra pleural hematoma
MC lung injury from blunt trauma
pulmonary contusion (alv hemorrhage w/o alveolar disruption)
img pulmonary contusion
- opacities, sub pleural sparing
- 6–>72hrs (if longer: aspiration, PNA, laceration)
ductus bump
normal variant aortic bulge mimicking aortic injury
MC areas of aortic injury
- isthmus
- root
- diaph hernia
fat embolism timing, app, where
- 1-2 d s/p long bone fx
- pulm edema, no arterial defect!
- resolves 1-3 wks
- skin (rash), lungs, brain
who’s most at risk and who’s protected from barotrauma?
- COPD
- fibrotic lungs (don’t stretch)
Fleishsner Society breakdown of rules
- <6 mm: 12 mo f/u high risk
- 6-8mm: single 6-12mo f/u, mult 3-6mo f/u
- > 8 mm: single: PET or bx, mult: 3-6mo
Mesothelioma causes
80% asbestos. NOT dose dependent.
“pleural ring along medial surface”
mesothelioma
gold standard PE diagnosis
catheter angiography
utility of D-dimer in PE diagnosis
100% negative predictive value
Diagnosis chronic PE
VQ scan
pulmonary neuroendocrine tumors
- in order of aw–> not in aw
- typical carcinoid (low grade malignant)
- atypical carcinoid (intermediate grade malignant)
- large & small cell carcinoma (high grade malignant)
img pulmonary NE tumors
- typical carcinoid (50 yo)
- central endobronchial (distal to carina, rare in trachea and parenchyma).
- <3cm
- central lumen
- Ca 30%
- homog enh+
- parenchymal=welldefined nodules
- atypical carcinoid (60 yo, smoker)
- peripheral (distal to segm bronchi)
- > 3 cm
- partially endobronchial
- enh+
- Large cell (per, 3.5cm)
- SCLC-large central/mediastinal/hilar mass
- DIPNECH-diffuse idiopathic pulmonary neuroendocrine cell HP-multiple lung nodules/tumorlets <5mm
syx carcinoid
- hemoptysis (highly vascular)
- obstructive
carcinoid nuclear medicine
- ocreotide
- PET cold 25%
endobronchial vs GI carcinoid
- endobronchial: Left heart. Uveal tract met
- GI: right heart, extra ocular
2nd mc tracheal malignancy
adenoid cystic (low grade, 40 yo, no ass w/ smoking)
- upper trachea (pstlat), main or lobar bronchus
- *perineural, submuc spread
- var app: infil trach & med fat OR nodular stenosis
- HOT on pet
MC tracheal malignancy
SCC
-lower trachea/prox bronch
endobronchial mets
lung, thyroid, esophagus
mc benign tumor of trachea
squamous cell papilloma
- single=smoking
- mult=HPV-6. (laryngeal MC, trach 5%)
Endobronchial tumors
- SCC-mc mal
- adenoid cystic=2nd mc mal
- carcinoid/atypical carcinoid/small cell
- squamous cell papilloma
- mets (breast, renal, lung, thyroid, esophagus) (BREaTh)
- mucoepidermoid
- tracheal lymphoma (MALT), low grade
CF vs 1˚ ciliary dyskinesia
CF -abN mucous, cilia cannot move it -normal sperm, absent vd -UL bronchiectasis 1˚ CDK -abN cilia, normal M -abN sperm (can't swim), N vd -LL bronchiectasis
Intrathoracic findings lupus
- pl eff, pericardial eff MC
- fibrosis UC. “shrinking lung”
collagen vascular induced UIP
-sarcoid, RA, scleroderma
pulm findings RA
UIP or COP
-lower lobe
Scleroderma pulmonary
NSIP> UIP
LL
-dilated fluid filled es
Sjogren pulmonary
LIP
ankylosing spnondylitis
fibrobullous disease UL–>BL
-UL
lower lobe diseases
- RA, scleroderma
- asb-(particles too large to be cleared by lymph)
- 1˚ciliary dyskinesia
- 1˚ tb
Fleischner sign
widening pulmonary arteries due to clot
right heart strain numeric suggestions
RV:LV >1, >1.5 severe
Single pulmonary eusinophlia/Loffler syndrom
idiopathic transiet, migratory consolidations (otherwise appears ID to drug rxn, parasites)
-eusinophila
eusinophilic lung dx
- single pulmonary eusinophlia
- chronic eusinophilic PNA
pulmonary vasculitis
- churg-strauss
- microscopic polyangiitis
- wegener granulomatosis
churg-strauss/allergic angiitis & granulomatosis img
- transient/migratory peripheral consolidation/gg, interlob wall thickening
- asthma, peripheral eosinophilia, P-ANCA
- other orgn (renal fx, arthraligia, myocarditis, pericarditis)
p-ACNA
- churg strauss
- microscopic polyangiitis
- collagen vascular dx
churg-strauss triad
1) eusinmophilia
2) necrotizing vasculitis
3) asthma
MCC pulmonary hemorrhage w/ renal fx
microscopic polyangiitis
-renal (90%)> pulm (10%)
microscopic polyangiitis img
central gg (hemorrhage)
lung hemorrhage and renal dx
- microscopic polyangiitis
- goodpasture syndrome
- wegeners/granulomatous polyangiitis
orgz PNA pattern drug tox
-bleomycin, cyclophosphamide, MTX, amdiodarone, nitrofurantoin, penicllamine
lung radiation injury timing
- radiation pneumonitis (1-4 mo, most sev at 4 mo)
- ggo centered on radiation port & beyond
- fibrosis- 6-12 mo
- fibr, traction bronchiectasis w/I radiation port & 20% beyond
- LAD
stage HSP
acute
subacute
chronic
acute HSP-img
inflamm exudate filling alv
-non spec ggo +/- CL nods
subacute HSP-img
ill define CL gg nodules + mosaic attenuation (air trapping)
-head cheese
chronic HSP
-UL predominance pulmonary fibrosis + superimposed findings of subacute (gg CL nods + MA)
MC radiographic finding sarcoid
symmetric adenopathy
pneumoconioses acute vs chronic img
- acute-confl ggo +. interlobular thickening, alveolar filling w/ PAS (all proteinosis) (fatal ~ 1yr)
- chronic-progressive massive fibrosis, hilar/arch distortion
sarcoid signs
- 1-2-3 (right paratracheal, bilateral hilar)
- doughnut-LAD on lat view
- galaxy sign-perilymphatic nodules coalesce into mass w/ small nods per
what other organs may sarcoid involve?
-spleen, brain, rarely bone
mediastinal stripes
- pst junction line
- anterior junction line
- right and left paratracheal stripes
- right and left paraspinal lines
- azygoesophageal recess
azygoesophageal recess
interface formed by contact of posteromedial right lower lobe and retrocardial mediastinum
-es mass, hiatal hernia, LA enlargement, LAD
classifications thymoma
- history: low vs high risk
- intact capsule: invasive vs non-invasive
thymoma + hemidiaphragm elevation
invasive thymoma (phrenic n invasion)
ddx eggshell calcification
- silicosis, CWP
- sarcoid (LC, but probably see more often bc MC as a dx)
- histoplasmosis
very rare causes of focal tracheal stenosis
behcet
Crohn
bronchiectasis pathway
bronchial wall injury (infi/inflamm) –> lumen obstruction –> traction from adj fibrosis
bronchiectasis types
- cylindrical-mild dil
- varicocele-beaded, irregular
- saccular/cystic-enlarged, ballooned, multiple cysts that may not connect to aw
CAPTAIn Kangaroo has Mounier Kuhn
CF (one of MCC) ABPA Post infection Tb/atypical mycobacterium Agammaglobulinemia Immunodef Kartagener Mounier Kuhn
tracheoes fistula
SCC
mc bronchial tumor in children
carcinoid (v rare in adults)
-almost always distal to carina)
enhancing endobronchial mass
- carcinoid (homog)
- mucoepidermoid CA
- hemangioma
- glomus tumor
mucoepidermoid endobronchial tumor
- rare, from tiny salivary glands lining TB tree.
- Younger pts.
- Round/oval, indistinguishable from carcinoid
BREaTh Lung
mets to endobronchial tree
-breast, renal, es, thyroid, lung
benign endobronchial lesions
- papilloma=mc
- chondroma
- schwannoma, adenoma, hamartoma, hemangioma, lipoma, leiomyoma
pleural based mass that changes position
fibrous tumor of pleura
fibrous tumor of pleura-what, img, mx, ass
- pleural based mass
- excised (20-30% mal)
- PET low
- hypoglycemia, hypertrophic pulmonary osteoarthropathy
what does cisterns chyli drain?
BL LE and LUE
MC sarcoid stage
stage 1. 60% compl resolution
significance of right hilum higher than left
-RUL collapse or fibrosis
eparterial bronchus vs hyparterial bronchus
- eparterial- R pulm a cross in front of R mainstream bronchus
- hyparterial- L pulm a cross over left bronchus
secondary pulmonary lobule size and contents
- 1-2.5 cm
- contains: terminal bronchiole, artery, 30-50 1˚ pulmonary lobules, v’s/lymph
role of bronchoalveolar lavage in alveolar proteinosis
-dx and rx
gossypiboma
retained FB
utility of decubitus views in setting of pleural effusion
obtained when in doubt of presence or absence of effusion and whether it is free layering
pleural mets vs mesothelioma
- mets=early enhancing
- mesothelioma-enhance less intensely and better seen delayed (45s)
BL vs UL pleural plaques
- BL-asbestosis
- UL-trauma, hemothorax, empyema
suggestion of life-threatening injury on cxr
- med widening
- PMX
- diaphgragmatic contour abN
dose length product
- most accurate reflection of effective radiation dose to a patient from a aCT scan, calculated base on actual exposure parameters used during the scan (although can be estimated prospectively.)
- (CTDI for each slice) x (distance)
- mGy * cm
gossypiboma
retained FB
utility of decubitus views in setting of pleural effusion
obtained when in doubt of presence or absence of effusion and whether it is free layering
pleural mets vs mesothelioma
- mets=early enhancing
- mesothelioma-enhance less intensely and better seen delayed (45s)
BL vs UL pleural plaques
- BL-asbestosis
- UL-trauma, hemothorax, empyema
suggestion of life-threatening injury on cxr
- med widening
- PMX
- diaphgragmatic contour abN
dose length product
- most accurate reflection of effective radiation dose to a patient from a aCT scan, calculated base on actual exposure parameters used during the scan (although can be estimated prospectively.)
- (CTDI for each slice) x (distance)
- mGy * cm
smoking related lung disease
- LCH
- RB-ILD
- DIP
mediastinal widening-next step.
- Acute-CTA
- chronic-PA and/or compare to prior images
course of Right main PA
- behind asc aorta
- anteroinferior to right main stem bronchus
- subdiv into truncus ant and descending artery
right pulmonary descending artery supply
-RML, RLL, RUL pst segm (90%)
RV:LV ratio for 50% chance death in setting of cPE
2.3
“mediastinal invasion”
tumor contact w/ mediastinum of >3cm and ext of tumor into fat
-T4
necrobiotic nodules
lower lung caveating or non caveating nodules in pts w/ RA or silicopneumconiosis
primary lung lymphoma appearance
consolidations w/ air bronchograms
sources of cavitating lung mets
- bladder
- SCC h/n, uterine cervice
appearance: ritalin lung, amiodarone, ibuprofen/nsaids, mercury fumes
- ritralin lung (IV injection oral ritalin)-basal bull ae
- amio-lower lung fibrosis
- ibuprofen/nsaids-eosinophilic PNA
- mercury fumes-ARDS
MC loc boerhaave related esophageal rupture
Left posterolateral distal esophagus
mediastinal compartment: well demarcated outline in the thorax that becomes indistinct in the neck
anterior
injuries to which arteries are life threatening?
internal mammary artery
intercostal a
typical location pulmonary infarcts
peripheral, sub pleural
which sequestration sometimes presents with CHF syx’s, why?
intralobar with drainage to pulmonary vein via L to L shunt
what worsens transient interruption of contrast?
hyperventilation
deep inspiration just before scan
when to treat pulmonary AVM
when to treat pulmonary AVM
ARDS related fibrosis
- anterior
- extensive post inflammatory bronchiectasis
risk of lung cancer in fibrosis
4x increased
course of azygos v
over right mainstem bronchus
lies in tracheobronchial angle
left mediastinal border above aortic arch
left subclavian artery
safest route to biopsy apical mass
posterior (vessels and nerves in supraclavicular region run ant to apical bps)
order of basal branch take off
superior, medial, ant, lateral, pst
orientation of pulmonary v’s
horz
how often does left SVC dump into LA?
10%. Not serious enough to cause cyanosis
Left SVC ass
cong heart dx (ASD highest)