ILD Flashcards
DDx for cystic lung disease
- Cystic bronchiectasis
- Bullae
- Langerhans cell histiocytosis
- Lymphangioleiomyomatosis
- Laryngotracheal papillomatosis
Causes of cystic bronchiectasis
- Pneumonia
- Chronic bronchitis
- Asthma (allergic bronchopulmonary aspergillosis)
- Bronchial atresia
Cystic Bronchiectasis
Cystic Bronchiectasis
1 French is ?
1/3 mm in diameter
1/3 x French in mm
Position of a chest tube
- directed anterosuperiorly to evacuate a pneumothorax
- directed posteroinferiorly for fluid collections
- Malpositioned chest tube
- within the interlobar fissure
- abut the mediastinum
Types of chest tubes
- Thoracostomy chest tube
- Pigtail catheter - for empyema drainage
Position of an endotracheal tube
- 5 cm above the tracheal carina
- when extending the neck, upward excursion of 2cm
- when flexing the neck, downward excursion of 2cm
Idean position of a esophageal pH probe
distal esophagus, just above the gastroesophageal junction
Bronchial stents
Used in patietns who have undergone lung transplantation and have developed a stricture at the anastomosis between the native tracheobronchial tree and the transplanted one
Swan-Ganz catheter
Pulmonary artery catheter
Which valve?
3 finger rule
T-A-M
Epicardial pacing wires
- placed at the time of cardiac surgery for immediate packmaker access, should the need arise
- simply pulled out through the incision when the patient is ready for discharge
Types of coronary artery stents
- balloon-expandable
- self-expandable
- thermally expandable
- stainless steel
- nitinol
Types of sternotomy
- median sternotomy - vertical incision
- calmshell sternotomy - horizontal incision - transplant
Intraaortic balloon pump (IABP)
- 25 cm long inflatable balloon mounted on a catheter
- intraduced via a femoral artery
- tip of the catheter is placed just distal to the take off of the left SCA
- inflated with CO2
- balloon is inflated during ventricular diastole
- augment diastolic coronary artery perfusion
- reduce LV afterload
Maximal thickness of right paratracheal strip
4mm
Contents of the AP window
- mediastinal fat
- left vagus nerve
- left recurrent laryngeal nerve
- left bronchial artery
- ligamentum arteriosum
- lymph nodes
Where to search for an abrnomality in a patient with vocal cord and left diaphragm paralysis?
AP window
Azygoesophageal recess
- Right superior convexity may be seen in children and younger adults but is abnormal in the elderly.
- Abnormal contour and convexity may be due to
- lymphadenopathy
- hiatal hernias
- bronchopulmonary-foregut malformations
- esophageal neoplasms
- pleural abnormalities
- cardiomegaly with left atrial enlargement
Posterior wall of bronchus intermedius
- projects through the LUL bronchus
- maximal thickness 3mm
- bandlike thickening of the posterior wall of BI is often due to pulmonary edema
- other causes
- lung carcinoma
- LAD
- metastatic disease
- TB
- sarcoidosis
Most common pattern of interstitial lung disease (ILD) in patients with rheumatoid arthritis
UIP
Reserve Halo / Atoll Sign
COP
Most common pattern of interstitial lung disease (ILD) in scleroderma
NSIP
Pattern of distal clavicle resoprtion in patients with RA
“penciling” of undersurface
How to distinguish UIP from NSIP
- UIP - basal and subpleural predominance; honeycombing
- NSIP - basal but NOT subpleural; NO honeycombing; more volume loss and traction bronchiectasis
Most common manifestation in chest in patients with SLE and RA?
Pleural effusions
pericardial effusion
When can you most often see lymphocytic interstitial pneumonia (LIP)?
- Sjogren’s syndrome
- thin-walled cysts
- perivascular cysts - with vessels along the walls of the cysts
2012 ATS-ERS Classification of idiopathic interstitial pneumonia (IIP)
- Chronic fibrosing IP
- UIP
- NSIP
- Smoking-related IP
- Respiratory bronchiolitis
- RB-ILD
- Desquamative IP
- Acute/subacute IP
- Organizing pneumonia/OP
- Diffuse alveolar damage/DAD
- Rare entity
- Lymphoid IP pattern (lymphocytic IP)
Most common IIP?
- UIP - 40%
- NSIP - 20%
DDx of UIP
- Causes unknown - IPF
- Causes known - other causes
- If inconsistent - biopsy
Diagnostic criteria for UIP
- subpleural and basal predominance
- reticular abnormality
- HONEYCOMBING
- with or without traction bronchiectasis
- absence of features inconsistent with UIP
Diagnostic criteria for NSIP
- better survival than UIP
- often associated with collagen vascular disease/HP/drugs
- basal predominance
- subpleural SPARING - peribronchovascular
- confluent pattern
- volume loss - inferior displacement of the major fissures
- reticular
- groundglass opacity
- traction bronchiectasis
- NO honeycoming
Underlying disease in NSIP
- collagen vascular disease
- environmental exposures - HP
- drugs
- smoking
Smoking-related lung disease
- Respiratory bronchiolitis - RB
- centrilobular nodules
- patchy GGO
- RB-ILD
- reticular marking
- GGO
- DIP
- GGO
- cysts within the GGO
Organizing pneumonia / OP
- subpleural/peribronchial
- patchy consolidation
- GGO
- peribronchial thickening
- reverse halo sign/Atoll sign
Causes of Organizing Pneumonia
- Cryptogenic
- CVD
- drug toxicity
- aspiration
- infection
Approach to micronodular disease
- Distribution
- centrilobular
- perilymphatic
- random
Centrilobular nodules
- does not extend to the interlobular septum and pleural surface
- further features
- solid/discrete - silicosis/CWP, pulmonary LCH, infection, aspiration, metastases
- tree-in-bud - linear opacities connecting the nodules - infection (TB, NTMB), viral; aspiration
- GGO - centrilobular “opacities” - HSP, bronchiolitis (RB, infection/viral), BAC, OP/NSIP, edema/vasculitis
Perilymphatic nodules
- peribronchiovascular, peri-interlobular septal, subpleural, peri-fissural
- sarcoidosis
- lymphangtic carcinomatosis
- rare: silicosis/CWP, lymphocytic IP, amyloidosis
Random nodules
- disseminated infection (miliary TB, histoplasmosis)
- sarcoidosis
- hematogeneous metastatic disease
- rare - LCH, silicosis/CWP
Sarcoidosis nodules
- perilymphatic (most common)
- random
Pulmonary fibrosis of sarcoidosis
- upper lobe predominance
- traction bronchiectasis - airway distortion
Air crescent sign
vs
Monod sign
Air crescent sign - angioinvasive aspergillosis
Monod sign - aspergillosis/mycetoma
Causes of Acute Lung Injury (ALI) and
Acute Respiratory Distress Syndrome (ARDS)
- Pulmonary
- aspiration
- infection - bacterial, viral, PCP
- Extra-pulmonary
- systemic sepsis
- trauma
- hyppertransfusion - TRALI
- cardiopulmonary bypass
Typical / atypical pattern of ARDS
gradient density from front to back - exptra-pulmonary cause
bilateral abnormality
vs
patchy distribution - pulmonary causes
unilateral abnormality
Clinical presentation of HSP
- Acute
- rapid onset 4-8 hr after exposure
- self-limited 24-48 hrs
- fever, chills, cough, dyspnea
- heavy exposure
- Chronic
- insidious onset over months to years
- chronic progressive
- chronic cough and SOB
- low grade, chronic exposure
Exposures to cause HSP
- Microbes - thermophillic actinomycetes - hottub lung
- animals - birds, rodents
- plant material - soybeans
- chemicals - paints, plastics
Acute HSP
Subacute HSP
Chronic HSP
- Acute HSP - limited CT data
- Subacute HSP
- patchy GGO
- centrilobular GGO nodules
- mosaic perfusion/air trapping - headcheese sign
- Chronic HSP
- fibrosis with/without honeycombing
- peripheral and central
- SPARING of costophrenic angles
- superimposed subacute findings
- GGO, centrilobular gg nodules
- mosaic air-trapping
DDx for
headcheese sign
and
centrilobular ggo nodules
- HSP
- RB-ILD, DIP
- LIP
- atypical infections
- edema and asthma
Lung cysts
1mm thin wall
vs
emphysema - no wall
vs
cavitating mass - thick wall
DDx for cystic lung disease
L3ABC
- Langerhans cell histiocytosis (late)
- Lymphangioleimyomatosis (LAM)
- lymphocytic interstitial pneumonia (LIP)
- Amyloidosis/light chain deposition disease
- Birt Hogg Dube
- Cystic metastases
All cystic lesions - unifying concept
bronchiolocentric lesion
Langerhans Cell Histocytosis
- Young smokers - 90%
- centrilobular nodules
- central lucency or cavitation with time
- apical to base gradient of severity
- SPARING costophrenic angles
- late - air cysts and air trapping
- rare to have adenopathy and pl effusion
Lymphangioleiomyomatosis
LAM
- sporadic or associated with TS
- exclusively in women!
- air cysts - no zonal distribution
- adenopathy
- patchy GGO - pulm hemorrhage
- no large nodules
- find miliary nodules may be seen
- chylous pleural effusion from lymphatic obstruction
- pleural effusion
Lymphocytic interstitial pneumonia
LIP
- associated with Sjogren’s disease
- poorly defined centrilobular or peribronchial nodules
- GG
- septal thickening
- perivascular cysts/pericystic dot*
- mosaic air trapping
Amyloidosis
Light chain deposition disease (LCDD)
Birt-Hogg-Dube Syndrome
- autosomal dominant disorder
- skin - fibrofolliculomas
- lungs - lung cysts - basilar and subpleural predominance
- kidneys - oncocytomas, RCC, etc
Cystic pulmonary metastases
- leimyosarcoma
- synovial cell sarcoma
- endometrial stromal cell sarcoma
- angiosarcoma
Min IP
Max IP
Max IP - nodules and tree-in-bud
Min IP - emphysema
Interlobular septal thickening
- venous
- smooth
- pulmonary edema
- lymphatic
- nodular
- lymphangitic carcinomatosis
- sarcoidosis, UIP…
