Pathologies of the respiratory system

Question 1

CATEGORIES of PATHOLOGY of respiration system

Answer 1

Pleural
Atelectasis
Obstructive Airways Disease
Consolidation
Lung Masses
Trauma

Question 2

What does atelectasis mean?

Answer 2

Partial collapse or incomplete inflation of the lung.
Obstructive atelectasis due to tumour, FB or mucus plug
Can witness mediastinal shift
It occurs when the tiny air sacs (alveoli) within the lung become deflated or possibly filled with alveolar fluid.

Question 3

What is the pleural?

Answer 3

Pleura is a thin layer of tissue that covers the lungs and also lines the interior wall of the chest cavity.
Between these two layers a serous fluid fills the space. About 10-20mls in the healthy person.

Question 4

What is dyspnoea?

Answer 4

Shortness of breath — known medically as dyspnoea — is often described as an intense tightening in the chest, air hunger, difficulty breathing, breathlessness or a feeling of suffocation.

Question 5

What is the parietal pleura?

Answer 5

Parietal pleura lines the inner aspect of the thoracic cavity and the mediastinum. It is thicker and more robust than the visceral pleura.
Its the pleura side that lines your chest.

Question 6

What is Visceral Pleura?

Answer 6

Lines the surface of the lungs.

Question 7

What is PNEUMOTHORAX?

Answer 7

We get a leak of air into the pleura cavity. So this causes the differences in pressure within your chest to be misaligned, leaving to air escaping your lung into that plural cavity, causing the lung to shrink and collapse.

Abnormal collection of air in the pleural space between the lung and the chest wall.

Question 8

What are the symptoms of pneumothorax?

Answer 8

Symptoms = sudden onset of sharp, one-sided chest pain and SOB

If you were to listen to the chest with a stethoscope patient, you would hear decreased sounds of breath on the one side with a numerical set.

Question 9

What is the difference between primary pneumothorax, secondary pneumothorax and haemothorax?
and Traumatic Pneumothorax

Answer 9

Primary pneumothorax = no lung disease

Secondary pneumothorax = lung disease

Haemothorax - collection of blood in the pleural space and may be caused by blunt or penetrating trauma.

Traumatic Pneumothorax- May be due to traumatic injury, e.g. Rib fracture
Could also be due to surgical intervention e.g.
Thoracotomy, Tracheostomy, Biopsy, NG Perforation

Question 10

Pneumothorax is more common in who?

Answer 10

More typical men and more typical people who are ectomorphic. So people who are quite tall, slim.
Also quite more common people who have connected tissue disorders like Mart Max disease or Ella Danlos.

Question 11

PNEUMOTHORAX CXR appearance

Answer 11

When viewing on a chest image, you will see a lack of lung markings to one side of the chest. This makes the lung look black

It can happen to both and this is known as a bilateral pneumothorax. This is rare and often happens during trauma.

They can also be very subtle.

Question 12

PNEUMOTHORAX CXR appearance

Answer 12

When viewing on a chest image, you will see a lack of lung markings to one side of the chest. This makes the lung look black

It can happen to both and this is known as a bilateral pneumothorax. This is rare and often happens during trauma.

They can also be very subtle.

Question 13

Pneumothorax on CT

Answer 13

You can see the Lung window to see all the markings clearly. In pneumothorax, there will be a lack of lung markings in an area and it will be black as there is air there.

Question 14

Lateral Decubitus CXR technique

Answer 14

Patient Preparation
Remove all clothing waist up and put on a hospital gown
Remove any artefacts

Patient Positioning
Lie on the unaffected side for a pneumothorax x-ray (lie on affected side if looking for fluid, e.g. pleural effusion)
Extend arms above head to avoid any superimposition on lung fields
Same checks for rotation as with any chest x-ray

Can be achieved AP or PA
Position patient for 5 minutes prior to exposure to allow air to rise if present
Breathe in… Breathe out… Breathe in (Max Insp)
Place appropriate marker so we know which side is up!
Ensure you add Decubitus annotation when post-processing the image

Question 15

What is TENSION PNEUMOTHORAX?

Answer 15

A complicated pneumothorax where air enters the pleural cavity but cannot escape due to the formation of a one-way valve at the rupture point. Pressure builds.

Pneumothorax is when air collects in between the parietal and viscera pleurae resulting in lung collapse. It can happen secondary to trauma (traumatic pneumothorax). When mediastinal shifts accompany it, it is called a tension pneumothorax

Question 16

Tension pneumothorax CXR?

Answer 16

Mediastinal shift, diaphragm lowered. Its similar to normal pneumothorax but the heart shifts the opposite way due to the pressure. So rather the heart being in the middle like a normal chest x-ray its off to the side.

Question 17

How to treat pneumothorax?

Answer 17

Treatment for a pneumothorax usually involves inserting a needle or chest tube between the ribs to remove the excess air. However, a small pneumothorax may heal on its own.
The drain can be seen on chest x-rays as radiopaque.

Question 18

What is Pleural Effusion?

Answer 18

Excess fluid accumulation in the pleural cavity

Pressure of fluid can impair breathing

Can be due to a build up of different fluids

Exudate or Transudate

Question 19

What are the common causes of Pleural effusion?

Answer 19

The most common causes of pleural effusion are congestive heart failure, cancer, pneumonia, and pulmonary embolism.

Question 20

What does exudate mean?

Answer 20

Means to ooze

Increased permeability of the pleural capillaries or interference with drainage of the pleural space to the lymph nodes

Associated with pulmonary malignancy or lymphatic drainage interference

Question 21

What does transudate mean?

Answer 21

Increased pressure within the pleural capillaries causing the pressure within the vessels to increase

Associated with heart failure, hypertension, ascites

Question 22

Pleural effusion appearance on CXR?

Answer 22

small amount-Horizontal Fluid Level /
Blunted Costophrenic Angle, the fluid is white/radiopaque

Large amount- Meniscus Sign, large white lung

Question 23

Pleural effusion appearance on ultrasound?

Answer 23

Liquid is black on ultrasound, so the area would be black

Question 24

What is Haemothorax?

Answer 24

Haemothorax is a collection of blood in the space between the chest wall and the lung (pleural cavity) and can be life threatening if untreated.
On CXR it can look like pleural effusion so further imaging (CT) is needed for diagnosing.

Question 25

Examples of OBSTRUCTIVE AIRWAYS DISEASE?

Answer 25

COPD EMPHYSEMA BRONCHIECTASIS

Question 26

What is emphysema?

Answer 26

Mucus in bronchiole Long term obstructive lung disease Loss of airway support and inflammation Gas exchange is either slowed or stopped due to very reduced movement of gases in the alveoli Causes change to healthy lung anatomy Destruction of lung tissue surrounding bronchioles Capillary networks affected Shortness of breath due to hyperinflation of the alveoli Associated hypertension

Question 27

What causes Emphysema?

Answer 27

Smoking Risk increases with quantity and length of time Scarring due to long term irritation and inflammation of the lungs Rarely; Fumes Dust Air pollution Genetics

Question 28

What does emphysema look like on CT?

Answer 28

It looks like almost large area/ or a large bubble called a bullae

Question 29

EMPHYSEMA CXR appearance

Answer 29

Large overinflated lungs, heart appears long and thin, this happens because the alveoli dilate.

Question 30

Surgical Emphysema (AKA Subcutaneous Emphysema or Tissue Emphysema), what does it look like on a CXR?

Answer 30

Lucent stripes across soft tissue (this is the air in the tissue) Usually you can also see the cause e.g Chest drain

Question 31

Subcutaneous Emphysema on CT appearance?

Answer 31

Black spots/strips/bubbles throughout the soft tissue, it can be on either side of the patient

Question 32

What is Bronchiectasis? common symptoms?

Answer 32

Bronchiectasis is a long-term condition where the airways of the lungs become widened, leading to a build-up of excess mucus that can make the lungs more vulnerable to infection. The most common symptoms of bronchiectasis include: a persistent cough that usually brings up phlegm (sputum) shortness of breath. Sometimes the cause is unknown. Abnormal widening of the airways – up to 4 x size Increased mucus production

Question 33

Causes of Bronchiectasis?

Answer 33

A childhood lung infection that damages the bronchi Underlying immune system disorders Allergic Bronchopulmonary Aspergillosis Cystic Fibrosis Idiopathic

Question 34

Idiopathic meaning?

Answer 34

relating to or denoting any disease or condition which arises spontaneously or for which the cause is unknown.

Question 35

Bronchiectasis CXR appearance?

Answer 35

Increased density within the airways, giving it this kind of morts spread out mosaic kind of patterns. X rays are two dimensional image of a three dimensional object. So lots of this will be superposed, and a lot of it will also be bronchial and bronchitis that are facing us head on which can account for some of the higher density, lower densities and, the lack of homogeneity

Question 36

CT Bronchiectasis appearance

Answer 36

On CT you can see cross sections through the bronchioles so you can see the thicken wall and see that its dilated.

Question 37

What is Bronchography?

Answer 37

Bronchography is a radiological technique, which involves x-raying the respiratory tree after coating the airways with contrast. Bronchography is rarely performed, as it has been made obsolete with improvements in computed tomography and bronchoscopy

Question 38

What is Consolidation?

Answer 38

Non-specific airspace opacification Alveoli and terminal bronchioles filled with dense material Pus (pneumonia) Fluid (oedema) Blood (haemorrhage) Cells (cancer) Dense and white appearance Consolidation refers to an area of homogeneous increase in lung parenchymal attenuation that obscures the margins of vessels and airway walls. Pathologically, consolidation represents an exudate or other product of disease that replaces alveolar air, rendering the lung solid, hence, the dense white appearance.

Question 39

What is Pneumonia?

Answer 39

An infection of the lungs characterised by inflammation of the alveoli that become fluid and pus filled Bacterial or viral Symptoms Productive cough with green/brown sputum SOB or DIB Chills/Fever Rigors Fatigue Sweating Chest pain Lobar pneumonia affects one or more sections (lobes) of the lungs

Question 40

Pneumonia CXR appearance?

Answer 40

APPEARANCE Non-uniform shadowing Air bronchogram Ill-defined border of area of whiteness/increased density Shadowing likely to be more dense at the bases, or lower border of affected lobe

Question 41

HOW ELSE DO WE IMAGE PNEUMONIA?

Answer 41

Ultrasound- If pleural effusion is also suspected MRI- Rule out other causes of pathology Needle Biopsy of the Lung- To identify the cause of pneumonia WHY CT? Finer detail of the lungs More sensitive than CXR Demonstrates airways clearly Can assess lymph nodes for enlargement

Question 42

What is Pulmonary Oedema?

Answer 42

Abnormal fluid accumulation in the lungs which collects in the alveoli Affects ability for gas exchange to occur Cardiogenic vs. Non-Cardiogenic Low oxygen saturations

Question 43

What is Pulmonary Oedema?

Answer 43

Abnormal fluid accumulation in the lungs which collects in the alveoli Affects ability for gas exchange to occur Cardiogenic vs. Non-Cardiogenic Low oxygen saturations

Question 44

Pulmonary oedema CXR appearance?

Answer 44

Patchy densities in lungs Fluid in alveoli – white Air still retained in bronchioles – black Overall – a patchy/fluffy effect Cardiogenic: originating in the heart or caused by a cardiac condition cardiogenic pulmonary oedema.

Question 45

What are nodules? information about them?

Answer 45

Found on 1 in 500 CXRs Lesion 3cm or less in size Benign Slow growing, smooth and regular shape Malignant Fast growing, irregular shape, rough surface, heterogenous appearance Monitoring – Fleischner Society Recommendations small masses in the lungs

Question 46

Lung carcinoma stats

Answer 46

Lung carcinoma Small Cell Lung Cancer (SCLC) – 10-15% Non-Small Cell Lung Cancer (NSCLC) – 85-90% Other – 5%

Question 47

Non-SMALL CELL LUNG CARCINOMA (NSCLC) types and info

Answer 47

Largest group of lung malignancies Adenocarcinoma 40% of lung cancers Start in cells which would normally secrete mucus Commonly seen in current/former smokers however also the most common lung cancer in non-smokers More likely to affect younger people and women Slow-growing – likely to be found before it has spread Squamous Cell Carcinoma 25-30% of all lung cancers Develops from cells that line the airways Linked to history of smoking Tend to be found in central parts of the lungs, near the bronchi Large Cell Carcinoma 10-15% of lung cancers Appear in any part of the lung Grows and spreads quickly

Question 48

Small Cell Lung Cancer (SCLC) info

Answer 48

About 10-15% of all lung cancers Very small cancer cells seen under microscope Starts in the bronchi (central chest) Grows and spreads quickly Difficult to differentiate on imaging – histology provides diagnosis of SCLC

Question 49

Other Types of Lung Tumour?

Answer 49

Carcinoid tumours of the lung Less than 5% of all lung tumours Slow growing Lymphomas and Sarcomas Metastatic Cancers (Metastatic cancer is a cancer that has spread from the part of the body where it started (the primary site) to other parts of the body. When cancer cells break away from a tumor, they can travel to other parts of the body through the bloodstream or the lymph system)

Question 50

Other imaging for lung tumours

Answer 50

MRI Allows assessment of location and size of tumour- Difficult due to movement of lungs Metastatic spread Needle lung biopsy Can be CT or Ultrasound guided Sample of tissue is taken from lungs for analysis CT scanner or U/S probe used to guide the needle to the area where the biopsy should be taken Usually takes 30-45 minutes Can demonstrate any complications

Question 51

Apical Projection technique and why do it?

Answer 51

Indications – suspect apical lesion on PA Patient erect, AP Stands forward, leans back 30 degrees Horizontal beam Centre at sternal angle in the midline Allows you to see the Pancoast area of lung, as clavicles are not in the way

Question 52

What is Pulmonary Contusion?

Answer 52

Bruising of the lung due to chest trauma Haemorrhages in the alveoli Can be associated with rib fractures and flail chest injuries Low sats, cyanosis, dyspnoea, tachypnoea, tachycardia, wheezing, haemoptysis, hypotension May see a contre-coup injury

Question 53

Pulmonary contusion CXR appearance

Answer 53

Areas of consolidation appear more dense on the image (whiter) Not sensitive immediately after injury unless very severe injury 6 hours post injury average time taken to show on CXR

Question 54

What are the benefits and limitations of CXR?

Answer 54

BENEFITS Quick Readily available Cheap compared to other modalities Low dose of ionising radiation LIMITATIONS Almost ½ of the lungs can be obscured Variations in technique affect image quality and diagnosis

Question 55

What is HIGH RESOLUTION CT (HRCT)?

Answer 55

Used in the assessment of generalised lung disease Scan does not image the entire chest – nearer 10% Offers a selection of images that are representative of the lungs in general Narrow Beam Collimation 2 stages 1.5mm thick images taken at 10mm spacings on inspiration 1.5 mm thick images at 30 mm spacing on expiration Improves appearance of vessels and bronchi High spatial reconstruction algorithm Edge enhancing Makes structures sharper but increases noise Small field of view Maximum diameter of reconstructed image by minimising the size of each pixel Increases spatial resolution

Question 56

What is RESPIRATORY GATING MRI?

Answer 56

RESPIRATORY GATING MRI is a technique used to measure when there is no movement in the chest cavity. The way we do this is with a sensory placed on the chest that will begin scanning on expiration and stop scanning as soon as inspiration occurs.

Question 57

What is RNI – VQ SCANNING used for?

Answer 57

Ventilation – Perfusion Uses radioactive material to examine airflow (ventilation) and blood flow (perfusion) in the lungs Used to identify blood clots in the lungs – diagnosis of Pulmonary Embolism Perfusion scan alone can be used to rule out PE

Question 58

Information about Positron Emission Tomography (PET)?

Answer 58

Shows how the lungs and surrounding tissues are working in the presence of pathology Used for; Thoracic malignancy prior to surgery Can also identify; Infection Inflammation Low spatial resolution so best interpreted alongside either CT or MRI High specificity and sensitivity for detecting size, shape and location of tumour

Question 59

Information about ARTERIOGRAPHY?

Answer 59

High sensitivity and specificity for detecting PE Invasive and high risk procedure Often undertaken in CT or MRI now as an alternative Conventional Arteriography still undertaken for pulmonary arteriovenous malformations

Question 60

What is DIFFUSE INTERSTITIAL LUNG DISEASE?

Answer 60

A large number of disorders that are characterised by cellular infiltrates in a periacinar (around the alveoli) location. Affects interstitium of the lung On x-ray interstitial pattern – linear/reticular/nodular/reticulo-nodular Number of causes – can be due to genes, inhaled irritants, idiopathic, radiation, infection, drugs Most common is idiopathic pulmonary fibrosis Lower zone, bilateral, peripheral predominance

Question 61

What is the interstitium (in reference to the lungs)?

Answer 61

The interstitium refers to the tissue area in and around the wall of the airsacs (alveoli) of the lung area where oxygen moves from the alveoli into the capillary network (small blood vessels) that covers the lung like a thin sheet of blood.

Question 62

Pulmonary oedema information?

Answer 62

Broad descriptive term and is usually defined as an abnormal accumulation of fluid in the extravascular compartments of the lung. Cardiogenic cause = heart failure (congestive) Non cardiogenic = smoke inhalation, ARDS, near drowning/aspiration, post operative, fluid overload Chest x-ray = fluffy, homogenous, bilateral

Question 63

What does ARDS mean?

Answer 63

adult respiratory distress syndrome.

Question 64

What is Respiratory failure?

Answer 64

Respiratory failure = inadequate gas exchange Can be acute or chronic ARDS – acute respiratory distress syndrome Appearances on chest x-ray – usually bilateral – homogenous opacification – widespread Acute = high mortality – 50% those that survive have chronic lung disease Treatment = depends on chronic/acute + underlying cause. Oxygen therapy, ventilation (invasive/non-invasive), fluids (beware too much) lung transplant

Question 65

Cardiogenic Pulmonary Oedema CXR appearance

Answer 65

“Batwing” – peri hilar opacification Pleural effusion Kerley B/septal lines Its dense around the heart

Question 66

Non-Cardiogenic Pulmonary Oedema CXR appearance

Answer 66

Diffuse Bilateral Widespread Homogenous Its dense all over the lungs, common cause could be drowning.

Question 67

What does CAP mean?

Answer 67

Community-acquired pneumonia

Question 68

What does HAP mean?

Answer 68

Hospital-acquired pneumonia

Question 69

Differences between HAP and CAP

Answer 69

Homogenous opacification, can be sharply defined at the fissures, air bronchograms Diffuse alveolar pattern (more homogenous opacification) widespread/bilateral)

Question 70

What is chronic lung disease?

Answer 70

Long term condition – irreversible Many causes – strongly linked to COPD Abnormal widening of the airways – up to 4 x size Increased mucus production Symptoms include a persistent productive cough and SOB Can be exacerbated by chest infections Abx and physiotherapy to treat – lung transplant Difficult to appreciate on chest x-ray – CT is more sensitive However “tramlines” or “donut sign” indicate bronchial wall thickening CXR-lungs appear to be really long

Question 71

Lobar collapse + atelectasis of RUL

Answer 71

RUL Increased density in the upper medial aspect of the right hemithorax Elevation and/or superior bowing of the horizontal fissure loss of the normal right medial cardio-mediastinal contour Elevation of the right hilum

Question 72

Lobar collapse + atelectasis of RML

Answer 72

RML Right mid to lower zone air space opacification (which can be subtle) The normal horizontal fissure is no longer visible (as it rotates inferiorly) Obscuration of the right heart border Increased opacity adjacent to the right heart border requires a degree of consolidation as well as atelectasis

Question 73

Lobar collapse + atelectasis of RLL

Answer 73

RLL Triangular opacity at the right lower zone (usually medially) with the apex pointing towards the right hilum Obscuration of the medial aspect of the dome of right hemi-diaphragm Inferior displacement of the right hilum preservation of a clear right heart border, which is contacted by the right middle lobe inferior displacement of the horizontal fissure

Question 74

Lobar collapse + atelectasis of LUL

Answer 74

LUL Hazy, vailing opacity (collapses anteriorly) Fades out inferiorly, originates at left hilum Parts of the aortic arch may be obscured Left hilum displaced superiorly – horizontal left main bronchus, vertical left lower lobe bronchus

Question 75

Lobar collapse + atelectasis of LLL

Answer 75

LLL triangular opacity in the posteromedial aspect of the left lung (retrocardiac sail sign) left lower zone opacification (usually medially) with the apex pointing towards the left hilum edge of the collapsed lung may create a 'double cardiac contour' inferior displacement of the left hilum obscuration of the left hemidiaphragm obscuration of the descending aorta preservation of a clear left heart border, which is contacted by the lingular segments of the left upper lobe

Question 76

Benign calcifications- diffuse meaning

Answer 76

Widespread density over a larger area.

Question 77

Benign calcifications- central meaning

Answer 77

A central tight lesion will have a higher and more densely packed middle, and then a less dense outer rim.

Question 78

Benign calcifications- Laminated meaning

Answer 78

A laminated lesions will have layers to it. So some areas of high density in layered areas and some dont.

Question 79

Benign calcifications- popcorn meaning

Answer 79

Looks like a popcorn, it is bumpy almost

Question 80

What is mesothelioma?

Answer 80

Mesothelioma – tumour of the mesothelium (the tissue that surrounds the organs of the chest, pleura and pericardium) Strong association with asbestos exposure (40-80% of patients have a history of exposure). More commonly affects men (traditional worked in roles where asbestos exposure was greater). On x-ray pleural opacity that covers lung, reduced volume of the affected hemithorax, possible pleural effusions. CT – pleural mass, inward infilltartion, chest wall/diaphragm involvement

Question 81

What is flail chest?

Answer 81

Three or more ribs are each broken in more than one place, causing a segment of bone to detach from the chest wall. Paradoxical breathing – moves in when inspiration occurs and out on expiration Requires urgent treatment Usually accompanied by pulmonary contusion

Question 82

What is Bronchogenic cyst?

Answer 82

Congenital malformation of the bronchial tree Usually present as a mediastinal mass Can enlarge and cause compression Usually asymptomatic Do not communicate with bronchial tree – therefore can be… Pulmonary Mediastinal (most common) Fluid filled, not air, which explains their appearance on x-ray (appear similar to a mass)

Question 83

What is Pulmonary sequestration?

Answer 83

Also called accessory lung No communication with bronchial tree or pulmonary arteries V rare – incidence 0.1% Prone to infection Usually surgically removed Extralobar sequestration (ELS) more commonly presents in newborns as respiratory distress, cyanosis, or infection, whereas intralobar sequestration (ILS) presents in late childhood or adolescence with recurrent pulmonary infections.