Pulmonary Radiology Part 2

Pulmonary edema

• Signs and Sx:
• -DOE
• -Orthopnea
• -Paroxysmal nocturnal respiratory distress
• -Weight gain
• -Lower extremity edema
• -Cough
• -Hemoptosis

• Etiologies:
• -Cardiogenic
• -Neurogenic
• -Increased permeability (toxin-inhalation, high-altitude sickness, aspiration, contusion, fat embolism)

• Image findings:
• -Patchy infiltrates
• -Kerly B lines
• -Interlobular fissure thickening
• -Pleural fluid
• -Redistribution (increased size of vessels to the upper lobes)
• -Parahilar zone bronchial cuffing
• -Parahilar vessels less distinct

• Pulmonary edema
• (Pt is laying down; haziness is almost confluent)

• Pulmonary effusion (right posterior)
• Pulmonary edema (left lung field)

Pulmonary Embolism

• Etiologies:
• -Venous (postsurgical, bed rest, trauma, neoplasm)
• -Foreign body (bone marrow after long bone fracture, Amniotic)
• -Septic emboli
• -Air

• Image findings:
• -Radiograph, can be normal (Hampton's Hump: pleural base cone shaped opacity)
• -CT, most common way to diagnose: filling defects in the pulmonary artery
• -VQ mismatch
• -Pulmonary angiogram: gold standard

Asthma

• Imaging findings:
• -75% normal radiographs
• -Bronchial wall thickening
• -Hyperinflation
• -Mosaic attenuation (CT)
• -Atelectasis (rarely)

COPD

• Image finding:
• -Poor sensitivity in early disease (25% normal)
• -Later: hyperinflation, increased AP diameter, flattening of hemidiaphragms
• -Bullae
• -Peripheral olligemia (emphysema)
• -Bronchial wall thickening
• -Pulmonary artery hypertension
• -Saber sheath trachea (highly sensitive)
• -Centrilobular lucencies (CT)

• Lung cancer
• Etiology: most common cause of cancer mortality worldwide
• -Cigarette smoking accounts for 90% of all lung cancers
• -NO current screening test

• Image findings:
• -Radiograph: almost always need additional imaging
• -CT: 
• -Positron emission tomography: improved detection (sensitivity)
• -MRI: only useful for chest wall or mediastinal tumors

• Cystic fibrosis
• Image findings:
• -Hyperinflation
• -Peribronchial cuffing with tramlines or tram tracks
• -Bronchiectasis and opacities (Upper lung predominant)
• -Signet ring sign (dilated bronchus abutting a PA branch)

Pneumonia

• Image findings:
• -Focal segmental/lobar opacity (in the setting of fever and productive cough)
• -parapneumonic effusions (loculated empyema)
• -Signs of volume loss will help to differentiate from atelectasis (i.e. elevated hemidiaphragm and acute angle of mainstem bronchus)

Tuberculosis

• Image findings:
• -Primary: lobar airspace consolidation wiht accompanying unilateral lymphadenopathy and pleural efusion

-Post Primary: Cavitary lesions, fibrosis, retraction of the hila; usually affecting the lung apices (upper lobes or superior segment of lower lobes)

-Miliary: innumerable diffuse tiny nodules measuring 2-3mm (predominantly upper lobe)

Fungal lung disease

• Image findings:
• -Varying manifestations

Histo: lamellated or diffuse Ca++ of a nodule. Ipsilateral LAD

Blasto: Lung nodules/mass or consolidation. Cavitation in 15-29%,

Cocci: Cavitating segmental or lobar consolidation in an endemic area

• Aspergillosis
• -invasive: lobar or peribronchial consolidation
• -Semi-invasive: nodule, mass, or consolidation
• -Aspergilloma: fungus ball or sponge-like mass of mycelia filling cavity

• Ddx:
• -lung cancer
• -infectious abscess
• -inflammatory
• -trauma
• -silicosis

Classic PCP findings (immunocompromised pt)

• findings:
• -Ground glass opacity - diffuse, symmetric
• -Peripheral sparing
• -Thin walled cysts with upper lobe distribution
• -Predisposition to pneumonia

Bronchiectasis (but poor image)

• -Thickened cystic bronchi containing air fluid levels, tramlines or tram tracks
• -signet ring sign (dilated bornchus adjacent to a PA branch)
• -Severity ranges from cylindrical to varicose (string of pearls), to saccular (cluster of grapes)

• Location:
• -CF: upper lobe, central and peripheral
• -ABPA: central asymmetric bilateral
• -TB: upper lobe predominant unilateral
• -Atypical mycobacterium: RML and lingular predominance
• -Viral: lower lobe predominance

Lung transplant

• Findings:
• -Post surgical: clips hilum and pleura
• -Thoracotomy changes
• -If unilateral - abnormal contralateral lung
• -Rejection - hypersensitivity pneumonitis: peripheral ground glass

• Diffuse parenchymal lung disease
• 1. IPF

• Findings:
• -Upper lobe: silicosis, pneumoconiosis, Sarcoidosis, EG (architectural distortion, bronchiectasis, nodules)
• -Lower lobe: idiopathic pulmonary fibrosis, rheumatoid (honeycombing, fibrosing, pleural based)

Poland's syndrome

-hard to tell if the lucent side is abnormal or the dense side is abnormal

Poland's syndrome has congenital malformation; pts lack pectoralis major and minor

Thoracic scoliosis

Endotracheal tube

• -optimal location is 2-7 cm above corina
• -"hose moves with nose" - moving the nose down (forward flexion at the neck), moves the tube down closer to the corina

• Locating the corina:
• -find the aortic arch; continue the arch to draw a circle
• -the corina is at the base of that circle

Tracheostomy tube