20. Most of our knowledge about imaging findings in interstitial lung disease comes from HRCT. Several studies have reported that MDT diagnosis is associated with higher levels of diagnostic confidence and better interobserver agreement when compared to the individual components of the MDT in isolation. CT showing reticular opacities, traction bronchiectasis and honeycombing. On HRCT there are four patterns: reticular, nodular, high and low attenuation (table). The presence of reticular opacities, traction bronchiectasis, and honeycombing indicates fibrosing ILD; namely UIP, NSIP, or chronic hypersensitivity pneumonitis. This policy is subject to change without notice and was last updated on 23rd Sept, 2018. Interstitial lung diseases (ILD) are a heterogeneous group of diseases that produce inflammation and fibrosis of the parenchyma, affecting the alveolar, interstitial and vascular spaces.5 Sometimes the causative etiology or mechanism can be identified (eg, collagen vascular disease, environmental or drug related), while other times it may remain unknown or idiopathic.4 Idiopathic interstitial pneumonias comprise the following disease entities, listed in decreasing order of frequency: Idiopathic pulmonary fi… Step 1: a preliminary review of available chest radiographs, including the “scanogram” obtained at the time of the CT examination. Consolidation is the defining feature of only one interstitial lung disease: organizing pneumonia. The presence or absence of nodules coupled with CT demonstration of differential involvement of the three interstitial compartments is useful in limiting diagnostic possibilities in interstitial disease. Obtaining good quality HRCT images is an essential step for evaluating pulmonary pathologies. ii. 18. 15. A lot (of education) can happen over coffee! Following an initial review of pertinent lung anatomy, the following steps are included. endobj Regression following treatment with steroids is seen in NSIP and not UIP. i. Dr Bhavin Jankharia has shared his ppts on HRCT in diffuse lung diseases (parts I and II) on slideshare. endobj The ILDs will usually be easily diagnosed based on the combination of these nine findings along with associated history. endobj 100 0 obj When the chest radiograph shows a clear pattern of ILD or ALD, one can render a differential diagnosis on the basis of the pattern of parenchymal disease (Table 3.1). The ILD consist of disorders of known cause (e.g., collagen vascular diseases, drug-related diseases) as well as disorders of unknown etiology. <>/Font<>/ProcSet[/PDF/Text/ImageC]/XObject<>>>/Rotate 0/TrimBox[28.346449 28.346449 623.62207 822.047241]/Type/Page>> This stepwise radiologic diagnostic approach can be helpful in reaching a correct diagnosis for various cystic lung diseases. 99 0 obj The clinical evaluation of a patient with ILD includes a thorough… Remember; CT has a high specificity but low sensitivity for diagnosing UIP. 10. Change ). 6. General approach to the diagnosis of fibrotic interstitial lung diseases 1.1. Assuming that the patient is not a smoker and is not immunocompromised, the differentials would include hypersensitivity pneumonitis and NSIP.’. presence of honeycombing on HRCT). Having appropriate history is of paramount important. If there is any clinical doubt, a follow-up CT or a biopsy should be performed. <> Granulomatous lung disease refers to a broad group of infectious and non-infectious conditions characterized by the formation of granulomas. 7. Considering that an ILD may complicate t … endobj One way to confirm whether the CT has been obtained in inspiration or expiration is by observing the contour of the trachea. application/pdf Intralobular insterstitial thickening (at the level of the primary pulmonary lobule) is seen in the form of reticular opacities. uuid:aefc6736-b92f-48d8-bc41-4e6fd91440ce Interpretation of “pattern” in relation to distribution, 3. The diagnostic approach to idiopathic interstitial pneumonias (IIPs) has long been confusing because these disorders were categorized according to different clinical, radiologic, and histologic classifications (, 1,, 2).In 2001, the American Thoracic Society (ATS) and European Respiratory Society (ERS) standardized the terminology for IIPs (, Fig 1) (, 3). 64 0 obj The term interstitial lung diseases (ILD) comprises a diverse group of diseases that lead to inflammation and fibrosis of the alveoli, distal airways, and septal interstitium of the lungs. Fibrotic interstitial lung diseases. These heterogeneous parenchymal lung disorders overlap in their clinical presentations and patterns of lung injury. endobj 1. Abstract Interstitial lung diseases (ILDs) encompass a wide range of diffuse pulmonary disorders, characterized by a variable degree of inflammatory and fibrotic changes of the alveolar wall and eventually the distal bronchiolar airspaces. Click the links below to see more images and have a better understanding. Follow-up, treatment, and prognosis are strongly influenced by the underlying pathogenesis. We propose an algorithmic approach to the interpretation of diffuse lung disease on high-resolution CT. In this review, we describe a practical approach to high-resolution CT diagnosis of diffuse lung disease, emphasizing (1) analysis of "distribution" of the abnormalities, (2) interpretation of "pattern" in relation to distribution, (3) utilization of associated imaging findings and … <> A major problem in India regarding thoracic CT imaging is suboptimal quality of the scans due to the patient not having received adequate instructions regarding taking a deep breath and holding it for the duration of the scan. Approach To Interstitial Lung Diseases or Diffuse Parenchymal Lung Diseases 3. An older patient with age > 70 years is more likely to have UIP, whereas a younger patient with age < 50 years is more likely to have NSIP. 1. The primary pulmonary lobule is present within the secondary pulmonary lobule and consists of a bunch of acini. SECTION 11 Immunologic and Interstitial Diseases CHAPTER 54 Interstitial Lung Disease: A Clinical Overview and General Approach Danielle Antin-Ozerkis INTRODUCTION Commonly, interstitial lung disease (ILD) presents with dyspnea on exertion, diffuse bilateral infiltrates on chest imaging, and restriction with diffusion impairment on physiologic testing. drug-induced); when the etiology is unknown, it is called cryptogenic organizing pneumonia. Enter your email address to follow this blog and receive notifications of new posts by email. HRCT images should always be obtained in maximum inspiration as well as in end expiration. UIP pattern. For example, a combination of ground glass opacities + septal thickening (crazy paving pattern) is seen in pulmonary alveolar proteinosis. APPROACH TO DIAGNOSING ILD 6. http://pubs.rsna.org/doi/full/10.1148/rg.2015140334, iii. Proper lung window width and window level settings are a must for evaluating and filming pulmonary pathologies adequately. 101 0 obj Radiology Fellowships, DMs and Super-Speciality DNBs in India, What to read during radiology residency? <> Classification of findings in a fibrosing ILD seen on HRCT: 11. A conundrum arises when widespread small opacities are difficult to categorize into one group or the other on chest radiography, or when ILD and ALD are both present. uuid:9cb20b7f-1dd1-11b2-0a00-aa00687aceff Thus, interlobular interstitial thickening is usually seen due to pulmonary edema/pulmonary vein compression or stenosis, leading to backpressure changes and fluid retention within the septae; or due to cells (tumor cells in lymphangitis; proteins in alveolar proteinosis) within the septum. <> 103 0 obj endobj The trachea is round and expanded in inspiration, and collapsed and crescent shaped in expiration. endobj 5. http://err.ersjournals.com/content/23/132/215, http://www.atsjournals.org/doi/full/10.1164/rccm.2009-040GL, The Art and Science of Radiology Reporting, Fellowship in Oncoimaging and Intervention, Tata Medical Center, Kolkata, What to Read to understand the Basics of AI and How to Engage with AI as a Radiologist, Pediatric Radiology Fellowship, AIIMS Delhi, Fellowship in Neuro and Vascular Interventional Radiology, AIIMS Jodhpur. 104 0 obj Respiratory bronchiolitis causing interstitial lung disease: a clinicopathologic study of six cases. If you have any questions feel free to contact directly at caferoentgen@gmail.com. Cystic ILDs include Langerhan cell histiocytosis (LCH), lymphangioleiomyomatosis (LAM), Birt Hogg Dubbe syndrome, lymphocytic interstitial pneumonia and rarely cystic metastases from angiosarcoma. (Image from Wikimedia Commons; contributed by Darel Heitkamp, MD.). Once the presence of the various HRCT findings is jotted down, the combination of these findings along with appropriate history helps clinch the diagnosis or appropriate differential. Approach to Interstitial Lung Disease: DAMS Unplugged Thursday, June 28, 2018 chest radiology , video Presenting a short teaching video with pulmonologist and Radiologist discussing different aspects of ILD Introduction. If the only finding is the presence of ground glass opacities, there are multiple differentials. A useful pointer to check whether the window level and width are appropriate is that the interfaces between the lung, pleura and rib should be well seen. Multiple/diffuse cysts with ground-glass opacity include pneumocystis pneumonia, desquamative interstitial pneumonia, and lymphocytic interstitial pneumonia. 2021-01-19T06:07:29-08:00 Interstitial lung diseases (ILDs) encompass a broad range of conditions, with an estimated 200 individual entities. Chest 2005; 127: 178–184. 2009-04-07T20:32:48Z https://www.slideshare.net/bhavinj/hrct-in-diffuse-lung-diseases-i-techniques-and-quality, https://www.slideshare.net/bhavinj/hrct-in-diffuse-lung-diseases-ii?qid=76403b37-2d5b-4cfc-8677-b0e302433160&v=&b=&from_search=3. Diseases that present with insidious dyspnea or spontaneous pneumothorax: 1. lymphangioleiomyomatosis 2. The patient should be made to lie on the CT table in prone position for 5 minutes for the dependent blood flow to normalize and the densities to vanish, before repeating the CT. 3. Change ), You are commenting using your Twitter account. 4. <> The official statement for evidence-based guidelines and management of IPF: http://www.atsjournals.org/doi/full/10.1164/rccm.2009-040GL, – Ameya Kawthalkar, Senior registrar, Tata Memorial Hospital, – Akshay Baheti, Assistant Professor, Tata Memorial Hospital. CONCLUSION. These usually begin at the bases posteriorly but then will track anteriorly as well. We haven’t put a lot of images into the notes; we suggest reading the notes with the slideshare open in another tab to look at relevant images, and then finish it off by reading the two pdfs. 71 0 obj Apogee Create Series3 v1.0 On HRCT there are four patterns: reticular, nodular, high and low attenuation (table). 102 0 obj You can read more on honeycombing at. Change ), You are commenting using your Google account. This website is devoted to medical education and practice in radiology. A common imaging conundrum when the CT is not obtained in maximum inspiration is the appearance of reticular opacities in the gravity dependent segments of the lung, especially at the lung bases. 2021-01-19T06:07:29-08:00 You can turn off the use of cookies at anytime by changing your specific browser settings. These nine findings are. Once you see a fibrosing ILD, it should be classified as one of the following patterns. ( Log Out /  Practical approach to diffuse lung diseases 1. It is important to understand the anatomy of the secondary pulmonary lobule and interlobular septum. There are a couple of links as well at the end to read more from, and links to two ppts put up on this topic on slideshare by Dr Jankharia sometime back (they have more images to refer to). The interpretation of interstitial lung diseases is based on the type of involvement of the secondary lobule. If the diagnosis is of a non-fibrosing ILD, the presence of the combination of other findings on HRCT can help make the diagnosis. This chapter on interstitial lung disease (ILD) is followed by a chapter on alveolar lung disease (ALD). %PDF-1.5 %���� Fleishner Society defines radiologic honeycombing as ‘clustered cystic air spaces, cysts of comparable diameters, and cyst diameters typically <10 mm surrounded by well-defined walls’. Nodules should be considered well-defined if they can be clearly delineated, and ill-defined if not. Diffuse Parenchymal Lung Diseases A systematic approach to differential diagnosis of diffuse parenchymal lung diseases based on the radiologic findings is given in Chapter 24. Desquamative interstitial pneumonia and respiratory bronchiolitis-associated interstitial lung disease. Publicationdate 2007-12-20. 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