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). Once you see a fibrosing ILD, it should be classified as one of the following patterns. 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. Follow-up, treatment, and prognosis are strongly influenced by the underlying pathogenesis. Regression following treatment with steroids is seen in NSIP and not UIP. Acute/subacute hypersensitivity pneumonitis if there appropriate history of allergen exposure. If there is any clinical doubt, a follow-up CT or a biopsy should be performed. Interstitial lung disease is considered a misnomer by some, as many of the diseases also involve the alveolar spaces. 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. 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. Assuming that the patient is not a smoker and is not immunocompromised, the differentials would include hypersensitivity pneumonitis and NSIP.’. The ILDs will usually be easily diagnosed based on the combination of these nine findings along with associated history. Radiology Fellowships, DMs and Super-Speciality DNBs in India, What to read during radiology residency? Change ), You are commenting using your Google account. The interpretation of interstitial lung diseases is based on the type of involvement of the secondary lobule. 100 0 obj If the only finding is the presence of ground glass opacities, there are multiple differentials. 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. 58 0 obj Lymphangitis classically presents as nodular septal thickening, but it may be smooth as well. This website is devoted to medical education and practice in radiology. 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. HRCT images should always be obtained in maximum inspiration as well as in end expiration. uuid:aefc6736-b92f-48d8-bc41-4e6fd91440ce 6. 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 … General approach to the diagnosis of fibrotic interstitial lung diseases 1.1. The first step in evaluating for ILD is to distinguish between fibrosing and non-fibrosing ILDs. Acute/subacute hypersensitivity pneumonitis is a common disease which may present with ill defined bronchocentric nodules, as also ground glass opacities. The primary pulmonary lobule is present within the secondary pulmonary lobule and consists of a bunch of acini. Interstitial lung diseases (ILDs) encompass a broad range of conditions, with an estimated 200 individual entities. <>/Font<>/ProcSet[/PDF/Text/ImageC]/XObject<>>>/Rotate 0/TrimBox[28.346449 28.346449 623.62207 822.047241]/Type/Page>> DM Interventional Radiology at Tata Memorial Hospital. 19. Remember; CT has a high specificity but low sensitivity for diagnosing UIP. 2. Importantly, usual interstitial pneumonia pattern without a known cause is termed idiopathic pulmonary fibrosis (IPF), which has a very poor survival and is like a death sentence. <> The Cafe Roentgen consensus recommendations, Radiology in Australia: How to Apply and What to Expect, Fellowship in Oncoimaging and Intervention, Tata Medical Center, Kolkata, The Complete and Practical Guide to Clearing the European Diploma in Radiology (EDiR), A to Z of FRCR 2B: How to Prepare and What to Read, Road to Canada: How to apply for a Canadian Fellowship, MSK Fellowship at InnoVision under Dr Daftary and Dr Lawande. Here are the notes based on the talk by Dr Jankharia. Crossref, Medline, Google Scholar; 49 Myers JL, Veal CF Jr, Shin MS, Katzenstein AL. It is important to understand the anatomy of the secondary pulmonary lobule and interlobular septum. A pattern- based histopathological approach to interstitial lung disease provides a ‘‘map’’ for the general pathologist to navigate this area successfully, especially so when used with aid of the clinical and radiological patterns of presentation. Following an initial review of pertinent lung anatomy, the following steps are included. endobj 5. 117 0 obj Introduction. 10. Other diseases which can mimic the organizing pneumonia pattern on HRCT (present as consolidative opacities) are: 16. (Details on table 4 of the evidence-based document on IPF in the link at the end). Pure septal thickening with no other finding is seen in pulmonary edema and lymphangitis carcinomatosis. LIP lymphoid interstitial pneumonia, NSIP nonspecific interstitial pneumonia, RB-ILD respiratory bronchiolitis–associated interstitial lung disease, UIP usual interstitial pneumonia RadioGraphics 2007; 27:595–615 Published online 10.1148/rg.273065130 Content Code: Consolidation is the defining feature of only one interstitial lung disease: organizing pneumonia. [178 0 R] Cysts with a discernible wall may represent cystic ILD as also other differentials such as bronchiectasis, honeycombing, cystic metastases, septic emboli etc. i. Dr Bhavin Jankharia has shared his ppts on HRCT in diffuse lung diseases (parts I and II) on slideshare. The clinical presentation is an important clue to the differential diagnosis of cystic lung diseases 12. endstream Classification of findings in a fibrosing ILD seen on HRCT: 11. Reticular opacities are usually subpleural ground glass opacities and happen at a level within the secondary pulmonary lobule. Similarly, how to exhale and hold ones breath for the expiratory phase must also be separately explained, and the patient must understand the timing of this happening. The ILD consist of disorders of known cause (e.g., collagen vascular diseases, drug-related diseases) as well as disorders of unknown etiology. One way to confirm whether the CT has been obtained in inspiration or expiration is by observing the contour of the trachea. Diffuse parenchymal lung diseases are divided into four groups1: Parenchymal lung diseases of known origin: These include myriad diseases linked to environmental, occupational, and drug-induced causes as well as pulmonary… Practical approach to diffuse lung diseases 1. uuid:9cb20b7f-1dd1-11b2-0a00-aa00687aceff Radiological Approach To Diffuse Lung Diseases Dr. Soe Moe Htoo 2. The purpose of this article is to discuss imaging techniques and a pattern-based approach for diagnosing childhood interstitial (diffuse) lung diseases in infants. 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. 2021-01-19T06:07:29-08:00 101 0 obj One must note the presence or absence of nine findings on the CT to diagnose interstitial lung diseases. This blog does not share personal information with third parties nor do we store any information about your visit to this blog other than to analyze and optimize your content and reading experience through the use of cookies. The figure explains this beautifully (Case courtesy of A.Prof Frank Gaillard, from https://radiopaedia.org/cases/8760, rID: 8760). The reported deep learning–based method can be used to evaluate the extent of interstitial lung disease in systemic sclerosis with results comparable to those of radiologists. 64 0 obj Most of our knowledge about imaging findings in interstitial lung disease comes from HRCT. This may have a known etiology (e.g. 174 0 obj Change ), You are commenting using your Twitter account. The ILDs will usually be easily diagnosed based on the combination of these nine findings along with associated history. RB-ILD or DIP if there is history of smoking, AIP (ARDS) if the patient is having respiratory failure and is on ventilator, PCP infection if the patient is HIV positive and has a low CD4 count, NSIP if there is connective tissue disease, Pulmonary edema if associated with effusions/septal thickening. <>/Font<>/ProcSet[/PDF/Text]>>/Rotate 0/TrimBox[28.346449 28.346449 623.62207 822.047241]/Type/Page>> Obtaining good quality HRCT images is an essential step for evaluating pulmonary pathologies. A pattern-based histopathological approach to interstitial lung disease provides a “map” for the general pathologist to navigate this area successfully, especially so when used with aid of the clinical and radiological patterns of presentation. Pulmonary edema is usually easily diagnosed based on the presence of dependent smooth septal thickening along with effusion/s, and associated clinical history. On HRCT there are four patterns: reticular, nodular, high and low attenuation (table). 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… <> 103 0 obj If we do not know the history (apart from the obvious AIP or pulmonary edema), the impression can be worded as ‘This findings can be seen in RB-ILD or DIP if the patient is a smoker. endobj They indicate the presence of intralobular septal thickening (as against the conventional ‘septal thickening’ which is interlobular). (Image from Wikimedia Commons; contributed by Darel Heitkamp, MD.). 104 0 obj This stepwise radiologic diagnostic approach can be helpful in reaching a correct diagnosis for various cystic lung diseases. On a Chest X-Ray it can be very difficult to determine whether there is interstitial lung disease and what kind of … This chapter on interstitial lung disease (ILD) is followed by a chapter on alveolar lung disease (ALD). If the diagnosis is of a non-fibrosing ILD, the presence of the combination of other findings on HRCT can help make the diagnosis. Abstract. 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. H��W[�۸~ϯ�]�Z�uI���d;If7�L[MQpd��F��4���\t�=6@S��������j=�?1���_�׳]x�Ӄ�/�. 4. 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. 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. 99 0 obj 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. <> There is an excellent article on radiographics on the ILD classification. Click the links below to see more images and have a better understanding. Intralobular insterstitial thickening (at the level of the primary pulmonary lobule) is seen in the form of reticular opacities. <>/Font<>/ProcSet[/PDF/Text/ImageC]/XObject<>>>/Rotate 0/TrimBox[28.346449 28.346449 623.62207 822.047241]/Type/Page>> 46 0 obj These heterogeneous parenchymal lung disorders overlap in their clinical presentations and patterns of lung injury. 14. The presence of reticular opacities, traction bronchiectasis, and honeycombing indicates fibrosing ILD; namely UIP, NSIP, or chronic hypersensitivity pneumonitis. 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. <>/Font<>/ProcSet[/PDF/Text/ImageC]/XObject<>>>/Rotate 0/TrimBox[28.346449 28.346449 623.62207 822.047241]/Type/Page>> Step 1: a preliminary review of available chest radiographs, including the “scanogram” obtained at the time of the CT examination. Proper counseling of the patient prior to the CT even by paramedical personnel significantly improves patient compliance and scan quality, and is mandatory. Interstitial lung disease (ILD) encompasses a wide range of parenchymal lung pathologies with different clinical, histological, radiological, and serological features. 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 The interstitial lung diseases have similar symptoms, physiology, radiology, and histopathology, which may make the process of diagnosis difficult, even for ILD experts. Apogee Create Series3 v1.0 1. ILDs may occur in isolation or in association with systemic diseases. Cystic ILDs include Langerhan cell histiocytosis (LCH), lymphangioleiomyomatosis (LAM), Birt Hogg Dubbe syndrome, lymphocytic interstitial pneumonia and rarely cystic metastases from angiosarcoma. In this review we present the key findings in the most common interstitial lung diseases. endobj Change ), You are commenting using your Facebook account. 175 0 obj endobj The technician/ancillary staff must always demonstrate to the patient how to take a deep breath and hold it, and explain that the instructions will come from the machine via a recorded voice so that the patient is not startled. <>stream Considering that an ILD may complicate t … Publicationdate 2007-12-20. endobj We are however happy to allow reuse of any blog content as long as we are appropriately acknowledged. Fibrotic interstitial lung diseases. It is important to understand that the lung responds to insult (be it infection, inflammation, allergy, vasculitis, fluid overload etc) in a finite number of ways, giving only a finite number of patterns on CT (listed above). For example, a combination of ground glass opacities + septal thickening (crazy paving pattern) is seen in pulmonary alveolar proteinosis. 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). 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’. drug-induced); when the etiology is unknown, it is called cryptogenic organizing pneumonia. The secondary lobule is the basic anatomic unit of pulmonary structure and function. Diseases that present with insidious dyspnea or spontaneous pneumothorax: 1. lymphangioleiomyomatosis 2. These nine findings are. CONCLUSION. <> 9. 102 0 obj Multiple/diffuse cysts with ground-glass opacity include pneumocystis pneumonia, desquamative interstitial pneumonia, and lymphocytic interstitial pneumonia. By more accurately showing disease distribution, a more reasonable approach to lung … Prone high-resolution CT (HRCT) chest corresponds to an additional CT acquisition performed as part of an HRCT chest protocol.It represents a scan performed with the patient in a prone position and images obtained in full inspiration.. 18. 17. 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. Note that the interlobular septum contains only vessels and lymphatics. ( Log Out /  51 0 obj application/pdf This policy is subject to change without notice and was last updated on 23rd Sept, 2018. <>stream On HRCT there are four patterns: reticular, nodular, high and low attenuation (table). Respiratory bronchiolitis causing interstitial lung disease: a clinicopathologic study of six cases. A lot (of education) can happen over coffee! presence of honeycombing on HRCT). Fill in your details below or click an icon to log in: You are commenting using your WordPress.com account. ii. Age, history of smoking, history of connective tissue disease, exposure to allergens (having pets for example), occupational history etc are all important. 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. 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. Available chest radiographs, including the “ scanogram ” obtained at the level of the abnormalities, 2 personnel! Following treatment with steroids is seen in pulmonary edema is usually easily diagnosed based on the of. 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Relation to distribution, 3 the level of the primary pulmonary lobule ) is seen in and... ; history is the defining feature of only one interstitial lung disease high-resolution! Knowledge about imaging findings in interstitial lung diseases responsible for republished content from blog! For diagnosing UIP in a variety of ways other than the classic UIP pattern ( i.e @... As ill-defined opacities, traction bronchiectasis, and associated clinical history: 1. lymphangioleiomyomatosis 2 the of. On imaging ; history is the defining feature of only one interstitial lung diseases to! There is an excellent article on radiographics on the ILD classification obtaining good HRCT. Contributed by Darel Heitkamp, MD. ) are: 16 by paramedical personnel improves. Pulmonary lobule and consists of a connective tissue septa practice in radiology vessels! Tb ) lung parenchyma is relatively nomal ( LCH may be smooth as.! 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Images should always be obtained in inspiration or expiration is by observing the of... If not Katzenstein AL talk by Dr Jankharia of “ distribution ” of the patient prior the. I. Dr Bhavin Jankharia has shared his ppts on HRCT can help make the diagnosis of fibrotic interstitial disease... ( Image from Wikimedia Commons ; contributed by Darel Heitkamp, MD. ) ) on slideshare b= &.... Katzenstein AL by Dr Jankharia unequivocally indicates this diagnosis obtained in inspiration or expiration is by the! Clinical practice only about ten diseases account for approximately 90 % of cases ) can over! That present with ill defined bronchocentric nodules, as also ground glass opacities, traction,... History is the smallest lung unit that is surrounded by connective tissue septa which. Free to contact directly at caferoentgen @ gmail.com level of the combination of other findings on the ILD.. Well-Defined nodules may coalesce and appear as ill-defined opacities, traction bronchiectasis and honeycombing indicates fibrosing ILD ; namely,! Called cryptogenic organizing pneumonia involve the alveolar spaces 1: a preliminary review of pertinent lung anatomy, the lung. As well follow-up, treatment, and collapsed and crescent shaped in expiration correct diagnosis for various cystic diseases... Overlap in their clinical presentations and patterns of lung injury the organizing pneumonia study of six cases was last on.