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CHEST

SOME THINGS THAT KEEP GETTING ASKED:

The Right Bronchus, wider, shorter, and more vertical in direction than the left, is about 2.5 cm. long, and enters the right lung nearly opposite the fifth thoracic vertebra. The azygos vein arches over it from behind; and the right pulmonary artery lies at first below and then in front of it. About 2 cm. from its commencement it gives off a branch to the upper lobe of the right lung. This is termed the eparterial branch of the bronchus, because it arises above the right pulmonary artery. The bronchus now passes below the artery, and is known as the hyparterial branch; it divides into two branches for the middle and lower lobes. (Grays)

 

The Left Bronchus is smaller in caliber but longer than the right, being nearly 5 cm. long. It enters the root of the left lung opposite the sixth thoracic vertebra. It passes beneath the aortic arch, crosses in front of the esophagus, the thoracic duct, and the descending aorta, and has the left pulmonary artery lying at first above, and then in front of it. The left bronchus has no eparterial branch, and therefore it has been supposed by some that there is no upper lobe to the left lung, but that the so-called upper lobe corresponds to the middle lobe of the right lung. (Grays)

 

 

SOME SHUNTS:

some of these keep getting asked on the exam: 

pulmonary varix (this is an abnormally dilated and tortuous pulm vein and does not produce a shunt): no shunt

pulmonary avm (R to L) so this causes peripheral oxygen desaturaton

intralobar sequestration (L to L) so no shunt

extralobar sequestration (L to R): no peripheral oxygen desaturation

scimitar syndrome (hypoplastic pulmonary artery so lung is supplied by systemic artery and drained by anomalous pulmonary veins to the IVC which makes this a L to R (Weissleder says that the hyplastic lung is perfused from the aorta and drained by the IVC or portal vein. The vein has morphology similar to a sword). It is associated with bony abnormalities such as hemivertebrae, rib notching, rib hypoplasia,  as well as CHD, and accessory diaphagm or diaphragmatic hernia as well as dextrapostion of the heart due to the small lung

 

 

CRURA THICKNESS:

R>L

 

 

LUNG FUNCTION:

TVor tidal volume  is amount of gas moving in and out of lungs without effort with each breathing cycle

RV is amoount of gas remaining in the lung after a  maximum expiration

TLC or total lung capacity is gas contained in the lung at the end of a maximum inspiration

VC or vital capacity is the amount of gas that can be expired after a maximum inspiration without force

FRC is the amount of gas remaining in the lungs after the end of a quiet expiration

 

 

 

MUELLER MANEUVER:

deep inspiration by the patient in the supine position is the best way to maximally distend to azygous vein

 

 

SIGNS OF PTX ON SUPINE CHEST FILM:

deep sulcus sign, rounded epicardial fat pad, increased lucency at the lung base

 

 

TRACHEAL DISEASE:

saber sheath, tracheopathia osteochondroplastica (distal 2/3 and proximal bronchi), relapsing polychondritis, tracheobroncomalacia, tracheobronchomegaly

 

 

BRONCHIAL ANATOMY:

PA accompanies bronchi, PV runs independently of PA and bronchi, bronchial arteries accompany bronchi, lymphatics accompany PV and do not run along side the bronchi (Grays Anatomy)

Schematic longitudinal section of a primary lobule of the lung (anatomical unit); r. b., respiratory bronchiole; al. d., alveolar duct; at., atria; a. s., alveolar sac; a, alveolus or air cell; p. a.: pulmonary artery: p. v., pulmonary vein; l., lymphatic; l. n., lymph node. (Miller.)

 

 

 

SOME SIGNS IN THORACIC RADIOLOGY:

air bronchogram - indicates a parenchymal process, including non-obstructive atelectasis, as distinguished from pleural or mediastinal process

air crescent sign – indicates a lung cavity, often due to fungal infection

deep sulcus sign on a supine radiograph  - indicates pneumothorax

continuous diaphragm sign - indicates pneumomediastinum

ring around the artery sign (around pulmonary artery on lateral chest radiograph) - indicates pneumomediastinum

fallen lung sign - indicates a fractured bronchus

 flat waist sign- indicates left lower lobe collapse

gloved finger sign - indicates bronchial impaction, which can be seen in allergic bronchopulmonary aspergillosis

Golden S sign - indicates lobar collapse with a central mass, suggesting an obstructing bronchogenic carcinoma in an adult

 luftsichel sign - indicates upper lobe collapse, potentially due to an obstructing bronchogenic carcinoma in an adult

Hampton’s hump - indicates a pulmonary infarct

silhouette sign - loss of the contour of the heart or diaphragm used to localize a parenchymal process (e.g. a process involving the medial segment of the right middle lobe obscures the right heart border; a lingula process obscures the left heart border; a basilar segmental lower lobe process obscures the diaphragm)

cervicothoracic sign – a mediastinal opacity that projects above the clavicles is retrotracheal and posteriorly situated while an opacity effaced along its superior aspect and projecting at or below the clavicles is situated anteriorly

tapered margins sign - a lesion in the chest wall, mediastinum or pleura will have smooth tapered borders and obtuse angles with the chest wall or mediastinum while parenchymal lesions usually form acute angles

figure 3 sign – abnormal contour of the descending aorta, indicating coarctation of the aorta

fat pad sign or sandwich sign – indicates pericardial effusion on lateral chest radiograph

scimitar sign – an abnormal pulmonary vein in venolobar syndrome

double density sign – contour projecting over the right side of the heart, indicating enlargement of the left atrium

 hilum overlay sign and hilum convergence sign – used to distinguish a hilar mass from a non-hilar mass

many more signs in chest radiology can be obtained from: http://www.cgmh.com.tw/intr/intr2/c3100/orien/orien-cxr.htm

 

 

SEGMENTAL LUNG ANATOMY:

rul: apical: B1

anterior: B2

posterior: 3

ML: lateral: 4

medial: 5

LL: sup: 6

med: 7

ant: 8

lat: 9

post: 10

 

 

LUL: apicoposterior: B1,3

ant: 2

ling: sup: 4

inf: 5

LL: sup: 6

med: 7

ant: 8

lat: 9

post:10

 

 

ASBESTOSIS:

Pleural plaques in asbestosis: posterolateral and diaphragmatic

Benign mesothelioma: not associated with asbestos exposure, also, involves visceral pleura in 80%. Hypoglycemia associated

 

 

MOST COMMON PRESENTATION OF BAL:

BAL ca presents most commonly as a solitary pulm nodule. According to Dr. Westcott, a high % of persisitent solitary or focal ground glass density seen on high res CT turns out to be BAL carcinoma on subsequent bx. If there is a cystic component in the ground glass, then it is  more likely to be adenoca. Multifocal ground glass is most likely inflammatory in nature

 

 

DEFINITION OF FRIEDLANDER PNEUMONIA

The PA chest x-ray reveals a homogeneous opacity extending from the right heart border to the lateral chest wall. This opacity obscures the right atrial border placing it in the right middle lobe. This is known as the "silhouette" sign as described in Dr. Felson's textbook and it allows the process to be localized accurately from the PA chest x-ray alone. There is right middle lobe infiltrate producing convex bulging of the minor and major fissures. This is characteristic of Friedlander's pneumonia and can be seen with any acute exudative pulmonary infection. The organism classically associated with Friedlander's pneumonia is Klebsiella pneumoniae. Other organisms causing bulging of fissures include Streptococcus pneumoniae and Mycobacterium tuberculosis. This sign may also be seen with lung abcesses and bronchogenic carcinoma. The bulging fissure sign is known as the Fleishner sign like the Fleishner ring around the eye in Wilsons disease

 

 

INFECTIONS IN HEART TRANSPLANT PATIENTS:

most common viral agent: CMV which usually appears in the 2 nd month after transplant

 

 

MOST COMMON HIV FUNGAL PNEUMONIA:

aspergillus.

 

 

MOST COMMON HIV LUNG INFECTION:

bacterial pneumonia

 

 

PLASMA ONCOTIC PRESSURE:

25mm Hg

 

 

VOLUME OF FLUID IN PLEURAL SPACE:

1-5 cc but may be up to 15 to 20 cc and still be normal

 

 

ACINUS:

describes all structures distal to one terminal bronchiole. Acinus measures about 7mm and contains about 400 alveoli. So the acinus is the best term for the terminal bronchial subunit

 

 

SECONDARY PULMONARY LOBULE:

polygonal structure which is 1.5 to 2 cm in diameter and contains about 3 to 5 acini per lobule and supplied by several terminal bronchioles

 

 

CARNEY TRIAD:

carney triad=pulmonary chondroma, gastic leiomyosarcoma, and extraadrenal paraganglioma  

 

 

CARNEY SYDROME:

complex myoma, pituitary tumor, breast tumors, L atrial myxoma, pit adenoma, pigmented skin lesions

 

 

LUNG INVOLVEMENT WITH SCLERODERMA:

schleroderma causes basal interstitial fibrosis  

 

 

PULMONARY SARCOID

Staging of pulmonary sarcoidosis is based on the appearance demonstrated on chest x-ray. Stage 0 is a normal chest x-ray; stage I has nodal (especially hilar) enlargement only; stage II has nodal enlargement and parenchymal infiltrates; stage III demonstrates parenchymal shadowing only; and stage IV represents end-stage fibrosis. Isolated posterior adenopathy is rare in sarcoidosis. Sarcoidosis and tuberculosis are both common predisposing conditions for mycetoma formation. Laboratory findings associated with sarcoidosis include blood eosinophilia (up to 25%), hypercalcemia (10% to 20%), hypercalciuria, and elevated angiotensin-converting enzyme levels (50% to 60% of patients). Pleural effusion is a relatively rare finding in sarcoidosis.

 

 

MALIGNANT VS BENIGN LUNG TUMOR:

best is difference in enhancement with and without contrast of 20 HU. this number gives the highest sensitivity and specificity

 

 

LUNG LESIONS:

Sequestration: intralobar 60% L base and extralobar 80% L base or below diaphragm. Both are in the posteriomedial segments of the lower lobes

CCAM: all lobes equally. Malignant degeneration is a potential complication

CLE: LUL 40%, RML 35% and RUL 20%

Bronchogenic cyst: mediastinum 85% (posterior>middle>anterior) and lung 15%. They like the medial third of the lung

Scimitar syndrome: R>L

Swyer James: whole lung, no preferences. Sometimes lobar or segmental  

 

 

SCIMITAR SYNDROME:

also called hypogenetic lung syndrome

it is a special form of hypoplastic lung in which the lung is perfused from the aorta and drained by the portal vein or IVC. The anomalous vein has the morphology of a scimitar or sword. It is associated with an accessory diaphragm or diaphragmatic hernia. Bony abnormalities include rib notching, hemivertebrae, rib hypoplasia, CHD, ASD, VSD, PDA, TOF. The lung is usually small. R>L for incidence. There can be dextoposition (shift) of the heart because of the hypoplastic lung

 

 

DRUG TOXICITY ON LUNGS:

drug tox affects lung bases most commonly

 

 

PCP LUNG:

in pcp can have a normal cxr in 10%. Pneumatoceles in 10%

 

 

DDX OF UPPER LOBE INTERSTITIAL DISEASE (CASSET):

Cystic fibrosis

Ankylosing spondylitis

Silicosis / Berryliosis

Sarcoidosis

Eosinophilic granuloma

Tuberculosis, Fungus

 

 

DDX OF BASILAR DISEASE (BAD LASS RIF):

bronchiectases

aspiration

dermatomyositis

lymphangitic spread

asbestosis

sarcoidosis

schleroderma

rheumatoid

ipf

furantin

 

 

SOME MORE THINGS WITH A UL PREDOMINANCE:

AS, post 1ary TB, bronchocentric granulomatosis, CF, bronchial atresia

 

 

DIFFERENTIAL OF UNILATERAL HYPERLUCENT LUNG:

faulty technique (patient rotation)

chest wall defect (mastectomy, absent pec muscle)

large airway obstruction (eg hilar mass compressing LLL bronchus, endobronchial obstruction with air trapping such as from foreign body, bronchogenic ca, carcinoid, bronchial mucocele)

small airway obstruction (bronchiolitis obliterans, swyer james, emphsema particularly the bullous type, ptx)

pulmonary vascular cause (pulm artery hypoplasia, pulm embolism, CLE, compensatory overinflation)

 

 

CONGEN ABSENCE OF THE PERICARDIUM:

PA  view looks like the rao view

 

 

PERICARDITIS:

50% of pts with Ca++ have constrictive pericarditis and 90% of pts with constrictive pericarditis have Ca++

 

 

ASSOCIATION OF PCP WITH CA++

extrapulmonary PCP infection is associated with Ca++

most common location  of Ca++ is in the LN's

 

 

LYMPHOID GRANULOMATOSIS:

this is frequently a premalignant condition

 

 

PSEUDOLYMPHOMA VS LIP:

they both share the same histologic features. In fact, pseudolymphoma is just another name for LIP and represents the localized form of LIP. However, LIP is diffuse, while pseudolymphoma tends to be a solitary mass. In pts with LIP, if LAN develops, lymphomatous change should be suspected

 

 

PANCOAST TUMOR IMAGING:

coronal MR is mandatory. Note that the superior sulcus is the groove in the apex of the lung formed by the subclavian vessels

 

 

LARGE AND SMALL CELL LUNG CA:

massive hilar lan is a well recognized feature of both

 

 

SQUAMOUS CELL CA:

consolidation, and collapse is most commonly seen with SCC as they are frequently central lesions. Cavitation is seen in 6% of adenoca's and 12% of SCC's

 

 

BRONCHIAL CARCINOIDS:

more likely to produce Cushings syndrome than non bronchial carcinoids

 

 

AN APPROACH TO ILD (temple U: http://blue.vm.temple.edu/~pathphys/pulmonary/)

this is one area that I really have a lot of trouble with:

 

Establishing the diagnosis

 

If you add cystic fibrosis, then you get CASSETT

 

 

HERE IS THE DDX OF ILD:

 

ETIOLOGY OF ILD:

no cause is identifiable in over 60% of pts with ild, and so this category is called idiopathic pulmonary fibrosis. In other forms of ild, the injury is introduced via the circulation or the airway. The following is the sequence of events that lead to ild:

(1) primary insult by toxin, antigen or unknown

(2) interstitial infiltration by polys, monos, macrophages, or eosinophils. Monos are usually predominant

(3) alviolar cell ulceration and basal lamina destruction

(4) persistent inflammation with abnormal repair mechanisms

(5) alveoalar fibrosis and collapse

(6) honeycombing and bronchiectasis

 

in terms of hypersensitivity connective tissue disorder associated lung disease, the following immune mechanisms are important:

type 2 IgG mediated cytoxic reaction: Goodpastures (antibodies directed against glomerular basement membranes and alveolar walls)

type 3 immune complex mediated: Wegeners and SLE. There are known or more commonly unknown immune complexes which deposit within the alveolar capillary bed and lead to endothelial complement activation resulting  necrosis and thrombosis

type 4 delayed type hypersensitivity associated with respiratory exposure to organic dusts. 

Antigen exposure activates T-helper cells (CD4+) and Cytotoxic T-cells (CD8+) which mediate the immune respose toward the offending antigen. Symptoms may present acutely or be slowly progressive. An intense lymphocytic alveolitis with or without granuloma formation is seen on histology.

Example: Sarcoidosis

 

 

EXTRINSIC ALLERGIC ALVEOLITIS:

acute affects the LL, and when chronic affects the UL (get fibrosis)

 

 

LANGERHANS CELL HISTIOCYTOSIS:

M>F by 4:1

 

 

STAGING OF LUNG CANCER:

here are the tumor and node descriptors:

The stage of a lung cancer is very important in the clinical management of a patient. Staging is based on diagnostic evaluations as noted above. The currently accepted staging system for non-small cell lung cancer was adopted in 1997 by the American Joint Committee on Cancer and the Union Internationale Contre le Cancer, as a response to the need for more specific patient groupings. The four stages are based on the TNM descriptors as described below, and provides a consistent and reproducible classification for describing the extent of disease:

Primary Tumor (T)

TX

Primary tumor cannot be assessed, or tumor proven by the presence of malignant cells in sputum or bronchial washings but not visualised by imaging or bronchoscopy.

T0

No evidence of primary tumor

T1

Tumor £ 3 cm in greatest dimension, surrounded by lung or visceral pleura, without bronchoscopic evidence of invasion more proximal than the lobar bronchus {ie not in the main bronchus}

T2

Tumor with any of the following features of size or extent:

 

> 3cm in greatest dimension

 

Involves main bronchus, 2 cm distal to the carina

 

Invades the visceral pleura

 

Associated with atelectasis or obstructive pneumonitis that extends to the hilar region but does not involve the entire lung

T3

Tumor of any size that directly invades any of the following: chest wall (including superior sulcus tumors), diaphragm, mediastinal pleura, parietal pericardium; or tumor in the main bronchus <2cm distal to the carina, but without involvement of the carina; or associated atelectasis or obstructive pneumonitis of the entire lung.

T4

Tumor of any size that invades any of the following: mediastinum, heart, great vessels, trachea, oesophagus, vertebral body, carina; or tumor with a malignant pleural or pericardial effusionb, or with satellite tumor nodule(s) within the ipsilateral primary-tumor lobe of the lung.

 

 

Regional Lymph Nodes (N)

NX

Regional lymph nodes cannot be assessed

N0

No regional lymph node metastasis

N1

Metastasis to ipsilateral peribronchial and/or ipsilateral hilar lymph nodes, and intrapulmonary nodes involved by direct extension of the primary tumor.

N2

Metastasis to ipsilateral mediastinal, or subcarinal LN's
N3 contralateral mediastinal or hilar nodes, supraclavicular or scalene nodes

 

Distant metastasis (M)

MX

presence of distant metastasis cannot be assessed

M0

No distant metastasis

M1

Distant metastasis presentc

a) The uncommon superficial tumor of any size with its invasive component limited to the bronchial wall, which may extend proximal to the main bronchus, is also classified T1

b) Most pleural effusions associated with lung cancer are due to tumor. However, there are a few patients in whom multiple cytopathology examinations of pleural fluid show no tumor. In these cases, the fluid is non bloody and is not an exudate. When these elements and clinical judgement dictate that the effusion is not related to the tumor, the effusion is not related to the tumor, the effusion should be excluded as a staging element and the patient’s disease should be staged T1, T2 or T3. Pericardial effusion is classified according to the same rules.

c) Separate metastatic tumor nodule(s) in the ipsilateral non-primary tumor lobe(s) of the lung are also classified M1.

There are four stages, each corresponding to one or more TNM classification. Stage 1 reflecting the best prognosis and stage IV the worst.

Stage

TNM subset

0

Carcinoma in situ

 

 

IA

T1N0M0

IB

T2N0M0

 

 

IIA

T1N1M0

IIB

T2N1M0, T3N0M0

 

 

IIIA

T3N1M0, T1N2M0

 

T2N2M0, T3N2M0

IIIB

T4N0M0, T4N1M0

 

T4N2M0, T1N3M0

 

T2N3M0, T3N3M0, T4N3M0

 

 

IV

Any T Any N M1

*Staging is not relevant for occult carcinoma, designated TXN0M0
 

The complex TNM system is not used in small cell lung cancer, a simple two stage system of limited and extensive disease. Limited disease is defined as disease confined to one hemithorax with or without ipsilateral mediastinal or supraclavicular lymphadenopathy, while extensive disease covers any disease spread outside this defined area.Recently patients with contralateral mediastinal and supraclavicular nodes and ipsilateral pleural effusion have been included in the ‘limited disease’ category.

 

HOW TO CONVERT THE NODES AND T TO STAGE:

 

DEFINITION OF UNRESECTABLE LUNG CANCER:

resectable is stage 0,1,2,3A, touching visceral pleura is resectable ie T2

unresectable is 3B or 4

another way of looking at unresectable lung cancer is T4. N3, or M1

 

 

CHEST LN STAGING:

2R,L: paratracheal

4R,L: superior tracheobroncial

5,6: anterior mediastinum

7: subcarinal

8,9: posterior mediastinal

10R,L: bronchopulmonary

11 R,L: pulmonary

14: diaphragmatic

 

 

OSTIAL ANOMALIES:

primum: lie immediately next to the AV valves. The defect is associated with Downs syndrome (ie it is "down" near the AV valves). It can cause asd, vsd, mitral incompetence, tricuspid incompetence, lv to ra shunt

secundum: this is the most frequent type (60%) and involves the fossa ovale in the midseptal location. This defect is associated with Holt oram

venosus: this is near the entry of the svc and is associated with anomalous entry of the pulmonary veins

 

 

HEMODYNAMICS OF ASD:

enlarged RA and normal LA. Enlarged RV and normal LV. Inreased size of PA and not change in size of the aorta

 

 

THYMOMA:

thymomas are invasive in 30 to 35% (they are heterogeneous and can spread by contiguity along pleural reflections). They can have pleural masses that surround and encase the lung circumferentially and may encroach on the vessels. Pleural effusions are uncommon

15% of pts with myesthenia gravis have thymoma and 30% of pts with thymoma have myesthenia gravis.  The association is higher with thymic hyperplasis where 65% of pts with myestenia gravis have thymic hyperplasia (source is Dahnert)

 

 

PLEURAL EFFUSION:

left:

voorhave: left sided esophageal perforation leading to L sided effusion

pancreatitis: L

ruptured thoracic duct in upper chest: L

dissecting aortic aneurysm: L

traumatic rupture of the aorta distal to the L subclavian artery: L

SLE (L >R)

 

right:

ruptured thoracic duct in lower chest: R

CHF: R

RA: R>L (ie R in 75%)

Meigs: R sided effusions with ascites are seen in this condition

 

note the following:

Diseases adjacent to the diaphragm: cause an effusion on that side: eg hepatic absess produces a R sided effusion

note that on a PA view, the first 300 cc is not visualized. The left lateral decubitus may detect as litlle as 25 cc. In subpulmonic effusion, the peak of the diaphagm is laterally positioned

note also that the most common cause of a unilateral pl effusion is malignancy (lymphoma, mets, primary lung ca)

most bilateral effusions are transudates, the exceptions being SLE, mets, PE, lymphoma

 

 

ORIGIN OF PHRENIC NERVE:

brachial plexus; therefore, diaphragmatic paralysis can be a sequela of brachial plexus trauma. An important mimic of diaphragmatic paralysis is eventration of the diaphragm usually on the L

 

 

AIR LEAK:

BPF usually occurs at 10-14 w. A small amount of air may reside within the hemothorax for months without any significance. A drop in the fluid level by >20mm or reappearance of air suggests a BPF. Early fistulae are due to poor surgical technique and late ones are due to recurrent tumor

 

 

NEUROBLASTOMA:

can occur in the anterior mediastinum, but occurs most commonly in the posterior mediastinum. Nerve sheath tumors are spherical whereas ganglioneuromas tend to be sausage shaped

 

 

BRONCHOPNEUMONIA VS LOBAR PNEUMONIA:

bronchopneumonia is a finding in Staph pneum and lobar pneumonia is a feature of Strep pneum

 

 

HYPOPLASTIC LUNG RELATIONS:

TOF and TGA. There is agenesis of the PA

 

 

PULMONARY STENOSIS:

the most common cause is valvular disease

 

 

PULMONARY GANGRENE:

most common organisms are strep pneumonia and klebsiella

 

 

CENTRAL BRONCHIECTASIS:

think aspergillus fumigatus

 

 

PCP IN AIDS:

the miliary pattern is less common. Thin walled cysts (10%) occur due to parenchymal obstruction. If you see PTX in a pt with aids, the dx is pcp until proven otherwise

 

 

CF:

the increased Cl and Na applies to sweat, not saliva. The disease affects the apical and posterior segments of the UL's with a RUL predominace. One complication of the lung involvement is ptx. Other findings are rectal prolapse and hypoplastic frontal sinuses

 

 

SWYER JAMES:

bronchilitis obliterans. It occurs post viral infection, organ transplant, idiopathic. Classical is post viral. There is abrupt cut off of the airways at the 5th level. Air trapping occurs during expiration. With hypogenetic lung syndrome, there is no air trapping and small hemithorax. One sees pruned vessels on angio

 

 

CHF CAUSES:

back pressure from the LV which is long standing, aortic valve dz, CAD, cardiomyopathy, MI

obstructive phenomena: prox LV, MVD, LA myxoma, cor tritriatrium

note that LA myxoma usually comes from the lower part of the intraatrial septum. This together with the fact that they usually occur on a stalk accounts for their propensity to protrude into the right or LV during atrial systole. Note also that myxomas rarely calcify

 

 

LATITUDE:

cxr is low contrast and high latitide. By comparison, a mammogram would be high contrast and low latitude

 

 

LOEFFLERS:

fleeting opacities in a pt with atopic hx. Frequently see it in ascariasis and filariasis. It can be unilat, bilat, segmental, nonsegmental. Typically it is periperal

 

 

CHRONIC EOSINOPHILIC PNEUMONIA:

not fleeting. More serious. Insidious. Dense. Ill defined opacities. Reverse pulmonary edema pattern

 

 

LYMPHOID GRANULOMATOSIS:

vasculitis in the same category as wegeners. Angiocentric distribution. Also involves kidney, skin, CNS. May be a frank lymphoma of B cells. M>F. Looks similar to wegeners. Multiple pulm nodules 1-10 mm. More numerus than wegeners. Cavitation is common

 

 

WEGENERS:

it is more common in males

 

 

PTX IN ASTHMA:

occurs more frequently in children than in adults

 

 

CATAMENIAL PTX:

R>>L. It is associated with endometriosis of the diaphragm

 

 

SOME CAUSES OF TRACHEAL NARROWING:

TPO, relapsing polychondritis, TB, amyloidosis, schleroma. Note that amyloidosis is a cause of parenchymal lung ca++ in 40%. A schleroma is caused by Klebsiella

 

 

RHEUMATOID LUNG:

Rheum lung: M>F, RA: F>M

 

 

SUPERIOR RIB NOTCHING:

most likely non cardiogenic from rubbing of bones. HPT, polio, marfan, OI

 

 

INFERIOR RIB NOTCHING:

blalock taussig (unilateral first 2 or 3 ribs), aortic obstruction, interupted aortic arch, tof, pulm atresia, svc obstruction, ebsteins, intercostal neuroma

 

 

CAUSES OF UNILATERAL RIB NOTCHING:

coarct with L arch with aberrent R SCA

coarct with R arch with aber L SCA

AVM of arm

BT shunt

 

 

AIDS CD4:

mtb: <400 reinfection pattern

bacterial pneumonia: 175-250

AIDS definition: <200

PCP<200

primary pattern pulm TB: <200

Kaposi and fungi: <150

lymphoma, CMV, MAI <50

 

 

TB IN AIDS:

primary tb pattern is infiltrate (<200)

secondary tb pattern is ul predominant

miliary pattern is not uncommon

posterior seg of UL  and superior seg of lower lobe are classic but TB can occur in the anterior segments of the upper and lower lobes

 

 

DDX OF LAN WITH CENTRAL HYPODENSITY IN HIV:

aids related lymphoma, fungal, atypical mycobacterial

 

 

MEDIASTINAL MASSES IN CHILDREN:

children:

anterior 30%: lymphoma, leukemia, teratoma

middle 30%: lymphoma, leukemia

posterior 40%: neurogenic (most common), lymphoma, leukemia, teratoma

note that thymoma is very rare in children. It is most common in the anterior mediastinum of adults

 

 

THYMOMA ASSOCIATIONS IN ADULTS:

aplastic anemia, hypogammaglobinemia, red cell aplasia

 

 

PRIMARY VS SECONDARY TB:

primary:

lung bases, focal, no cavitation, LAN commonly seen as the only finding, effusion is common, miliary pattern, pleural effusion more common with primary than with secondary (Weisleder). In immunocomprimized, you see progressive primary disease where it spreads to all parts of the body. The occurrence of cavitation in primary disease indicates progressive disease

secondary:

Apicoposterior segment of UL and superior seg of LL predominant. Patchy, frequent cavitation, no LAN, effusion is uncommon, can have miliary pattern (same incidence as for primary). Note that miliary pattern is more commonly from primary than from secondarty TB

 

 

CAVITARY PNEUMONIA:

most commonly in staph, gram negative (kleb, proteus, pseudomonas), anaerobic, mycobacterial. Less commonly from fungal, amebic, and helminth

 

 

PCP PNEUMONIA:

pneumatoceles from  pcp pneumonia resolve after treatment

 

 

PNEUMATOCELES:

those in pts with S. Aureus usually resolve

 

BULLA:

1 cm cystic space in the lung parenchyma which is due to destruction of alveolar walls

 

TRANSUDATE VS EXUDATE:

LDH>0.6, PROT>0.5, PLEUR LDH>200 is accurate in 99% for exudate. LDH is the most specific

 

 

PNEUMONIA IN AIDS:

bacterial pneumonia is more common than pcp pneumonia

 

 

RIGHT MAIN BRONCHUS AND BRONCHUS INTERMEDIUS:

both are normally outlined by air

 

 

RATIO OF ARTERY TO BRONCHUS IN UPPER AND LOWER LOBES:

upper: 0.85, lower: 1.3. If a vessel is more than 1.5 times its accompanying bronchus, it should be considered abnormal

 

 

NORMAL RANGE OF EXCURSION OF THE DIAPHRAGM:

as demonstrated by US: 2-8.6 cm (grainger and allison)

 

 

CONSOLIDATION:

it respects lobes, not segments

 

 

SOME CAUSES OF AIR BRONCHOGRAM ON A CXR:

non obstructive collapse, passive atelectasis, lymphoma, PMF, alveolar cell ca

 

 

SOME CAUSES OF EXPANSIVE LUNG CONSOLIDATION:

consolidation 2ary to neoplasm (commonly SCC which obstructs the bronchus), klebsiella, pneumococcal pneumonia

expansive consolidation is sometimes referred to as drowned lung but has nothing to do with drowning

 

 

LOWER VS UPPER ESOPHAGEAL RUPTURE:

the upper 1/3 is adjacent to the mediastinal surface on the R and so upper esophageal rupture will give a R effusion. The lower 1/3 tends to lie next to the left and is adjacent to the L inferomedial surface which would give an effusion on the L

 

 

EGGSHELL CA++:

silicosis, berylliosis, CWP, treated lymphoma, granulomatous dz such as histoplasmosis rarely contains eggshell ca++; diffuse ca++ are more common in granulomatous dz, sarcoid (rare and late in the disease)

note that eggshell ca++ is not usually seen in TB

 

 

ASBESTOSIS:

the short fibers of crocodilite are more likely to produce chest dz than the longer fibers of chrysotile

note that malignant mesotheliomas arise independently from pleural plaques

asbestosis is specific for the lungs and refers to pulmonary and not pleural fibrosis

 

 

IN ACUTE PE:

fleishners sign is dilatation of the main pulmonary vessel by back pressure or clot, westermark sign is alteration of the pulmonary vasculature distal to the embolus, and hampton's hump is a shallow hump shaped lesion on the pleural surface near the pulmonary infarct

 

 

PULMONARY VASCULARITY:

grade 1: vascular redistribution 10-17mm

grade 2: interstitial edema 18-25 mm

grade 3: alveolar edema >25mm

 

 

PULMONARY CONTUSION:

pulmonary contusion resolves in 5-10 days while localized pulmonary hematoma takes months or years to resolve

 

 

PULMONARY EDEMA WEDGE PRESSURE:

the first signs of pulm edema (perihilar haze, kerley a and b lines, peribronchial cuffing, etc ) occur at a pulmonary capillary wedge pressure of 20-25 mm

 

 

LOWER LOBE COLLAPSE:

causes an apparent reduction in the size of the hilum

 

 

LINGULAR COLLAPSE:

has no minor fissure to give a clear upper border to the increased density

 

 

CASTLEMAN'S DISEASE:

has mediastinal and not hilar LAN. M>F for the general type and M=F for the plasma cell type. There is angiofollicular LN proliferation. Unknown etiology. The LN's have muscle density. It is indistinguishable from lymphoma

 

 

GARLANDS TRIAD:

40% of pts with intrathoracic sarcoid have lan on the CXR at the time of diagnosis. Garlands triad is bilateral hilar and R paratracheal lan and is present in 75 to 95% of pts with intrathoracic sarcoid lan

 

 

CCAM:

intralobar mass of disorganized pulmonary tissue. It communicates with the bronchial tree and has a normal vascular supply and drainage, but delayed clearance of fetal lung fluid. It is proliferation of bronchial structures at the expense of alveolar saccular development. The mass tends to compress the mediastinum and thus the esophagus resulting in polyhydramnios

there are 3 types

1: multiple cysts up to 10 cm (50% ie type 1 is the most common); prognsosis is excellent following resection

2: multiple small cysts <1.5 cm (40%); px is poor due to associated abnormalities

3: solid lung (10%); px is poor secondary to pulmonary hypoplasia and hydrops

 

 

BRONCHIAL ATRESIA:

most commonly involves the segmental UL bronchus, but may be seen in the LL. It usually affects an older child or adult

 

 

EMPYEMA NECESSITANS:

chronic empyema attempting to decompress through chest wall. The common organisms that result in this are: actinomyces, TB, aspergillosis, norcardia, blastomycosis

 

 

KS IN AIDS:

10% overall. 30% pulmonary involvement if you have skin involvement. Get sub pleural nodule. Adenopathy is not common and if present is a late finding. Presence of ground glass density suggests hemorrage. 67Ga scan is negative which can be used to differentiate it from lymphoma

 

 

MOST COMMON LUNG LESION IN LYMPHOMA:

infection or pneumona.

 

 

NON HODGKINS VS HODGKINS DISEASE IN THE CHEST:

the main difference is that HL demonstrates a contiguous  spread of disease to nodal chains while NHL skips adjacent nodes.  For distribution, see below

 

 

DISTRIBUTION OF LYMPHOMA INVOLVEMENT WITH HD VS NHD

for thorax: HD>NHD

Lung parechymal involvemnt:

HD (12%) >NHD (4%)

for abdominal involvement: HD>NHD

for splenic involvement:

HD>NHD

 

 

AORTIC INVOLVEMENT BY LUNG CA:

<90 degrees of circumferential involvement means the tumor is resectable. >90degrees of circumferential  involvement=unresectable

 

 

CAUSES OF BRONCHOVASCULAR BEADING:

sarcoid, lymphangitic carcinomatosis, kaposi, lymphoma, pulm edema

 

 

SILSBACH CLASSIFICATION OF SARCOID:

0: normal (10%)

1: adenopathy (50%)

2: adenopathy and lung dz (30%)

3: lung dz only (10%)

4: fibrosis

 

in terms of prognosis: 75% of stage 1 regresses to normal, and 10% remains enlarged and 15% progresses to stage 2 and 3

 

 

EARLIEST ASBESTOS RELATED PLEURAL ABNORMALITY:

pleural effusion

 

 

LUNG TRANSPLANT:

acute rejection: occurs after the first 3 months in 60-80% and presents as edema and increased effusions without signs of LV dysfunction. Other things that can be seen are airway stricture and torsion

 

 

CAUSE OF AORTIC NIPPLE:

left superior intercostal vein

 

 

PULMONARY EDEMA PATTERN DUE TO ALVEOLAR PROTEINOSIS:

think norcardia

 

 

PERCUTANEOUS NEEDLE BX PTX RATE:

25%

 

 

DRUG TOXICITY TO LUNGS:

radiologic abnormalities commonly involve the lower lobes

 

 

WIDTH OF POSTERIOR WALL OF BRONCHUS INTERMEDIUS:

should not be > than 3 mm

 

 

LUNG ABCESS:

it does not displace the lung vessels, it destroys them

 

 

MR VS CT:

mr has better contrast resolution than ct

 

 

MILIARY LUNG DZ IN THYROID CA:

suggests follicular

 

 

SPICULATED BORDER OF A SPN:

hightly specific for malignant lesion

 

 

RADIATION PNEUMONITIS:

most pronounced 1-6 mo post XRT. Fibrosis follows up to 18 mo post treatment. Acute reaction is confined to the radiation port. Chronic reaction extends outside the radiation port ( ie the radiation fibrosis)

 

 

PERIPHERAL LUNG OPACITIES:

infarct, UIP, loefflers, hemophilus, influenza, sarcoid, amiodarone

 

 

NF:

this can cause interstitial fibrosis in up to 20%

 

 

LOCALIZED MESOTHELIOMA:

75% arise from the visceral pleura, no association with asbestosis, pts are symptomatic with cough and CP, hypoglycemia

 

 

ENDOBRONCIAL LESIONS:

breast, kidney, colon

 

 

ATYPICAL CARCINOID:

it is more aggressive than typical carcinoid. ACTH, acromegaly, ZE are all paraneoplastic syndromes associated with bronchial carcinoid

 

 

DEFINITION OF TRACHEAL NARROWING:

M: <13mm

F: <10mm

 

 

ACCESSORY PLEURAL FISSURE (SOMETHING I AM REAL WEAK ON!)

the best known of these in the azygous fissure in < 1% of the population

minor fissure on the L separating the lingula from the rest of the upper lobe

inferior accessory fissure or Twinings line: R>L, separates the medial and anterior basal segments, it runs obliquely upward and medially toward the hilum

superior accessory fissure: R=L, horizontally oriented, separates the apical from the basal segments of either lower lobe

 

 

FALLEN LUNG SIGN:

caused by tracheobronchial rupture

 

 

PTX:

40% LAM, 5-30% LCH, trauma (70% have rib fx)

 

 

CYSTS IN HIV:

hiv by itself can cause cysts in 42% of pts independent of PCP. There is a UL predominance

 

 

MOST COMMON BACTERIAL PNEUMONIAS IN HIV:

H. flu, Strep are the most common bacterial pneumonias and the most common lung infections in HIV. PCP pneumonia is the most common HIV related lung dz in adults and children. Another way of putting it is most common pneumonia in hiv is bacterial (h. flu, strep) while most common pneumonia in aids is pcp

 

 

ASBESTOS RELATED PLEURAL PLAQUES:

most commonly between the 6th to 10th ribs and no more than 4 ribs wide

 

 

MALIGNANT EFFUSIONS:

lung 36%, breast 25%, lymphoma 10%

 

 

PULMONARY LIGAMENT:

the L is more commonly visible on CT (72%). The phrenic n is located anteriorly to the pulm ligament

 

 

TWO TYPES OF ASBESTOS FIBERS (SEE ABOVE):

serpentines which are long, curly and flexible, chrysotile is the main one used in the USA (90%)

amphiboles which are straight and needle like and are more carcinogenic and fibrogenic (main ones here are crocidolite, amosite, anthropyllite). In terms of carcinogenicity: crododilite>chrysotile>amosite.

 

 

ASBESTOS PLEURAL DZ

20 yr latency, usually parietal, apices and costophrenic angles are spared. It affects the posterolateral chest wall. Not greater than 4 rib widths affected. Ca++ require a 30 to 40 year latency. They are called "holly leaf" ca++ when seen en face, rounded atelectasis with comet tail sign. Malig pleural dz is usually > 1cm thick, cirumferential, nodular, and the mediastinial pleura are involved.Visceral and parietal pleura are both involved in the case of malignancy

 

 

BENIGN ASBESTOS PLEURAL EFFUSION:

no malignancy within 3 years of onset of the effusion by definition. Usually small effusion. Most common abnormality within 10 years of asbestos exposure

 

 

FIBROUS PLEURAL TUMOR

M=F, not related to asbestos. Arises from mesenchymal cells rather than epithelial cells and from the visceral pleura in 80% and parietal in 20% and 14-30% are malignant. Associated with HPO and hypoglycemia. Slow growing and pedunculateed and can change position

 

 

ASPIRATED FB:

adult: presents as air trapping

children: presents with hyperinflation

 

 

LOEFFLERS SYNDROME:

most common inciting drugs are sulfonamides, ASA, methotrexate, penicillin, chlorpromazine, chlorpropamide

 

 

INCREASED RISK OF LUNG CA:

predisposing: smoking, asbestos

associated: tb, asbestos, ipf, scleroderma

 

 

BRONCHIOALVEOLAR CELL CA:

a subtype of adenocarcinoma, like adeno, it is not associated with smoking. The most common presentation is a SPN

 

 

SCC:

2/3 are central endobronchial lesions. Most common type to cavitate. See earlier;

 

 

LARGE CELL CA:

strong association with smoking like small cell ca. It is a large tumor at presentation. Poor survival

 

 

PULMONARY VASCULITIS:

most common cause is #1 wegeners, churg strauss, bronchocentric granuloma, (PAN is not a common cause)

#2 is hypersensitivity, extrinsic alveolitis, drugs, malignancy

#3 is CTD's

#4 is behcets

 

 

TB IN AIDS:

the miliary pattern is the most common pattern particulary when the CD4 is low

 

 

AIDS DEFINING ILLNESSES:

in addition to PCP pneumonia, CNS lymphoma is also an AIDS defining illness

 

 

PRIMARY TRACHEAL TUMORS:

malignant (90% of malignancies): SCC (50%), adenoid cystic (33%), mucoepidermoid

 

 

CAUSES OF BRONCHIECTASIS:

tb, abpa, adenovirus, pertussis, chronic aspiration, neoplasm eg carcinoid, fb, inflammatory nodes as in RML sydrome, ciliary dyskinesia sydrome (quoted from UMDNJ) notes

 

 

KARTAGENERS:

50% of ciliary dyskinesia syndrome

 

 

DIVERTICULUM OF KOMMERALL:

if diameter origin of aberrant R subclavian artery is dilated

 

 

THYMIC LYMPHOMA:

usually secondary to HD

 

 

PNEUMOMEDIASTINUM:

associated with asthma, dka, mechanical ventilation, severe cough, trauma, voorhave, instrumentation, air tracking into the mediastinum after perforation of a mediastinal structure or even the pharynx

 

 

MORE ON LV ANEURYSMS:

congenital: 

usually young african american adults (submitral and subaortic)

 

acquired:

true: s/p transmural MI located in L anterior and anteroapical and with a wide mouth. Less likely to rupture than a pseudoaneurysm

pseudoaneursym: s/p MI or trauma. Involves the posterolateral or diaphagmatic wall of the LV. Has a narrow neck

 

 

CARDIAC TUMORS:

 

benign:

#1: atrial myxoma L>R

#2: rhabdomyoma (in TS)

#3: ventricular fibroma (part of Gorlins syndrome); pedunculated

note that mets are 40x more common than 1 ary cardiac tumors

 

malignant:

the most common malignant cardiac tumor is angiosarcoma

 

 

HILUM OVERLAY SIGN:

anteromediastinal mass will overlap with the hila. Cardiac enlargement or pericardial effusion will displace the hila laterally. It is used to distinguish a true hilar mass from a non hilar mass, or put another way:

Differentiation of the true cardiomegaly from a large anterior mediastinal mass mimicking cardiac enlargement. An anterior mediastinal mass is indicated on a PA chest film whenever more than 1 cm of the right or left pulmonary artery is visualized within the lateral edge of what appears to be the cardiac silhouette.

 

 

ARCH ANOMALIES:

L arch with aberrant R SCA is the most common

R arch with mirrow image branching is the 2nd most common

 

 

ESOPHAGEAL AND TRACHEAL IMPRESSIONS ONCE MORE (FROM GLICKMAN and WEISLEDER):

anterior trachea and posterior esopagus: DAA, R arch with aberrant L subclavian and L ductus

anterior trachea: anomalous inominate which arises to the L of the trachea,  anomalous L common carotid

posterior esophageal: L arch and aberrant R SCA or mirror image to this

anterior esophageal and posterior tracheal: pulm sling with L PA arising from the R PA

 

 

MAS:

an increase in the kvp of 20% will double the MAs. To maintain image quality between big and small patients, fix the KVP and vary the MAS

 

 

GRID RATIO:

upright chest: 10:1

portable: 6:1

 

 

POSTERIOR MEDIASTINAL TUMOR MOST LIKELY TO BRIDGE THE NF:

schwannomas are the ones that will do this

 

 

THYMOLIPOMAS:

occur most often in children and young adults

 

 

MORGAGNI:

most contain fat (omentum). Enema is usually diagnostic, not UGI. These are not usually diagnosed in childhood as are the bochdalek hernias

 

 

LUNG NODULE CA++

focal central CA++ is more suggestive of malignancy then focal eccentric Ca++ (according to ACR syllabus)

 

 

HIGHEST YIELD ON SPUTUM CYTOLOGY:

SCC

 

WHAT EXACTLY IS BOOP?

this one still gets me even after 4 years of radiology training!

main features are patchy, non segmental, predominantly subpleural with small effusions in 10-20%. It is not the same things as bronchiolitis obliterans and its name is unfortunate

 

 

PULMONARY ANGIITIDES AND GRANULOMATOSES:

these range in spectrum from benign (necrotizing sarcoid granulomatosis) to malignant (lymphomatoid granulomatosis). Most pts respond to rx with steroids plus or minus cyclophosphamide. The lungs are most commonly involved because of the vascular network they contain. Wegeners and Churg Strauss are the only ones associated with a systemic vasculitis. Lymphomatoid gran. is considered to be a form of lymphoma with angioinvasive infiltrate. Bronchocentric angiomatosis has histo features in common with ABPA. It primarily involves the bronchi

 

 

ECTOPIC PARATHYROID ADENOMA:

in the thymus posterior to the junction of the BCV's, adjacent to the aortic knob, and in the TE groove below the thyroid (this is a common location)

 

 

UNILATERAL LYMPHANGITIC SPREAD OF TUMOR IN LUNG:

most common cause is lung ca

 

 

MORE ON THYMOMAS:

the spindle cell variety is the one associated with hypogammaglobinemia. Eaton Lambert is not associated with thymoma

 

 

ASKIN TUMOR:

caucasian female. It arises from intercostal nerves and causes rib destruction and pleural effusion. It is a neuroectodermal small cell tumor

 

 

IF GET AIR IN THE LV DURING BX OF  A LUNG NODULE:

place pt on the L side and raise the legs ie trendelenberg

 

 

AORTIC RUPTURE:

deviation of the NGT: 67% specific

depression of the L mainstem bronchus: 53% spec

mediastinal widening: not very spec but very sensitive (100%)

aortic knob contour: less specific than deviation of the NGT and depression of the L mainstem

 

 

BRANHAM SIGN:

this is bradycardia on closing a hemodynamically significant AVF

 

 

LUPUS:

lung:

effects on the lung are frequent (30-40%).  This is due to chronic antibody damage to alveolar membrane. Lupus pneumonitis is patchy infiltrate with an alveolar pattern at lung bases peripherally secondary to infection, uremia. Get interstitial  reticulations in lower lung fields in 30% (chronic). In infarct due to vasculitis, get fleeting plate like atelectases at both bases. Cavitary nodules represent vasculitis. 

pleura:

bilateral pleural thickening and pleural effusion. There is also pericardial effusion, and cardiomegaly from primary lupus cardiomyopathy

 

 

MOST COMMON CAUSES OF DIAPHRAGMATIC ELEVATION:

eventration, atelectasis, abdominal mass, phrenic nerve paralysis

 

 

ANTERIOR MEDIASTINAL MASSES:

think the 5 T's

 

 

WHAT IS IN THE MIDDLE MEDIASTINUM:

aorta, esophagus, trachea, bifurcation, great vessels, PA, paratracheal nodes

 

 

TYPES OF ATELECTASIS:

obstructive, compressive, passive, cicratizing, adhesive

 

 

DIFFUSE FINE NODULAR OPACITIES:

dust inhalation

siderosis

silicosis

beryliosis

infection eg viral, bacterial with norcardia, bronchopneumonia, and fungal (eg TB, histo, coccidio)

EG

sarcoid

TB

neoplasm (thyroid, melanoma)

other eg BOOP, Wegeners

 

MILIARY:

considered 1-2 mm

 

 

CAUSES OF PRIMARY LUNG ABSCESS:

aspiration, necrotizing pneumonia, septic emboli, complication of chronic lung dz

 

 

BOARDS APPROACH TO THE CXR:

see lesion and decide what it is. Describe where lesion is. do a focussed ddx. Do a CT to decide on where the lesion is. If you see a medial mass in the lung, dont confuse it with a mediastinal mass. The ddx for a lung mass is ca, mets, granuloma, hamartoma, and dont forget carcinoid. The things which suggest carcinoid is a well marginated mass (indicating slow growth), which is partially endobroanchial or abutting the bronchus. 

 

for anterior mediastinal mass, think the 4T's. Mature teratoma is seen in <40 and thymoma is in those >40. The mature teratoma is a cystic lesion with heterogeneous low attenuation areas due to the presence of fat inside. There can  be Ca++ lobulated borders.

 

for posterior mediasinal mass, neurogenic tumor, neuroenteric cyst etc. 

 

 

INCOMPLETE BORDER SIGN:

think lesions of chest wall or pleura. Pressure erosions of the ribs in association with chest wall mass is highly specific for NF

 

 

ROUNDED ATX:

aspesos exposure with pleural thickening. See vol loss, comet tail sign, swirling vessels. If no volume loss with rounded atx, then it is suspicious for carcinoma

 

 

LAM:

increased volume, reticulonodular opacities, cysts, effusion on one side, prior h/o ptx. LCH can also present the same way with a high incidence of ptx

 

 

ASTHMA:

increased vols, central airways thickened, centra bronchiectasis with areas of mucoid impaction, associated with abpa

 

 

TB LOCATION:

most TB is apical and posterior and also in the superior seg of the RLL. If it is the anterior portion of the UL, then suspect malignancy

 

 

LADY WINDERMERE SYNDROME:

MAI (chronic) in the inferior RML or lingula from chronic cough suppression. Get bronchiectasis,. They have no predisposing factors for MAI. The ddx is middle lobe sydrome (but no vol loss), ABPA, MTB, asthma, immunoglobulin deficiency sydrome

 

 

UIP:

lower lobe predominance, fibrosis, with traction bronchiectasis distal to the airways out in the periphery. The ddx is asbestosis, coll vascular dz, hypersensitivity pnemonitis, sarcoidosis

 

 

BOOP:

synonymous with cryptogenic organizing pneumonia. No infective organism found. Dense consolidation in 60%. Nodules regularly spaced. The ddx is wide and includes bacterial infection, vasculitis, BAL ca, lymphoma, eostinophilic pneumonia, and NSIP

 

 

FLOATING LILY SIGN:

seen with echinococcal cyst in liver and lung

 

 

TRACHEAL LESIONS:

only 10% of tracheal lesions are benign and 90% are malignant. Primary are squamous, adenoid cystic, mucoepidermoid. Mets are from local extenion eg from thyroid, and from distant sources eg breast, melanoma

benign: papilloma, hemangioma, hamatoma (contains fat and popcorn Ca++), adenoma (rare)

saber sheath: only intrathoracic. 95% of the pts have COPD. Ring Ca++ are common

TPO: benign, rare. There are osteocartilagenous growths within the trachea. The lumen is narrowed and filled with calcified nodules. The distal 3/4 of the trachea and proximal bronchi are most commonly affected

relapsing polychondritis: destruction and inflammation of cartilage throughout the body. The trachea is thick walled and with diffuse slit like intraluminal narrowing

tracheobroncomalacia: primary or secondary. In the secondary form, there is compression of the trachea by vessels or a mediastinal mass. Can also be from copd or intubation

tracheobronchomegaly: atrophy and dysplasia of trachea and proximal bronchi. Also known as Mounier Koun

 

 

TYPES OF EMPHYSEMA:

panacinar: LL

centriacinar: UL

paraseptal: periphery of the lung along the septal lines

overinflation: flattening of the diaphragms is the most reliable sign

 

 

TYPES OF BRONCHIECTASIS:

congenital (CF, kartageners, pulm sequestration)

post infectious: viral, bacterial

bronchial obstruction: neoplasm, inflammatory nodes f.b.

types: cylindrical, saccular (varicose), cystic.

the bronchi appear larger than the accompanying vessels and appear thick walled

 

 

CAUSES OF CHYLOTHORAX:

trauma, lac of thoracic duct, LAM, filariasis, idiopathic, tumor especially lyphoma

 

 

FIBROUS TUMOR OF THE PLEURA:

comes from the visceral pleura in 70%. Has no relation to asbestos exposure

 

 

5T's OF ANTERIOR MEDIASTINAL MASS:

thymoma, thymolipoma, thyroid hyperplasia, thyroid, terrible lymphoma

note that terrible lymphoma includes the germ cell tumors: wihich can be remenbered by thinking of SECTE or seminoma, embryonal cell ca, choriocarcinoma, teratoma (20% malig), endodermal sinus tumor

 

 

BRONCHOPULMONARY FORGUT MALFORATIONS:

bronchogenic cysts are ventral, subcarinal, mediastinal (75%), and pulmonary (25%). Enteric are posterior, supracarinal

 

 

CHURG STRAUSS:

allergic granulomatosis. Presents as asthma, fever, necrotizing vasculitis, extravascular granuloma, eosinophilia

 

 

ANGIITIS GRANULOMATA:

this is includes wegeners, allergic granulomatosis, and PAN, and is characterized by transient pulmonary shadows

 

 

HODGKINS:

the LAN is almost always anterior

 

 

HYPOPLASTIC  LEFT PA:

it is associated with a R aortic arch

 

 

SOME CAUSES OF DIAPHRAGMATIC ELEVATION:

hepatic mass or abscess

interposition of colon

diaphragmatic paralysis (phrenic nerve paralysis)

subpulmonic abscess

volume loss, atelectasis

lobectomy

diaphragmatic hernia

eventration

diaphragmatic rupture

diaphragmatic tumor

 

the most common causes of diaphragmatic elevation are: eventration, atelectasis, abdominial mass, and phrenic n paralysis