Respiratory disease

1. Respiratory disease Liu lin xiang, Radiology school, 6222136 lxliu@tsmc.edu.cn

2. Bronchiectasis • Chronic irreversible dilatation of bronchi • Major cause of morbidity in less developed countries • Causes: • Postinfectious • Mechanical obstruction • Congenital • Granulomas and fibrosis

3. Bronchiectasis: Clinical features • Large volumes of purulent sputum • Finger clubbing • Frequent infective exacerbation • Recurrent hemoptysis • Mild bronchiectasis: few physical signs

4. Bronchiectasis Cylindrical varicose cystic

5. Radiological findings • Margins of pulmonary vessels indistinct • Tramlines, ill-defined ring opacities • Filled with pus and mucus lead to tubular and ovoid opacities • Cystic: multiple thin-walled ring opacities and contain fluid levels • Coarse honeycombing pattern • Patchy peribronchial consolidation and focal areas of subsegmental collapse in diffuse disease • Affected lobe overinflated or relatively collapsed

6. Bronchiectasis • Plain radiograph • 10% may be normal • margins of pulmonary vessels indistinct • coarse honeycomb

7. Bronchiectasis • Plain film • margins of pulmonary vessels indistinct • coarse honeycomb

8. BronchiectasisCT • Dilatation of bronchi w\o bronchial wall thickening • Bronchial dilatation in isolate cystic spaces grouped along a fissure or mediastinal pleura • Volume loss of lung associated crowding of mildly dilated airways and displaced fissure • Accumulation of secretions easily recognizable as lobulated glove-finger, V or Y densities • Bronchiolitis may present in the same areas

9. BronchiectasisCT • Cylindrical: smooth dilatation of the affected bronchi, not taper normally towards the periphery, but no actual loss of bronchi • Varicose: irregularity and beading of the affected bronchi. destruction and loss of the bronchial lumen peripherally • Saccular: increasing dilatation of bronchi towards the periphery, with ballooning, and a loss of bronchial subdivisions

10. BronchiectasisCT • Define the extent, severity and location • Thick-walled dilated bronchi, with a diameter greater than their accompanying pulmonary artery • In cross-section, ring-shaped, "signet ring" • In long axis, bronchi look like tramlines • Associated: air-fluid levels in dilated bronchi, cystic spaces, and occasional ectatic beaded bronchi • Bronchi visible in peripheral half of lung • Focal volume loss, hyperlucency or oligaemia

14. BronchiectasisCT

15. Bronchiectasis

16. BronchiectasisCT MPR

17. Lobar pneumonia • Result of alveolar wall injury with severe hemorrhagic edema induced by inhaled infectious organisms that reach the subpleural zone of the lung • Rapid multiplication of organisms and invasion of the infected edematous fluid by polynuclear leukocytes • Spreads rapidly through the pores of Kohn leading to a consolidation of an entire lobe or segment • The most common causes are streptococcus pneumonia, klebsiella pneumonial infection, legionella infection and mycoplasma pneumonia infection

18. Radiological findings • Air space consolidation involving an entire lobe containing air bronchograms • Because of antibiotics, the pneumonia is limited to one or more segments within a lobe • Sometimes, voluminous edema may result in expansion of the lobe recognized radiographically by bulging of the fissures • Necrosis and cavitation represent the potential complication of lobar pneumonia

19. Lobarpneumonia • Consolidation in entire lobe with air bronchograms

20. Lobar pneumonia • Consolidation in apical segment of superior lobe

21. Lobar pneumonia

22. Lung abscess • Certain virulent bacteria create focal areas of necrosis or lung abscess • Abscess may not be recognized on chest films because of surrounding lung consolidation or no communication with a conducting airway and thus no cavitation is appreciated • Abscess formation is most likely with anerobic and Gram-negative bacteria • Lung abscess may occur because of inflammatory necrosis of otherwise normal lung or occasionally secondary to vascular involvement leading to ischemic necrosis and death of lung

23. Lung abscess • Radiographically, a lung abscess may be difficult to appreciate secondary to surrounding lung consolidation • but will be recognized when air enters the abscess cavity creating either a large single abscess or multiple smaller microabscesses • With the larger abscess cavities the inner walls are thick and irregular

24. Lung abscess • Resolution of an abscess is recognized when abscess cavity decreases in size or amount of fluid within an abscess fluctuates • This is not related to healing necessarily but instead to ease of communication between abscess cavity and a conducting airway • Fluid levels will rise in cavity if exit is blocked and will fall if opening remains patent

25. Lung abscess • Thick-walled cavity • Fluid level

26. Lung abscess • Thick-walled cavity and fluid level

27. Lung abscess

28. abscess

29. Lung abscess

30. Pulmonary tuberculosis • Infection by Mycobacterium tuberculosis bacillus by respiratory inhalation, with the organism multiplying in the alveolar walls • Primary tuberculosis represents the development of a positive reaction to tubercle bacilli following the first exposure • Often subclinical, but in infants or those with impaired defence due to poor nutrition or underlying illness, may be present clinically

31. Pulmonary tuberculosis • As the immune system develops a positive reaction to the bacillus, the multiplication of the organism is halted • Localized inflammatory response in the lung parenchyma and the draining lymph nodes • Central necrosis within this area, later heals by fibrosis and calcification

32. Pulmonary tuberculosis • If response is delayed, organisms may spread from draining lymph nodes into regional nodes and, via thoracic duct into circulation to pass by hematogenous spread throughout the body. This can also give rise to tuberculous meningitis and miliary tuberculosis • Bronchogenic spread of tuberculosis occurs following poor containment of the original infection, with pulmonary consolidation • Spread can occur as infected material expectorated and enters other non-affected bronchi

33. Primary tuberculosis • Reaction to the tubercle bacillus following first exposure to the organism, typically by inhalation • presence of primary tuberculosis in childhood varies from subclinical to overwhelming and life-threatening • In healthy child, should be a self-limiting condition, lasting at most a few weeks. If there are clinical symptoms there is fever, loss of appetite, general malaise and, possibly, a skin rash • Inspired bacilli lodge on the alveolar walls and multiply. A localized, mainly histiocytic, inflammatory reaction is set up • Draining lymph nodes may enlarge as part of this sensitivity reaction

34. Primary tuberculosis • Usually, the immune response is sufficient to contain the initial infection, which heals as a small granuloma. The granuloma may show associated lymph node calcification. There may be central necrosis within this area, which later heals by fibrosis and calcification, which may take 6 months or more to appear • In infants, this process may not be adequate and pulmonary consolidation may occur as part of the primary infection. Bronchogenic spread may then cause widespread pulmonary infection, while hematogenous spread may cause a miliary pattern of pulmonary infection. Once it is in the circulation, the child is at risk from hepatic and meningeal infection. This bacteremia is also the source of miliary tuberculosis

35. Primary tuberculosis • Radiography of the chest in primary tuberculosis varies from a small subpleural exudative reaction, w\o unilateral hilar lymphadenopathy, to more extensive disease such as multifocal pneumonic change or a diffuse interstitial nodularity • Enlarged lymph nodes cause distal atelectasis • Pleural effusion is not an unusual feature • Lung changes take months or years to clear, and any calcified lesions persist indefinitely

36. Primary tuberculosis • In children without tuberculous consolidation, the radiographic changes represent the development of the immune reaction to the infection • Main reason for regular radiography is to allow early diagnosis of miliary tuberculosis, which may be visible before there is any clinical suspicion • As this is a manifestation of hematogenous spread, meningitis is also a very likely complication • Radiographic changes in uncomplicated primary tuberculosis are not visible until after the immune response has developed, so skin testing is a more sensitive method of diagnosis

37. Primary pulmonary tuberculosis • Exudative • Draining lymph nodes • hilar lymphadenopathy

38. Primary pulmonary tuberculosis

39. Primary pulmonary tuberculosis • hilar lymphadenopathy

40. Miliary tuberculosis • Clinical presentation is variable, with infants being relatively asymptomatic • Seen some time following a bacteraemia • Usually occurs during the incubation period, when the tubercle bacilli are deposited throughout the lungs • Patients are generally very ill with respiratory failure, fever and malaise at the time of diagnosis

41. Miliary tuberculosis • Chest film demonstrates multiple, small nodular opacities throughout both lungs that are too numerous to count • Untreated disease results in steady enlargement of these nodules until death of the patient ensues • Lymphadenopathy and pleural fluid or other evidence of primary tuberculosis may not be present on chest film • Diagnosis may require transbronchial biopsy to identify acid-fast bacilli • When treated the miliary pattern gradually disappears leaving a normal chest film within several weeks to months

42. Miliary tuberculosis • multiple, small nodular opacities throughout both lungs that are too numerous to count

43. Acute military pulmonary tuberculosis • multiple, small nodular opacities throughout both lungs that are too numerous to count

44. Subacute hematogenous disseminated pulmonary tuberculosis

45. Hematogenous disseminated pulmonary tuberculosis

46. Lung cancer • Also called bronchogenic carcinoma • The most common fatal malignant neoplasm in men and it has now surpassed breast cancer as the leading cause of cancer death in women • The risk of lung cancer occurrence is related to the number of cigarettes smoked, the number of smoking years, the age at which smoking began, and the depth of inhalation • The risk decreases with cessation of smoking but never completely disappears

47. Lung cancer • Most patients with lung cancer present with clinical symptoms, and only a minority are asymptomatic • Patients with central tumors obstructing a major bronchus may present with cough, wheezing, hemoptysis and lung infection • Local intrathoracic spread result in left laryngeal nerve paralysis, pleural or chest wall pain, symptoms related to SVC obstruction or Pancoasts neoplasm • Sometimes symptoms resulting from distant metastases may reveal the lung cancer

48. Lung cancer • A large variety of paraneoplastic syndromes may also be associated with lung cancer • Include skeletal abnormalities such as clubbing, hypertrophic pulmonary osteoarthropathy and osteomalacia or endocrine and metabolic disorders such as Cushing's syndrome from adenocorticotrophic hormone production, hyponatraemia associated with inappropriate antidiuretic hormone syndrome production, and insulin-like activity

49. Histological type • The common types include adenocarcinoma, squamous cell carcinoma, small cell carcinoma and large cell undifferentiated carcinoma • Multidifferentiated carcinomas may also occur (adenosquamous carcinoma) • Giant cell carcinoma is a subset of large-cell undifferentiated carcinoma • Bronchioalveolar cell carcinomatosis is a subset of adenocarcinoma

50. Squamous cell carcinoma • A frequent type representing about one third of all lung cancers, associating with smoking • Pathologically, often arise in squamous metaplasia commonly seen in the bronchial mucosa of cigarette smokers • Centrally located involving the proximal bronchi and growth is mainly endobronchial • Extension through the bronchial walls and along the bronchial mucosa