RADIOLOGICAL IMAGE

DR.AKASH DEEPAK -JR

PROF.DR.PARANTHAMAN SIR’S UNIT
HISTORY

 A 48/M WHO IS A COOK BY OCCUPATION AND A CHRONIC SMOKER COMPLAINTS

OF DRY COUGH AND EXERTIONAL DYSPNOE,THAT HE HAS HAD FOR THE PAST
12 MONTHS .WITHIN THE LAST 3 MONTHS HE HAS DISTRESSING SYMPTOMS .

 O/E) bp-120/80mmhg; PR-120/min; RR-29/min T-NORMAL

 GC FAIR S/E) CVS- S1,S2+
 S/E)CVS-S1,S2+
 RS- B/LAE+, BI-BASILAR END INSPIRATORY CRACKLES +
 P/A-SOFT
 CNS-NFND
DIAGNOSIS????????
CHEST RADIOGRAPHY

► An diffusely abnormal chest radiograph often the initial

finding and is the leading clue to a diagnosis of ILD,
however a normal chest X-ray does not exclude ILD.
► The interstitial infiltrates are seen as
► Discrete linear
► Nodular or reticulonodular shadows diffusely
distributed in both the lungs. The individual nodular
shadows are usually of less than 2mm in diameter.
► Occasionally, fluffy alveolar shadows may be present
due to coalescence of interstitial shadows or a
complicating infection.
Patterns of ILD in Chest X
Ray
PATTERNS ON CHEST X-RAY

LINEAR
reticular
NODULAR
RETICULONODULAR
BEDSIDE DD’S FOR ILD

 INFECTIONS(ATYPICAL PNEUMONIA)
 LYMPHANGITIS CARCINOMATOSIS
 PULMONARY EDEMA
 ASPIRATION PNEUMONITIS
 PNEUMOCONIOSIS
What does ILD look like?

 ILD can include some or all of:

 Fine lines (reticular shadowing)
 Small nodules
 Larger nodules
 Lung volume loss
 Honeycombing
 Fibrosis
 A good place to look for ILD is between rib spaces; close to the chest wall,
there should normally be very few lung markings, and certainly no nodules or
fine lines
HRCT

 Ground glass appearance

 Reticulonodular shadowing
 Honey-comb lung-small,uniform sized,cystic spaces representing patent
bronchioles
 Traction bronchiectasis
 Provides quantitative assesment of pulmanary fibrosis
RETICULAR INFILTRATES

Schwarz, ILD, 2003, HP

HONEYCOMB LUNG
 Hrct of ipf

On HRCT, a confident diagnosis of IPF is based on the presence of bilateral,

predominantly subpleural, and basal reticular opacities with associated traction
bronchiectasis and honeycombing in the absence of small nodules or extensive
ground-glass opacity .this is known as “confident” pattern of IPFon HRCT.
 IPF

Normal Lung- cut surface and pleura smooth and homogenous

IPF- cut surface demonstrates patchy involvement of lung with fibrous scarring
around dilated airspaces forming a honey comb pattern
► Diffuse reticulonodular pattern is the most
common finding on chest radiograph in patients
with ILD.

► The shadows are generally bibasilar in

distribution in early stages. In later stages,
diffuse involvement occurs all over the lungs.

► In advanced disease, when fibrosis is extensive,

the lungs get shrunken and reduced in volume

Indian journal of chest disease & allied sciences (2018)

 STANDARD HRCT PROTOCOL FOR ILD
► SCANNING TECHNIQUE
SUPINE
❖ inspiratory volue scan,reconstructed 1 mm at 0.5mm
intervals or better
❖ Expiratory scan ,volume or incremental

► PRONE (in all fibrosing ILDs @ the first instance)

❖ Inspiratory volume scan, reconstructed 1mm @

0.5 mm intervals or better
Honeycombing
Traction Bronchiectasis
Reticular opacities
Nodular shadows
Ground-Glass Opacities
Cystic ILD
 HRCT criteria for UIP pattern
UIP pattern1 Possible UIP pattern1 Inconsistent with UIP1
Since the past
years, HRCT has All 4 features All 3 features Any of the 7 features
become central ▪ Subpleural, basal ▪ Subpleural, basal ▪ Upper or mid-lung
to the predominance predominance predominance
diagnostic ▪ Reticular ▪ Reticular ▪ Peribronchovascular
pathway of IPF.1 abnormality abnormality predominance
▪ Absence of features ▪ Absence of features ▪ Extensive ground-glass
listed in the “not UIP listed in the “not UIP abnormality (extent >
HRCT provides pattern” section pattern” section reticular abnormality)
critical data ▪ Honeycombing with or ▪ Profuse micronodules
needed to without traction (bilateral, predominantly
determine bronchiectasis upper lobes)
whether ▪ Discrete cysts (multiple,
bilateral, away from
surgical lung areas of honeycombing)
biopsy or ▪ Diffuse mosaic
further tests attenuation/air-trapping
are required to (bilateral, in ≥3 lobes)
achieve a 1. Raghu G, et al. Am J Respir Crit Care Med 2011;183:788–824.
▪ Consolidation in
specific 2. Ryu JH, et al. Mayo Clin Proc 2007;82:976–986. bronchopulmonary
IPF diagnosis based on HRCT
UIP pattern:
In conjunction with the exclusion of other known
causes of ILDs, the evidence of a UIP pattern on
HRCT is considered sufficient for a definitive
diagnosis of IPF.1
Possible UIP pattern:
According with 2011 guidelines, if HRCT findings
yield a possible UIP pattern, lung biopsy may be
In about two thirds of the
cases IPF can be diagnosed by
clinical and radiological
criteria. Thus, surgical lung
biopsy is needed in about one
third of cases to achieve the
ultimate diagnosis, which
requires multidisciplinary
cooperation.3

necessary to confirm the diagnosis of IPF.1

Inconsistent with UIP pattern:

HRCT results that are inconsistent with a UIP
pattern necessitate lung biopsy to make a
diagnosis.1
 GUIDELINES FOR DIAGNOSIS
According to current guidelines (ATS/ERS/JRS/ALAT )
a diagnosis of IPF requires the following diagnostic criteria:1
The presence of a usual interstitial pneumonia (UIP) pattern on high-resolution
computed tomography (HRCT) in patients not subjected to surgical lung biopsy

Exclusion of other known interstitial lung diseases (ILDs) (e.g., domestic and
occupational environmental exposures, connective tissue disease, and drug
toxicity)

Specific combinations of HRCT and surgical lung biopsy pattern in patients

subjected to surgical lung biopsy
► RETICULAR PTTERN

Indian journal of chest disease & allied sciences (2018)

When should a surgical lung

biopsy be performed?
Risks and benefits of surgical lung biopsy

Benefits Risks

• Confirm a diagnosis if • Prolonged air leak

Before
HRCT is unclear or (6-12%)3-5
deciding to
perform a atypical1,2 • Mortality (3-5%)3-5
lung biopsy • Pneumonia3-5
the potential • Determination of • Need for mechanical
benefits cellular characteristics ventilation4
must be of affected lung tissue • Pneumothorax5
weighed for prognosis2 • Haemothorax5
against the • Increased risk of
potential exacerbation in patients
risks.1 diagnosed with
IPF3-5
 LUNG BIOPSY

► Lung biopsy is indicated when a confident

diagnosis cannot be made based on the clinical,
physiologic and radiographic evaluations
► Transbronchial lung biopsy
► Transthoracic lung biopsy
► open surgical lung biopsy
► Transbronchial lung biopsy with the help of
fiberoptic bronchoscopy is less rewarding
especially in patients with IPF.
Other tests and tools
Bronchoalveolar lavage (BAL) cellular
analysis
• BAL cellular analysis may be useful in
excluding other conditions, especially chronic
hypersensitivity pneumonitis which may mimic
IPF.2
• The evidence regarding whether or not BAL
generally increases accuracy of IPF diagnosis is
currently still unclear.1
• Typical cellular analysis of BAL in IPF shows
neutrophilia,eosinophilia& lack of lymphocyte
Serologic testing for connective tissue
disease
• Serologic testing is valuable to rule out
connective tissue disease, as this may present
with UIP pattern.2
• Tests should include rheumatoid factor, anti-
cyclic citrullinated peptide, and anti-nuclear
antibody titer and pattern.1,2
• Serologic evaluation should be performed even
in the absence of signs or symptoms of
connective tissue disease.1,2
 MDD

► PATIENT WHO DON’T HAVE A DEFENITE

UIP PATTERN ON HRCT

► WHOM FEATURES ,SUCH AS AGE,SEROLOGIC

PROFILE,ENVIORNMENTAL EXPOSURE OR
OTHERS ARE NOT CONSISTENT WITH A CLEAR
IDIOPATHIC NATURE OF THE DISORDER
Diagnostic algorithm for IPF
Suspected IPF

Yes
Identifiable causes for ILD?
No?

HRCT
UIP* Possible UIP*
Inconsistent w/ UIP*
Not UIP†
Surgical Lung Biopsy
UIP†
Probable UIP†/Possible UIP†
Non-classifiable †

MDD

IPF IPF/Not IPF Not IPF

MANAGEMENT
 Mild or Early Disease

► Asymtomatic or may have a mild ,

nonproductive cough and dyspnea with
substantial exertion
► Reticular opacities and area of honyecombing –
limited to subpleural basilar areas, involving
less than 10 percent of the lung parenchyma
► Pulmonary function – normal or may show mild
reduction in forced vital capacity [ FVC ],
diffusing capacity [ DLCO ], and /or distance
walked on the six – minute walk test
► Alveolar to arterial oxygen gradient [P[A-a]O2]
is normal or mild elevated [<20 mmhg]
 Advanced Disease
► Dyspnea on mild exertion [ eg.
Walking <300 feet or climbing more
than one flight of stairs]

► Supplemental oxygen.

► Extensive honeycombing on HRCT

[>5 percent of the parenchyma
in three or more zones]
Advanced disease

► Pulmonary function testing – moderate to

severe reduction in the FVC [ <50 percent of
predicted ], DLCO [ <50 percent of predicted ]
► Oxygen desaturation [ >4 percent ] during a
six
– minute walk test
► Room air spo2 below 88 percent
► P[A-a]o2 difference elevated [>30mmmhg]
 PIRFENIDONE
► Pyridine derivative
► Anti inflammatory,anti oxidant & anti fibrotic
► Starting dose 200 mg TDS
► Increased by 600 mg per day every 2-3 day
► Till a dose of 2400 mg per day
► Nausea,photosensitive rash,dyspepsia,vomiting
► LFT – baseline, monitored every 2 weeks for
the 1st month
❑ every month for the next five month
❑ then every 3 months
❑ Reduce mortality & hospitalisation
Nintedanib

► Nintedanib is a triple kinase inhibitor and acts

on tyrosine kinase receptors for:
► PDGF [platelet derived growth factor]
► VEGF [vascular endothelium growth factor]
► FGF [fibroblast growth factor]
► Inhibits fibroblast migration, proliferation, and
myofibroblast transformation
 NINTEDANIB

► Reduse the risk of exacerebration

► Dose: 150mg BD
► Diarrhoea,nausea,wt loss,
nasophryngiti
► Risk of bleeding
 Follow up
► Follow up with LFT reports
► Spirometry to be performed every 3
months initially & then 6 monthly

► DLCO to be performed every 6

months

► 6MWT TO BE PERFORMED
MONTHS
EVERY 6 Indian journal of chest disease & allied sciences (2018)