Approach To Interstitial Lung Disease 1

IMAGING APPROACH TO
INTERSTITIAL LUNG DISEASE
• DR. MICHAEL &

• DR. HARMIT
• Introduction
• Interstitial lung disease
Inflammation of the interstitium of the lungs.
The interstitium is the tissue that surrounds

and separates the tiny air sacs (alveolae) in the
lungs
Interstitial lung disease involves an

inflammation of this supportive tissue
between the air sacs rather than inflammation
in the air sacs themselves.
 More than 100 entities manifest as diffuse lung disease.
 In clinical practice only about ten diseases account for

approximately 90% of cases.
 Knowing how these common interstitial lung diseases

present both radiologically and clinically is of
importance in recognizing them.
 Some less common interstitial lung diseases are also

presented because their HRCT presentation can be
very typical, allowing you to make a 'spot diagnosis'.
Secondary lobule
Is the basic unit of pulmonary structure and function.
 It is the smallest lung unit that is surrounded by conn tissue septa.
 Made up of 5-15 pulmonary acini
 Irregularly polyhedral in shape and vary in size, measuring from 1 to 2.5 cm

 Supplied by a small bronchiole (terminal bronchiole) in the
center, that is parallelled by the centrilobular artery.
 Pulmonary veins and lymphatics run in the periphery

of the lobule within the interlobular septa
 Normally only a few of these very thin
septa will be seen.
 There are two lymphatic systems:
 A central network, that travels along the

BV bundle to the centre of the lobule and a
 A peripheral network, that is located within

the interlobular septa and along pleural linings.
The pulmonary acinus
 The pulmonary acinus is smaller than
the secondary lobule.
 It is defined as the portion of lung distal to

a terminal bronchiole (the last purely conducting
airway) and is supplied by a first-order respiratory
bronchiole or bronchioles
 Respiratory bronchioles are the largest airways

that have alveoli in their walls,
 And an acinus is the largest lung unit in which all

airways participate in gas exchange.
 Acini are usually described as ranging from

6 to 10 mm in diameter
• Pulm. Interstitium
 The scaffolding of the lung (airways &vessels)
 Begins at the lung hilum & extends to
the visceral pleura
Divided in to:
>axial(bronchovascular)
…central, surround the BV bundle
>Centrilobular
…surrounding the small centrilobular
arterioles & bronchioles
>Subpleural\peripheral interstitium
…b\n the lung & the visceral pleura;
…invaginates in to the lung parenchyma
>intralobular interstitium
…b\n the interlobular & subpleural
interstitium
Imaging
modalities
.
CXR : .
 Has vital role as a first line imaging modality.
 Sensitivity 80%
Radiographic appearance of ILD

.thickening of interstitial compartment
.patterns
1)Reticular
..fine - 1-2mm lucent space,
- network of curvilinear opacities ,
- seen in UIP & interst. Pulm. Edema
..medium - 3-10mm lucent space,
- mostly in pulm. fibrosis
..coarse - 10mm lucent diam,
- in parenchymal destruction:IPF,sarcoid,EG)
2)reticulonodular:
- overlap of reticules or presence of both
reticules & nodules
- sarcoid ,lymphangitis carcinomatoses
3)nodular opacity:
- small rounded lesion with in the
interstitium ;
- homogenous, no airbronchogram,
- sharply marginated &varying sized ;
..micro.. <3mm(mill. Tb, histoplasmosis),
..small.. 3-5mm(thyroid& renal met.),
..medium.. 5-10mm,
..large.. >10mm(met. from colorectal
& lung ca)
-alveolar nodules :similar sized( 8mm)
4)Linear:
thickening of the axial &
peripheral interstitium
- central : Kerley A lines;
. 2 to 6 cm long within the lungs

. oriented radially toward the hila
pulm edema ,
emphysema
- peripheral: Kerley B lines;
. 1 to 2 cm long at right angles to, & in

contact with, the lat. pleural surfaces.
pulm. edema,
lymphangitis carcinomatosis,
atypical bacterial pneumonia
HRCT
 Technical aspect
 Sensitivity..94% .
 20%..abn. in normal CXR
Indications are :
 Equivocal clinical & radiographic findings ;
 Strong clinical background with normal or
non conclusive radiographic finding ,
 For a better characterization of radiological
manifestations ,
 Follow up of treatment, planning of biopsy
Normal HRCT
 Interlobular septa:
> up to 1mm thick, can be seen
in the lung periphery, esp.
ant. mediastinal pleura
 Cenrilobular arteries:
> y or v shaped stru. within
5-10mm of pleura
 Intralobular arteries (0.7mm) &
acinar arteries (0.3mm-0.5mm)
are also seen
 Normal airways seen only to
within 3cm of the pleura
 Pulm. Veins (0.5cm) seen occasionally
with in 2cm of the pleura
 Peribronchovascular, centrilobular
& intralobular septa are not
normally seen
 These above findings have to be combined with the history of the patient and
important clinical findings.
 When we study patients with HRCT, we have to realize that we are looking at a very
selected group of patients.
 Most common diseases like pneumonias, pulmonary emboli, cardiogenic edema and
lung carcinoma are already ruled out.
Reticular pattern
In the reticular pattern there are too many lines, either as a

result of thickening or fibrosis 0f the interlobular septa
I. Septal thickening
Thickening of the lung interstitium by fluid, fibrous tissue, or infiltration by cells
results in a pattern of reticular opacities due to thickening of the interlobular
septa.
Although thickening of interlobular septa is relatively common in patients with
interstitial lung disease, it is uncommon as a predominant finding and has a
limited differential diagnosis
II.Honeycombing /Septal
fibrosis
Represents the second reticular pattern
recognizable on HRCT.
Defined by the presence of small cystic

spaces lined by bronchiolar epithelium
with thickened walls composed of dense
fibrous tissue.
Nodular pattern
• The distribution of nodules

- Perilymphatic,
. Seen PS,ILS and the peri BV
. Almost always visible in a subpleural
location, particularly in relation to the fiss
- Centrilobular or
. Spare the pleural surfaces
. 5-10 mm from fissures or the pleural surf
- Random distribution
. Usualy due to Haematogeneous spread
of infection
Sarcoidosis PL & PBV Dist.
Random Dist.(Miliary TB)

Tree-in-bud
In centrilobular nodules the recognition

of 'tree-in-bud' is of value in narrowing
the differential diagnosis.
Tree-in-bud describes the appearance

of an irregular and often nodular
branching structure, most easily
identified in the lung periphery.
It represents dilated and impacted

(mucus or pus-filled) centrilobular
bronchioles.
High Attenuation pattern
1.Ground-glass-opacity
- hazy increase in lung opacity without obscuration of underlying vessels
- small bronchi are relatively dark. 'dark bronchus' sign

. Could be - Filling of the alveolar spaces with pus, edema, hemorrhage,
inflammation or tumor cells or
- Thickening of the interstitium or alveolar walls as seen in fibrosis.
location of the abnormalities in

ground glass pattern can also
be helpful
UZ: Respiratory bronchiolitis, PCP.
LZ: UIP, NSIP, DIP.
Centrilobular: Hypersensitivity pneumonitis,
Respiratory bronchiolitis
Crazy Pavin
Ground glass opacity with septal thickening
seen in:
• Alveolar proteinosis
• Sarcoid
• NSIP
• Organizing pneumonia (COP/BOOP)
• Infection
@ PCP,
@ viral,
@ Mycoplasma,
@ bacterial)
• Neoplasm (BAC)
• Pulmonary hemorrhage
• Edema (heart failure, ARDS,AIP)
2. Consolidation
- the inc. in lung opacity obscures the
vessels.
- air in the large bronchi only

'air bronchogram'.
- pus, edema, blood, tumor cells, fibrous

or granul tissue is replacing the air in the
alveoli'
Low Attenuation pattern
The fourth pattern includes abnormalities

that result in decreased lung
attenuation or air-filled lesions.
These include:
 Emphysema
 Lung cysts
 Bronchiectasis
 Honeycombing
Most diseases with a low attenuation

pattern can be readily distinguished on
the basis of HRCT findings.
1.Emphysema
Areas of low atten. w/o visible walls as
a result of parenchymal destruction.
• Centrilobular emphysema :
- the most common type

- seen in the centrilobular portion
- upper lobe predominance and
- uneven distribution
- strongly associated with smoking.
• Panlobular emphysema :
- Affects the whole 20 lobule

- lower lobe predominance.
- It is classically associated with
alpha-1-antitrypsin deficiency
- It may also be seen in smokers.
• Paraseptal emphysema :
 Located adjacent to the pleura & interlobar fissures.
 It can be an isolated phenomenon in young adults,
 Often associated with spontaneous pneumothorax,or
 With bullae formation (area of emphysema > 1 cm in diam.
 Apical bullae may lead to spontaneous pneumothorax.
 Giant bullae occasionally cause severe compression of adjacent
lung tissue.
 Can be seen in older pts with centrilobular emphysema
2.Cystic lung disease
Lung cysts have a wall < 4mm
Seen in true cystic lung diseases
Cavities have a wall > 4mm and are
Seen in
:- Inf.(TB, Staph, fungal, hydatid)

:- septic emboli;
:- squamous cell ca. & Wegener
3.Bronchiectasis
Defined as localized, irreversible
bronchial dilatation.
Dx. is usually based on a combination of :

> Bronchial dilatation (signet-ring sign)
> Bronchial wall thickening
> Lack of normal tapering with visibility
of airways in the peripheral lung
> Mucus retention in the broncial lumen
> Associated atelectasis and stms air trapping
A signet-ring sign
> Int. diam of a bronchus > accompaning artery
> This can sometimes be seen in normals.
The most common cause of bronchiectasis is prior

infection, usually viral, at an early age.
Bronchiectasis may mimic cystic lung disease

and bullous emphysema
4.Honeycombing
Defined by the presence of small cystic
spaces with thick irregular walls
composed of fibrous tissue
Often predominate in the peripheral

and subpleural lung regions regardless
of their cause
Subpleural honeycomb cysts typically

occur in several contiguous layers
This finding can allow honeycombing

to be distinguished from paraseptal
emphysema in which subpleural cysts
usually occur in a single layer
Distribution within the lung
Upper lung zone preference is seen in:
 Inhaled particles: pneumoconiosis (silica or coal)
 Smoking related diseases (centrilobular emphysema
 Respiratory bronchiolitis (RB-ILD)
 Langerhans cell histiocytosis
 Hypersensitivity pneumonitis
 Sarcoidosis
Lower zone preference is seen in:
 UIP
 Aspiration
 Pulmonary edema
Central distribution is seen in:
• Sarcoidosis and
• Cardiogenic pulmonary edema
Peripheral distribution is mainly seen in:
• Cryptogenic organizing pneumonia (COP)
• Chronic eosinophilic pneumonia
• UIP
In chronic eosinophilic pneumonia the distribution is sometimes called

reversed pulmonary edema.
Additional findings
Pleural effusion is seen in:
1. Pulmonary edema
2. Lymphangitic spread of carcinoma - often unilateral
3. Tuberculosis
4. Lymphangiomyomatosis (LAM)
5. Asbestosis
Hilar and mediastinal lymphadenopathy
In sarcoidosis the common pattern is RPT & BHA

In lung ca. & lymphangitic carcinomatosis adenopathy is usu. unilateral
'Eggshell calcification' in lymph nodes
- Commonly occurs in pts with silicosis and coal-worker's pneumoconiosis
- Stm.s seen in sarcoidosis, postirradiation HD, blastomycosis and scleroderma
REFERRENCES
 J.M Taveras and J. T.Ferrucci;Radiology on CD-
ROM;Diagnosis,imaging,Intervention;2000Ed.
 William E. Brant Fundamentals of Diagnostic Radiology

(third edition)
 R.G. Granger &D.J. Allison Diagnostic Radiology
 Internet (e medcine, learningradiology.com & yottalook

radiology.com)
 Imaging of the chest ,DavidM Hansen, 3rd edition

THANK
YOU

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IMAGING APPROACH TO

INTERSTITIAL LUNG DISEASE

• DR. MICHAEL &

The interstitium is the tissue that surrounds

Interstitial lung disease involves an

 In clinical practice only about ten diseases account for

 Knowing how these common interstitial lung diseases

 Some less common interstitial lung diseases are also

 It is the smallest lung unit that is surrounded by conn tissue septa.

 Made up of 5-15 pulmonary acini

 Irregularly polyhedral in shape and vary in size, measuring from 1 to 2.5 cm

 Pulmonary veins and lymphatics run in the periphery

 There are two lymphatic systems:

 A central network, that travels along the

 A peripheral network, that is located within

 It is defined as the portion of lung distal to

 Respiratory bronchioles are the largest airways

 And an acinus is the largest lung unit in which all

 Acini are usually described as ranging from

Radiographic appearance of ILD

- central : Kerley A lines;

. 2 to 6 cm long within the lungs

- peripheral: Kerley B lines;

. 1 to 2 cm long at right angles to, & in

In the reticular pattern there are too many lines, either as a

Defined by the presence of small cystic

• The distribution of nodules

Random Dist.(Miliary TB)

In centrilobular nodules the recognition

Tree-in-bud describes the appearance

It represents dilated and impacted

- small bronchi are relatively dark. 'dark bronchus' sign

location of the abnormalities in

Ground glass opacity with septal thickening

- air in the large bronchi only

- pus, edema, blood, tumor cells, fibrous

The fourth pattern includes abnormalities

Most diseases with a low attenuation

- the most common type

- Affects the whole 20 lobule

Seen in true cystic lung diseases

Cavities have a wall > 4mm and are

:- Inf.(TB, Staph, fungal, hydatid)

Dx. is usually based on a combination of :

The most common cause of bronchiectasis is prior

Bronchiectasis may mimic cystic lung disease

Often predominate in the peripheral

Subpleural honeycomb cysts typically

This finding can allow honeycombing

In chronic eosinophilic pneumonia the distribution is sometimes called

Hilar and mediastinal lymphadenopathy

In sarcoidosis the common pattern is RPT & BHA

 William E. Brant Fundamentals of Diagnostic Radiology

 R.G. Granger &D.J. Allison Diagnostic Radiology

 Internet (e medcine, learningradiology.com & yottalook

 Imaging of the chest ,DavidM Hansen, 3rd edition

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