1. Chronic dyspnea of pulmonary origin
DIAGNOSTIC IMAGING
Chronic dyspnea of pulmonary origin
Davide Stoppa

2. Chronic dyspnea of pulmonary origin
Chronic: duration >1 month
Dyspnea: breathlessness or shortness of breath
Usually caused by cardiopulmonary disease
myocardial infarction
congestive heart failure
Distinction between cardiac and pulmonary causes not always obvious
Multifactorial etiology in up to one-third of patients
Pulmonary origin - most common causes:
Chronic Obstructive Pulmonary Disease (COPD)
Interstitial Lung Disease (ILD)
Dyer DS, Mohammed TL, Kirsch J, et al. ACR Appropriateness Criteria(R) Chronic Dyspnea: Suspected Pulmonary Origin. J Thorac Imaging. 2013; 28(5):W64-W66.

3. DYSPNEA
... ?

4. DYSPNEA
Anamnesis - Physical examination

5. DYSPNEA
Anamnesis - Physical examination
IMAGING?

6. Variant 1: any age First imaging approach?
X-Ray
CT without contrast
CT with contrast
CT without and with contrast
MRI without contrast
MRI without and with contrast
FDG-PET/CT

7. Variant 1: any age First imaging approach?
X-Ray
CT without contrast
CT with contrast
CT without and with contrast
MRI without contrast
MRI without and with contrast
FDG-PET/CT

8. ACR appropriateness Criteria®
Dyer DS, Mohammed TL, Kirsch J, et al. ACR Appropriateness Criteria(R) Chronic Dyspnea: Suspected Pulmonary Origin. J Thorac Imaging. 2013; 28(5):W64-W66.

9. Chest X-Ray DYSPNEA IMAGING? Anamnesis - Physical examination
negative?
positive!
Spirometry
Pulmonary
Cardiac
negative
Pleural effusion
Pneumonitis
Pneumothorax
Pulmonary edema
ILD
Vascular pathologies
COPD
Chest wall deformity
Right failure
Left failure
ABG
Other
PaO2 < 70 mmHg
Mediastinum
Great vessels
IMAGING?

10. CT without and with contrast MRI without contrast
Variant 2: any age, nonrevealing or nondiagnostic clinical, standard radiography, and laboratory studies Second imaging approach?
CT without contrast
CT with contrast
CT without and with contrast
MRI without contrast
MRI without and with contrast
FDG-PET/CT

11. CT without and with contrast MRI without contrast
Variant 2: any age, nonrevealing or nondiagnostic clinical, standard radiography, and laboratory studies Second imaging approach?
CT without contrast
CT with contrast
CT without and with contrast
MRI without contrast
MRI without and with contrast
FDG-PET/CT

12. ACR appropriateness Criteria®
Dyer DS, Mohammed TL, Kirsch J, et al. ACR Appropriateness Criteria(R) Chronic Dyspnea: Suspected Pulmonary Origin. J Thorac Imaging. 2013; 28(5):W64-W66.

13. Chest X-Ray Chest CT DYSPNEA Anamnesis - Physical examination
positive!
negative?
Spirometry
Pulmonary
Cardiac
negative
Pleural effusion
Pneumonitis
Pneumothorax
Pulmonary edema
ILD
Vascular pathologies
COPD
Chest wall deformity
Right failure
Left failure
ABG
Other
PaO2 < 70 mmHg
Mediastinum
Great vessels
Chest CT

14. Chronic dyspnea of pulmonary origin
How do these Patients present? Let’s see some examples

15. COPD Represents a spectrum of obstructive airway diseases
It includes two key components:
chronic bronchitis / small airways disease
emphysema

16. COPD
Most important risk factor: tobacco smoking!

17. COPD
Some clinical cases…

18. COPD – Case 1 No patient information available…
Known history of chronic bronchitis

19. COPD – Case 1

20. COPD – Case 1

21. COPD – Case 1 Chronic obstructive pulmonary disease
with prevalent chronic bronchitis

22. COPD – Case 2 Presentation: Patient Data:
Chronic, worsening shortness of breath
Patient Data:
Age: 60 years
Gender: Female
Race: Caucasian

23. COPD – Case 2

24. Chronic obstructive pulmonary disease with marked hyperinflation
COPD – Case 2
Chronic obstructive pulmonary disease
with marked hyperinflation

25. COPD – Case 3 Presentation: Patient Data: History of smoking Age: 55
Gender: Male
Race: Hispanic/Latino

26. COPD – Case 3

27. Centrilobular pulmonary emphysema
COPD – Case 3
Centrilobular pulmonary emphysema

28. COPD – Case 4 Presentation: Patient Data:
Severe breathlessness and recurrent infections
Patient Data:
Age: 49
Gender: Male

29. COPD – Case 4

30. Pan-lobular emphysema due to alpha-1-antitrypsin deficiency
COPD – Case 4
Pan-lobular emphysema
due to alpha-1-antitrypsin deficiency

31. COPD – Case 5 Presentation: Patient Data:
45 year history of smoking with shortness of breath
Patient Data:
Age: 60
Gender: Male
Race: Hispanic/Latino

32. COPD – Case 5

33. Paraseptal emphysema and subpleural bullae
COPD – Case 5
Paraseptal emphysema and subpleural bullae

34. Different types of emphysema

35. ILD
More than 200 chronic lung disorders affecting the interstitium (the tissue between the air sacs of the lungs) by inflammation or scarring (fibrosis)
Fibrosis causes lung tissue to permanently lose the ability to breathe and carry oxygen
Air sacs, as well as the lung tissue between and surrounding the air sacs, and the lung capillaries, are destroyed by the formation of scar tissue.

36. ILD – Large number of disorders…
Idiopathic
Major idiopathic interstitial pneumonias
Idiopathic Pulmonary Fibrosis / Usual Interstitial Pneumonia (IPF / UIP)
Idiopathic Nonspecific Interstitial Pneumonia (NSIP)
Respiratory Bronchiolitis-Interstitial Lung Disease (RB-ILD)
Desquamative Interstitial Pneumonia (DIP)
Cryptogenic Organising Pneumonia (COP)
Acute Interstitial Pneumonitis (AIP)
Rare idiopathic interstitial pneumonias
Idiopathic Lymphoid Interstitial Pneumonia(LIP)
Idiopathic PleuroParenchymal FibroElastosis (PPFE)
Unclassifiable idiopathic interstitial pneumonias
Other entities
Combined Pulmonary Fibrosis and Emphysema (CPFE)
Multisystem diseases
Autoimmune and collagen vascular diseases
Systemic lupus erythematosus
Rheumatoid arthritis
Progressive systemic sclerosis
Dermatomyositis and polymyositis
Anti-synthetase syndrome
Ankylosing spondylitis
Sjögren syndrome
Wegener's granulomatosis
Mixed connective tissue disease
Sarcoidosis
Langerhans cell histiocytosis
Inherited diseases
Neurofibromatosis
Tuberose sclerosis (lymphangioleiomyomatosis)
Amyloidosis
External causes
Inhaled substances
Inorganic
Silicosis
Asbestosis
Berylliosis
Organic
Hypersensitivity pneumonitis
Drug induced
Antibiotics
Chemotherapeutic drugs
Antiarrhythmic agents
Statins
Radiation induced
Infections
Atypical pneumonia
Pneumocystis pneumonia (PCP)
Tuberculosis
Chlamydia trachomatis
Respiratory Syncytial Virus
Miscellaneous
Pulmonary alveolar proteinosis
Pulmonary eosinophilia
Idiopathic pulmonary haemosiderosis (IPH)
Malignancy
Primary
Lymphoma, other lymphoproliferative diseases
Secondary
Pulmonary metastases, lymphangitis carcinomatosis

37. ILD
Some other clinical cases…

38. ILD – Case 1 Presentation: Patient Data:
Progressive shortness of breath
Patient Data:
Age: 50
Gender: Male
Race: Hispanic/Latino

39. ILD – Case 1

40. ILD – Case 1

41. ILD – Case 1

42. Usual interstitial pneumonia (UIP)
ILD – Case 1
Usual interstitial pneumonia (UIP)

43. UIP

44. ILD – Case 2
Presentation:
Dyspnea
Patient Data:
Age: 47
Gender: Male

45. ILD – Case 2

46. ILD – Case 2

47. Non-specific interstitial pneumonia (NSIP)
ILD – Case 2
Non-specific interstitial pneumonia (NSIP)

48. NSIP

49. UIP vs NSIP

50. UIP vs NSIP

51. ILD – Case 3 Presentation: Patient Data:
Consolidations (on X-Ray, non available) not responding to multiple courses of antibiotics
Patient Data:
Age: 33
Gender: Female
Race: Caucasian

52. ILD – Case 3

53. Cryptogenic organising pneumonia
ILD – Case 3
Cryptogenic organising pneumonia

54. ILD – Case 4 Presentation: Patient Data: Shortness of breath
Age: Adult
Gender: Female

55. ILD – Case 4

56. Patient had clinically established scleroderma!
ILD – Case 4
Patient had clinically established scleroderma!

57. Scleroderma with interstitial fibrosis
ILD – Case 4
Scleroderma with interstitial fibrosis

58. ILD – Case 5 Presentation: Patient Data: Dyspnea and dry cough
Age: 42 years old
Gender: Male
Race: Middle eastern

59. ILD – Case 5

60. ILD – Case 5

61. ILD – Case 5

62. ILD – Case 5 Sarcoidosis - stage II

63. ILD – Case 6 Presentation: Patient Data:
1-month history of sore throat and 9-month history of worsening nonproductive cough; dyspnea only after prolonged coughing episodes
Provisionally diagnosed with asthma 9 months earlier, but not response to fluticasone
Admission of smoking one pack of cigarettes per day for the past 3 years
Patient Data:
Age: 21
Gender: Female

64. ILD – Case 6

65. ILD – Case 6

66. Pulmonary Langerhans Cell Histiocytosis
ILD – Case 6
Pulmonary Langerhans Cell Histiocytosis

67. ILD – Case 7 Presentation: Patient Data:
Increasing shortness of breath over several months
Patient Data:
Age: 32
Gender: Female

68. ILD – Case 7

69. ILD – Case 7

70. Lymphangiomyomatosis
ILD – Case 7
Lymphangiomyomatosis

71. ILD – Case 8 Presentation: Patient Data: Shortness of breath Age: 64
Gender: Male
Race: Caucasian

72. ILD – Case 8

73. ILD – Case 8

74. ILD – Case 8

75. Patient has an occupational history of sand blasting!
ILD – Case 8
Patient has an occupational history of sand blasting!

76. ILD – Case 8 Silicosis with acute findings of congestive heart failure
and pulmonary alveolar edema

77. ILD – Case 9
Patient Data:
Age: 80 years
Gender: Male

78. ILD – Case 9

79. ILD – Case 9

80. ILD – Case 9

81. Patient was previously exposed to asbestos fibres!
ILD – Case 9
Patient was previously exposed to asbestos fibres!

82. Asbestos related lung and pleural disease
ILD – Case 9
Asbestos related lung and pleural disease

83. ILD – Case 10 Presentation: Patient Data:
Hypoxia with lung infiltrates on CXR
Steroid responsive: asthma?
Patient Data:
Age: 12
Gender: Female
Race: Caucasian

84. ILD – Case 10

85. ILD – Case 10

86. Further history: patient slept with a pet parrot!
ILD – Case 10
Further history: patient slept with a pet parrot!

87. Hypersensitivity pneumonitis
ILD – Case 10
Hypersensitivity pneumonitis

88. ILD – Case 11
Patient data:
Elderly age
Cardiac arrhythmia

89. ILD – Case 11

90. ILD – Case 11

91. Patient was using Amiodarone!
ILD – Case 11
Patient was using Amiodarone!

92. ILD – Case 11 Amiodarone lung

93. ILD – Case 12 Presentation: Patient Data:
Shortness of breath of 4 days duration
Patient Data:
Age 35
Gender: Male

94. ILD – Case 12

95. ILD – Case 12

96. Pulmonary alveolar proteinosis
ILD – Case 12
Pulmonary alveolar proteinosis

97. ILD – Case 13 Presentation: Patient Data:
Acute exacerbation of asthma, requiring hospitalisation
Patient Data:
Age: 56
Gender: Female
Race: Caucasian

98. ILD – Case 13

99. ILD – Case 13

100. Patient had blood eosinophilia!
ILD – Case 13
Patient had blood eosinophilia!

101. Eosinophilic lung disease - chronic
ILD – Case 13
Eosinophilic lung disease - chronic

102. ILD – Case 14 Presentation: Patient Data: Previous history of Age: 60
breast carcinoma
non-Hodgkin lymphoma
MALToma
Patient Data:
Age: 60
Gender: Female

103. ILD – Case 14

104. ILD – Case 14

105. Lymphangitis carcinomatosis
ILD – Case 14
Lymphangitis carcinomatosis

106. Lymphangitis carcinomatosis

107. Take Home Points
Patient with chronic dyspnea of pulmonary origin: what to do?
1° approach: X-Ray
2° approach: CT without contrast (HRCT)
CT with contrast in selected cases
Different pathologies may appear similar on X-ray and even on CT
Importance of correlation to
Patient data (don’t forget occupational anamnesis)
Clinical presentation
Laboratory studies

108. Thank You for Your Attention!