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Interstitial Lung Disease

Apr 29 | 3:30 PM

Interstitial lung disease (ILD) is a term used to describe a collection of about 100 chronic lung diseases that are characterised by inflammation and scarring, making it difficult for the lungs to get enough oxygen. Pulmonary fibrosis is the term for the scarring. The symptoms and progression of various disorders can differ from one person to the next. Inflammation is a common thread that runs across all of the different types of the disease. Bronchiolitis, alveolitis, and vasculitis are all characteristics. Let's learn all about the pathogenesis, clinical presentation, diagnosis, and management from this outstanding Medflix select creator, Dr. Salil Bendre.

[Music] hi dr richard welcome you all on behalf of team metrics uh we have gathered here for the second part of ild session uh sir has covered uh all the basics of ird in part one after the session if you want to brush up the entire session you can go back to the replay section and watch it uh right now we will be uh building up on that and sir will be explaining two basics as well in between uh there is a renowned pulmonologist and transplant physician practicing at local hospital in masina uh in mumbai and uh sir has conducted amazing sessions in cases in medicine shop on netflix uh so uh welcome sir and i'm glad you are here for this super interesting session again yeah yeah so thank you once again so we will be continuing from where we left last time that was the interstitial lung diseases and for those who have joined again this time they would be perhaps be able to correlate with this slide which was shown last time and i want them to again go through this specifically because since we talked about ilds last time it was about the classification of interstitial lung diseases it was about the extra pulmonary symptoms of interstitial lung diseases and it was also about the different uh acute subacute and the chronic forms and how ild progresses to fibrosis that's what we had all discussed and first we had started with anatomy and then talked about the pathogenesis where we discussed how there is a destruction of the interstitium and finally this is how we will be seeing ct scans today the hallmark of an ild is actually to read a hrct chest scan that is very very important we cannot really go and proceed with even diagnosis of ild without a ct scan so today we'll be laying emphasis on lot of ct scans radiological pictures so that we are more efficient in handling cases of interstitial lung disease obviously you need to know the different types of ilds which we have classified i hope you remember this those who can't remember this slide would be there in a replay of the netflix session on first part ild so you can go through this slide and try to remember the classification as clinicians you need to classify them because you need to know the prognosis the stage of the ild and the treatment to the particular form of ild so we started talking of ipf we have discussed hp that is hypersensitivity pneumonitis we have discussed sarcoidosis and ctd ild which is connective tissue disease ild and straight away going off to the particular slides which we left off so that we can start discussing further on rather than you know going on with the different parts which we discussed last time uh give me a moment yeah so let's orient ourselves you need to be orienting yourself with this ct scan for the fresh learners who are seeing a ct scan chest for the first time or have not really read a ct scan you can see that it's a three dimensional picture and the black circle in the center is the trick here and on the right side we can actually see the lung on left side also there is the lungs so there is lung on either side the spine is at the base that is we can say at the six o'clock position so the patient is lying supine and when the patient is lying supine the head end is is towards the opposite side so you can see that the head end is if the head end is towards the i can see the 12 o'clock position the head end and is lying down then whatever you see on the left is actually the patient's the left side of the patient you can see a white arc like structure that is the arch of aorta so now you can understand which is the left side so if you can see a wide left structure on the side of the trachea then the left side is you can now make out which is the left and obviously the opposite side will be the right side so first you need to orient yourself with the architecture and the ct scans and interstitium is a very very small minute microscopic space though on diagrams we think as it's a very wide space but it is really a microscopic space and we have talked about how it presents itself in the different parts of the interceptal interlobular septum even in the peri-bronchial areas now i need to bring your attention to this particular slide and please spend some time on this because these are the different patterns of interstitial lung disease on a ct scan this is of course a diagrammatic representation so this would not be as very very clear as it is seen in this particular picture but if you start from the upper part you can see that small cubicles likes are present which are actually the septal thickening so there are white lines which are the septal thickening you can see them like boxes one above the other there is a septal thickening and of course there are there is a parent camel there is a normal parenchyme also which is seen which is a uniform greyish black structure coming below that you can see a marking called as interstitial thickening intra lobular interstitial thickening so there is a interlobular and intralobular interstitial thickening when you see the ct scans you'll be able to exactly know what i meant by this thickening coming still below that you can see a arrow marking as peripheral honeycombing peripheral honey now what is honeycombing is that there are small small cysts so those black black dots are actually air containing cysts and the white lining are the walls of the cyst they are stacked one upon the other and this stacking of this peripheral cysts is called as the honeycomb pattern on the ct scan honeycomb pattern okay so this is honeycomb pattern you can see a sub plural line without any honeycombing there is no cysts but there is a subtle line so it can be present in that way also we can see one more arrow which says signet ring appearance signet ring appearance so it's like a ring there is a black dot which is actually the bronchi which is dilated and a white dot next to it which looks like a ring so there is a signet ring appearance this is called as a signaturing appearance and this implies that the bronchi is dilated like in bronchiactases so there is a signet ring appearance above that you can see traction wrong cactuses now what is traction bronchitis means the entire lumen or the entire cylindrical form of the bronchi is the lion dilated so it's called the traction bronchiectasis you can see the traction bronchitis is arrow and then there is a bronchi above it which is a narrow tube the black structure is the narrow tube that's a normal diameter but in this particular area of the traction bronchitis is dilated so there is traction bronchitis there is signet ring appearance there is subterral line there is honeycomb appearance there is intra lobular thickening and there is interlobular septal thickening so try to remember these words these all are findings which can be present in the case of interstitial lung disease all of them there could be all of them together or only one of them or only three of them or only two of them but you need to orient and you need to understand these terminologies okay again i'm trying to re-emphasize it in a different slide so for those who could not make out on this on that slide try to see this slide again there are those inter lobular septal thickening you can make out there are small small small small cubicles which are there it's exactly in the 12 o'clock position you can see so that because i don't have a pointer so i'm trying to explain that's the 12 o'clock position there is an inter globular septal thickening coming right in the center you can see areas of traction bronch bronchial where there is dilatation okay irregular and torches so there is a branching of the bronchi but the the one which is going upwards is very smooth and there is no tortuocity of the wall but the lower one is having a appearance like it is tortures so that is traction bronch cactuses you can see a area of honeycombing also so all these different terminologies are going to be used in the ct scans now i have superimposed these terminologies with the actual ct scan images it may be a little difficult at the outset just to see and think about all these different terminologies because when we read a scan it is almost like a gray black white tissues but you will have to start seeing ct scans so gradually you will come to know about them now this is a close-up picture let us see what we can see now if you see the say the three o'clock position okay three o'clock position there is honey combing so there are multiple cysts one above the other that is honey there is traction bronchiactasis means dilated and torches bronchi which is the traction bronchiectasis there are cysts also we can see there are lung cysts means there is no area of disease around but only a black area of wall and there is a thin wall around it so those are lung cysts and exactly in the center of it of this uh lung field we can see a upper upper the return is there signaturing appearance there's a white dot and a black area which is the signet ring appearance if you have any questions you can post it you can write them down or put it so that i can actually you know try to answer them now what is the meaning of honeycombing let me tell you that when we say fibrosis the most dreaded part of an ild is fibrosis so every interstitial lung disease goes through two phases one is the inflammatory phase and second is the fibrotic phase and we have already understood the pathogenesis but we are going to see what happens in the radiology so in radiology if there is honeycombing the way you have seen on this picture it means there is fibrosis if there is traction bronchuses it means there is fibrosis if there are certain areas of signaturing appearance it means that there is fibrosis all right so presence of honeycombing means fibrosis traction bronchitis means fibrosis signaturing appearance is very typical of bronchiectasis but in ild also there are areas of bronchitis which can happen so there are these few features which suggest that there is a fibrosis which is going on we have last time we had said that every ild may be sarcoidosis made with hypersensitivity demonitis may be nsip all of them finally go into the stage of fibrosis so they may present with honeycomb being they may present with traction or bronchuses and any of these things all right now this is a ct scan you can see there are on the right you can see on my right i am saying you can see that there is a black scan and one is a little grayish scan so then a ct scan of the chest you will see two windows one is the mediastinal window and one is the lung window the pulmonary window the mediastinal window is is uh is completely black absolutely black because there we are trying to focus on the mediastinum that is the heart the pericardium lymph nodes in the mediastinum even for that matter the pleura so these structures will be very clear in a mediastinal window the pulmonary window where we can see the lung markings is more specific for the pulmonary shadows that is septa fibrosis bronchiectasis nodules cavities so that is where we see the lung diseases so there are mediational windows and lung windows so whenever you get a ct scan plate you can definitely see completely a mediastinal window where there is nothing seen in the lung only black areas but the mediastinum is important and there is another big film which has only the lung windows so this is the mediastinal window okay this i have put up so that you know what i meant by mediastinal window you can see on either side of where the lung is it's completely black we can't see the lung at all no lung markings at all so this is the mediastinal window and in the media channel window we can make out the vessels the pulmonaries the aorta very well even for that matter the eso figures the ascending aorta and the descending aorta so that is where it is important to see the mediastinum if i ask you can you give me an example of an interstitial lung disease which is commonly seen with hilar will you be able to answer that we have discussed this last time that's why i'm asking this question let me see if any one of you can answer it so dr kiran has correctly answered yes sarcoid dr vigneshwar dr lokesh everyone is answering correctly that there is sarcoidosis as a possibility if we see mediastinal adenopathy lymph adenopathy all right so mediastina and this is the lung so now you can see the lung markings very well so the lung markings are typically containing having bronchi there will be vessels small small white dots anything which is white is tissue anything which is black is air so if there are small small marking these are the normal bronchovascular markings in a lung window okay these are the normal bronchovascular markings in the lung window so if that was a normal scan let us see what will be an abnormal scan so let us start from say we can see the heart obviously uh at say one o'clock position okay there is a arrow at a one o'clock position which has something which is starting with gr i hope you can make out that there is a whitish area or opacity which is at one o'clock position and that is called as ground glass appearance it is called as a ground glass appearance it is not the texture of a normal lung it is grayish area grayish opacities it is called as a ground glass or appearance or ground glass opacity ggo as dr monty is saying it is ggo ground glass opacity so ground glass opacity means that there is an inflammation going on in that area some amount of air is being replaced by a tissue that's the only meaning of ground glass opacity so ground glass opacity does not mean it has to be only and only interstitial lung disease even in a parenchymal disease means even in a disease where there is an alveolar inflammation since there is lot of inflammation there the air will reduce and it may look like a ground glass but as it becomes more and more dense more and more dense like in a patient of pneumonia we will be something seeing something like a consolidation very dense and white so that is exactly at the 11 o'clock position you can see the 11 o'clock position it is completely white and though the number the it's not the markings are not very completely seen but you can see parenchymal consolidation uh scene written over there so the consolidation looks more white and you can see small bronchial uh tracks running through it black lines running through it black markings running through it this is called the air bronchogram bronchogram means the bronchi are being lined by the air so they are called as air bronchogram so dr vigneshwar is correct that is exactly the air bronchogram which means that there is a consolidation so consolidation is dense and there has to be air bronchogram whereas ground glass is not so wide it is whiter than the normal lung but it is like almost like a very in between a normal lung and a completely dense opacity is it it is halfway and what i was talking about the ground glass is anything which is excessive tissue even in the apparent time it will look groundless even in the interstitium it will look ground glass i'll give you a simple example if a patient is having hemoptysis okay hemoptysis blood in the sputum but some of the blood remains in the alveoli and the ct scan is done even that aspirated blood will look like a ground glass opacity so ground glass opacity is seen in ild but ground glass opacity does not always mean ild i hope you get that very clearly if you see ground glass opacity then yes there is a possibility of ild but does not mean that it has to be only in an interstitial languages so naturally you are going to take help of the history you are going to take help of examination and then you are going to correlate the ct scan with the history yes we will go to go to the ground glass opacity and the mosaic attenuation as well but let's first see the perilous pattern so it's a peripheral lobular pattern of ground glass opacity now you can see on the seven o'clock position fibrotic pattern is written fibrotic because there are small small cysts which are arranged one above the other which is also called as honeycombing so that is a fibrotic pattern so that honeycombing if you see it means that this patient is having fibrotic interstitial lung disease okay so here we are just trying to explain ground glass opacity consolidation with an air bronchogram fibrosis will have honeycomb pattern okay now let's see what's next now what do we see over here though the answers have been given still you should be able to make out now okay it's very important for you yourself to ascertain what you can see you can see opacities which is called as ground glass because it is not as black or as normal structure as a normal lung so there is a ground glass opacity in both the sides okay you can see that just at the periphery means at the pleura there is a normal lung and within the normal lung there is again a sub there is a ground glass opacity so i would just put it at this point that there is bilateral subtle ground glass opacity even if you are able to be diagnosing or looking into that that is more than enough so if you see such a picture bilateral interstitial lung diseases are bilateral okay it won't be only on right sided ild or left sided so interstitial lung this is bilateral ground glass opacities you can think of a ild okay i hope you are able to understand and diagnose ild at that now let us see what is your impression in this ild this x this ct scan picture let me see who can try i would put it in a very easy manner is this ground glass opacity or is it honeycombing so many of you are writing honeycombing those who are writing honeycombing i i hope it is not guesswork you should be able to see that there is sub plural peripheral cysts which are stacked one upon the other okay they are stacked one upon the other they are stacked one upon the other and there are small small small small distributed bilaterally but more of them are in the right side in the posterior means towards the spine you can make out the vertebral body the vertebrae so you know which is the posterior part of the lung and there is definitely honeycomb appearance however however have you been people been able to make out the traction bronchiactases in this ct scan picture if anyone has not been able to make out the traction brom cactuses please put it up on the message so that i can explain where is the traction bronchiactis is yes it is on the left side very good so there is a traction this is on the left side so if you see the left side all right the left side uh i will say you go to the one o'clock position i wish i had a pointer i could have easily told you but you go to the one o'clock position and just below the one o'clock position you can see a dilated black line a black line which is actually the dilated tortuous bronchi and ectasia means traction bronchiactes is bronchiactasis means dilated bronchi so actasia is dilatation so there is traction bronchiactes is on the left side and there is dilatation so that is the traction from cactuses if it is peripheral yeah there is a question how do we know it is bronchiolectasia so bronchiolectasia is not in the midline it is much much peripheral so if in fact on the left lung there are few areas of peripheral traction bronchiolectasia also they are much peripheral posteriorly means towards the vertebral column i can see in the five o'clock position but a little more in the inside part of the lungs so there is a traction bronchiolectasia also the smaller airways are getting dilated now let us see this particular scan first you orient to the left lung and the right lung i hope you people have been able to make out which is the left lung and the right lung so there is a left lung and there is a right lung can you make out the consolidation or the dense opacities on both the sides posteriorly means para spinal para vertebral posteriorly so they are dense they are not ground glass only okay they are more dense like a consolidation so there is a consolidation going on more dense shadow this will not be suggest you offer interstitial lung disease given this picture it is more like a pneumonia a consolidation there is some groundless pattern in the 11 o'clock position can you make out at 11 o'clock there is a ground glass opacity 11 o'clock 10 o'clock there is opacity but it is not as dense so that will be a ground glass opacity but if you come towards the say the seven o'clock or even five o'clock five six seven all this entire area it will be dense consolidation okay it will be a dense consolidation now when i say consolidation and if we push it to the classification if you remember the first group on ields was the idiopathic interstitial pneumonia the iip and one of the iips was cryptogenic organizing pneumonia the cop cryptogenic organizing pneumonia so that could be presenting like this also that there is a dense consolidation so it could be an organizing pneumonia we had discussed last time what is a cryptogenic organizing pneumonia so you need to remember or read up or listen to that lecture and then only we can think of what exactly is cryptogenic organizing pneumonia now let me see what you can think of in this particular ct scan forget what is written on the slide you can actually try to read what you feel so you can make out first of all right in the center the karana we can see the right main bronchus and the left main bronchus okay at least that much we can definitely see the right main bronchus and the left main bronchus now if you remember the normal ct scan then in this particular ct scan let's go clockwise 11 o'clock at the 11 o'clock position oh sorry not the 11 o'clock the one o'clock position you can see haziness or there are white lines which are thick so these are called as reticular markings okay reticular markings means they are lines or linear opacities which are marked hazardously by like a pencil they are just marked so these are called as linear opacities or reticular markings they are seen here in the one o'clock position even in the five o'clock position and again in the seven o'clock position so there are areas of reticular markings seen in this ct scan this is again a picture of interstitial lung disease yes it can be uh no no it can be the question one someone dr ankita is asking is how do we differentiate between reticular markings and honeycombing so honeycombing i will just show you a scan of honeycombing so this is what a honeycomb bag is so if you see the seven o'clock position or eight o'clock position you can see multiple small small cysts so that is honeycombing okay you cannot miss it multiple cysts will be seen the seven o'clock eight o'clock position even for that matter if you go to the 11 o'clock position also there are small small cis which are seen but if you see here you can't see much of honeycombing but there are definitely faint lines throughout the lung fields even in the right side left side so this could be yeah yeah but though it is dr mohanty though it was difficult to say intra lobular or interlobular i don't think you need to really really go into that depth what you need to know first of all do you feel they are reticular markings and do you feel they are septal thickening even if you have been able to make it perfect you are on the right track of diagnosing a interstitial lung disease this is more than enough at least we are not going to mistake that oh this could be just a bronchitis or maybe an emphysema or a copd so see the progression of idiopathic pulmonary fibrosis now one of the main diseases which we talked about was idiopathic pulmonary fibrosis this is the scan which starts from the top from the trachea so you can see the trachea in the first box the trachea in the second box in the third box it branches into the right main bronchus and the left main bronchus and then we move on and then it branches and we come to the lower lobes now what is seen here is very very interesting that honeycombing first of all let me ask all of you can you see honeycombing in this ct scan yes or no so you can see honeycombing in the ct scan fantastic and you can see that in the upper part where we are talking of the trachea where we are talking of the karena at the level of the trachea at least there is no honeycomb big you can make out the first two boxes is not showing any honeycomb when you reach the karina there is honeycombing starting at the five o'clock position then throughout the lower parts there is honeycombing throughout bilateral so we can say that this patient is having bilateral basal subplural honeycombing which is characteristic of a feature called as usual interstitial pneumonia uip so u i p is a ct scan description okay it's a ct scan description usual interstitial pneumonia the moment you see bilateral basal subplural honeycombing the pattern is described as uip pattern it's a uip pattern and uip pattern is characteristic of ipf idiopathic pulmonary fibrosis so you are putting all the three together one of course you will know the history he's a middle-aged man who comes with dry cough exertional breathlessness going on for a couple of years bilateral repetitions are heard you do a ct scan ground glass appearance you do a ct scan x-ray you do a c you do x-rays ground-glass appearance you do a ct scan and you see that there is bilateral subplural basal honeycombing so your impression uip pattern of ipf uip pattern is of ct scan ipf is a clinical diagnosis so what is radiographic characteristics of uip pattern peripheral sub plural basal friction from cactuses honeycombing okay these would be the primary features where you can say that okay this is a uip pattern once you start saying uip pattern you yourself know that you are dealing with a patient with fibrosis and fibrosis and fibrosis so in this patient with uip pattern steroids will not work so yeah now we are coming to the treatment mycophinolate mmf which we discussed last time will not work as a thioprin will not work the only thing which will work and should be given will be anti-fibrotics so you have got a patient you know the history you have examined you did a ct scan and now you plan the treatment now here the arrows are clearly pointing towards the ground glass opacities okay there is a ground glass opacities which is seen in a particular disease like again it's a part of iip for those who remember the classification that's why on the first part one i took almost five minutes to talk of just the classification in iip one of the parts or subdivisions is nsip non-specific interstitial pneumonia so you need to remember this as well nsip ground glass ground glass responds to steroids okay steroids will work very well in this phase of interstitial lung disease but this is a pattern it's a nsip pattern of ct scan so it can be even with early connective tissue ild also it may present with the nsip pattern ground glass opacities so the treatment may vary okay now let's see who can answer this what is seen in a and what is seen in b i am taking some 5 to 10 seconds to let you people see what you feel and let me know i'm not wanting the diagnosis just the exam just the explanation of what is it what is a and what is b perfect so now you can make out the difference between honeycombing and traction bronchiactasis so traction bronchitis is dilatation throughout okay that is attraction bronchitis and honeycomb being a small small small small cysts which are one upon the other stacked one upon the other now if i ask you can this be sarcoidosis can this be uh hypersensitivity pneumonitis can this be arya ld rheumatoid arthritis is ild the answer can be yes okay it can be yes because all the ilds in the later part of the disease become fibrotic and they can present as traction as well as honeycombing so very difficult to differentiate each ild when they are in the fibrotic phase of a disease okay very difficult to differentiate them someone was asking me about bronchiolectases bronchule ectasia so as you can see in the picture b the even the peripheral bronchioles are dilated so there is bronchiolectase also in this particular slide bronchi also are dilated and bronchioles are also dilated the question comes that once we know that these are the different patterns then you need to know the treatments as well so you can i mean take the photo of this slide or you can get it on google also there is nothing big i can explain or different i can explain because these are treatment schedules these are the doses these are the medicines which are used in different types of ild that you need to just remember read and remember and read and remember and read okay so you need to remember them but on a broad scale i can tell you that if there is honeycombing if there is traction from cactuses then the treatment would be more of anti-fibrotics if it is ground glass pattern the treatment would be steroids or the disease modifying drugs so that is how you will have to think about not to forget certain symptoms like the dermatologic symptoms okay certain patients may have dermatomyositis they may have rashes which should not be missed which should not be missed because they are a part of the arma the complete group of ild which could be related to a connective tissue disorder so not to forget that if a patient of a lady has got rashes around the eyes or dryness of the eyes or there is pain along the joints or there are rashes then please don't miss dermatomyositis same is true with reynolds there are patients with renard phenomena there are patients with ulcers and scars so these are also presentations which can happen with interstitial lung disease or sle patient who comes with malar rash photosensitivity skin reaction hair loss finally if there is an nsip pattern like we saw on the ct scan ground glass patches and a lady comes with these features you may actually think that this could be related to a sle patient with nsip pattern on a ct scan think of the medication history there are certain causes of ild also okay there are nitrofurantine amiodarone nsaids so many of them are there and these can lead to actually interstitial lung disease bleomycin is one of the anti-cancer drugs which has been known to cause interstitial lung disease methotrexate has been known to cause interstitial lung disease so these also are very important when you are treating a patient of ild you need to go to the history of treatment taken there are certain ilds which may present with hemoptysis now hemoptysis is a symptom of any chronic lung disease but it is also present in specific interstitial lung diseases like vaginas granulomatosis multiple cavities in the lungs violator lung fields and patients may have hemoptysis patient could could have vasculitis a good pasture syndrome why this is important is out of say thousand patients you see of ild three to four patients you may have a patient of ild with recurrent hypothesis so you need to remember that as well smoking of course is is definitely a part of ild and we had one ild which was mentioned in the iip which was respiratory bronchiolitis ild rbild which was in the iip group which is definitely having a strong association with smoking so please remember that all these factors have to be considered this is a slide which you may uh you know you may again get it in the on the internet where all the different antibody tests are written for different different different connective tissue disorder so there is a connection between them and so you need to have a specific investigation for them so we'll just go through a few slides quickly and then stop at that if there are any questions we will take up so if i say that this patient needs steroids or anti-fibrotics what should be the answer very good so the answer will be anti-fibrotics one more question i should ask you should we ask this patient to undergo a lung biopsy so it's the answers are coming yes no yes no yes no lung biopsy yes no yes no yes no so remember that lung biopsy is done first of all to know the type of ild okay whether it is a connective tissue ild whether it is sarcoidosis whether it is hypersensitivity pneumonitis but once all of them sarcoid hp all of them go into fibrosis with honeycombing there is no point of doing a biopsy because our treatment is not going to change okay our treatment is not going to change plus this is more of a basal bilateral honeycombing which is typically of a uip pattern so when the treatment is not going to change there is no need to actually go ahead and do a lung biopsy lung biopsies are reserved for those patients like a ground glass opacity young patient 26 year old or 34 year old bilateral groundless obesity and we really don't know what is the cause of that ild now let me ask this question someone was asking in between about this particular pattern but i want to know from the people who are here my question here to you is one do you see fibrosis or do you see ground glass pattern perfect so there is a ground glass opacities which are bilateral here i am so happy that you people have been started to diagnose ground glass opacity now in the ground glass opacities okay just look at the ground glass opacities say on the seven or seven o'clock position you can see a area which is black and white means there is ground glass in between again a normal and or same is true on the five o'clock position that there is a black area which is a normal lung and again around it is the ground glass opacity it is not a uniform texture of ground glassing there is patches of normal lung in between this patchy normal lung in between the ground glass opacity is called as a mosaic attenuation attenuation means obesity it is becoming more white but mosaic like pattern this is a patchy patchy opacity so it is called as mosaic attenuation okay so mosaic attenuation is seen when there is patchy ground glass opacities and that normal lung is actually the air trapping so usually this mosaic attenuation is is com is considered to be very typical of it is very typical of hypersensitivity pneumonitis so in mosaic white is deceased or black so it is the white which is deceased and the black is the air trapping okay white is the deceased form and it black is the air trapping so that is the how the way you will have to interpret please remember one more thing a very very important point i am making now in doing ct scans and if you see such a opacity of ground glass we need to actually turn the patient and make him prone okay prone because if it is fluid a patient with early pulmonary edema will also have fluid in the lungs and it will look like a ground glass opacity early pulmonary edema so if you tell him to go prone position then if it is fluid it will move but if it is actually interstitial inflammation it will not change in the presence so you need to have a prone position ct scan when you see ground glass opacity posteriorly or along the lower lobes you need to do a prone position ct scan you can see a mosaic attenuation here very well i hope you can see it very well now this is also one slide which i suppose will help you give a clue about uh you know which are the different types of uh location of the interstitial lung disease like sarcoidosis is usually in the upper lobes hypersensitivity pneumonite is usually in the upper lobes so there are different typical features of course not that every time it will be so there are patients of sarcoid we see with lower lobe involvement also okay and this is coming to the last one or two slides possibly is just to make you understand that in the ct scan we can actually uh you know make out the lows better the upper lobe the middle lobe that someday we can do just reading of a cd scan but you can make out that there are fissures so these lobes have been colored in a different color texture so that you can understand there is a fissure which can be seen the green area is the lower lobe above that the ray red is the middle lobe there is a left upper lobe which is the blue and again the lower lobe which is yellowish brown and there are the fissures which are seen so it gives such a classical representation of which lobe is involved is it the middle lobe is it the lower lobe it can be easily seen yes crazy paving pattern is also seen on ct scan i have not kept it on this particular presentation but maybe sometime when we do ct scans you can go through it we can decide about it so you can actually see the comparative now whatever you you have missed on a ct scan reading you can see that the first first one is the emphysema it's completely black more black and the emphasis matters lung is seen then there are the second one it shows the ground glass patchy areas of ground glass okay then we can see that there is honeycombing appearance in one of the ct scans at the extreme end so each of these scans finally help us in finding out and telling us what is the type of interstitial lung disease present not to forget that the past medical history is very important especially if there is liver disease if there is any acute or chronic kidney disease even fluid overload patients may present with fluid in the interstitium and give rise to interstitial edema so there could be a confusion that is it interstitial edema as an interstitial lung disease so history does make a big difference if the patient is having hiv there can be an acute interstitial pneumonia which may be present which which if you remember is a part of the iip so i think in whatever best time we could think about this is uh the most i can you know try to explain in terms of interstitial lung disease and the ct scan pictures there is many things to be discussed yet i am sure of that and there would be many questions also so with that i thank netflix for inviting me again for this session and i'm sure if there are any queries doubts we can suggestions we can take them yeah so definitely so i'll just stop this presentation and it will superb so the series that you have taken starting from plural effusion then we covered uh uh ild in part one and part two and then there was session on chest x-ray so to everyone if you want to just go back and brush up all the concepts that we have discussed you can just uh go there and watch in the replay so uh i'll just take few questions sir right now uh and after that we can stop uh so if anyone wants to ask uh questions to sir directly you can raise your hand i'll accept your request you can come on stage and ask uh said doctor raja drani is asking so much and says cause fibrosis or is there any thing specific so i would not be able to take a specific uh maybe that list of things it would be there but i haven't come across any specific uh insane cause it i haven't come across no right okay uh how to differentiate between cop so they are the same so they are the same see the earlier terminology was bronchiolitis obliterans with organizing pneumonia and now the terminology has changed to cop that is cryptogenic organizing the one so that it's just again i in my experience i have not seen a case of brucellosis so i will not be able to explain that it would be more theoretical so i'm sorry to say that but i haven't seen a case of brucellosis yet okay thank you so doctor kiran is asking so what is crazy paving pattern on ct yeah that's what i mentioned that that's the cd's picture and i have not kept it in this presentation but maybe if we can take up some session only on cd scans in general then we can have that you know pattern to be shown because it's a ct picture i mean unless i show that picture it's it's not possible yeah yeah uh so the mosaic pattern that you've shown so by is deceased or the black one is diseased yeah so that i answered during the talk that the white is the deceased one and the black is the air trapping so air trapping is also a disease form only because there is bronchiolitis so small airway narrowing so air is not able to go out there is lot of blackness and the white is that inflammatory parts so both are diseased but here we are talking of ild so we are considering that is the white which is abnormal and the black is the air trapping right uh so thank you so dr praveen i have accepted your request to come on stage uh you can turn on your mic yeah hello sir good evening sir yeah yes sir so pulmonary edema would be showing as a bilateral basal haziness and what we call the batwing appearance so there would be prominence of the vessels throughout okay from the midline peripheral whereas pulmonary hypertension would not be showing in the lung field or anything but the pulmonary vascular will be more prominent where we talk of the hilum and the pulmonary is coming out of the highlands only those areas will be prominent not the lung areas which are showing the edema just that would be not very difficult to uh you know make out on the x-ray only in upper side only pulmonary hypertension will be more prominent also so i can see lot of amazing comments like this was very elaborative lecture and amazing session uh so we'll be definitely planning future sessions with sir uh so if you have any topic suggestion you have seen some presenting i mean a lot of answer has covered almost all the basics now so if you want to you're anything specific just put in the comment section we'll take that up as well uh so there are a few more uh questions that i would like to take so uh duration of anti-five dot x uh is so so duration of see the primarily the role of anti-fibrotics is not to reverse the process it is to slow down the progression so once we say that that means they are going to be lifelong uh there are two anti-fibrotics one is perfect on and second is nintendo so if you have started perform then we need to give a trial of at least six months if there is a decline of the fvc and the dlc even after six months of anti-fibrotic you may consider changing the anti-fibrotic and going on with nintendo so that's how you will have to plan the treatment right understood thank you sir uh are there any indications uh to go for lung transplant in ild and what stage and if yes what are the success rates so ild is the most common indication for lung transplant okay that is western world cystic fibrosis is considered but yes in our country ild is the most common cause of reason for indication for lung transplant when do we do a lung transplant so a patient who needs to be on oxygen first of all you cannot subject a patient for a lung transplant if he is maintaining of oxygen saturation of 89 to 90 percent and above so patient has to be on oxygen at home patients who have a fvc decline by at least 25 to 30 percent every three months or six months a patient's six minute walk test should be showing a decline or a patient desaturates even after 250 meters of a walk patient's dlc or declines by about 20 percent on optimal anti-fibrotic therapy patient with severe pulmonary hypertension and hypoxia so all these would be the indications of a lung transplant for ild younger the patient better it is right and what are the success rates are when we go for it i mean you have taken a whole session on lung transplant uh but if you could just so so as far as statistics and outcomes are concerned we talk of a five-year survival rate of 70 so that's the quality of life and uh you know patient living without oxygen no need of any uh adjuvant oxygen so the survival rate of five years is 70 percent more the survival than says what the number of years the number of uh the percentage of survival goes down to almost 40 to 50 percent so we talk a five year survival rate seventy percent of uh life expectancy okay understood so i would highly recommend everyone to go back to that lung transplant panel discussion you will find it uh in netflix exclusives and or in the replay section and do watch it it was amazing panel discussion sir uh has covered and dr kumar though she was there so we have covered many aspects of lung transplant uh so there is one more question post copied uh if the patient is diagnosed as ild and patient on steroid clinically and clinically responsive so do we need anti-fibrotics in this case no need i see the anti-fibrotics are given when there is fibrosis so if the ct scan is showing honeycombing if the ct scan is showing traction wrong cactuses then obviously there is no role of steroids you need to put them on anti-fibrotics but since you are specifically asking of post covid so almost 90 percent of post coverage ilds they respond and reverse even without any treatment means just a supportive treatment is enough so you keep a close watch keep surveillance keep a ct scan check again after three months and watch whether it is declining or it is improving right right so uh there are more questions and so i can see lot of uh recommendations we are waiting for amazing webinar and ventilator bipap cpap and aov support uh i i could see two three more suggestions dmd on lung and management uh someday yeah some day we'll plan it i guess we have covered many of the questions now one last i would like to take any uh recommendations cystic side effects while patient is on anti-fibrotics systemic side effects so systemic side effects yes so both of them are phenol and interior we need to be watching the liver enzymes so keep a monitor on the liver enzymes initially you may do it after two weeks and then maybe once in three months if the patient is having no liver illness but if he is a patient of cirrhosis or an alcoholic liver disease you need to be very careful and monitor them much more closely there are certain patients even with phototoxicity or skin itching which are seen but not very common with nintendo the problem has been of diarrheas so you need to be again watchful whether the patient is tolerating these medications or not anorexia and weight loss is also common with these drugs so again they are to be managed with good dietary advice and giving them supplements right understood so with this we have covered everything that was there in the comment box few things that you have answered during session and few things that we have taken uh in the end dr mustafa i have accepted your request once again okay you have put it in the comment box so indications to stop steroids in a patient uh who has developed fibrosis how long so so again uh it's it's we cannot generalize this answer because every patient has got a different uh reason why he has been started on steroids if there is a proper a proper fibrosis which is seen which i mentioned as honeycomb being or traction bronchus is septal thickening then there is no role of steroids you need to stop steroids at that point itself you may taper them and stop them but if you feel that there is still an inflammatory component if there is a ground glassing which is present then you may give steroids if it is indicated at the same time remember that there are disease modifying drugs like mycophenolate as a thioprin which can be given and the steroids can be tapered off and stopped so now it is very clear that we can easily use these drugs to match and mix so that the side effects of steroids are avoided as much as possible possible right thank you sir uh yeah dr puja will definitely plan sessions on pftn investigations in palmer haloge thanks for the suggestion so so with this uh we have taken all the questions all the requests and thank you for the wonderful session and thanks a lot for your time thank you thank you my pleasure thank you everyone good night thank you

BEING ATTENDED BY

Dr. Kiran Tambe & 1480 others

SPEAKERS

dr. Salil Bendre

Dr. Salil Bendre

Pulmonologist & Transplant Physician, Nanavati Max Hospital, Global Hospital & Masina Hospital, Mumbai

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dr. Salil Bendre

Dr. Salil Bendre

Pulmonologist & Transplant Physician, Nanavat...

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