Release date: 2007-09-04
Diagnostic ideas and classification of diffuse interstitial lung disease At present, many clinicians have unclear concepts and classifications of interstitial lung disease (ILD), and see diffuse lesions in both lungs. It is "pulmonary interstitial fibrosis", which leads to errors in diagnosis and treatment, so it is necessary to explain the concept and classification of ILD. ILD is a group of diseases mainly composed of alveolar wall and including lesions around the alveoli and its adjacent supporting structures, with nearly 200 causes. Because most ILD lesions are not limited to the alveolar interstitial, but may involve alveolar epithelial cells, pulmonary capillary endothelial cells and bronchioles, and often accompanied by changes in lung parenchyma such as alveolitis, alveolar protein leakage, etc. It is called diffuse pulmonary parenchymal disease (DDPLD contains the same concept and is a general term for all diffuse interstitial lung diseases.
Idiopathic Interstitial Pneumonia (IIP) is one of ILD/DPLD. Idiopathic Pulmonary Fibrosis (IPF) is a type of IIP that is pathologically known as UIP (interstitial pneumonia). The specific concepts and classifications are shown in Figure 1.
Clinical Diagnostic Ideas The diagnosis of ILD relies on medical history, physical examination, chest X-ray (especially HRCT) and pulmonary function tests for comprehensive analysis. The diagnosis steps include the following three points: firstly, whether it is diffuse interstitial lung disease (ILD/DPLD); which type of ILD/DPLD is clearly defined; and how to diagnose idiopathic interstitial pneumonia (IIP).
1, to determine whether it is diffuse interstitial lung disease The most important symptoms in the history of sexual shortness, dry cough and fatigue. Physical examination of most ILD patients can be heard in the bilateral lungs and Velcro. In patients with advanced hypoxia, cyanosis can be seen. Chest X-ray plays an important role in the diagnosis of ILD/DPLD. A ground-glass change is seen early in the disease, and a more typical change is a nodular shadow, a linear (mesh) shadow, or a network of nodular shadows. Alveolar filling disease manifests as a diffuse borderless alveolar nodules, sometimes with a gas-containing bronchial sign, and a late-stage lung volume reduction can result in a honeycomb-like change. Pulmonary function tests were mainly characterized by a decrease in restrictive ventilatory dysfunction and diffuse function (DLCO). Arterial blood gas analysis can show varying degrees of hypoxemia, while carbon dioxide retention is rare.
2. Which type of ILD/DPLD does it belong to? (1) A detailed medical history is the basis: including environmental contact history, occupational history, personal history, treatment history, medication history, family history, and underlying disease. (2) Chest X-ray images (especially HRCT) can provide clues: differential diagnosis of ILD/DPLD can be based on imaging characteristics, lesion distribution, presence or absence of lymph nodes and pleural involvement. 1 lesions with the distribution of the upper lobe of the lungs suggest lung Langerhans cell histiocytosis (PLCH), cystic pulmonary fibrosis and ankylosing spondylitis. 2 lesions in the middle and lower lungs mainly suggest cancerous lymphangitis, chronic eosinophilic pneumonia, idiopathic pulmonary fibrosis and pulmonary fibrosis associated with rheumatoid arthritis and scleroderma. 3 lesions mainly involving the lower lung field and pleural plaque or localized pleural thickening suggest asbestosis lung. 4 chest X-ray showed a migratory infiltrates suggesting allergic granulomatous vasculitis, allergic bronchopulmonary aspergillosis, chronic eosinophilic pneumonia. 5 paratracheal and symmetrical double hilar lymphadenopathy strongly suggest sarcoidosis, also seen in lymphoma and metastatic cancer. 6 eggshell-like calcification suggests silicosis and silicosis. When the Keley B line appears and the heart shadow is normal, it suggests cancerous lymphangitis. If pulmonary hypertension is involved, pulmonary vein obstructive disease should be considered. 7 pleural effusion showed rheumatoid arthritis, systemic lupus erythematosus, drug reaction, asbestosis, amyloidosis, pulmonary lymphangioleiomyoma or cancerous lymphangitis. 8 lung volume unchanged and increased suggestive coexisting obstructive ventilatory disorders such as pulmonary lymphangioleiomyomatosis, PLCH and so on. (3) bronchoalveolar lavage examination has a diagnostic value or is helpful for diagnosis: 1 to find the original infection, such as Pneumocystis carinii; 2 to find cancer cells; 3 alveolar proteinosis: bronchoalveolar lavage fluid is bovine milky, over Iodine-Schiff staining positive; 4 hemosiderosis: bronchoalveolar lavage fluid was rust-colored and found hemosiderin cells; 5 asbestos body count exceeded 1 / ml: suggesting asbestos exposure. Analysis of the classification of cellular components of bronchoalveolar lavage fluid can help to distinguish the class of ILD/DPLD to some extent. (4) Some laboratory tests include: 1 anti-neutrophil cytoplasmic antibody: found in Wegener's granulomatosis; 2 anti-glomerular basement membrane antibody: found in pulmonary hemorrhagic nephritis syndrome; 3 serum sedimentation against organic antigen Antibody: seen in exogenous allergic alveolitis; 4 specific autoantibody detection: suggesting the corresponding connective tissue disease.
3, how to differentiate the diagnosis of idiopathic interstitial pneumonia, if the detailed history of the above, the necessary laboratory and bronchoalveolar lavage examination and chest imaging analysis, still can not determine which ILD / DPLD, it should be For idiopathic interstitial pneumonia. Idiopathic interstitial pneumonia includes: idiopathic pulmonary fibrosis (pathologically known as interstitial pneumonia), desquamation-type interstitial pneumonia, respiratory bronchiolitis with interstitial lung disease, non-specific Interstitial pneumonia, acute interstitial pneumonia, lymphocytic interstitial pneumonia, and cryptogenic organizing pneumonia (see Figure 1). Among them, idiopathic pulmonary fibrosis/interstitial pneumonia is the most common, accounting for more than 60% of all idiopathic interstitial pneumonia, followed by non-specific interstitial pneumonia, and the other types of idiopathic interstitial Pneumonia is relatively rare. The final diagnosis of idiopathic interstitial pneumonia, in addition to idiopathic pulmonary fibrosis can be based on medical history, signs, bronchoalveolar lavage examination and chest HRCT clinical diagnosis, the diagnosis of other idiopathic interstitial pneumonia Need to rely on pathological diagnosis.
In summary, for patients with clinically suspected DPLD, a detailed clinical assessment, including medical history, physical examination, chest X-ray and pulmonary function tests, is required. Accordingly, patients were divided into two groups: one group of patients had no clinical manifestations of IIP due to their associated condition or underlying disease; the other group had typical IIP performance. The latter should be performed HRCT. This group can be divided into four categories: 1 with typical clinical features, can clearly diagnose idiopathic pulmonary fibrosis (IPF) / common interstitial pneumonia (UIP); 2 typical without IPF Clinical manifestations; 3 clinical features can diagnose another DPLD, such as PLCH; 4 suspect other types of DPLD. Transbronchial lung biopsy (TBLB) or bronchoalveolar lavage (BAL) is required for patients in groups 2 or 4, and an open lung biopsy is required if the diagnosis is still unclear - Medi Medical Network
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