CLUBBING

Definition :

Clubbing of the fingers designates the selective bulbous enlargement of the distal segments of the digits due to an increase in soft tissue.

Mechanism :

1.The circulating megakaryocytes and large platelet particles present in the venous circulation normally break up in the pulmonary vascular bed. Megakaryocyte or platelet clusters, lodged in the peripheral vasculature of the digits, release platelet-derived growth factor (PDGF) and lead to the increased vascularity, permeability, and connective tissue changes that are the hallmark of clubbing.

Release of VEGF and PDGF occurred after platelet impaction and is enhanced by hypoxia. VEGF along with PDGF induces the pathological changes of digital clubbing.

Unilateral clubbing :-

Anomalous aortic arch 
Aortic or subclavian artery aneurysm 
Pulmonary hypertension with patent ductus arteriosus 
Brachial arteriovenous aneurysm or fistula 
Recurrent shoulder dislocation 
Superior sulcus (Pancoast) tumor 

Unidigital :- 
Median nerve injury 
Sarcoidosis 

Clubbing of toes without fingers (differential clubbing) :- 
Coarctation of aorta

From LUNG INDIAMalay Sarkar¹, DM Mahesh², Irappa Madabhavi^3
1 Department of Pulmonary Medicine, Indira Gandhi Medical College, Shimla, India

ORTHOSTATIC HYPOTENSION

 DEFINITION :

reduction in systolic blood pressure of at least 20 mmHg or 

diastolic blood pressure of at least 10 mmHg 

within 3 min of standing or head-up tilt on a tilt table,

It is a manifestation of sympathetic vasoconstrictor (autonomic) failure.

Ref : Harrison

SUBPULMONIC EFFUSION

 The first place for pleural fluid to accumulate in an erect patient is the space between the inferior surface of the lower lobe and the diaphragm. Only after filling this space, it will spill over into the costophrenic angles.

In CXR, the subpulmonic effusion stimulates diaphragmatic elevation thus called as pseudo diaphragmatic contour.

1. PA view :-The peak of pseudo diaphragmatic configuration is lateral to that normal hemidiaphragm being situated near the junction of middle and lateral third of diaphragm.

2.PA view :-On the left side, subpulmonic effusion is suspected if the distance between the gastric air bubble shadow and pseudo diaphragmatic shadow is more than 2cm.

3.Lateral view ;-upper margin of fluid meets the major fissure.

4.PA view: thin triangular opacity in the left paramediastinal zone with apex half way upto the mediastinum and its base continuous with pseudo diaphragmatic shadow.

5.PA view : The pulmonary vessels normally visible below the diaphragmatic contour, cannot be seen through the pseudo diaphragmatic contour of the subpulmonic effusion. 

Ref : Fraser

CAVITY

 

According to Fleischner Society, 

pulmonary cavities are defined as "a gas-filled space, seen as a lucency or low-attenuation area, creating wall thickness >2-4 mm , within pulmonary consolidation, a mass, or a nodule" 

CYST/BULLA/BLEB

                             Bleb                             Bulla                                         Cyst

Site : Within visceral pleura             Arises within secondary lobule        Lung parenchyma or mediastinum

Size  :          1–2 cm                              1 cm to 75% of a lung                                     2–10 cm

Lining :Elastic laminae of  pleura        Connective tissue septa                             Epithelium

Associated: Spontaneous pneumothorax     Bronchogenic carcinoma                  Respiratory infection

condition

BULLA:

A bulla is an air-containing space within the lung parenchyma that

arises from destruction, dilatation, and confluence of airspaces

distal to terminal bronchioles and is larger than 1 cm in diameter

BLEB:

A bleb is an accumulation of air between the two layers of the

visceral pleura that arises when the thin covering of the bleb ruptures

and permits entry of air.

CYST:

Cysts are epithelial-lined cavities that may resemble bullae on radiographs

(FISHMAN)

BRONCHOPULMONARY SEGMENTS

 

• Bronchopulmonary segments of human lung.
•  Left and right upper lobes: (1) apical, (2) posterior, (3) anterior, (4) superior lingular and (5) inferior lingular segments.
•  Right middle lobe: (4) lateral and (5) medial segments.
•  Lower lobes (6): superior (apical), (7) medial–basal, (8) anterior–basal, (9) lateral–basal, and (10) posterior–basal segments
• The medial–basal segment (7) is absent in the left lung. 

(FISHMAN)

Minimum fluid to visualise pleural effusion on CXR

 Effusions first become apparent on lateral upright radiographs with blunting of the posterior costophrenic angle. An accumulation of 200 ml of fluid is necessary for the effusion tp affect the lateral angles of frontal standing radiographs. Lateral decubitus radiograph with the affected side down is the more sensible view to identify an effusion of 5 to 15 ml. 

Pneumatocele

 Are thin walled, air filled structures that often develop early in the course of staphylococcal pneumonia, particularly in infants and young children, and usually disappear over the course of a few months. These cystic spaces are believed to be the consequence of check valve opening between a peribronchial abcess and an adjacent bronchus. 

BRONCHIAL ARTERIES

 The right bronchial artery usually (78% of people) arises within a common stem, with the first aortic intercostal (inter-costobronchial artery) from the posteromedial aspect of the descending aorta.

 On the left side, there is generally a superior and an inferior branch, both arising from the anterior aspect of the descending thoracic aorta.

The bronchial arteries run into the hilum, where they branch in a parallel manner and close to the bronchus to the peripheral airways.

 The diameters of these arteries are small, usually 1–1.5 mm at its origin within the mediastinum. 

Tongue in HIV

Leukoplakia 

Oral thrush

Atypical kaposi sarcoma.

Oral hairy leukoplakia.

White coated tongue