0:00

So here is a nice example of UIP.

0:04

So this is a little older,

0:05

so this is when we were doing axial acquisitions,

0:08

but I think that in this case the axial slices do it justice

0:12

'cause we catch these areas in exactly the right areas in

0:15

the right portion of the lung parenchyma.

0:17

And so this obviously is a prone image,

0:19

that's why everything is sort of is backwards.

0:21

And so in your PAC system, I'm sure you could sort

0:24

of rotate this,

0:25

but I think some people will just read it like this.

0:28

I have no problem reading like this.

0:30

We are looking at the pulmonary fibrosis here

0:32

and we see a lot of the subpleural honeycombing.

0:34

I think you guys could see that. And so

0:36

to invoke honeycomb you wanna see these fibrotic cysts.

0:39

So how do I know they're fibrotic cyst?

0:41

Because you see associated adjacent reticulation

0:44

and some architectural distortion,

0:46

but you wanna see them at least line up in rows.

0:48

Some people say well you need three cyst to line up in rows.

0:50

Other people say you only need two, I use two as my number.

0:54

And then you can be really confident they start

0:56

stacking like right in here.

0:57

These are stacked honeycomb cysts.

1:00

And so we're thinking this is UIP

1:03

because we see honeycombing, right?

1:04

Honeycomb is one, one

1:05

of the more specific binds of pulmonary fibrosis.

1:07

But really we wanna make sure

1:09

that this is peripheral and basal predominant.

1:11

And so that requires us scroll all the way through.

1:13

Clearly this is peripheral predominant

1:15

and I think there's probably a bit of a basal gradient.

1:18

This is not sort of a slapping the bases kind

1:20

of basal gradient, but I think overall there's more fibrosis

1:23

at the lung bases than the upper lung zone.

1:25

So this is one where I would call peripheral basal

1:28

predominant pulmonary fibrosis.

1:29

But even if it wasn't basal predominant, just the fact

1:33

that it's four predominant, you can get some cases

1:36

of UIP which have more of a diffuse zonal,

1:39

so superior inferior distribution.

1:42

See a little bit of traction bronchiectasis here as well.

1:45

So even if you have a UIP pattern, you're not done though,

1:48

you want to get the expiratory phase imaging.

1:49

And so here is the expiratory phase images here.

1:55

And so you wanna make sure there's no

1:56

significant air trapping.

1:58

And so there are two ways you could do

2:00

expiratory images here.

2:02

And so one is you get one axial slice

2:06

and you sort of have the patient

2:07

breathe in and then breathe out.

2:08

Slice example here and you look for air trapping.

2:11

So actually I think, uh, I like that.

2:13

I like having this option.

2:15

So it goes from inspiratory to expiratory

2:17

so you can see the lungs turn hyperdense from

2:19

hypodense, right?

2:21

So inspiration to expiration

2:22

and again, you're looking for areas that stay

2:25

as hypodense on expiration as you do an inspiration.

2:28

I don't see any evidence of air trapping there.

2:31

And so we will do this on three planes at UCSD.

2:35

Uh, this is something that I think will originally start at

2:37

U at UCSF and then, so no air trapping here,

2:41

but for those of you guys who have Hawkeyes,

2:44

you guys probably notice this.

2:45

Patient's trachea is not normal. Let's blow this up.

2:50

So on expiration dynamic exploration, look

2:53

how tiny that trachea gets.

2:54

So it goes from this, which is pretty gigantic,

2:57

maybe a little saber chief

2:58

Shaped here, which usually goes with COPD,

3:01

but I don't see much emphysema

3:02

to this little sliver there, right?

3:04

So imagine trying to breathe through that thing, right?

3:07

So this is classic tracheal malacia.

3:10

So it's not just the posterior memory,

3:12

it's not just extensive dynamic airway collapse.

3:14

This posterior aspect trachea pooching forward the

3:17

cartilaginous wall, the trachea clearly is abnormal, okay?

3:20

It's, it's just not keeping the airway open

3:22

during expiration.

3:24

So the patient clearly has pulmonary fibrosis, a UIP pattern

3:27

of pulmonary fibrosis, but this is certainly not helping in

3:30

terms of their dyspnea.