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Geriatric Chest Imaging: When and How to Image the Elderly Lung, Age-Related Changes, and Common Pathologies

Geriatric Chest Imaging: When and How to Image the Elderly Lung, Age-Related Changes, and Common... Hindawi Publishing Corporation Radiology Research and Practice Volume 2013, Article ID 584793, 9 pages http://dx.doi.org/10.1155/2013/584793 Review Article Geriatric Chest Imaging: When and How to Image the Elderly Lung, Age-Related Changes, and Common Pathologies 1 2 J. Gossner and R. Nau Department of Clinical Radiology, Go¨ttingen-Weende Hospital, An der Lutter 24, 37074 Gott ¨ ingen, Germany Department of Geriatric Medicine, Go¨ttingen-Weende Hospital, An der Lutter 24, 37074 Gott ¨ ingen, Germany Correspondence should be addressed to J. Gossner; johannesgossner@gmx.de Received 25 April 2013; Accepted 11 June 2013 Academic Editor: Paul Sijens Copyright © 2013 J. Gossner and R. Nau. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Even in a global perspective, societies are getting older. We think that diagnostic lung imaging of older patients requires special knowledge. Imaging strategies have to be adjusted to the needs of frail patients, for example, immobility, impossibility for long breath holds, renal insufficiency, or poor peripheral venous access. Beside conventional radiography, modern multislice computed tomography is the method of choice in lung imaging. It is especially important to separate the process of ageing from the disease itself. Pathologies with a special relevance for the elderly patient are discussed in detail: pneumonia, aspiration pneumonia, congestive heart failure, chronic obstructive pulmonary disease, the problem of overlapping heart failure and chronic obstructive pulmonary disease, pulmonary drug toxicity, incidental pulmonary embolism pulmonary nodules, and thoracic trauma. 1. Introduction patients have to be transferred to the radiology department and may need supervision while waiting. Positioning requires The population in many societies is getting older. eTh United more time, and oen ft patients need assistance. With bedrid- Nations estimate that the number of people older than 65 den patients, more than one person is needed for proper years will increase from 743 million in 2009 to 2 billions in positioning. This need for more time and staff has to be kept 2050.Atthistime, therewillbemorepeopleolder than 65 in mind but is in most cases not reimbursed [4]. The ideal years than children younger than 15 years [1]. In fact, around imaging test for elderly patient is fast and needs few changes 15% of patients treated in German hospitals are already older in positioning. than 80 years [2]. With age, the frequency of multimor- bidity increases. Geriatric medicine uses the term frailty 2.1. Chest Radiography. The standard examination in imaging to describe the process of progredient loss of mental and of the lung is chest radiography with a posterior-anterior and physical performance making the patients more vulnerable a lateral projection. Chest radiography is easy to perform, to further disease [3]. Sometimes it is difficult to separate the cheap, and, according to the ACR Appropriateness Criteria, process of ageing from disease itself. er Th efore, diagnostic in most scenarios the initial test when lung disease is imaging of older patients requires special knowledge. In this suspected [5]. In frail patients, standard projections of the review, aeft r a short description of imaging strategies, ethical chest often cannot be obtained, and a chest radiograph in considerations, and the normal ageing processes of the lung, supine position hastobetaken with well-known limitations. distinct pathologies with a special relevance for the elderly patient are discussed. 2.2. Computed Tomography. In addition to conventional X- ray, the ideal test in more complex cases is computed 2. Imaging Strategies tomography (CT). With modern multislice CT scanners, the In contrast to younger people, handling of elderly patients is lung can be examined in a few seconds. But even with modern different and usually takes more time. In most cases, elderly CT scanners, motion artifacts due to breathing may be a 2 Radiology Research and Practice problem in the elderly. Strategies to reduce these motion iodinated contrast media, nephropathy or manifest hyperthy- artifacts include the caudal start of the scan, where motion roidism scintigraphy is a good alternative. artifacts due to breathing are pronounced, and the use of a higher pitch. If there are still marked motion artifacts 2.5. Magnet Resonance Imaging (MRI). Although recent causing problems with image interpretation, we are adding advances with lung MRI are not used in everyday imaging several axial slices in classical high resolution CT technique of thelung, an exceptionisthe detailedimaging in Pancoast (Figure 1). tumors. If lung imaging with MRI is performed in the elderly, Imaging of the lung parenchyma is possible without a comprehensive examination to avoid excessive examination contrast media, but for imaging of lung vessels with computed timesshouldbeused, forexample,acombinationoffastspin tomographic pulmonary angiography (CTPA) or tumor echo T2-weighted coronal images and diffusion weighted staging, contrast media are mandatory. Elderly patients are images [13]. With poor renal function, the use of contrast at higher risk for contrast medium-induced nephropathy media is also of concern because of possible nephrogenic (CIN). In some cases, renal function is already impaired and systemic fibrosis. A lot of older patients have contraindica- there are other risk factors like diabetes, high blood pressure, tions for MRI like cardiac pace makers or older ferromagnetic heart insufficiency, hypovolemia, and atherosclerosis. Age surgical material. > 75 years is also an independent risk factor for CIN [6]. It has to be considered, however, that only a very small 2.6. A Practical Approach of Lung Imaging in the Elderly. The part of patients with CIN require hemodialysis [6]. The basic examination is chest radiography. If further workup is most important prophylaxis is adequate hydration, which is needed (suspected pulmonary embolism, immunocompro- especially important in elderly patients who oeft n drink too mised patient, consolidation without clinical or laboratory little. eTh incidence of CIN is also related to the amount of signs of inflammation, and mass or complex effusion), a used contrast media [7]. Interestingly, it has been reported chest CT should be performed. A thin collimated scan (1 mm that even thoracic CT scans with 15 mL iodinated contrast slice thickness) in caudocranial direction is recommended. media showed satisfactory diagnostic quality for routine Contrast media should be administered only if necessary. chest scans, for example, in the staging of mediastinal lymph In the followup, the modality should be chosen conidering nodes [8]. CTPA requires optimal opacification of the lung the underlying disease. A possible imaging algorhithm is vessels, and therefore a minimum of 60 mL contrast media provided in Scheme 1. should be used. A high flow rate is usually recommended to obtain a good vascular enhancement. Unfortunately, poor peripheral venous access is common in the elderly and 3. Ethical Considerations sometimes only small bore cannulas can be placed. We have Ethical considerations are important in the care of the elderly. shown that even with low flow rates (2.0 or 2.5 mL/s) and Treating physicians always need to consider if a potential 60 mL of contrast media, sufficient vascular enhancement can diagnosis obtained by imaging may alter treatment. Other- be obtained [9]. Another strategy to minimize the dose of wise, the test should not be done. Even in cases where an exact contrast media is the use of low kV settings [10]. diagnosis, for example, staging in a malignant disease, may help to plan further optimal treatment, it has to be accepted 2.3. Transthoracic Ultrasound. Transthoracic ultrasound may that patients may refuse imaging and insist on palliation only oer ff additional information to conventional chest radiogra- towards the end of their life. In particular, elderly patients phy [11]. In the frail patient, it is easy to use bedside test. should not feel to be obliged to agree with further diagnostics In the case of pleural effusion, it is more sensitive than [14]. radiography (especially compared to supine radiographs) and adds further information about the composition of the 4. Changes of the Lungs with Ageing pleural u fl id [ 11]. For example, it may show septations, a major cause for insufficient drainage aer ft pleural tube placement. With ageing, an enlargement of the distal airspaces due to the With transthoracic ultrasound, further information about loss of supporting tissue can be found, a condition for which congestive heart failure, pneumothorax, or pleura-based the terms “senile lung,” “senile hyperinflation,” or “senile consolidations can be obtained [11]. emphysema” have been proposed [15, 16](Figure 2). Histologically, a homogeneous dilatation of the airspaces 2.4. Nuclear Medicine. Ventilation-perfusion scintigraphy without signs of inflammation, fibrosis, or other architectural hasbeenreplacedinthe imagingofacute pulmonary distortions can be seen [15]. As a result, signs of hyperinfla- embolism (PE) by CTPA in most departments. In elderly tion can be seen on conventional chest radiography [17]. In patients, prevalence of existing lung disease and therefore a recent study, there were more elderly asymptomatic adults abnormal chest X-ray is relatively high, and therefore in this (age> 75 years) with centrilobular emphysematous changes patient group, the sensitivity for scintigraphy in diagnosing in CT imaging compared to a younger control group (age< 55 PE is impaired [12]. In the elderly patient, CT scanning should years) [18]. In thesamestudy,interstitialchanges of thelung be the preferred test, especially as in a substantial number of with a subpleural reticular pattern could be found in 60% patients, diagnosis other than PE can be found (pneumonia, of the elderly patients. Bronchial wall thickening was shown congestive heart failure). In patients with known allergy to in 50%. In another study, 25% of the elderly asymptomatic Radiology Research and Practice 3 Figure 1: Motion artifacts due to breathing in an elderly patient impairing interpretation of the interstitial changes. An additional scan with the use of a standard high resolution technique is substantially improving diagnostic performance. Further imaging Normal If PE suspected −→ CTPA/scintigraphy If patient immunocompromised −→ CT Chest radiography Suspected lung disease (p.a./lateral view) Consolidation - Repeat X-ray to ensure resolution - Persistent consolidation or consolidation without signs of inflammation −→ CT Abnormal Heart failure Monitoring with ultrasound Effusion Monitoring with ultrasound complex effusion −→ ultrasound/CT Interstitial lung disease −→ CT Solitary pulmonary nodule Look for older radiographs for comparison/if unavailable or new/ enlarged nodule −→ CT Suspected malignancy −→ CT Scheme 1 patients showed small cysts [17]. Lee et al. showed an 5. Borderlands of the Normal: Possible increased air trapping with age [19]. The frequent finding Problems in Differentiation between of small basal atelectasis in asymptomatic elderly patients Age-Related Changes and Pathology has been reported [20]. Further morphological changes with ageing are progressive calcifications of the airways and the rib As described previously, it has been shown that emphysema- cage [15, 16, 20](Figure 3). tous changes and basal b fi rotic changes are a common nding fi Like other muscles, there is a loss of diaphragmatic in elderly patients, especially on CT. There are no normative muscle mass [16], but in an older CT study, no measurable values described in the literature, but age-related changes decrease in muscle thickness of the diaphragm could be are usually described to be moderate. So, it is obvious that found [21]. eTh reduced mass of other thoracic muscles has differentiation may be difficult to early changes in chronic been described but has not been studied in detail [20]. obstructive lung disease or interstitial lung disease. 4 Radiology Research and Practice Figure 2: Senile emphysema in an 88-year-old patient. Chest X-ray (on the left) and centrilobular emphysematous changes on computed tomography (on the right). Imaging was ordered because of suspected mesenterial ischemia. butmay be duetocongestiveheart failureorinfection. Correlation with preexisting imaging should be performed to assess disease progression. Stehend The finding of senile emphysema is usually not accompa- nied by the clinical ndin fi gs of chronic obstructive pulmonary diseaselikecough andsputumproduction. In some cases, dieff rentiation may be not possible and follow-up imaging is needed. 6. Pathologies with a Special Relevance in the Geriatric Population 6.1. Pneumonia. Pneumonia still is one of the leading causes of death from infection and is most commonly at the extreme of ages, that is, in the very young and in the elderly population [22]. In elderly patients, the immune system is oen ft com- promised. Beside an age-related decrease in immune activity, there are medications altering immune function. For exam- ple, long-term use of systemic corticosteroids in rheumatic Figure 3: Extensive calcifications of the cartilaginous parts of the ribcageinan85-year-old patient(suspectedfracture). disease significantly increases the risk of severe pneumonias with need for hospitalization [23]. Clinically, pneumonia can be divided into typical or atypical presentation, and in accordance to history in community acquired, nosocomial or For example, the finding of a moderate basal lung fibrosis infections in the immunocompromised. eTh most important may be due to age-related changes or findings of interstitial imaging tool is conventional chest radiography. The role lung disease (usual interstitial pneumonia (UIP) or non- of radiography is to detect or rule out infiltrates, to show specific interstitial pneumonia (NSIP)), which can be found the extent of disease and possible complications, and to along with autoimmune disease or idiopathic interstitial show response to treatment [24]. If pneumonia is suspected lung disease. A differentiation is important as the latter in an immunocompromised patient, a negative X-ray is two need specific treatment in opposition to age-related not adequate to rule out infection and a CT should be changes. eTh refore, close correlation between the morpho- advocated. Complications like empyema or abscesses are logical extent of the fibrotic changes, clinical history (i.e., shown superiorly by CT [24]. There is a considerable overlap known autoimmune disease), and observation of associated in the radiological morphology due to different pathogenic changesiscrucial.Extensive changesaswellasmarked agents, so the morphological type of pneumonia is only a honeycombing or traction bronchiectasis are unlikely to be weak indicator of certain pathogens [25]. But in synopsis only age-related associated signs like ground glass opacities with clinical history and findings, chest X-ray will restrict which have not been reported with age-related changes the spectrum of possible pathogens and guide the calculated Radiology Research and Practice 5 use of antibiotics. It has to be stressed that without clinical information, the differentiation between infectious infiltrates and other consolidating lung processes like cryptogenic orga- nizing pneumonia is not possible [24]. If there are persistent infiltrations, bronchioalveolar carcinoma, now known as lepidic type of adenocarcinoma, should be included in the differential diagnosis. Clearance of pneumonic infiltration in the elderly takes usually more time. It has been shown that 15% of elderly patients still showed radiographic abnormali- ties beyond 3 months. Delayed clearance could be correlated to existing comorbidity [26]. We recommend a minimum interval of 3 months for the follow-up X-ray to to rule out preceeding malignant changes. Attention should be paid to the reactivation of tuberculosis. Many elderly patients are showing posttuberculotic changes on imaging. In reactivated pulmonary tuberculosis, patchy consolidations in the upper Figure 4: Consolidation in the right lower lobe due to aspiration lobes or the superior segments of the lower lobes are the most in an 85-year-old patient (aspiration was confirmed using u fl o- common finding. Cavitations with a predilection in the upper roscopy). lung zones can be found in up to 45% of patients [27]. 6.2. Aspiration Pneumonia. Oropharyngeal contents or gas- tric acid which is misdirected to the lower airways can cause severe inflammation. In addition to the chemical pneumonitis pathogens from the oral flora, reaching the lower respiratory tract may cause difficult-to-treat bacterial pneumonia [28]. It has been shown that even healthy elderly people are swallowing more slowly than younger persons and the cough reflex is impaired. This may lead to pharyngeal colonisation with pathogenic bacteria [29, 30]. Aspiration of small amounts is common during sleep even in healthy young adults [31]. In conclusion to this, it seems that the amount of aspiration and/or colonization of the pharynx or gastric content by bacteria is important. It should be kept in mind that proton pump inhibitors and H antagonists causeanincreaseingastric pH whichsupportsbacterial colonisation of the stomach. In everyday practice, the major cause of dysphagia is stroke and Parkinson’s syndrome [28]. In a study by Nakagawa et al. [32], in the followup aeft r stroke, 24% of patients with dysphagia developed pneumonia within one year. In contrast, none of the stroke patients Figure 5: Spot view from a uo fl roscopic examination in a 76-year- without dysphagia developed pneumonia. Radiologically, old patient aer ft stroke showing aspiration. recurrently found infiltrates involving the right lower lobe or the upper lobes in elderly patients should raise the suspicion of aspiration pneumonia (Figure 4). If aspiration is suspected, we perform a fluoroscopic this problem, butithas to be kept in mind that jejunaltubes swallowing study with the use of barium in dieff rent formed areeasilycongested making theclinicalhandlingofthese boluses (thick liquids, semithick liquids, semisolid food, or patients problematic. At last, the side effects of medications solid food). This may guide dietary modifications, which are should be remembered. Neuroleptics may cause dyskinesia the most common management approach [28]. A commonly of the muscles needed for swallowing with consecutive found phenomenon in elderly patients is laryngeal penetra- aspiration. In one study, the use of neuroleptic medication tion, which means that small amounts of contrast media are was associated with a higher risk of aspiration pneumonia entering the larynx. Only if the barium passes, the glottis [33]. aspiration can be diagnosed (Figure 5). Another problem to be kept in mind is reflux in patients with percutaneous gastroenterostomy feeding tubes. In these 6.3. Lung Changes with Congestive Heart Failure. Cardiac patients, reflux may ultimately lead to aspiration. eTh diag- disease, especially left heart failure, is a major differential nostic approach of choice is also fluoroscopy. eTh change to diagnosis for dyspnea in the elderly. With pulmonary venous, a jejunal position of the tip of the feeding tube can solve hypertension hydrostatic edema of the lungs occurs with a 6 Radiology Research and Practice well-known appearance on conventional chest X-ray: cra- considerable debate, but most authors state that the n fi dings nialization of the pulmonary blood flow, increased vascular of a “dirty chest” are insensitive and have the problem and interstitial markings with Kerley B lines, peribronchial of low reproducibility and interobserver variability [37]. cun ffi g, heart enlargement, and pleural effusions. With pro- The imaging of emphysema with chest radiography has gression, alveolar edema occurs which in most cases can undergone less debate, because the signs of hyperinflation be differentiated from edema of noncardiogenic causes, like of thelungs areobvious andobjective measurements can renal edema or capillary permeability edema (e.g., ARDS) be made [37]. The lateral view is of special importance, and [34]. From our experience, the diagnosis of early stages of it shows widening of the retrosternal space (>2.5 cm) and congestive heart failure may be complicated by concomitant the flattening of the diaphragm (the angle between the chest b fi rotic changes. Correlation with already existing images or wall and diaphragm is becoming larger than 90 degrees). If serial imagingwillhelptosolve this problem. In patients with hyperinflation is found, atypical forms of pulmonary edema emphysema due to chronic obstructive pulmonary disease should be expected and kept in mind. Patients with initial (COPD) the distribution relies on the remaining intact emphysematous changes or senile emphysematous changes parenchyma, so atypical ndings fi are common. Pulmonary are normally not showing signs of significant hyperinflation edema in the right upper lobe can occur in patients with on conventional X-ray. Our observations suggest that the severe mitral regurgitation. Pulmonary venous hypertension destruction of normal pulmonary vascularity in these early has typical features on CT imaging (enlargement of the upper stages is not marked enough to show noticeable asymmetric lobe pulmonary vessels, thickening of the bronchial walls, edematous changes with congestive heart failure. Because diffuse smooth thickening of the interlobular septae, and of the flattened costophrenic angles and scarring changes, ground glass opacities accompanied by effusions and heart ultrasound is oeft n needed to make the diagnosis of small enlargement, Figure 6)[35]. pleural effusion in patients with emphysema. In particular, in elderly patients with dyspnea undergoing CTPA for pulmonary embolism, we oeft n nd fi signs of 6.5. Pulmonary Drug Toxicity. Pulmonary drug toxicity has congestive heart failure recently received increased attention. Once believed to occur only with a few drugs, the list of causative agents is steadily growing. In a 2001 review, already about 150 causative drugs 6.4. The Problem of Overlapping Pathology in COPD/Congest- were mentioned and even more can be found in an internet ive Heart Failure. Beside the difficulty in discriminating age- database (PneumoTox) [38, 39]. The incidence is unclear, related changes from pathology, there is the problem of because systematic studies are lacking [40]. Age is not a clinical overlapping pathology with multimorbidity. With risk factor per se, but as an eeff ct of their multimorbidity, respect to imaging of the lung, the distinction between heart elderly people oen ft take a variety of drugs. So, they are failure and COPD is a major concern. Up to 50% of patients exposed to a wider range of possible causative agents and drug with heart failure have concomitant COPD, and in most interactions (e.g., degradation via similar enzymatic mech- studies the prevalence was around 20%. On the other hand, anisms) which may cause an enhanced pulmonary toxicity about 20% of patients with COPD also have signs of left [40]. If pulmonary drug toxicity is suggested or is a potential heart failure [36]. Heart failure mimics any clinical sign of differential diagnosis, imaging with high resolution chest COPD andviceversa,likecough,breathlessness, andexercise CT should be performed because of its superior sensitivity fatigue. Lung function tests may be misleading, and there is over plain radiography [41]. On imaging, common forms of no established laboratory marker for differentiation between toxic changes are b fi rosing alveolitis (with a pattern oen ft these two diseases. er Th efore, in the case of acute dyspnea, resembling findings in nonspecific interstitial pneumonia), it is aclinicalroutine to order achest X-rayfor further predominantly subpleural consolidations (resembling cryp- differential diagnosis. eTh major problem is that signs of togenic organizing pneumonia or eosinophilic pneumonia), heart failure may be atypical and asymmetric according to and in the more acute setting hypersensitivity reactions with the areas with preserved normal pulmonary structure in imaging ndin fi gs ranging from ground glass opacities and patients with emphysematous lung changes in consequence alveolar consolidations to severe diffuse alveolar damage to COPD.This mayeasilybeconfoundedwithperibronchial indistinguishable from ARDS [38, 40](Figure 7). infiltrations, which are common during exacerbations of Different clusters of drugs according to the radiological COPD. For a systematic differentiation, it is important to look presentation have been proposed [39], but in general, the for signs of COPD rfi st. eTh oretically, two extreme forms of most important point is to consider the possibility of drug- COPD may be constructed: “pure” chronic bronchitis and induced lung disease in the elderly. “pure” emphysema. In clinical practice, as can be seen on CT, a mixture of these components is found in almost all patients with COPD.Thepureforms areshowing distinct 6.6. Incidental Pulmonary Embolism. With the evolution changes in imaging. With “pure chronic bronchitis,” there of multislice CT, incidental PE has been shown to be an is the ndin fi g of a “dirty chest” with increased interstitial incidental ndin fi g in up to 6% of inpatients undergoing lung markings and bronchial wall thickening. With further imaging of the chest with CT [42]. Incidental PE is more disease, progression signs of right heart enlargement and common in patients with known malignancy. Interestingly, pulmonary arterial hypertension can be found. The value in a study by Ritchie et al. [42], an increased prevalence of chest radiography in chronic bronchitis has undergone with age was found. It is known that elderly people have a Radiology Research and Practice 7 Figure 6: Computed tomography in 77-year-old patients showing signs of congestive heart failure with ground glass opacities, smooth thickening of interlobular septae, and bilateral effusions. Figure 7: Drug induces lung changes with the use of amiodarone in an 81-year-old patient. Computed tomography shows the pattern of cryptogenic organizing pneumonia. higher incidence of thromboembolic disease (symptomatic as only benign forms of calcifications are a clear sign of nonma- well as asymptomatic). This may be explained by an elevated lignant nodules, these include complete, central, or popcorn- incidence of risk factors such as malignancy or immobility. In like calcifications. As the chance of malignancy increases with most cases, these incidental PEs are found on the subsegmen- size, this is the major criterium for the need of further assess- tal level. eTh clinical significance of incidental PE is unclear. ment and is central part of current guidelines [47]. Recently, As reviewed by Desai, currently available data suggests that special attention has been paid to the subset of subsolid even without treatment, mortality is not elevated [43]. Some nodules, becauseofthe closecorrelation to thespectrum authors argue that the lung acts as a filter, and the clearance of adenocarcinoma dedicated guidelines by the Fleischner of small emboli is a physiological process [44]. Society have been proposed. If possible, the comparison with older X-ray images is recommended as a large portion of nodules can be detected retrospectively, and a constant size over 2 years indicates benignancy [46]. In daily practice, 6.7. eTh Problem of Pulmonary Nodules. With the develop- small solid nodules are found in the majority of elderly ment of thin-section helical CT, the detection of small nod- patients. In our department, the following strategy is used in ules, especially when using maximum intensity projections, these cases: rfi st we are looking for morphological signs of hasbecomeroutine.Onchest X-ray, pulmonarynodules could be found in about 0.2% of patients [45]. In contrast, benignancy: benignant forms of calcifications, the presence of fat, the configuration of typical intrapulmonary lymph nodes, with multislice CT especially in lung cancer screening studies, the majority of patients showed pulmonary nodules [45]. andcluster-likeappearanceinbronchiolitis with thetypical There is a wide differential diagnosis, and the vast majority “tree-in-bud” pattern. If none of these previously mentioned applies to the nodules, we are using adjusted guidelines of (over 80%) are granulomas or intrapulmonary lymph nodes with another 10% being hamartomas [46]. Morphologically, the Fleischner Society; that is, prolonged follow-up intervals 8 Radiology Research and Practice (minimum 6 months) are recommended in close correlation (viii) Follow-up imaging is usually the appropriate manage- with the clinical state of the patient [47]. It is important ment strategy with pulmonary nodules. to remember that even in patients with known malignancy (ix) If in doubt, look out for existing radiographs for only asmall portionofnodules smallerthan10mmare in comparison. fact metastasis [48]. eTh refore, follow-up imaging is also the method of choice in oncologic elderly patients with small Conflict of Interests pulmonary nodules. eTh authors have no conflict of interests to declare. 6.8. Trauma. The increasing risk of falls with ageing is an everyday topic in geriatric medicine. Ojo et al. studied the References type of injuries with falls in elderly people and found chest injuries in 6.9% of patients [49]. 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Geriatric Chest Imaging: When and How to Image the Elderly Lung, Age-Related Changes, and Common Pathologies

Gossner, J.; Nau, R.
Radiology Research and Practice , Volume 2013 – Jul 1, 2013
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Copyright © 2013 J. Gossner and R. Nau. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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10.1155/2013/584793
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Hindawi Publishing Corporation Radiology Research and Practice Volume 2013, Article ID 584793, 9 pages http://dx.doi.org/10.1155/2013/584793 Review Article Geriatric Chest Imaging: When and How to Image the Elderly Lung, Age-Related Changes, and Common Pathologies 1 2 J. Gossner and R. Nau Department of Clinical Radiology, Go¨ttingen-Weende Hospital, An der Lutter 24, 37074 Gott ¨ ingen, Germany Department of Geriatric Medicine, Go¨ttingen-Weende Hospital, An der Lutter 24, 37074 Gott ¨ ingen, Germany Correspondence should be addressed to J. Gossner; johannesgossner@gmx.de Received 25 April 2013; Accepted 11 June 2013 Academic Editor: Paul Sijens Copyright © 2013 J. Gossner and R. Nau. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Even in a global perspective, societies are getting older. We think that diagnostic lung imaging of older patients requires special knowledge. Imaging strategies have to be adjusted to the needs of frail patients, for example, immobility, impossibility for long breath holds, renal insufficiency, or poor peripheral venous access. Beside conventional radiography, modern multislice computed tomography is the method of choice in lung imaging. It is especially important to separate the process of ageing from the disease itself. Pathologies with a special relevance for the elderly patient are discussed in detail: pneumonia, aspiration pneumonia, congestive heart failure, chronic obstructive pulmonary disease, the problem of overlapping heart failure and chronic obstructive pulmonary disease, pulmonary drug toxicity, incidental pulmonary embolism pulmonary nodules, and thoracic trauma. 1. Introduction patients have to be transferred to the radiology department and may need supervision while waiting. Positioning requires The population in many societies is getting older. eTh United more time, and oen ft patients need assistance. With bedrid- Nations estimate that the number of people older than 65 den patients, more than one person is needed for proper years will increase from 743 million in 2009 to 2 billions in positioning. This need for more time and staff has to be kept 2050.Atthistime, therewillbemorepeopleolder than 65 in mind but is in most cases not reimbursed [4]. The ideal years than children younger than 15 years [1]. In fact, around imaging test for elderly patient is fast and needs few changes 15% of patients treated in German hospitals are already older in positioning. than 80 years [2]. With age, the frequency of multimor- bidity increases. Geriatric medicine uses the term frailty 2.1. Chest Radiography. The standard examination in imaging to describe the process of progredient loss of mental and of the lung is chest radiography with a posterior-anterior and physical performance making the patients more vulnerable a lateral projection. Chest radiography is easy to perform, to further disease [3]. Sometimes it is difficult to separate the cheap, and, according to the ACR Appropriateness Criteria, process of ageing from disease itself. er Th efore, diagnostic in most scenarios the initial test when lung disease is imaging of older patients requires special knowledge. In this suspected [5]. In frail patients, standard projections of the review, aeft r a short description of imaging strategies, ethical chest often cannot be obtained, and a chest radiograph in considerations, and the normal ageing processes of the lung, supine position hastobetaken with well-known limitations. distinct pathologies with a special relevance for the elderly patient are discussed. 2.2. Computed Tomography. In addition to conventional X- ray, the ideal test in more complex cases is computed 2. Imaging Strategies tomography (CT). With modern multislice CT scanners, the In contrast to younger people, handling of elderly patients is lung can be examined in a few seconds. But even with modern different and usually takes more time. In most cases, elderly CT scanners, motion artifacts due to breathing may be a 2 Radiology Research and Practice problem in the elderly. Strategies to reduce these motion iodinated contrast media, nephropathy or manifest hyperthy- artifacts include the caudal start of the scan, where motion roidism scintigraphy is a good alternative. artifacts due to breathing are pronounced, and the use of a higher pitch. If there are still marked motion artifacts 2.5. Magnet Resonance Imaging (MRI). Although recent causing problems with image interpretation, we are adding advances with lung MRI are not used in everyday imaging several axial slices in classical high resolution CT technique of thelung, an exceptionisthe detailedimaging in Pancoast (Figure 1). tumors. If lung imaging with MRI is performed in the elderly, Imaging of the lung parenchyma is possible without a comprehensive examination to avoid excessive examination contrast media, but for imaging of lung vessels with computed timesshouldbeused, forexample,acombinationoffastspin tomographic pulmonary angiography (CTPA) or tumor echo T2-weighted coronal images and diffusion weighted staging, contrast media are mandatory. Elderly patients are images [13]. With poor renal function, the use of contrast at higher risk for contrast medium-induced nephropathy media is also of concern because of possible nephrogenic (CIN). In some cases, renal function is already impaired and systemic fibrosis. A lot of older patients have contraindica- there are other risk factors like diabetes, high blood pressure, tions for MRI like cardiac pace makers or older ferromagnetic heart insufficiency, hypovolemia, and atherosclerosis. Age surgical material. > 75 years is also an independent risk factor for CIN [6]. It has to be considered, however, that only a very small 2.6. A Practical Approach of Lung Imaging in the Elderly. The part of patients with CIN require hemodialysis [6]. The basic examination is chest radiography. If further workup is most important prophylaxis is adequate hydration, which is needed (suspected pulmonary embolism, immunocompro- especially important in elderly patients who oeft n drink too mised patient, consolidation without clinical or laboratory little. eTh incidence of CIN is also related to the amount of signs of inflammation, and mass or complex effusion), a used contrast media [7]. Interestingly, it has been reported chest CT should be performed. A thin collimated scan (1 mm that even thoracic CT scans with 15 mL iodinated contrast slice thickness) in caudocranial direction is recommended. media showed satisfactory diagnostic quality for routine Contrast media should be administered only if necessary. chest scans, for example, in the staging of mediastinal lymph In the followup, the modality should be chosen conidering nodes [8]. CTPA requires optimal opacification of the lung the underlying disease. A possible imaging algorhithm is vessels, and therefore a minimum of 60 mL contrast media provided in Scheme 1. should be used. A high flow rate is usually recommended to obtain a good vascular enhancement. Unfortunately, poor peripheral venous access is common in the elderly and 3. Ethical Considerations sometimes only small bore cannulas can be placed. We have Ethical considerations are important in the care of the elderly. shown that even with low flow rates (2.0 or 2.5 mL/s) and Treating physicians always need to consider if a potential 60 mL of contrast media, sufficient vascular enhancement can diagnosis obtained by imaging may alter treatment. Other- be obtained [9]. Another strategy to minimize the dose of wise, the test should not be done. Even in cases where an exact contrast media is the use of low kV settings [10]. diagnosis, for example, staging in a malignant disease, may help to plan further optimal treatment, it has to be accepted 2.3. Transthoracic Ultrasound. Transthoracic ultrasound may that patients may refuse imaging and insist on palliation only oer ff additional information to conventional chest radiogra- towards the end of their life. In particular, elderly patients phy [11]. In the frail patient, it is easy to use bedside test. should not feel to be obliged to agree with further diagnostics In the case of pleural effusion, it is more sensitive than [14]. radiography (especially compared to supine radiographs) and adds further information about the composition of the 4. Changes of the Lungs with Ageing pleural u fl id [ 11]. For example, it may show septations, a major cause for insufficient drainage aer ft pleural tube placement. With ageing, an enlargement of the distal airspaces due to the With transthoracic ultrasound, further information about loss of supporting tissue can be found, a condition for which congestive heart failure, pneumothorax, or pleura-based the terms “senile lung,” “senile hyperinflation,” or “senile consolidations can be obtained [11]. emphysema” have been proposed [15, 16](Figure 2). Histologically, a homogeneous dilatation of the airspaces 2.4. Nuclear Medicine. Ventilation-perfusion scintigraphy without signs of inflammation, fibrosis, or other architectural hasbeenreplacedinthe imagingofacute pulmonary distortions can be seen [15]. As a result, signs of hyperinfla- embolism (PE) by CTPA in most departments. In elderly tion can be seen on conventional chest radiography [17]. In patients, prevalence of existing lung disease and therefore a recent study, there were more elderly asymptomatic adults abnormal chest X-ray is relatively high, and therefore in this (age> 75 years) with centrilobular emphysematous changes patient group, the sensitivity for scintigraphy in diagnosing in CT imaging compared to a younger control group (age< 55 PE is impaired [12]. In the elderly patient, CT scanning should years) [18]. In thesamestudy,interstitialchanges of thelung be the preferred test, especially as in a substantial number of with a subpleural reticular pattern could be found in 60% patients, diagnosis other than PE can be found (pneumonia, of the elderly patients. Bronchial wall thickening was shown congestive heart failure). In patients with known allergy to in 50%. In another study, 25% of the elderly asymptomatic Radiology Research and Practice 3 Figure 1: Motion artifacts due to breathing in an elderly patient impairing interpretation of the interstitial changes. An additional scan with the use of a standard high resolution technique is substantially improving diagnostic performance. Further imaging Normal If PE suspected −→ CTPA/scintigraphy If patient immunocompromised −→ CT Chest radiography Suspected lung disease (p.a./lateral view) Consolidation - Repeat X-ray to ensure resolution - Persistent consolidation or consolidation without signs of inflammation −→ CT Abnormal Heart failure Monitoring with ultrasound Effusion Monitoring with ultrasound complex effusion −→ ultrasound/CT Interstitial lung disease −→ CT Solitary pulmonary nodule Look for older radiographs for comparison/if unavailable or new/ enlarged nodule −→ CT Suspected malignancy −→ CT Scheme 1 patients showed small cysts [17]. Lee et al. showed an 5. Borderlands of the Normal: Possible increased air trapping with age [19]. The frequent finding Problems in Differentiation between of small basal atelectasis in asymptomatic elderly patients Age-Related Changes and Pathology has been reported [20]. Further morphological changes with ageing are progressive calcifications of the airways and the rib As described previously, it has been shown that emphysema- cage [15, 16, 20](Figure 3). tous changes and basal b fi rotic changes are a common nding fi Like other muscles, there is a loss of diaphragmatic in elderly patients, especially on CT. There are no normative muscle mass [16], but in an older CT study, no measurable values described in the literature, but age-related changes decrease in muscle thickness of the diaphragm could be are usually described to be moderate. So, it is obvious that found [21]. eTh reduced mass of other thoracic muscles has differentiation may be difficult to early changes in chronic been described but has not been studied in detail [20]. obstructive lung disease or interstitial lung disease. 4 Radiology Research and Practice Figure 2: Senile emphysema in an 88-year-old patient. Chest X-ray (on the left) and centrilobular emphysematous changes on computed tomography (on the right). Imaging was ordered because of suspected mesenterial ischemia. butmay be duetocongestiveheart failureorinfection. Correlation with preexisting imaging should be performed to assess disease progression. Stehend The finding of senile emphysema is usually not accompa- nied by the clinical ndin fi gs of chronic obstructive pulmonary diseaselikecough andsputumproduction. In some cases, dieff rentiation may be not possible and follow-up imaging is needed. 6. Pathologies with a Special Relevance in the Geriatric Population 6.1. Pneumonia. Pneumonia still is one of the leading causes of death from infection and is most commonly at the extreme of ages, that is, in the very young and in the elderly population [22]. In elderly patients, the immune system is oen ft com- promised. Beside an age-related decrease in immune activity, there are medications altering immune function. For exam- ple, long-term use of systemic corticosteroids in rheumatic Figure 3: Extensive calcifications of the cartilaginous parts of the ribcageinan85-year-old patient(suspectedfracture). disease significantly increases the risk of severe pneumonias with need for hospitalization [23]. Clinically, pneumonia can be divided into typical or atypical presentation, and in accordance to history in community acquired, nosocomial or For example, the finding of a moderate basal lung fibrosis infections in the immunocompromised. eTh most important may be due to age-related changes or findings of interstitial imaging tool is conventional chest radiography. The role lung disease (usual interstitial pneumonia (UIP) or non- of radiography is to detect or rule out infiltrates, to show specific interstitial pneumonia (NSIP)), which can be found the extent of disease and possible complications, and to along with autoimmune disease or idiopathic interstitial show response to treatment [24]. If pneumonia is suspected lung disease. A differentiation is important as the latter in an immunocompromised patient, a negative X-ray is two need specific treatment in opposition to age-related not adequate to rule out infection and a CT should be changes. eTh refore, close correlation between the morpho- advocated. Complications like empyema or abscesses are logical extent of the fibrotic changes, clinical history (i.e., shown superiorly by CT [24]. There is a considerable overlap known autoimmune disease), and observation of associated in the radiological morphology due to different pathogenic changesiscrucial.Extensive changesaswellasmarked agents, so the morphological type of pneumonia is only a honeycombing or traction bronchiectasis are unlikely to be weak indicator of certain pathogens [25]. But in synopsis only age-related associated signs like ground glass opacities with clinical history and findings, chest X-ray will restrict which have not been reported with age-related changes the spectrum of possible pathogens and guide the calculated Radiology Research and Practice 5 use of antibiotics. It has to be stressed that without clinical information, the differentiation between infectious infiltrates and other consolidating lung processes like cryptogenic orga- nizing pneumonia is not possible [24]. If there are persistent infiltrations, bronchioalveolar carcinoma, now known as lepidic type of adenocarcinoma, should be included in the differential diagnosis. Clearance of pneumonic infiltration in the elderly takes usually more time. It has been shown that 15% of elderly patients still showed radiographic abnormali- ties beyond 3 months. Delayed clearance could be correlated to existing comorbidity [26]. We recommend a minimum interval of 3 months for the follow-up X-ray to to rule out preceeding malignant changes. Attention should be paid to the reactivation of tuberculosis. Many elderly patients are showing posttuberculotic changes on imaging. In reactivated pulmonary tuberculosis, patchy consolidations in the upper Figure 4: Consolidation in the right lower lobe due to aspiration lobes or the superior segments of the lower lobes are the most in an 85-year-old patient (aspiration was confirmed using u fl o- common finding. Cavitations with a predilection in the upper roscopy). lung zones can be found in up to 45% of patients [27]. 6.2. Aspiration Pneumonia. Oropharyngeal contents or gas- tric acid which is misdirected to the lower airways can cause severe inflammation. In addition to the chemical pneumonitis pathogens from the oral flora, reaching the lower respiratory tract may cause difficult-to-treat bacterial pneumonia [28]. It has been shown that even healthy elderly people are swallowing more slowly than younger persons and the cough reflex is impaired. This may lead to pharyngeal colonisation with pathogenic bacteria [29, 30]. Aspiration of small amounts is common during sleep even in healthy young adults [31]. In conclusion to this, it seems that the amount of aspiration and/or colonization of the pharynx or gastric content by bacteria is important. It should be kept in mind that proton pump inhibitors and H antagonists causeanincreaseingastric pH whichsupportsbacterial colonisation of the stomach. In everyday practice, the major cause of dysphagia is stroke and Parkinson’s syndrome [28]. In a study by Nakagawa et al. [32], in the followup aeft r stroke, 24% of patients with dysphagia developed pneumonia within one year. In contrast, none of the stroke patients Figure 5: Spot view from a uo fl roscopic examination in a 76-year- without dysphagia developed pneumonia. Radiologically, old patient aer ft stroke showing aspiration. recurrently found infiltrates involving the right lower lobe or the upper lobes in elderly patients should raise the suspicion of aspiration pneumonia (Figure 4). If aspiration is suspected, we perform a fluoroscopic this problem, butithas to be kept in mind that jejunaltubes swallowing study with the use of barium in dieff rent formed areeasilycongested making theclinicalhandlingofthese boluses (thick liquids, semithick liquids, semisolid food, or patients problematic. At last, the side effects of medications solid food). This may guide dietary modifications, which are should be remembered. Neuroleptics may cause dyskinesia the most common management approach [28]. A commonly of the muscles needed for swallowing with consecutive found phenomenon in elderly patients is laryngeal penetra- aspiration. In one study, the use of neuroleptic medication tion, which means that small amounts of contrast media are was associated with a higher risk of aspiration pneumonia entering the larynx. Only if the barium passes, the glottis [33]. aspiration can be diagnosed (Figure 5). Another problem to be kept in mind is reflux in patients with percutaneous gastroenterostomy feeding tubes. In these 6.3. Lung Changes with Congestive Heart Failure. Cardiac patients, reflux may ultimately lead to aspiration. eTh diag- disease, especially left heart failure, is a major differential nostic approach of choice is also fluoroscopy. eTh change to diagnosis for dyspnea in the elderly. With pulmonary venous, a jejunal position of the tip of the feeding tube can solve hypertension hydrostatic edema of the lungs occurs with a 6 Radiology Research and Practice well-known appearance on conventional chest X-ray: cra- considerable debate, but most authors state that the n fi dings nialization of the pulmonary blood flow, increased vascular of a “dirty chest” are insensitive and have the problem and interstitial markings with Kerley B lines, peribronchial of low reproducibility and interobserver variability [37]. cun ffi g, heart enlargement, and pleural effusions. With pro- The imaging of emphysema with chest radiography has gression, alveolar edema occurs which in most cases can undergone less debate, because the signs of hyperinflation be differentiated from edema of noncardiogenic causes, like of thelungs areobvious andobjective measurements can renal edema or capillary permeability edema (e.g., ARDS) be made [37]. The lateral view is of special importance, and [34]. From our experience, the diagnosis of early stages of it shows widening of the retrosternal space (>2.5 cm) and congestive heart failure may be complicated by concomitant the flattening of the diaphragm (the angle between the chest b fi rotic changes. Correlation with already existing images or wall and diaphragm is becoming larger than 90 degrees). If serial imagingwillhelptosolve this problem. In patients with hyperinflation is found, atypical forms of pulmonary edema emphysema due to chronic obstructive pulmonary disease should be expected and kept in mind. Patients with initial (COPD) the distribution relies on the remaining intact emphysematous changes or senile emphysematous changes parenchyma, so atypical ndings fi are common. Pulmonary are normally not showing signs of significant hyperinflation edema in the right upper lobe can occur in patients with on conventional X-ray. Our observations suggest that the severe mitral regurgitation. Pulmonary venous hypertension destruction of normal pulmonary vascularity in these early has typical features on CT imaging (enlargement of the upper stages is not marked enough to show noticeable asymmetric lobe pulmonary vessels, thickening of the bronchial walls, edematous changes with congestive heart failure. Because diffuse smooth thickening of the interlobular septae, and of the flattened costophrenic angles and scarring changes, ground glass opacities accompanied by effusions and heart ultrasound is oeft n needed to make the diagnosis of small enlargement, Figure 6)[35]. pleural effusion in patients with emphysema. In particular, in elderly patients with dyspnea undergoing CTPA for pulmonary embolism, we oeft n nd fi signs of 6.5. Pulmonary Drug Toxicity. Pulmonary drug toxicity has congestive heart failure recently received increased attention. Once believed to occur only with a few drugs, the list of causative agents is steadily growing. In a 2001 review, already about 150 causative drugs 6.4. The Problem of Overlapping Pathology in COPD/Congest- were mentioned and even more can be found in an internet ive Heart Failure. Beside the difficulty in discriminating age- database (PneumoTox) [38, 39]. The incidence is unclear, related changes from pathology, there is the problem of because systematic studies are lacking [40]. Age is not a clinical overlapping pathology with multimorbidity. With risk factor per se, but as an eeff ct of their multimorbidity, respect to imaging of the lung, the distinction between heart elderly people oen ft take a variety of drugs. So, they are failure and COPD is a major concern. Up to 50% of patients exposed to a wider range of possible causative agents and drug with heart failure have concomitant COPD, and in most interactions (e.g., degradation via similar enzymatic mech- studies the prevalence was around 20%. On the other hand, anisms) which may cause an enhanced pulmonary toxicity about 20% of patients with COPD also have signs of left [40]. If pulmonary drug toxicity is suggested or is a potential heart failure [36]. Heart failure mimics any clinical sign of differential diagnosis, imaging with high resolution chest COPD andviceversa,likecough,breathlessness, andexercise CT should be performed because of its superior sensitivity fatigue. Lung function tests may be misleading, and there is over plain radiography [41]. On imaging, common forms of no established laboratory marker for differentiation between toxic changes are b fi rosing alveolitis (with a pattern oen ft these two diseases. er Th efore, in the case of acute dyspnea, resembling findings in nonspecific interstitial pneumonia), it is aclinicalroutine to order achest X-rayfor further predominantly subpleural consolidations (resembling cryp- differential diagnosis. eTh major problem is that signs of togenic organizing pneumonia or eosinophilic pneumonia), heart failure may be atypical and asymmetric according to and in the more acute setting hypersensitivity reactions with the areas with preserved normal pulmonary structure in imaging ndin fi gs ranging from ground glass opacities and patients with emphysematous lung changes in consequence alveolar consolidations to severe diffuse alveolar damage to COPD.This mayeasilybeconfoundedwithperibronchial indistinguishable from ARDS [38, 40](Figure 7). infiltrations, which are common during exacerbations of Different clusters of drugs according to the radiological COPD. For a systematic differentiation, it is important to look presentation have been proposed [39], but in general, the for signs of COPD rfi st. eTh oretically, two extreme forms of most important point is to consider the possibility of drug- COPD may be constructed: “pure” chronic bronchitis and induced lung disease in the elderly. “pure” emphysema. In clinical practice, as can be seen on CT, a mixture of these components is found in almost all patients with COPD.Thepureforms areshowing distinct 6.6. Incidental Pulmonary Embolism. With the evolution changes in imaging. With “pure chronic bronchitis,” there of multislice CT, incidental PE has been shown to be an is the ndin fi g of a “dirty chest” with increased interstitial incidental ndin fi g in up to 6% of inpatients undergoing lung markings and bronchial wall thickening. With further imaging of the chest with CT [42]. Incidental PE is more disease, progression signs of right heart enlargement and common in patients with known malignancy. Interestingly, pulmonary arterial hypertension can be found. The value in a study by Ritchie et al. [42], an increased prevalence of chest radiography in chronic bronchitis has undergone with age was found. It is known that elderly people have a Radiology Research and Practice 7 Figure 6: Computed tomography in 77-year-old patients showing signs of congestive heart failure with ground glass opacities, smooth thickening of interlobular septae, and bilateral effusions. Figure 7: Drug induces lung changes with the use of amiodarone in an 81-year-old patient. Computed tomography shows the pattern of cryptogenic organizing pneumonia. higher incidence of thromboembolic disease (symptomatic as only benign forms of calcifications are a clear sign of nonma- well as asymptomatic). This may be explained by an elevated lignant nodules, these include complete, central, or popcorn- incidence of risk factors such as malignancy or immobility. In like calcifications. As the chance of malignancy increases with most cases, these incidental PEs are found on the subsegmen- size, this is the major criterium for the need of further assess- tal level. eTh clinical significance of incidental PE is unclear. ment and is central part of current guidelines [47]. Recently, As reviewed by Desai, currently available data suggests that special attention has been paid to the subset of subsolid even without treatment, mortality is not elevated [43]. Some nodules, becauseofthe closecorrelation to thespectrum authors argue that the lung acts as a filter, and the clearance of adenocarcinoma dedicated guidelines by the Fleischner of small emboli is a physiological process [44]. Society have been proposed. If possible, the comparison with older X-ray images is recommended as a large portion of nodules can be detected retrospectively, and a constant size over 2 years indicates benignancy [46]. In daily practice, 6.7. eTh Problem of Pulmonary Nodules. With the develop- small solid nodules are found in the majority of elderly ment of thin-section helical CT, the detection of small nod- patients. In our department, the following strategy is used in ules, especially when using maximum intensity projections, these cases: rfi st we are looking for morphological signs of hasbecomeroutine.Onchest X-ray, pulmonarynodules could be found in about 0.2% of patients [45]. In contrast, benignancy: benignant forms of calcifications, the presence of fat, the configuration of typical intrapulmonary lymph nodes, with multislice CT especially in lung cancer screening studies, the majority of patients showed pulmonary nodules [45]. andcluster-likeappearanceinbronchiolitis with thetypical There is a wide differential diagnosis, and the vast majority “tree-in-bud” pattern. If none of these previously mentioned applies to the nodules, we are using adjusted guidelines of (over 80%) are granulomas or intrapulmonary lymph nodes with another 10% being hamartomas [46]. Morphologically, the Fleischner Society; that is, prolonged follow-up intervals 8 Radiology Research and Practice (minimum 6 months) are recommended in close correlation (viii) Follow-up imaging is usually the appropriate manage- with the clinical state of the patient [47]. It is important ment strategy with pulmonary nodules. to remember that even in patients with known malignancy (ix) If in doubt, look out for existing radiographs for only asmall portionofnodules smallerthan10mmare in comparison. fact metastasis [48]. eTh refore, follow-up imaging is also the method of choice in oncologic elderly patients with small Conflict of Interests pulmonary nodules. eTh authors have no conflict of interests to declare. 6.8. Trauma. The increasing risk of falls with ageing is an everyday topic in geriatric medicine. Ojo et al. studied the References type of injuries with falls in elderly people and found chest injuries in 6.9% of patients [49]. 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