Pulmonary Interstitial Emphysema (PIE) Workup

  • Author: Abhay J Bhatt, MD, MBBS; Chief Editor: Ted Rosenkrantz, MD   more...
 
Updated: Jun 8, 2011
 

Approach Considerations

Pulmonary interstitial emphysema (PIE) is a radiographic and pathologic diagnosis.

In addition, blood gases should be obtained in these patients, to ensure adequate gas exchange.

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Radiography

The classic radiologic appearance of pulmonary interstitial emphysema often provides a clear diagnosis. Pulmonary interstitial emphysema is best visualized in the anteroposterior supine projection. Pulmonary interstitial emphysema has two basic radiographic appearances, linear and cystlike radiolucencies, although both types often appear together.

Linear radiolucencies are coarse and nonbranching, measure from 3-8 mm, and vary in width but rarely exceed 2 mm. Cystlike radiolucencies are small, ranging from 1-4 mm in diameter. Although generally round, they may also appear oval or slightly lobulated.

The disorganized haphazard distribution of pulmonary interstitial emphysema in localized areas is unlike the anatomically organized pattern of the air-bronchogram. The air-bronchogram is a classic radiographic sign of respiratory distress syndrome (RDS), which should not be confused with pulmonary interstitial emphysema.

In RDS, long, smooth, branching, linear radiolucencies decrease in caliber from the hilum and frequently disappear at the lung periphery. Pulmonary interstitial emphysema should be suspected when coarse radiolucencies appear in the lung periphery or when the lucencies do not branch in a pattern consistent with the normal bronchial tree.

In some patients receiving mechanical ventilation, distended airways and alveoli have a somewhat similar radiographic appearance to that of pulmonary interstitial emphysema. Over time, it either progresses to a classic radiographic picture of pulmonary interstitial emphysema or resolves very rapidly as ventilator settings are decreased.

Pulmonary interstitial emphysema can rarely be misinterpreted as normally aerated lung surrounded by exudate as in an aspiration syndrome or pulmonary edema.[15]

This radiograph, obtained from a 1-day-old prematuThis radiograph, obtained from a 1-day-old premature infant at 24 weeks' gestation, shows bilateral pulmonary interstitial emphysema (PIE). Linear radiolucencies extending up to the lung periphery are visible. This radiograph, obtained from a premature infant This radiograph, obtained from a premature infant at 26 weeks' gestation, shows characteristic radiographic changes of pulmonary interstitial emphysema (PIE) of the right lung. This radiograph shows pneumothorax and pulmonary iThis radiograph shows pneumothorax and pulmonary interstitial emphysema (PIE) on the right side. Interstitial air prevents collapse of the underlying lung by a tension pneumothorax. In such cases, extreme caution is required during drainage of a pneumothorax to avoid perforation of the underlying lung.

Go to Imaging in Pulmonary Interstitial Emphysema for complete information on this topic.

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Histologic Findings

The histology of pulmonary interstitial emphysema is well described by Plenat et al.[1] The histology demonstrates interstitial slits preferentially located in perivenous topography.

Sometimes, the peribronchial arterial or arteriolar sheaths are involved. Air dissects through a plane just next to the arterial or arteriolar face, opposite the bronchus, which is pushed into adjoining parenchyma. The bronchoarterial solidarity most often is respected.

Seldom, air can dissect arterioles and bronchioles and isolate them from the adjacent lobules. On the periphery of interstitial slits, the small vessels are compressed but never ruptured, whereas the collagen fibers are constantly broken and squeezed together.

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Contributor Information and Disclosures
Author

Abhay J Bhatt, MD, MBBS  Associate Professor, Department of Pediatrics, Division of Newborn Medicine, University of Mississippi Medical Center

Abhay J Bhatt, MD, MBBS is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Coauthor(s)

Rita M Ryan, MD  Professor of Pediatrics, Chief, Division of Neonatology, Director, Neonatal-Perinatal Medicine Fellowship Program, University of Buffalo State University of New York School of Medicine and Biomedical Sciences, Women's and Children's Hospital of Buffalo

Rita M Ryan, MD is a member of the following medical societies: American Academy of Pediatrics, American Thoracic Society, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Brian S Carter, MD, FAAP  Professor of Pediatrics (Neonatology), Vanderbilt University School of Medicine; Director, Neonatal Follow-up Program, Monroe Carell Jr Children's Hospital at Vanderbilt

Brian S Carter, MD, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Hospice and Palliative Medicine, American Academy of Pediatrics, American Society for Bioethics and Humanities, American Society of Law, Medicine & Ethics, National Hospice and Palliative Care Organization, Society for Pediatric Research, and Southern Society for Pediatric Research

Disclosure: Nothing to disclose.

Chief Editor

Ted Rosenkrantz, MD  Professor, Departments of Pediatrics and Obstetrics/Gynecology, Division of Neonatal-Perinatal Medicine, University of Connecticut School of Medicine

Ted Rosenkrantz, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Pediatric Society, Connecticut State Medical Society, Eastern Society for Pediatric Research, and Society for Pediatric Research

Disclosure: Nothing to disclose.

References

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This radiograph, obtained from a 1-day-old premature infant at 24 weeks' gestation, shows bilateral pulmonary interstitial emphysema (PIE). Linear radiolucencies extending up to the lung periphery are visible.
This radiograph, obtained from a premature infant at 26 weeks' gestation, shows characteristic radiographic changes of pulmonary interstitial emphysema (PIE) of the right lung.
This radiograph shows pneumothorax and pulmonary interstitial emphysema (PIE) on the right side. Interstitial air prevents collapse of the underlying lung by a tension pneumothorax. In such cases, extreme caution is required during drainage of a pneumothorax to avoid perforation of the underlying lung.
 
 
 
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