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The chest and aging: radiological findings

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Jornal Brasileiro de Pneumologia - The chest and aging: radiological findings

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English Portuguese. Register your email below and receive our newsletter with news. Continuous and bimonthly publication ISSN on-line : As a result, the greatest challenge is to differentiate between the normal aging process and the onset of disease. Healthy elderly people commonly present borderline findings on chest imaging.

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English Portuguese. Register your email below and receive our newsletter with news. Continuous and bimonthly publication ISSN on-line : As a result, the greatest challenge is to differentiate between the normal aging process and the onset of disease. Healthy elderly people commonly present borderline findings on chest imaging. We systematically reviewed the medical literature on the subject, covering the period between and , including articles in Portuguese, English, French, Italian, and Spanish.

We searched the PubMed, LILACS, and SciELO databases, using the search terms "age", "aging", "lung", "thorax", "chest", "X-ray", "radiography", "pulmonary", and "computed tomography"-as well as their corresponding translations-in various combinations. We included only original or review articles on aging-related chest imaging findings.

In broad terms, aging results in physiological modifications that must be recognized so as not to be erroneously interpreted as pathological. Keywords: Aging; Thorax; Lung; Diagnostic imaging. Como resultado, o principal problema consiste em diferenciar o ponto em que o envelhecimento é normal daquele no qual a doença começa.

Revisamos sistematicamente a literatura médica sobre o assunto, abrangendo o período entre e , incluindo artigos em português, inglês, francês, italiano e espanhol. A busca foi feita através das bases de dados PubMed, LILACS e SciELO, utilizando os seguintes termos: age, aging, lung, thorax, chest, X-ray, radiography, pulmonary, computed tomography e suas traduções correspondentes, em combinações variadas.

Development by:. Home Previous Issue Summary Vol. Introduction With increasing frequency, imaging tests are performed in elderly patients; this is due to a progressive increase in life expectancy, which in turn is due to improved living conditions and medical advances.

This is due to the numerous anatomical and physiological changes that occur during the aging process. In clinical practice, the challenge is to determine the extent to which the changes found in elderly individuals are due to the aging process. We conducted a systematic review of the medical literature on the subject, covering the period between and and including articles in Portuguese, English, French, Italian, and Spanish.

We search the PubMed, LILACS, and SciELO databases for relevant references, using the search terms "age", "aging", "lung", "thorax", "chest", "X-ray", "radiography", "pulmonary", and "computed tomography"-as well as their corresponding translations-in various combinations.

In addition, review articles on the subject were hand searched for articles for inclusion in the present review, as were the references in all of the articles that were considered relevant. We included original or review articles on aging-related chest imaging findings. We found articles. Of those, 12 were selected by reading the abstract.

In addition to the articles on aging-related chest imaging findings, we included 39 articles on clinical, pathological, and functional aspects in order to underpin the discussion. The imaging findings were didactically divided into three major groups: findings in the chest wall; findings in the mediastinum; and findings in the lung parenchyma. Aging-related changes in radiological findings in the chest wall One of the most common imaging findings in the aging chest wall is a reduction in the thickness of the parietal muscles, particularly when compared with that of those in younger individuals, a change that can be easily seen on CT scans Figure 1.

This reduction is one of the major causes of increased pulmonary transparency on chest X-rays in the elderly. Although no studies have established the age at which this finding is first seen, this is known to be due to aging-related muscle mass loss, becoming more pronounced with age.

Another common finding is costal cartilage calcification, which is seen as small islands of compact bone tissue or as nodules, being mistaken for solitary pulmonary nodules in some cases. The main changes are osteoporosis and spondylosis. The term spondylosis refers to degenerative changes of the spinal column, including reduced intervertebral space, bone sclerosis adjacent to the intervertebral discs, and marginal vertebral osteophytes. In general, vertebral osteophytes are more commonly seen on the right side of the spinal column, which is due to the presence of the descending aorta on the left side.

The association of pronounced dorsal kyphosis with a more convex sternum contributes to the so-called "barrel chest" deformity, a phenotypic configuration of the chest in elderly individuals.

When combined, these parietal changes cause stiffening of the chest wall, having an unfavorable impact on respiratory mechanics. The differential diagnosis should be made primarily with COPD. The diagnosis of COPD should be based on other findings, such as pulmonary emphysema, bronchial wall thickening, and bronchiectasis. However, the individual roles of age and COPD in barrel chest cannot be determined by imaging tests.

Common imaging findings in the elderly include diaphragmatic bulging due to muscle hypertrophy and dyskinesia in some areas, particularly on the right side, probably caused by the effort of the hemidiaphragm to maintain the anatomical relationship between the lung and the liver. This select group of individuals is characterized by the exclusive presence of primary findings of cardiac aging, i. In most cases, the signs of right heart overload are due to increased pulmonary capillary resistance as occurs in COPD and mitral valve dysfunction and generally have a pathological basis; in contrast, the signs of left heart overload left ventricular hypertrophy are exclusively associated with cardiac aging in some cases.

In most patients, parietal calcifications of the aorta are most commonly seen in the aortic arch and in the descending portion of the aorta, constituting nonspecific radiological findings. However, in elderly individuals, calcification of the thoracic aorta, heart valves, and coronary arteries indicates a higher risk of cardiovascular diseases. The maximum number of alveoli is reached at approximately years of age, and maturation of the respiratory system occurs at approximately 20 years of age in females and at approximately 25 years of age in males.

The two components of the elastic properties of the lung are surface and tissue forces. No changes in the quality or quantity of alveolar surfactant have been described, and there is no evidence of changes in type II pneumocyte function. Chest wall compliance decreases with age, which is principally due to musculoskeletal limitations, such as vertebral fractures, spondylosis, and progressive loss of respiratory muscle strength.

However, biochemical studies have suggested that the total collagen and elastin content of the lung does not change with age. The most widely accepted hypothesis is that lung elastic recoil is lost because of changes in the spatial arrangement of the network of collagen fibers or because of a protein known as pseudoelastin.

Enlarged terminal air spaces have also been reported, having been characterized as a relatively homogeneous destruction, with few cellular infiltrates in the alveoli, suggesting that, unlike what occurs in emphysema, air space enlargement was not due to inflammation of the lung parenchyma. After the fourth decade of life, part of the elastic fibers in the respiratory bronchioles and alveoli degenerate, their complacency therefore decreasing.

Consequently, there is alveolar duct dilatation, followed by air space enlargement. Morphometric studies have shown a progressive increase in the average distance between air space walls, as well as a decrease in the surface area of air space wall per unit of lung volume. The initial pathophysiological consequence of these changes is air trapping due distal airway closure, with a progressive increase in RV. This mechanism is analogous to that of pulmonary emphysema, with no signs of inflammation and no significant increase in TLC.

Therefore, TLC remains constant throughout life. This premature closure begins to exceed functional residual capacity at age 44 years and exceeds it at age 65 years, 45 being closely related to the loss of supporting tissues around the airways.

These findings are laminar atelectasis, mostly posterior and basal, located in the dependent regions of the lungs Figure 5 ; subpleural linear thickening Figure 6 ; areas of air trapping Figure 7 ; bronchial thickening and ectasia Figure 8 ; and lung cysts. Monitoring these lesions is often necessary, and comparison with previous tests is indispensable. Likewise, correlation with pulmonary function test results particularly DLCO can demonstrate how gas exchange is occurring and guide a conservative approach.

Another fact that should be taken into consideration in the elderly is life expectancy and the metabolic need for gas exchange, given that patients whose activity is limited by extrathoracic disease have lower physiological needs. This brings us to the well-known Hippocratic principle of primum non nocere above all, do no harm , which is increasingly true today, given the various choices of procedures and the increase in survival of the population.

References 1. Aging and the respiratory system. Radiol Clin North Am. Epidemiologia dell'invecchiamento. Radiologia geriatrica. Milano: Springer; Radiology of normal chest structures in the elderly patient [Article in Italian]. Radiol Med. Barreto SM. J Pneumol.

Normal values for handgrip strength in men and women aged over 65 years, and longitudinal changes over 4 years in survivors. Clin Sci Lond. Carmeli E, Reznick AZ. The physiology and biochemistry of skeletal muscle atrophy as a function of age. Proc Soc Exp Biol Med. CT quantification of emphysema in young subjects with no recognizable chest disease.

Effect of aging on human skeletal muscle and motor function. Med Sci Sports Exerc. M Strength and muscle quality in a well-functioning cohort of older adults: the Health, Aging and Body Composition Study.

J Am Geriatr Soc. Bernadac P. Le poumon du troisième age. Respiratory function in the aged. Bull Physiopathol Respir Nancy. Zeleznik J. Normative aging of the respiratory system. Clin Geriatr Med.

PMid PMCid Chest X-ray and computed tomography in the evaluation of pulmonary emphysema. J Bras Pneumol. Age-induced changes in the cardiovascular system in normal subjects [Article in Italian].

G Ital Cardiol. Midiri M. Thoracic examination in cardiac aging [Article in Italian]. Feasibility of diastolic function assessment with cardiac CT: feasibility study in comparison with tissue Doppler imaging.

Diastolic heart failure.

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