AC Portal
Document Navigator

Diffuse Lung Disease

Variant: 1   Suspected diffuse lung disease. Initial Imaging.
Procedure Appropriateness Category Relative Radiation Level
Radiography chest Usually Appropriate ☢
CT chest without IV contrast Usually Appropriate ☢☢☢
CT chest with IV contrast May Be Appropriate ☢☢☢
MRI chest without and with IV contrast Usually Not Appropriate O
MRI chest without IV contrast Usually Not Appropriate O
CT chest without and with IV contrast Usually Not Appropriate ☢☢☢
FDG-PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢☢

Variant: 2   Confirmed diffuse lung disease. Suspected acute exacerbation or acute deterioration. Initial Imaging.
Procedure Appropriateness Category Relative Radiation Level
Radiography chest Usually Appropriate ☢
CT chest without IV contrast Usually Appropriate ☢☢☢
CT chest with IV contrast May Be Appropriate ☢☢☢
MRI chest without and with IV contrast Usually Not Appropriate O
MRI chest without IV contrast Usually Not Appropriate O
CT chest without and with IV contrast Usually Not Appropriate ☢☢☢
FDG-PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢☢

Variant: 3   Confirmed diffuse lung disease without acute clinical deterioration. Routine follow-up imaging clinically indicated.
Procedure Appropriateness Category Relative Radiation Level
CT chest without IV contrast Usually Appropriate ☢☢☢
Radiography chest May Be Appropriate (Disagreement) ☢
CT chest with IV contrast May Be Appropriate ☢☢☢
MRI chest without and with IV contrast Usually Not Appropriate O
MRI chest without IV contrast Usually Not Appropriate O
CT chest without and with IV contrast Usually Not Appropriate ☢☢☢
FDG-PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢☢

Panel Members
Stephen B. Hobbs, MDa; Jonathan H. Chung, MDb; Christopher M. Walker, MDc; Tami J. Bang, MDd; Brett W. Carter, MDe; Jared D. Christensen, MD, MBAf; Sonye K. Danoff, MD, PhDg; Asha Kandathil, MDh; Rachna Madan, MBBSi; William H. Moore, MDj; Sachin D. Shah, MDk; Jeffrey P. Kanne, MDl.
Summary of Literature Review
Introduction/Background
Special Imaging Considerations
Initial Imaging Definition

Initial imaging is defined as imaging at the beginning of the care episode for the medical condition defined by the variant. More than one procedure can be considered usually appropriate in the initial imaging evaluation when:

  • There are procedures that are equivalent alternatives (i.e., only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care)

OR

  • There are complementary procedures (i.e., more than one procedure is ordered as a set or simultaneously wherein each procedure provides unique clinical information to effectively manage the patient’s care).
Discussion of Procedures by Variant
Variant 1: Suspected diffuse lung disease. Initial Imaging.
Variant 1: Suspected diffuse lung disease. Initial Imaging.
A. CT Chest
Variant 1: Suspected diffuse lung disease. Initial Imaging.
B. FDG-PET/CT Skull Base to Mid-Thigh
Variant 1: Suspected diffuse lung disease. Initial Imaging.
C. MRI Chest
Variant 1: Suspected diffuse lung disease. Initial Imaging.
D. Radiography Chest
Variant 2: Confirmed diffuse lung disease. Suspected acute exacerbation or acute deterioration. Initial Imaging.
Variant 2: Confirmed diffuse lung disease. Suspected acute exacerbation or acute deterioration. Initial Imaging.
A. CT Chest
Variant 2: Confirmed diffuse lung disease. Suspected acute exacerbation or acute deterioration. Initial Imaging.
B. FDG-PET/CT Skull Base to Mid-Thigh
Variant 2: Confirmed diffuse lung disease. Suspected acute exacerbation or acute deterioration. Initial Imaging.
C. MRI Chest
Variant 2: Confirmed diffuse lung disease. Suspected acute exacerbation or acute deterioration. Initial Imaging.
D. Radiography Chest
Variant 3: Confirmed diffuse lung disease without acute clinical deterioration. Routine follow-up imaging clinically indicated.
Variant 3: Confirmed diffuse lung disease without acute clinical deterioration. Routine follow-up imaging clinically indicated.
A. CT Chest
Variant 3: Confirmed diffuse lung disease without acute clinical deterioration. Routine follow-up imaging clinically indicated.
B. FDG-PET/CT Skull Base to Mid-Thigh
Variant 3: Confirmed diffuse lung disease without acute clinical deterioration. Routine follow-up imaging clinically indicated.
C. MRI Chest
Variant 3: Confirmed diffuse lung disease without acute clinical deterioration. Routine follow-up imaging clinically indicated.
D. Radiography Chest
Summary of Highlights
Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name

Appropriateness Rating

Appropriateness Category Definition

Usually Appropriate

7, 8, or 9

The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.

May Be Appropriate

4, 5, or 6

The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.

May Be Appropriate (Disagreement)

5

The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.

Usually Not Appropriate

1, 2, or 3

The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.
Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations

Relative Radiation Level*

Adult Effective Dose Estimate Range

Pediatric Effective Dose Estimate Range

O

0 mSv

 0 mSv

☢

<0.1 mSv

<0.03 mSv

☢☢

0.1-1 mSv

0.03-0.3 mSv

☢☢☢

1-10 mSv

0.3-3 mSv

☢☢☢☢

10-30 mSv

3-10 mSv

☢☢☢☢☢

30-100 mSv

10-30 mSv

*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”
References
1. Bradley B, Branley HM, Egan JJ, et al. Interstitial lung disease guideline: the British Thoracic Society in collaboration with the Thoracic Society of Australia and New Zealand and the Irish Thoracic Society. Thorax 2008;63 Suppl 5:v1-58.
2. Travis WD, Costabel U, Hansell DM, et al. An official American Thoracic Society/European Respiratory Society statement: Update of the international multidisciplinary classification of the idiopathic interstitial pneumonias. American Journal of Respiratory & Critical Care Medicine. 188(6):733-48, 2013 Sep 15.
3. Jokerst C, Chung JH, Ackman JB, et al. ACR Appropriateness Criteria® Acute Respiratory Illness in Immunocompetent Patients. J Am Coll Radiol 2018;15:S240-S51.
4. Lee C, Colletti PM, Chung JH, et al. ACR Appropriateness Criteria® Acute Respiratory Illness in Immunocompromised Patients. J Am Coll Radiol 2019;16:S331-S39.
5. de Groot PM, Chung JH, Ackman JB, et al. ACR Appropriateness Criteria® Noninvasive Clinical Staging of Primary Lung Cancer. J Am Coll Radiol 2019;16:S184-S95.
6. McComb BL, Ravenel JG, Steiner RM, et al. ACR Appropriateness Criteria® Chronic Dyspnea-Noncardiovascular Origin. J Am Coll Radiol 2018;15:S291-S301.
7. Cox CW, Chung JH, Ackman JB, et al. ACR Appropriateness Criteria® Occupational Lung Diseases. J Am Coll Radiol 2020;17:S188-S97.
8. Lynch DA, Godwin JD, Safrin S, et al. High-resolution computed tomography in idiopathic pulmonary fibrosis: diagnosis and prognosis. Am J Respir Crit Care Med 2005;172:488-93.
9. Raghu G, Remy-Jardin M, Myers JL, et al. Diagnosis of Idiopathic Pulmonary Fibrosis. An Official ATS/ERS/JRS/ALAT Clinical Practice Guideline. American Journal of Respiratory & Critical Care Medicine. 198(5):e44-e68, 2018 09 01.
10. Raghu G, Remy-Jardin M, Ryerson CJ, et al. Diagnosis of Hypersensitivity Pneumonitis in Adults. An Official ATS/JRS/ALAT Clinical Practice Guideline. Am J Respir Crit Care Med 2020;202:e36-e69.
11. Silva CI, Muller NL, Fujimoto K, et al. Acute exacerbation of chronic interstitial pneumonia: high-resolution computed tomography and pathologic findings. Journal of Thoracic Imaging. 22(3):221-9, 2007 Aug.
12. Akira M, Kozuka T, Yamamoto S, Sakatani M. Computed tomography findings in acute exacerbation of idiopathic pulmonary fibrosis. American Journal of Respiratory & Critical Care Medicine. 178(4):372-8, 2008 Aug 15.
13. Tachikawa R, Tomii K, Ueda H, et al. Clinical features and outcome of acute exacerbation of interstitial pneumonia: collagen vascular diseases-related versus idiopathic. Respiration. 83(1):20-7, 2012.
14. Collard HR, Ryerson CJ, Corte TJ, et al. Acute Exacerbation of Idiopathic Pulmonary Fibrosis. An International Working Group Report. Am J Respir Crit Care Med 2016;194:265-75.
15. Arai T, Kagawa T, Sasaki Y, et al. Heterogeneity of incidence and outcome of acute exacerbation in idiopathic interstitial pneumonia. Respirology. 21(8):1431-1437, 2016 11.
16. Kawamura K, Ichikado K, Ichiyasu H, et al. Acute exacerbation of chronic fibrosing interstitial pneumonia in patients receiving antifibrotic agents: incidence and risk factors from real-world experience. BMC Pulmonary Medicine. 19(1):113, 2019 Jun 25.
17. Kim DS, Park JH, Park BK, Lee JS, Nicholson AG, Colby T. Acute exacerbation of idiopathic pulmonary fibrosis: frequency and clinical features. Eur Respir J 2006;27:143-50.
18. American College of Radiology. ACR–STR Practice Parameter for the Performance of High-Resolution Computed Tomography (HRCT) of the Lungs in Adults. Available at: https://gravitas.acr.org/PPTS/GetDocumentView?docId=83+&releaseId=2
19. Hodnett PA, Naidich DP. Fibrosing interstitial lung disease. A practical high-resolution computed tomography-based approach to diagnosis and management and a review of the literature. Am J Respir Crit Care Med 2013;188:141-9.
20. Honda O, Takenaka D, Matsuki M, et al. Image quality of 320-detector row wide-volume computed tomography with diffuse lung diseases: comparison with 64-detector row helical CT. J Comput Assist Tomogr 2012;36:505-11.
21. Schoepf UJ, Bruening RD, Hong C, et al. Multislice helical CT of focal and diffuse lung disease: comprehensive diagnosis with reconstruction of contiguous and high-resolution CT sections from a single thin-collimation scan. AJR Am J Roentgenol. 2001 Jul;177(1):179-84.
22. Studler U, Gluecker T, Bongartz G, Roth J, Steinbrich W. Image quality from high-resolution CT of the lung: comparison of axial scans and of sections reconstructed from volumetric data acquired using MDCT. AJR Am J Roentgenol 2005;185:602-7.
23. Beigelman-Aubry C, Hill C, Guibal A, Savatovsky J, Grenier PA. Multi-detector row CT and postprocessing techniques in the assessment of diffuse lung disease. Radiographics 2005;25:1639-52.
24. Johkoh T, Muller NL, Nakamura H. Multidetector spiral high-resolution computed tomography of the lungs: distribution of findings on coronal image reconstructions. J Thorac Imaging 2002;17:291-305.
25. Prosch H, Schaefer-Prokop CM, Eisenhuber E, Kienzl D, Herold CJ. CT protocols in interstitial lung diseases--a survey among members of the European Society of Thoracic Imaging and a review of the literature. Eur Radiol 2013;23:1553-63.
26. Remy-Jardin M, Campistron P, Amara A, et al. Usefulness of coronal reformations in the diagnostic evaluation of infiltrative lung disease. J Comput Assist Tomogr 2003;27:266-73.
27. Lynch DA, Sverzellati N, Travis WD, et al. Diagnostic criteria for idiopathic pulmonary fibrosis: a Fleischner Society White Paper. [Review]. Lancet Respir Med. 6(2):138-153, 2018 02.
28. Chung JH, Chawla A, Peljto AL, et al. CT scan findings of probable usual interstitial pneumonitis have a high predictive value for histologic usual interstitial pneumonitis. Chest. 2015;147(2):450-459.
29. Elicker B, Pereira CA, Webb R, Leslie KO. High-resolution computed tomography patterns of diffuse interstitial lung disease with clinical and pathological correlation. J Bras Pneumol. 2008;34(9):715-744.
30. Sundaram B, Gross BH, Martinez FJ, et al. Accuracy of high-resolution CT in the diagnosis of diffuse lung disease: effect of predominance and distribution of findings. AJR. American Journal of Roentgenology. 191(4):1032-9, 2008 Oct.
31. Verrastro CG, Antunes VB, Jasinowodolinski D, D'Ippolito G, Meirelles GS. High-Resolution Computed Tomography in the Diagnosis of Diffuse Parenchymal Lung Diseases: Is it Possible to Improve Radiologist's Performance?. Journal of Computer Assisted Tomography. 40(2):248-55, 2016 Mar-Apr.
32. Johkoh T, Fukuoka J, Tanaka T. Rare idiopathic intestinal pneumonias (IIPs) and histologic patterns in new ATS/ERS multidisciplinary classification of the IIPs. European Journal of Radiology. 84(3):542-546, 2015 Mar.
33. Chung JH, Lynch DA. The Value of a Multidisciplinary Approach to the Diagnosis of Usual Interstitial Pneumonitis and Idiopathic Pulmonary Fibrosis: Radiology, Pathology, and Clinical Correlation. [Review]. AJR. American Journal of Roentgenology. 206(3):463-71, 2016 Mar.
34. Walsh SLF, Wells AU, Desai SR, et al. Multicentre evaluation of multidisciplinary team meeting agreement on diagnosis in diffuse parenchymal lung disease: a case-cohort study. The Lancet Respiratory Medicine. 4(7):557-565, 2016 07.
35. Walsh SLF.. Multidisciplinary evaluation of interstitial lung diseases: current insights: Number 1 in the Series "Radiology" Edited by Nicola Sverzellati and Sujal Desai. [Review]. European Respiratory Review. 26(144), 2017 Jun 30.
36. Ishii H, Watanabe K, Kushima H, et al. Pleuroparenchymal fibroelastosis diagnosed by multidisciplinary discussions in Japan. Respiratory Medicine. 141:190-197, 2018 08.
37. Ovcharenko SI, Son EA, Kapustina VA. Multidisciplinary approach in the diagnosis of idiopathic nonspecific interstitial pneumonia. Terapevticheskii Arkhiv. 91(3):101-106, 2019 Mar 30.
38. Grenier P, Chevret S, Beigelman C, Brauner MW, Chastang C, Valeyre D. Chronic diffuse infiltrative lung disease: determination of the diagnostic value of clinical data, chest radiography, and CT and Bayesian analysis. Radiology. 191(2):383-90, 1994 May.
39. Grenier P, Valeyre D, Cluzel P, Brauner MW, Lenoir S, Chastang C. Chronic diffuse interstitial lung disease: diagnostic value of chest radiography and high-resolution CT. Radiology. 179(1):123-32, 1991 Apr.
40. Klein JS, Gamsu G, Webb WR, Golden JA, Muller NL. High-resolution CT diagnosis of emphysema in symptomatic patients with normal chest radiographs and isolated low diffusing capacity. Radiology. 182(3):817-21, 1992 Mar.
41. Martin SG, Kronek LP, Valeyre D, et al. High-resolution computed tomography to differentiate chronic diffuse interstitial lung diseases with predominant ground-glass pattern using logical analysis of data. Eur Radiol. 20(6):1297-310, 2010 Jun.
42. Mathieson JR, Mayo JR, Staples CA, Muller NL. Chronic diffuse infiltrative lung disease: comparison of diagnostic accuracy of CT and chest radiography. Radiology. 171(1):111-6, 1989 Apr.
43. Miller A, Warshaw R, Nezamis J. Diffusing capacity and forced vital capacity in 5,003 asbestos-exposed workers: relationships to interstitial fibrosis (ILO profusion score) and pleural thickening. Am J Ind Med. 56(12):1383-93, 2013 Dec.
44. Muller NL, Mawson JB, Mathieson JR, Abboud R, Ostrow DN, Champion P. Sarcoidosis: correlation of extent of disease at CT with clinical, functional, and radiographic findings. Radiology. 171(3):613-8, 1989 Jun.
45. Padley SP, Hansell DM, Flower CD, Jennings P. Comparative accuracy of high resolution computed tomography and chest radiography in the diagnosis of chronic diffuse infiltrative lung disease. Clinical Radiology. 44(4):222-6, 1991 Oct.
46. Remy-Jardin M, Degreef JM, Beuscart R, Voisin C, Remy J. Coal worker's pneumoconiosis: CT assessment in exposed workers and correlation with radiographic findings. Radiology. 177(2):363-71, 1990 Nov.
47. Sener MU, Simsek C, Ozkara S, Evran H, Bursali I, Gokcek A. Comparison of the International Classification of High-resolution Computed Tomography for occupational and environmental respiratory diseases with the International Labor Organization International Classification of Radiographs of Pneumoconiosis. Industrial Health. 57(4):495-502, 2019 Aug 03.
48. Sverzellati N, Lynch DA, Hansell DM, Johkoh T, King TE Jr, Travis WD. American Thoracic Society-European Respiratory Society Classification of the Idiopathic Interstitial Pneumonias: Advances in Knowledge since 2002. Radiographics. 35(7):1849-71, 2015 Nov-Dec.
49. Tamura T, Suganuma N, Hering KG, et al. Relationships (I) of International Classification of High-resolution Computed Tomography for Occupational and Environmental Respiratory Diseases with the ILO International Classification of Radiographs of Pneumoconioses for parenchymal abnormalities. Industrial Health. 53(3):260-70, 2015.
50. Tiwari RR.. Agreement between chest radiography and high-resolution computed tomography in diagnosing dust-related interstitial lung fibrosis. Toxicol Ind Health. 31(3):235-8, 2015 Mar.
51. Xing J, Huang X, Yang L, Liu Y, Zhang H, Chen W. Comparison of high-resolution computerized tomography with film-screen radiography for the evaluation of opacity and the recognition of coal workers' pneumoconiosis. J Occup Health. 56(4):301-8, 2014.
52. Jacob J, Bartholmai BJ, Rajagopalan S, et al. Mortality prediction in idiopathic pulmonary fibrosis: evaluation of computer-based CT analysis with conventional severity measures. European Respiratory Journal. 49(1), 2017 01.
53. Papiris SA, Daniil ZD, Malagari K, et al. The Medical Research Council dyspnea scale in the estimation of disease severity in idiopathic pulmonary fibrosis. Respir Med. 2005; 99(6):755-761.
54. Robbie H, Daccord C, Chua F, Devaraj A. Evaluating disease severity in idiopathic pulmonary fibrosis. [Review]. European Respiratory Review. 26(145), 2017 Sep 30.
55. Staples CA, Muller NL, Vedal S, Abboud R, Ostrow D, Miller RR. Usual interstitial pneumonia: correlation of CT with clinical, functional, and radiologic findings. Radiology. 1987; 162(2):377-381.
56. Tamura T, Suganuma N, Hering KG, et al. Relationships (II) of International Classification of High-resolution Computed Tomography for Occupational and Environmental Respiratory Diseases with ventilatory functions indices for parenchymal abnormalities. Industrial Health. 53(3):271-9, 2015.
57. Terriff BA, Kwan SY, Chan-Yeung MM, Muller NL. Fibrosing alveolitis: chest radiography and CT as predictors of clinical and functional impairment at follow-up in 26 patients. Radiology. 1992; 184(2):445-449.
58. Best AC, Meng J, Lynch AM, et al. Idiopathic pulmonary fibrosis: physiologic tests, quantitative CT indexes, and CT visual scores as predictors of mortality. Radiology 2008;246:935-40.
59. Choi SH, Lee HY, Lee KS, et al. The value of CT for disease detection and prognosis determination in combined pulmonary fibrosis and emphysema (CPFE). PLoS ONE. 9(9):e107476, 2014.
60. Hochhegger B, Sanches FD, Altmayer SPL, et al. Air trapping in usual interstitial pneumonia pattern at CT: prevalence and prognosis. Scientific Reports. 8(1):17267, 2018 11 22.
61. Hozumi H, Nakamura Y, Johkoh T, et al. Nonspecific interstitial pneumonia: prognostic significance of high-resolution computed tomography in 59 patients. Journal of Computer Assisted Tomography. 35(5):583-9, 2011 Sep-Oct.
62. Hwang JH, Misumi S, Curran-Everett D, Brown KK, Sahin H, Lynch DA. Longitudinal follow-up of fibrosing interstitial pneumonia: relationship between physiologic testing, computed tomography changes, and survival rate. Journal of Thoracic Imaging. 26(3):209-17, 2011 Aug.
63. Iwasawa T, Takemura T, Okudera K, et al. The importance of subpleural fibrosis in the prognosis of patients with idiopathic interstitial pneumonias. European Journal of Radiology. 90:106-113, 2017 May.
64. Kim HC, Ji W, Kim MY, et al. Interstitial pneumonia related to undifferentiated connective tissue disease: pathologic pattern and prognosis. Chest. 147(1):165-172, 2015 Jan.
65. Lee JS, Lynch DA, Sharma S, Brown KK, Muller NL. Organizing pneumonia: prognostic implication of high-resolution computed tomography features. J Comput Assist Tomogr 2003;27:260-5.
66. Ley B, Elicker BM, Hartman TE, et al. Idiopathic pulmonary fibrosis: CT and risk of death. Radiology. 273(2):570-9, 2014 Nov.
67. Martinez FJ, Flaherty KR. Comprehensive and Individualized Patient Care in Idiopathic Pulmonary Fibrosis: Refining Approaches to Diagnosis, Prognosis, and Treatment. Chest. 151(5):1173-1174, 2017 05.
68. Moon JW, Bae JP, Lee HY, et al. Perfusion- and pattern-based quantitative CT indexes using contrast-enhanced dual-energy computed tomography in diffuse interstitial lung disease: relationships with physiologic impairment and prediction of prognosis. European Radiology. 26(5):1368-77, 2016 May.
69. Mooney JJ, Elicker BM, Urbania TH, et al. Radiographic fibrosis score predicts survival in hypersensitivity pneumonitis. Chest. 144(2):586-592, 2013 Aug.
70. Oda K, Ishimoto H, Yatera K, et al. High-resolution CT scoring system-based grading scale predicts the clinical outcomes in patients with idiopathic pulmonary fibrosis. Respir Res 2014;15:10.
71. Park JH, Kim DS, Park IN, et al. Prognosis of fibrotic interstitial pneumonia: idiopathic versus collagen vascular disease-related subtypes. Am J Respir Crit Care Med 2007;175:705-11.
72. Ryerson CJ, Urbania TH, Richeldi L, et al. Prevalence and prognosis of unclassifiable interstitial lung disease. Eur Respir J. 42(3):750-7, 2013 Sep.
73. Tokgoz Akyil F, Sevim T, Akman C, et al. The predictors of mortality in IPF - Does emphysema change the prognosis?. Sarcoidosis Vasc Diffuse Lung Dis. 33(3):267-274, 2016 Oct 07.
74. Travis WD, Matsui K, Moss J, Ferrans VJ. Idiopathic nonspecific interstitial pneumonia: prognostic significance of cellular and fibrosing patterns: survival comparison with usual interstitial pneumonia and desquamative interstitial pneumonia. Am J Surg Pathol 2000;24:19-33.
75. Vehmas T, Oksa P. Chest HRCT signs predict deaths in long-term follow-up among asbestos exposed workers. Eur J Radiol. 83(10):1983-7, 2014 Oct.
76. Zhang L, Zhang C, Dong F, et al. Combined pulmonary fibrosis and emphysema: a retrospective analysis of clinical characteristics, treatment and prognosis. BMC Pulmonary Medicine. 16(1):137, 2016 11 03.
77. Best AC, Lynch AM, Bozic CM, Miller D, Grunwald GK, Lynch DA. Quantitative CT indexes in idiopathic pulmonary fibrosis: relationship with physiologic impairment. Radiology 2003;228:407-14.
78. Humphries SM, Swigris JJ, Brown KK, et al. Quantitative high-resolution computed tomography fibrosis score: performance characteristics in idiopathic pulmonary fibrosis. Eur Respir J 2018;52.
79. Humphries SM, Yagihashi K, Huckleberry J, et al. Idiopathic Pulmonary Fibrosis: Data-driven Textural Analysis of Extent of Fibrosis at Baseline and 15-Month Follow-up. Radiology 2017;285:270-78.
80. Kim HJ, Brown MS, Chong D, et al. Comparison of the quantitative CT imaging biomarkers of idiopathic pulmonary fibrosis at baseline and early change with an interval of 7 months. Acad Radiol 2015;22:70-80.
81. Lee SM, Seo JB, Oh SY, et al. Prediction of survival by texture-based automated quantitative assessment of regional disease patterns on CT in idiopathic pulmonary fibrosis. European Radiology. 28(3):1293-1300, 2018 Mar.
82. Milanese G, Mannil M, Martini K, Maurer B, Alkadhi H, Frauenfelder T. Quantitative CT texture analysis for diagnosing systemic sclerosis: Effect of iterative reconstructions and radiation doses. Medicine. 98(29):e16423, 2019 Jul.
83. Nakagawa H, Nagatani Y, Takahashi M, et al. Quantitative CT analysis of honeycombing area in idiopathic pulmonary fibrosis: Correlations with pulmonary function tests. European Journal of Radiology. 85(1):125-130, 2016 Jan.
84. American College of Radiology. ACR Appropriateness Criteria®: Suspected Pulmonary Embolism. Available at: https://acsearch.acr.org/docs/69404/Narrative/.
85. Adams H, Keijsers RG, Korenromp IH, Grutters JC. FDG PET for gauging of sarcoid disease activity. SEMIN. RESPIR. CRIT. CARE MED.. 35(3):352-61, 2014 Jun.
86. Ambrosini V, Zompatori M, Fasano L, et al. (18)F-FDG PET/CT for the assessment of disease extension and activity in patients with sarcoidosis: results of a preliminary prospective study. Clinical Nuclear Medicine. 38(4):e171-7, 2013 Apr.
87. Capitanio S, Nordin AJ, Noraini AR, Rossetti C. PET/CT in nononcological lung diseases: current applications and future perspectives. [Review]. EUR. RESPIR. REV.. 25(141):247-58, 2016 Sep.
88. Costabel U, Bonella F, Ohshimo S, Guzman J. Diagnostic modalities in sarcoidosis: BAL, EBUS, and PET. Seminars in Respiratory & Critical Care Medicine. 31(4):404-8, 2010 Aug.
89. Cremers JP, Van Kroonenburgh MJ, Mostard RL, et al. Extent of disease activity assessed by 18F-FDG PET/CT in a Dutch sarcoidosis population. Sarcoidosis Vasculitis & Diffuse Lung Diseases. 31(1):37-45, 2014 Apr 18.
90. Groves AM, Win T, Screaton NJ, et al. Idiopathic pulmonary fibrosis and diffuse parenchymal lung disease: implications from initial experience with 18F-FDG PET/CT. Journal of Nuclear Medicine. 50(4):538-45, 2009 Apr.
91. Jacquelin V, Mekinian A, Brillet PY, et al. FDG-PET/CT in the prediction of pulmonary function improvement in nonspecific interstitial pneumonia. A Pilot Study. European Journal of Radiology. 85(12):2200-2205, 2016 Dec.
92. Keijsers RG, Grutters JC, Thomeer M, et al. Imaging the inflammatory activity of sarcoidosis: sensitivity and inter observer agreement of (67)Ga imaging and (18)F-FDG PET. The Quarterly Journal of Nuclear Medicine & Molecular Imaging. 55(1):66-71, 2011 Feb.
93. Koo HJ, Kim MY, Shin SY, et al. Evaluation of Mediastinal Lymph Nodes in Sarcoidosis, Sarcoid Reaction, and Malignant Lymph Nodes Using CT and FDG-PET/CT. Medicine (Baltimore). 94(27):e1095, 2015 Jul.
94. Milman N, Graudal N, Loft A, Mortensen J, Larsen J, Baslund B. Effect of the TNF-alpha inhibitor adalimumab in patients with recalcitrant sarcoidosis: a prospective observational study using FDG-PET. The clinical respiratory journal. 6(4):238-47, 2012 Oct.
95. Mostard RL, van Kroonenburgh MJ, Drent M. The role of the PET scan in the management of sarcoidosis. Curr Opin Pulm Med. 2013;19(5):538-544.
96. Mostard RL, Voo S, van Kroonenburgh MJ, et al. Inflammatory activity assessment by F18 FDG-PET/CT in persistent symptomatic sarcoidosis. Respiratory Medicine. 105(12):1917-24, 2011 Dec.
97. Nobashi T, Kubo T, Nakamoto Y, et al. 18F-FDG Uptake in Less Affected Lung Field Provides Prognostic Stratification in Patients with Interstitial Lung Disease. J Nucl Med. 2016;57(12):1899-1904.
98. Rubini G, Cappabianca S, Altini C, et al. Current clinical use of 18FDG-PET/CT in patients with thoracic and systemic sarcoidosis. Radiologia Medica. 119(1):64-74, 2014 Jan.
99. Sobic-Saranovic D, Grozdic I, Videnovic-Ivanov J, et al. The utility of 18F-FDG PET/CT for diagnosis and adjustment of therapy in patients with active chronic sarcoidosis. Journal of Nuclear Medicine. 53(10):1543-9, 2012 Oct.
100. Sobic-Saranovic DP, Grozdic IT, Videnovic-Ivanov J, et al. Responsiveness of FDG PET/CT to treatment of patients with active chronic sarcoidosis. Clinical Nuclear Medicine. 38(7):516-21, 2013 Jul.
101. Treglia G, Annunziata S, Sobic-Saranovic D, Bertagna F, Caldarella C, Giovanella L. The role of 18F-FDG-PET and PET/CT in patients with sarcoidosis: an updated evidence-based review. [Review]. Academic Radiology. 21(5):675-84, 2014 May.
102. Uehara T, Takeno M, Hama M, et al. Deep-inspiration breath-hold 18F-FDG-PET/CT is useful for assessment of connective tissue disease associated interstitial pneumonia. Modern Rheumatology. 26(1):121-7, 2016.
103. Umeda Y, Demura Y, Morikawa M, et al. Prognostic Value of Dual-Time-Point 18F-FDG PET for Idiopathic Pulmonary Fibrosis. Journal of Nuclear Medicine. 56(12):1869-75, 2015 Dec.
104. Win T, Thomas BA, Lambrou T, et al. Areas of normal pulmonary parenchyma on HRCT exhibit increased FDG PET signal in IPF patients. European Journal of Nuclear Medicine & Molecular Imaging. 41(2):337-42, 2014 Feb.
105. Yakar A, Yakar F, Sezer M, et al. Use of PET-CT for the assessment of treatment results in patients with sarcoidosis. Wiener Klinische Wochenschrift. 127(7-8):274-82, 2015 Apr.
106. Brady D, Lavelle LP, McEvoy SH, et al. Assessing fibrosis in pulmonary sarcoidosis: late-enhanced MRI compared to anatomic HRCT imaging. QJM 2016;109:257-64.
107. Hekimoglu K, Sancak T, Tor M, Besir H, Kalaycioglu B, Gundogdu S. Fast MRI evaluation of pulmonary progressive massive fibrosis with VIBE and HASTE sequences: comparison with CT. Diagnostic & Interventional Radiology. 16(1):30-7, 2010 Mar.
108. Lavelle LP, Brady D, McEvoy S, et al. Pulmonary fibrosis: tissue characterization using late-enhanced MRI compared with unenhanced anatomic high-resolution CT. Diagn Interv Radiol. 23(2):106-111, 2017 Mar-Apr.
109. Mammarappallil JG, Rankine L, Wild JM, Driehuys B. New Developments in Imaging Idiopathic Pulmonary Fibrosis With Hyperpolarized Xenon Magnetic Resonance Imaging. [Review]. Journal of Thoracic Imaging. 34(2):136-150, 2019 Mar.
110. Mirsadraee S, Tse M, Kershaw L, et al. T1 characteristics of interstitial pulmonary fibrosis on 3T MRI-a predictor of early interstitial change?. Quant. imaging med. surg.. 6(1):42-9, 2016 Feb.
111. Ohno Y, Nishio M, Koyama H, et al. Pulmonary MR imaging with ultra-short TEs: utility for disease severity assessment of connective tissue disease patients. European Journal of Radiology. 82(8):1359-65, 2013 Aug.
112. Ohno Y, Nishio M, Koyama H, et al. Oxygen-enhanced MRI for patients with connective tissue diseases: comparison with thin-section CT of capability for pulmonary functional and disease severity assessment. Eur J Radiol. 2014;83(2):391-397.
113. Pinal-Fernandez I, Pineda-Sanchez V, Pallisa-Nunez E, et al. Fast 1.5 T chest MRI for the assessment of interstitial lung disease extent secondary to systemic sclerosis. Clin Rheumatol. 35(9):2339-45, 2016 Sep.
114. Pusterla O, Sommer G, Santini F, et al. Signal enhancement ratio imaging of the lung parenchyma with ultra-fast steady-state free precession MRI at 1.5T. J Magn Reson Imaging. 48(1):48-57, 2018 07.
115. Renne J, Lauermann P, Hinrichs JB, et al. Chronic Lung Allograft Dysfunction: Oxygen-enhanced T1-Mapping MR Imaging of the Lung. Radiology. 276(1):266-73, 2015 Jul.
116. Torres L, Kammerman J, Hahn AD, et al. "Structure-Function Imaging of Lung Disease Using Ultrashort Echo Time MRI". [Review]. Academic Radiology. 26(3):431-441, 2019 03.
117. Wang JM, Robertson SH, Wang Z, et al. Using hyperpolarized 129Xe MRI to quantify regional gas transfer in idiopathic pulmonary fibrosis. Thorax. 73(1):21-28, 2018 01.
118. Yi CA, Lee KS, Han J, Chung MP, Chung MJ, Shin KM. 3-T MRI for differentiating inflammation- and fibrosis-predominant lesions of usual and nonspecific interstitial pneumonia: comparison study with pathologic correlation. AJR Am J Roentgenol. 2008; 190(4):878-885.
119. Epler GR, McLoud TC, Gaensler EA, Mikus JP, Carrington CB. Normal chest roentgenograms in chronic diffuse infiltrative lung disease. New England Journal of Medicine. 298(17):934-9, 1978 Apr 27.
120. Laney AS, Petsonk EL, Attfield MD. Intramodality and intermodality comparisons of storage phosphor computed radiography and conventional film-screen radiography in the recognition of small pneumoconiotic opacities. Chest. 140(6):1574-1580, 2011 Dec.
121. Larson TC, Holiday DB, Antao VC, et al. Comparison of digital with film radiographs for the classification of pneumoconiotic pleural abnormalities. Academic Radiology. 19(2):131-40, 2012 Feb.
122. Henry TS, Donnelly EF, Boiselle PM, et al. ACR Appropriateness Criteria® Rib Fractures. J Am Coll Radiol 2019;16:S227-S34.
123. Churg A, Wright JL, Tazelaar HD. Acute exacerbations of fibrotic interstitial lung disease. [Review]. Histopathology. 58(4):525-30, 2011 Mar.
124. Simon-Blancal V, Freynet O, Nunes H, et al. Acute exacerbation of idiopathic pulmonary fibrosis: outcome and prognostic factors. Respiration 2012;83:28-35.
125. Akira M, Inoue Y, Arai T, Okuma T, Kawata Y. Long-term follow-up high-resolution CT findings in non-specific interstitial pneumonia. Thorax 2011;66:61-5.
126. Akira M, Kozuka T, Inoue Y, Sakatani M. Long-term follow-up CT scan evaluation in patients with pulmonary sarcoidosis. Chest 2005;127:185-91.
127. Akira M, Yamamoto S, Hara H, Sakatani M, Ueda E. Serial computed tomographic evaluation in desquamative interstitial pneumonia. Thorax 1997;52:333-7.
128. Araki T, Putman RK, Hatabu H, et al. Development and Progression of Interstitial Lung Abnormalities in the Framingham Heart Study. Am J Respir Crit Care Med 2016;194:1514-22.
129. Brauner MW, Grenier P, Tijani K, Battesti JP, Valeyre D. Pulmonary Langerhans cell histiocytosis: evolution of lesions on CT scans. Radiology 1997;204:497-502.
130. Dhariwal J, Tennant RC, Hansell DM, et al. Smoking cessation in COPD causes a transient improvement in spirometry and decreases micronodules on high-resolution CT imaging. Chest. 145(5):1006-1015, 2014 May.
131. Gafa G, Sverzellati N, Bonati E, et al. Follow-up in pulmonary sarcoidosis: comparison between HRCT and pulmonary function tests. Radiol Med 2012;117:968-78.
132. Hartman TE, Primack SL, Kang EY, et al. Disease progression in usual interstitial pneumonia compared with desquamative interstitial pneumonia. Assessment with serial CT. Chest 1996;110:378-82.
133. Jeong YJ, Lee KS, Muller NL, et al. Usual interstitial pneumonia and non-specific interstitial pneumonia: serial thin-section CT findings correlated with pulmonary function. Korean J Radiol 2005;6:143-52.
134. Kawabata Y, Takemura T, Hebisawa A, et al. Desquamative interstitial pneumonia may progress to lung fibrosis as characterized radiologically. Respirology 2012;17:1214-21.
135. Kawano-Dourado L, Baldi BG, Kay FU, et al. Pulmonary involvement in long-term mixed connective tissue disease: functional trends and image findings after 10 years. Clin Exp Rheumatol 2015;33:234-40.
136. Kim EY, Lee KS, Chung MP, Kwon OJ, Kim TS, Hwang JH. Nonspecific interstitial pneumonia with fibrosis: serial high-resolution CT findings with functional correlation. AJR Am J Roentgenol 1999;173:949-53.
137. Kim MY, Song JW, Do KH, Jang SJ, Colby TV, Kim DS. Idiopathic nonspecific interstitial pneumonia: changes in high-resolution computed tomography on long-term follow-up. J Comput Assist Tomogr 2012;36:170-4.
138. Lazor R, Vandevenne A, Pelletier A, Leclerc P, Court-Fortune I, Cordier JF. Cryptogenic organizing pneumonia. Characteristics of relapses in a series of 48 patients. The Groupe d'Etudes et de Recherche sur les Maladles "Orphelines" Pulmonaires (GERM"O"P). Am J Respir Crit Care Med 2000;162:571-7.
139. Lee HY, Lee KS, Jeong YJ, et al. High-resolution CT findings in fibrotic idiopathic interstitial pneumonias with little honeycombing: serial changes and prognostic implications. AJR Am J Roentgenol 2012;199:982-9.
140. Lee JW, Lee KS, Lee HY, et al. Cryptogenic organizing pneumonia: serial high-resolution CT findings in 22 patients. AJR Am J Roentgenol 2010;195:916-22.
141. Murdoch J, Muller NL. Pulmonary sarcoidosis: changes on follow-up CT examination. AJR Am J Roentgenol 1992;159:473-7.
142. Nagao T, Nagai S, Hiramoto Y, et al. Serial evaluation of high-resolution computed tomography findings in patients with idiopathic pulmonary fibrosis in usual interstitial pneumonia. Respiration 2002;69:413-9.
143. Nakanishi M, Demura Y, Mizuno S, et al. Changes in HRCT findings in patients with respiratory bronchiolitis-associated interstitial lung disease after smoking cessation. Eur Respir J 2007;29:453-61.
144. Nishiyama O, Kondoh Y, Taniguchi H, et al. Serial high resolution CT findings in nonspecific interstitial pneumonia/fibrosis. J Comput Assist Tomogr 2000;24:41-6.
145. Nishiyama O, Taniguchi H, Kondoh Y, et al. Familial idiopathic pulmonary fibrosis: serial high-resolution computed tomography findings in 9 patients. J Comput Assist Tomogr 2004;28:443-8.
146. Nogueira CR, Napolis LM, Bagatin E, et al. Lung diffusing capacity relates better to short-term progression on HRCT abnormalities than spirometry in mild asbestosis. Am J Ind Med 2011;54:185-93.
147. Remy-Jardin M, Remy J, Wallaert B, Muller NL. Subacute and chronic bird breeder hypersensitivity pneumonitis: sequential evaluation with CT and correlation with lung function tests and bronchoalveolar lavage. Radiology 1993;189:111-8.
148. Screaton NJ, Hiorns MP, Lee KS, et al. Serial high resolution CT in non-specific interstitial pneumonia: prognostic value of the initial pattern. Clin Radiol 2005;60:96-104.
149. Silva CI, Muller NL, Hansell DM, Lee KS, Nicholson AG, Wells AU. Nonspecific interstitial pneumonia and idiopathic pulmonary fibrosis: changes in pattern and distribution of disease over time. Radiology 2008;247:251-9.
150. Tateishi T, Ohtani Y, Takemura T, et al. Serial high-resolution computed tomography findings of acute and chronic hypersensitivity pneumonitis induced by avian antigen. J Comput Assist Tomogr. 35(2):272-9, 2011 Mar-Apr.
151. Tsushima K, Sone S, Yoshikawa S, Yokoyama T, Suzuki T, Kubo K. The radiological patterns of interstitial change at an early phase: over a 4-year follow-up. Respir Med 2010;104:1712-21.
152. Yamauchi H, Bando M, Baba T, et al. Clinical Course and Changes in High-Resolution Computed Tomography Findings in Patients with Idiopathic Pulmonary Fibrosis without Honeycombing. PLoS One 2016;11:e0166168.
153. Hoffmann-Vold AM, Aalokken TM, Lund MB, et al. Predictive value of serial high-resolution computed tomography analyses and concurrent lung function tests in systemic sclerosis. Arthritis & Rheumatology. 67(8):2205-12, 2015 May.
154. Lee G, Kim KU, Lee JW, Suh YJ, Jeong YJ. Serial changes and prognostic implications of CT findings in combined pulmonary fibrosis and emphysema: comparison with fibrotic idiopathic interstitial pneumonias alone. Acta Radiologica. 58(5):550-557, 2017 May.
155. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/Clinical/Appropriateness-Criteria/ACR-Appropriateness-Criteria-Radiation-Dose-Assessment-Introduction.pdf.
Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked.  Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.