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Diagnostic Procedures inRespiratory Disease
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Routine Radiography
The standard chest examination consists of a PA
(posterioranterior) and lateral chest x-rayUsed for evaluation of the pulmonary
parenchyma, the pleura, the airways and the
mediastinum
Lateral decubitus position => assess the volumeof pleural effusion and demonstrate whether a
pleural effusion is mobile or loculated
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Portable Radiography
Used for acutely ill patients who cannot be transported or
cannot stand for PA and lateral views
Portable films are more difficult to interpret because of
several limitation:
1) the single AP projection
2) variability in over- and underexposure of film
3) a shorter focal spot-film distance leading to lack of edge
sharpness, and loss of fine detail
4) magnification of the cardiac silhouette and other anterior
structures by the AP projection
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Chest Radiography
Normal PA Chest X-ray Normal Lateral Chest X-ray
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Radiographic Patterns
Patient with severe emphysema. Chestradiograph shows hyperexpansion
of both lungs with bullous changes at the
right lung base and leftward mediastinal
shift.
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Radiographic Patterns
Patient with hydrostatic
pulmonary edema due to left-sided heart failure. Chest frontal
radiograph demonstrates classic
batwing distribution of
pulmonary edema
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Radiographic Patterns
Multifocal pulmonary opacities
Bilateral large and small pulmonary
nodules and masses due to metastatic
tumor
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Radiographic Patterns
Basilar pneumothorax with visible pleural
reflection (red arrows)
Subcutaneous emphysema (yellow arrow).
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Radiographic Patterns
Right upper lobe pneumonia Bilateral pleural effusion
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Radiographic Patterns
The red arrows indicate the edge of
the collapsed right lung. Their is
also significant shift of the
mediastinum to the left
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Computed Tomography
CT is particularly valuable in:
assessing hilar and mediastinal (valuableespecially in the staging of lung cancer)
identifying and characterizing the chest wall andspine disease
identifying areas of fat density or calcification inpulmonary nodules
distinguish vascular from nonvascular structures(particularly lymph nodes and masses fromvascular disorders) by using of contrast material
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High-resolution CT (HRCT)
In HRCT the thickness of cross-sectional
images is ~ 1-2 mm, narrower than the usual7-10 mm in conventional CT
Used for diagnosis and the assessment of
interstitial lung disease such as lymphangitic
carcinoma, idiopathic pulmonary fibrosis,sarcoidosis, and eosinophilic granuloma and
other generalized lung diseases such as
emphysema , bronchiectasis
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Multidetector CT
(MDCT 2 to 64 detectors)
Multiple slices in a single rotation and in a shorter period
of time = > increased image reconstruction ability
Shorter breath holds is beneficial for all patientsespecially for children ,the elderly and the critically ill
Improved imaging of the pulmonary vasculature and the
ability to detect segmental and subsegmental emboli
CT pulmonary angiography is the test of choice in theevaluation of pulmonary embolism
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Magnetic Resonance Imaging
MR is less used than CT in the evaluation of the respiratory systemdisease because of several disadvantages:
poorer spatial resolution and less detail of the pulmonary parenchymaimages difficult to obtain in patients who cannot lie on their backs or
cannot hold their breaths as a require to get good MR images
Contraindications: - unstable and/or ventilated patients
- presence of metallic foreign bodies, pacemakersand intracranial aneurysm clips
MR is well suited to distinguish vascular from nonvascular structureswithout the need for contrast
MR is useful in the assessment of vascular abnormalities (pulmonaryemboli, aortic aneurysms or dissection) when radiation and IV contrastmedium cannot be usedGadolinium can be used as an intravascular contrast agent for MR
angiography
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Nuclear Medicine Techniques
Nuclear imaging is based on the selective uptake ofvarious compounds by organs of the body
Radioactive isotopes can be administered by IV orinhaled routes, or both. The most commonly usedradionuclides are: technetium-99m (intravenous) andXenon-133 (gaseous)radiolabeled xenon gas inhalation is used to
demonstrate the distribution of ventilationVentilation-perfusion lung scanning is used for theevaluation of patients with impaired lung function whoare being considered for lung resection and those withpulmonary embolism
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Positron Emission Tomographic (PET)
Scanning
Used to identify malignant lung lesions based
on their increased uptake and metabolism ofglucose
The technique involves injection of F-fluoro-2-
deoxyglucose (FDG) which is taken up by
metabolically active malignant cellsUsed in the evaluation of solitary pulmonary
nodules and in staging lung cancer
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Positron Emission Tomographic (PET)
Scanning
The hybrid PET/CT scans provide images that helppinpoint the abnormal metabolic activity to anatomical
structures seen on CT
more accurate diagnoses thanthe two scans performed separatelyFDG-PET can differentiate benign from malignant
lesions as small as 1 cmFalse-negative findings: low metabolic activity lesions
(carcinoid tumors, bronchioloalveolar cell carcinomas) orlesions< 1cmFalse-positive findings: due to FDG uptake in
inflammatory conditions (pneumonia and granulomatousdiseases)
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Whole body PET CT
coronal images show
abnormal focal FDGuptake in right lung mass
lesion - Primary Ca lung
(First image is contrast-
enhanced CT, next is
corresponding PET slice
and third is fused PET CT)
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Pulmonary Angiography
Visualization of pulmonary arterial system after
injection of a radiopaque contrast medium through a
catheter placed in the pulmonary artery
Indications:
pulmonary embolism (most common)
pulmonary arteriovenous malformation
pulmonary arterial invasion by a neoplasm
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Ultrasound
US produces images using reflection of the ultrasound beamfrom interfaces between tissues with differing acoustic
properties US involves no exposure to X-ray or magnetic waves, which
it makes safe to use in pregnant patients and patients withimplanted medical devices
Used for:
detection of pleural abnormalities guiding percutaneous needle biopsy of peripheral lung,
pleural or chest wall lesions
identifying septations within loculated collections
placement of a needle for sampling of pleural liquid
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Collection of Sputum
Sputum can be collected by spontaneous
expectoration or by sputum induct ion(after
inhalation of an irritating aerosol such as
hypertonic saline)
Sputum can be processed for:
staining and culture for routine bacterialpathogens, mycobacteria, fungi, viruses,
Pneumocystis jiroveci
cytologic staining for malignant cells
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Percutaneous Needle Aspiration
(Transthoracic)
Can be used to aspirate material from a
pulmonary lesion through a needle inserted
through the chest wall
Used to obtain a diagnosis or to decompress or
drain a fluid collection
Usually performed under CT or US guidanceSampling error due to the small size of the tissue
sample is a disadvantages of the technique
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Thoracentesis
Is an invasive
procedure to removefluid orairfrom the
pleural space for
diagnostic or
therapeutic
purposes(palliation ofdyspnea)
Performed by blind
needle aspiration or
by US guidance
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Thoracentesis
Analysis the pleural fluid to determine the cause
and to determinewhether the effusion is atransudate or an exudate
pleural fluid glucose,
amylase
Lactate dehydrogenase
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Transudative or exudative pleural
effusions ?
Exudativepleural effusions meet at least one of thefollowing criteria :
1. Pleural fluid protein/serum protein >0.5
2. Pleural fluid LDH/serum LDH >0.6
3. Pleural fluid LDH more than two-thirds normal upper limitfor serum
transudative pleural effusions meet none
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Transudative Pleural Effusions:
Congestive heart failure
Cirrhosis
Pulmonary embolization
Nephrotic syndrome
Peritoneal dialysis
Superior vena cava obstruction
Myxedema
Urinothorax
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Exudative Pleural Effusions:
Neoplastic diseases
Infectious diseases
Pulmonary embolization
Gastrointestinal disease
Collagen vascular diseases
Post-coronary artery bypass surgery
Asbestos exposure
Sarcoidosis
Meigs' syndrome Drug-induced pleural disease
Radiation therapy
Hemothorax
Iatrogenic injury
Pericardial disease
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Bronchoscopy
direct visualization of the tracheobronchial tree
I. flexible fiberoptic bonchoscopy
II. rigid bronchoscopy
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I. Flexible Fiberoptic Bronchoscopy
Usually performed in an awake but sedated patientThe bronchoscope is passed through the mouth or the
nose , between the vocal cords and into trachea andpermit to visualize virtually all airways to the level ofsubsegmental bronchiUsed to identify endobronchial pathology (tumors,
granulomas, bronchitis, foreign bodies and sites ofbleeding)
To take samples from airway lesions by specificmethods including washing, brushing, and biopsy
To take samples from the distal pulmonaryparenchyma (bronchoalveolar lavage, transbronchialbiopsy)
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II. Rigid Bronchoscopy
Performed in an operating room on a patient
under general anesthesia
Rarely used, in some situations (the retrieval
of a foreign body and the suctioning of a
massive hemorrhage) because of a largersuction channel
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Transbronchial Needle Aspiration
TBNA is a minimally invasive procedure that
provides a nonsurgical means to diagnose and
stage bronchogenic carcinoma by sampling the
mediastinal lymph nodes
allows also sampling of peripheral, submucosal,
and endobronchial lesions involves use of a needle passed through the
bronchoscope for sampling of tissue through the
trachea or bronchial wall
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Transthoracic needle aspiration and
biopsy
Transthoracic needle aspiration and biopsy(TTNA/B) is a safe rapid method used to
achieve definitive diagnosis for most thoracic
lesions, whether the lesion is located in the
pleura, the lung parenchyma, or themediastinum
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Autofluorescence Bronchoscopy
(AFB) uses bronchoscopes with an additional lightsource that allows distinguish between normal and
abnormal tissue
Used for screening of premalignant lesions(airway dysplasia) and carcinoma in situ among
high-risk patients
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Medical Thoracoscopy/Pleuroscopy
A minimally invasive procedure that allows access
to the pleural space using a combination of
viewing and working instruments
Used fordiagnostic (evaluation of a pleural
effusion or biopsy of presumed parietal pleural
carcinomatosis) and therapeutic procedures(pleurodesis for prevent recurrent pleural effusion
or pneumothorax)
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Therapeutic Bronchoscopy
Therapeutic bronchoscopy includes removalof foreign body, control of active bleeding
(hemoptysis) management of benign airway
stenosis, laser bronchoscopy, cryotherapy,
endobronchial brachytherapy, photodynamictherapy and airway stents
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Mediastinoscopy and Mediastinotomy
Surgical procedures used to examine andsampling mediastinal masses and lymph nodes
Mediastinoscopy via a suprasternal incisionprovides access to mediastinal masses andlymph node levels 2R, 2L, 3, 4R, 4L
Mediastinotomy (the Chamberlain procedure)
via a parasternal incision allows access to thestation 5 and 6 lymph nodes
An alternative to surgery procedures is thecombination of EUSFNA and EBUSFNA
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Video-assisted thoracoscopic surgery
(VATS)
VATS is a keyhole surgical procedure in the
operating room, under general anesthesia with
one-lung ventilation using disposable instruments,
generally for therapeutic purpose
Used to biopsy lesions of the pleura, peripherallung tissue or to remove peripheral nodules for
both diagnostic and therapeutic purposes
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Indications for video-assistedthoracoscopic surgery (VATS)
General intrathoracic cavity
Diagnosis or biopsy of any intrathoracic structure
Laser application for treatment of tumors
Diagnosis and drainage of pleural effusions
Treat chylothorax
Lungs
Wedge resection, segmentectomy, lobectomy
Closure of persistent/recurrent pneumothorax
Identification of broncho-pleural fistula
Pleura
Lysis of adhesions
Pleurodesis
Mediastinum
Removal of mediastinal cysts
Thymectomy
Resection of posterior mediastinal neurogenic tumors
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Thoracotomy
Now is frequently replaced by VATS
Can be used to biopsy and/or excise lesionsthat are too deep or too close to vital structuresfor removal by VATS
The choice between VATS and thoracotomyneeds to be made on a case-by-case basis