G  Ferretti    University  hospital  of  Grenoble,  France    

¡  Dyspnea  is  generally  defined  as  a  subjective  experience  of  breathing  discomfort  

¡  Equivalent:  breathlessness  or  shortness  of  breath  or  unpleasant  urge  to  breathe  

¡  Acute  vs.  chronic  if  >  1  month  in  duration  

¡  Dyspnea  is  one  of  the  most  frequent  symptoms  of  presentation  of  thoracic  diseases  in  the  ED  

Dyspnea  may  be  of  neurogenic,  respiratory,  or  cardiac  origin,  and  may  be  associated  with  conditions  such  as  anemia,  deconditioning,  or  anxiety.  

85%  of  all  cases  of  shortness  of  breath  are  caused  by:  ¡  congestive  heart  failure  and  myocardial  ischemia    ¡  asthma,  COPD,  interstitial  lung  disease,  pneumonia,  ¡  psychogenic  disorders  

▪  SARKAR  S  EVALUATION  OF  THE  DYSPNEIC  PATIENT  IN  THE  OFFICE.  PRIM  CARE.  2006;33(3):643–657  

 >  30%  of  cases  are  related  multifactorial  etiology  

▪  AMERICAN  COLLEGE  OF  RADIOLOGY.  ACR  APPROPRIATENESS  CRITERIA.  CHRONIC  DYSPNEA—SUSPECTED  PULMONARY  ORIGIN.  2012.    

 

¡  lung  parenchyma  

¡  airways    

¡  vessels  

¡  pleura  

¡  thoracic  wall  

Initial  Diagnostic  Studies  includes  

¡  Electrocardiography    

¡  Spirometry    

¡  Laboratory  evaluation  

¡  Chest  Radiography  

Acute infectious pneumonia Left atelectasis

¡  The  cases  in  which  CXR  shows  evident  etiology  of  dyspnea  will  not  be  discussed  here    

¡  But  more  difficult  cases  will  be  presented  with  emphasize  on  the  role  of  CT  

§  Chronic  presentation  §  Acute  presentation  

§  FEV1  /  FVC    <  70%    post-­‐bronchodilator  

§  Role  of  CT  

§  Phenotyping  COPD  

§  Search  for  complications  

§  Selection  of  patient  before  treatment    

Centrilobular  emphysema  45  yo  smoking  man  

Bronchial wall thickening Bronchiectasis Air trapping Small airway diseases Expiration

constrictive bronchiolitis

minIP inspiration

inspiration

expiration

séquelle bronchiolite 2d SERGEANT_FREDERIc

17 yo man chronic dyspnea MacLeod / Syver James syndrome

minIP MIP average

focal areas of decreased lung opacity with sharp margins, reduced-size pulmonary vessels, bronchial wall thickening, and bronchiectasis.

Sub acute Hypersensitivity Pneumonitis

Tracheobronchomalacia (TBM)

●  characterized by increased compliance and excessive collapsibility of trachea and / or bronchi (acquired / congenital)

●  an important cause of chronic nonspecific pulmonary symptoms

●  identified in 1–10% of bronchoscopies (Nuutinen Ann Clin Res 1977)

●  but is an under diagnosed condition as it escapes detection on inspiratory CT

56 yo man, COPD Recent worsening of chronic dyspnea End inspiratory CT: saber-sheath trachea

Inspiration End expi

End expiratory VCT: airway collapse < 50%

During expi

Dynamic expiratory VCT shows expiratory airway collapse > 70% VCT shows bowing of posterior membranous TBM confirmed by bronchoscopy

High grade mucoepidermoid carcinoma in a 53 yo woman

¡  25  yo  female    ¡  Chronic  obstructive  disease  ¡  FEV1:  2.36L;  64%  ¡  FEV1  /  VC:  72%  ¡  Treatment  for  asthma  failed  ¡  Proposed  diagnostic:  complicated  asthma  

1.  IV  contrast  injection    2.  Expiratory  CT  3.  MIP    4.  Nothing,  I’m  glad  with  the  CT  I’ve  done  

1.  IV  contrast  injection    2.  Expiratory  CT  3.  MIP    4.  Nothing,  I’m  glad  with  the  CT  I’ve  done  

¡  Dynamic  stenosis  of  the  LMB  due  to  the  compression  between  the  aorta  and  the  thoracic  spine    

¡  HRCT  is  the  most  sensitive  modality  for  diagnosing  early  emphysema  in  smokers  with  dyspnea.    

¡  HRCT  is  more  sensitive  than  pulmonary  function  tests  for  diagnosing  emphysema.  

¡  HRCT  phenotypes  BPCO  §  Emphysema  §  Diseases  of  the  airways  

¡  HRCT  helps  choosing  appropriate  treatment    

Pulmonary lymphangioleiomyomatosis

Langerhans cell histiocytosis

42 yo woman Mild dyspnea

Possible NSIP in a patient with systemic sclerosis

83 yo man Dyspnea at exercise Worked as a dentist

Silicosis complicated with emphysema

¡  HRCT  the  best  non  invasive  tool  

¡  particularly  appropriate  when  the  results  of  clinical,  radiographic,  and  laboratory  studies  are  either  nonrevealing  or  nondiagnostic.  

 ¡  Many  diseases  have  features  characteristic  enough  to  enable  experienced  radiologists  to  make  a  confident,  probable,  or  limited  differential  diagnosis  in  most  cases.  

¡  Thanks  to  HRCT,  biopsy  and  additional  diagnostic  testing  are  often  unnecessary.  

 

¡  Rarely  needed  

¡  Useful  in  diagnosing    §  Chronic  Thromboembolism  of  PA    §  fibrosing  mediastinitis  

¡  Is  recommended  in  case  of  mosaic  pattern  with  unremarkable  PFT.  

62yo patient with chronic dyspnea at exercise CT without CM injection

50 yo woman complaining of dyspnea at exercise associated with palpitation. 53 kg for 163cm

TDM  

A 77-year-old woman was referred to our center for the workup of progressive exertional dyspnea.

Ventilation perfusion lung scan with multiple nonmatched perfusion defects in the right superior lobe and right median lobe and hypoperfusion of the left lung.

Seferian A et al. Circulation 2012;125:2045-2047

Copyright © American Heart Association by Andrei Seferian, et al

Contrast-enhanced high-resolution computed tomography of the chest.

Seferian A et al. Circulation 2012;125:2045-2047

Copyright © American Heart Association

PAHT VOD

¡  Frequent  in  ER  or  ICU  

¡ May  be  associated  with  a  severe  prognosis  

¡  Need  a  quick  diagnosis  and  treatment  

¡  De  novo  or  complicating  a  chronic  dyspnea  

¡  Common  pulmonary  causes  include    §  asthma  §  pneumothorax  §  upper  airway  obstruction  §  interstitial  lung  disease  §  pulmonary  embolism  §  pulmonary  hypertension  

¡  2005  ¡  83  yo  women  ¡  No  particular  history    ¡  Acute  dyspnea  ¡  Unremarkable  CXR  ¡  Angio  CT  for  suspected  PE    

Acute PE

¡  2010    ¡  88  yo  ¡  Rapid  onset  of  dyspnea  

¡ Weight  loss  

New epidode of thrombo-embolic PE?

Sarcoma of the pulmonary artery

Collomb Eur Radiol 2002

Gravité de l’EP : signes d’ICDA

VD / VG > 1 : valeur pédictive forte pour réanimation, thrombolyse, mortalité à 30 j

Schoepf U Circulation 2004

68 yo man acute leukemia Fever Dyspnea CXR 22/02/2013

Crazy paving

PCP pneumonia

Measles severe

¡  62  yo  man  ¡  Immunocompetent    ¡  Recent  fatigue  weigh  loss  anorexia    ¡  Fever    ¡  Cough  ¡  acute  respiratory  distress…  ICU  

Invasive Aspergillosis

42 yo female Chronic dyspnea: PHT CT: PA embolism ?

Undiagnosed partial anomalous pulmonary venous return

¡  CXR  is  the  first  line  technique  in  patients  with  dyspnea  

¡  in  case  of  unremarkable  CXR,  HRCT,  Expiratory  CT  and  angio  CT  play  an  important  role  for  diagnosing  patients  with  dyspnea  

¡  V/Q  scan  remains  the  most  sensitive  technique  for  diagnosing  chronic  thromboembolism    

Grenoble