Investigations in chest medicine

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Investigations in chest medicine

• Dr. Aya Abdel Dayem
• Lecturer of chest diseases
• Ain Shams University Egypt
• Ibn Sina college

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Sputum examination

• Clear and colorless ( chronic bronchitis)
• Yellow to green( pulmonary infection )
• Red( haemoptysis)
• Black (smoke, coal )
• Send the sample to laboratory for microscopic,
  culture and cytology
• AAFB

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Tuberculin skin test

• Tuberculin skin test TB antigen is injected to
  intradermally and the cell-mediated response
  48-72 h is recorded. A positive test indicates
  that the patient has immunity. It may indicate
  previous exposure of BCG. A strong positive test
  probably means active infection. False negative
  test occur in immunosuppression, including
  miliary TB, sarcoid, AID, lymphoma.

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Tuberculin skin test

• Mantoux Test Serial dilutions of antigens
  provide 1, 10, and 100, tuberculin units (TU),
  respectively. The test is ve if it produces gt
  10mm induration, and ve if lt5 mm. This test is
  overrated in diagnosing TB and its use is
  controversial.
• I f active TB is strongly suspected, use 1 TU. If
  it is positive, infection is likely. Otherwise,
  interpret in the clinical context.

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Lung volumes

• Tidal volume
• FRC
• VC
• RV
• TLC

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Spirometry

• It measures changes in lung volume by recording
  changes in the volume of air exchanged through
  the air way opening.
• Forced expiratory volume in 1 s (FEV)
• Forced vital capacity (FVC)
• FEVI/FVC 75

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Spirometry

• Obstructive defect
• FEV1is reduced more than the FVC
• The FEV/FVC is lt75
• Asthma
• COPD
• Bronchiectasis
• Cystic fibrosis

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Spirometry

• Restrictive defect
• FVC reduced
• The FEV /FVC ratio is normal.
• Sarcoidosis
• Pneumoconiosis
• Obesity
• Connective tissue disease
• Pleural effusion

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Peak expiratory flow (PEF)

• Is measured by a maximal forced expiration
  through a peak flow meter.
• The best of three.
• Diffuse airways obstruction.
• Monitoring course of asthma.

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Oximetry

• Pulse oximetry
• Peripheral O2saturation
• Two light emitting diodes detector.

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Arterial blood gas (ABG)

• Analysis heparin zed blood is taken from radial,
  brachial, femoral artery .
• PH
• PaCO2
• PaO2

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Acid base balance

• Normal PH 7.35-7.45
• ?A PH lt7.35 acidosis
• A PHgt7.45 alkalosis

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Acid base balance

• PaO2 is 10.5-13.5-kpa
• Ventilation perfusion mismatch
• Hypoventilation
• Abnormal diffusion
• Right to left shunt
• Sever hypoxia Pao2lt8kpa

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Acid base balance

• PaCO2 is a 4.5-6.0 kpa
• A PaCO2lt4.5 kpa hyperventilation
• A PaCO2 gt6.0 kpa hypoventilation

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Radiology

• Chest x ray
• Posteroanterior view (PAV)
• Trachea central
• Heart lt 1/2the width of the thorax

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Radiology (CXR)

• Mediastinum
• widened
• Retrosternal goiter
• Lymph node enlargement
• Tumor
• Aortic aneurysm
• Cyst
• Paravertebral mass (TB)
• Oesophageal dilation

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Radiology (CXR)

• The diaphragm
• Right side is usually higher
• High
• Lung volume loss
• Stroke
• Phrenic nerve palsy
• Hepatomegaly
• Subphrenic lesion

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Radiology (CXR)

• Lung fields
• Nodular shadows
• Neoplasia metastases, lung carcinoma, adenoma
  hamartoma)
• Infection (pneumonia, hydatid, septic emboli)
• Granulomas (military TB, sarcoidsis)
• Pneumoconiosis

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Radiology (CXR)

• Lung fields
• Reticular shadows
• Fibrosis, TB
• Neoplasia (lymphangitis carcinomatosis)
• Sarcoidosis
• Silicosis

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Radiology (CXR)

• Lung fields
• Alveolar shadows
• LVF
• Pneumonia
• Renal failure
• Liver failure
• ARDS
• Drugs ( heroin,cytotoxics)
• Smoke inhalation

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Radiology (CXR)

• Lung fields
• Ring shadows
• Air ways seen end-on (pulmonary edema,
  bronchiectasis)
• Cavitating lesion (abscess)
• Tumor
• Pulmonary infarct

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Radiology (CXR)

• Lung fields
• Linear opacities
• Septa lines
• Atelectasis

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Ultrasound

• Ultrasound is used in the diagnosis and drainage
  of pleural effusions (particularly loculated
  effusions) and empyema

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Radionuclide scans Ventilation/perfusion (VIQ)

• Radionuclide scans Ventilation/perfusion (VIQ)
  scans are used to diagnose pulmonary embolism
  (PE) (unmatched perfusion defects are seen). Bone
  scans are used to diagnose bone metastases.

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Computer tomography (CT)

• Computer tomography (CT) of the thorax is used
  for diagnosing and staging lung ca. Imaging the
  hilar, mediastinum and pleura, and guiding
  biopsies. Thin (1-1.5mm) section high resolution
  CT (HRCT) is used in the diagnosis of
  interstitial lung disease and bronchiectasis (
  Spiral CT)

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Pulmonary angiography (CTPA)

• Pulmonary angiography (CTPA) is used
  increasingly in the diagnosis of PE. Pulmonary
  angiography is also used for diagnosing PE and
  pulmonary hypertension.

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Fibreoptic Bronchoscopy

• It is performed under local anesthetic via the
  nose or mouth.
• Diagnostic Indications suspected lung ca,
  slowly resolving pneumonia, pneumonia in the
  immunosuppressed, interstitial lung disease.
  Bronchial lavage fluid may be sent to the lab for
  microscopy, culture, and cytology. Mucosal
  abnormalities may be brushed (cytology) and
  biopsied (histopathology

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Fibreoptic Bronchoscopy

• Therapeutic indications aspiration of mucus
  plugs causing lobar collapse or removal of
  foreign bodies.

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Fibreoptic Bronchoscopy

• Pre-procedure investigations
• FBC
• CXR
• Spirometry
• Pulse oximetry
• Arterial blood gases (if indicated)
• Check clotting if recent anticoagulation and a
  biopsy may be performed.

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Fibreoptic Bronchoscopy

• Complications
• Respiratory
• Depression
• Bleeding
• Pneumothorax

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Bronchoalveolar lavage (BAL)

• It is performed at the time of bronchoscopy by
  instilling and aspirating a known volume of
  warned buffered 0.9 saline into the distal
  airway.

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Bronchoalveolar lavage (BAL)

• Diagnostic indications suspected malignancy,
  pneumonia in the immunosuppressed (especially
  HIV), suspected TB (if sputum negative),
  interstitial lung diseases (eg sarcoidosis,
  extrinsic allergic alveolitis, histocytosis X).

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Bronchoalveolar lavage (BAL)

• Therapeutic indications alveolar proteinosis.
• Complications hypoxia (give supplemental O2),
  transient CXR shadow, infection (rare).

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Lung Biopsy

• It may be perfumed in several ways.
• Percutaneous needle biopsy is performed under
  radiological guidance and is useful for
  peripheral lung and pleural lesions may be
  performed in several ways.

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Lung Biopsy

• Transbronchial biopsy performed at bronchoscopy
  may help in diagnosing diffuse lung diseases, eg
  sarcoidosis. If these are unsuccessful, an open
  lung biopsy may be performed under general
  anesthetic.

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Surgical Procedures

• They are performed under general anesthetic.
• Rigid bronchoscopy provides a wide lumen,
  enables larger mucosal biopsies, controlling
  bleeding, and removal of foreign bodies.
• Mediastinoscopy and mediastinotomy enable
  examination and biopsy of the mediastinal lymph
  nodes/lesions, drainage of pleural effusions, and
  talc pleurodesis.

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Thank you