Diagnostic methods in pulmonary medicine

1. Diagnostic methods in pulmonary medicine Dr. S. Özdoğan

2. Imaging • Chest x-ray • Computed Tomography • Magnetic Resonance Imaging • PET CT • Ventilation Perfusion Scan

3. Pulmonary function tests • Skin Prick Test • Bacteriologic evaluation • PPD (Tuberculin test) • Blood gas analysis • Thoracentesis and drainage • Pleural biopsy • Bronchoscopy

4. Plain Chest Radiography

5. Right anterior oblique Normal position and technique

6. Right anterior obligue

9. Examination in order • Trachea, mediastinum • Bilateral diaphragm, sinuses • Hiler regions • Lung Paranchym • Bone and soft tissue

10. Pathologicsigns in chest x ray • Changes in the size orlocalization of the normal components • Extradensities • Whiteshadows, consolidation • Homogenious • Inhomogenious • Calcification • Blackareas, (pureair) • Aircysts • Bullae • pneumothorax

11. Paranchymal Radiologic patterns • Reticular: lineer density • Kerley B (basal) • Kerley C: Central short • Kerley A: longer in middlezone • Nodule: roundshaped < 3cm opacities • Asiner: 4-8 mm • Milier: 2-4 mm • Mass: > 3cm diameter

12. Silhouette sign (-) Silhouette sign (+)

13. Bone andsofttissue • Fractures • Air • Extradensities

14. PA Chest x ray • Lateralchest x-ray • Lateraldecubitis

15. Apicolordotic chest x-ray

16. Thorax CT (Indications) • Any abnormality seen on a chest radiograph • To examine the borders of a lesion and its relation to neighbouring tissues • To get hystospecific details according to the density (HU) • To examine chest wall and vertebral pathologies • Evaluation of metastasis

17. Normal Anatomy

18. Pathologies on Thorax CT • Solidlesions in thelung, localization, density • Pleurallesions, density? • Mediastinal lesionsandlymphnodes • Vasculerpathologies (intraluminaltrombus) in contrastenhancement

19. HRCT Pathologies: Reticular Normal paranchym Nodular

20. Consolidation, Ground grass Cystic

21. Skin Prick Test • Type I immunologic reaction • Sensitivity to a particular antigen is detected

22. Negative control (SF) should be negative • Positive control (Histamine) should be positive

23. False negative: Antihistamine Test solution quality First week after an anaphylactic reaction Technical problem Old age Diabetes, peripheral neuropathy False positive Dermografism Egzema

24. Materials: Sputum Bronchial lavage Pleural effusion Gastric aspiration Serebrospinal fluid Urine Debrids of abscess Bone marrow Any tissue Microbiologic examination for tuberculosis Sputum ARB examination (smear) should be performed in at least 3 different materials

25. 5000-10000 bacilli/ml • Directmicroscopicexam. • Homogenisation • Culture Directmicroscopy is themostrapidandsimplediagnosticmethodforpulmonarytuberculosisand it showstheinfectiouspotential of thepatient. 10-100 bacilli/ml

26. Ziehl’s Neelsen Staining Carbolfuchsin Alcohol Methylen blue

29. Flourescent microscopic technique (Auromin rhodamine dye)

30. Culture for tb • Higher sensitivity • Isolation of MOTT • Drug sensitivity examination

31. Solid medium Löwenstein-Jensen: Conventional technique, egg based, sensitivity 80-85 %, specificity 98 %. 4-6 weeks of incubation. Middlebrook 7H10-7H11:non egg based Liquid medium BACTEC: radiometric determination of CO2, 14-21 days for bacterial growth MGIT: Flouresans increases as the oksigen is used by bacilli, 15-18 days of incubation

32. Other techniques for rapid diagnosis of tb: • PCR • Nucleic acide hybridization • HPLC (High performance liquid chromatoraphy) • RFLP (Restriction fragment length polymorphism) Typing, index case evaluation, resistance evaluation

33. Tuberculin skin test (PPD) • TheMantoux test (intracutaneusadministration of 5 units of purified protein derivatetuberculin) • Type IV (delayedtypehypersensitivity) reactionmaximum at 48-72 hours • 0,1 ml 5TU PPD is injectedintradermallyandthediameter of endurationformedafter 72 hours is recorded

34. In BCG vaccinated 0-4 mm negative 5-14 mm can be due to BCG >=15 mm positive Innon BCG vaccinated 0-4 mm negative If 5-9 mm Should be repeated in 7-14 days; ifsamenegative, If >=10 mm positive Interpretation

35. >=5 mm is accepted positive in: • Immunosuppresive patients • HIV (+) • Malnutrition

36. (Booster Phenomenon) • Delayedtypehypersensitivityresultingfrommycobacterialinfectionor BCG vaccinationmaygraduallywanewithyears. • Initial skin test resultsmay be negative, thestimulus of a first test mayboostorincreasethe size of thereactionto a second test administered 1 weeklater.

37. False Negative Reactions • Ante-allergicperiod • Causes of Anergy : • Viralinfections, varicella • Typhoo, Brucellosis, leprosy, pertusis • Lymphoidtissuediseases • Lymphoma, leukemia, sarcoidosis

38. Renalinsufficiency • Malnutrition • Viralvaccines • Imminosuppresivetreatment • Atopicdermatitis • MilierTb

39. Blood gas analysis • Examination of Arterial Blood Gas • Drawn from artery- radial, brachial, femoral • Invasive technique • Allen test should be performed if radial artery will be preferred

40. What Is An ABG? pH [H+] PCO2 Partial pressure CO2 PO2 Partial pressure O2 HCO3 Bicarbonate BE Base excess SaO2 Oxygen Saturation

41. Normal ABG values pH 7.35 – 7.45 PCO2 35 – 45 mmHg PO2 80 – 100 mmHg HCO3 22 – 26 mmol/L BE -2 - +2 SaO2 >95%

42. THORACENTESIS Diagnostic Thoracentesis is performed for the examination of fluid accumulated in the pleural cavity and is indicated in all cases of pleural efusion of unknown origin Therapotic thoracentesis is performed for the drainage of excess fluid accumulated in the pleural cavity

43. The site should be selected according to clinical examination If the effusion is small thoracentesis can be performed under ultrasound guidance After cleaning the skin with antiseptic solution a 20 gauge or larger needle is inserted above the superior aspect of the lower rib

44. Above the superior aspect of the lower rib to minimize the danger of injury to intercostal vessels and nerves

45. Pleural biopsy • Small biopsy from pariethal pleura • Cope needle or Abrams needle is used most frequently • Local anesthesia with 5-10 cc lidocain 2% • Indications: exudative effusions with unknown etiology

47. Bronchoscopy • Performed by Flexible Fiberoptic bronchoscope • Local anesthesia, sedation

48. Rigid Bronchoscopy

49. Diagnostic Abnormal chest radiograph Chronic cough Hemoptysis Localised wheese and stridor Bronchogenic carcinoma (Staging, follow up) Recurrent pneumonia Atelectasis Foreign body aspiration? Vocal cord paralysis, hoarseness Pulmonary infections Vocal cord or diaphragmatic paralysis Therapeutic Retained secretions, mucus plugs Foreign body Laser therapy Brachytherapy Tracheobronchial stent palcement Dilatation of stenosis Intralesional injection Therapeutic lavage Indications

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