Respiratory Diagnostics (Images)

19 Respiratory Diagnostics | David Chi-Leung Lam, Christopher Kim-Ming Hui, | Jamie Chung-Mei Lam, Julie Kwan-Ling Wang, | and Macy Mei-Sze Lui 19.1 CXRs and CT thorax images Case 1 A 56-year-old man presented with fever and cough with the fol- lowing chest X-ray. What is the radiological sign indicated by the arrows? Answer: Air bronchogram.

270 Problem-Based Medical Case Management 19.1 Below is the CT thorax of the same patient 5. 0y What is the name of this CT window? Answer: Lung window. Which lobes are most severely affected? Answer: The right and the left lower lobes, with the left lower lobe more extensively affected than the right lower lobe. What is the clinical diagnosis? Answer; Community-acquired pneumonia (bilateral lower lobe pneumonia). . Case 2 A 64-year-old woman who returned from an overseas trip com- . plained of fever and dyspnoea. With the following chest X-ray, the clinical diagnosis was community-acquired pneumonia.

19.1 Respiratory Diagnostics 271 Which lobe(s) of the lungs was/were involved? Answer: The right middle lobe and right lower lobe. The CXR shows right lower lobe consolidation and right middle lobe consolidation-collapse. The patient was suspected to have pneumonia. Suggest which anatomical description best fits this type of pneumonia. Answer: Multilobar pneumonia. Which are the common pathogens isolated in community- acquired pneumonia? Answer: Streptococcus pneumoniae, Hemophilus influenza, Moraxella catarrhalis, and Staphylococcus aureus. What are the tests for identification of these microbiologic pathogens? Answer: * Bacterial smear and culture of airway specimens (sputum or bronchial lavage). Blood culture for bacteria. “Atypical pneumonia” caused by Legionella pneumophila, Mycoplasma pneumoniae or Chlamydia psittacci are not

272 Problem-Based Medical Case Management 19.1 considered “isolates” as these microorganisms are difficult to be cultured and the diagnosis rely on clinical presentation, acute, and convalescent antibody titres, or urine for legionella antigen. In some laboratories, PCR tests for the microbes are available. Case 3 A 67-year-old lady, being a lifetime non-smoker and a housewife, complained of on-and-off cough and mucopurulent sputum pro- duction for the past 10 years, which was worse on getting up in the morning. She started to have low-grade fever, increased purulent, and bloodstained sputum 3 days ago. What is the radiological diagnosis? Answer: Bilateral infiltrates especially the lower lobes, with con- - solidation and areas suggestive of saccular dilatation of bronchi.

19.1 Respiratory Diagnostics 273 What is the clinical diagnosis? Answer: Given the long history of productive cough and CXR features of ring-shaped shadows, a clinical diagnosis of bronchi- ectasis is made. What is the most compatible radiological classification of this type of bronchiectasis? Answer: This radiological appearance is best described as vari- cose bronchiectasis. The radiological appearance of bronchiec- tasis could reflect the severity of the disease, with cylindrical bronchiectasis usually representing the least severe, varicose bronchiectasis the intermediate one, and cystic bronchiectasis being the most severe. If her sputum smear for acid-fast bacilli is positive, what is the Ppossible microbe? Answer: Culture may show Mycobacterium tuberculosis or atypi- cal mycobacteria (non-tuberculous mycobacteria).

274 Problem-Based Medical Case Management 19.1 Case 4 What is the best radiological description? Answer: Multiple cannon ball lesions. What is the likely cause? Answer: Metastatic cancer disease. Multiple cannon ball lesions are usually due to haematogenous spread from an extrapulmonary cancer primary, i.e., secondary tumor deposits in the lungs.

19.1 Respiratory Diagnostics 275 Case 5 A 30-year-old man was admitted for progressive dry cough and exertional dyspnoea for 1 week. How would you describe the abnormality in the lung fields? Answer: Bilateral ground glass opacification. His blood results showed lymphopenia. Which pathogen should be suspected with such radiological appearance? Answer: Pneumocystis jeroveci (in the past it was called Pneumocystis carinii) What is the blood test you would request? Answer: Test for HIV, especially if he has no known immunosup- Pression like lymphoma. How is the diagnosis of Pneumocystis pneumonia usually confirmed? Answer: Bronchoscopy with bronchoalveolar lavage showing Pneumocystis jeroveci (silver methenamine stain). In HIV-positive Subjects, induced sputum also has a high yield.

276 Problem-Based Medical Case Management 19.1 Case 6 What is this radiological pattern? Answer: Reticulonodular pattern. .00 ‘, 8 er

19.1 Respiratory Diagnostics 277 What is the best radiological description? Answer: Honeycombing, characteristic of interstitial pulmonary fibrosis. Case 7 A 70-year-old man presented with cough and exertional dyspnoea and the following chest X-ray. Where is the exact anatomical location of the abnormality? PA Erect Answer: Left upper lobe. See left upper lobe collapse in his lateral chest X-ray below.

278 Problem-Based Medical Case Management 19.1 Unlike the right side, there is no horizontal fissure in left lung, thus left upper lobe will collapse in antero-posterior dimension, folding up anterior to the oblique fissure.

19.1 Respiratory Diagnostics 279 Case 8 You were consulted on this chest X-ray of a patient just admitted to the adult intensive care unit with severe respiratory failure. She has just undergone emergency operation for ruptured appendix with peritonitis and septic shock last night. The health system record showed that her chest X-ray was reported to be completely normal 2 weeks ago during routine medical follow-up. How would you describe this pattern of lung shadow? Answer: Ground glass opacity and patchy airspace consolidation.

280 Problem-Based Medical Case Management 19.1 After endotracheal intubation and mechanical ventilatory support, a CT scan was done for the patient. What do you see on the CT thorax? Answer: Multilobar distribution of airspace consolidation with reticular opacities air bronchogram. What is the best description for those shadow locations (arrows)? Answer: Patchy peripheral airspace consolidation. What is the overall clinical scenario most compatible with? Answer: Acute respiratory distress syndrome. ARDS is characterized by acute onset of respiratory failure with severe hypoxaemia and bilateral diffuse infiltrates on chest X-ray in the absence of left atrial hypertension.

19.1 Respiratory Diagnostics 281 Case 9 This man complains of blood-streaked sputum for 3 months. Where is the lesion on the CXR? Answer: A mass is seen behind the heart (in the left lower lobe).

282 Problem-Based Medical Case Management 19.1 Case 10 What is the best description for the abnormality seen on following CXR? Answer: Right hydropneumothorax. This “straight line” appearance of fluid level is typical of hydro- pneumothorax, and not simply pleural effusion or hydrothorax. The right lung is collapsed. What are the possible causes? I. Lung entrapment syndrome. 1L Iatrogenic (post-chest tapping). Lung entrapment means the collapsed and diseased lung becomes entrapped after prolonged compression from fluid in chest cavity, especially when there is endobronchial obstruction preventing lung expansion. The lung fails to re-expand when the compressing fluid is removed, leaving an almost vacuum space in the pleural cavity.

19.1 Respiratory Diagnostics 283 Case 11 - A 60-year-old female patient presented with recent onset of haem- optysis. She has a long history of scanty chronic sputum produc- tion daily and consulted a general practitioner a few times a year for increased purulent sputum. Name two abnormalities on this chest X-ray and the working diagnosis. Answer: CXR showed nodular fibrocalcific foci over left lung apex, with left apical fibrosis and deviation of trachea to the left side, compatible with old pulmonary tuberculosis (TB).

284 Problem-Based Medical Case Management 19.1 Name three investigations important for delineating the reason for her haemoptysis. 1. Sputum for acid-fast bacilli and culture to look for reactivation of TB. 2. Bronchoscopy to assess for airway lesion. 3. Computed tomography of the thorax—having both HRCT and spiral CT would be useful to look for bronchiectasis and further define parenchymal lesions as patient has new onset of hemoptysis. What do you see on the CT thorax? Answer: Left apical fibrosis, calcific nodules, and bronchiectasis, consistent with old pulmonary tuberculosis. ‘What may you find on bronchoscopy? Answer: Bronchoscopy showed stenotic left upper lobe orifice, with bloody effluent retrieved from the left lung apex.

19.2 Respiratory Diagnostics 285 19.2 Lung function tests Case 1 A 33-year-old man complained of nocturnal cough for 2 months. Spirometry was performed both pre- and post- bronchodilator (Salbutamol MDI for 2 puffs, i.e., 200 ug, via spacer) DEPARTMENT OF MEDICINE UNIVERSITY OF HONG KONG QUEEN MARY HOSPITAL ( E3-04) Gender: Male Date: 11/08/15 Age; 33 Race: Asian Temp: 23 PBar: 741 Height(cm): 172 Weight(kg): 74.0 PRERX POST-RX Spirometry TP PRED BEST %PRED BEST %PRED % CHO Fve Liters 4.29 498 16 499 "7 0 FEVY Liters 3.60 32 L 374 104 17 FEVIFVC % 8 o 7% 75 88 16 FEF26-78% Lisec. 4.00 1.68 42 290 73 kel F Usec 8.67 9.851 101 9.80 101 0 PEFT Sec 0.08 011 @ Five Liters 382 462 118 450 18 -3 Fivi Liters 437 414 5 FEFIFIFSO <%0 037 088 78 Vol Extrap Liters 0.05 0.43 160 FVL ECode 000000 000000 M Umin 31 f BPM 16, Al PRED __ PRED., PRE POST 2 PRE T POST _— 8l 1 Volume o 3 0 6+ « pul s s i 1 Fr s o ?Inl “m'l 8 8 2 Time. 5 L] 7 8 Technician Remark(s) EX-SMOKER HALF A YEAR Interpretation: CALIBRATION: Prod Volume: 3.00 Expire Avg: 301 Inspire Avg: 3.00 Flow Cal Date: 11108115 )= OUTSIDE 95% CONFIDENCE INTERVAL PF Reference: Mary Ip HK Ref Set. Version: IVS-0101-27-3b

286 Problem-Based Medical Case Management 19.2 Questions 1. 2. Describe the spirometric abnormalities. What is the diagnosis? Answers 1. 2. Mild airflow obstruction with significant reversibility after bronchodilator (i.e., positive bronchodilator response). Asthma Description 1. Reduced FEV, (at 89% of predicted when FVC was at 116% of predicted) and reduced FEV,/FVC ratio (at 64% when the predicted is 85%), compatible with airflow obstruction . There was significant improvement in FEV, after bronchodila- tor (530 ml and 17% increase), which was consistent with a': diagnosis of asthma. ' Discussion 1. The American Thoracic Society defines that a 12% or more representing a 200 mL or more increase in FVC or FEV, in the post-bronchodilator result above the pre-bronchodilator state suggests a significant bronchodilator response in adults. . The diagnosis of asthma is based upon the presence or history of symptoms consistent with asthma (most commonly episodic . cough, wheezing, or dyspnoea provoked by typical triggers). The diagnosis of asthma is substantiated by the demonstration . of variable expiratory airflow obstruction or a significant bron- chodilator response in spirometry. However, a normal spirom etry at stable state does not rule out asthma.

19.2 Respiratory Diagnostics 287 Case 2 A 37-year-old woman complained of dry cough and progressive shortness of breath on exertion for 3 months. DEPARTMENT OF MEDICINE Page1of 1 UNIVERSITY OF HONG KONG QUEEN MARYHOSPITAL (E3-04) LUNG FUNCTION STUDY REPORT Name: ABC, 1d: 01111 Gender; Female Date: 01/01/00 Age:37 Race: Asian Temp: 22 PBar: 743 Height(cm): 157 Weight(kg): 59.1 Physician: Diagnosis: Technician: Da Fl Sty Ref Pre Pre Post Post Post fl Mess % Ref Meas % Ref % Chg FVC Liters 287 126 44 FEV1 Liters. 243 106 Bl FEVIFVC % 85 B4 bl FEF25-T5%L/sec 27 155 56 Livec 530 368 75 FEFTS% Usec 126 045 3 PEF Liec 697 43 & FVC e 27 103 3 FIF50% Lisec 115 Lung Volume e Liters 423 244 ve Liers 281 126 45 ic Liters 219 085 3 ERV Liters 110 033 30 1 RV Liters. 124 118 05 i RUTLC % % 48 88 ] Dfi;::gcaanw Hb: 106 grvdl. -, . - _ Q mUmmigmin 208 66 a2 - DLAG mmmm: 208 713 35 N2 Vound DLCOVA mlimHg/mink 516 363 70 & Kroghs K 1/min 313 VA Liers a2 1 @ FICHs % 0300 © 0.300 FECO & 0086 » BHT Sec 1268 Ve e 106 2 L S S T s ¢ Voidme ol — Volums DLCO (Volume & Gast% vs Time) 0 . 4 . il 0.4 4 4 00 2 4] 0 e [ EINAT T SR T NON-s'fl'" Rumnk(s) T LUNG VOLUME DONE BY N2 WASHOUT | Intarprotation lwmm.uarthKRefSet

288 Problem-Based Medical Case Management 19.2 Questions 1. What are the abnormalities seen in this full lung function test? 2. Name one medical condition with these lung function test findings. Answers 1. A restrictive pattern with reduced total lung capacity, functional residual capacity, residual volume, and diffusion capacity from carbon monoxide. Decreased KCO as well as DLCO suggests parenchymal involvement. Flow rates (FEV, and FVC) are reduced, and this is related to the decreased lung volumes. The FEV /FVC ratio is normal. . Interstitial lung disease (ILD). Discussion 1. In a patient of this sex (female) and age (37 years), one must consider ILD including pulmonary fibrosis associated with con- nective tissue diseases. , This lung function test pattern suggests diffuse parenchymal lung disease, and the diagnosis of disease will depend on the clinical features of the patient. Patients are usually in hypoxaemic state, in type 1 respiratory - failure. The resting arterial blood gas may be normal or showing . low PO, (secondary to ventilation-perfusion mismatching) and - respiratory alkalosis. .

19.3 Respiratory Diagnostics 289 19.3 Sleep case studies with polysomnograms Case 1 A 65-year-old man presents with shortness of breath and bilateral ankle oedema. ¢ sy L " 1 i = i 1 3 i 3 iBER i o = 9 H i i 3 g o Ei i . 3 - % 4 . 3 = P 3 = 3 R = ~ 1 | ® 5 i il [ Fe T =11 dk 4 L ks 5 » N I T 1 : B W

290 Problem-Based Medical Case Management 19.3 Question What is shown in this epoch of polysomnographic tracing? Answer 1. Cheyne-Stokes breathing with central sleep apnoea. 2. Cheyne-Stokes breathing is defined as a crescendo-decrescendo pattern of breathing with central hypopnoea or apnoea at trough. 3. This may be associated with frequent arousals from sleep, which occur at the highest point of ventilatory effort, rather than at apnoea termination. Discussion The two most common causes of Cheyne-Stokes breathing are congestive heart failure and neurological diseases. Significant arterial oxygen desaturation is common in patients with Cheyne-Stokes breathing during sleep, despite a normal daytime oxygen saturation.

19.3 . Respiratory Diagnostics 291 Case 2 This polysomnographic result belongs to a 50-year-old man who kicks in sleep. o] i & o]l [nfnf o] ] ] 9] [—

292 Problem-Based Medical Case Management 19.3 Question What is the diagnosis? Answer Periodic limb movements (PLM) in sleep. Description There are repetitive right leg movements that occur at regular inter- vals in this polysomnography (LEMG-R). Some of these leg movements are associated with arousals. Discussion Periodic leg movements in sleep occur most commonly in sleep stages 1 and 2, and less commonly during REM sleep. Periodic leg movements can be idiopathic, or caused by end- stage renal failure, pregnancy, iron deficiency, and certain drugs. There may be an abnormality in iron transport into the central nervous system or in use of iron in dopaminergic neuronal transmission. ‘ PLM does not necessarily cause excessive daytime sleepiness, and if so, it is called PLM disorder (PLMD). They should be dif- ferentiated from restless leg syndrome (RLS), which is a clinical diagnosis of daytime symptoms of “restless legs”.

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294 Problem-Based Medical Case Management 19.3 Question What might this patient’s spouse notice during the recording period? Answer ¢ Episodes of cessation of breathing (apnoea). ¢ Interrupted snoring. Description Snoring is produced by vibration of the soft tissues of the upper airway during sleep. In apnoea, there should be no airflow at nose or mouth nor snoring due to complete cessation of airflow. Snoring, however, may persist during partial collapse of upper airway (in hypopnoea). She may notice persistent thwarted move- ments of the thorax and abdomen. Discussion This tracing shows episodes of obstructive apnoea. Note that - during an episode of obstructive apnoea, respiratory effort persists (thoracic and abdominal movements), but there is no inspiratory flow, and Sa0, drops progressively till a greater respiratory effort (producing snoring) overcomes the obstruction temporarily and results in rise of Sa0, again. The diagnosis of obstructive sleep apnoea, however, cannot be made based on this tracing alone : because at least 4 hours of sleep study is needed to document the - total number of apnoea/hypopnoea during sleep. An apnoea/hypo- pnoea index = 5 (total no. of apnoea/hypopnoea divided by total sleep time in hours) is a commonly used definition for obstructive - sleep apnoea. -