Diagnostic methods in pulmonology RASOUL ALIANNEJAD Diagnostic methods

Diagnostic methods in pulmonology RASOUL ALIANNEJAD

Diagnostic methods in pulmonology

Diagnosis Prognosis Treatment

Diagnostic Methods Tools/tes t process

Symptoms Signs disease

Hypothesis Test Diagnosis

• Hypothesis DDx Physical ex • Hypothesis History • Hypothesis generation/revis ion Problem list • Testing hypothesis Diagnostic tests Final diagnostic

Data Hypothesis generation Diagnosis Patient Questions Data gathering Hypothesis evaluation

History & PHx Anatomical investigation functional investigation Infectious test Integrative test : CPET, PSG • Radiology imaging • Bronchoscopy • Ventilation tests • Perfusion tests • Diffusion tests • Sputum based • Blood samples based

Taking history

Physical examination

Anatomical investigation

Chest X-ray

Chest CT scan

CHEST CT Angiography

Ventilation/perfusion scan

CHEST PET/CT scan

Fiberoptic bronchoscopy

Fiberoptic bronchoscopy(FOB)

Endobronchial ultrasound(EBUS)

Thoracentesis

Plural biopsy

Medical Thoracoscopy

Mediastinoscopy

Functional investigation

History & PHx • Radiology imaging Anatomical investigation • Bronchoscopy functional investigation Infectious test Integrative test : CPET, PSG • Ventilation tests • Perfusion tests • Diffusion tests • Sputum based • Blood samples based

What is Spirometry? Spirometry is a method of assessing lung function by measuring the volume of air the patient can expel from the lungs after a maximal expiration.

Why Perform Spirometry? Confirm presence of airway obstruction Assess severity of airflow obstruction Monitor disease progression Assess response to therapy Assess prognosis (FEV 1)

Flow Measuring Spirometer

Small Hand-held Spirometers

muscles of respiration inspiratory muscles neck musculature expiratory muscles internal intercostal abdominal musculature external intercostal diaphragm

maximal deep inspiration sternocleidomastoideus scalenis

the limits of breathing maximal inspiration maximal expiration

mechanics during spirometry volume neck muscles elasticity diaphragm elasticity & abdominal muscles diaphragm abdominal muscles time

maximal movements of the chest “vital capacity” maximal inspiration TLC-niveau maximal expiration RV-niveau

limits of the vital capacity volume deep inspiration _ VC visceral pleura VC deep expiration + time _ 0 _ + + intrathoracic pressure airway closure

trumpet or funnel model sum of the transverse areas of each branching generation amount crosssection total area trachea 0 convection 3 cm 2 segmental bronchi 3 diffusion 1 0 flow speed 20 0, 15 cm 2 6 cm 2 respiratory bronchioli 18 2. 105 0, 00195 cm 2 390 cm 2

airflow PPAlv VV PAtm Poiseuille’s law alveolar pressure muscular strength airflow is dependent on: elasticity resistance airway collapse airway obstruction

alveolar and intrathoracic pressure PAlv Palv = Pint. th = Pcw + Pmusc + Plung

expiratory airway collaps PAlv pressure PAtm transmural pressure Plung Pcw intra-thoracic pressure Equal Pressure Point Pmusc alveolus airway mouth

airways and lung parenchyma connective tissue cartilage smooth muscle alveolar walls loss alveolar septa

airway mechanics in lung emphysema flow + Plung + P volume expiration Plung Pcw Pmusc alveolus airway mouth F-V curve in lung emphysema inspiration

Lung Volume Terminology Inspiratory reserve volume Total lung capacity Inspiratory capacity Tidal volume Expiratory reserve volume Residual volume Vital capacity

Normal Trace Showing FEV 1 and FVC Volume, liters 5 4 FEV 1 = 4 L 3 FVC = 5 L 2 FEV 1/FVC = 0. 8 1 1 2 3 4 5 Time, seconds 6

Flow Volume Curve Maximum expiratory flow (PEF) Expiratory flow rate L/sec TLC FVC Inspiratory flow rate L/sec Volume (L) RV

FEV 1 FVC • Forced expiratory volume in one second • Forced vital capacity: • The total volume of air that can be forcibly exhaled in one breat FEV 1/FVC • The fraction of air exhaled in the first second relative to the total volume exhaled MEFR • Derived from the mid portion of the flow volume curve VC • A volume of a full breath exhaled in the patient’s own time and not forced. Often slightly greater than the FVC, particularly in COPD

Criteria for Normal Post-bronchodilator Spirometry • FEV 1: % predicted > 80% • FVC: % predicted > 80% • FEV 1/FVC: > 0. 7

Normal Trace Showing FEV 1 and FVC Volume, liters 5 4 FEV 1 = 4 L 3 FVC = 5 L 2 FEV 1/FVC = 0. 8 1 1 2 3 4 5 Time, seconds 6

Spirometry: Obstructive Disease Volume, liters 5 4 Normal 3 FEV 1 = 1. 8 L 2 FVC = 3. 2 L 1 FEV 1/FVC = 0. 56 1 2 3 4 5 Time, seconds 6 Obstructive

Criteria: Restrictive Disease • FEV 1: % predicted < 80% • FVC: % predicted < 80% • FEV 1/FVC: > 0. 7

Spirometry: Restrictive Disease Normal Volume, liters 5 4 3 Restrictive FEV 1 = 1. 9 L 2 FVC = 2. 0 L 1 FEV 1/FVC = 0. 95 1 2 3 4 5 Time, seconds 6

Flow Volume Curve Patterns Obstructive and Restrictive Severe obstructive Volume (L) Reduced peak flow, scooped out midcurve Restrictive Expiratory flow rate Obstructive Volume (L) Steeple pattern, reduced peak flow, rapid fall off Volume (L) Normal shape, normal peak flow, reduced volume

Spirometry: Abnormal Patterns Restrictive Time Slow rise, reduced volume expired; prolonged time to full expiration Mixed e Volume Obstructive Time Fast rise to plateau at reduced maximum volume Time Slow rise to reduced maximum volume; measure static lung volumes and full PFT’s to confirm

Body Plethysmography TGV =FRC TLC RV Raw

Lung diffusion capacity(DLco)

Arterial blood gas(ABG) Pa. O 2 Pa. CO 2 PH HCO 3

Pulse oximetry

Ergospirometry VO 2 VCO 2 pulse Breathing reserve EQ CO 2 EQ O 2 ET CO 2

Polysomnography

Sputum examination

Sputum culture