Thorax cardio adult dyspnea imaging g ferretti

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Thorax cardio adult dyspnea imaging g ferretti

  1. 1. G  Ferretti     University  hospital  of  Grenoble,  France    
  2. 2. ¡  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  
  3. 3. 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.    
  4. 4. ¡  lung  parenchyma   ¡  airways     ¡  vessels   ¡  pleura   ¡  thoracic  wall  
  5. 5. Initial  Diagnostic  Studies  includes   ¡  Electrocardiography     ¡  Spirometry     ¡  Laboratory  evaluation   ¡  Chest  Radiography  
  6. 6. Acute infectious pneumonia Left atelectasis
  7. 7. ¡  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  
  8. 8. §  FEV1  /  FVC    <  70%    post-­‐bronchodilator   §  Role  of  CT   §  Phenotyping  COPD   §  Search  for  complications   §  Selection  of  patient  before  treatment    
  9. 9. Centrilobular  emphysema   45  yo  smoking  man  
  10. 10. Expiration Bronchial wall thickening Bronchiectasis Air trapping Small airway diseases
  11. 11. constrictive bronchiolitis inspiration minIP inspiration expiration
  12. 12. séquelle bronchiolite 2d SERGEANT_FREDERIc average 17 yo man chronic dyspnea MacLeod / Syver James syndrome minIP MIP focal areas of decreased lung opacity with sharp margins, reduced-size pulmonary vessels, bronchial wall thickening, and bronchiectasis.
  13. 13. Sub acute Hypersensitivity Pneumonitis
  14. 14. 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
  15. 15. 56 yo man, COPD Recent worsening of chronic dyspnea End inspiratory CT: sabersheath trachea End expiratory VCT: airway collapse < 50% Dynamic expiratory VCT shows expiratory airway collapse > 70% VCT shows bowing of posterior membranous TBM confirmed by bronchoscopy Inspiration End expi During expi
  16. 16. High grade mucoepidermoid
  17. 17. ¡  25  yo  female     ¡  Chronic  obstructive  disease   ¡  FEV1:  2.36L;  64%   ¡  FEV1  /  VC:  72%   ¡  Treatment  for  asthma  failed   ¡  Proposed  diagnostic:  complicated  asthma  
  18. 18. IV  contrast  injection     Expiratory  CT   MIP     4.  Nothing,  I’m  glad  with  the  CT  I’ve  done   1.  2.  3. 
  19. 19. IV  contrast  injection     Expiratory  CT   MIP     4.  Nothing,  I’m  glad  with  the  CT  I’ve  done   1.  2.  3. 
  20. 20. ¡  Dynamic  stenosis  of  the  LMB  due  to  the   compression  between  the  aorta  and  the   thoracic  spine    
  21. 21. ¡  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  
  22. 22. Pulmonary lymphangioleiomyomatosis
  23. 23. Langerhans cell histiocytosis
  24. 24. 42 yo woman Mild dyspnea
  25. 25. Possible NSIP in a patient with systemic sclerosis
  26. 26. 83 yo man Dyspnea at exercise Worked as a dentist Silicosis complicated with emphysema
  27. 27. ¡  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.    
  28. 28. ¡  Rarely  needed   ¡  Useful  in  diagnosing     §  Chronic  Thromboembolism  of  PA     §  fibrosing  mediastinitis   ¡  Is  recommended  in  case  of  mosaic  pattern   with  unremarkable  PFT.  
  29. 29. 62yo patient with chronic dyspnea at exercise CT without CM injection
  30. 30. 50 yo woman complaining of dyspnea at exercise associated with palpitation. 53 kg for 163cm
  31. 31. TDM  
  32. 32. 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
  33. 33. Contrast-enhanced high-resolution computed tomography of the chest. Seferian A et al. Circulation 2012;125:2045-2047 Copyright © American Heart Association
  34. 34. PAHT VOD
  35. 35. ¡  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  
  36. 36. ¡  Common  pulmonary  causes  include     §  asthma   §  pneumothorax   §  upper  airway  obstruction   §  interstitial  lung  disease   §  pulmonary  embolism   §  pulmonary  hypertension  
  37. 37. ¡  2005   ¡  83  yo  women   ¡  No  particular  history     ¡  Acute  dyspnea   ¡  Unremarkable  CXR   ¡  Angio  CT  for  suspected  PE    
  38. 38. Acute PE
  39. 39. ¡  2010     ¡  88  yo   ¡  Rapid  onset  of   dyspnea   ¡  Weight  loss  
  40. 40. New epidode of thrombo-embolic PE?
  41. 41. Sarcoma of the pulmonary artery
  42. 42. Gravité de l’EP : signes d’ICDA Collomb Eur Radiol 2002 VD / VG > 1 : valeur pédictive forte pour réanimation, thrombolyse, mortalité à 30 j Schoepf U Circulation 2004
  43. 43. 68 yo man acute leukemia Fever Dyspnea CXR 22/02/2013
  44. 44. Crazy paving PCP pneumonia
  45. 45. Measles severe
  46. 46. ¡  62  yo  man   ¡  Immunocompetent     ¡  Recent  fatigue  weigh  loss  anorexia     ¡  Fever     ¡  Cough   ¡  acute  respiratory  distress…  ICU  
  47. 47. Invasive Aspergillosis
  48. 48. 42 yo female Chronic dyspnea: PHT CT: PA embolism ?
  49. 49. Undiagnosed partial anomalous pulmonary venous return
  50. 50. ¡  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    
  51. 51. Grenoble

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