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G	
  Ferretti	
  	
  
University	
  hospital	
  of	
  Grenoble,	
  France	
  
	
  
¡ 

Dyspnea	
  is	
  generally	
  defined	
  as	
  a	
  subjective	
  
experience	
  of	
  breathing	
  discomfort	
  

¡...
Dyspnea	
  may	
  be	
  of	
  neurogenic,	
  respiratory,	
  or	
  cardiac	
  
origin,	
  and	
  may	
  be	
  associated	
...
¡  lung	
  parenchyma	
  
¡  airways	
  	
  
¡  vessels	
  
¡  pleura	
  
¡  thoracic	
  wall	
  
Initial	
  Diagnostic	
  Studies	
  includes	
  
¡  Electrocardiography	
  	
  
¡  Spirometry	
  	
  
¡  Laboratory	
  ...
Acute infectious pneumonia

Left atelectasis
¡  The	
  cases	
  in	
  which	
  CXR	
  shows	
  evident	
  etiology	
  

of	
  dyspnea	
  will	
  not	
  be	
  discusse...
§ 

FEV1	
  /	
  FVC	
  	
  <	
  70%	
  	
  post-­‐bronchodilator	
  

§ 

Role	
  of	
  CT	
  
§  Phenotyping	
  COPD	...
Centrilobular	
  emphysema	
  
45	
  yo	
  smoking	
  man	
  
Expiration

Bronchial wall thickening
Bronchiectasis
Air trapping
Small airway diseases
constrictive bronchiolitis

inspiration

minIP inspiration

expiration
séquelle bronchiolite 2d
SERGEANT_FREDERIc

average
17 yo man chronic dyspnea
MacLeod / Syver James syndrome

minIP

MIP

...
Sub acute Hypersensitivity Pneumonitis
Tracheobronchomalacia (TBM)
● 

characterized by increased compliance and
excessive collapsibility of trachea and / or
bro...
56 yo man, COPD
Recent worsening of
chronic dyspnea
End inspiratory CT: sabersheath trachea
End expiratory VCT:
airway col...
High grade mucoepidermoid
¡  25	
  yo	
  female	
  	
  
¡  Chronic	
  obstructive	
  disease	
  
¡  FEV1:	
  2.36L;	
  64%	
  

¡  FEV1	
  /	
  ...
IV	
  contrast	
  injection	
  	
  
Expiratory	
  CT	
  
MIP	
  	
  
4.  Nothing,	
  I’m	
  glad	
  with	
  the	
  CT	
  I...
IV	
  contrast	
  injection	
  	
  
Expiratory	
  CT	
  
MIP	
  	
  
4.  Nothing,	
  I’m	
  glad	
  with	
  the	
  CT	
  I...
¡  Dynamic	
  stenosis	
  of	
  the	
  LMB	
  due	
  to	
  the	
  

compression	
  between	
  the	
  aorta	
  and	
  the	...
¡ 

HRCT	
  is	
  the	
  most	
  sensitive	
  modality	
  for	
  diagnosing	
  
early	
  emphysema	
  in	
  smokers	
  wi...
Pulmonary lymphangioleiomyomatosis
Langerhans cell histiocytosis
42 yo woman
Mild dyspnea
Possible NSIP in a patient with systemic sclerosis
83 yo man
Dyspnea at exercise
Worked as a dentist

Silicosis complicated
with emphysema
¡ 

HRCT	
  the	
  best	
  non	
  invasive	
  tool	
  

¡ 

particularly	
  appropriate	
  when	
  the	
  results	
  of	...
¡  Rarely	
  needed	
  
¡  Useful	
  in	
  diagnosing	
  	
  
§  Chronic	
  Thromboembolism	
  of	
  PA	
  	
  
§  fibr...
62yo patient with chronic dyspnea at
exercise
CT without CM injection
50 yo woman complaining of dyspnea at
exercise associated with palpitation.
53 kg for 163cm
TDM	
  
A 77-year-old woman was referred to our center for the workup of progressive exertional
dyspnea.
Ventilation perfusion lun...
Contrast-enhanced high-resolution computed tomography of the chest.

Seferian A et al. Circulation 2012;125:2045-2047

Cop...
PAHT
VOD
¡  Frequent	
  in	
  ER	
  or	
  ICU	
  
¡  May	
  be	
  associated	
  with	
  a	
  severe	
  prognosis	
  
¡  Need	
  ...
¡  Common	
  pulmonary	
  causes	
  include	
  	
  
§  asthma	
  
§  pneumothorax	
  
§  upper	
  airway	
  obstructio...
¡  2005	
  
¡  83	
  yo	
  women	
  
¡  No	
  particular	
  history	
  	
  
¡  Acute	
  dyspnea	
  
¡  Unremarkable	
...
Acute PE
¡  2010	
  	
  
¡  88	
  yo	
  
¡  Rapid	
  onset	
  of	
  

dyspnea	
  
¡  Weight	
  loss	
  
New epidode of thrombo-embolic PE?
Sarcoma of the pulmonary artery
Gravité de l’EP : signes d’ICDA
Collomb Eur Radiol 2002

VD / VG > 1 : valeur pédictive forte pour
réanimation, thrombolys...
68 yo man acute leukemia
Fever
Dyspnea
CXR 22/02/2013
Crazy paving
PCP pneumonia
Measles severe
¡  62	
  yo	
  man	
  
¡  Immunocompetent	
  	
  
¡  Recent	
  fatigue	
  weigh	
  loss	
  anorexia	
  	
  
¡  Fever	
...
Invasive Aspergillosis
42 yo female
Chronic dyspnea: PHT
CT: PA embolism ?
Undiagnosed partial anomalous pulmonary venous return
¡ 

CXR	
  is	
  the	
  first	
  line	
  technique	
  in	
  patients	
  with	
  dyspnea	
  

¡ 

in	
  case	
  of	
  unre...
Grenoble
Thorax cardio adult dyspnea imaging g ferretti
Thorax cardio adult dyspnea imaging g ferretti
Thorax cardio adult dyspnea imaging g ferretti
Thorax cardio adult dyspnea imaging g ferretti
Thorax cardio adult dyspnea imaging g ferretti
Thorax cardio adult dyspnea imaging g ferretti
Thorax cardio adult dyspnea imaging g ferretti
Thorax cardio adult dyspnea imaging g ferretti
Thorax cardio adult dyspnea imaging g ferretti
Thorax cardio adult dyspnea imaging g ferretti
Thorax cardio adult dyspnea imaging g ferretti
Thorax cardio adult dyspnea imaging g ferretti
Thorax cardio adult dyspnea imaging g ferretti
Thorax cardio adult dyspnea imaging g ferretti
Thorax cardio adult dyspnea imaging g ferretti
Thorax cardio adult dyspnea imaging g ferretti
Thorax cardio adult dyspnea imaging g ferretti
Thorax cardio adult dyspnea imaging g ferretti
Thorax cardio adult dyspnea imaging g ferretti
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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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