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Sputum, chest x rays & spirometry
- 2. Examination of sputum Radiology of chest CT MRI Bronchoscopy Lung biopsy Thoracoscopy Pulmonary function test
- 7. Three layer test In conditions like bronchiectasis and lung abscess the sputum forms three distinct layers Thick Nummular purulent sputum below Serous fluid in middle Froth above
- 8. RUSTY SPUTUM
- 10. CURSHMANS SPIRAL
- 11. SPUTUM IN BRONCHIAL ASTHMA
- 14. BRONCHIAL ASTHMA
- 15. CYSTIC FIBROSIS
- 25. PULMONARY FUNCTION TESTING • Process of having the patient perform specific inspiratory and expiratory maneuvers • Important to be familiar with these tests and values even if you do not work in a PFT lab • Used for the following: • Medical diagnosis • Surgery related evaluation • Disability evaluation • Public Health/Research • Studying the effects of exercise on the lungs
- 26. CONTRAINDICATIONS •Recent abdominal, thoracic, or eye surgery •Hemodynamic instability •Symptoms of acute severe illness •Chest pain, nausea, vomiting, high fever, dyspnea •Recent hemoptysis •Pneumothorax •Recent history of abdominal, thoracic, or cerebral aneurysm
- 27. PATIENT INSTRUCTIONS PRIOR TO TESTING • Should not drink alcohol for four hours prior to test • Should not smoke at least one hour before test • Do not eat a large meal two hours prior to test • No vigorous exercise 30 minutes before test • Do not wear tight fitting clothes • May need to remove loose dentures for test • Should wait at least one month post MI, consider impact of problems that may affect results (chest/abdominal pain, oral or facial pain, stress incontinence, dementia, physical deformities or medical conditions) • Bring a list of all medications – potentially withhold bronchodilators, corticosteroids
- 28. CLASSIFICATION OF LUNG DEFECTS OBSTRUCTIVE • Expiratory flow is below normal • Anatomic site can be identified • Diseases: • Cystic fibrosis • Bronchitis • Asthma • Bronchiectasis RESTRICTIVE • Lung volumes are reduced • Diseases: • Neuromuscular • Cardiovascular • Pulmonary • Trauma/chest wall dysfunction • Obesity
- 29. NORMAL SPIROGRAM
- 30. SPIROGRAM Volumes • Tidal Volume • Minute Volume • Residual Volume • Inspiratory Reserve Volume • Expiratory Reserve Volume Capacities • Vital Capacity • Total Lung Capacity • Function Residual Capacity • Inspiratory Capacity
- 31. VITAL CAPACITY •Forced (FVC) •Requires proper coaching •Three distinct phases •Decreased in both obstructive and restrictive diseases
- 32. SLOW VITAL CAPACITY Slow (SVC) Helps avoid air trapping
- 33. TOTAL LUNG CAPACITY • Increased with obstructive disease • Decreased with restrictive disorders • Sum of the vital capacity and residual volume • Obtain RV by: • Body plethysmography • Nitrogen washout • Helium dilution
- 34. BODY PLETHYSMOGRAPHY • Uses the “body box” • Boyles Law Unknown lung gas vol = Gas pressure of the box Known box gas vol Gas pressure of the lungs
- 35. In body plethysmography, the patient sits inside an airtight box, inhales or exhales to a particular volume (usually FRC), and then a shutter drops acroSs their breathing valve. The subject makes respiratory efforts against the closed shutter causing their chest volume to expand and decompressing the air in their lungs. The increase in their chest volume slightly reduces the box volume and thus increases the pressure in the box. This method of measuring FRC actually measures all the conducting pathways including abdominal gas; the actual measurement made is VTG (Volume of Thoracic gas).
- 36. NITROGEN WASHOUT • Open circuit method • Patient breathes 100% oxygen while the nitrogen washed out of the lungs • Assumes 79% of lung volume is nitrogen • Several “problems” with this test
- 37. HELIUM DILUTION • Closed system • Known volume and concentration of He added and it will be diluted in proportion to the size of the lung volume
- 38. FEV1 • Maximal volume exhaled during the first second of expiration • Best indicator of obstructive lung disease • Flow characteristics of the larger airways • Best expressed as a percentage of the FVC (FEV1/FVC) • Should be able to exhale 70% of the vital capacity in the first second • Decreased in obstructive disorders
- 39. FORCED EXPIRATORY FLOW • Examines the middle 50% of the exhaled curve • Reflects degree of airway patency/condition of the medium to small airways • Early indicator of obstructive dysfunction • Normal value is 4-5 L/sec FEF 25-75%
- 40. FORCED EXPIRATORY FLOW FEF 200-1200 • Average flow after the first 200ml is exhaled • Good indicator of the integrity of large airway funtioning • Decreased in obstructive disorders • Normal value is 6-7L/se
- 41. PEAK EXPIRATORY FLOW RATE • Maximum flow rate achieved during an FVC • Used in asthmatics to identify the severity of airway obstruction and guide therapy • Dependent on patient effort • Normal value is 10L/sec (600L/min), decreases with age and obstruction
- 42. MAXIMUM VOLUNTARY VENTILATION • MVV – patient breathes as fast and deep as possible for 12-15 seconds • Tests for overall lung function, ventilatory reserve capacity and air trapping • Normal = 170L/min • Decreased in obstructive disorders
- 43. FLOW VOLUME LOOPS Restrictive Obstructive
- 45. DIFFUSION CAPACITY (DL) • Represents the gas exchange capabilities of the lungs • Measures the ability of gas to diffuse across the alveolar-capillary membrane using carbon monoxide: DLCO
- 46. DLCO • Diseases that reduce surface area – DL • emphysema • Interstitial altering of the membrane integrity - DL • Pulmonary fibrosis, Asbestosis, Sarcoidosis
- 47. EVALUATION OF RESULTS Evaluation of the Vital Capacity • can be reduced in obstructive and restrictive disease • if VC is reduced, evaluate the TLC • if the TLC is increased = obstruction • if the TLC is decreased = restriction • if VC is normal, evaluate the TLC • if the FVC is greater than 90% of the SVC = normal • if the FVC is less than 90% of the SVC = obstruction
- 48. EVALUATION OF RESULTS • Evaluation of FEF 25-75% • if normal then normal lungs or possible restriction • if reduced = peripheral obstruction • Evaluation of the FEV1/FVC • if the FEV1/FVC is normal then the lungs are normal or restrictive • if the FEV1/FVC is reduced = obstruction • Evaluation of the Total Lung Capacity: % pred. • increased =hyperinflation present evaluate the FEV1 Normal = normal lungs Decreased = obstruction • Decreased evaluate the FEV1 Normal = restrictive Decreased = obstructive and restrictive
- 49. Investigations Indication/comment Bedside Peak flow rate Monitoring of asthma/acute asthma Oximetry Respiratory failure Assessment of oxygen requirements
- 50. Investigations Indication/comment Urine tests Pneumococcal capsular antigen Pneumococcal bacteraemia Legionella urinary antigen Legionnaire’s disease
- 51. Investigations Indication/comment Skin tests Mantoux test Exposure to Mycobacterium tuberculosis Allergen skin prick tests Atopic status (asthma) Sweat test Cystic fibrosis in children
- 52. Investigations Indication/comment Blood tests White cell count High in lower respiratory tract infection Haematocrit Elevated in polycythaemia Eosinophil count High in: Allergic asthma Pulmonary eosinophilia Allergic bronchopulmonary aspergillosis Churg–Strauss syndrome
- 53. Investigations Indication/comment C REACTIVE PROTEIN High in: Pneumonia Empyema Serum sodium Reduced in: Small cell lung cancer (inappropriate antidiuretic hormone (ADH) secretion) Legionnaire’s disease and any severe pneumonia
- 54. Blood and urine osmolality Inappropriate ADH secretion Serum calcium Elevated in bony metastases, sarcoidosis and squamous cell lung cancer Liver function tests Metastatic liver disease Immunoglobulins Deficiencies in bronchiectasis Angiotensin-converting enzyme activity Elevated in sarcoidosis
- 55. Alpha-1-antitrypsin Deficiency in hereditary panacinar emphysema Total and specific (radioallergosorbent test) IgE Atopic status (asthma) Antinuclear factor Idiopathic pulmonary fibrosis (fibrosing alveolitis) Antineutrophil cytoplasmic antibody (ANCA) Proteinase 3 (cANCA) Myeloperoxidase (pANCA) Granulomatosis with polyangiitis (Wegener’s granulomatosis) Microscopic polyangiitis Churg–Strauss syndrome Farmer’s lung and avian precipitins Hypersensitivity pneumonitis (extrinsic allergic alveolitis) Cold agglutinins (IgM) Mycoplasma infection
- 56. Serology (IgG antibodies) Viral respiratory tract infection, e.g. influenza, respiratory syncytial virus Small bacterial infection, e.g. Mycoplasma, Legionella, Chlamydia D-dimer Venous thromboembolism Immunoreactive trypsin Screening for cystic fibrosis Complement fixation transmembrane regulator (CFTR) genotyping Cystic fibrosis Gamma-interferon release assay Latent infection with Mycobacterium tuberculosis
- 57. Respiratory function Arterial blood gas tensions Respiratory failure acid–base balance Spirometry Diagnosis/monitoring of COPD and asthma Carbon monoxide gas transfer Reduced in: Interstitial lung disease Emphysema/COPD Flow–volume curves Detection of extra- and intrathoracic large airway obstruction Maximal mouth pressures Respiratory neuromuscular disorders
- 58. Exercise test 6-minute run Diagnosis of asthma in children and young adults 6-minute walk test Assessment of disability, e.g. in COPD Cardiopulmonary exercise test Peak oxygen consumption (VO2) Differentiates breathlessness due to lung disease from that due to heart disease Bronchial challenge test Exclusion of asthma Bronchial provocation studies Asthma, especially occupational asthma Exhaled nitric oxide Inhaled steroid dosage in asthma Overnight sleep study Sleep apnoea/hypopnoea syndrome
- 59. Radiology CT thorax Pulmonary or mediastinal mass Staging of lung cancer Pleural disease High-resolution CT Interstitial lung disease Bronchiectasis Isotope VQ lung scan Pulmonary thromboembolism CT pulmonary angiogram Pulmonary thromboembolism Pulmonary hypertension Echocardiogram Right heart dilatation (cor pulmonale) Ultrasound of chest wall Localisation of pleural effusion Positron emission tomography/CT Staging of lung cancer
- 60. Invasive Lymph node aspiration Cervical lymphadenopathy Bronchoscopy Suspected lung cancer Suspected foreign-body inhalation Obtaining specimens for microbiology Transbronchial lung biopsy Suspected pulmonary sarcoidosis Suspected diffuse malignancy Pleural aspiration and biopsy Undiagnosed pleural effusion Percutaneous fine-needle lung aspiration Peripheral lesion/suspected lung cancer Mediastinoscopy Staging of lung cancer Mediastinal mass Thoracoscopy Undiagnosed pleural disease Lung biopsy (open or video-assisted thoracoscopic surgery) Interstitial lung disease