The document discusses dyspnea (shortness of breath), which is a common symptom in patients presenting to the emergency department with thoracic diseases. High-resolution computed tomography (HRCT) is highlighted as the best non-invasive tool for evaluating dyspnea, as it can identify underlying causes such as emphysema, asthma, pulmonary embolism, and interstitial lung diseases. The document presents several case examples where HRCT provided a diagnosis when other tests were nondiagnostic or revealed atypical features of diseases. HRCT is particularly useful when initial clinical exams and tests fail to identify a cause of dyspnea.

1. G
Ferretti
University
hospital
of
Grenoble,
France

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. 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. ¡ lung
parenchyma
¡ airways
¡ vessels
¡ pleura
¡ thoracic
wall

5. Initial
Diagnostic
Studies
includes
¡ Electrocardiography
¡ Spirometry
¡ Laboratory
evaluation
¡ Chest
Radiography

6. Acute infectious pneumonia
Left atelectasis

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

9. §
FEV1
/
FVC
<
70%
post-­‐bronchodilator
§
Role
of
CT
§ Phenotyping
COPD
§ Search
for
complications
§ Selection
of
patient
before
treatment

10. Centrilobular
emphysema
45
yo
smoking
man

12. Expiration
Bronchial wall thickening
Bronchiectasis
Air trapping
Small airway diseases

13. constrictive bronchiolitis
inspiration
minIP inspiration
expiration

14. 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.

15. Sub acute Hypersensitivity Pneumonitis

17. 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

18. 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

19. High grade mucoepidermoid

20. ¡ 25
yo
female
¡ Chronic
obstructive
disease
¡ FEV1:
2.36L;
64%
¡ FEV1
/
VC:
72%
¡ Treatment
for
asthma
failed
¡ Proposed
diagnostic:
complicated
asthma

24. IV
contrast
injection
Expiratory
CT
MIP
4. Nothing,
I’m
glad
with
the
CT
I’ve
done
1.
2.
3.

25. IV
contrast
injection
Expiratory
CT
MIP
4. Nothing,
I’m
glad
with
the
CT
I’ve
done
1.
2.
3.

27. ¡ Dynamic
stenosis
of
the
LMB
due
to
the
compression
between
the
aorta
and
the
thoracic
spine

28. ¡
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

30. Pulmonary lymphangioleiomyomatosis

31. Langerhans cell histiocytosis

32. 42 yo woman
Mild dyspnea

33. Possible NSIP in a patient with systemic sclerosis

34. 83 yo man
Dyspnea at exercise
Worked as a dentist
Silicosis complicated
with emphysema

35. ¡
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.

37. ¡ Rarely
needed
¡ Useful
in
diagnosing
§ Chronic
Thromboembolism
of
PA
§ fibrosing
mediastinitis
¡ Is
recommended
in
case
of
mosaic
pattern
with
unremarkable
PFT.

38. 62yo patient with chronic dyspnea at
exercise
CT without CM injection

42. 50 yo woman complaining of dyspnea at
exercise associated with palpitation.
53 kg for 163cm

44. TDM

47. 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

48. Contrast-enhanced high-resolution computed tomography of the chest.
Seferian A et al. Circulation 2012;125:2045-2047
Copyright © American Heart Association

49. PAHT
VOD

51. ¡ 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

52. ¡ Common
pulmonary
causes
include
§ asthma
§ pneumothorax
§ upper
airway
obstruction
§ interstitial
lung
disease
§ pulmonary
embolism
§ pulmonary
hypertension

54. ¡ 2005
¡ 83
yo
women
¡ No
particular
history
¡ Acute
dyspnea
¡ Unremarkable
CXR
¡ Angio
CT
for
suspected
PE

55. Acute PE

56. ¡ 2010
¡ 88
yo
¡ Rapid
onset
of
dyspnea
¡ Weight
loss

57. New epidode of thrombo-embolic PE?

58. Sarcoma of the pulmonary artery

59. 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

61. 68 yo man acute leukemia
Fever
Dyspnea
CXR 22/02/2013

62. Crazy paving
PCP pneumonia

63. Measles severe

64. ¡ 62
yo
man
¡ Immunocompetent
¡ Recent
fatigue
weigh
loss
anorexia
¡ Fever
¡ Cough
¡ acute
respiratory
distress…
ICU

66. Invasive Aspergillosis

67. 42 yo female
Chronic dyspnea: PHT
CT: PA embolism ?

68. Undiagnosed partial anomalous pulmonary venous return

69. ¡
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

70. Grenoble