DIAGNOSIS GANGGUAN DIAGNOSIS GANGGUAN PERNAPASAN DENGAN FOTO PERNAPASAN DENGAN FOTO

THORAKTHORAKPrijo SidipratomoPrijo Sidipratomo

Ketua PDSRIKetua PDSRIDisampaikan pada PIT IDI Jakarta TimurDisampaikan pada PIT IDI Jakarta Timur

14 Agustus 200914 Agustus 2009

Dyspnoea

……uncomfortable sensation of breathing or awareness of respiratory distress…

Wang CS - Jama 2005; 294: 1944

it causes more than 2.5 million clinician visits/year in the United States

The dyspnoeic patient

The dyspnoeic patientCauses of dyspnoeaAirways Cardiac - Obstruction foreign body Rapid onset of dyspnoea - Angioedema - Congestive cardiac failure - Epiglottitis and other infections - Acute pulmonary edemaLung - Acute myocardial infarctionRapid onset of dyspnoea - Cardiac arrhythmias - Asthma Vascular - Pneumonia Rapid onset of dyspnoea - Croup (laryngotracheobronchitis) - Pulmonary embolism - Bronchiolitis Slower onset of dyspnoea - Pulmonary contusion - Pulmonary hypertension - Adult respiratory distress syndrome OthersSlower onset of dyspnoea Rapid onset of dyspnoea - Chronic obstructive pulmonary disease - Psychogenic hyperventilation

- Pneumoconiosis - Poisoning, eg. carbon monoxide, cyanide

Chest - Metabolic acidosisRapid onset of dyspnoea Slower onset of dyspnoea - Pneumothorax, tension/simple - Anaemia - Pleural effusion, haemo/pneumothorax - Guillain-Barre syndrome - Rib fractures, flail chest

Dyspnoea

Acute Subacute Chronic

The dyspnoeic patient

Thomas P – Australian Family Physician 2005; 34: 523

Dyspnoea

Acute Subacute Chronic

The dyspnoeic patient

Thomas P – Australian Family Physician 2005; 34: 523

Acute dyspnoea challenge for physicians

needs accurate and rapid diagnosis

The dyspnoeic patient

Wang CS – JAMA 2005; 294: 1944

early institution of appropriate symptomatic and evidence-based therapy

The dyspnoeic patient

How to manage the patient with acute dyspnoea?

Thomas P – Australian Family Physician 2005; 34: 523

History (chronic disease, recent infections, trauma environmental exposure, drugs, aspiration) Onset of dyspnoea (sudden vs days)

Associated symptoms and signs (chest pain, cough, sputum, haemoptysis, stridor, wheeze, etc.)

Assessment of Airway, Breathing, Circulation (ABC)

Main causes of acute dyspnoea

Shiber JR – Med Clin N Am 2006; 90: 453

The dyspnoeic patient

Congestive Heart Failure (CHF) Acute Myocardial Infarction (AMI)

Cardiac

Pulmonary Embolism (PE) COPD/asthma Pneumonia Pneumothorax

Pulmonary

D//D Cardiac vs Pulmonary Dyspnoea difficult to assess

The dyspnoeic patient

physical findings similar

Malas Ö – Respiratory Medicine 2003; 97: 1277

different treatment and probability of worsening of the primary disease with the wrong therapy require early and correct diagnosis

How to propose a differential diagnosis?

The dyspnoeic patient

Symptoms

CHF: dyspn.on exertion/paroxysmal nocturnal,orthopnea

AMI: radiating chest pressure, dyspnoea, diaphoresis

PE: sudden onset of dyspn, pleuritic chest pain, syncope

COPD/asthma: cough, dyspnoea relieved with therapy

Pneumonia: fever, productive cough, dyspnoea

Pneumothorax: pleuritic chest pain, dyspnoea not relieved with 02

Shiber JR – Med Clin N Am 2006; 90: 453

The dyspnoeic patient Chest X-ray

ACR Criteria of appropriateness for dyspnoea – Radiology 2000; 215: 641

> 40 years only 14 % normal findings

< 40 years 68 % normal findings 13 % acute findings 18 % chronic findings

chest X-ray not indicated unless physical exam + or haemoptysis present

routinely performed in acute dyspnoeic pts.

The dyspnoeic patient

Congestive Heart Failure (CHF)

Acute Myocardial Infarction (AMI)

PULMONARY EMBOLISM (PE)

potentially life-threatening diagnoses!!!

The dyspnoeic patient

Chen J-Y – Int Heart J 2006; 47: 259

Most commonly missed diagnosis

PE can lead to early death or serious morbidity

Early diagnosis and appropriate management can decrease mortality and morbidity

* mortality rate: 2-8% if treated ~ 30% if not treated

*Harrison A – Am J Emerg Med 2005; 23: 371

Pulmonary Embolism

The dyspnoeic patientPulmonary Embolism

Dyspnoea: 73% (most common)

Tachypnoea: 70%

Pleuritic chest pain: 66%

Symptoms and signs

Shiber JR – Med Clin N Am 2006; 90: 453

Cough, Haemoptysis, Syncope, Fever (less frequent)

similar frequency in patients without PE

NOT SPECIFIC !

The dyspnoeic patientPulmonary Embolism

Risk factor stratification (immobilization, surgery, history of VTE, malignancy, etc.)

Shiber JR – Med Clin N Am 2006; 90: 453

Physical examination (tachypnoea, tachycardia, hypotension, hypoxia, II heart sound accentuated, right-sided S4, leg edema/ warmth/ erythema)

ECG (sinus tachycardia, non specific ST-T wave changes, right-sided heart strain, new right bundle branch block)

Echocardiography (right-sided heart strain, thrombus in RV)

Chest X-ray (generally normal or non specific)

Diagnostic TestingDiagnostic Testing- CXR’s- CXR’s

Chest X-Ray Myth:Chest X-Ray Myth:

““You have to do a chest x-ray so you can find You have to do a chest x-ray so you can find Hampton’s hump or a Westermark sign.”Hampton’s hump or a Westermark sign.”

Reality:Reality:

Most chest x-rays in patients with PE are Most chest x-rays in patients with PE are nonspecific and insensitivenonspecific and insensitive

Diagnostic Testing Diagnostic Testing -- CXR’s CXR’s

Chest radiograph findings in patient with Chest radiograph findings in patient with pulmonary embolismpulmonary embolism

ResultResult PercentPercentCardiomegalyCardiomegaly 27%27%Normal studyNormal study 24%24%AtelectasisAtelectasis 23% 23% Elevated HemidiaphragmElevated Hemidiaphragm 20%20%Pulmonary Artery EnlargementPulmonary Artery Enlargement 19%19%Pleural EffusionPleural Effusion 18%18%Parenchymal Pulmonary InfiltrateParenchymal Pulmonary Infiltrate 17%17%

Chest X-ray Eponyms of PEChest X-ray Eponyms of PEWestermark's signWestermark's sign

– A dilation of the pulmonary vessels proximal to the A dilation of the pulmonary vessels proximal to the embolism along with collapse of distal vessels, embolism along with collapse of distal vessels, sometimes with a sharp cutoff. sometimes with a sharp cutoff.

Hampton’s HumpHampton’s Hump

– A triangular or rounded pleural-based infiltrate with A triangular or rounded pleural-based infiltrate with the apex toward the hilum, usually located adjacent to the apex toward the hilum, usually located adjacent to the hilum.the hilum.

Radiographic EponymsRadiographic Eponyms- Hampton’s Hump, Westermark’s Sign - Hampton’s Hump, Westermark’s Sign

Westermark’s Sign

Hampton’s Hump

The dyspnoeic patient Chest CT

ACR Criteria of appropriateness for dyspnoea – Radiology 2000; 215: 641

not recommended for the initial evaluation (unless suspected PE) appropriate when clinic, X-ray, laboratory tests are non revealing/non diagnosticCT allows confident diagnosis or limited differential diagnosis

COPD, fibrosisbronchiectasis pneumoconiosis interstitial lung diseases

MDCT-PA < 25% respiratory motion artifacts *

*Remy-Jardin M, Eur Radiol 2002; 12:1971

The dyspnoeic patient

better image quality in dyspnoeic patients **

**Remy-Jardin M, Radiology 2007; 245: 315

partial or complete filling defects proximal extent of PE

CoronalMIP

Occlusion &

Infarcts

The dyspnoeic patient

MDCT & Dyspnoea CT can identify alternative causes other than PE in dyspnoeic patients, also potentially life-threatening recent advances in MDCT have improved patient care by minimizing diagnostic delay

2- prognostic information in PE patients (RVF), useful to guide therapeutic decisions (surgery/ thrombolysis)

emerging use of whole-chest ECG-gated CT (also at low dose*) reinforces the role of CTA in acute clinical setting:

*d’Agostino AG – Eur Radiol 2006; 16: 2137

1- assessment of CAD as potential cause of dyspnoea

Erasmus MC

CT-venography: one-stop shopping?

Erasmus MC

Schoepf, Eur Radiol 2001

FOTO THORAKFOTO THORAK

Be systematic

:

1) Check the quality of the film

Film QualityFilm Quality

First determine is the film a PA or AP view.First determine is the film a PA or AP view.

PAPA- - the x-rays penetrate through the back of the patient the x-rays penetrate through the back of the patient on to the filmon to the film

APAP--the x-rays penetrate through the front of the patient the x-rays penetrate through the front of the patient on to the film.on to the film.

All x-rays in the PICU are portable and are AP viewAll x-rays in the PICU are portable and are AP view

Film Quality Film Quality (cont)(cont)

Was film taken under full inspiration?Was film taken under full inspiration?-10 posterior ribs should be visible.-10 posterior ribs should be visible.

Why do I say posterior here?Why do I say posterior here?

When X-ray beams pass through the anterior chest on to the film Under the patient, the ribs closer to the film (posterior) are most apparent.

A really good film will show anterior ribs too, there shouldBe 6 to qualify as a good inspiratory film.

Quality (cont.)Quality (cont.)

Is the film over or Is the film over or under penetrated if under penetrated if under penetrated you under penetrated you will not be able to see will not be able to see the thoracic the thoracic vertebrae.vertebrae.

Quality (cont)Quality (cont)

Check for rotationCheck for rotation

– Does the thoracic Does the thoracic spine align in the spine align in the center of the sternum center of the sternum and between the and between the clavicles?clavicles?

– Are the clavicles level?Are the clavicles level?

Verify Right and Left sidesVerify Right and Left sides

Gastric bubble should be on the leftGastric bubble should be on the left

Now you are ready Now you are ready

Look at the diaphram:Look at the diaphram:for tentingfor tentingfree airfree airabnormal elevationabnormal elevationMargins should be Margins should be sharpsharp((the right hemidiaphram is the right hemidiaphram is usually slightly higher thanusually slightly higher than

the leftthe left))

Check the HeartCheck the Heart

SizeSizeShapeShapeSilhouette-margins should be sharpSilhouette-margins should be sharpDiameter (>1/2 thoracic diameter is Diameter (>1/2 thoracic diameter is enlarged heart)enlarged heart)

Remember: AP views make heart appear larger than it Remember: AP views make heart appear larger than it actually isactually is..

Cardiac Silhouette

1. R Atrium2. R Ventricle3. Apex of L Ventricle

4. Superior Vena Cava5. Inferior Vena Cava6. Tricuspid Valve

7. Pulmonary Valve8. Pulmonary Trunk9. R PA 10. L PA

Check the costophrenic anglesCheck the costophrenic angles

Margins should be sharp

Loss of Sharp Costophrenic Angles

Check the hilar regionCheck the hilar region

The hilar – the large The hilar – the large blood vessels going blood vessels going to and from the lung to and from the lung at the root of each at the root of each lung where it meets lung where it meets the heart.the heart.Check for size and Check for size and shape of aorta, shape of aorta, nodes,enlarged nodes,enlarged vesselsvessels

Finally, Check the Lung FieldsFinally, Check the Lung Fields

InfiltratesInfiltratesIncreased interstitial markingsIncreased interstitial markingsMassesMassesAbsence of normal marginsAbsence of normal marginsAir bronchogramsAir bronchogramsIncreased vascularityIncreased vascularity

AbnormalsAbnormals

Lung findingsLung findings

Darker areasDarker areas– radiolucentradiolucent– PneumothoraxPneumothorax– Cysts/bullaCysts/bulla– Air bronchogramsAir bronchograms

Lighter areasLighter areas– OpacitiesOpacities– ““infiltrates”infiltrates”

BloodBloodPusPusWaterWater

– Nodules or massNodules or mass

OpacitiesOpacities

Lobar or not….Lobar or not….PneumoniaPneumoniaPulmonary EdemaPulmonary Edema– ““fluffy,” diffuse, “bat wing” distributionfluffy,” diffuse, “bat wing” distribution

HemorrhageHemorrhage– Cant tell by xray, need bronchCant tell by xray, need bronch

Pasien dengan asma bronkhiale kronik

RANGKUMANRANGKUMAN

Foto thorak dilakukan setelah penilaian Foto thorak dilakukan setelah penilaian klinik dilakukan dengan cermatklinik dilakukan dengan cermatBila foto thorak negatip maka dilakukan Bila foto thorak negatip maka dilakukan CT Scan thorakCT Scan thorakBila kecurigaan akan Emboli paru maka Bila kecurigaan akan Emboli paru maka multislices CT Scan dapat langsung multislices CT Scan dapat langsung dikerjakandikerjakan

TERIMAKASIH/THANK YOUTERIMAKASIH/THANK YOU