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Wednesday, April 12, 2023

Anwser,sDr :ANAS SAHLE

1. Chest xr cases.2. Chest clinical case.

3. Chest ct cases.4. MRCP exam.

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chest xr casesDr :anas sahle

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Cxr -7

• Compare between tow view\PA\LATERAL:• DIAGNOSIS IS:


DISCUSSION

Mass density is seen in the lateral view, but not in the PA view.

• This suggests a chest wall or external problem.• In film below mass in the axilla is projecting as

a mass in the chest.

CXR -8


Non-anatomical Lines

• The linear shadows do not correspond to any anatomical structure.

• Consider the following: • Pleural fibrosis• Extra-thoracic density• Bleb wall• Lung fibrosis

• This example represents pleural fibrosis.

CXR-9


Inlet to Outlet Shadow

• In-homogeneous cardiac density: Right half more dense than left

• Density crossing midline (right black arrow).• Right sided inlet to outlet shadow• Right para spinal line (left black arrow).• This is a case of achalasia cardia.

CXR-10


One Diaphragm (in lateral view)• You should be able to detect both diaphragms in

the lateral view. • If one is missing, it indicates that there is a

problem in that hemithorax. • By identifying which diaphragm is missing, you can

locate the side of the problem. • Naturally it is easy to identify the problem from

the PA view.

Which lung is resected?• Note that you can see only one diaphragm in the

film on the left. • The film below is pre-pneumonectomy, where you

can identify both diaphragms.• The visible diaphragm has a stomach bubble

underneath, indicating that it is on the left. • Hence, right lung pneumonectomy has occurred.


chest clinical casesPersistent Dyspnea Despite

Maximal Medical Therapy in COPD

Submitted byBrian P. Mieczkowski, DOFellowDivision of Pulmonary, Allergy, Critical Care and Sleep MedicineThe Ohio State University Medical CenterColumbus, OhioMichael E. Ezzie, MDAssistant Professor of Internal MedicineDivision of Pulmonary, Allergy, Critical Care and Sleep MedicineThe Ohio State University Medical CenterColumbus, Ohio

http://www.thoracic.org/index.php


History• A 64-year-old woman with a history of smoking presented with progressive shortness of breath with

exertion. • The patient smoked one to two packs of cigarettes per day for forty-two years and quit smoking one

year ago. • She had increasing dyspnea on exertion over the past few years that accelerated over the last year. • She reported she could now only walk short distances before sitting down to catch her breath. • Her family doctor started her on bronchodilators a few years ago.• She had improvement at the time, but now feels very limited. • She had several episodes of increased dyspnea, wheezing, and productive cough over the past two

years. • These exacerbations were treated as an outpatient with oral corticosteroids and antibiotics. • Two years ago, she participated in a four week course of pulmonary rehab which resulted in

improvement in her dyspnea. • She denied chest pain or palpitations with breathing symptoms. • She reported no shortness of breath at rest, except when talking for more than a few minutes. • She had no emergency department visits and had not required mechanical ventilator support for

breathing. • She had no nocturnal symptoms of wheezing or shortness of breath, but did have occasional wheezing

during the day along with a dry cough. • The patient was interested in discussing additional therapies for her lung disease.


CONTIN-• Her past medical history was significant for smoking, depression,

arthritis, hypertension, hyperlipidemia, and squamous cell carcinoma of the skin on the leg that was removed.

• Her current medications included amlodipine, sertraline, aspirin, tiotropium, albuterol, salmeterol/fluticasone, and simvastatin.

• The patient reported that her father had chronic obstructive pulmonary disease (COPD). There was no other family history of lung disease.

• The patient had been married for forty-five years and had two children. • She was a former smoker of one to two packs per day for forty-two

years. She denied alcohol or drug use. • She reported no significant occupational exposures.• A review of systems was pertinent for fatigue and occasional heartburn.


Physical Exam• On examination, the patient’s weight was 118 pounds with a body mass

index (BMI) of 20.3. • Her blood pressure was 120/70 mmHg with a pulse of 96 beats per minute. • Her oxygen saturation was 91% breathing ambient air. • Her general appearance was thin, and notable for a pleasant female who

was alert and oriented in no acute distress.• Her oropharynx was clear without exudate and neck exam revealed no

lymphadenopathy. • Her lung exam had diminished breath sounds bilaterally with comfortable

respirations and an appreciably long expiratory phase. No wheezes, rhonchi or rales were noted.

• Cardiac exam was normal rate with a regular rhythm. • Abdomen was thin, soft and nontender.• extremities showed no evidence of clubbing or edema.


Diagnostic studies• Pulmonary Function Tests:• (FEV1): 0.84 L (34% predicted) • (FVC): 2.46 L (56% predicted) • FEV1/FVC: 0.34 • Total lung capacity (TLC): 138% of predicted • Residual volume (RV): 227% of predicted • Diffusing Capacity of Carbon Monoxide (DLCO): 31% of predicted • 6-minute walk distance: She walked 900 feet and desaturated to

91%. • Cardiopulmonary exercise testing: Her power output was 20 watts.• Arterial blood gas: Baseline measurement of pCO2 was 37 and pO2 was

72. • The carboxyhemoglobin level was 0.


CXR


CT


Lung Perfusion Scan

Demonstrating her right upper lobe with 3.6% of total perfusion, her left upper lobe with 5% of total perfusion, her right middle lobe 13.6% of the total, her right lower lobe 26.3% of the total, and her left lower lobe 25.8% with left middle area 25.7%.


Question 1• Based on our current understanding of gender differences in

COPD, which of the following might be expected in this female patient compared to a male with an equivalent degree of airflow obstruction?

A. She has more evidence of emphysema on her chest CT than her male counterpart.

B. She has a greater bronchodilator response than her male counterpart.

C. She has a greater number of cigarette pack-years with the same disease as her male counterpart.

D. She would have greater improvement in her FEV1 one year after smoking cessation than her male counterpart.

E. She is older than her male counterpart with equivalent disease.


DISCUSSION• Chronic Obstructive Pulmonary Disease (COPD) is defined as airflow limitation that is not fully

reversible and is progressive with an associated abnormal inflammatory response of the lung to noxious stimuli.

• COPD is diagnosed by spirometry, with a forced expiratory volume in one second (FEV1) to forced vital capacity (FVC) ratio of less than 0.7 and is classified by the degree of loss of FEV1.

• The leading cause of COPD in the United States is cigarette smoking and the number of women dying from COPD is now equal to or surpassing the number of men.

• There is an increased understanding of gender differences in COPD development and progression.

• Women tend to develop COPD at an earlier age and generally have less pack-years of smoking compared to men with similar FEV1 values.

• Chest CT scans of female patients have less evidence of emphysema and histological examinations demonstrate thicker airways and narrower lumens when compared to men with equivalent levels of obstruction.

• Even with this phenotypic difference, there has been no data to suggest that women have a greater response to bronchodilators.

• Given the increased risk of smoking-induced lung impairment, women may benefit from smoking cessation more than men.

• The Lung Health Study found women had 2.5 times greater percentage improvement in FEV1 compared to men one year after smoking cessation.


Question 2• Which of the following indices used to

evaluate severity and mortality in COPD includes the numbers of exacerbations in the evaluation of the patient?

• A.DOSE • B.BODE • C.ADO • D.Both A and B are correct


DISCUSSION• Multiple indices have been developed to predict outcomes in COPD. • The BODE index described additional parameters to improve upon the FEV1-based mortality

prediction in patients with COPD. • It has also been validated to predict hospitalizations. • The BODE index includes: BMI, degree of obstruction, symptoms of dyspnea, and exercise

tolerance based on a six minute walk test. • The DOSE index, in addition to functional status, includes the frequency of exacerbation in its

prediction for hospitalization, respiratory failure and subsequent exacerbations over the next year.

• The components include dyspnea symptoms, degree of obstruction, smoking status, and exacerbation frequency.

• The ADO index was designed to simplify and improve the all-cause mortality prediction of the BODE index and found age to be an important factor.

• It includes age, dyspnea symptoms, and degree of obstruction. • The COPD prognostic index (CPI) is another index that uses exacerbation history to help

predict future exacerbations, hospitalizations, and mortality. • The CPI was developed from pooled data of 12 randomized controlled trials. • The components include age, gender, degree of obstruction, quality of life, BMI, frequency of

exacerbations, and history of cardiovascular disease.


Question 3• Of the following therapies for COPD, which potential benefits would

you expect to see in our patient?• A. Supplemental oxygen will improve her life expectancy by five

years. • B. Tiotropium will decrease her annual exacerbation rate, but may

increase her cardiac mortality. • C. The combination of salmeterol (long-acting beta agonist) and

fluticasone (inhaled corticosteroid) will improve mortality related to COPD.

• D. Pulmonary Rehabilitation will improve her quality of life, but will increase her healthcare utilization.

• E. Lung volume reduction surgery will improve her quality of life, dead space ventilation and long term mortality.


DISCUSSION• The patient does have moderately low oxygen levels on her six minute walk test to 91%,

but there is no data to suggest she would have a 5 year mortality benefit from supplement oxygen.

• Patients with very low oxygen levels at rest (paO2 less than 55 mmHg) had improved survival in early studies of home oxygen use (10, 11).

• The ongoing Long-term Oxygen Treatment Trial (LOTT) (Clinicaltrials.gov identifier NCT00692198) is assessing the effect of supplement oxygen in COPD patients with moderate hypoxemia.

• The TORCH trial evaluated the effectiveness of a long acting beta agonist (LABA) with and without an inhaled corticosteroid (ICS).

• The combination was most effective at improving lung function and quality of life as well as decreasing the time to the next exacerbation (12).

• The study did not however, demonstrate a statistically significant mortality benefit in regard to death from COPD with the use of a LABA with ICS.

• The INSPIRE trial reported that both tiotropium and a LABA with ICS were equally effective at decreasing the annual exacerbation rate.

• Similar to other trials with inhaled corticosteroids, INSPIRE did show an increased risk of pneumonia in the ICS treatment group (13).


CONTIN-• The GOLD guidelines currently suggest adding an ICS in symptomatic

patients with an FEV1 less than 50% who also have frequent exacerbations (1).

• Based on retrospective data showing ipratropium may increase adverse cardiac events, there was a concern with a class effect with tiotropium.

• The UPLIFT trial found fewer cardiac events and a decreased cardiac mortality in the tiotropium treatment group (14).

• Pulmonary rehabilitation has been shown to improve exercise tolerance, quality of life, and decrease healthcare utilization, but studies have not been powered to assess the effect on mortality (15).

• Lung volume reduction surgery (LVRS) has been shown to improve dyspnea scores, dead space ventilation, exercise tolerance, and quality of life.

• In select patients, including our patient, LVRS may improve long-term mortality as well (16-18).


Question 4• What patient population has the greatest mortality

risk from LVRS?• A. Patients with homogeneous emphysema and a

low exercise capacity • B. Patients with upper lobe predominate

emphysema and low exercise capacity • C. Patients with homogenous emphysema and high

exercise capacity • D. Patients with upper lobe predominant

emphysema and high exercise capacity


DISCUSSION• Lung Volume Reduction Surgery (LVRS) is done by performing a wedge resection of emphysematous

lung tissue in select patients with COPD that are poorly controlled despite maximal medical therapy. • LVRS is thought to improve a patient’s functional status by increasing the elastic recoil and expiratory

airflow by restoring the outward circumferential pull on small airways. • In addition, it is thought to help improve the strength and efficiency of the diaphragm by decreasing

the radius of its curvature. • The National Emphysema Treatment Trial (NETT) showed that LVRS improved dyspnea symptom

scoring, minute ventilation with exercise, and maximal exercise capacity (16). • A group of patients with an FEV1 less than 20% predicted and a diffusion capacity of less than 20%

predicted were found to have a 30-day mortality rate of 16%. • These patients were termed high risk and were eliminated from further analysis (19). • Among the remaining non-high risk patients, mortality at 30-days was increased (2.2% in the LVRS

group versus 0.2% in the maximal medical therapy group), but long term mortality at two years was similar.

• A subgroup analysis divided patients into groups based on location of emphysema and high versus low exercise capacity defined by a cut off of 40 watts in men and 25 watts in women.

• At 24 months, the subgroup of upper lobe predominate emphysema and low exercise capacity had improved survival, while the subgroup of patients with homogeneous emphysema and a high exercise tolerance had decreased survival.

• The other two groups did not show survival benefit or an increased risk of death.


Question 5• Which of the following changes to the patient’s history

would exclude her from Lung Volume Reduction Surgery (LVRS)?

• A. A post-rehabilitation six-minute walk test of 150 meters • B. A room air partial pressure of oxygen of 48 mmHg • C. A diffusing capacity of inhaled carbon monoxide (DLCO)

that is 30% predicted • D. A total lung capacity of 100% predicted. • E. A requirement of 30 mg of prednisone a day to control

symptoms


DISCUSSION• Patients that have COPD with severe obstruction and upper lobe predominate emphysema with poor

control despite maximal medical therapy can be considered for LVRS. • To better stratify which patients will benefit from LVRS, further evaluation of their physiology and

functional status is needed. • This evaluation should include a full set of pulmonary function testing, a six minute walk, a

cardiopulmonary exercise test, an ABG, and an echocardiogram. • The Centers for Medicare and Medicaid Services (CMS) require that a patient have an FEV1 less than 45%

predicted and if over 75 years of age, the FEV1 must be greater than 15% predicted. • If the FEV1 is less than 20% predicted, the DLCO must be greater than 20% predicted. • The patient must also be stable on less than 20 mg of prednisone a day. • A minimal total lung capacity of 100% predicted and a residual volume of 150% predicted are needed to

qualify. • There is evidence that a higher RV to TLC ratio yields greater improvement in post-operative FVC. • Participation in a minimal 6-week pre-operative pulmonary rehabilitation program is required and a post-

rehabilitation six minute walk of greater than 140 meters is needed to be considered for LVRS. • An arterial partial pressure of oxygen of 45 mmHg or greater and a partial pressure of carbon dioxide less

than 60 mmHg are also requirements from CMS. • If a patient has an ejection fraction of less than 45% then evaluation and approval by a cardiologist is

required. • Other factors that may exclude a patient from LVRS include: active smoking, severe cachexia or obesity,

comorbid lung or pulmonary vascular disease, and prior thoracic surgery.


Question 6• What is the most common complication seven

days out from LVRS?• A. Persistent chest tube air leak • B. Pneumonia • C. Renal failure • D. Arrhythmias


DISCUSSION• The most common post-operative complications from LVRS are persistent air

leaks, cardiac arrhythmias, pneumonia, and respiratory failure requiring sustained mechanical ventilation or re-intubation.

• NETT found that air leaks occurred in 90% of patients with a median duration of seven days and 12% of patients had an air leak for greater than thirty days.

• Cardiac arrhythmias were the next most common complication with 23% of patients developing an arrhythmia within the first thirty days.

• Pneumonia develops in approximately 18% of patients in the post-operative period.

• Renal failure is not a common complication after LVRS surgery (16). • A recent review of patients that underwent LVRS based on the NETT criteria had

prolonged air leak (greater than 7 days) as the most common complication, occurring in 43% of patients (17).

• Persistent air leaks often lead to a protracted time that the patient needs a chest tube, longer hospitalizations, and may require further surgical intervention to repair the bronchopleural fistula.


chest ct cases-3Dr :anas sahle

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HRCT-1

HRCT-1

• What is the major abnormality in this case?• a) Linear opacities• b) Nodules• c) Consolidation• d) Ground-glass opacity

Note: The vessels are very prominent in this case because the computer was set to optimize

visualization of the subtle major abnormality.

HRCT-2

HRCT-2

• 2. What is the distribution of the abnormalities?

• a) Bronchovascular.• c) Centrilobular.• d) Pleural.

Note: D = dome of diaphragm

HRCT-3

HRCT-3

• Find an area of ground-glass opacity in the right lung.

• Find 2 pleural nodules in the right lung.• Find a nodule at the end of a vessel in the

right lung.• Find 3 centrilobular nodules in the right lung.

HRCT-3

HRCT-4

HRCT-4

• Find a pleural nodule in the right lung.• Find 2 nodules along the major fissure of the

right lung.*Identification of fissure:

Vessels from upper and lower lobes branch and taper toward the fissure and are absent at the fissure.

HRCT-4

Histologic Features

• Find two arteries obstructed by a cellular mass with central hemorrhagic necrosis.

• Find the small subpleural hemorrhagic infarct caused by the arterial obstruction.

Histologic FeaturesThese two vessels would appear on HRCT as nodules at ends of vessels.

Note that on HRCT, some of the subpleural nodules in these cases may represent infarcts.

Histologic Features

• Find and outline the cellular mass within the vessel.

• What is the nature of the cellular masses in this picture and in the one above?

• Find and outline the cellular mass within the vessel.

• What is the nature of the cellular masses in this picture and in the one above?

• Hematogenous metastatic neoplasm, which may be confined to the vessel or may spread into the surrounding lung

Diagnosis:

Hematogenous metastatic tumor

Summary

• diagnostic features of numerous hematogenous metastatic nodules on HRCT:–Usually random distribution –Often smooth, well-defined –Varying size common

random nodules

• Differential diagnosis of on HRCT:– hematogenous metastasis (particularly from thyroid,

kidney, and breast) and – miliary infections.

Langerhans' cell histiocytosis, sarcoidosis, and silicosis are common causes of nodules, but such nodules are rarely diffuse and haphazard.

• Random nodules occur along the pleura and fissures, in a centrilobular location, and in the bronchovascular region.

• The bronchovascular nodules in the case of random nodules are seen at the ends of small arteries and not in the proximal bronchovascular interstitium.

• Nodules in lymphangitic tumor and sarcoidosis are frequently seen in the central bronchovascular interstitium.


04/12/202355

MRCP EXAMRespiratory

04/12/202356

Q1•The following are recognised associations

with pulmonary hypertension:•A- An apgar of 3 at 5 minutes

•B- Meconium aspiration•C- Hyaline membrane disease

•D- Hypo-glycaemia•E- Oligo-hydraminos

04/12/202357

A1 •The following are recognised associations

with pulmonary hypertension:•A- An apgar of 3 at 5 minutes (true)

•B- Meconium aspiration (true)•C- Hyaline membrane disease (true)

•D- Hypo-glycaemia (true)•E- Oligo-hydraminos (true)


Q2•The following are recognised causes of

pulmonary eosinophilia:•A- Asthma

•B- Loeffler's Syndrome•C- Hookworm infestation•D- Aspergillus fumigatus

•E- Schistosomiasis


A2 •The following are recognised causes of

pulmonary eosinophilia:•A- Asthma (True)

•B- Loeffler's Syndrome (True)•C- Hookworm infestation (True)•D- Aspergillus fumigatus (True)

•E- Schistosomiasis(false)


Q3The following are recognised treatments for complications of cystic fibrosis:

A- DNAase to assist in reinflating collapsed lung segments .

B- Rectal pull-through and anastamosis for rectal prolapse .C- Pancreatic transplant for diabetes mellitus .

D- Nebulised tobramycin for pseudomonas colonisation of the lower respiratory tract.E- Hypotonic saline drinks for hypernatraemic dehydration.


A3 The following are recognised treatments for complications of cystic fibrosis:

A- DNAase to assist in re-inflating collapsed lung segments (false) .

B- Rectal pull-through and anastamosis for rectal prolapse (false) .C- Pancreatic transplant for diabetes mellitus (false) .

D- Nebulised tobramycin for pseudomonas colonisation of the lower respiratory tract (true).E- Hypotonic saline drinks for hypernatraemic dehydration (false).


Q4Regarding the sweat test:A- Sweating is enhanced by application of atropine .

B- The filter paper is left on for a total of about 4 hours .

C- At least 25mg of sweat is necessary for a reliable result .

D- More than 60mmol/L of chloride in sweat is diagnostic of cystic fibrosis .

E- False/positive results may be encountered in children with nephrotic syndrome.


A4 Regarding the sweat test:

A- Sweating is enhanced by application of atropine (false) .

B- The filter paper is left on for a total of about 4 hours (false) .

C- At least 25mg of sweat is necessary for a reliable result (false) .

D- More than 60mmol/L of chloride in sweat is diagnostic of cystic fibrosis (true) .

E- False/positive results may be encountered in children with nephrotic syndrome (false).


Q5Diffusion capacity of carbon monoxide:A- Is a specific measure of lung perfusion .

B- Depends on the thickness of the alveolar wall .

C- Depends on the surface area available for gas exchange .D- Is increased in cigarette smokers .E- Is increased in emphysema.


A5 Diffusion capacity of carbon monoxide:

A- Is a specific measure of lung perfusion (false) .

B- Depends on the thickness of the alveolar wall (true) .

C- Depends on the surface area available for gas exchange (true) .D- Is increased in cigarette smokers (false) .E- Is increased in emphysema (false).


Q6The following respiratory symptoms may be exacerbated by gastro-oesophageal

reflux:A- Asthma

B- Central apnoea

C- Obstructive apnoea

D- Stridor

E- Wheeze


A6 The following respiratory symptoms may be exacerbated by gastro-oesophageal

reflux:A- Asthma (true)

B- Central apnoea (true)

C- Obstructive apnoea (true)

D- Stridor (true)

E- Wheeze (true)


Q7In lung perfusion scanning:

A- Emphysema and pulmonary embolism give similar appearances .B- Iodine sensitivity is a contraindication .C- Is always abnormal in Scimitar Syndrome .

D- May show decreased upper lobe perfusion in mitral stenosis .

E- Shows decreased perfusion in McLeod's Syndrome.


A7 In lung perfusion scanning:

A- Emphysema and pulmonary embolism give similar appearances (false) . B- Iodine sensitivity is a contraindication (false) .

C- Is always abnormal in Scimitar Syndrome (true) .

D- May show decreased upper lobe perfusion in mitral stenosis (false) .

E- Shows decreased perfusion in McLeod's Syndrome (true).


Q8In cystic fibrosis:A- The sweat chloride is higher than the sodium .

B- The secretions are viscid because water cannot be actively transported form the respiratory epithelial cell.

C- The amino acid at position 508 of the CTRE gene acts as a regulator of the chloride channel.

D- The DeltaF508 mutation explains most of the inter-racial differences in the incidence of cystic fibrosis.

E- The CFTR traverses the cell membrane 7 times, and is arranged in ring formation.


A8 In cystic fibrosis:A- The sweat chloride is higher than the sodium (true) .

B- The secretions are viscid because water cannot be actively transported form the respiratory epithelial cell (false).

C- The amino acid at position 508 of the CTRE gene acts as a regulator of the chloride channel (true).

D- The DeltaF508 mutation explains most of the inter-racial differences in the incidence of cystic fibrosis (true).

E- The CFTR traverses the cell membrane 7 times, and is arranged in ring formation (true).


Q9Pneumocystis carinii:A- Predisposes to pneumothorax .

B- Can cause pneumonia with very few signs on chest x-ray .C- Is an obligate intracellular organism .D- May cause extrapulmonary infection .

E- Is usually diagnosed by finding a rising titre of neutralising antibodies.


A9 Pneumocystis carinii:A- Predisposes to pneumothorax (true) .

B- Can cause pneumonia with very few signs on chest x-ray(false) .C- Is an obligate intracellular organism(false) .

D- May cause extra-pulmonary infection (true) .

E- Is usually diagnosed by finding a rising titre of neutralising antibodies(false).


Q10Recognised complications of bronchoscopy include:

A- Haemorrhage

B- Pneumothorax

C- Segmental collapse

D- Hypoxic ischaemic encephalopathy

E- Empyema


A10 Recognised complications of bronchoscopy include:

A- Haemorrhage (true)

B- Pneumothorax (true)

C- Segmental collapse (true)D- Hypoxic ischaemic encephalopathy(false)

E- Empyema (true)


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