Chapter 307 - Diagnostic Procedures in Respiratory Disease

Question 1

What is the best view on roentgraphy to study apical pulmonary disease?

Answer 1

Lordotic apical view.

Question 2

Name the different applications of ultrassonography as a diagnostic procedure in respiratory disease.

Answer 2

“Diagnostic ultrasound (US) (…) is nonionizing and safe to perform on pregnant patients and children. It can detect and localize pleural abnormalities and is a quick and effective way of guiding percutaneous needle biopsy of peripheral lung, pleural, or chest wall lesions. US is also hepful in identifying septations within loculated collections and can facilitate placement of a needle (…) (thoracentesis), improving yield and safety of the procedure. Bedside availability makes it valuable in the intensive care setting. Real-time imaging can be used to assess the movement of the diaphragm (…). Endobronchial US (…) allowing identification and localization of pathology adjacent to airway walls or within the mediastinum.”

Question 3

What are the three mechanisms that might lead to concentration of compounds used in nuclear medicine to study thoracic pathology?

Answer 3

“blood pool or compartmentalization (e.g., within the heart), physiologic incorporation (e.g., bone or thyroid) and capillary blockage (e.g., lung scan).”

Question 4

Name the main procedure techniches used to diagnose pulmonary tromboembolism.

Answer 4

Scintigraphic imaging (mismatch ventilation-perfusion) and CT angiography.

Question 5

What imagiological technic would you use to document emphysema on a patient?

Answer 5

Thoracic Computed tomography (CT) scan.

Question 6

Name the different applications of computed tomography (CT) scan as a diagnostic procedure in respiratory disease.

Answer 6

“CT is particulary valuable in assessing hilar and mediastinal disease (…), in identifying and characterizing disease adjacent to the chest wall or spine (including pleural disease), and in identifying areas of fat densitiy or calcification in pulmonary nodules. (…) CT an important tool in the staging of lung cancer. With additional use of contrast material, CT also makes it possible to distinguish vascular from nonvascular structures, which is particulary important in distinguishing lymph nodes and masses from vascular structures primarily in the mediastinum, and vascular disorders such as pulmonary embolism.”

Question 7

How much thicker are cross-sectional images obtained with conventional CT in comparison to high-resolution CT?

Answer 7

7-10mm instead ~1-2mm, respectively.

Question 8

Which intersticial lung diseases have characteristic patterns on high-resolution CT?

Answer 8

“Lymphangitic carcinoma, idiopathic pulmonary fibrosis, sarcoidosis, and eosinophilic granuloma.”

Question 9

What are the main advantages and disadvantages from the use of multidetector CT (MDCT) over single-detector CT?

Answer 9

“MDCT scanners can obtain multiple slices in a single rotation that are thinner and can be acquired in a shorter period of time. This results in enchanced resolution and increased image reconstruction ability. As the technology has progressed, higher numbers (currently up to 64) of detectors are used to produce clearer final images. MDCT allows for even shorter breath holds, which are beneficial for all patients but especially children, the elderly, and the citically ill. However, it should be noted that despite the advantages of MDCT, there is an increase in radiation dose compared to single-detector CT to consider.”

Question 10

Virtual bronchoscopy can be used to assess accurately the extent and lenght of an airway stenosis, the relantionship of an airway abnormality to adjacent mediastinal structures and preprocedure planning for therapeutic bronchoscopy, such as endobronchial lung volume reduction surgery.
True or False?

Answer 10

True.

Question 11

What is the radiolabeled compound used in positrion emisson tomographic scanning?

Answer 11

18F-fluoro-2-deoxyglucose (FDG)

Question 12

PET scans might have false-negative results for neoplastic processes. Name examples.

Answer 12

“false-negative findings can occur in lesions with low metabolic activity such as carcinoid tumors and bronchioloalveolar cell carcinomas, or in lesions

Question 13

Pneumonia and granulomatous diseases might be responsible for false-positive results in PET scanning.
True or False?

Answer 13

True.

Question 14

Magnetic resonance is superior to computed tomography because the former one provides poorer spatial resolution and less detail of the pulmonary parenchyma.
True or False?

Answer 14

False.

Question 15

Name contraindications for Magnetic Resonance.

Answer 15

“The presence of metallic foreign bodies, pacemakers, and intracranial aneurysm clips also preclude use of MRI.”

Question 16

Name three indications for pulmonary angiography.

Answer 16

Diagnosis of pulmonary embolism, pulmonary arterivenous malformations and assessment of pulmonary arterial invasion by a neoplasm.

Question 17

What do you expect to find in an atelectasis of the upper right lobe?

Answer 17

Besides the opacity of the involved pulmonary lobe, once can find homolateral shift of the trachea and mediastinum, aswell as elevation of the respective minor fissure, diaphragmatic hemicupule and pulmonary hilum.

Question 18

What cytological findings support the fact that the sputum is a sample derived from the tracheobronchial tree rather than the upper airway?

Answer 18

“The presence of alveolar macrophages and other inflammatory cells is consistent with a lower respiratory tract origin of the sample, whereas the presence of squamous epithelial cells in a “sputum” sample indicates contamination by secretions from the upper airways.”

Question 19

What is the cytological staining to detect malignant cells present in the sputum?

Answer 19

Papanicolaou method.

Question 20

Name two possible complications due to percutaneuos needle aspiration.

Answer 20

Pneumothorax and intrapulmonar hemorrhage.

Question 21

Although flexible fiberoptic instruments are widely used for bronchoscopy, rigid bronchoscopy might be preferable in some situations. Name two examples in which this may verify.

Answer 21

“These situations include the retrievel of a foreign body and the suctioning of a massive hemorrhage, for which the small suction channel of the bronchoscope may be insufficient.”

Question 22

What is the difference between washing and bronchoalveolar lavage?

Answer 22

“Washing involves instillation of sterile saline through a channel of the bronchoscope and onto the surface of a lesion.”

“With the bronchoscope wedged into a subsegmental airway, aliquots of sterile saline can be instilled through the scope, allowing sampling of cells and organisms from alveolar spaces. This procedure, called bronchoalveolar lavage, has been particularly useful for recovery of organisms such as P. jirovecci.”

Question 23

How do you explain the method for narrow band imaging (NBI)?

Answer 23

“NBI capitalizes on the increased absorption of blue and green wavelengths of light by hemoglobin to enhance the visibility of vessels of the mucosa and differentiate between inflammatory versus malignant mucosal lesions.”

Question 24

What is the colour of the light and how much deeper does optical coherence tomography (OCT) visualizes in comparison to confocal fluorescent laser microcosopy (CFM)?

Answer 24

“OCT uses near-infrared light source and has a spatial resolution advantages over CT and MRI. It can penetrate the airway wall up to three times deeper than CFM.”

“CFM uses a blue laser to induce fluorescence”

Question 25

Medical thoracoscopy can be performed in a endoscopy suite or operating room with the patient under local anesthesia and conscious sedation, while Video-assited Thoracoscopic Surgery requires general anesthesia and is only performed in the operating room.
True or False?

Answer 25

True.

Question 26

What are the indications for medical thoracoscopy?

Answer 26

“A common diagnostic indication for medical thoracopy is the evaluation of a pleural effusion or biopsy of presumed parietal pleural carcinomatosis. It can also be used to place a chest tube under visual guidance, or perform chemical or talc pleurodesis, a therapeutic intervention to prevent a recurrent pleural effusion (usually malignant) or recurrent pneumothorax.”

Question 27

Which nodes are accessible using the suprasternal mediastinoscopy technic?

Answer 27

“levels 2R, 2L, 3, 4R, 4L”

Question 28

Which nodes are accessible using parasternal mediastinostomy?

Answer 28

“levels 5,6” (Chamberlain procedure)

Question 29

Transbronchial needle Aspiration (TBNA) allows one to access only the levels 10, 11 of the mediastinal lymph nodes.
True or False?

Answer 29

False.
TBNA allows one to access the same nodes as mediastinoscopy (levels 2R, 2L, 3, 4R, 4L) aswell as the peri-hilar nodes (levels 10,11).”

Question 30

Name one limitation of Video-assisted thoracoscopic surgery (VATS) over thoracotomy.

Answer 30

VATS is preformed using single-lung ventilation with double-lume endotracheal intubation.

Question 31

Name possible procedures using Video-assisted thoracoscopy sugery (VATS).

Answer 31

“VATS can be used to perform procedures previously requiring thoracotomy, including stalped lung biopsy, resection of pulmonary nodules, lobectomy, pneumonectomy, pericardial window, or other standard thoracic surgical procedures, but allows them to be performed in a minimally invasive manner.”