DIAGNOSIS GANGGUAN

PERNAPASAN DENGAN FOTO

THORAK
Prijo Sidipratomo
Ketua PDSRI
Disampaikan pada PIT IDI Jakarta Timur
14 Agustus 2009
 The dyspnoeic patient

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

it causes more than 2.5 million clinician

visits/year in the United States

Wang CS - Jama 2005; 294: 1944


Causes of dyspnoea
Airways
- Obstruction foreign body
- Angioedema
- Epiglottitis and other infections
Lung
Rapid onset of dyspnoea
- Asthma
- Pneumonia
- Croup (laryngotracheobronchitis)
- Bronchiolitis
- Pulmonary contusion
- Adult respiratory distress syndrome
Slower onset of dyspnoea
- Chronic obstructive pulmonary disease
- Pneumoconiosis
Chest
Rapid onset of dyspnoea
- Pneumothorax, tension/simple
- Pleural effusion, haemo/pneumothorax
- Rib fractures, flail chest
The dyspnoeic patient
Cardiac
Rapid onset of dyspnoea
- Congestive cardiac failure
- Acute pulmonary edema
- Acute myocardial infarction
- Cardiac arrhythmias
Vascular
Rapid onset of dyspnoea
- Pulmonary embolism
Slower onset of dyspnoea
- Pulmonary hypertension
Others
Rapid onset of dyspnoea
- Psychogenic hyperventilation
- Poisoning, eg. carbon monoxide, cyanide
- Metabolic acidosis
Slower onset of dyspnoea
- Anaemia
- Guillain-Barre syndrome
 The dyspnoeic patient

Dyspnoea
 Acute
 Subacute
 Chronic

Thomas P – Australian Family Physician 2005; 34: 523

 The dyspnoeic patient

Dyspnoea
 Acute
 Subacute
 Chronic

Thomas P – Australian Family Physician 2005; 34: 523

 The dyspnoeic patient

Acute dyspnoea
 challenge for physicians

 needs accurate and rapid diagnosis

 early institution of appropriate symptomatic

and evidence-based therapy

Wang CS – JAMA 2005; 294: 1944

 The dyspnoeic patient

How to manage the patient with acute dyspnoea?

 Assessment of Airway, Breathing, Circulation (ABC)

 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.)

Thomas P – Australian Family Physician 2005; 34: 523

 The dyspnoeic patient

Main causes of acute dyspnoea

 Congestive Heart Failure (CHF)

Cardiac
 Acute Myocardial Infarction (AMI)
 Pulmonary Embolism (PE)
 COPD/asthma
Pulmonary
 Pneumonia
 Pneumothorax

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

 The dyspnoeic patient

D//D Cardiac vs Pulmonary Dyspnoea

 difficult to assess
 physical findings similar

 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?

Malas Ö – Respiratory Medicine 2003; 97: 1277

 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
routinely performed in acute dyspnoeic pts.
> 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

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

 The dyspnoeic patient

 PULMONARY EMBOLISM (PE)

 Congestive Heart Failure (CHF)

 Acute Myocardial Infarction (AMI)

potentially life-threatening
diagnoses!!!
 The dyspnoeic patient
Pulmonary Embolism
 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

Chen J-Y – Int Heart J 2006; 47: 259

*Harrison A – Am J Emerg Med 2005; 23: 371
 The dyspnoeic patient
Pulmonary Embolism
 Symptoms and signs
 Dyspnoea: 73% (most common)
 Tachypnoea: 70%
 Pleuritic chest pain: 66%
 Cough, Haemoptysis, Syncope, Fever (less frequent)

 similar frequency in patients without PE

NOT SPECIFIC !

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

 The dyspnoeic patient
Pulmonary Embolism
 Risk factor stratification (immobilization, surgery,
history of VTE, malignancy, etc.)

 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)

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

 Diagnostic Testing
- CXR’s

Chest X-Ray Myth:

“You have to do a chest x-ray so you can find

Hampton’s hump or a Westermark sign.”

Reality:

Most chest x-rays in patients with PE are

nonspecific and insensitive
 Diagnostic Testing
- CXR’s
Chest radiograph findings in patient with
pulmonary embolism
Result Percent
Cardiomegaly 27%
Normal study 24%
Atelectasis 23%
Elevated Hemidiaphragm 20%
Pulmonary Artery Enlargement 19%
Pleural Effusion 18%
Parenchymal Pulmonary Infiltrate 17%
 Chest X-ray Eponyms of PE
Westermark's sign

– A dilation of the pulmonary vessels proximal to the

embolism along with collapse of distal vessels,
sometimes with a sharp cutoff.

Hampton’s Hump

– A triangular or rounded pleural-based infiltrate with

the apex toward the hilum, usually located adjacent to
the hilum.
Radiographic Eponyms
- Hampton’s Hump, Westermark’s Sign

Westermark’s
Sign
Hampton’s Hump
 The dyspnoeic patient
 Chest CT
 not recommended for the initial evaluation (unless
suspected PE)
 appropriate when clinic, X-ray, laboratory tests are
non revealing/non diagnostic
CT allows confident diagnosis or limited differential
diagnosis
COPD, fibrosis
bronchiectasis
pneumoconiosis
interstitial lung diseases
ACR Criteria of appropriateness for dyspnoea – Radiology 2000; 215: 641
 The dyspnoeic patient

 MDCT-PA
< 25% respiratory motion artifacts *

better image quality in dyspnoeic patients **

*Remy-Jardin M, Eur Radiol 2002; 12:1971
**Remy-Jardin M, Radiology 2007; 245: 315
 partial or complete filling defects
 proximal extent of PE
Coronal
MIP

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
 emerging use of whole-chest ECG-gated CT (also at low
dose*) reinforces the role of CTA in acute clinical setting:
1- assessment of CAD as
potential cause of dyspnoea
2- prognostic information in PE
patients (RVF), useful to guide
therapeutic decisions (surgery/
thrombolysis)
*d’Agostino AG – Eur Radiol 2006; 16: 2137
 CT-venography:
one-stop shopping?

Erasmus MC
Schoepf, Eur Radiol 2001

Erasmus MC
FOTO THORAK
Be
systematic

:
1) Check the quality of the film
 Film Quality

First determine is the film a PA or AP view.

PA- the x-rays penetrate through the back of the patient

on to the film

AP-the x-rays penetrate through the front of the patient

on to the film.

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

 Film Quality (cont)
Was film taken under full inspiration?
-10 posterior ribs should be visible.

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 should
Be 6 to qualify as a good inspiratory film.
 Quality (cont.)
Is the film over or
under penetrated if
under penetrated you
will not be able to see
the thoracic
vertebrae.
 Quality (cont)
Check for rotation

– Does the thoracic

spine align in the
center of the sternum
and between the
clavicles?
– Are the clavicles level?
 Verify Right and Left sides

Gastric bubble should be on the left

 Now you are ready
Look at the diaphram:
for tenting
free air
abnormal elevation
Margins should be
sharp
(the right hemidiaphram is
usually slightly higher than
the left)
 Check the Heart
Size
Shape
Silhouette-margins should be sharp
Diameter (>1/2 thoracic diameter is
enlarged heart)

Remember: AP views make heart appear larger than it

actually is.
 Cardiac Silhouette

1. R Atrium 4. Superior Vena Cava 7. Pulmonary Valve

2. R Ventricle 5. Inferior Vena Cava 8. Pulmonary Trunk
3. Apex of L Ventricle 6. Tricuspid Valve 9. R PA 10. L PA
Check the costophrenic angles

Margins should
be sharp
Loss of Sharp Costophrenic Angles
 Check the hilar region
The hilar – the large
blood vessels going
to and from the lung
at the root of each
lung where it meets
the heart.
Check for size and
shape of aorta,
nodes,enlarged
vessels
Finally, Check the Lung Fields
Infiltrates
Increased interstitial markings
Masses
Absence of normal margins
Air bronchograms
Increased vascularity
Abnormals
 Lung findings
Darker areas Lighter areas
– radiolucent – Opacities
– Pneumothorax – “infiltrates”
– Cysts/bulla Blood
– Pus
Air bronchograms
Water
– Nodules or mass
 Opacities
Lobar or not….
Pneumonia
Pulmonary Edema
– “fluffy,” diffuse, “bat wing” distribution
Hemorrhage
– Cant tell by xray, need bronch
Pasien dengan
asma bronkhiale kronik
 RANGKUMAN
Foto thorak dilakukan setelah penilaian
klinik dilakukan dengan cermat
Bila foto thorak negatip maka dilakukan
CT Scan thorak
Bila kecurigaan akan Emboli paru maka
multislices CT Scan dapat langsung
dikerjakan
TERIMAKASIH/THANK YOU