INVESTIGATIONS OF THE CHEST DISEASES

Radiological investigations

Comm ent

Chest X-ray The plain postero-anterior view - It is the most excellent and frequently - requested radiological examination for visualisation of the lungs because of the inherent contrast of the tissue of the thorax The lateral view - It should not be undertaken routinely - The lesions obsecured on the postero-anterior view are often clearly demonstrated on the lateral view as anterior mediastinal mass and encysted pleural effusion CT scanning High resolusion CT scanning - It is of a proven value in the diagnosis of diffuse lung disease, particulary in the early stages when, the chest radiograph is normal, for follow-up and for detection of bronchiectasis Con ventional CT scanning - It is used for staging of malignanacy, detecting pulmonary metastasis and assessing chest wall and pleural lesions as well as the lung, hilurn and the mediastinal masses

Magnetic Resonance Imaging "MRI It is helpful in a high intrinsic soft tissue discremination and allowing vascular structures and lesions in the mediastinal and hilar regions to be defined separately from the other tissues On the other side it is ineffective in visualise small branching pulmonary vessels, bronchi and lung parenchyma; these structures are better depicted on CT scanning

Ultrasound US The acoustic mismatch between the chest wall and the aerated lung leading to total reflection of the ultrasonic beam at the lung pleura interference so the normal lung can not be demonstrated so it is used for assessing superficial pulmonary,

Bronchography Indications - It is a definitive investigation for diagnosis of the bronchiectasis - lt is helpful in assessing the extent of the disease - It is used for investigation of recurrent haemoptysis when other investigations are negative and demonestrate a broncho-pleural fistula and the congenital lesions as sequestrated lobe or agenesis Techni que - A catheter passes in the tracheo-bronchial tree and injection of a radio-opaque dye as lipidol - The patient must be in a certain position to allow deposition of the dye to the designed area Contrai ndications - Acute chest infections, partial impairment of the pulmonary functions - Massive haemoptysis, recurrent pneumonia and active tuberculosis Compli cations - Bronchial obstruction by a thick iodine - Iodine sensitivity, lipoid pneumonia and fat embolism Flouroscopy It is of value for assessing the chest wall and diaphragm motion It is helpful in uncooperative children when the radiograph is nondiagnostic due to movement and poor inspiration and may be used to differentiate pulmonary from pleural lesions by rotating the patient with noting the movements of the lesion with respect to the sternum and spine Pulmonary angiography It remains the golden standerd for diagnosis of the pulmonary embolism, and helps in evaluation of the pulmonary hypertension, diagnosis of the vascular lesions as pulmonary hypoplasia and

Endoscopic investigations Bronchosc opy It is a surgical procedure that permits the visual examination of the tracheobronchial tree and including the ability to see the fifth to seventh segmental bronchi and permits collection of respiratory secretions Types of bronchoscopy - Flexible fibre-optic bronchoscope It can be inserted through a nostril, mouth or tracheostomy stoma - Rigid bronchoscope It can only be inserted through the mouth or tracheostomy stoma Diagnostic indications of bronchoscopy - Suspicion of malignancy in the lungs or airways - Pulmonary infections and infiltrates - Uncommon diffuse respiratory disease and haemoptysis - Suspected airway trauma or foreign body Therapeutic indications of bronchoscopy - Mucous plugs, clots and foreign bodies - Retained airway secretions and treatment of haemoptysis - Placement of the endotracheal tube - Obstructing neoplasms airways Mediastin oscopy It is used for taking biopsy of the mediastinal lymph nodes to detect the spread of the bronchial carcinoma to mediastinurn Thoracoscopy Types - Medical thoracoscopy: for examination of the thoracic cavity - After thorough evaluation with pleural fluid analysis and closed pleural biopsy used primarily for the diagnosis of the pleural diseases and pleurodesis - Surgical thoracoscopy: for minimally invasive thoracic surgery and offers the opportunity to proceed with open thoracotomy if necessary Diagnostic indications of thoracoscopy - Exudative pleural effusions of

Other investigations Sputum examination For bacteriological examination as in culture and sensitivity test and bacterial flora or for cytological examination as in malignancy Lung biopsy Open lung biopsy - It is obtained at surgery and entails the risks of a thoracotomy and general anaesthesia although an adequate specimen is obtained Cathet er biopsy - It is made with seven or eight catheters inserted via the cricothyroid membrane and screened into the relevant bronchus Percutaneous biopsy - It my be performed with a fine needle for aspiration, has a high diagnostic yield for malignancy, excluding lymphoma and with a low incidence of complication or with a cutting needle is associated with a higher complication rate but is more helpful in the diagnosis of lymphoma and benign lung conditions Thoracpcentesis "Pleural fluid aspiration" The patients with a small pleural effusion, loculated pleural effusion, pleural effusion on the side of elevated hemidiaphragm, patients on mechanical ventilation and bleeding diathesis undergo diagnostic thoracocentesis guided by ultrasound It is performed by abram's needle and the pleural aspirate is subjected into physical, bacteriological and cytological examinations Pulmonary function tests It is of a proven value in the differentiation between obstructive I and restrictive lung diseases "later" Tuberculin test It is used for diagnosis of

(A) Chest X-ray : The chest PA film of a patient shows numerous calcified foci in both upper zones of the lung With the left upper lobes fibrosis due to pulmonary tuberculosis (B) Bronchography : Until recently bronchography was done as a definitive investigation for the diagnosis of the brofichiectasis so this bronchogram reveals the patient with a cystis bronchiectasis as it shows that the majority of the bronchi in the lung parenchyma are outlined with a contrast medium and are dilated in their lumen

(A) CT scanning

CT scanning of the chest reveals the carcinoma of the lung incorporating calcification from a previous tuberculous granuloma; it is extending into the mediastinurn (B) Ultrasound "US" Ultrasound of the lung is an excellent method for locating the loculated pleural fluid prior to diagnostic or therapeutic aspiration of the pleural fluid so it reveals the large left pleural effusion due to carcinoma of the bronchus and there is a large echo-free effusion above the hemidiaphragm arrow heads and spleen