Diagnostic Methods

in Pulmonary Diseases

Ayse Baha, MD
Near East Univeristy Faculty of Medicine
Department of Chest Diseases
1
 Diagnostic Methods
• Chest x-ray
• Pulmonary Function Tests
• Arterial Blood Gases
• Bronchoscopy

2
 Introduction
• Chest X-Ray is one of the most frequently using tools
• It is esily available and inexpensive method according
to another imaging studies.
• The basic interpretation is of most importance in
answering several clinical questions.
• It is an important tool to complement both history
and initial clinical examination.

TO UNDERSTAND AN ABNORMALY, WE HAVE TO KNOW

WHAT NORMAL IS!!

3
 General Principles
• Have a systematic approach
• Evaluate the chest x-ray (CXR) and clinical findings
together
• If we have, we have to compare the old x-ray with the new
one.

NEW FINDING
NEW DIAGNOSIS
NEW TREATMENT

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 How to Take a Standard Chest X-ray?

Clothing and jewelry (all metals) should be removed

The patient should be stand position (ideal)
Must take a deep breath and hold
There should be distance 180 cm between the patient and the x-
ray
The x-ray should travel from the patient's back to the anterior
chest wall
How to Take a Standard Chest (PA) X-ray?

• The standard imaging

technique is
posteroanterior!
– Laterally/ Anteroposterior/ Apicolordotic/
Lateral Decubitis can be applied (in need)

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How to Take a Standard Laterally (left) X-ray?

The standard lateral radiograph is taken

from the "left side" because two-thirds of
the heart is on the left.

Thus, the heart appears true to size and

does not cover the lung areas.

However, if there is pathology in the right

hemithorax during examination, a "right
lateral radiograph" should be taken.
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Apicolordotic technique

8
clavicale

Lesions distant from the clavicle are

better seen.

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PA grafi

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 Technically Acceptable X-Ray Features

• The spinous process of T3 should be

Symmetry equidistant from the sternoclavicular joints.

Scapulae • Scapulae should not cover the lung areas

• Shooting should be done at the end of inspiration.

Inspiration 6th anterior rib or 10th posterior rib should be
above the diaphragm

Vascular shadows should be seen at the

Penetration periphery of the lungs. The thoracic vertebrae and

big vascular shadows of the lower lobes should
be seen behind the heart.

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 Systematic Approach
• Firstly check;
• Name/marker (R/L)/rotation (symmetry)/ penetration
(dose)/inspiration.
• Should look;
• Heart
• Mediastinum
• Diaphragm
• Lungs zones (upper/middle/lower)
• Bones
• Soft Tissues

Inside-out approach

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A 2-SIDED CHEST X-ray HAVE TO BE TAKEN
for every patient who can stand!

1. Postero-Anterior (PA) x-ray

2. Lateral (Standard lateral radiograph is taken from the left side)

– But if the problem is right lung in examination, right laterally xray

should be taken

Not prefer bedside (Antero-Posterior) xray.

Ideal Xray should be taken while standing (Postero-anterior
and lateral)
14
 SPIROMETRY
(PULMONARY FUNCTION TEST)

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 Types of Lung function tests

• Standard
– Spirometry
• Use for obstructive and restrictive
lung disease
– Lung Volumes
– DLCO
• Good for vascular disease and interstitial lung disease
• Specialised lung function tests
– blood gases, exercise oximetry, 6MWT (another lesson
issues)
 What is Spirometry?

• The most common test type of pulmonary function or

breathing test.
• Measures how much air you can breathe in and out of your
lungs, as well as how easily and fast you can the blow the
air out of your lungs.
• Spirometry is a method of assessing
lung function by measuring the
total volume of air the patient can
expel from the lungs after a
maximal inhalation.
 Why Perform Spirometry?
Airflow Measure airflow obstruction

Severity Assess severity of airflow obstruction

Detect airway pathologies in smokers who may have few or no

Airway symptoms

Response Assess one aspect of response to therapy

Prognosis Assess prognosis in pulmonary disease

Preoperative Perform pre-operative assessment

Screen Screen workforces in occupational environments

Dive Assess fitness to dive

Pre-
Perform pre-employment screening in certain professions
employement
 Contraindications for Spirometry

▪ Recent myocardial infarction (in the last 3 monts)

▪ Unstable angina

• Recent thoraco abdominal surgery (in the last 3 monts)

• Recent ophthalmic surgery (in the last 3 monts)

▪ Thoracic / Abdominal / Cerebral aneurysm

▪ Pneumothorax

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 Standard Spirometric Parameters
• FEV1 - Forced expiratory volume in one second:
It is The volume of air expired in the first second of the blow
• Best indicator of obstructive lung disease
• Flow characteristics of the larger airways

• FVC - Forced vital capacity:

The total volume of air that can be forcibly exhaled in one
breath

• FEV1/FVC ratio:
The fraction of air exhaled in the first second relative to
the total volume exhaled
 Lung Volume Terminology
Tidal volume:
Normal breathing
Inspiratory reserve Inspiratory Inspiratory capacity:
volume capacity The maximum volume
of air that can be
Total Tidal volume inspired after reaching
lung the end of a normal,
capacity Expiratory reserve quiet expiration.
Vital
volume capacity Vital capacity:
It is the total amount of
air exhaled after
Residual volume
maximal inhalation.

The inspiratory reserve volume is the amount of air a person can inhale forcefully after
normal tidal volume inspiration
The expiratory reserve volume is the amount of air that can be pushed out of the lungs
(beyond the tidal volume) upon forced expiration.
Residual volume (RV) is the volume of air remaining in the lungs after maximum forceful
expiration
 SPIROMETRY
Volume Time Curve
Flow Volume Curve

Volume Time Curve; forced expiration time

(acceptable PFT: at least 6 second)
 VOLUME TIME CURVE

At every test, expirium should be at least

6 second.
If expirium lower than 6 second, the test
is unacceptable.
 FLOW VOLUME CURVE

Maximum
expiratory After 3 short breathing cycles, 1
flow (PEF) deep breath is taken. At this
Expiratory moment, the patient reaches total
flow rate
lung capacity. (red line)
L/sec

Patient blowing forcefully in one go

TLC FVC RV and continues to blow (at least 6
seconds). (blue line)
Inspiratory
flow rate Starting point
The start and end points must be
L/sec PFT
the same.
 Flow Volume Curve
Obstructive and Restrictive Patterns
Obstructive Severe obstructive Restrictive

Expiratory flow rate

Expiratory flow rate

Expiratory flow rate

Peak volume

Volume (L) Volume (L) Volume (L)

Reduced peak flow, scooped Steeple pattern, reduced Normal shape, normal
out mid-curve peak flow, rapid fall off peak flow, reduced
volume
Towards the end of expiration, Both the line collapsed inward There is no obstruction. The
the line collapsed inward. and reduced PEF. line did not collapse. Only the
volume narrowed.
 Limits for Normal Spirometry

• FEV1: % predicted > 80%

• FVC: % predicted > 80%

• FEV1/FVC: > 0.7 - 0.8 (%70-80)

 Criteria: Obstructive Disease
• FEV1: Reduced (<80%)

• FVC: Normal (>%80) (or slightly reduce)

• FEV1/FVC: < 0.7 (%70)

SPIROMETRY

RESTRICTIVE
DISEASE
 Criteria: Restrictive Disease
• FEV1: normal or mildly reduced

• FVC: < 80% predicted

• FEV1/FVC: > 0.7 (%70)

 Mixed Obstructive/Restrictive
• FEV1: < 80% predicted

• FVC: < 80% predicted

• FEV1 /FVC: < 0.7 (%70)

Carbonmonoxide • Lung diffusion testing measures how well the lungs
exchange gases.
Diffusion Test • This is an important part of pulmonary funtion test,
(DLCO Test/ because the major function of the lungs is to allow
oxygen to diffuse or pass into the blood from the lungs,
Diffusion test) and to allow carbon dioxide to diffuse from the blood
into the lungs.

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 Diffusion of Oxygen Across the Alveolar
Wall

Any disorder in these stages causes hypoxia. The purpose of the diffusion test is
to reveal whether there is a pathology that disrupts oxygen transport in the
parenchyma. 34
 A number of factors determine how well oxygen
transfers from lungs to blood (diffusion), including:

• The amount of surface area in alveoli.

• The amount of blood in capillaries.
• The concentration of hemoglobin (a protein that carries
oxygen) in blood.
• The thickness of the membrane between alveoli and
capillaries.
• Excess fluid in alveoli.

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36
• ILDs;
– PFT: Restriction
– DLCO: decrease in diffusion

• COPD (empysema);
– PFT: Obstruction
– DLCO: decrease in diffusion

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38
 Introduction

• An arterial blood gas (ABG) test

measures the levels of oxygen and
carbon dioxide in the body.
• It can measure how well the lungs
and kidneys are working and how
well the body is using energy.
• One of the first tests ordered to
assess respiratory status because it
helps evaluate gas exchange in the
lungs.
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22
 Basic Principles

Arterial blood gases (ABG) are obtained for two basic purposes:
1.To determine oxygenation
2.To determine acid-base status

Why is an ABG required?

1.To establish a diagnosis
2.To assess illness severity
3.To guide and monitor treatment
 Arterial blood gas analysis
Pulmonary gas exchange: partial pressure

• Help us to assess the effectiveness of gas

exchange by providing measurements of the
partial pressure of O2 and CO2 in arterial
blood.
• Partial pressure is the contribution of a gas to
the overall gas mixture. Gases move from
areas of higher partial pressure to lower
partial pressure.
• At the alveolar-capillary membrane, air in
alveoli has a higher PO2 and lower PCO2. O2
molecules move from alveoli to blood and
CO2 move from blood to alveoli.
 Arterial blood gas analysis - pulmonary gas exange

Carbon dioxide elimination:

• The level of ventilation is adjusted to maintain PaCO2
within tight limits (ref. range: PaCO2= 35-45 mm Hg).
• Increased PaCO2 (hypercapnia) implies reduced
alveolar ventilation
• Ventilation is regulated by an area in brainstem
called respiratory center. This area contains receptors
that sense PaCO2 and connect with the muscles
involved in breathing.
• If PaCO2 is abnormal, the respiratory center adjusts
the rate and depth of breathing accordingly.
 Arterial blood gas analysis;
pulmonary gas exange

Oxygenation:
• O2 bind to Hb!! The amount of O2 in blood depends on the two factors:
1.Hb concentration - how much O2 blood has the capacity to carry.
2.Saturation of Hb with O2 (SO2) - the percentage of available binding sites on Hb
occupied by O2 molecules.

Note
• SO2 – saturation in (any) blood
• SaO2 – saturation in arterial blood (>95% in healty person)
• With a normal PaO2 (80-100 mm Hg), Hb is maximally saturated (SaO2>95%).
This means blood has used up its O2-carrying capacity and any further
increase in PaO2 will not significantly increase arterial O2 content.
 Arterial blood gas analysis;
Hypoxia, hypoxemia and impaired oxygenation

• Hypoxia: reduced O2 delivery to

tissues.
• Hypoxemia: reduced O2 content
(PaO2) in arterial blood. It may
result from impaired oxygenation,
low haemoglobin (anaemia) or
reduced affinity of haemoglobin
for O2 (e.g. carbon monoxide)
• Impaired oxygenation refers to
hypoxaemia resulting from
reduced transfer of O2 from lungs
to the bloodstream. It is identified
by a low PaO2 (<10.7 kPa; <80
mmHg).
 ABG
(ARTERIAL BLOOD GAS)

It is a diagnostic procedure
in which a blood is obtained
from an artery directly!

Only a physician can perform arterial

interventions. Both nurses and
physicians can perform venous
interventions.
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 ABG component

• PH:
Measures hydrogen ion concentration in the blood, it shows blood’ acidity or alkalinity

• PCO2 :
It is the partial pressure of CO2 that is carried by the blood for excretion by the lungs, known
as respiratory parameter

• PO2:
It is the partial pressure of O2 that is dissolved in the blood , it reflects the body ability to pick
up oxygen from the lungs

• HCO3 :
known as the metabolic parameter, it reflects the kidney’s ability to retain and excrete
bicarbonate

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 Normal values

PH = 7.35 – 7.45

PCO2 = 35 – 45 mmhg

PO2 = 80 – 100 mmhg

HCO3 = 22 – 28 meq/L
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 EQUIPMENT
Blood gas kit;
• 1ml syringe
• Stopper or cap
• Alcohol swab
• Disposable gloves
• Vial of heparin (1:1000)
• Label
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 Preparation phase

• Record patient oxygen saturation (with pulse oxymeter)

• Explain the procedure to the patient
• Perform Allen's test

ALLEN’S TEST
It is a test done to determine
that collateral circulation is
present from the ulnar
artery in case thrombosis
occur in the radial
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 Allen’s test

• The radial artery is located by palpation at the proximal skin area of the
wrist and then compressed with three digits.
• The ulnar artery is similarly located and then compressed with three digits.
• With both arteries compressed, the subject is asked to clench and unclench
the hand 10 times.
• The hand is then held open, ensuring that the wrist and fingers are not
hyperextended and splayed out.
• The palm is observed to be blanched. The ulnar artery is released and the
time is taken for the palm and especially the thumb and thenar eminence to
become flush is noted.
• If the capillary refill time is less than 6 seconds the test is considered
positive. The test is then completed with the radial artery tested in a similar
fashion. Both hands should be tested for comparison.
 Sites for obtaining ABG

• Radial artery ( most common )

• Brachial artery
• Femoral artery

Radial is the most preferable site used

because:
• It is easy to access
• It is not a deep artery which facilitate
palpation, stabilization and
puncturing
• The artery has a collateral blood
circulation
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 Performance phase

• Wash hands
• Put on gloves
• Palpate the artery for maximum pulsation
• If radial, perform Allen's test
• Place a small towel roll under the patient wrist
• Clean with alcohol swab in circular motion
• Insert needle at 45 degree radial ,60 degree
brachial and 90 degree femoral
• Withdraw the needle and apply digital pressure
• Check bubbles in syringe
• Place the capped syringe in the container of ice
immediately
• Maintain firm pressure on the puncture site for 5
minutes, if patient has coagulation abnormalities
apply pressure for 10 – 15 minutes
 Complication

• Arteriospasm
• Hematoma
• Hemorrhage
• Distal ischemia
• Infection
• Numbness
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Flexible Fiberoptic Bronchoscopy

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 Endoscopy
• Procedures that look into the body’s tubes
and cavities
– Colonoscopy
– Esophagoscopy/Gastroscopy
– Bronchoscopy
• Used to diagnose various diseases and explain
conditions

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 Bronchoscopy
• Bronchoscopy is an endoscopic technique.
• Allows visualization of the airways (tracheobronchial tree)
• Performed to diagnose
problems with the airway
or treat problems such as
an object or growth in
the airway

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 Types of Bronchoscopy
• Rigid bronchoscope • Flexible Fiberoptic
Bronchoscopy

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 Rigid bronchoscope
• A rigid bronchoscope is a straight, hollow, metal tube. Chest
surgeons perform rigid bronchoscopy less often today, but it
remains the procedure of choice for removing foreign
material and for several other treatments.

• Rigid bronchoscopy also becomes useful when bleeding

interferes with visualizing the area.

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 Flexible bronchoscope
• A flexible bronchoscope is a long thin tube that contains small
clear fibers that transmit light images as the tube bends. Its
flexibility allows this instrument to reach the farthest points in
an airway.

• The procedure can be performed easily and safely under local

anesthesia.

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• The bronchoscope is a thin tube-like instrument that passes
through the nose or mouth and can be used to inspect the
various parts of the airways in the lungs.

• The tube acts as a camera and is able to carry pictures back to

a video screen.

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 Fiberoptic Equipment
Portable light source

Flexible fiberoptic
bronchoscope

Fiberoptic light cable

12/4/2024 BI, All Rights Reserved, 2005 61

Figure 4-4 Flexible fiberoptic bronchoscope. The four channels consist of two that
provide a light source, one vision channel, and one open channel that
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accommodates instruments or allows administration of an anesthetic or oxygen.
 Anatomic Exam
• The bronchoscope is advanced
through the vocal cords and into
the trachea.
• 1% Lidocaine again is
administered through the
bronchoscope biopsy channel.
• The trachea, main bronchi,
lower, middle and upper lobes of
the lungs are visualized and
examined by bronchoscopist as
he/she carefully advances and
skillfully guides the flexible
bronchoscope while observing
the video images.

12/4/2024 BI, All Rights Reserved, 2005 63

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 Procedure
– The patient's nasopharynx and oropharynx are anesthetized topically with
lidocaine spray before the insertion of the bronchoscope. A bite block may be
used.
– The patient is placed in the sitting or supine position, and the scope is inserted
through the nose or mouth and into the pharynx.
– After the scope passes into the larynx and through the glottis, more lidocaine
is sprayed into the trachea to prevent the cough reflex.
– The scope is passed farther, well into the trachea, bronchi, and the first- and
second-generation bronchioles, for systematic examination of the bronchial
tree.
– Biopsy specimens and washings are taken if a pathologic condition is
suspected.
– If bronchoscopy is performed for removal of mucus, each bronchus is
aspirated until clear.
– Monitor the patient's oxygen saturation to be sure that the patient is well
oxygenated. These patients often have pulmonary diseases that already
compromise their oxygenation. When a scope is placed, breathing may be
further impaired.
 Post Procedure
• Instruct the patient not to eat or drink anything until the tracheobronchial
anesthesia has worn off and the gag reflex has returned, usually in
approximately 2 hours.
• Observe the patient's sputum for hemorrhage if biopsy specimens were
removed. A small amount of blood streaking may be expected and is
normal for several hours. Large amounts of bleeding can cause a chemical
pneumonitis.
• Observe the patient closely for evidence of impaired respiration or
laryngospasm. The vocal cords may go into spasms after intubation.
Emergency resuscitation equipment should be readily available.
• Inform the patient that postbronchoscopy fever often develops within the
first 24 hours.
• If a tumor is suspected, collect a postbronchoscopy sputum sample for a
cytologic determination.
• Inform the patient that warm saline gargles and lozenges may be helpful if
a sore throat develops.
• Note that a chest x-ray film may be ordered to identify a pneumothorax if
a deep biopsy was obtained.
 There are two main reasons a person
might need a bronchoscopy:

• Evaluation
– Suspicion of disease

• Treatment
• Removing fluid or mucus from airways
• Removing a foreign object from airways
• Widening (dilating) an airway that is blocked or narrowed
– Washing out an airway

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 Indications
• Abnormal CXR • Atelectasis
• Excessive bronchial • Laser excision
secretions • Removal of foreign bodies
• Acute smoke inhalation • Lung lavage
injuries • Difficult intubations
• Hemoptysis • Suctioning of excessive
• Pneumonia secretions, mucus plugs
• Unexplained Cough • Selective lavage
• Tracheal disease, stridor • Management of life
and localized wheezing threatening hemoptysis
• Intubation damage

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 Bronchoscopy contraindications
• Recent myocard infarction
• Lack of patient cooperation
• Unstable severe asthma
• Severe hypoxia
• Severe hypercapnia
• Bleeding disorders
• Potentially lethal cardiac arrhythmias
• Lung abscess
• Renal failure
• Immunosupression
• Obstruction of the vena cava superior

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 Biopsy Techniques for Diagnosis

• Biting forceps
• Grasping forceps
• Shielded brushes
• Unshielded brushes
• Sheathed needles
• Sampling catheters

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 Interventional Bronchoscopy
• Interventional bronchoscopy is a rapidly
expanding field in respiratory medicine
offering minimally invasive therapeutic and
palliative procedures for all types of lung
neoplasms.

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 Interventional Bronchoscopy
• Laser Therapy • Stents
– Thermal tissue damage – Tracheobronchial
to destroy obstructing prostheses
lesions – May require opening the
– Saline lavage to clean airway with other
debris techniques prior to
• Cryotherapy placement
– Tissue destruction via
intracellular freezing
– Bronchogenic
carcinomas
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 Bronchoscopy Complications
• Most people tolerate both types of bronchoscopy quite well.
There are some potential risks, however.
• Though they are not common, they include:

• Fever
• Bronchospasm
• Hemorrhage (after biopsy)
• Hypoxemia
• Pneumothorax
• Infection
• Laryngospasm
• Aspiration
• Cardiac arrest – arrhythmias
• Respiratory depression
• hypotension

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• Good luck

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