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CT For PE Breathing Technique PRESENTATION
CT For PE Breathing Technique PRESENTATION
CT For PE Breathing Technique PRESENTATION
The importance of correct breathing technique
for “CT pulmonary emboli” – it is not just about
having many “slices” in your scanner.
Professor Jonas Rydberg, MD
E-mail: jrydberg@iuhealth.org
Indiana University School of Medicine
Department of Radiology Methodist Hospital
Indianapolis, Indiana, USA
Outline: 1. This presentation takes a focus on the most common reason for failed
CT exams namely – The breathing instructions given to the patient.
2. It will also discuss how patient size affects the exam quality.
Conclusions: • Most often the failed exams depend on dilution of the contrast media in the
pulmonary arteries due to mixing with non-opacified blood from the Inferior
Vena Cava.
• The breathing instruction to the patient should be: Stop breathing!” and not:
Take a deep breath and hold it!
• Another reason why some exams do not turn out excellent is due to the
large size of some patients.
This is how we want to see the opacification of the
pulmonary arteries – well opacified arteries allowing for
definite diagnostic evaluation for pulmonary emboli.
(The slab MIP technique above is not used for the routine PE protocol. Here it is used just to
show good opacification.)
Jonas Rydberg Oct 2011
QA process to evaluate if attenuation is acceptable:
Use a ROI and measure the attenuation in the pulmonary
trunk or in the left pulmonary artery.
600 HU
150 HU
300 HU
- Incorrect triggering?
- Incorrect timing?
- Something wrong with the CT scanner?
What is the reason? - Fast blood flow?
- Size of patient?
- Breathing technique?
- Valsalva maneuver?
Jonas Rydberg Oct 2011
Some important facts about multislice CT scanners
which potentially can cause the exams to fail
The more slices a scanner has the faster the scan scan.
From the moment bolus triggering software triggers the scan start it
usually takes 5-6 seconds before the scanner reaches the start position
for the scanning and start scanning.
Note that for 40-slice CT and up the total scan time matches the delay
from triggering to scan start. We are looking at processes that are fast.
Paradoxically it is the fastest scanners that have the highest incident of
failed exams. Keep reading to learn why! Jonas Rydberg Oct 2011
Here is the faulty assumption we all are making:
Intuitively, but incorrectly, do we assume that the contrast media flows
through a single “pipe line” (see red arrows below) starting in the arm,
continuing through the superior vena cava, right atrium, right ventricle,
pulmonary arteries and then out via the pulmonary veins to reach the
aorta.
- But that is wrong. Please, continue reading!
We forget that there is a major inflow to the above “pipeline” from the Inferior
Vena Cava containing non-opacified blood.
But, this is what happens after a “Take a deep breath and hold
it!” command.
Scanning period
SVC RA-RV PA PV-RA-RV Aorta
1200 HU
280 HU
90 HU 90 HU
90 HU
280 HU
(Go back to slide 3 to check the QA Inflow of non-opacified
process with HU values.) blood from liver and IVC Jonas Rydberg Oct 2011
Solution: “Stop breathing” technique.
Be sure to give the patient instructions to stop breathing and
not make any inhalation when the scanner starts scanning.
Scanning will be over in a few seconds so there will be no
oxygen issues. Be certain that the patient has understood the
instructions.
300.00 Series1
200 HU 200.00
100.00
0.00
0 5 10 15 20 25 30 35 40
RULE: If attenuation is low in both pulmonary arteries and aorta the reason is likely
large size of the patient and not an issue with the breathing technique.
152 HU
126 HU
150HU
1. If Pulmonary artery > Aorta
= Correct breath hold technique 300HU
300HU
2. If Aorta > Pulmonary artery
= Incorrect breath hold technique 150HU
Inflow of “Bad blood” from IVC and liver
Exam 1 – Non diagnostic exam. Radiologist Exam 2 (next morning) – Radiologist ordered
analyzed images and concluded that the repeat scanning with careful attention to “No
exam had failed because of incorrect breath breathing instructions” to patient. Exam now
hold technique. (Note that not even central diagnostic showing large central emboli.
arteries can be evaluated.)
? ?
?
Case provided by: Julio A. Lemos, MD., Fletcher Allen Health Care, University of Vermont, Burlington, VT.
Jonas Rydberg Oct 2011
Conclusions:
• Most often the failed exams depend on dilution of the contrast
media in the pulmonary arteries due to mixing with non-opacified
blood from the Inferior Vena Cava.
• The breathing instruction to the patient should be: Stop breathing!”
and not: Take a deep breath and hold it!
• Another reason why some exams do not turn out excellent is due to
the large size of some patients.