Dr. Ali Sattar Lec.

1/ Investigations

Pulmonology

Objectives
🔺 To know what investigations are required to make a diagnosis in patients
presenting with respiratory symptoms & signs.

Investigations of the respiratory diseases

Imaging study
1. Chest X ray
2. Computed tomography
3. MRI
4. Ultrasound
5. PET scan
 Invasive investigations
1. Laryngoscopy
2. Bronchoscopy
3. Endoscopic ultrasound
4. Thoracoscopy

Microbiological investigations

🔹 Sputum, pleural uid, throat swabs, blood and bronchial washings and aspirates can be
examined for bacteria, fungi and viruses. The use of hypertonic saline to induce
expectoration of sputum may obviate the need for more invasive procedures such as
bronchoscopy.
🔹 Molecular tests (nucleic acid ampli cation tests, NAATs) are being used increasingly as
rst-line diagnostic tests for respiratory viruses (including in uenza & coronaviruses
such as ), as well as bacterial pathogens (e.g. Legionella, Mycoplasma), for
which they have largely replaced paired serology and antigen-based tests. NAATs are
also gaining an increased role as rst-line diagnostic tests for tuberculosis and for rapid
identi cation of antimicrobial drug resistance.

Immunological & serological investigations

🔹 The presence of atopy can be detected by demonstrating an elevated level of
immunoglobulin E (IgE) and the measurement of IgE directed against speci c antigens.
This can be useful to support the diagnosis of asthma and in identifying triggers. IgG
enzyme immunoassay or identi cation of serum precipitins can be used to identify a
reaction to fungi such as Aspergillus or to antigens involved in hypersensitivity
pneumonitis such as farmer’s lung or bird fancier’s lung. The presence of pneumococcal
antigen in sputum, blood or urine may be of diagnostic importance in pneumonia.
Respiratory viruses can be detected in nose/throat swabs by immuno uorescence and
legionella infection may diagnosed by detection of a legionella’s antigen.

🔹 Aspergillus galactomannan (in blood & bronchial lavage uid) is used to diagnose
invasive aspergillus. Interferon-gamma release assays are useful in the detection of
latent tuberculosis.

Cytology and Histopathology

🔹 Cytological examination of exfoliated cells in pleural uid or bronchial brushings &
washings, or of ne needle aspirates from lymph nodes or pulmonary lesions, can
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support a diagnosis of malignancies. A larger tissue biopsy is often necessary,
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however, as this allows immunihistochemistry and genetic testing to characterise
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the tumor and guide variant-speci c therapy. Histopathology may also allow
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identi cation of microorganisms using conventional staining or NAATs. Differential
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cell counts in bronchial lavage uid may help to distinguish pulmonary changes
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due to sarcoidosis, idiopathic pulmonary brosis or hypersensitivity pneumonitis.
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 📌 Pulmonary function test
The four pulmonary function tests commonly used to measure static lung function are
spirometry, ow volume loops, lung volume and Dlco.
Pulmonary function testing is indicated for patients with unexplained pulmonary symptoms,
abnormal pulmonary ndings (abnormal chest X-ray, hypoxemia, crackles), monitoring
known pulmonary disease, and preoparative assessment for lung resection.

Spirometry
▪ Is used to diagnose air ow obstruction such as asthma, COPD and bronchiectasis.

▪ FEV1 / FVC < 0.7 indicates air ow obstruction.

▪ A > 12% increase in either FEV1 or FVC and an increase > 200 ml from baseline in
either parameter with bronchodilator therapy indicates reversible airway obstruction.

▪ Equal reductions in FEV1 & FVC suggest restrictive lung disease.

Flow-volume loops
Can help localize anatomic sites of airway obstruction. Refer to the “Flow-volume
loops” gures and consider the following factors:

▪ A “scooped-out” pattern with a COPD.

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▪ A “scooped-out” pattern with a decreased slope on the expiratory curve that improves
with bronchodilation indicates reversible obstructive airway disease (asthma).
▪ “Flattening” in both inspiratory & expiratory curves and decreased air ow indicates
xed obstruction (e.g. tracheal stenosis).
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▪ Following attainment of peak ow, the ow rate declines linearly and proportionally to
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volume, producing a relatively straight slope characteristic of a normal ow-volume
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loop.
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 Lung volumes ‫الصورة مقاربة‬

Aid in con rming ndings on spirometry :

▪ TLC < 80% indicates restrictive lung disease

( brosis, neuromuscular disease, skeletal
abnormalities).
▪ Decreased vital capacity with increased residual
volume indicates air ow obstruction.

Dlco
▪ Evaluates gas transport across the alveolar-
capillary membrane.

Dlco and reduced lung volumes Pulmonary brosis

Dlco and normal lung volumes Pulmonary vascular disease, anemia
Dlco and air ow obstruction COPD, bronchiectasis
or normal Dlco and air ow obstruction Asthma

Dlco Pulmonary haemorrhage, left to right shunt, HF, polycythemia

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🔸 Peak ow meter : is a cheap, portable and easy-to-use device used to measure
peak expiratory ow (PEF) in L min-1, which is a measure of resistance to air ow
through the larger airways. The patient is asked to take a full inspiration and then
breathe out as hard and as fast as possible into the mouthpiece, with an open glottis,
to measure the maximum ow rate. The PEF is reached within the rst 100
milliseconds and is sustained for approximately 100 ms. This is demonstrated in the
supplementary material. The PEF will be reduced in those with obstructive airways
disease, especially conditions that result in narrowing of the medium-sized & large
airways such as asthma & COPD.

🔸 As COPD is largely an irreversible condition, routine PEF monitoring is not usually

recommended. Diurnal PEF monitoring is an important test in the diagnosis &
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monitoring of asthma, which is a reversible condition. In a patient suspected of having
asthma, measuring of PEF in the morning & evening should be done over several
weeks to see if there is a greater than 15% variability in readings, which is
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approximately 50 ml/L . The patient should also be given a peak ow dairy card to
document the readings and to write down the symptoms experienced. The normal
diurnal variation is 8%.
🔸 Figure 4.31 shows diurnal PEF measurements in an individual with poorly controlled
asthma. PEF monitoring is essential in the self-management of asthma, guiding the
patient as to when they may require oral corticosteroids or admission to hospital. PEF
monitoring may be used to diagnose occupational asthma. PEF may also be reduced
in diseases affecting the chest wall, such as neuromuscular diseases, kyphoscoliosis,
and in conditions that affect the upper airways, such as tracheal tumor or a thyroid
goitre. Therefore, PEF results cannot be interpreted on their own and spirometry
testing is required.
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 The six-minute walk test (SMWT) :
🔸 Is easy to do, safe & well tolerated, even in patients who have limited exercise tolerance.
The patient is asked to walk along a straight line on a hard surface, on his/her own and the
distance walked in 6 minutes is measured. The oxygen saturation & extent of breathlessness
should be determined. The SMWT correlates well with pulmonary function tests, quality of
life measures and mortality. Spirometry testing before & after exercise can help to reveal
exercise-induced asthma. Walk tests include the self-paced 6-minute walk and the externally

“Shuttle” test :
🔸 Where patients walk at increasing pace between two cones 10 m apart. These
provide simple, repeatable assessments of disability and response to treatment.
Cardiopulmonary bicycle exercise testing, with measurement of metabolic gas
exchange, ventilation & ECG changes, is useful for quantifying exercise limitation and
detecting occult cardiovascular or respiratory limitation in a breathless patient.

📌 A variety of investigations are available to aid the diagnosis of patients presenting

with respiratory symptoms & signs.

🔰 Many of the blood tests are non speci c but can rule out other causes of the
symptoms, for example, anemia can contribute to breathlessness.
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🔰 Radiological investigations are essential in the diagnosis of respiratory diseases.
🔰 The CXR is the commonest radiological investigation worldwide & can be helpful in
many conditions,including pneumonia & lung cancer.
🔰 CT thorax gives information about the main structures in the thorax & mediastinum,
including masses & lymph nodes, and is an essential investigation in the diagnosis of
lung cancer, pleural disease & mediastinal tumors. A CT guided biopsy can be done
to take samples from tumors and the pleura.
🔰 The CTPA will detect acute pulmonary emboli by visualising the pulmonary arteries up
to the segmental arteries.
🔰 The HRCT is necessary in diagnosing parancymal lung diseases, including
pulmonary brosis & sarcoidosis.
🔰 The VQ scan is less speci c and sensitive than a CTPA for diagnosing pulmonary
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embolism but is indicated in young women & pregnant women as it exposes them to
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less radiation. It is also the investigation of choice if chronic pulmonary emboli are
suspected.
🔰 The PET scan uses “ uoro-deoxyglucose” , a glucose analogue, which is taken up by
rapidly metabolising cells. It is essential in the staging of lung cancers & other
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malignancies. It can detect local & distant metastases but is not good at detecting
brain metastases.
🔰 Thoracic ultrasound is a noninvasive investigation used in the investigation of pleural
diseases & to guide the insertion of a needle for pleural aspiration, pleural biopsy and
for chest drain insertion
🔰 An MRI scan of the thorax is important in the diagnosis of mediastinal masses &
chest wall diseases , including invasion by tumor, spinal cord compression & brain
metastases.
🔰 Lung function tests are essential in the diagnosis of many respiratory diseases, in
determining the prognosis & in monitoring progression and response to treatment.
This includes peak expiratory ow measurement, spirometry and measurement of
static lung volumes, total lung capacity, residual volume & functional residual capacity.
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