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G	
  Ferretti	
  	
  
University	
  hospital	
  of	
  Grenoble,	
  France	
  
	
  
¡ 

Dyspnea	
  is	
  generally	
  defined	
  as	
  a	
  subjective	
  
experience	
  of	
  breathing	
  discomfort	
  

¡ 

Equivalent:	
  breathlessness	
  or	
  shortness	
  of	
  breath	
  
or	
  unpleasant	
  urge	
  to	
  breathe	
  

¡ 

Acute	
  vs.	
  chronic	
  if	
  >	
  1	
  month	
  in	
  duration	
  

¡ 

Dyspnea	
  is	
  one	
  of	
  the	
  most	
  frequent	
  symptoms	
  of	
  
presentation	
  of	
  thoracic	
  diseases	
  in	
  the	
  ED	
  
Dyspnea	
  may	
  be	
  of	
  neurogenic,	
  respiratory,	
  or	
  cardiac	
  
origin,	
  and	
  may	
  be	
  associated	
  with	
  conditions	
  such	
  as	
  
anemia,	
  deconditioning,	
  or	
  anxiety.	
  
85%	
  of	
  all	
  cases	
  of	
  shortness	
  of	
  breath	
  are	
  caused	
  by:	
  
¡  congestive	
  heart	
  failure	
  and	
  myocardial	
  ischemia	
  	
  
¡  asthma,	
  COPD,	
  interstitial	
  lung	
  disease,	
  pneumonia,	
  
¡  psychogenic	
  disorders	
  
	
  

▪  SARKAR	
  S	
  EVALUATION	
  OF	
  THE	
  DYSPNEIC	
  PATIENT	
  IN	
  THE	
  OFFICE.	
  PRIM	
  CARE.	
  
2006;33(3):643–657	
  

>	
  30%	
  of	
  cases	
  are	
  related	
  multifactorial	
  etiology	
  
	
  

▪  AMERICAN	
  COLLEGE	
  OF	
  RADIOLOGY.	
  ACR	
  APPROPRIATENESS	
  CRITERIA.	
  CHRONIC	
  
DYSPNEA—SUSPECTED	
  PULMONARY	
  ORIGIN.	
  2012.	
  	
  
¡  lung	
  parenchyma	
  
¡  airways	
  	
  
¡  vessels	
  
¡  pleura	
  
¡  thoracic	
  wall	
  
Initial	
  Diagnostic	
  Studies	
  includes	
  
¡  Electrocardiography	
  	
  
¡  Spirometry	
  	
  
¡  Laboratory	
  evaluation	
  
¡  Chest	
  Radiography	
  
Acute infectious pneumonia

Left atelectasis
¡  The	
  cases	
  in	
  which	
  CXR	
  shows	
  evident	
  etiology	
  

of	
  dyspnea	
  will	
  not	
  be	
  discussed	
  here	
  	
  

¡  But	
  more	
  difficult	
  cases	
  will	
  be	
  presented	
  with	
  

emphasize	
  on	
  the	
  role	
  of	
  CT	
  
§  Chronic	
  presentation	
  
§  Acute	
  presentation	
  
Thorax cardio adult dyspnea imaging g ferretti
§ 

FEV1	
  /	
  FVC	
  	
  <	
  70%	
  	
  post-­‐bronchodilator	
  

§ 

Role	
  of	
  CT	
  
§  Phenotyping	
  COPD	
  
§  Search	
  for	
  complications	
  
§  Selection	
  of	
  patient	
  before	
  treatment	
  	
  
Centrilobular	
  emphysema	
  
45	
  yo	
  smoking	
  man	
  
Thorax cardio adult dyspnea imaging g ferretti
Expiration

Bronchial wall thickening
Bronchiectasis
Air trapping
Small airway diseases
constrictive bronchiolitis

inspiration

minIP inspiration

expiration
séquelle bronchiolite 2d
SERGEANT_FREDERIc

average
17 yo man chronic dyspnea
MacLeod / Syver James syndrome

minIP

MIP

focal areas of decreased lung opacity with sharp
margins, reduced-size pulmonary vessels,
bronchial wall thickening, and bronchiectasis.
Sub acute Hypersensitivity Pneumonitis
Thorax cardio adult dyspnea imaging g ferretti
Tracheobronchomalacia (TBM)
● 

characterized by increased compliance and
excessive collapsibility of trachea and / or
bronchi (acquired / congenital)

● 

an important cause of chronic nonspecific
pulmonary symptoms

● 

identified in 1–10% of bronchoscopies (Nuutinen Ann
Clin Res 1977)

● 

but is an under diagnosed condition as it
escapes detection on inspiratory CT
56 yo man, COPD
Recent worsening of
chronic dyspnea
End inspiratory CT: sabersheath trachea
End expiratory VCT:
airway collapse < 50%
Dynamic expiratory VCT
shows expiratory airway
collapse > 70%
VCT shows bowing of
posterior membranous
TBM confirmed by
bronchoscopy

Inspiration

End expi

During expi
High grade mucoepidermoid
¡  25	
  yo	
  female	
  	
  
¡  Chronic	
  obstructive	
  disease	
  
¡  FEV1:	
  2.36L;	
  64%	
  

¡  FEV1	
  /	
  VC:	
  72%	
  
¡  Treatment	
  for	
  asthma	
  failed	
  

¡  Proposed	
  diagnostic:	
  complicated	
  asthma	
  
Thorax cardio adult dyspnea imaging g ferretti
Thorax cardio adult dyspnea imaging g ferretti
Thorax cardio adult dyspnea imaging g ferretti
IV	
  contrast	
  injection	
  	
  
Expiratory	
  CT	
  
MIP	
  	
  
4.  Nothing,	
  I’m	
  glad	
  with	
  the	
  CT	
  I’ve	
  done	
  
1. 
2. 
3. 
IV	
  contrast	
  injection	
  	
  
Expiratory	
  CT	
  
MIP	
  	
  
4.  Nothing,	
  I’m	
  glad	
  with	
  the	
  CT	
  I’ve	
  done	
  
1. 
2. 
3. 
Thorax cardio adult dyspnea imaging g ferretti
¡  Dynamic	
  stenosis	
  of	
  the	
  LMB	
  due	
  to	
  the	
  

compression	
  between	
  the	
  aorta	
  and	
  the	
  
thoracic	
  spine	
  	
  
¡ 

HRCT	
  is	
  the	
  most	
  sensitive	
  modality	
  for	
  diagnosing	
  
early	
  emphysema	
  in	
  smokers	
  with	
  dyspnea.	
  	
  

¡ 

HRCT	
  is	
  more	
  sensitive	
  than	
  pulmonary	
  function	
  
tests	
  for	
  diagnosing	
  emphysema.	
  

¡ 

HRCT	
  phenotypes	
  BPCO	
  
§  Emphysema	
  
§  Diseases	
  of	
  the	
  airways	
  

¡ 

	
  

HRCT	
  helps	
  choosing	
  appropriate	
  treatment	
  
Thorax cardio adult dyspnea imaging g ferretti
Pulmonary lymphangioleiomyomatosis
Langerhans cell histiocytosis
42 yo woman
Mild dyspnea
Possible NSIP in a patient with systemic sclerosis
83 yo man
Dyspnea at exercise
Worked as a dentist

Silicosis complicated
with emphysema
¡ 

HRCT	
  the	
  best	
  non	
  invasive	
  tool	
  

¡ 

particularly	
  appropriate	
  when	
  the	
  results	
  of	
  clinical,	
  
radiographic,	
  and	
  laboratory	
  studies	
  are	
  either	
  
nonrevealing	
  or	
  nondiagnostic.	
  

	
  
¡ 

Many	
  diseases	
  have	
  features	
  characteristic	
  enough	
  
to	
  enable	
  experienced	
  radiologists	
  to	
  make	
  a	
  
confident,	
  probable,	
  or	
  limited	
  differential	
  diagnosis	
  
in	
  most	
  cases.	
  

¡ 

Thanks	
  to	
  HRCT,	
  biopsy	
  and	
  additional	
  diagnostic	
  
testing	
  are	
  often	
  unnecessary.	
  

	
  
Thorax cardio adult dyspnea imaging g ferretti
¡  Rarely	
  needed	
  
¡  Useful	
  in	
  diagnosing	
  	
  
§  Chronic	
  Thromboembolism	
  of	
  PA	
  	
  
§  fibrosing	
  mediastinitis	
  

¡  Is	
  recommended	
  in	
  case	
  of	
  mosaic	
  pattern	
  

with	
  unremarkable	
  PFT.	
  
62yo patient with chronic dyspnea at
exercise
CT without CM injection
Thorax cardio adult dyspnea imaging g ferretti
Thorax cardio adult dyspnea imaging g ferretti
Thorax cardio adult dyspnea imaging g ferretti
50 yo woman complaining of dyspnea at
exercise associated with palpitation.
53 kg for 163cm
Thorax cardio adult dyspnea imaging g ferretti
TDM	
  
Thorax cardio adult dyspnea imaging g ferretti
Thorax cardio adult dyspnea imaging g ferretti
A 77-year-old woman was referred to our center for the workup of progressive exertional
dyspnea.
Ventilation perfusion lung scan with multiple nonmatched perfusion defects in the right
superior lobe and right median lobe and hypoperfusion of the left lung.

Seferian A et al. Circulation 2012;125:2045-2047

Copyright © American Heart Association

by Andrei Seferian, et al
Contrast-enhanced high-resolution computed tomography of the chest.

Seferian A et al. Circulation 2012;125:2045-2047

Copyright © American Heart Association
PAHT
VOD
Thorax cardio adult dyspnea imaging g ferretti
¡  Frequent	
  in	
  ER	
  or	
  ICU	
  
¡  May	
  be	
  associated	
  with	
  a	
  severe	
  prognosis	
  
¡  Need	
  a	
  quick	
  diagnosis	
  and	
  treatment	
  
¡  De	
  novo	
  or	
  complicating	
  a	
  chronic	
  dyspnea	
  
¡  Common	
  pulmonary	
  causes	
  include	
  	
  
§  asthma	
  
§  pneumothorax	
  
§  upper	
  airway	
  obstruction	
  
§  interstitial	
  lung	
  disease	
  
§  pulmonary	
  embolism	
  
§  pulmonary	
  hypertension	
  
Thorax cardio adult dyspnea imaging g ferretti
¡  2005	
  
¡  83	
  yo	
  women	
  
¡  No	
  particular	
  history	
  	
  
¡  Acute	
  dyspnea	
  
¡  Unremarkable	
  CXR	
  

¡  Angio	
  CT	
  for	
  suspected	
  PE	
  	
  
Acute PE
¡  2010	
  	
  
¡  88	
  yo	
  
¡  Rapid	
  onset	
  of	
  

dyspnea	
  
¡  Weight	
  loss	
  
New epidode of thrombo-embolic PE?
Sarcoma of the pulmonary artery
Gravité de l’EP : signes d’ICDA
Collomb Eur Radiol 2002

VD / VG > 1 : valeur pédictive forte pour
réanimation, thrombolyse, mortalité à 30 j
Schoepf U Circulation 2004
Thorax cardio adult dyspnea imaging g ferretti
68 yo man acute leukemia
Fever
Dyspnea
CXR 22/02/2013
Crazy paving
PCP pneumonia
Measles severe
¡  62	
  yo	
  man	
  
¡  Immunocompetent	
  	
  
¡  Recent	
  fatigue	
  weigh	
  loss	
  anorexia	
  	
  
¡  Fever	
  	
  
¡  Cough	
  

¡  acute	
  respiratory	
  distress…	
  ICU	
  
Thorax cardio adult dyspnea imaging g ferretti
Invasive Aspergillosis
42 yo female
Chronic dyspnea: PHT
CT: PA embolism ?
Undiagnosed partial anomalous pulmonary venous return
¡ 

CXR	
  is	
  the	
  first	
  line	
  technique	
  in	
  patients	
  with	
  dyspnea	
  

¡ 

in	
  case	
  of	
  unremarkable	
  CXR,	
  HRCT,	
  Expiratory	
  CT	
  
and	
  angio	
  CT	
  play	
  an	
  important	
  role	
  for	
  diagnosing	
  
patients	
  with	
  dyspnea	
  

¡ 

V/Q	
  scan	
  remains	
  the	
  most	
  sensitive	
  technique	
  for	
  
diagnosing	
  chronic	
  thromboembolism	
  	
  
Grenoble

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Thorax cardio adult dyspnea imaging g ferretti

  • 1. G  Ferretti     University  hospital  of  Grenoble,  France    
  • 2. ¡  Dyspnea  is  generally  defined  as  a  subjective   experience  of  breathing  discomfort   ¡  Equivalent:  breathlessness  or  shortness  of  breath   or  unpleasant  urge  to  breathe   ¡  Acute  vs.  chronic  if  >  1  month  in  duration   ¡  Dyspnea  is  one  of  the  most  frequent  symptoms  of   presentation  of  thoracic  diseases  in  the  ED  
  • 3. Dyspnea  may  be  of  neurogenic,  respiratory,  or  cardiac   origin,  and  may  be  associated  with  conditions  such  as   anemia,  deconditioning,  or  anxiety.   85%  of  all  cases  of  shortness  of  breath  are  caused  by:   ¡  congestive  heart  failure  and  myocardial  ischemia     ¡  asthma,  COPD,  interstitial  lung  disease,  pneumonia,   ¡  psychogenic  disorders     ▪  SARKAR  S  EVALUATION  OF  THE  DYSPNEIC  PATIENT  IN  THE  OFFICE.  PRIM  CARE.   2006;33(3):643–657   >  30%  of  cases  are  related  multifactorial  etiology     ▪  AMERICAN  COLLEGE  OF  RADIOLOGY.  ACR  APPROPRIATENESS  CRITERIA.  CHRONIC   DYSPNEA—SUSPECTED  PULMONARY  ORIGIN.  2012.    
  • 4. ¡  lung  parenchyma   ¡  airways     ¡  vessels   ¡  pleura   ¡  thoracic  wall  
  • 5. Initial  Diagnostic  Studies  includes   ¡  Electrocardiography     ¡  Spirometry     ¡  Laboratory  evaluation   ¡  Chest  Radiography  
  • 7. ¡  The  cases  in  which  CXR  shows  evident  etiology   of  dyspnea  will  not  be  discussed  here     ¡  But  more  difficult  cases  will  be  presented  with   emphasize  on  the  role  of  CT   §  Chronic  presentation   §  Acute  presentation  
  • 9. §  FEV1  /  FVC    <  70%    post-­‐bronchodilator   §  Role  of  CT   §  Phenotyping  COPD   §  Search  for  complications   §  Selection  of  patient  before  treatment    
  • 10. Centrilobular  emphysema   45  yo  smoking  man  
  • 14. séquelle bronchiolite 2d SERGEANT_FREDERIc average 17 yo man chronic dyspnea MacLeod / Syver James syndrome minIP MIP focal areas of decreased lung opacity with sharp margins, reduced-size pulmonary vessels, bronchial wall thickening, and bronchiectasis.
  • 17. Tracheobronchomalacia (TBM) ●  characterized by increased compliance and excessive collapsibility of trachea and / or bronchi (acquired / congenital) ●  an important cause of chronic nonspecific pulmonary symptoms ●  identified in 1–10% of bronchoscopies (Nuutinen Ann Clin Res 1977) ●  but is an under diagnosed condition as it escapes detection on inspiratory CT
  • 18. 56 yo man, COPD Recent worsening of chronic dyspnea End inspiratory CT: sabersheath trachea End expiratory VCT: airway collapse < 50% Dynamic expiratory VCT shows expiratory airway collapse > 70% VCT shows bowing of posterior membranous TBM confirmed by bronchoscopy Inspiration End expi During expi
  • 20. ¡  25  yo  female     ¡  Chronic  obstructive  disease   ¡  FEV1:  2.36L;  64%   ¡  FEV1  /  VC:  72%   ¡  Treatment  for  asthma  failed   ¡  Proposed  diagnostic:  complicated  asthma  
  • 24. IV  contrast  injection     Expiratory  CT   MIP     4.  Nothing,  I’m  glad  with  the  CT  I’ve  done   1.  2.  3. 
  • 25. IV  contrast  injection     Expiratory  CT   MIP     4.  Nothing,  I’m  glad  with  the  CT  I’ve  done   1.  2.  3. 
  • 27. ¡  Dynamic  stenosis  of  the  LMB  due  to  the   compression  between  the  aorta  and  the   thoracic  spine    
  • 28. ¡  HRCT  is  the  most  sensitive  modality  for  diagnosing   early  emphysema  in  smokers  with  dyspnea.     ¡  HRCT  is  more  sensitive  than  pulmonary  function   tests  for  diagnosing  emphysema.   ¡  HRCT  phenotypes  BPCO   §  Emphysema   §  Diseases  of  the  airways   ¡    HRCT  helps  choosing  appropriate  treatment  
  • 32. 42 yo woman Mild dyspnea
  • 33. Possible NSIP in a patient with systemic sclerosis
  • 34. 83 yo man Dyspnea at exercise Worked as a dentist Silicosis complicated with emphysema
  • 35. ¡  HRCT  the  best  non  invasive  tool   ¡  particularly  appropriate  when  the  results  of  clinical,   radiographic,  and  laboratory  studies  are  either   nonrevealing  or  nondiagnostic.     ¡  Many  diseases  have  features  characteristic  enough   to  enable  experienced  radiologists  to  make  a   confident,  probable,  or  limited  differential  diagnosis   in  most  cases.   ¡  Thanks  to  HRCT,  biopsy  and  additional  diagnostic   testing  are  often  unnecessary.    
  • 37. ¡  Rarely  needed   ¡  Useful  in  diagnosing     §  Chronic  Thromboembolism  of  PA     §  fibrosing  mediastinitis   ¡  Is  recommended  in  case  of  mosaic  pattern   with  unremarkable  PFT.  
  • 38. 62yo patient with chronic dyspnea at exercise CT without CM injection
  • 42. 50 yo woman complaining of dyspnea at exercise associated with palpitation. 53 kg for 163cm
  • 47. A 77-year-old woman was referred to our center for the workup of progressive exertional dyspnea. Ventilation perfusion lung scan with multiple nonmatched perfusion defects in the right superior lobe and right median lobe and hypoperfusion of the left lung. Seferian A et al. Circulation 2012;125:2045-2047 Copyright © American Heart Association by Andrei Seferian, et al
  • 48. Contrast-enhanced high-resolution computed tomography of the chest. Seferian A et al. Circulation 2012;125:2045-2047 Copyright © American Heart Association
  • 51. ¡  Frequent  in  ER  or  ICU   ¡  May  be  associated  with  a  severe  prognosis   ¡  Need  a  quick  diagnosis  and  treatment   ¡  De  novo  or  complicating  a  chronic  dyspnea  
  • 52. ¡  Common  pulmonary  causes  include     §  asthma   §  pneumothorax   §  upper  airway  obstruction   §  interstitial  lung  disease   §  pulmonary  embolism   §  pulmonary  hypertension  
  • 54. ¡  2005   ¡  83  yo  women   ¡  No  particular  history     ¡  Acute  dyspnea   ¡  Unremarkable  CXR   ¡  Angio  CT  for  suspected  PE    
  • 56. ¡  2010     ¡  88  yo   ¡  Rapid  onset  of   dyspnea   ¡  Weight  loss  
  • 57. New epidode of thrombo-embolic PE?
  • 58. Sarcoma of the pulmonary artery
  • 59. Gravité de l’EP : signes d’ICDA Collomb Eur Radiol 2002 VD / VG > 1 : valeur pédictive forte pour réanimation, thrombolyse, mortalité à 30 j Schoepf U Circulation 2004
  • 61. 68 yo man acute leukemia Fever Dyspnea CXR 22/02/2013
  • 64. ¡  62  yo  man   ¡  Immunocompetent     ¡  Recent  fatigue  weigh  loss  anorexia     ¡  Fever     ¡  Cough   ¡  acute  respiratory  distress…  ICU  
  • 67. 42 yo female Chronic dyspnea: PHT CT: PA embolism ?
  • 68. Undiagnosed partial anomalous pulmonary venous return
  • 69. ¡  CXR  is  the  first  line  technique  in  patients  with  dyspnea   ¡  in  case  of  unremarkable  CXR,  HRCT,  Expiratory  CT   and  angio  CT  play  an  important  role  for  diagnosing   patients  with  dyspnea   ¡  V/Q  scan  remains  the  most  sensitive  technique  for   diagnosing  chronic  thromboembolism