Chest X Ray- The Diaphragm is unique and provides clue to your diagnosis!!!

Pulmonary Medicine Blog By Dr Deepu

There are a few things which beginners often miss in a chest x ray, one among those is failure to comment on the diaphragms.
Today I am going to discuss importance of tracing diaphragm in a chest X ray with an example.
          Normal diaphragm in a chest X ray has the following characteristics
1.     Trace the diaphragm on right and left
2.     The right diaphragm is usually placed between the fifth and the sixth Rib in the mid clavicular line, It can be seen upto middle of sixth and seventh rib.
3.     The Diaphragms are usually not at the same level on the frontal , erect , inspiratory chest X rays, but they are usually within one rib intercostals space height ( roughly 2 cm) of each other.
4.     The left diaphragm is usually lower than right.
5.     The costophrenic angles should be sharp, making an acute angle.
6.      If the left hemidiaphragm is equal to Right or higher than Right or Right diaphragm is higher than left by more than 3 cms, Causes of diaphragmatic elevation should be considered.
The causes of elevated hemidiaphragm are
1.            Causes above the diaphragm- decreased lung volume due to Lung Collapse, lobectomy, pneumonectomy , fibrosis and pulmonary Hypoplasia
2.            Causes in the diaphragm- Phrenic nerve palsy , diaphragmatic evantration
3.            Causes below the diaphragm- abdominal malignancy, subphrenic abscess, distended   hollow viscus.
After knowing the cause I want to discuss with you a chest x ray where the subtle change in the diaphragm was missed.
Before we proceed Read the chest X ray

 The Chest X ray showed a subtle change in Diaphragm
1. Both the diaphragms are at the same levels.
2. The air shadow underneath the left diaphragm is more prominent.
3. The patient was not evaluated further because chest X Ray appeared normal and sent home with conservative treatment for COPD. 
He came back to our center with hemoptysis one month later referred from the center which treated him initially, a second Radiograph was performed. study the Chest X Ray before proceeding further.  


The chest X ray  now shows features of full blown disease, the hilum is prominent with CORONA RADIATA SIGN suggestive of bronchogenic carcinoma, The left Diaphragm is now placed higher compared to right. Further HR and CECT revealed a tumor in the Left Main bronchus with lymph node metastasis. With Bronchoscopy the diagnosis of squamous cell carcinoma was made.

With this I will end this post, requesting everyone to look at any subtle changes in diaphragm which if ignored may cause some grave diagnosis at a later date.
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NEW TREATMENT CAN CURE ASTHMA COMPLETELY!!!!

Pulmonary Medicine Blog By Dr Deepu

Scientists discover asthma's potential root cause and a novel treatment
Cardiff scientists have for the first time identified the potential root cause of asthma and an existing drug that offers a new treatment.

Published today in Science Translational Medicine journal, University researchers, working in collaboration with scientists at King's College London and the Mayo Clinic (USA), describe the previously unproven role of the calcium sensing receptor (CaSR) in causing asthma, a disease which affects 300 million people worldwide.

The team used mouse models of asthma and human airway tissue from asthmatic and non-asthmatic people to reach their findings.

Crucially, the paper highlights the effectiveness of a class of drugs known as calcilytics in manipulating CaSR to reverse all symptoms associated with the condition. These symptoms include airway narrowing, airway twitchiness and inflammation - all of which contribute to increased breathing difficulty.

"Our findings are incredibly exciting," said the principal investigator, Professor Daniela Riccardi, from the School of Biosciences. "For the first time we have found a link airways inflammation, which can be caused by environmental triggers - such as allergens, cigarette smoke and car fumes – and airways twitchiness in allergic asthma.

"Our paper shows how these triggers release chemicals that activate CaSR in airway tissue and drive asthma symptoms like airway twitchiness, inflammation, and narrowing. Using calcilytics, nebulized directly into the lungs, we show that it is possible to deactivate CaSR and prevent all of these symptoms."

Dr Samantha Walker, Director of Research and Policy at Asthma UK, who helped fund the research, said:

"This hugely exciting discovery enables us, for the first time, to tackle the underlying causes of asthma symptoms. Five per cent of people with asthma don't respond to current treatments so research breakthroughs could be life changing for hundreds of thousands of people.

"If this research proves successful we may be just a few years away from a new treatment for asthma, and we urgently need further investment to take it further through clinical trials. Asthma research is chronically underfunded; there have only been a handful of new treatments developed in the last 50 years so the importance of investment in research like this is absolutely essential."
While asthma is well controlled in some people, around one-in-twelve patients respond poorly to current treatments. This significant minority accounts for around 90% of healthcare costs associated with the condition.

According to Cardiff Professor Paul Kemp, who co-authored the study, the identification of CaSR in airway tissue means that the potential for treatment of other inflammatory lung diseases beyond asthma is immense. These include chronic obstructive pulmonary disease (COPD) and chronic bronchitis, for which currently there exists no cure. It is predicted that by 2020 these diseases will be the third biggest killers worldwide.Professor Riccardi and her collaborators are now seeking funding to determine the efficacy of calcilytic drugs in treating asthmas that are especially difficult to treat, particularly steroid-resistant and influenza-exacerbated asthma, and to test these drugs in patients with asthma.
Calcilytics were first developed for the treatment of osteoporosis around 15 years ago with the aim of strengthening deteriorating bone by targeting CaSR to induce the release of an anabolic hormone. Although clinically safe and well tolerated in people, calcilytics proved unsuccessful in treating osteoporosis.
But this latest breakthrough has provided researchers with the unique opportunity to re-purpose these drugs, potentially accelerating the time it takes for them to be approved for use asthma patients. Once funding has been secured, the group aim to be trialling the drugs on humans within two years.
"If we can prove that calcilytics are safe when administered directly to the lung in people, then in five years we could be in a position to treat patients and potentially stop asthma from happening in the first place," added Professor Riccardi.
The study was part-funded by Asthma UK, the Cardiff Partnership Fund and a BBSRC 'Sparking Impact' award.
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JOURNALS IN RESPIRATORY SYSTEM / LUNG DISEASES















































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ECG changes in Acute severe Asthma

Pulmonary Medicine Blog By Dr Deepu

Reversible ECG changes in Acute severe Asthma

Dear Friends I got a call from the emergency department to treat a patient who was gasping for air, the intern at the ER department informed me that the patient had RAD, RBBB and P pulmonale, After examining the patient and taking proper history from the attendants we came to know that the patient is an asthmatic and this was an acute asthmatic attack. Then the intern was baffled by the ECG changes, he thought the event to be a acute cardiac event, I then explained him the ECG changes which are seen in acute asthma. I thought to share the same with you
Here are the ECG changes in Acute Severe Asthma
1.     Sinus tachycardia
2.      Right axis deviation
3.      P pulmonale 
4.      Precordial leads -  voltage of the "p" wave is reduced
5.      Poor progression of the R wave in the precordial leads and marked persistence of the S wave in the left precordial leads
6.      Right bundle branch block
7.      Ventricular premature complexes
8.     Atrial enlargement
9.     Transient ST-segment depression or elevation     in inferior leads ; T-wave abnormalities
10.                        Ventricular repolarization shows a lowered J point with an upward oblique ST segment in the peripheral leads
The mechanism of these electrocardiographic changes appears to depend on the vertical position of the heart caused by over expansion of the lungs and pulmonary arterial hypertension
What are the causes of ECG changes???
1.     Adrenergic stimulation
2.     Hyperventilation
3.     Hyperinflation
4.     Primary or secondary coronary insufficiency
5.     Severity of ECG signs correlates with the degree of airway obstruction.

So, Various ECG changes can occur in acute severe asthma which are nonspecific and these may mimic an acute cardiac event and can cause diagnostic dilemma, most of these changes are reversible usually within 10 days of treatment
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The HRCT findings of Bronchiectasis.

Pulmonary Medicine Blog By Dr Deepu



CT findings in bronchiectasis include the following:

·        Let me first describe the specific findings in the bronchiectasis
      Has parallel tram track lines, or
       It may have a signet-ring appearance, 
     Let me make it more clearer, it is composed of a dilated bronchus  cut in a horizontal section representing the golden ring; with an adjacent  pulmonary artery representing the stone of the Ring. Take a look at the signet ring to get the idea.

·         The diameter of the bronchus lumen is normally 1-1.5 times that of the adjacent vessel; a diameter greater than 1.5 times that of the adjacent vessel suggests bronchiectasis. Let us correlate it in the CT scan
Second Sign is lack of bronchial tapering, Normally as we move to the peripheral parts of the HRCT, the Bronchus should start tapering, as the diameter of the bronchus progressively decreases, whereas in the patients with bronchiectasis this tapering is not seen as the bronchial wall is destroyed and dilated , see the images below
NORMAL BRONCHIAL TAPERING
LACK OF BRONCHIAL TAPERING

 We can also see the abnormal bronchial contour due to the tractional forces applied by the fibrosed and diseased lungs
Visibility of peripheral airways within 1 cm of the pleura
Normally airways are not seen upto 1 cm from the pleura but with bronchiectasis we may be able to see the dilated peripheral airways
ARROWS POINTING TO THE DILATED PERIPHERAL AIRWAYS WITHIN 1 CM OF PLEURA

Its time to describe the non specific findings in the bronchiectasis
•Peribronchial cuffing (thickened hazy bronchial wall).
•Finger in glove opacities (mucus filled bronchi).
  •Multiple air fluid levels (fluid filled bronchi). 

Peripheral cuffing- here we have a thickened bronchial wall due to constant underlying inflammatory process in the bronchial wall
PATIENT WITH LONG STANDING ABPA SHOWING BRONCHIECTASIS IN THE RIGHT LUNG, WITH BRONCHIAL WALL THICKENING
 Finger in glove opacities( Mucus filled bronchi)
mucus plugging of the bronchus causes bronchus to appear as a gloved hand 

let us see how it appears in the CT Scan



Does this look like a gloved finger???
Next sign is multiple air fluid levels
tThis occurs due to the dilated bronchus and the fluid collected in the dilated bronchus.

Along with these specific and non specific finding we will be able to see few ancillary findings associated with bronchiectasis
•Mosaic perfusion.
•Air trapping.
•Tree in bud opacities.

Mosaic Perfusion
It occurs due to areas alternating areas of normal lung and trapped air in the lungs



Air Trapping, to see air trapping specifically ask for expiratory film, the air gets trapped in the blocked small airways causing dark areas,  whereas the air  is squeezed out from normal lung.

 Tree in Bud Appearance-
occurs due to active infection, study the image and find tree in bud, I have marked it in 2nd image
Image shows bronchiectasis and tree in Bud

tIf you liked the post please comment , comments activates the search engine, Thanks 
Suggested Reading

The Rings !!!The Trams!!!, Chest X Ray Findings in Bronchiectasis


My Next post will be on "SOLITARY PULMONARY NODULE"

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