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Medical Tests and What they Mean

James  L.  Coyle,  Ph.D.,  CCC-­‐SLP  

Department  of  Communica@on  Science  &  Disorders  

University  of  PiEsburgh  

Chest  imaging,    pneumonia  differen@al  diagnosis,  bloodwork  

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Pneumonia,  inadequate  nutri/on,  

dehydra/on  

Dysphagia-­‐  aspira/on  

Pulmonary  disease  

Diges/ve  diseases  

Iatrogenic  disorders  

Neurological  diseases  

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Aging,  Frailty  

Dysphagia  

Another  Disease  

Disease  

Dysphagia and disease

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Dysphagia and disease

Disease  

Pulmonary   Iatrogenic   Neurologic  Diges@ve  &  Other  

Dysphagia  

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Medical Tests and their Meanings

• 1.  Chest  imaging  • Chest  X-­‐ray  • Chest  axial  scans  (CT)  

• 2.  Imaging  findings  in  reports    • 3.  Bloodwork:  

• Arterial  blood  gases,  WBC,  Pulse  oximetry  • bacteriology  

• 4.  Pneumonia  findings  of  interest  • 5.  Introduc@on  to  medica@ons  

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Chest Imaging

• Chest  x-­‐ray  • Chest  CT  

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Chest x-ray

• Shadows  • X-­‐rays  penetrate  air  filled  areas  and  strike  film  

• X-­‐rays  are  absorbed  by  denser  @ssue  

• Differences  in  grayscale  color  indicate  areas  of  “more  solid”  maEer  

• Causes  a  “shadow”  on  the  film  7  

Chest CT •  Slices  of  body  part  are  looked  at  

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Rostral  (toward  head)  

Caudal  (toward  feet)  

Anterior  (front  surface)  

Images © Nevit Dilmen  

Normal  

Pneumonia  

Public  domain:  hEp://upload.wikimedia.org/wikipedia/commons/a/a6/Pneumonia_x-­‐ray.jpg  9  

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RUL,    RML,    RLL,    LLL  OVERLAP  RUL+RLL  OVERLAP  RML+RLL  

Posterior                              Anterior  Right                                                  Le@  

Right  lung  

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Anterior                              Posterior  Right                                                  Le@  

LUL,    LLL  OVERLAP  LUL  +  LLL  

Leg  lung  

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Chest x-ray reports • Terms  

• Consolida@on,  density,  opacity:  •  “there  is  a  shadow  indica@ng  something  denser  than  air.”  

• Infiltrates:  • More  solid  maEer  has  infiltrated  an  air-­‐filled  space  

•  Alveolar,  airway  • Edema:  Fluid  satura@ng  area    

• Alveolar,  inters@@al  • Effusion:  fluid  fills  a  body  cavity  (pleural)  

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Chest x-ray reports

• Terms  • Pulmonary  vascular  conges@on  

• NOT  airway  conges@on  • Blood  back-­‐up  in  pulmonary  vessels  

• Alveolar  infiltrates  are  inside  alveoli!  •  The  rest  of  these  are  NOT  alveolar  infiltrates.  

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Chest x-ray • Costophrenic  angles:  intersec@on  between  chest  wall  and  diaphragm  

• Costo  =  ribs  • Phrenic  =  diaphragm  

• Blunted  costophrenic  angles  

•  Typically”  pleural  effusions  

Image © Aldan Jones  

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Pleural effusion •  Fluid  filling  parts  of  pleural  cavity  • Preven@ng  lung  expansion  during  inspira@on  • Gravity  dependent  “bag  of  water”  

Pleural  cavity  

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Pleural Effusions

Images public domain  

Costophrenic  angle  16  

Chest x-ray

• Cardiac  sillouheEe  •  Shadow  of  the  heart  

• Cardiomegaly  

Image © Aldan Jones  

Image © Nevit Dilmen   17  

Chest x-ray reports • Atelectasis:  collapsed  alveoli  

• Obstruc@ve  • Blocked  airways;  gas  within    alveoli  absorbed  into  blood  

• Non-­‐obstruc@ve  • Compressive  • Dependent  

•  Pt.  posi@on  prevents  infla@on  of  alveoli;  poor  inspira@on  

• Adhesive:  lack  of  surfactant  cause  collapse  • Passive:  widened  pleural  space  enables  collapse  

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Atelectasis

Image  ©  MaEeo  Di  Nardo,  Daniela  PerroEa,  Francesca  Stoppa,  Corrado  Ceccheo,  Marco  Marano  and  Nicola  Pirozzi  

(R)  Apical  (apex)  

(L)  basal  (inferior)  

Infant  with  RSV  pneumonia  

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Pneumothorax

• Perfora@on  of  pleural  membrane  •  Destroys  intrapleural  vacuum  that  holds  lung  open  

Subatmospheric  pressure  

Pleural  cavity  

Atmospheric  pressure  20  

Pneumothorax

©  en:User:Clinical  Cases  

©  Hellerhoff  

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Pulmonary edema

•  Leakage  of  circulatory  fluid  into  alveoli  •  Most  common  cause  =  conges@ve  heart  failure  •  Pulmonary  hypertension  “pushes”  fluid  out  of  capillaries  

Pulmonary  hypertension  

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Pulmonary edema • Other  causes  

•  Intra-­‐alveolar  hyperosmolality  •  Contents  of  alveoli  are  “hypertonic”  compared  to  body  fluids  

•  Fluid  “osmosis”  into  alveoli  to  equalize  osmo@c  pressure  

• Net  fluid  volume  increase  within  alveoli  

• Aspira@on  of  strongly  hypertonic  materials  •  Some  Foods!  •  Sea  water  drowning  syndrome  (NaCl  in  sea  water)  •  Some  nonionic  contrast  agents  (Gastrografin)  

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Pulmonary  edema  in  massive  pneumoni@s  (ARDS  –  sepsis)  (NON-­‐CARDIOGENIC  PULMONARY  EDEMA)  

Image  pubic  domain  

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Bloodwork

• WBC:  normal  value  =  ~4.500  –  11,000  c/mcl  • Neutrophils:  most  abundant,  first  line  WBC  •  First  WBC  to  fight  infec@on  

•  Segmented:  mature;  bands:  immature  •  >1500  cells/mcl  

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Blood Gases • Arterial  blood  gases  &  normal  ranges  

• paCO2  =  par@al  pressure  of  CO2:  38-­‐45  mmHg  • paO2  =  par@al  pressure  of  O2:  85-­‐100  mmHg  • pH:  acidity:  ~7.4  

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Oxygen saturation • SaO2  =  %  hemoglobin  O2  satura@on:  90-­‐100%  

•  SpO2  =  pulse  oximetry  (es@mate  of  SaO2)  • Red  &  infrared  light  

•  More  red  absorbed:  less  O2  •  More  infrared  absorbed:  more  O2  satura@on  

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Bacteriology

• Sputum  sample  • Nondiagnos@c  for  aspira@on  pneumonia  if…  

•  Sample  obtained  at  bedside  (“spit  into  this  cup…”)  

• Diagnos@c  for  may  other  diagnoses  • Protected  specimen  brush  (PSB)  or  trap  are  reliable  

• …for  evidence  of  oral  coloniza@on  of  lung  • HOWEVER…requires  bronchoscopy  

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Summary chest imaging/bloodwork • Radiographic  signs  reflect  pathology  

• They  may,  or  may  not  explain/support    • Respiratory  func@on  of  pa@ent  •  Likelihood  that  dysphagia  is  a  poten@al  factor  

• Bloodwork  • Arterial  gases  reflect  respiratory  func@on  

• May  explain  abnormal  respiratory  signs  • WBC,  sputum  are  clues:  is  it  pneumonia?  

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Pneumonitis and Pneumonia

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Pneumonitis: lung inflammation

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Inflamma/on  

Chemical  Medica/ons  

Irritant  trauma/zes  lung  

Irritants,  Allergens    

Radia/on  Therapy    

Inhaled  or  aspirated  sources  

EDEMA  

Pneumonia: lung infection

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Pneumonia    (Infec/on  and  Pneumoni/s)  

Pathogen  Colonizes  lung  

Bacterial    

Inhaled  or  aspirated  or  hematogenous  sources  

Systemic  Spread  

Resolu@on  

Sepsis,    Hypotension,  Mul@-­‐organ    Failure,  Shock  

Viral  With  or  without  other  debris  

Infec/on  causes  inflamma/on:  pneumonia  =  infec/on  +  inflamma/on  Pathogens  and  their  waste  are  irritants  

Pneumonia

33  Bilateral,  mul@lobar  infiltrates  

Na@onal  Cancer  Ins@tute  

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Pneumonia with effusions

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Infiltrates    

Cavita/ons  (abscess)  

effusions  

Inage:  GNU  free  documenta@on  license  

Is pneumonia related to dysphagia? • Pa@ent  MUST  have  dysphagia!  

• A  diagnosis  known  to  produce  dysphagia  

• Dysphagia  must  precede  the  pneumonia  

•  Frail  people  with  pneumonia  develop  ACUTE  dysphagia    

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Summary

• Not  all  pneumonias  are  related  to  dysphagia  • Signs  of  pneumonia  are  found  in  the  medical  record  

• Importance  of  connec@ng  the  dots  to  ensure  • We  are  managing  dysphagia-­‐related  pneumonia  and  not…  

• PNEUMONIA-­‐RELATED  DYSPHAGIA    

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Medications and their effects

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Neuropharmacological Actions • Medica@ons  alter  membrane  ac@vity  at  the  synapse  

• Presynap@c  Changes  •  increased/decreased  produc@on,  storage,  release  •  increased/decreased  Ca++  channel  flow  

• Postsynap@c  Changes  •  s@mula@on/blocking  of  receptor  sites  

• Metabolic  Changes  (Synap@c  Cleg)  •  speeding/slowing  of  NT  reuptake    

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Action Potential Transmission by Neurotransmitters animation (NIH) http://science.education.nih.gov/supplements/nih2/addiction/activities/lesson2_neurotransmission.htm

Neuropharmacological Actions •  1.  Increase/  decrease  NT  in  Pre-­‐S.T.  

•  2.  Presynap@c      inhibi@on  or  facilita@on  

•  assoc.  neuron  synapse  proximal  to  target  synapse  

•  3.  Enhancement  or  inhibi@on  of  NT  re-­‐absorp@on  or  metabolism  

•  4.  Similarly  “shaped”  molecule  binds  to  receptors  

•  Receptor  facilita@on  •  Agonist  

•  Receptor  inhibi@on  •  Antagonist     39  

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Neuron Anatomy and Physiology

• Neuromuscular  junc@on  

•  Similar  ac@vity  except…  

•  Post-­‐synap@c  terminal  is  MUSCLE    

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1.  presynaptic terminal 2. sarcolemma 3. synaptic vesicles 4. Acetylcholine receptors 5. mitchondrion    

©  Dake,  GNU  Free  Documenta@on  License  

Neuromuscular  junc@on  

Neuropharmacological Actions

• Most  medica@ons  are  designed  to  perform  one  or  more  of  these  ac@ons  at  the  synap@c  level.  

•  Synap@c  site  predicts  physiologic  change  resul@ng  from  medica@on  ac@ons  

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Medications affecting swallowing • Mental  status  changes  •  Skeletal  muscle  func@on  

•  Contrac@lity  •  Neuromuscular  junc@on  ac@vity  

• Coordina@on    •  Smooth  muscle  func@on  •  LES  res@ng  pressure  and  func@on  •  Salivary  flow  •  Esophageal  injury  • Mimicking  signs  and  symptoms,  anorexia  

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Acid suppression medications

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Gastric colonization

• Aggressive  acid  suppression  may  create  condi@ons  favoring  pathogenesis  of  pneumonia*  

•  PPI:  >2  @mes  increase  in  pneumonia  risk,  incidence  •  Ambulatory  and  hospitalized  pa@ents  

•  H2  blockers:  increased  risk  (lower  risk)  

•  Sucralfate  (Carafate)  subs@tute  

• CDC  advisory:    PPI  and  C.  difficile  

*Marik,  2001;  Marik  and  Zaloga,  2002;  Laheij,  et  al.,  2004;  Eurich,  2010;  Herzig  et  al.,  2009     44  

Thank you.

•  All  images  used  in  this  presenta@on  are  public  domain,  or  licensed  under  Crea@ve  Commons  AEribu@on  (Share-­‐Alike  3.0  or  Generic  2.5)  License,  CeCILL,  or  GNU  Free  Documenta@on  license.  

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