LABORATORY INVESTIGATION IN

RESPIRATORY DISORDER

dr. Rahma Triliana, M.KesBlock of Respiration Systems II

June 2010

THE LAB TEST TO DETECT STRUCTURE DEFECTS

Imaging Studies Anatomical Changes Used In Diagnosis (Localizing defects), Tx & Follow-up. Imaging Guided For Selective Sampling (Biopsy) or

Interventional Procedures/Surgery Chest Radiographic Techniques Plane Chest Postero-

Anterior film, Decubitus & Oblique Films, & Apical Lordotic Films

Digital Chest Radiography Ultrasound Bronchoscopy Flexible Fiberoptic Bronchoscopy Computed Tomography (CT-Scan) Nuclear Imaging Of The Thorax Pulmonary Angiography Magnetic Resonance Imaging (MRI)

THE LAB TEST TO DETECT STRUCTURE DEFECTS… Biopsy Procedures

For Cancer Diagnosis or other lung diseases Histological changes

TypesEndobronchial &Transbronchial BiopsyScalene Node BiopsyPercutaneous Needle Biopsy

Transthoracic, Lung Biopsy, Pleural Biopsy & Drainage Of Fluid Collections

Transtracheal & Transbronchial Needle Aspiration

Bronchoalveolar LavageOpen Lung & Pleural Biopsy

THE LAB TEST TO DETECT STRUCTURE DEFECTS…

Surgery ProceduresUseful in diagnosis & therapeuticImaging guided surgery Chest

Fluoroscopy, Mediastinoscopy, Cervical Mediastinoscopy, Thoracoscopy, Pulmonary Angioscopy

Thoracentesis fluid removalParasternal Anterior MediastinotomyVideo-Assisted Thoracoscopic SurgerySurgery of Pleural Space Fibrothorax,

Thoracoscopy, and Pleurectomy

If 3 simple questions and 1 well chosen laboratory test lead to

an unambiguous diagnosis, why harry the patient with more?

AnonymousEditorial, Clinical decision by numbers.

Lancet 1: 1077 (1975)

SPUTUM ANALYSIS Obtained from

Cough process Transtracheal Aspiration Bronchoscopy & Bronchoalveolar Lavage

Macroscopic evaluation Amount, color, consistency, odor, hemoptysis

Microscopic evaluation Antigen testing Culture technique Others

MICROBES DETECTIONS Examining specimens to detect, isolate, and

identify pathogens or their products using:Microscopy of specimen Culture techniquesBiochemical methods Immunological (antigen) testsGene test

Testing serum for antibodies produced in response to infection, i.e. serological response.

MICROSCOPY EVALUATION

MICROSCOPY OF SPUTUM SPECIMEN

Staining result e.g Gram, KOH, Ziehl-Neelsen Number/sum (-), (+), (++), (+++) Domination of certain microbes Epitel & Leukocyte presence Presence of Intracellular organism Phagocytosis +

Shape & size determination Rod, cocci, coliform,

Structure & position Remember Lung Tropism

LUNG TROPISM/POSSIBLE SPUTUM PATHOGENS

BACTERIA Streptococcus pneumoniae, Haemophilus influenzae,

Staphylococcus aureus Klebsiella pneumoniae, Streptococcus pyogenes, Pseudomonas aeruginosa, Proteus species, Yersina pestis, Moraxella catarrhalis, Mycobacterium tuberculosis, Mycoplasma pneumoniae, and Legionella pneumophila.

FUNGI AND ACTINOMYCETES Pneumocystis jiroveci, Blastomyces dermatitidis, Histoplasma

capsulatum, Aspergillus species, Candida albicans, Cryptococcus neoformans, and Nocardia species.

PARASITES Paragonimus species.

Commensals Contamination from commensal organisms in upper respiratory tract

and mouth see picture

CULTURE TECHNIQUES Pathogens culture for isolation, identification & antimicrobial

susceptibility testing. Every pathogens have their cultural requirements Preparation, inoculation & culture media main types of

culture media: Basic media simple media to support microorganisms that do not

require special nutrition e.g. nutrient agar. Enriched media to grow by enriching medium with necessary

ingredients to promote its growth Selective media solid media contain substances to selectively

growth certain organism Indicator/differential media Contained dyes or other substances to

differentiate microorganisms = Identification media to help identify bacteria isolated on primary cultures

Transport media semisolid media to prevent overgrowth of commensals & ensure survival of pathogens.

BIOCHEMICAL METHODS Following culture of sputum Identify pathogens by their enzymatic and fermentation

reactions e.g. Catalase differentiate staphylococci from streptococci Coagulase test pathogenous Staphylococcus. Fermentation tests Differentiate enterobacteria groups Urease test identify Proteus, Morganella, Yersinia E, H. pylori. Beta-glucuronidase E. coli Bile solubility S. pneumoniae from other α-haemolytic Citrate utilization differentiate enterobacteria DNA-ase S. aureus Indole differentiate Gram negative rods, particularly E. coli Litmus milk Enterococcus and some clostridia Lysine decarboxylase assist ID of salmonellae & shigellae Oxidase Neisseria, Pasteurella, Vibrio, Pseudomonas

Use reagents prepared in laboratory, ready-made reagents in strip, disc, or tablet reagents.

IMMUNOLOGICAL TESTS Antigen tests

Rapid, simple to perform, and have good stability. Enable early diagnosis of infectious disease To identify a pathogen from culture (e.g. Salmonella serovars,

Shigella species, and Vibrio cholerae) direct slide agglutination. To identify pathogens in specimens (e.g. respiratory viruses, rabies

virus, cytomegalovirus, Pneumocystis jiroveci, and Chlamydia) direct immunofluorescence

Techniques The use of specific antibody (antisera or labelled antibody) use

highly specific monoclonal antibody reagents. Agglutination techniques (direct, latex, coagglutination) Enzyme immunoassays (EIA) Immunochromatographic (IC) tests Dipstick dot immunoassays Direct immunofluorescence

NON-CULTURAL METHODS FOR MICROBE DETECTION

GAS TRANSPORT SYSTEM STEPSStep Purpose Structure(s) Tests to Characterize

Structure or FunctionVenti-lation

Maintain normal PAO2 & PACO2

Air pump (lungs, chest wall, and neuro-muscular apparatus)

PaCO2, spirometry, lung volumes, airway resistance, respiratory muscle strength

Gas transfer (lung)

Gas transfer alveolar -- pulmonary capillary blood

Alveolar capillary membrane

Arterial blood gases (PaO2 & PaCO2, PAO2 - PaO2), oxygen content, carbon monoxide diffusing capacity

Circu-lation

O2 & CO2 delivery. Lungs Peripheral

Blood pump (heart and blood)

Heart function (e.g., cardiac output, oxygen content, oxygen delivery)

Gas transfer (periph

ery)

Gas transfer Systemic capillaries ---metabolizing cells

Systemic capillary membranes and metabolizing cells

Difficult to assess. Tests of end-organ function Lactic acidosis in tissue hypoxemia

PAO2, alveolar partial pressure of oxygen; PACO2, alveolar partial pressure of carbon dioxide; PaCO2, arterial partial pressure of carbon dioxide; PAO2 - PaO2, alveolar-arterial gradient in partial pressure of oxygen

PULMONARY FUNCTION TESTING Static Lung Volumes

Gas Dilution Techniques Plethysmography Radiographic Total Lung Capacity

Dynamic Tests of Lung Function Spirometry Maximum Voluntary Ventilation Peak Expiratory Flow and Peak Flow Meters Bronchodilator Administration and Testing Bronchial Reactivity Testing Exercise Bronchoprovocation

Diffusion Arterial Blood Gases

Ventilation Respiratory Muscle Strength Tests Of Elastic Properties

EXERCISE TESTING The Integrative Cardiorespiratory Exercise Test To understand Normal and Abnormal Cardiovascular,

Ventilatory, and Gas Exchange Responses to an Incremental Work Rate Exercise Test

To find Systems, Ventilatory & Cardiovascular Limitation to Exercise

Parameters Used for Exercise Data Maximal or Peak O2 Uptake Peak Heart Rate and Heart Rate Reserve Oxygen Pulse Ventilatory Equivalents for Oxygen and Carbon Dioxide and the

Dead Space-Tidal Volume Ratio PaO2 and P(A-a)O2 Difference PaCO2 and P(a-ET)CO2 Difference

OTHER TEST Throat & Mouth Swab Fluid analysis of Pleural Effusion Diagnosis of genetic diseases

Detect mutation or genetic. Improve diagnosis & determine prognosisDNA analyses from peripheral blood cellsAmplification by PCR & sequenced with DNA

sequencing. Screening for Respiratory Diseases

Chest X-RaySputum exam

Even in the hands of the greatest physicians,

the practice of medicine is never identified with laboratory medicine,

but Its application.

Rudolf Virchow 1821–1902German pathologist

Quoted in ‘Medical Proverbs’ by F. H. Garrison, Bulletin of the New York Academy of Medicine

October: 979 – 1005 (1928)

MEDICAL APPLICATION Interstitial Lung Diseases

Immunologically Mediated Lung Diseases Systemic Sarcoidosis Major Pulmonary Disease Syndromes of Unknown Etiology Drug-Induced Pulmonary Disease

Infectious Diseases Upper Respiratory Tract Infections Community-Acquired Pneumonia Hospital-Acquired Pneumonia Pulmonary Complications of HIV Infection Pulmonary Fungal Infections Tuberculosis Nontuberculous Mycobacterial Pulmonary Disease (NTM) Embolic Infections of the Lungs and Lipoid Pneumonia Aspiration Pneumonia, Lipoid Pneumonia, and Lung Abscess

MEDICAL APPLICATION… Environmental Lung Disease

Occupational Lung Diseases Caused by Asbestos, Silica, and Other Silicates

Occupational Lung Diseases: Coal Workers', Beryllium, and Other Pneumoconioses

Occupational Asthma and Industrial Bronchitis Byssinosis and Respiratory Disease Caused by Vegetable Dusts Occupational Pulmonary Neoplasms Noxious Gases and Fumes Pulmonary Effects of Radiation Clinical Evaluation of Individuals with Suspected Indoor Air Quality

Problems Respiratory Insufficiency

Sleep Apnea Syndrome and Sleep-Disordered Breathing Adaptation and Maladaptation to High Altitude Near-Drowning and Diving Accidents Acute Respiratory Failure Mechanical Ventilatory Support Chronic Respiratory Failure and Noninvasive Ventilation

Obstructive Lung Disease Bronchial Asthma Bronchiectasis Chronic Obstructive Pulmonary Disease

Pulmonary Vascular Diseases The Normal Adult Pulmonary Circulation Pulmonary Hypertension: Pathophysiology and Clinical Disorders Thromboembolic Syndromes Pulmonary Heart Disease

Neoplastic Diseases Bronchogenic Carcinoma Tumors of the Lung Other Than Bronchogenic Carcinoma Tumors of the Mediastinum, Pleura, Chest Wall, and Diaphragm Extrapulmonary Syndromes Associated with Tumors of the Lung

Pleural Diseases Diseases of the Pleura and Pleural Space

MEDICAL APPLICATION…

Pulmonary Manifestations of Systemic Diseases Rheumatologic Diseases Vasculitis Syndromes Immunodeficiency Diseases Hematologic Diseases Renal Diseases Gastroenterologic Diseases Endocrine and Metabolic Diseases Neurologic Diseases Skeletal Diseases Dermatologic Diseases Obstetric, Gynecology, and Reproductive Organs

Congenital, Developmental, & Genetic Diseases of the Lung Developmental Anomalies of the Respiratory System Genetic Diseases of the Lung Vascular and Other Genetic Diseases Affecting the Lungs

MEDICAL APPLICATION…

Modern medicine is one of those extraordinary works of reason:

an elaborate system of specialised knowledge, technical procedures,

and rules of behaviour.

Paul Starr 1949 – Professor of Sociology, Harvard University

The Social Transformation of American Medicine Introduction, p.3, Paul Starr. Basic Books, New York

(1982)