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Lung Disease Diagnosis and Evaluation

Using Spirometry and DLCO to evaluate airflow and gas exchange efficiency.

Pulmonology focuses on diagnosing and treating lung and airway conditions such as asthma, COPD, and pneumonia, as well as overall respiratory health.

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The Detective Work of Pulmonology

Diagnosing lung disease is a systematic process of elimination and confirmation. Because many lung conditions share similar nonspecific symptoms (cough, shortness of breath, fatigue), relying on symptoms alone is insufficient. At Liv Hospital, we employ a sophisticated, stepwise diagnostic algorithm that starts with non-invasive physiological tests and progresses to advanced imaging, microbiological analysis, and tissue sampling when necessary. The goal is not just to name the disease but to phenotype it—understanding its severity, rate of progression, specific biological drivers, and treatable traits.

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Clinical Assessment: The Foundation

  • Detailed History: We probe for the “3 Ps”:
  • Past: Childhood illnesses, TB exposure, previous pneumonias, family history.
  • Personal: Smoking habits (calculated in pack-years), hobbies (e.g., bird keeping causing hypersensitivity pneumonitis), drug use.
  • Professional: Detailed occupational history is crucial for identifying work-related causes (e.g., asbestos, silica, chemical fumes).
  • Physical Examination:
  • Inspection: Looking for barrel chest (emphysema), kyphosis (restriction), use of accessory muscles, cyanosis, or clubbing.
  • Auscultation: Identifying specific adventitious sounds:
  • Wheezes: Musical, continuous sounds suggesting airway narrowing (asthma/COPD).
  • Crackles (Rales): Discontinuous, Velcro-like sounds suggesting fluid (edema) or fibrosis (scarring opening up).
  • Rhonchi: Low-pitched snoring sounds suggesting mucus in large airways.

Absent Breath Sounds: Suggesting pneumothorax, pleural effusion, or severe emphysema.

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Pulmonary Function Testing (PFTs): Measuring Physiology

PFTs are the cornerstone of diagnosis, severity grading, and monitoring response to therapy.

  • Spirometry: The most common test. It measures airflow and volume.
  • FVC (Forced Vital Capacity): Total air exhaled forcefully. Reduced in restrictive diseases.
  • FEV1 (Forced Expiratory Volume in 1 sec): Air exhaled in the first second. Reduced in obstructive diseases.
  • FEV1/FVC Ratio: The diagnostic number. A ratio <70% confirms obstruction (COPD/Asthma).
  • Reversibility Testing: Repeating spirometry after a bronchodilator. A significant improvement (>12% and >200ml) suggests asthma; a lack of improvement suggests COPD.
  • Body Plethysmography (Body Box): Measures lung volumes, including air that cannot be exhaled.
  • TLC (Total Lung Capacity): The gold standard for diagnosing restriction (reduced TLC).
  • RV (Residual Volume): Increased in air trapping (emphysema).
  • Diffusion Capacity (DLCO): Measures how well gas transfers from alveoli to blood across the membrane.
  • Low DLCO: Suggests destruction of the alveolar-capillary bed (emphysema, fibrosis, pulmonary hypertension).

Normal DLCO: Seen in uncomplicated asthma or chronic bronchitis.

Radiological Imaging: Visualizing the Pathology

  • Chest X-ray (CXR): The initial screening tool. Suitable for detecting pneumonia, large tumors, pleural effusions, and pneumothorax. Limited sensitivity for early COPD or mild fibrosis.
  • Computed Tomography (CT):
  • High-Resolution CT (HRCT): The gold standard for Interstitial Lung Diseases. It captures thin lung slices to visualize specific patterns of fibrosis (honeycombing, ground-glass opacity, traction bronchiectasis) that distinguish IPF from other conditions.
  • Contrast CT (CTPA): Used to diagnose Pulmonary Embolism by visualizing clots in the pulmonary arteries.
  • Low-Dose CT Screening: Recommended annually for high-risk smokers to detect lung cancer at early, curable stages (nodules).
  • PET-CT (Positron Emission Tomography): Used in cancer staging to distinguish metabolic activity of active tumors from inert scar tissue and to detect distant metastases.

V/Q Scan (Ventilation/Perfusion): Used when CT is contraindicated (renal failure/allergy) to look for a mismatch indicative of PE.

Interventional Pulmonology and Biopsy

When imaging is inconclusive, tissue or cellular samples are needed.

  • Bronchoscopy: A flexible tube with a camera is passed into the airways.
  • Inspection: Visualizing tumors, foreign bodies, or bleeding sources.
  • BAL (Bronchoalveolar Lavage): “Washing” a lung segment to collect cells and germs. Diagnostic for infections (PCP, TB) and some ILDs (eosinophilic pneumonia).
  • Endobronchial Ultrasound (EBUS): Using ultrasound through the bronchoscope to guide needles into mediastinal lymph nodes for cancer staging (a minimally invasive alternative to surgery).
  • Transbronchial Biopsy: Taking small bites of lung tissue through the airway wall.
  • Cryobiopsy: Using a freezing probe to obtain larger, higher-quality chunks of tissue during bronchoscopy, increasing diagnostic yield for fibrosis without surgery.
  • Thoracentesis: Using a needle to drain and analyze fluid from the pleural space to diagnose cancer, infection (empyema), or heart failure.
  • Surgical Lung Biopsy (VATS): Video-Assisted Thoracoscopic Surgery. The gold standard for diagnosing complex interstitial lung diseases is when other methods fail, but it is more invasive.

Advanced Physiological Testing

  • Arterial Blood Gas (ABG): Measures precise pH, PaO2 (oxygen), and PaCO2 (carbon dioxide). Essential for assessing respiratory failure severity and acid-base balance in critical illness.
  • 6-Minute Walk Test: A functional test measuring distance walked and oxygen desaturation. Predicts mortality and assesses the need for home oxygen therapy.
  • Cardiopulmonary Exercise Testing (CPET): A sophisticated stress test measuring gas exchange. Distinguishes whether dyspnea is cardiac, respiratory, or muscular/deconditioning in origin.

FeNO (Fractional Exhaled Nitric Oxide): Measures eosinophilic airway inflammation. High levels suggest asthma that will respond well to inhaled steroids.

Microbiological and Genetic Analysis

  • Sputum Culture/PCR: Identifying specific bacteria (TB, Pseudomonas), fungi, or viruses (Flu, COVID).
  • Alpha-1 Testing: Blood test for AAT protein levels and genotype.
  • Genetic Panels: Testing for CFTR mutations (Cystic Fibrosis) or telomere/surfactant genes (Familial Pulmonary Fibrosis).

Liquid Biopsy: Testing blood for circulating tumor DNA in lung cancer to guide targeted therapy (EGFR, ALK, ROS1 mutations).

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FREQUENTLY ASKED QUESTIONS

Why do I have to blow into the machine so many times?

CT scans use X-rays to create detailed cross-sectional images and are excellent for visualizing kidney stones, detecting tumors, and evaluating traumatic injuries. They are fast and widely available. MRI uses strong magnetic fields and radio waves to produce detailed images of soft tissues, making it superior for staging prostate cancer, evaluating bladder wall invasion, and assessing pelvic floor disorders without ionizing radiation.

Contrast dye, usually iodine-based, is injected into a vein to highlight the blood vessels and urinary tract organs. As the kidneys filter the dye from the blood, it opacifies the urine. This allows the radiologist to see the internal structure of the kidneys, the ureters, and the bladder clearly, revealing blockages, tumors, or structural abnormalities that would be invisible on a non-contrast scan.

Multiparametric MRI is an advanced imaging technique that combines standard anatomical sequences with functional sequences like Diffusion-Weighted Imaging and Dynamic Contrast-Enhanced imaging. This provides a comprehensive assessment of the prostate, allowing doctors to distinguish between benign conditions like BPH and significant prostate cancer, and to guide targeted biopsies.

CT scans do involve exposure to ionizing radiation, which carries a small theoretical risk of cellular damage over time. However, modern CT scanners use dose-modulation technology to minimize this exposure to the lowest level necessary for a diagnostic image. The benefit of an accurate and timely diagnosis for serious urological conditions typically far outweighs the minimal risk of radiation.

Many modern orthopedic implants are MRI-safe, although they may cause some image distortion. However, older pacemakers, defibrillators, and certain metal clips may be unsafe in the strong magnetic field. It is critical to inform the imaging team of any metallic implants so they can verify their safety compatibility or recommend an alternative test like a CT scan.

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