Chest standard texts

CTPA

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Auto-inserted clinical details: <RequestCaseHistory> <RequestReason> Report: Scan quality: [Good/Adequate/Poor/Non-diagnostic.]. Pulmonary emboli? [Yes/No.] Location: [Saddle/Main left/Main right/Segmental left/Segmental right/Subsegmental left/Subsegmental right/Multiple/Right heart] Features of right heart strain/raised pulmonary artery pressure: [Straightening/reverse bowing of interventricular septum/Pulmonary artery enlargement/Reflux of contrast into hepatic veins] Right ventricular/Left ventricular diameter ratio: [] Lymphadenopathy: [Axillary/Hilar/Mediastinal] Lung parenchyma: [] Pleural disease: [] Pulmonary nodules: [] Upper abdominal organs: [] Bones: [] Vasculature including coronary arteries: []

Explanatory notes
Heading	Options	Reason
Pulmonary emboli?	Yes/No.
Location	Saddle/Main left/Main right/Segmental left/Segmental right/Subsegmental left/Subsegmental right/Multiple/Right heart	High clot burden may correlate with prognosis (not all studies find this to be so), but the most significant factor is whether there is haemodynamic compromise/shock. The PE index (Wu et al) may predict outcome. Right heart clot is associated with increased mortality.
Features of right heart strain/raised pulmonary artery pressure	Straightening/reverse bowing of interventricular septum/Pulmonary artery enlargement/Reflux of contrast into hepatic veins	Classification of PE into massive, submassive and nonmassive (high, intermediate and low risk) does not rely on CT and relies on the patient's clincal status specifically blood pressure and other signs of shock. However, various combinations of CT and clinical signs have been studied and shown to predict mortality - Jaff et al provide a good summary.
Right ventricular/Left ventricular diameter ratio:		Originally assessed on the 4 chamber view, but you may not need to reformat - measurements on axial images (not necessarily the same images) have been shown to give equivalent results. > 0.9 is significant, although not across all studies - reformatting into a 4 chamber view is quick and easy. Again various combinations of this ratio and other factors may help stratify patients e.g. Kyoung Kang et al.
Lymphadenopathy:	Axillary/Hilar/Mediastinal	Many other features are likely to contribute to prognosis including acute infection and cancer.
Lung parenchyma:
Pleural disease:
Pulmonary nodules:
Upper abdominal organs:
Bones
Vasculature including coronary arteries		High pitch CTPAs will often demonstrate some detail relating to the coronary arteries.

References: 1.
2. T Lu, Michael & Demehri, Shadpour & Cai, Tianxi & Parast, Layla & Hunsaker, Andetta & Goldhaber, Samuel & J Rybicki, Frank. (2012). Axial and Reformatted Four-Chamber Right Ventricle-to-Left Ventricle Diameter Ratios on Pulmonary CT Angiography as Predictors of Death After Acute Pulmonary Embolism. AJR. American journal of roentgenology. 198. 1353-60. 10.2214/AJR.11.7439.
3. Prognostic Factors for Pulmonary Embolism The PREP Study, A Prospective Multicenter Cohort Study Sanchez, Trinquart L, Caille V, Couturaud F, Pacouret G, Meneveau N, Verschuren F, Roy PM, Parent F, Righini M, Perrier A, Lorut C, Tardy B, Benoit MO, Chatellier G, Meyer G. American Journal of Respiratory and Critical Care Medicine https://www.atsjournals.org/doi/full/10.1164/rccm.200906-0970OC
4. Moroni, Chiara & Bartolucci, Maurizio & Vanni, Simone & Nazerian, Peiman & Bartolini, Marco & Miele, Vittorio. (2017). Prognostic value of CT pulmonary angiography (CTPA) parameters in acute pulmonary embolism (APE). 10.1594/ecr2017/C-3066.
5. Wu AS, Pezzullo JA, Cronan JJ, Hou DD, Mayo-Smith WW. CT Pulmonary Angiography: Quantification of Pulmonary Embolus as a Predictor of Patient Outcome—Initial Experience Radiology https://pubs.rsna.org/doi/10.1148/radiol.2303030083?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed
6. Int J Cardiovasc Imaging. 2016 Jul;32(7):1153-61. doi: 10.1007/s10554-016-0887-z. Epub 2016 Apr 13. Normal ventricular diameter ratio on CT provides adequate assessment for critical right ventricular strain among patients with acute pulmonary embolism. Kumamaru KK, George E, Ghosh N, Quesada CG, Wake N, Gerhard-Herman M, Rybicki FJ
7. Doo KyoungKangMD ChristianThiloMD U. JosephSchoepfMD J. MichaelBarrazaJrBS John W.NanceJrMD GorkaBastarrikaMD, PhD Joseph A.AbroMA James G.RavenelMD†PhilipCostelloMD Samuel Z.GoldhaberMD JACC: Cardiovascular Imaging Volume 4, Issue 8, August 2011, Pages 841-849 CT Signs of Right Ventricular Dysfunction: Prognostic Role in Acute Pulmonary Embolism https://doi.org/10.1016/j.jcmg.2011.04.013
8. Michael R. Jaff , M. Sean McMurtry , Stephen L. Archer , Mary Cushman , Neil Goldenberg , Samuel Z. Goldhaber , J. Stephen Jenkins , Jeffrey A. Kline , Andrew D. Michaels , Patricia Thistlethwaite , Suresh Vedantham , R. James White , Brenda K. Zierler Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis, and Chronic Thromboembolic Pulmonary Hypertension Circulation https://www.ahajournals.org/doi/full/10.1161/CIR.0b013e318214914f?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed
9. Masotti L, Righini M, Vuilleumier N, et al. Prognostic stratification of acute pulmonary embolism: focus on clinical aspects, imaging, and biomarkers. Vasc Health Risk Manag. 2009;5(4):567-75.

Nodule follow up CT

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Auto-inserted clinical details: <RequestCaseHistory> <RequestReason> Report: Comparison is made with the previous scan(s) dated []. The time after baseline is: [] The nodule volume on [date] was: [] mm3. The nodule volume now is: [] mm3. This gives a volume doubling time of: [] days. According to BTS guidelines [CT in 2 years/Discharge/consider discharge or follow up depending on patient preference/consider biopsy or surveillance based on patient preference/further workup and consideration of definitive management] is advised

References:
1. Callister MEJ, Baldwin DR, Akram AR on behalf of the British Thoracic Society Standards of Care Committee, et alBritish Thoracic Society guidelines for the investigation and management of pulmonary nodules: accredited by NICEThorax 2015;70:ii1-ii54.

Pectus excavatum pre-surgery

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Auto-inserted clinical details: <RequestCaseHistory> <RequestReason> Report: Haller index: [widest measurement/smallest AP spine to sternum]. Correction index: [(largest anterior spine to anterior most part of chest (rib) - anterior spine to posterior sternum)/largest anterior spine to anterior most part of chest (rib)] Asymmetry index: [largest AP posterior rib to anterior on left/largest on right] Sternal torsion angle: [Angle of sternum to horizontal] Depression index: [Sternal depression at level of mid sternum as measured from a line across the anterior ribs to the sternum/vertebral body width at that point] Lungs: [] Lymphadenopathy: [Yes/No.] Soft tissue and other organ abnormalities: [Present/Absent.]

References:
1. A novel measure for pectus excavatum: the correction index St. Peter, Shawn D. et al. Journal of Pediatric Surgery , Volume 46 , Issue 12 , 2270 - 2273
2. Classification of Pectus Excavatum According to Objective Parameters From Chest Computed Tomography Choi, Jin-Ho et al. The Annals of Thoracic Surgery , Volume 102 , Issue 6 , 1886 - 1891
3. The Depression Index: an objective measure of the severity of pectus excavatum based on vertebral diameter, a morphometric correlate to patient size Fagelman, Kerry M. et al. Journal of Pediatric Surgery , Volume 50 , Issue 7 , 1130 - 1133

Pre-navigation bronchoscopic biopsy

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Auto-inserted clinical details: <RequestCaseHistory> <RequestReason> Report: Scan quality: [Excellent/Good/Poor] Nodule or mass location: [Right/Left] lung [] lobe [] Segment Size: [] mm Bronchus sign: [Positive (type A), type B, negative (type C)] Lymphadenopathy: [] Lung parenchyma: [] Remaining soft tissues: [] Bones: []

Heading	Options	Reason
Scan quality:	Excellent/Good/Poor
Nodule or mass location:	Lung, lobe, segment
Size:	Insert options here	Usually nodules that can be targeted using this technique are between 1 and 2 cm or 2 cm and above (the latter is the size seen in the literature supporting electromagnetic navigational bronchoscopy).
Bronchus sign:	Insert options here	Bronchus sign type A is a bronchus leading straight to the lesion (positive), type C is no bronchus (negative) and type B is in between. If a lesion is below 10 mm it is difficult to target without a positive bronchus sign.
Lymphadenopathy:		Lymph node targeted EBUS may be combined with this procedure to give staging
Lung parenchyma:		These patients may have more severe lung disease than those considered for percutaneous biopsy.
Remaining soft tissues:
Bones:

References:
1. Bronchus sign on thin-section computed tomography is a powerful predictive factor for successful transbronchial biopsy using endobronchial ultrasound with a guide sheath for small peripheral lung lesions: a retrospective observational study Tomoyuki Minezawa, Takuya Okamura, Hiroshi Yatsuya, Naoki Yamamoto, Sayako Morikawa, Teppei Yamaguchi, Mariko Morishita, Yoshikazu Niwa, Tomoko Takeyama, Yuki Mieno, Tami Hoshino, Sakurako Uozu, Yasuhiro Goto, Masamichi Hayashi, Sumito Isogai, Masaki Matsuo, Toru Nakanishi, Naozumi Hashimoto, Mitsushi Okazawa and Kazuyoshi Imaizumi BMC Medical Imaging201515:21 https://doi.org/10.1186/s12880-015-0060-5
2. Gildea TR, Mazzone PJ, Karnak D, Meziane M, Mehta AC. Electromagnetic navigation diagnostic bronchoscopy: a prospective study. Am J Respir Crit Care Med. 2006;174(9):982-9.
3. The Annals of Thoracic Surgery Volume 93, Issue 3, March 2012, Pages 944-950 Electromagnetic Navigation Bronchoscopy Performed by Thoracic Surgeons: One Center's Early Success Presented at the Forty-seventh Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 31–Feb 2, 2011.
4. Khan KA, Nardelli P, Jaeger A, O'Shea C, Cantillon-Murphy P, Kennedy MP. Navigational Bronchoscopy for Early Lung Cancer: A Road to Therapy. Adv Ther. 2016;33(4):580-96.
5. Electromagnetic navigation bronchoscopy to access lung lesions in 1,000 subjects: first results of the prospective, multicenter NAVIGATE study Sandeep J. Khandhar†, Mark R. Bowling, Javier Flandes, Thomas R. Gildea, Kristin L. Hood, William S. Krimsky, Douglas J. Minnich, Septimiu D. Murgu, Michael Pritchett, Eric M. Toloza, Momen M. Wahidi, Jennifer J. Wolvers, Erik E. Folch BMC Pulmonary MedicineBMC series 201717:59 https://doi.org/10.1186/s12890-017-0403-9

Pre Lung volume reduction surgery/endobronchial valve placement

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Auto-inserted clinical details: <RequestCaseHistory> <RequestReason> Report: Presence of emphysema: [Yes/No.]. Type of disease: [centrilobular] [, paraseptal] [, panlobular] [, bullous] Location/distribution of severity: [Heterogenous (Focal)/Homogenous (diffuse)/state lobar predominance/Size of bulla] Pleural disease: [Yes/No. Type] Fissures: [Complete/Incomplete, which and amount] Bronchiectasis: [Yes/No]. Signs of pulmonary hypertension: [Yes/No]. [] Fibrosis: [Yes/No]. Lung nodules: [Yes/No]. Bones/thoracic cage: [Yes/No]. Extra-pulmonary findings: [].

Heading	Options	Reason
Presence of emphysema:	Yes/No.
Type of disease:	centrilobular, paraseptal, panlobular, bullous
Location/distribution of severity:	Heterogenous (Focal)/diffuse/state lobar predominance	Upper lobe predominance or focal disease responds better to this treatment
Pleural disease:	Yes/No. Type	This may inhibit lung expansion
Fissures	Complete/Incomplete, which and amount	This is relevant to the placement of bronchial valves, collateral air drift may prevent intended collapse. A complete fissure in one demonstrating integrity across 90% or more between separated lobes and this correlates with better outcomes. Collateral ventilation may also be assessed bronchoscopically.
Bronchiectasis:	Yes/No.	This is a separate disease process that would only benefit from resection in its own right and with different benefit e.g. reduced infective episodes as opposed to improved respiratory function. Presence in lung spared from emphysema indicates abnormal lung.
Signs of pulmonary hypertension:	Yes/No.	LVRS may increase pulmonary arterial hypertension
Fibrosis:	Yes/No. Type. Location	Interstitial disease may inhibit re-expansion.
Lung nodules:	Insert options here	In some cases resection and LVRS may be appropriate and beneficial
Bones/thoracic cage:		Any restrictive thoracic cage abnormality should be noted
Extra-pulmonary findings:

References:
1. Washko GR, Hoffman E, Reilly JJ. Radiographic evaluation of the potential lung volume reduction surgery candidate. Proc Am Thorac Soc. 2008;5(4):421-6.
2. Coxson HO, Whittall KP, Nakano Y, et al. Selection of patients for lung volume reduction surgery using a power law analysis of the computed tomographic scan. Thorax. 2003;58(6):510-4.
3. Criner GJ, Scharf SM, Falk JA, et al. Effect of lung volume reduction surgery on resting pulmonary hemodynamics in severe emphysema. Am J Respir Crit Care Med. 2007;176(3):253-60.
4. Am J Respir Crit Care Med. 1999 Feb;159(2):552-6. Development of pulmonary hypertension after lung volume reduction surgery. Weg IL1, Rossoff L, McKeon K, Michael Graver L, Scharf SM.
5. DeCamp MM, Lipson D, Krasna M, Minai OA, McKenna RJ, Thomashow BM. The evaluation and preparation of the patient for lung volume reduction surgery. Proc Am Thorac Soc. 2008;5(4):427-31.
6. Patients at High Risk of Death after Lung-Volume–Reduction Surgery October 11, 2001 N Engl J Med 2001; 345:1075-1083 DOI: 10.1056/NEJMoa11798
7. Eberhardt R, Gompelmann D, Herth FJ, Schuhmann M. Endoscopic bronchial valve treatment: patient selection and special considerations. Int J Chron Obstruct Pulmon Dis. 2015;10:2147-57. Published 2015 Oct 8. doi:10.2147/COPD.S63473
8. Endobronchial valve insertion to reduce lung volume in emphysema | Guidance and guidelines | NICE https://www.nice.org.uk/guidance/ipg600
9. Multicentre European study for the treatment of advanced emphysema with bronchial valves Vincent Ninane, Christian Geltner, Michela Bezzi, Pierfranco Foccoli, Jens Gottlieb, Tobias Welte, Luis Seijo, Javier J. Zulueta, Mohammed Munavvar, Antoni Rosell, Marta Lopez, Paul W. Jones, Harvey O. Coxson, Steven C. Springmeyer, Xavier Gonzalez European Respiratory Journal Jun 2012, 39 (6) 1319-1325; DOI: 10.1183/09031936.00019711
10. Browning RF, Parrish S, Sarkar S, et al. Bronchoscopic interventions for severe COPD. J Thorac Dis. 2014;6(Suppl 4):S407-15.

Pre re-do sternotomy

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Auto-inserted clinical details: <RequestCaseHistory> <RequestReason> Report: Technique: [Non-contrast/Contrast enhanced/Contrast enhanced, prospective/retrospective cardiac gated/4d contrast enhanced]. Previous surgery: [Type of valve replacement/CABG - which vessels/aortic surgery - type] Adhesions: [Yes/No] Right ventricular distance to sternum: [> 1 cm/< 1 cm/Adherent] Right ventricular outflow tract to sternum: [> 1 cm/< 1 cm/Adherent] Graft distance to sternum: [> 1 cm/< 1 cm/Adherent] Aortic distance to sternum: [> 1 cm/< 1 cm/Adherent] Distance of brachiocephalic veins from sternum: [] Degree of aortic atheromatous/calcific disease [None/Mild/Moderate/Severe]. Lungs: [] Lymphadenopathy: [Yes/No.] Bones: [] Other soft tissues: []

Heading	Options	Reason
Technique	Non-contrast/Contrast enhanced/Contrast enhanced, prospective/retrospective cardiac gated/4d contrast enhanced	Non contrast scans may give distances to major structures, but graft patency and precise location may be missed. Retrospective gating with cine images allows better identification of adhesions.
Previous surgery	Type of valve replacement/CABG - which vessels/aortic surgery - type	Previous coronary artery bypass grafting may expose grafts to injury.
Adhesions:	Yes/No.	These may be seen as bands extending to the sternum or as deformation of the structures deep to the sternum (see below for key measurements indicative of adhesions). Also, movement is inhibited on cine images where structures are adherent
Right ventricular distance to sternum:		Structures < 10 mm from the sternum are likely to be adherent or at high risk of damage. These include the right ventricle or any grafts that cross the midline. It is often appropriate to state the level in relation to the sternal wires. Also, a LIMA graft within 1 cm of the midline is at risk of injury as it may have an associated adhesion
Right ventricular outflow tract to sternum:
Graft distance to sternum:
Aortic distance to sternum:
Distance of brachiocephalic veins from sternum:
Degree of aortic atheromatous/calcific disease	None/Mild/Moderate/Severe	Heavy calcification may preclude aorto-pulmonary bypass via aortic cannulation. State the anatomy of alternative sites
Lungs:
Lymphadenopathy:
Bones:
Other soft tissues:

References:
1. Am Heart J. 2010 Feb;159(2):301-6. doi: 10.1016/j.ahj.2009.11.005. Perioperative outcomes in reoperative cardiac surgery guided by cardiac multidetector computed tomographic angiography. Maluenda G1, Goldstein MA, Lemesle G, Weissman G, Weigold G, Landsman MJ, Hill PC, Pita F, Corso PJ, Boyce SW, Pichard AD, Waksman R, Taylor AJ.
2. Hrvoje Gasparovic, Frank J. Rybicki, John Millstine, Daniel Unic, John G. Byrne, Kent Yucel, Tomislav Mihaljevic; Three dimensional computed tomographic imaging in planning the surgical approach for redo cardiac surgery after coronary revascularization, European Journal of Cardio-Thoracic Surgery, Volume 28, Issue 2, 1 August 2005, Pages 244–249, https://doi.org/10.1016/j.ejcts.2005.03.024
3. Dynamic Four-dimensional Computed Tomography (4D CT) Imaging for Re-entry Risk Assessment in Re-do Sternotomy - First experience Narayanan, Harish et al. Heart, Lung and Circulation , Volume 24 , Issue 10 , 1011 - 1019
4. Static and cine CT imaging to identify and characterize mediastinal adhesions as a potential complication for patients underdoing "redo sternotomy"(Article) Malguria, N., Hanley, M., Steigner, M., Kumamaru, K.K., Wake, N., Zenati, M., Rybicki, F.J. American Journal of Roentgenology Volume 201, Issue 1, July 2013, Pages W72-W74
5. Rajiah P, Schoenhagen P. The role of computed tomography in pre-procedural planning of cardiovascular surgery and intervention. Insights Imaging. 2013;4(5):671-89.