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Spirometry , urinalysis, joint fluid, CSF and pleuritic fluid analysis PRESENTED BY SARA RAMACHANDRAN AND JACK WELLINGTON Contents § Spirometry § Urinalysis § Joint fluid § CSF § Pleuritic fluid General pointers § What test § On whom - Name, DOB, patient ID § When – Date and time § Interpretation § Diagnosis/management § Any further investigations Spirometry Test of respiratory function - Best of 3 (2 within 5% of each other)* Classifications: Restrictive and obstructive Key measurements: FEV1, FVC, FEV1/FVC ratio Measurement Crudely FVC (forced expiratory volume) total volume of air forced out after maximal inspiration Capacity of lung FEV1 (Forced expiratory volume in Maximum volume of air forced out in 1 second Airflow to lungs FEV1/FVC ratio Normal ≥ 0.7 Obstructive Obstruction/narrowing of airways § Restricted airflow = lowered FEV1 (FVC largely unaffected) – consequentia↓FEV1/FVC ratio § Conditions: COPD (emphysema, chronic bronchitis), asthma, bronchiectasis, cystic fibrosis, airway obstructions Reversibility – 400mcg salbutamol + repeat FVC FEV1 ≥ 12% + volume increase ≥ 200ml FVC FEV1 FEV1 FVC e l FEV1 = ↓ FEV1/FVC ratio V FVC FEV1 Time Obstructive Most commonly asthma and COPD Asthma: FeNO in all adults and neg children § ≥ 40 in adults, ≥ 35 in children COPD (gold criteria) Stage FEV1/FVC (with bronchodilator) FEV1 % predicted Mild ≥ 80 Moderate 50-79 <0.7 Severe 30-49 Very severe <30 Restrictive Anything that reduces lung capacity/ability to expand – reduced lung compliance § Interstitial lung diseases (pulmonary fibrosis, ARDS, sarcoidosis, allergic pneumonitis) § Alveolar causes: pneumonia, pulmonary oedema, lobectomy, parenchymal tumours § Extrinsic: spinal (kyphosis/scoliosis), pneumothorax, pleural effusion, respiratory muscle weakness (GBS, ALS, MG) FVC FEV1 FEV1 e FVC u Both FVC and FEV1 <80% o FVC FEV1 Thus FEV1/FVC ratio normal V FVC = FEV1/FVC ratio FEV1 unaffected Time Spirometry summary FEV1/FVC ratio <0.7 YES NO Both FEV1 and FVC Obstructive <80% predicted YES Restrictive Reversibility Likely COPD and positive/FeNO others positive Asthma Urinalysis Normal Abnormality causes pH 4.5-8 Low: acidosis causes (met acidosis, DKA, lactate) Low: met alk, UTI Leukocyte esterase Negative UTI (and conditions with positive blood) Nitrites Negative UTI Blood Negative Positive: tests both haemoglobin and myoglobin Trauma (stones), rhabdomyolysis, nephritic syndromes, malignancies UTI (retest post treatment) Protein Negative Nephrotic syndrome, pre-eclampsia, UTI Glucose Negative Diabetes, drugs (SGLT2) Ketones Negative Ketoacidoses, severe hyperemesis gravidum Urobilinogen Negative Prehepatic and intrahepatic causes of jaundice Specific gravity Indicated range Low: diluted urine High: concentrated urine (urine osmolality) Diabetes insipidus Dehydration, HF, contrast use Urinalysis Case: 56-year-old lady presents 3/7 hx with increased frequency, dysuria and nocturia. No loin/back pain, systemically well. PMHx T2DM and rheumatoid arthritis. DHx metformin, empagliflozin, methotrexate and folate. Patient is allergic to penicillin. Her eGFR 1/52 on routine bloods was 89. Interpret the following: Value MC&S report: interpret pH 8 Culture: colonies of E.Coli Leukocyte esterase +++ Urinalysis Antibiotic Sensitivity Name Nitrites + DOB Blood + Trimethoprim Sensitive Patient ID Protein Negative nitrofurantoin Sensitive Date and time Glucose + Doxycycline Resistant Ketones - Co-amoxiclav Sensitive Urobilinogen - Ciprofloxacin negative Specific gravity Normal Arthrocentesis analysis Aspiration of synovial fluid from joint space Indications: suspected septic arthritis, gout/pseudogout, therapeutic (effusions/haemarthrosis) Normal Appearance Straw like, clear WBC 200-2000 Neutrophils <25% Gram stain Negative Crystals Negative Culture No growth Glucose (to blood) Around the same Arthrocentesis analysis Analysis of synovial fluid – suspecting arthritis or for therapeutic reasons (effusion relief) Osteoarthritis Inflammatory arthritis Gout Pseudogout Septic (RA, psoriatic etc) Appearance NAD Thicker, yellow Thicker, yellow Cloudy/opaque/yellow/green WBC NAD High High Very high Neutrophils NAD High High Very high Gram stain NAD NAD NAD Positive: gonococcal Negative: non-gonococcal Crystals Some calcium NAD Monosodium urate Calcium NAD phosphate (needle shaped – negatipyrophosphate birefringence) (positively birefringent – rhomboid shaped) Culture NAD NAD NAD Positive Glucose (to blood) NAD Low Low Very lowCSF Pleural fluid Pleural fluid – normal lubricating fluid between the two pleural layers = tested when increased (pleural effusion) Two types – transudative and exudative (failures and fancies) Transudative § Anything that pushes/pulls fluid into pleural space (oncotic pressure) § failures (HF, liver failure/cirrhosis, renal – nephrotic syndromes), low albumin (severe malnourishment/liver failure) Exudative § local leaking/lack of absorption § fancies - Infection, increased pressure (PE), malignancy/tumours Specific appearances: pus (empyema), anchovy sauce (amoebic abscess), milky (chylothorax), food (oesophageal rupture) Pleural fluid Transudative Exudative Pleural protein/serum protein ≤ 0.5 (Low) > 0.5 (high) Pleural LDH/Serum LDH ≤ 0.6 (low) > 0.6 (high) Light Pleural LDH < 2/3 of upper limit of serum > 2/3 (hiiiiigh LDH) criteria LDH Culture NAD Can be positive (infection) Cytology NAD Can be positive (malignancy) Glucose NAD Low in infectionThank you J