The importance of correct breathing technique
for “CT pulmonary emboli” – it is not just about
having many “slices” in your scanner.  
 
Professor Jonas Rydberg, MD
E-mail: jrydberg@iuhealth.org
 
Indiana University School of Medicine
Department of Radiology Methodist Hospital
Indianapolis, Indiana, USA

Outline: 1. This presentation takes a focus on the most common reason for failed
CT exams namely – The breathing instructions given to the patient.
2. It will also discuss how patient size affects the exam quality.
Conclusions: •  Most often the failed exams depend on dilution of the contrast media in the
pulmonary arteries due to mixing with non-opacified blood from the Inferior
Vena Cava.
•  The breathing instruction to the patient should be: Stop breathing!” and not:
Take a deep breath and hold it!
•  Another reason why some exams do not turn out excellent is due to the
large size of some patients.
This is how we want to see the opacification of the
pulmonary arteries – well opacified arteries allowing for
definite diagnostic evaluation for pulmonary emboli.

(The slab MIP technique above is not used for the routine PE protocol. Here it is used just to
show good opacification.)
Jonas Rydberg Oct 2011
QA process to evaluate if attenuation is acceptable:
Use a ROI and measure the attenuation in the pulmonary
trunk or in the left pulmonary artery.

150 HU - Too low

200 HU – Borderline
250 HU - Good
> 300 HU - Excellent

Jonas Rydberg Oct 2011

But, sometimes scans end up looking like this with very low
attenuation in the pulmonary arteries while the superior vena
cava and aorta have high degree of opacification.

600 HU

150 HU

300 HU

How is this possible?

Continue to read!
Jonas Rydberg Oct 2011
Many theories have been presented why exams fail seemingly
without a reason
Most central pulmonary
arteries almost without
opacification. Why?

Arrows points at fairly central arteries

but diagnosis is still hard to make.

- Incorrect triggering?
-  Incorrect timing?
-  Something wrong with the CT scanner?
What is the reason? -  Fast blood flow?
- Size of patient?
-  Breathing technique?
-  Valsalva maneuver?
Jonas Rydberg Oct 2011
Some important facts about multislice CT scanners
which potentially can cause the exams to fail
The more slices a scanner has the faster the scan scan.

Here are typical scan times for PE studies:

4-slice CT 35 sec
16-slice CT 17 sec
40-slice CT 8 sec
64-slice CT 6 sec
256-slice CT 3 sec

From the moment bolus triggering software triggers the scan start it
usually takes 5-6 seconds before the scanner reaches the start position
for the scanning and start scanning.

Note that for 40-slice CT and up the total scan time matches the delay
from triggering to scan start. We are looking at processes that are fast.
Paradoxically it is the fastest scanners that have the highest incident of
failed exams. Keep reading to learn why! Jonas Rydberg Oct 2011
Here is the faulty assumption we all are making:
Intuitively, but incorrectly, do we assume that the contrast media flows
through a single “pipe line” (see red arrows below) starting in the arm,
continuing through the superior vena cava, right atrium, right ventricle,
pulmonary arteries and then out via the pulmonary veins to reach the
aorta.
- But that is wrong. Please, continue reading!

Jonas Rydberg Oct 2011

Here is the single, uninterrupted, “pipeline” that we think exists and that we
think shall opacify evenly when we deliver our contrast media bolus.

SVC RA-RV PA PV-RA-RV Aorta

SVC = Superior Vena Cava PV = Pulmonary Veins

RA = Right Atrium RA = Right Atrium
RV = Right Ventricle RV = Right Ventricle
PA = Pulmonary Arteries Aorta
IVC = Inferior Vena Cava

We forget that there is a major inflow to the above “pipeline” from the Inferior
Vena Cava containing non-opacified blood.

SVC RA-RV PA PV-RA-RV Aorta

Jonas Rydberg Oct 2011

SVC RA-RV PA PV-RA-RV Aorta

If we ask the patient to take a deep breath and hold it the

pressure in the chest cage drops and non-opacified
blood is sucked in from the IVC and liver. The chest acts
like a “vacuum cleaner” and sucks in the blood from
below the diaphragm which does not contain any iodine.
The iodinated blood from SVC gets diluted!

SVC RA-RV PA PV-RA-RV Aorta

Scanning

A few seconds after the patient has filled the RA-RV-PA

with non-opacified blood the scanning starts. Scanning
will occur at the worst possible time – “Dilution time” -
when iodine concentration drops to the lowest point in
the pulmonary arteries. Jonas Rydberg Oct 2011
Just a repetition: We believe that this is what it looks like:

SVC RA-RV PA PV-RA-RV Aorta

But, this is what happens after a “Take a deep breath and hold
it!” command.

Scanning period
SVC RA-RV PA PV-RA-RV Aorta

(Valsalva maneuver at the end of taking

the breath is not the culprit. It stops more
inflow of blood. But, the damage has
already been done with the deep inhaling
and dilution.)
Jonas Rydberg Oct 2011
How failed can an exam become?
In this case the CT technologist did almost everything correctly – i.e. good IV line, high flow
rate, 100 ml of contrast media, correct triggering process while using a 64-slice scanner.
But, because of lack of correct breath hold technique the study became non-diagnostic.
(Right Axillary vein 1200 HU, Aorta 280 HU but the Pulmonary Trunk just 90 HU.)

1200 HU
280 HU

90 HU 90 HU

90 HU

280 HU
(Go back to slide 3 to check the QA Inflow of non-opacified
process with HU values.) blood from liver and IVC Jonas Rydberg Oct 2011
Solution: “Stop breathing” technique.
Be sure to give the patient instructions to stop breathing and
not make any inhalation when the scanner starts scanning.
Scanning will be over in a few seconds so there will be no
oxygen issues. Be certain that the patient has understood the
instructions.

Opacified blood will flow from

SVC to right side of heart and
into the pulmonary arteries.
No non-opacified blood will
flow in from the liver and IVC.

Remember to turn off the automatic voice in the scanner that

says: “Take a deep breath and hold it!”. Jonas Rydberg Oct 2011
Influence of patient size on exam quality

The graph shows Hounsfield values in the left pulmonary artery in 37

consecutive patients scanned with the PE protocol. The PE protocol included
“Stop breathing” instructions.
The average density for the 37 patients was calculated to 260 HU.
Despite “Stop breathing” instructions 11 of the patients had attenuation values
below 200 HU.
600.00

How could that be possible?

500.00

Answer on the next page!

400.00

300.00 Series1

200 HU 200.00

100.00

0.00
0 5 10 15 20 25 30 35 40

Jonas Rydberg Oct 2011

Influence of patient size on exam quality
A common reason for suboptimal attention in the pulmonary arteries is large size of
the patient. If the HU is low in the pulmonary arteries the HU is most often equally low
or lower in the aorta despite correct breathing instructions.

RULE: If attenuation is low in both pulmonary arteries and aorta the reason is likely
large size of the patient and not an issue with the breathing technique.

Example of “Low-Low HU”

152 HU

126 HU

Jonas Rydberg Oct 2011

QA process to determine if breathing technique was correct

Check HU values with ROIs in both Pulmonary artery and Aorta

150HU
1.  If Pulmonary artery > Aorta
= Correct breath hold technique 300HU

300HU
2.  If Aorta > Pulmonary artery
= Incorrect breath hold technique 150HU
Inflow of “Bad blood” from IVC and liver

3.  If Pulmonary artery = Aorta

126
but overall decreased 152
= Correct breath hold technique
(Either large patient or reduced CM volume)
Jonas Rydberg Oct 2011
Case that shows the value of analyzing failed exams
20-year old man. 5 days after MVA. Difficulty breathing. Pulmonary emboli?

Exam 1 – Non diagnostic exam. Radiologist
analyzed images and concluded that the
exam had failed because of incorrect breath
hold technique. (Note that not even central
arteries can be evaluated.)
Exam 2 (next morning) – Radiologist ordered
repeat scanning with careful attention to “No
breathing instructions” to patient. Exam now
diagnostic showing large central emboli.

? ?

?
Case provided by: Julio A. Lemos, MD., Fletcher Allen Health Care, University of Vermont, Burlington, VT.
Jonas Rydberg Oct 2011
 Conclusions:
•  Most often the failed exams depend on dilution of the contrast
media in the pulmonary arteries due to mixing with non-opacified
blood from the Inferior Vena Cava.
•  The breathing instruction to the patient should be: Stop breathing!”
and not: Take a deep breath and hold it!
•  Another reason why some exams do not turn out excellent is due to
the large size of some patients.

Stop the “bad blood” from coming in!

Jonas Rydberg Oct 2011