1. Introduction to Pulmonary Medicine
Dr. Gerald Supinski
Professor of Medicine and Physiology

2. Topics to Cover Classification of Pulmonary Disorders History
Physical Examination
PFT
CXR
ABG
Cases

3. Classification of Pulmonary Disorders

4. History: Dyspnea “Shortness of breath” Most common pulmonary symptom
Need further characterization as to timing, severity, relationship to exercise, body position, relationship to temperature (cold)

5. History: Other Symptoms
Cough
Fever
Sputum production
Nocturnal awakening
Chest pain
Weakness
Leg swelling

6. Physical Examination
Percussion
Auscultation

7. Percussion
Original use for wine casks:

9. Effect of Altering Media Density

11. Percussion Responses Condition Response Normal Lung Normal Percussion
Pneumothorax
Emphysema
Increased Percussion
“Hyperresonance”
Effusion
Consolidated Lung
Reduced Percussion
“Hyporesonance”

12. Auscultation Breath Sounds Bronchovesicular, Bronchial, Reduced Sounds
Adventitial Sounds
Rales, Wheezes, Rhonchi

13. Breath Sound Characteristics
Frequency of sounds (pitch)
Intensity or loudness of sounds

17. Breath Sound Classes Bronchovesicular Sounds Normal
Bronchial Breath Sounds
Consolidation around an open airway
Reduced Breath Sounds
Emphysema,
Asthma

18. Adventitial Sounds Rales End Inspiratory “Cellophane”
See in CHF, ILD, pneumonia
Wheezes
Can be either inspiratory (UAO)
or expiratory (asthma, COPD)
Rhonchi
Non specific

19. Summary of History/Exam
Disease
Symptoms
Breath
Sounds
Adventitial
Asthma
SOB with exercise, cold
Reduced
Wheeze
COPD
Sputum production
ILD
Severe dyspnea
Normal
Rales
RM Weakness
Limb weakness
Normal-Reduced
None
Chest Wall Abn.
Leg edema

20. PFTs Determine if normal or abnormal
Classify as restrictive or obstructive
Determine severity
Correlate with history, physical, CXR

21. PFT Classification

23. Standard PFTs Spirometry Flow-Volume Loops Lung Volumes DLCO
Pimax, Pemax

24. Spirometry

25. Obstructed vs Restricted

26. DDX of Spirometry Normal Obstruction Restriction FEV1 N ↓↓↓ ↓↓ FVC ↓
FEV1/FVC

27. Reversibility

28. Lung Volumes

29. Lung Volumes Components

30. Lung Volume Components

31. DLCO Diffusion capacity for carbon dioxide A measure of gas exchange
Patient breathes a small amount of CO and uptake determined

32. Concept of DLCO

33. DDX of DLCO DLCO Condition Normal
Normals, Muscle disease, Chest wall disease
Reduced
COPD, ILD, Sarcoidosis,
Pneumonia
Increased
Asthma

34. Pimax and Pemax Pimax measures inspiratory strength
Pemax measures expiratory strength
Patient inhales/exhales thru mouthpiece attached to transducer

35. Respiratory Muscle Strength

36. Summary of PFTs Disease FEV1 FEV1/FVC TLC DLCO Pimax Asthma ↓↓↓ ↓↓ ↑ N
COPD ↓
ILD
RM Weakness
Chest Wall Abn.
Normal

37. CXR (Chest Radiograph)
Obstruction
Clear lung fields, can see hyperinflation
Restricted-Interstitial Pattern
Lines and nodules
Restricted-Alveolar Pattern
See diffuse filling, air bronchograms
Chest Wall/Muscle Disorders
Reduced lung volume

46. Arterial Blood Gases pH
paCO2
paO2
FiO2

47. Mechanisms of Hypoxemia
Diffusion block
V/Q mismatch
Shunt
Hypoventilation

48. Determinants of PaO2 Alveolar Air Equation: PAO2=FiO2(BP-VP)-PaCO2/R
A-a Gradient= PAO2-PaO2
So PaO2=FiO2(BP-VP)-PaCO2/R - A-a Gradient

50. Increases in Inspired Oxygen Concentrations Do Not Substantially Improve paO2 in the Presence of Substantial Shunt

51. DDX of Hypoxemia A-a Gradient Response to 100% Oxygen Diffusion block↑ ↑↑
V/Q mismatch
Shunt
Poor response
Hypoventilation
Normal

52. Mechanisms of Hypercapnia
Increased CO2 production
Reduced minute ventilation
Increased dead space

53. Dead Space

54. Mathematical Relationships
The following equation determines paCO2:
paCO2 = VCO2 (k)
VE-VD

55. Causes of Hypercapnia Mechanism of ↑CO2 Etiologies
Increased CO2 production
Fever, thyrotoxicosis
Increased dead space
COPD, asthma, ILD, ARDS, pneumonia
Reduced ventilation
Weakness, chest wall disease, fatigue, UAO

56. Summary of CXR/ABG Disease CXR PaO2 Dead Space Ve Asthma Hyperinflated↓ ↑
Vary
COPD ↓↓
↑↑↑
ILD
Lines/nodules
↓↓↓
RM Weakness
Clear, small N
Chest Wall Abn.
Normal

58. A clinic patient complains of shortness of breath for the past 9 months. Spirometry and lung volume measurements are read as showing a restrictive abnormality. The differential diagnosis of this patient consists of three disorders, including:
A) Bronchitis, asthma, sleep apnea
B) Chest wall disorders, muscle weakness, interstitial lung disease
C) Upper airway diseases, asthma, COPD
D) Pulmonary embolism, cardiomegaly, liver disease
E) Emphysema, muscle weakness, hepatopulmonary syndrome

59. A clinic patient complains of shortness of breath for the past 9 months. Spirometry and lung volume measurements are read as showing a restrictive abnormality. The differential diagnosis of this patient consists of three disorders, including:
A) Bronchitis, asthma, sleep apnea
B) Chest wall disorders, muscle weakness, interstitial lung disease
C) Upper airway diseases, asthma, COPD
D) Pulmonary embolism, cardiomegaly, liver disease
E) Emphysema, muscle weakness, hepatopulmonary syndrome

61. A patient has a long history of dyspnea
A patient has a long history of dyspnea. The physical examination reveals reduced breath sound and hyperresonance. The chest radiograph shows emphysema. Which PFT results are likely to be observed?
A) A reduced FEV1, a reduced FVC and a normal FEV1/FVC ratio
B) A markedly reduced FEV1, a reduced FVC, a reduced FEV1/FVC ratio
C) A reduced FEV1, a normal FVC and a normal FEV1/FVC ratio
D) Reduced FEV1, increased FVC and an increased FEV1/FVC ratio
E) Normal FEV1, normal FVC, and a normal FEV1/FVC ratio

62. A patient has a long history of dyspnea
A patient has a long history of dyspnea. The physical examination reveals reduced breath sound and hyperresonance. The chest radiograph shows emphysema. Which PFT results are likely to be observed?
A) A reduced FEV1, a reduced FVC and a normal FEV1/FVC ratio
B) A markedly reduced FEV1, a reduced FVC, a reduced FEV1/FVC ratio
C) A reduced FEV1, a normal FVC and a normal FEV1/FVC ratio
D) Reduced FEV1, increased FVC and an increased FEV1/FVC ratio
E) Normal FEV1, normal FVC, and a normal FEV1/FVC ratio

63. Normal
Obstruction
Restriction
FEV1 N
↓↓↓ ↓↓
FVC ↓
FEV1/FVC

64. Summary of PFTs Disease FEV1 FEV1/FVC TLC DLCO Pimax Asthma ↓↓↓ ↓↓ ↑ N
COPD ↓
ILD
RM Weakness
Chest Wall Abn.
Normal

65. A patient has expiratory wheezing, shortness of breath and cough
A patient has expiratory wheezing, shortness of breath and cough. PFTs show a reduced FEV1, a mildly reduced FVC, a reduced FEV1/FVC ratio, a reduced DLCO. The chest Xray is clear. Which is the most likely diagnosis:
A) COPD
B) Bronchiectesis
C) Sarcoidosis
D) Asthma
E) Upper airway obstruction

66. A patient has expiratory wheezing, shortness of breath and cough
A patient has expiratory wheezing, shortness of breath and cough. PFTs show a reduced FEV1, a mildly reduced FVC, a reduced FEV1/FVC ratio, a reduced DLCO. The chest Xray is clear. Which is the most likely diagnosis:
A) COPD
B) Bronchiectesis
C) Sarcoidosis
D) Asthma
E) Upper airway obstruction

67. Summary of PFTs Disease FEV1 FEV1/FVC TLC DLCO Pimax Asthma ↓↓↓ ↓↓ ↑ N
COPD ↓
ILD
RM Weakness
Chest Wall Abn.
Normal

68. A clinic patient complains of dyspnea, has rales on physical examination, the FEV1 is reduced, the FEV1/FVC ratio is normal, DLCO is reduced and the CXR shows a reticulonodular infiltrate. What is the most consistent diagnosis:
A) Asthma
B) Emphysema
C) Interstitial Lung Disease
D) Upper Airway Obstruction
E) Chest wall disease

69. A clinic patient complains of dyspnea, has rales on physical examination, the FEV1 is reduced, the FEV1/FVC ratio is normal, DLCO is reduced and the CXR shows a reticulonodular infiltrate. What is the most consistent diagnosis:
A) Asthma
B) Emphysema
C) Interstitial Lung Disease
D) Upper Airway Obstruction
E) Chest wall disease

70. Summary of History/Exam
Disease
Symptoms
Breath
Sounds
Adventitial
Asthma
SOB with exercise, cold
Reduced
Wheeze
COPD
Sputum production
ILD
Severe dyspnea
Normal
Rales
RM Weakness
Limb weakness
Normal-Reduced
None
Chest Wall Abn.
Leg edema

71. Summary of PFTs Disease FEV1 FEV1/FVC TLC DLCO Pimax Asthma ↓↓↓ ↓↓ ↑ N
COPD ↓
ILD
RM Weakness
Chest Wall Abn.
Normal

72. Summary of CXR/ABG Disease CXR PaO2 Dead Space Ve Asthma Hyperinflated↓ ↑↑
Vary
COPD ↓↓
↑↑↑
ILD
Lines/nodules
↓↓↓ ↑
RM Weakness
Clear, small N
Chest Wall Abn.
Normal

73. You see a patient on the medical ward who complains of dyspnea and difficulty standing. The FEV1 is reduced, the FEV1/FVC is normal, the TLC is reduced, the DLCO is normal, the CXR is clear. A possible diagnosis is:
A) Interstitial lung disease
B) Asthma
C) Respiratory muscle weakness
D) Bronchiectesis
E) Asbestosis

74. You see a patient on the medical ward who complains of dyspnea and difficulty standing. The FEV1 is reduced, the FEV1/FVC is normal, the TLC is reduced, the DLCO is normal, the CXR is clear. A possible diagnosis is:
A) Interstitial lung disease
B) Asthma
C) Respiratory muscle weakness
D) Bronchiectesis
E) Asbestosis

75. Summary of PFTs Disease FEV1 FEV1/FVC TLC DLCO Pimax Asthma ↓↓↓ ↓↓ ↑ N
COPD ↓
ILD
RM Weakness
Chest Wall Abn.
Normal

76. A patient has been diagnosed with hypersensitivity pneumonitis, a form of interstitial lung disease. What lung volume measurements are likely to be present:
A) Reduced TLC, increased FRC
B) Increased TLC, normal FRC
C) Reduced TLC, normal FRC
D) Reduced TLC, reduced FRC
E) Increased TLC, normal FRC

77. A patient has been diagnosed with hypersensitvity pneumonitis, a form of interstitial lung disease. What lung volume measurements are likely to be present:
A) Reduced TLC, increased FRC
B) Increased TLC, normal FRC
C) Reduced TLC, normal FRC
D) Reduced TLC, reduced FRC
E) Increased TLC, normal FRC

79. A patient is breathing 50% oxygen, the barometric pressure is 747, the vapor pressure of water is 47, the carbon dioxide level is 40, the respiratory quotient is 0.8. What is the alveolar oxygen level (PA02)?
A) 33
B) 500
C) 300
D) 200
E) 97

80. A patient is breathing 50% oxygen, the barometric pressure is 747, the vapor pressure of water is 47, the carbon dioxide level is 40, the respiratory quotient is 0.8. What is the alveolar oxygen level (PA02)?
A) 33
B) 500
C) 300
D) 200
E) 97

81. PAO2=FiO2(BP-VP)-PaCO2/R

82. A patient presents with increased arterial carbon dioxide level, a history of muscle weakness, and prior thyrotoxicosis. Which of the following tests will help determine whether the current increased carbon dioxide is from muscle weakness or thyroid disease?
A) Measurement of dead space
B) Measurement of the level of carbon dioxide production
C) Measurement of nitrogen balance
D) Measurement of alveolar-arterial gradient
E) A chest radiograph

83. A patient presents with increased arterial carbon dioxide level, a history of muscle weakness, and prior thyrotoxicosis. Which of the following tests will help determine whether the current increased carbon dioxide is from muscle weakness or thyroid disease?
A) Measurement of dead space
B) Measurement of the level of carbon dioxide production
C) Measurement of nitrogen balance
D) Measurement of alveolar-arterial gradient
E) A chest radiograph

84. Causes of Hypercapnia Mechanism of ↑CO2 Etiologies
Increased CO2 production
Fever, thyrotoxicosis
Increased dead space
COPD, asthma, ILD, ARDS, pneumonia
Reduced ventilation
Weakness, chest wall disease, fatigue, UAO

85. A patient presents with blue lips
A patient presents with blue lips. An arterial blood gas shows a paO2 that is 40 mm Hg. The patient is placed on 100% oxygen and the arterial blood gas improves to 650 mm Hg. The A-a gradient is normal. What is the likely cause of hypoxemia in this patient?
A) Diffusion block
B) Ventilaton-perfusion mismatch
C) Shunt
D) Hypoventilation
E) Elevated dead space

86. A patient presents with blue lips
A patient presents with blue lips. An arterial blood gas shows a paO2 that is 40 mm Hg. The patient is placed on 100% oxygen and the arterial blood gas improves to 650 mm Hg. The A-a gradient is normal. What is the likely cause of hypoxemia in this patient?
A) Diffusion block
B) Ventilaton-perfusion mismatch
C) Shunt
D) Hypoventilation
E) Elevated dead space

87. DDX of Hypoxemia A-a Gradient Response to 100% Oxygen Diffusion block↑ ↑↑
V/Q mismatch
Shunt
Poor response
Hypoventilation
Normal