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

Introduction to Introduction to Pulmonary Pulmonary MedicineMedicine

Dr. Gerald SupinskiDr. Gerald Supinski

Professor of Medicine and Professor of Medicine and PhysiologyPhysiology

Topics to CoverTopics to Cover

Classification of Classification of Pulmonary DisordersPulmonary Disorders HistoryHistory Physical ExaminationPhysical Examination PFTPFT CXRCXR ABGABG CasesCases

Classification of Pulmonary Classification of Pulmonary DisordersDisorders

History: DyspneaHistory: Dyspnea

““Shortness of breath”Shortness of breath” Most common pulmonary symptomMost common pulmonary symptom

Need further characterization as to Need further characterization as to timing, severity, relationship to timing, severity, relationship to exercise, body position, relationship exercise, body position, relationship to temperature (cold)to temperature (cold)

History: Other SymptomsHistory: Other Symptoms

CoughCough FeverFever Sputum productionSputum production Nocturnal Nocturnal

awakeningawakening Chest painChest pain WeaknessWeakness Leg swellingLeg swelling

Physical ExaminationPhysical Examination

PercussionPercussion AuscultationAuscultation

PercussionPercussion Original use for wine casks:Original use for wine casks:

Effect of Altering Media Effect of Altering Media DensityDensity

Percussion ResponsesPercussion Responses

ConditionCondition ResponseResponse

Normal LungNormal Lung Normal PercussionNormal Percussion

PneumothoraxPneumothorax

EmphysemaEmphysemaIncreased Increased PercussionPercussion

““Hyperresonance”Hyperresonance”

EffusionEffusion

Consolidated LungConsolidated LungReduced Reduced PercussionPercussion

““Hyporesonance”Hyporesonance”

AuscultationAuscultation

Breath SoundsBreath Sounds

Bronchovesicular, Bronchial, Bronchovesicular, Bronchial, Reduced SoundsReduced Sounds

Adventitial Sounds Adventitial Sounds

Rales, Wheezes, RhonchiRales, Wheezes, Rhonchi

Breath Sound Breath Sound CharacteristicsCharacteristics

Frequency of sounds (pitch)Frequency of sounds (pitch) Intensity or loudness of soundsIntensity or loudness of sounds

Breath Sound ClassesBreath Sound Classes

Bronchovesicular Bronchovesicular Sounds Sounds

NormalNormal

Bronchial Breath Bronchial Breath SoundsSounds

Consolidation around Consolidation around an open airwayan open airway

Reduced Breath Reduced Breath SoundsSounds

Emphysema,Emphysema,

AsthmaAsthma

Adventitial SoundsAdventitial Sounds

RalesRales End Inspiratory “Cellophane”End Inspiratory “Cellophane”

See in CHF, ILD, pneumoniaSee in CHF, ILD, pneumonia

WheezesWheezes Can be either inspiratory (UAO)Can be either inspiratory (UAO)

or expiratory (asthma, COPD)or expiratory (asthma, COPD)

RhonchiRhonchi Non specificNon specific

Summary of Summary of History/ExamHistory/Exam

DiseaseDisease SymptomsSymptoms BreathBreath

SoundsSoundsAdventitAdventitialial

SoundsSounds

AsthmaAsthma SOB with SOB with exercise, exercise, coldcold

ReduceReducedd

WheezeWheeze

COPDCOPD Sputum Sputum productioproductionn

ReduceReducedd

WheezeWheeze

ILDILD Severe Severe dyspneadyspnea

NormalNormal RalesRales

RM RM WeaknessWeakness

Limb Limb weaknessweakness

NormalNormal--ReduceReducedd

NoneNone

Chest Wall Chest Wall Abn.Abn.

Leg Leg edemaedema

ReduceReducedd

NoneNone

NormalNormal NoneNone NormalNormal NoneNone

PFTsPFTs

Determine if normal or Determine if normal or abnormalabnormal

Classify as restrictive or Classify as restrictive or obstructiveobstructive

Determine severityDetermine severity Correlate with history, Correlate with history,

physical, CXRphysical, CXR

PFT ClassificationPFT Classification

Standard PFTsStandard PFTs

SpirometrySpirometry Flow-Volume LoopsFlow-Volume Loops Lung VolumesLung Volumes DLCODLCO Pimax, PemaxPimax, Pemax

SpirometrySpirometry

Obstructed vs RestrictedObstructed vs Restricted

DDX of SpirometryDDX of Spirometry

NormalNormal ObstructObstructionion

RestrictiRestrictionon

FEV1FEV1 NN ↓↓↓↓↓↓ ↓↓↓↓

FVCFVC NN ↓↓ ↓↓↓↓

FEV1/FEV1/FVCFVC

NN ↓↓↓↓ NN

Reversibility Reversibility

Lung VolumesLung Volumes

Lung Volumes Lung Volumes ComponentsComponents

Lung Volume Lung Volume ComponentsComponents

DLCODLCO

Diffusion capacity for carbon dioxideDiffusion capacity for carbon dioxide A measure of gas exchangeA measure of gas exchange Patient breathes a small amount of Patient breathes a small amount of

CO and uptake determinedCO and uptake determined

Concept of DLCOConcept of DLCO

DDX of DLCODDX of DLCO

DLCODLCO ConditionCondition

NormalNormal Normals, Muscle Normals, Muscle disease, Chest wall disease, Chest wall diseasedisease

ReducedReduced COPD, ILD, Sarcoidosis,COPD, ILD, Sarcoidosis,

Pneumonia Pneumonia

IncreasedIncreased AsthmaAsthma

Pimax and PemaxPimax and Pemax

Pimax measures inspiratory Pimax measures inspiratory strengthstrength

Pemax measures expiratory Pemax measures expiratory strengthstrength

Patient inhales/exhales thru Patient inhales/exhales thru mouthpiece attached to transducermouthpiece attached to transducer

Respiratory Muscle Respiratory Muscle StrengthStrength

Summary of PFTsSummary of PFTsDiseaseDisease FEVFEV

11FEVFEV1/1/FVCFVC

TLCTLC DLCDLCOO

PimaPimaxx

AsthmaAsthma ↓↓↓↓↓↓

↓↓↓↓ ↑↑ ↑↑ NN

COPDCOPD ↓↓↓↓↓↓

↓↓↓↓ ↑↑ ↓↓↓↓ ↓↓

ILDILD ↓↓↓↓ NN ↓↓↓↓ ↓↓↓↓ NN

RM RM WeaknesWeaknesss

↓↓ NN ↓↓↓↓ NN ↓↓↓↓

Chest Chest Wall Abn.Wall Abn.

↓↓ NN ↓↓↓↓ NN NN

NormalNormal NN NN NN NN NN

CXR (Chest Radiograph)CXR (Chest Radiograph)

ObstructionObstruction

Clear lung fields, can see Clear lung fields, can see hyperinflationhyperinflation

Restricted-Interstitial PatternRestricted-Interstitial Pattern

Lines and nodulesLines and nodules Restricted-Alveolar PatternRestricted-Alveolar Pattern

See diffuse filling, air See diffuse filling, air bronchogramsbronchograms

Chest Wall/Muscle DisordersChest Wall/Muscle Disorders

Reduced lung volumeReduced lung volume

Arterial Blood GasesArterial Blood Gases

pHpH paCO2paCO2 paO2paO2 FiO2FiO2

Mechanisms of Mechanisms of HypoxemiaHypoxemia

Diffusion blockDiffusion block V/Q mismatch V/Q mismatch ShuntShunt HypoventilationHypoventilation

Determinants of PaODeterminants of PaO22

Alveolar Air Equation:Alveolar Air Equation:

PAOPAO22=FiO=FiO22(BP-VP)-PaCO(BP-VP)-PaCO22/R /R

A-a Gradient= PAOA-a Gradient= PAO22-PaO-PaO2 2

So PaOSo PaO22=FiO=FiO22(BP-VP)-PaCO(BP-VP)-PaCO22/R - A-a /R - A-a GradientGradient

Increases in Inspired Oxygen Increases in Inspired Oxygen Concentrations Concentrations

Do Not Substantially Improve paO2 Do Not Substantially Improve paO2 in in

the Presence of Substantial Shuntthe Presence of Substantial Shunt

DDX of HypoxemiaDDX of Hypoxemia

A-a GradientA-a Gradient Response to Response to 100% 100% OxygenOxygen

Diffusion Diffusion blockblock

↑↑ ↑↑↑↑

V/Q V/Q mismatchmismatch

↑↑↑↑ ↑↑↑↑

ShuntShunt ↑↑↑↑ Poor Poor responseresponse

HypoventilatHypoventilationion

NormalNormal ↑↑↑↑

Mechanisms of Mechanisms of HypercapniaHypercapnia

Increased CO2 Increased CO2 productionproduction

Reduced minute Reduced minute ventilationventilation

Increased dead spaceIncreased dead space

Dead SpaceDead Space

Mathematical Mathematical RelationshipsRelationships

The following equation determines The following equation determines paCO2: paCO2:

paCO2 = paCO2 = VCO2 (k)VCO2 (k)

VE-VDVE-VD

Causes of HypercapniaCauses of Hypercapnia

Mechanism of Mechanism of ↑CO2↑CO2

EtiologiesEtiologies


Fever, Fever, thyrotoxicosisthyrotoxicosis

Increased dead Increased dead spacespace

COPD, asthma, COPD, asthma, ILD, ARDS, ILD, ARDS, pneumoniapneumonia

Reduced Reduced ventilationventilation

Weakness, chest Weakness, chest wall disease, wall disease, fatigue, UAOfatigue, UAO

Summary of CXR/ABGSummary of CXR/ABG

DiseaseDisease CXRCXR PaOPaO22

Dead Dead

SpaceSpaceVeVe

AsthmaAsthma HyperinflatHyperinflateded

↓↓ ↑↑ VarVaryy

COPDCOPD HyperinflatHyperinflateded

↓↓↓↓ ↑↑↑↑↑↑ VarVaryy

ILDILD Lines/Lines/nodulesnodules

↓↓↓↓↓↓ ↑↑ VarVaryy


Clear, Clear, smallsmall

↓↓ NN ↓↓



↓↓ NN ↓↓

NormalNormal NormalNormal NN NN NN

A clinic patient complains of shortness of breath A clinic patient complains of shortness of breath for the past 9 months. Spirometry and lung for the past 9 months. Spirometry and lung volume measurements are read as showing a volume measurements are read as showing a restrictive abnormality. The differential diagnosis restrictive abnormality. The differential diagnosis of this patient consists of three disorders, of this patient consists of three disorders, including:including:

A) Bronchitis, asthma, sleep apneaA) Bronchitis, asthma, sleep apneaB) Chest wall disorders, muscle weakness, B) Chest wall disorders, muscle weakness,

interstitial lung diseaseinterstitial lung diseaseC) Upper airway diseases, asthma, COPDC) Upper airway diseases, asthma, COPDD) Pulmonary embolism, cardiomegaly, liver D) Pulmonary embolism, cardiomegaly, liver

diseasediseaseE) Emphysema, muscle weakness, E) Emphysema, muscle weakness,

hepatopulmonary syndromehepatopulmonary syndrome

A clinic patient complains of shortness of breath A clinic patient complains of shortness of breath for the past 9 months. Spirometry and lung for the past 9 months. Spirometry and lung volume measurements are read as showing a volume measurements are read as showing a restrictive abnormality. The differential diagnosis restrictive abnormality. The differential diagnosis of this patient consists of three disorders, of this patient consists of three disorders, including:including:

A) Bronchitis, asthma, sleep apneaA) Bronchitis, asthma, sleep apneaB) B) Chest wall disorders, muscle weakness, Chest wall disorders, muscle weakness,

interstitial lung diseaseinterstitial lung diseaseC) Upper airway diseases, asthma, COPDC) Upper airway diseases, asthma, COPDD) Pulmonary embolism, cardiomegaly, liver D) Pulmonary embolism, cardiomegaly, liver

diseasediseaseE) Emphysema, muscle weakness, E) Emphysema, muscle weakness,

hepatopulmonary syndromehepatopulmonary syndrome

A patient has a long history of dyspnea. The A patient has a long history of dyspnea. The physical examination reveals reduced breath physical examination reveals reduced breath sound and hyperresonance. The chest sound and hyperresonance. The chest radiograph shows emphysema. Which PFT radiograph shows emphysema. Which PFT results are likely to be observed?results are likely to be observed?

A) A reduced FEV1, a reduced FVC and a normal A) A reduced FEV1, a reduced FVC and a normal FEV1/FVC ratioFEV1/FVC ratio

B) A markedly reduced FEV1, a reduced FVC, a B) A markedly reduced FEV1, a reduced FVC, a reduced FEV1/FVC ratioreduced FEV1/FVC ratio

C) A reduced FEV1, a normal FVC and a normal C) A reduced FEV1, a normal FVC and a normal FEV1/FVC ratioFEV1/FVC ratio

D) Reduced FEV1, increased FVC and an D) Reduced FEV1, increased FVC and an increased FEV1/FVC ratioincreased FEV1/FVC ratio

E) Normal FEV1, normal FVC, and a normal E) Normal FEV1, normal FVC, and a normal FEV1/FVC ratioFEV1/FVC ratio

A patient has a long history of dyspnea. The A patient has a long history of dyspnea. The physical examination reveals reduced breath physical examination reveals reduced breath sound and hyperresonance. The chest sound and hyperresonance. The chest radiograph shows emphysema. Which PFT radiograph shows emphysema. Which PFT results are likely to be observed?results are likely to be observed?

A) A reduced FEV1, a reduced FVC and a normal A) A reduced FEV1, a reduced FVC and a normal FEV1/FVC ratioFEV1/FVC ratio

B) B) A markedly reduced FEV1, a reduced FVC, a A markedly reduced FEV1, a reduced FVC, a reduced FEV1/FVC ratioreduced FEV1/FVC ratio

C) A reduced FEV1, a normal FVC and a normal C) A reduced FEV1, a normal FVC and a normal FEV1/FVC ratioFEV1/FVC ratio

D) Reduced FEV1, increased FVC and an D) Reduced FEV1, increased FVC and an increased FEV1/FVC ratioincreased FEV1/FVC ratio

E) Normal FEV1, normal FVC, and a normal E) Normal FEV1, normal FVC, and a normal FEV1/FVC ratioFEV1/FVC ratio

NormalNormal ObstructObstructionion

RestrictiRestrictionon

FEV1FEV1 NN ↓↓↓↓↓↓ ↓↓↓↓

FVCFVC NN ↓↓ ↓↓↓↓

FEV1/FEV1/FVCFVC

NN ↓↓↓↓ NN


11FEVFEV1/1/FVCFVC

TLCTLC DLCDLCOO

PimaPimaxx


↓↓↓↓ ↑↑ ↑↑ NN


↓↓↓↓ ↑↑ ↓↓↓↓ ↓↓

ILDILD ↓↓↓↓ NN ↓↓↓↓ ↓↓↓↓ NN


↓↓ NN ↓↓↓↓ NN ↓↓↓↓


↓↓ NN ↓↓↓↓ NN NN


A patient has expiratory wheezing, A patient has expiratory wheezing, shortness of breath and cough. PFTs shortness of breath and cough. PFTs show a reduced FEV1, a mildly reduced show a reduced FEV1, a mildly reduced FVC, a reduced FEV1/FVC ratio, a FVC, a reduced FEV1/FVC ratio, a reduced DLCO. The chest Xray is clear. reduced DLCO. The chest Xray is clear. Which is the most likely diagnosis:Which is the most likely diagnosis:

A) COPDA) COPDB) BronchiectesisB) BronchiectesisC) SarcoidosisC) SarcoidosisD) AsthmaD) AsthmaE) Upper airway obstructionE) Upper airway obstruction

A patient has expiratory wheezing, A patient has expiratory wheezing, shortness of breath and cough. PFTs shortness of breath and cough. PFTs show a reduced FEV1, a mildly reduced show a reduced FEV1, a mildly reduced FVC, a reduced FEV1/FVC ratio, a FVC, a reduced FEV1/FVC ratio, a reduced DLCO. The chest Xray is clear. reduced DLCO. The chest Xray is clear. Which is the most likely diagnosis:Which is the most likely diagnosis:

A) A) COPDCOPDB) BronchiectesisB) BronchiectesisC) SarcoidosisC) SarcoidosisD) AsthmaD) AsthmaE) Upper airway obstructionE) Upper airway obstruction


11FEVFEV1/1/FVCFVC

TLCTLC DLCDLCOO

PimaPimaxx


↓↓↓↓ ↑↑ ↑↑ NN


↓↓↓↓ ↑↑ ↓↓↓↓ ↓↓

ILDILD ↓↓↓↓ NN ↓↓↓↓ ↓↓↓↓ NN


↓↓ NN ↓↓↓↓ NN ↓↓↓↓


↓↓ NN ↓↓↓↓ NN NN


A clinic patient complains of dyspnea, has A clinic patient complains of dyspnea, has rales on physical examination, the FEV1 is rales on physical examination, the FEV1 is reduced, the FEV1/FVC ratio is normal, DLCO reduced, the FEV1/FVC ratio is normal, DLCO is reduced and the CXR shows a is reduced and the CXR shows a reticulonodular infiltrate. What is the most reticulonodular infiltrate. What is the most consistent diagnosis:consistent diagnosis:

A) AsthmaA) Asthma

B) EmphysemaB) Emphysema

C) Interstitial Lung DiseaseC) Interstitial Lung Disease

D) Upper Airway ObstructionD) Upper Airway Obstruction

E) Chest wall diseaseE) Chest wall disease

A clinic patient complains of dyspnea, has A clinic patient complains of dyspnea, has rales on physical examination, the FEV1 is rales on physical examination, the FEV1 is reduced, the FEV1/FVC ratio is normal, DLCO reduced, the FEV1/FVC ratio is normal, DLCO is reduced and the CXR shows a is reduced and the CXR shows a reticulonodular infiltrate. What is the most reticulonodular infiltrate. What is the most consistent diagnosis:consistent diagnosis:

A) AsthmaA) Asthma

B) EmphysemaB) Emphysema

C) C) Interstitial Lung DiseaseInterstitial Lung Disease

D) Upper Airway ObstructionD) Upper Airway Obstruction

E) Chest wall diseaseE) Chest wall disease

Summary of Summary of History/ExamHistory/Exam

DiseaseDisease SymptomsSymptoms BreathBreath

SoundsSoundsAdventitAdventitialial

SoundsSounds

AsthmaAsthma SOB with SOB with exercise, exercise, coldcold

ReduceReducedd

WheezeWheeze

COPDCOPD Sputum Sputum productioproductionn

ReduceReducedd

WheezeWheeze

ILDILD Severe Severe dyspneadyspnea

NormalNormal RalesRales


Limb Limb weaknessweakness

NormalNormal--ReduceReducedd

NoneNone


Leg Leg edemaedema

ReduceReducedd

NoneNone

NormalNormal NoneNone NormalNormal NoneNone


11FEVFEV1/1/FVCFVC

TLCTLC DLCDLCOO

PimaPimaxx


↓↓↓↓ ↑↑ ↑↑ NN


↓↓↓↓ ↑↑ ↓↓↓↓ ↓↓

ILDILD ↓↓↓↓ NN ↓↓↓↓ ↓↓↓↓ NN


↓↓ NN ↓↓↓↓ NN ↓↓↓↓


↓↓ NN ↓↓↓↓ NN NN


Summary of CXR/ABGSummary of CXR/ABG

DiseaseDisease CXRCXR PaOPaO22

Dead Dead

SpaceSpaceVeVe

AsthmaAsthma HyperinflatHyperinflateded

↓↓ ↑↑↑↑ VarVaryy

COPDCOPD HyperinflatHyperinflateded

↓↓↓↓ ↑↑↑↑↑↑ VarVaryy

ILDILD Lines/Lines/nodulesnodules

↓↓↓↓↓↓ ↑↑ VarVaryy



↓↓ NN ↓↓



↓↓ NN ↓↓

NormalNormal NormalNormal NN NN NN

You see a patient on the medical ward You see a patient on the medical ward who complains of dyspnea and difficulty who complains of dyspnea and difficulty standing. The FEV1 is reduced, the standing. The FEV1 is reduced, the FEV1/FVC is normal, the TLC is reduced, FEV1/FVC is normal, the TLC is reduced, the DLCO is normal, the CXR is clear. A the DLCO is normal, the CXR is clear. A possible diagnosis is:possible diagnosis is:

A) Interstitial lung diseaseA) Interstitial lung diseaseB) AsthmaB) AsthmaC) Respiratory muscle weaknessC) Respiratory muscle weaknessD) BronchiectesisD) BronchiectesisE) AsbestosisE) Asbestosis

You see a patient on the medical ward You see a patient on the medical ward who complains of dyspnea and difficulty who complains of dyspnea and difficulty standing. The FEV1 is reduced, the standing. The FEV1 is reduced, the FEV1/FVC is normal, the TLC is reduced, FEV1/FVC is normal, the TLC is reduced, the DLCO is normal, the CXR is clear. A the DLCO is normal, the CXR is clear. A possible diagnosis is:possible diagnosis is:

A) Interstitial lung diseaseA) Interstitial lung diseaseB) AsthmaB) AsthmaC) C) Respiratory muscle weaknessRespiratory muscle weaknessD) BronchiectesisD) BronchiectesisE) AsbestosisE) Asbestosis


11FEVFEV1/1/FVCFVC

TLCTLC DLCDLCOO

PimaPimaxx


↓↓↓↓ ↑↑ ↑↑ NN


↓↓↓↓ ↑↑ ↓↓↓↓ ↓↓

ILDILD ↓↓↓↓ NN ↓↓↓↓ ↓↓↓↓ NN


↓↓ NN ↓↓↓↓ NN ↓↓↓↓


↓↓ NN ↓↓↓↓ NN NN


A patient has been diagnosed with A patient has been diagnosed with hypersensitivity pneumonitis, a form of hypersensitivity pneumonitis, a form of interstitial lung disease. What lung volume interstitial lung disease. What lung volume measurements are likely to be present:measurements are likely to be present:

A) Reduced TLC, increased FRCA) Reduced TLC, increased FRC

B) Increased TLC, normal FRCB) Increased TLC, normal FRC

C) Reduced TLC, normal FRCC) Reduced TLC, normal FRC

D) Reduced TLC, reduced FRCD) Reduced TLC, reduced FRC

E) Increased TLC, normal FRCE) Increased TLC, normal FRC

A patient has been diagnosed with A patient has been diagnosed with hypersensitvity pneumonitis, a form of hypersensitvity pneumonitis, a form of interstitial lung disease. What lung volume interstitial lung disease. What lung volume measurements are likely to be present:measurements are likely to be present:

A) Reduced TLC, increased FRCA) Reduced TLC, increased FRC

B) Increased TLC, normal FRCB) Increased TLC, normal FRC

C) Reduced TLC, normal FRCC) Reduced TLC, normal FRC

D) D) Reduced TLC, reduced FRCReduced TLC, reduced FRC

E) Increased TLC, normal FRCE) Increased TLC, normal FRC

A patient is breathing 50% oxygen, the A patient is breathing 50% oxygen, the barometric pressure is 747, the vapor barometric pressure is 747, the vapor pressure of water is 47, the carbon dioxide pressure of water is 47, the carbon dioxide level is 40, the respiratory quotient is 0.8. level is 40, the respiratory quotient is 0.8. What is the alveolar oxygen level (PA02)?What is the alveolar oxygen level (PA02)?

A) 33A) 33B) 500B) 500C) 300C) 300D) 200D) 200E) 97E) 97

A patient is breathing 50% oxygen, the A patient is breathing 50% oxygen, the barometric pressure is 747, the vapor barometric pressure is 747, the vapor pressure of water is 47, the carbon dioxide pressure of water is 47, the carbon dioxide level is 40, the respiratory quotient is 0.8. level is 40, the respiratory quotient is 0.8. What is the alveolar oxygen level (PA02)?What is the alveolar oxygen level (PA02)?

A) 33A) 33B) 500B) 500C) C) 300300D) 200D) 200E) 97E) 97

PAOPAO22=FiO=FiO22(BP-VP)-PaCO(BP-VP)-PaCO22/R/R

PAOPAO22=.50(747-47)-40/0.8=.50(747-47)-40/0.8

PAOPAO22=.50(700)-50 = 350-50= =.50(700)-50 = 350-50= 300300

A patient presents with increased arterial carbon A patient presents with increased arterial carbon dioxide level, a history of muscle weakness, and dioxide level, a history of muscle weakness, and prior thyrotoxicosis. Which of the following tests prior thyrotoxicosis. Which of the following tests will help determine whether the current will help determine whether the current increased carbon dioxide is from muscle increased carbon dioxide is from muscle weakness or thyroid disease?weakness or thyroid disease?

A) Measurement of dead spaceA) Measurement of dead space

B) Measurement of the level of carbon dioxide B) Measurement of the level of carbon dioxide productionproduction

C) Measurement of nitrogen balanceC) Measurement of nitrogen balance

D) Measurement of alveolar-arterial gradientD) Measurement of alveolar-arterial gradient

E) A chest radiographE) A chest radiograph

A patient presents with increased arterial carbon A patient presents with increased arterial carbon dioxide level, a history of muscle weakness, and dioxide level, a history of muscle weakness, and prior thyrotoxicosis. Which of the following tests prior thyrotoxicosis. Which of the following tests will help determine whether the current will help determine whether the current increased carbon dioxide is from muscle increased carbon dioxide is from muscle weakness or thyroid disease?weakness or thyroid disease?

A) Measurement of dead spaceA) Measurement of dead space

B) B) Measurement of the level of carbon dioxide Measurement of the level of carbon dioxide productionproduction

C) Measurement of nitrogen balanceC) Measurement of nitrogen balance

D) Measurement of alveolar-arterial gradientD) Measurement of alveolar-arterial gradient

E) A chest radiographE) A chest radiograph

Causes of HypercapniaCauses of Hypercapnia

Mechanism of Mechanism of ↑CO2↑CO2

EtiologiesEtiologies


Fever, Fever, thyrotoxicosisthyrotoxicosis

Increased dead Increased dead spacespace

COPD, asthma, COPD, asthma, ILD, ARDS, ILD, ARDS, pneumoniapneumonia

Reduced Reduced ventilationventilation

Weakness, chest Weakness, chest wall disease, wall disease, fatigue, UAOfatigue, UAO

A patient presents with blue lips. An arterial A patient presents with blue lips. An arterial blood gas shows a paO2 that is 40 mm Hg. The blood gas shows a paO2 that is 40 mm Hg. The patient is placed on 100% oxygen and the patient is placed on 100% oxygen and the arterial blood gas improves to 650 mm Hg. The arterial blood gas improves to 650 mm Hg. The A-a gradient is normal. What is the likely cause A-a gradient is normal. What is the likely cause of hypoxemia in this patient?of hypoxemia in this patient?

A) Diffusion blockA) Diffusion blockB) Ventilaton-perfusion mismatchB) Ventilaton-perfusion mismatchC) ShuntC) ShuntD) HypoventilationD) HypoventilationE) Elevated dead space E) Elevated dead space

DDX of HypoxemiaDDX of Hypoxemia

A-a GradientA-a Gradient Response to Response to 100% 100% OxygenOxygen

Diffusion Diffusion blockblock

↑↑ ↑↑↑↑

V/Q V/Q mismatchmismatch

↑↑↑↑ ↑↑↑↑

ShuntShunt ↑↑↑↑ Poor Poor responseresponse

HypoventilatHypoventilationion

NormalNormal ↑↑↑↑

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

Documents

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