Introduction to
Pulmonary Medicine
Dr. Gerald Supinski
Professor of Medicine and Physiology
Topics to Cover
Classification of
Pulmonary Disorders
 History
 Physical Examination
 PFT
 CXR
 ABG
 Cases

Classification of Pulmonary Disorders
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)
History: Other Symptoms







Cough
Fever
Sputum production
Nocturnal awakening
Chest pain
Weakness
Leg swelling
Physical Examination


Percussion
Auscultation
Percussion

Original use for wine casks:
Effect of Altering Media Density
Percussion Responses
Condition
Response
Normal Lung
Normal Percussion
Pneumothorax
Emphysema
Increased Percussion
“Hyperresonance”
Effusion
Consolidated Lung
Reduced Percussion
“Hyporesonance”
Auscultation

Breath Sounds
Bronchovesicular, Bronchial, Reduced Sounds

Adventitial Sounds
Rales, Wheezes, Rhonchi
Breath Sound Characteristics


Frequency of sounds (pitch)
Intensity or loudness of sounds
Breath Sound Classes
Bronchovesicular
Sounds
Normal
Bronchial Breath
Sounds
Consolidation around
an open airway
Reduced Breath
Sounds
Emphysema,
Asthma
Adventitial Sounds
Rales
End Inspiratory “Cellophane”
See in CHF, ILD, pneumonia
Wheezes
Can be either inspiratory (UAO)
or expiratory (asthma, COPD)
Rhonchi
Non specific
Summary of History/Exam
Disease
Symptoms
Asthma
SOB with
exercise, cold
COPD
Sputum
production
ILD
Severe
dyspnea
RM Weakness
Limb
weakness
Chest Wall Abn. Leg edema
Normal
None
Breath
Sounds
Reduced
Adventitial
Sounds
Wheeze
Reduced
Wheeze
Normal
Rales
NormalReduced
Reduced
None
Normal
None
None
PFTs




Determine if normal or abnormal
Classify as restrictive or obstructive
Determine severity
Correlate with history, physical, CXR
PFT Classification
Standard PFTs





Spirometry
Flow-Volume Loops
Lung Volumes
DLCO
Pimax, Pemax
Spirometry
Obstructed vs Restricted
DDX of Spirometry
Normal
Obstruction Restriction
FEV1
N
↓↓↓
↓↓
FVC
N
↓
↓↓
↓↓
N
FEV1/FVC N
Reversibility
Lung Volumes
Lung Volumes Components
Lung Volume Components
DLCO



Diffusion capacity for carbon dioxide
A measure of gas exchange
Patient breathes a small amount of CO and
uptake determined
Concept of DLCO
DDX of DLCO
DLCO
Condition
Normal
Normals, Muscle
disease, Chest wall
disease
COPD, ILD, Sarcoidosis,
Pneumonia
Reduced
Increased
Asthma
Pimax and Pemax



Pimax measures inspiratory strength
Pemax measures expiratory strength
Patient inhales/exhales thru mouthpiece
attached to transducer
Respiratory Muscle Strength
Summary of PFTs
Disease
DLCO Pimax
Asthma
FEV1 FEV1 TLC
/FVC
↓↓↓
↓↓
↑
↑
N
COPD
↓↓↓
↓↓
↑
↓↓
↓
ILD
↓↓
N
↓↓
↓↓
N
RM
Weakness
Chest Wall
Abn.
Normal
↓
N
↓↓
N
↓↓
↓
N
↓↓
N
N
N
N
N
N
N
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
Arterial Blood Gases
pH
 paCO2
 paO2
 FiO2

Mechanisms of Hypoxemia




Diffusion block
V/Q mismatch
Shunt
Hypoventilation
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
Increases in Inspired Oxygen Concentrations
Do Not Substantially Improve paO2 in
the Presence of Substantial Shunt
DDX of Hypoxemia
A-a Gradient
Diffusion block
↑
Response to
100% Oxygen
↑↑
V/Q mismatch
↑↑
↑↑
Shunt
↑↑
Poor response
Hypoventilation Normal
↑↑
Mechanisms of Hypercapnia



Increased CO2 production
Reduced minute ventilation
Increased dead space
Dead Space
Mathematical Relationships

The following equation determines paCO2:
paCO2 =
VCO2 (k)
VE-VD
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
Summary of CXR/ABG
Disease
CXR
PaO2
Ve
↓
Dead
Space
↑
Asthma
Hyperinflated
COPD
Hyperinflated
↓↓
↑↑↑
Vary
ILD
Lines/nodules ↓↓↓
↑
Vary
Vary
RM Weakness Clear, small
↓
N
↓
Chest Wall
Abn.
Normal
Clear, small
↓
N
↓
Normal
N
N
N

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

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

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

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
Normal
Obstruction Restriction
FEV1
N
↓↓↓
↓↓
FVC
N
↓
↓↓
↓↓
N
FEV1/FVC N
Summary of PFTs
Disease
DLCO Pimax
Asthma
FEV1 FEV1 TLC
/FVC
↓↓↓
↓↓
↑
↑
N
COPD
↓↓↓
↓↓
↑
↓↓
↓
ILD
↓↓
N
↓↓
↓↓
N
RM
Weakness
Chest Wall
Abn.
Normal
↓
N
↓↓
N
↓↓
↓
N
↓↓
N
N
N
N
N
N
N

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

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
Summary of PFTs
Disease
DLCO Pimax
Asthma
FEV1 FEV1 TLC
/FVC
↓↓↓
↓↓
↑
↑
N
COPD
↓↓↓
↓↓
↑
↓↓
↓
ILD
↓↓
N
↓↓
↓↓
N
RM
Weakness
Chest Wall
Abn.
Normal
↓
N
↓↓
N
↓↓
↓
N
↓↓
N
N
N
N
N
N
N

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

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
Summary of History/Exam
Disease
Symptoms
Asthma
SOB with
exercise, cold
COPD
Sputum
production
ILD
Severe
dyspnea
RM Weakness
Limb
weakness
Chest Wall Abn. Leg edema
Normal
None
Breath
Sounds
Reduced
Adventitial
Sounds
Wheeze
Reduced
Wheeze
Normal
Rales
NormalReduced
Reduced
None
Normal
None
None
Summary of PFTs
Disease
DLCO Pimax
Asthma
FEV1 FEV1 TLC
/FVC
↓↓↓
↓↓
↑
↑
N
COPD
↓↓↓
↓↓
↑
↓↓
↓
ILD
↓↓
N
↓↓
↓↓
N
RM
Weakness
Chest Wall
Abn.
Normal
↓
N
↓↓
N
↓↓
↓
N
↓↓
N
N
N
N
N
N
N
Summary of CXR/ABG
Disease
CXR
PaO2
Ve
↓
Dead
Space
↑↑
Asthma
Hyperinflated
COPD
Hyperinflated
↓↓
↑↑↑
Vary
ILD
Lines/nodules ↓↓↓
↑
Vary
Vary
RM Weakness Clear, small
↓
N
↓
Chest Wall
Abn.
Normal
Clear, small
↓
N
↓
Normal
N
N
N

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

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
Summary of PFTs
Disease
DLCO Pimax
Asthma
FEV1 FEV1 TLC
/FVC
↓↓↓
↓↓
↑
↑
N
COPD
↓↓↓
↓↓
↑
↓↓
↓
ILD
↓↓
N
↓↓
↓↓
N
RM
Weakness
Chest Wall
Abn.
Normal
↓
N
↓↓
N
↓↓
↓
N
↓↓
N
N
N
N
N
N
N

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

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

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

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
PAO2=FiO2(BP-VP)-PaCO2/R
PAO2=.50(747-47)-40/0.8
PAO2=.50(700)-50 = 350-50= 300

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

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
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

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

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
DDX of Hypoxemia
A-a Gradient
Diffusion block
↑
Response to
100% Oxygen
↑↑
V/Q mismatch
↑↑
↑↑
Shunt
↑↑
Poor response
Hypoventilation Normal
↑↑