pulmonary diagnostics pft and cxr small group cases 2014
TRANSCRIPT
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Pulmonary Diagnostics Case Tutorials
Cases and Notes Compiled by James Allen MD
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IRV
Vt
ERVRV
FRC
TLC
VC
Derivation of the lung volumes
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4 Questions Of PFT Interpretation
1. Is the patient obstructed?• Is FEV1/FVC reduced? (use 75% as cut-off)
2. If obstructed, is obstruction reversible?• Use 12% improvement in FEV1 OR FVC
3. Is the patient restricted?• Is the TLC reduced? (use 80% as cut-off)
4. Is the diffusing capacity reduced?• DLCO vs. DLCO/VA
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Case #1: History
• 60 year old man with a 60 pack/year smoking history and dyspnea on exertion.
• PO2 = 56; PCO2 = 44.
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Case #1: PFTs
• FVC 3.1 L (73%)– After albuterol 3.3 L
• FEV1 0.7 L (23%)– After albuterol 0.8 L
• FEV1/FVC 25%• TLC 9.7 L (150%)• DLCO/VA 0.9 (19%)
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Case #2: History
• 50 year old man with a 65 pack/year smoking history and a cough.
• His chest x-ray shows a diffuse reticulonodular pattern
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Case #2: PFTs
• FVC 1.9 L (62%)• FEV1 1.1 L (42%)• FEV1/FVC 56%• TLC 3.0 L (64%)• DLCO/VA 1.5 (19%)
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Case #3: History
• 36 year old man with muscular dystrophy. He is presently wheelchair bound
• PO2 = 60; PCO2 = 52.
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Case #3: PFTs
• FVC 1.2 L (31%)• FEV1 1.0 L (33%)• FEV1/FVC 85%• TLC 2.7 L (50%)• DLCO/VA 7.2 (104%)
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Case #4: History
• 17 year old girl with cerebral palsy and severe kyphoscoliosis referred for pre-op evaluation.
• PO2 = 62; PCO2 = 48.
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Case #4: PFTs
• FVC 1.1 L (36%)• FEV1 0.8 L (29%)• FEV1/FVC 78%• TLC 2.1 L (54%)• DLCO/VA 7.0 (120%)
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Case #5: History
• 22 year old woman with dyspnea on exertion. She also notes dyspnea when exposed to cats.
• Physical exam: wheezing.
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Case #5: PFTs
• FVC 2.9 L (83%)• FEV1 1.8 L (60%)• FEF 25-75 0.9 LPS (23%)• FEV1/FVC 61%• TLC 4.9 L (104%)• DLCO/VA 6.8 (122%)
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Case #6: History
• 43 year old woman with progressive dyspnea on exertion.
• Chest x-ray shows bilateral reticular infiltrates, especially in the lung bases.
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Case #6: PFTs
• FVC 1.7 L (51%)• FEV1 1.4 L (49%)• FEF 25-75 1.3 LPS (35%)• FEV1/FVC 78%• TLC 2.7 L (52%)• DLCO/VA 2.6 (51%)
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Case #7: History
• 30 year old non-smoking man with a chronic cough.
• PO2 = 94; PCO2 = 32.
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Case #7: PFTs
• FVC 3.4 L (86%)• FEV1 2.5 L (81%)• FEF 25-75 1.3 LPS (34%)• FEV1/FVC 75%• TLC 6.1 L (97%)• DLCO/VA 4.6 (98%)
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Case #8: History
• 55 year old woman with dyspnea on exertion.
• Chest x-ray is normal. • PO2 is 48 (room air). • Physiologic shunt is 18% (calculated while
breathing 100% FiO2).• Physical exam: cutaneous spider angiomas.
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Spider angioma
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Spider angioma
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Case #8: PFTs
• FVC 3.5 L (95%)• FEV1 2.8 L (95%)• FEF 25-75 2.0 LPS (55%)• FEV1/FVC 80%• TLC 6.3 L (99%)• DLCO/VA 1.9 (44%)
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Case #9: History
• 26 year old man with acute lymphocytic leukemia treated with stem cell transplant 1 year ago; now with dyspnea on exertion
• He received chest irradiation prior to stem cell transplantation
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Case #9: PFTs
• FVC 2.8 L (59%)• FEV1 2.5 L (65%)• FEF 25-75 2.9 LPS (67%)• FEV1/FVC 88%• TLC 4.9 L (78%)• DLCO/VA 3.3 (60%)
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Case #10: History
• 55 year old music professor with cough and dyspnea. He has used a bronchodilator inhaler in the past with transient relief
• On physical examination, he is wheezing
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Case #10: PFTs
• Spirometry:– FVC 2.22 L (63%)– FEV1 1.12 L (40%)– FEV1/FVC 50%
• Diffusing Capacity:– DLCO 25.6 (97%)– VA 4.52 L (82%)– DLCO/VA 118%
• Lung Volumes:– SVC 2.73 (78%)– ERV 0.42 (42%)– FRC 3.30 (116%)– RV 2.88 (157%)– TLC 5.61 (100%)
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Case #11: History
• 45 year old man with increasing dyspnea for 2 years. He drives a delivery truck and is no longer able to carry boxes from the truck to stores.
• Smokes 2 packs/day for 20 years • Exam: prolonged expiratory phase with
globally diminished breath sounds
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Case #11: PFTs
• Spirometry:– FVC 3.58 L (77%)– FEV1 1.03 L (28%)– FEV1/FVC 29%
• Diffusing Capacity:– DLCO 18.9 (56%)– VA 6.35 L (95%)– DLCO/VA 59%
• Lung Volumes:– SVC 3.80 (82%)– ERV 1.23 (70%)– FRC 5.24 (138%)– RV 4.03 (197%)– TLC 7.83 (117%)
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A
CB
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A
B
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AA
B
C
D
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A
C
B
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A
CB
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AB
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A B
C
D
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ABCD
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LA
RVLV
RA
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LA
RV
LV
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RUL
RMLRLL
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LUL
LLL
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A
B
C
Right Left
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A
BC
D
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A
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Left pulmonary artery sits higher
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B
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A
C
B