pulmonary diagnostics pft and cxr small group cases 2014
TRANSCRIPT
Pulmonary Diagnostics Case Tutorials
Cases and Notes Compiled by James Allen MD
IRV
Vt
ERVRV
FRC
TLC
VC
Derivation of the lung volumes
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
Case #1: History
• 60 year old man with a 60 pack/year smoking history and dyspnea on exertion.
• PO2 = 56; PCO2 = 44.
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%)
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
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%)
Case #3: History
• 36 year old man with muscular dystrophy. He is presently wheelchair bound
• PO2 = 60; PCO2 = 52.
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%)
Case #4: History
• 17 year old girl with cerebral palsy and severe kyphoscoliosis referred for pre-op evaluation.
• PO2 = 62; PCO2 = 48.
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%)
Case #5: History
• 22 year old woman with dyspnea on exertion. She also notes dyspnea when exposed to cats.
• Physical exam: wheezing.
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%)
Case #6: History
• 43 year old woman with progressive dyspnea on exertion.
• Chest x-ray shows bilateral reticular infiltrates, especially in the lung bases.
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%)
Case #7: History
• 30 year old non-smoking man with a chronic cough.
• PO2 = 94; PCO2 = 32.
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%)
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.
Spider angioma
Spider angioma
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%)
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
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%)
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
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%)
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
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%)
A
CB
A
B
AA
B
C
D
A
C
B
A
CB
AB
A B
C
D
ABCD
LA
RVLV
RA
LA
RV
LV
RUL
RMLRLL
LUL
LLL
A
B
C
Right Left
A
BC
D
A
Left pulmonary artery sits higher
B
A
C
B