Pulmonary Board Review
SEEK
Mark J. Rosen, MD, Master FCCP
Medical Director, CHEST
Clinical Professor of Medicine
Hofstra North Shore-LIJ School of Medicine
© 2014 American College of Chest Physicians
QUESTION
1
A 63-year-old woman is admitted with fever, cough
and shortness of breath. The pulse is 132/minute,
the blood pressure 80/60, and the respirations 32/
minute. There are crackles throughout the right
posterior lower chest, and a radiograph confirms
the presence of right lower lobe consolidation.
VOLUME
17,
QUESTION
1
© 2014 American College of Chest Physicians
QUESTION
1
The following laboratory studies are reported:
pH 7.44
PaCO2 24 mm Hg
PaO2 (room air) 60 mm Hg
Sodium 140 mEq/L
Potassium 4 mEq/L
Chloride 100 mEq/L
Bicarbonate 16 mEq/L
VOLUME
17,
QUESTION
1
© 2014 American College of Chest Physicians
QUESTION
1
What is the correct interpretation of this acid-
base disorder?
A. Inconsistent and uninterpretable
B. Respiratory alkalosis with anion gap
metabolic acidosis
C. Respiratory alkalosis, anion gap
metabolic acidosis, metabolic alkalosis
D. Anion gap metabolic acidosis and
appropriate respiratory compensation
© 2014 American College of Chest Physicians
QUESTION
1
The following laboratory studies are reported:
pH 7.44
PaCO2 24 mm Hg
PaO2 (room air) 60 mm Hg
Sodium 140 mEq/L
Potassium 4 mEq/L
Chloride 100 mEq/L
Bicarbonate 16 mEq/L
VOLUME
17,
QUESTION
1
© 2014 American College of Chest Physicians
Modified Henderson-Hasselbach Equation
[H+] = 24 PaCO2
HCO3
36 = 24 x 24
16
Data consistent and
interpretable
© 2014 American College of Chest Physicians
Calculate Anion Gap
AG = Na – (Cl + HCO3)
= 140 – (100 + 16)
= 24
Normal AG = 12 ± 4
Therefore, patient has anion gap
metabolic acidosis
© 2014 American College of Chest Physicians
Calculate “Delta Gap”
• Each mEq increase in acid is buffered
by one mEq fall in HCO3-
• Δ gap = (AG – 12) – (24 – HCO3)
• Normal Δ gap = 0 ± 6
• This patient:
Δ gap = (24–12) – (24-16) = 4
• Therefore, no mixed acid-base disorder
© 2014 American College of Chest Physicians
Respiratory Compensation for Metabolic Acidosis
PaCO2 = (1.5 x HCO3) + 8 ± 2
Patient = (1.5 x 16) + 8 ± 2
= 24+ 8 ± 2 = 32 ± 2
24 is not ~ 32 ±
Respiratory alkalosis
© 2014 American College of Chest Physicians
Respiratory Compensation for Metabolic Acidosis
Hard way:
PaCO2 = (1.5 x HCO3) + 8 ± 2
Easy way:
Last two digits of pH ~ PaCO2
pH=7.44 PaCO2=24
Respiratory alkalosis
© 2014 American College of Chest Physicians
QUESTION
2
A 62 year-old white woman is referred to you
because of chronic productive cough and an
abnormal chest radiograph. She was in good
health until around six years ago, when she
developed the first episode of productive cough,
followed by recurrent exacerbations. She has
chronic fatigue and a 6-kg weight loss. The
cough usually subsides spontaneously, but also
seems to improve with oral antibiotics.
VOLUME
17,
QUESTION
100
© 2014 American College of Chest Physicians
QUESTION
2
• Past medical history is unremarkable.
• Never smoked, no family history lung
disease
Physical examination
• Thin, no acute distress, vital signs
normal.
• Chest - bilateral inspiratory “squeaks”
• Mild scoliosis and pectus excavatum
VOLUME
17,
QUESTION
100
© 2014 American College of Chest Physicians
© 2014 American College of Chest Physicians
© 2014 American College of Chest Physicians
QUESTION
2
Which of the following treatments is most
likely to be effective in this patient’s long-
term management?
A. Chest physical therapy and postural
drainage
B. Azithromycin, 250 mg daily indefinitely
C. Azithromycin, ethambutol and rifampin
D. Inhaled tobramycin
© 2014 American College of Chest Physicians
Mycobacterium avium
complex (MAC) disease
• Postmenopausal
• Chronic productive
cough
• Non-smoker
• Weight loss
• Nodules, bronchiectasis
• Pectus excavatum,
scoliosis, mitral valve
prolapse
© 2014 American College of Chest Physicians
© 2014 American College of Chest Physicians
© 2014 American College of Chest Physicians
MAC
Diagnosis
• 3 positive cultures with - smears
• 2 positive cultures and a + smear
• + culture of bronchial wash and >2+ growth or +
smear
• + culture of bronchoscopic biopsy
• Granuloma and/or + AFB smear with + culture
• Growth from sterile extrapulmonary site
Griffith DE, et al. AJRCCM 2007;175:367- 416 © 2014 American College of Chest Physicians
MAC
Treatment
• Thrice-weekly clarithromycin or
azithromycin, ethambutol and rifampin
• Equivalent outcomes fewer side effects
than daily
Griffith DE, et al. AJRCCM 2007;175:367-416 © 2014 American College of Chest Physicians
QUESTION
3
You evaluate a 69-year-old man with a chief
complaint of dyspnea on exertion. He has a 60-
pack-year history of cigarette smoking, but stopped
four years ago. He has well-controlled
hypertension and diabetes, mild cough and sputum
production, and cannot walk more than three
blocks without stopping due to dyspnea. Current
medications: salmeterol, ipratropium, enalapril,
hydrochlorthiazide, and glipizide.
VOLUME
17,
QUESTION
51
© 2014 American College of Chest Physicians
QUESTION
3
Height: 172 cm (68”)
Weight: 87 kg (191 lbs)
FEV1 and FEV1/FVC both 70% predicted
MVV 75 L/min
You perform a CPET to determine the cause or
causes of exercise limitation. The test was stopped
when the patient developed intolerable dyspnea.
The results are as follows:
VOLUME
17,
QUESTION
51
© 2014 American College of Chest Physicians
Parameter Predicted Measured (%)
VO2 peak 2.00 1.20 (60%)
HR max (/min) 151 145 (90%)
HR reserve 0 +/- 15/min 6/min
O2 pulse (ml/b) 125 8.3 (66%)
Anaerobic 1.13 (LLN 0.91) 0.72
threshold
BP (rest, max) 140/80, 210/110 125/78,165/80
© 2014 American College of Chest Physicians
Parameter Predicted Measured
VE/MVV (calc) 0.72 0.66
(vent reserve)
ABG (rest) 7.42/42/71
ABG (max ex) 7.33/34/68
VD/VT (rest, max) 0.30, 0.18 0.45, 0.30
© 2014 American College of Chest Physicians
Ques7on
3
© 2014 American College of Chest Physicians
The principal cause of this patient’s exercise
limitation is:
A. COPD
B. Peripheral vascular disease
C. Obesity
D. Cardiomyopathy
E. Pulmonary vascular disease
© 2014 American College of Chest Physicians
CPET INTERPRETATION
Sequential Questions
• Is exercise • VO2 max
capacity normal? • Work rate max
• Is cardiovascular • HR v. VO2 graph
function normal? • O2
pulse
• AT
• VO2
v.
work
rate
© 2014 American College of Chest Physicians
CPET INTERPRETATION
Sequential Questions
• Is ventilatory • VE/ MVV, MVV-VE
function normal? RR max, VT/VC
• Is gas exchange • VD/VT, VE/VCO2
normal? • PaO2, D(A-a)O2
© 2014 American College of Chest Physicians
Parameter Predicted Measured (%)
VO2 peak 2.00 1.20 (60%)
HR max (b/min) 151 145 (90%)
HR reserve 0+/-15/min 6/min
O2 pulse (ml/b) 125 8.3 (66%)
Anaerobic 1.13 (lower limit 0.72
threshold 0.91)
BP (rest, max) 140/80, 210/110 125/78, 165/80
© 2014 American College of Chest Physicians
CPET
Cardiomyopathy
§ ↓ VO2 max
§ No heart rate reserve
§ Chronotropic incompetence or beta
blockers may be misleading
§ Steep HR slope
§ ↓ AT
§ Increased ventilatory reserve
§ Gas exchange normal, or abnormal VD/VT
© 2014 American College of Chest Physicians
CPET
Cardiomyopathy
© 2014 American College of Chest Physicians
CPET
COPD
§ ↓ VO2 max
§ Increased heart rate reserve
§ AT normal or indeterminate
§ Ventilatory limitation
§ Gas exchange abnormal
© 2014 American College of Chest Physicians
CPET
Interstitial Lung Disease
§ ↓ VO2 max
§ Increased heart rate reserve
§ AT normal or reduced
§ Ventilatory limitation present
§ High maximum RR
§ Gas exchange abnormal
© 2014 American College of Chest Physicians
CPET
Pulmonary Vascular
§ ↓ VO2 max
§ No heart rate reserve
§ Steep HR slope
§ AT reduced
§ High VE present, but no ventilatory
limitation
§ VD/VT unchanged or increases with
exercise
© 2014 American College of Chest Physicians
CPET
Poor effort, malingering
§ ↓ VO2 max
§ Increased heart rate reserve
§ AT normal
§ Increased ventilatory reserve
§ Gas exchange normal
© 2014 American College of Chest Physicians
Question 4
A 65-year-old man has progressive
shortness of breath for the three years.
History of childhood asthma, stopped
smoking ten years ago. His physical
examination is normal except for obesity
(BMI 31.2 kg/m2 ). SpO2 96% breathing
room air, and the chest radiograph was
normal.
VOLUME
17,
QUESTION
135
© 2014 American College of Chest Physicians
% pred
FVC (L) 1.28 40
FEV1 (L) 0.95 37
FEV1/FVC 0.74
TLC (L) 3.66 68
SVC (L) 1.34 42
ERV (L) 0.09 15
RV (L) 2.11 110
DLCO 17.4 74
© 2014 American College of Chest Physicians
These pulmonary function tests are most
consistent with which of the following?
A. Interstitial lung disease
B. Obesity
C. Neuromuscular disease
D. Constrictive bronchiolitis
© 2014 American College of Chest Physicians
% pred
FVC (L) 1.28 40
FEV1 (L) 0.95 37
FEV1/FVC 0.74
TLC (L) 3.66 68
SVC (L) 1.34 42
ERV (L) 0.09 19
RV (L) 2.11 110
DLCO 17.4 74
© 2014 American College of Chest Physicians
Pulmonary Function Tests
Neuromuscular Disease
• Reduced FVC and FEV1
• Normal FEV1/FVC
• Reduced TLC: Can’t inhale
• Reduced ERV, normal or increased RV: can’t
exhale
• Poor effort: won’t inhale or exhale, but not
reproducible
© 2014 American College of Chest Physicians
% pred
FVC (L) 1.28 40
FEV1 (L) 0.95 37
FEV1/FVC 0.74
TLC (L) 3.66 68
SVC (L) 1.34 42
ERV (L) 0.09 15
RV (L) 2.11 110
DLCO 17.4 74
© 2014 American College of Chest Physicians
Ques7on
5
A
46-‐year-‐old
man
has
4
months
of
increasing
cough.
§ HIV
infec7on,
CD4+
lymphocyte
count
240
cells/
mm3
(0.24
x
109/L),
stable
for
several
years
§ Smokes
2
packs
of
cigareYes
daily
§ Stopped
using
IV
drugs
10
years
ago.
§ No
fever,
chills,
and
night
sweats
§ Lost
18
lb
(8
kg)
since
the
onset
of
this
illness.
VOLUME
17,
QUESTION
84
© 2014 American College of Chest Physicians
Ques7on
5
VOLUME
17,
QUESTION
84
© 2014 American College of Chest Physicians
Ques7on
5
© 2014 American College of Chest Physicians
Ques7on
5
What
is
the
most
likely
diagnosis?
A. Pneumocys,s
jiroveci
pneumonia
B. Kaposi
sarcoma.
C. Aspergillosis.
D. Adenocarcinoma.
VOLUME
17,
QUESTION
84
© 2014 American College of Chest Physicians
Ques7on
6
A 78 year old woman with a history of
emphysema and lung cancer is brought to the
ED with severe shortness of breath. She is
promptly intubated and started on mechanical
ventilation. Once receiving mechanical
ventilation, her pulse was 100/min, blood
pressure 90/60 mm Hg and oxygen saturation
measured by pulse oximetry at 96%.
VOLUME
17,
QUESTION
84
© 2014 American College of Chest Physicians
Ques7on
6
A few minutes later, the pulse was
140/min, the blood pressure 60/40
mm Hg and the oxygen saturation
80%. She has reduced breath
sounds bilaterally, and suctioning
reveals scant secretions.
© 2014 American College of Chest Physicians
© 2014 American College of Chest Physicians
Which is the most appropriate intervention
at this time?
A. Start norepinephrine infusion
B. Infuse normal saline, 500 ml over 15 minutes
C. Adjust the position of the endotracheal tube
D. Perform flexible bronchoscopy with directed
suctioning
E. Insert a chest tube
© 2014 American College of Chest Physicians
© 2014 American College of Chest Physicians
© 2014 American College of Chest Physicians
Tension Pneumothorax
• Intrathoracic positive pressure builds to
the point of hemodynamic compromise
• Unlikely in patients who breathe
spontaneously
• Usually occurs in patients receiving
mechanical or bag-mask ventilation
© 2014 American College of Chest Physicians
© 2014 American College of Chest Physicians
Ques7on
7
A. Patient in the supine position and the transducer
positioned posteriolaterally.
The image shows which of the following?
A. Pneumothorax
B. Pleural Effusion
C. Normal lung with fluid in the minor fissure
D. Ascites
VOLUME
21
QUESTION
15
14-30
© 2014 American College of Chest Physicians
© 2014 American College of Chest Physicians
Lung
Diaphragm
© 2014 American College of Chest Physicians
