Pulmonary Diagnostics Case Tutorials

Cases and Notes Compiled by James Allen MD

Derivation of the lung volumes

IRV

VC

Vt ERV FRC

TLC

RV

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

Is the TLC reduced? (use 80% as cut-off) DLCO vs. DLCO/VA

3. Is the patient restricted?

4. Is the diffusing capacity reduced?

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
After albuterol

3.1 L
3.3 L

(73%)
(23%)

FEV1
After albuterol

0.7 L
0.8 L

FEV1/FVC TLC DLCO/VA

25% 9.7 L 0.9

(150%) (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 FEV1 FEV1/FVC TLC DLCO/VA 1.9 L 1.1 L 56% 3.0 L 1.5 (62%) (42%)
(64%) (19%)

Case #3: History

36 year old man with muscular dystrophy. He is presently wheelchair bound PO2 = 60; PCO2 = 52.

Case #3: PFTs

FVC FEV1 FEV1/FVC TLC DLCO/VA 1.2 L 1.0 L 85% 2.7 L 7.2 (31%) (33%)
(50%) (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 FEV1 FEV1/FVC TLC DLCO/VA 1.1 L 0.8 L 78% 2.1 L 7.0 (36%) (29%)
(54%) (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 FEV1 FEF 25-75 FEV1/FVC TLC DLCO/VA 2.9 L 1.8 L 0.9 LPS 61% 4.9 L 6.8 (83%) (60%) (23%)
(104%) (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 FEV1 FEF 25-75 FEV1/FVC TLC DLCO/VA 1.7 L 1.4 L 1.3 LPS 78% 2.7 L 2.6 (51%) (49%) (35%)
(52%) (51%)

Case #7: History

30 year old non-smoking man with a chronic cough. PO2 = 94; PCO2 = 32.

Case #7: PFTs

FVC FEV1 FEF 25-75 FEV1/FVC TLC DLCO/VA 3.4 L 2.5 L 1.3 LPS 75% 6.1 L 4.6 (86%) (81%) (34%)
(97%) (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 FEV1 FEF 25-75 FEV1/FVC TLC DLCO/VA 3.5 L 2.8 L 2.0 LPS 80% 6.3 L 1.9 (95%) (95%) (55%)
(99%) (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 FEV1 FEF 25-75 FEV1/FVC TLC DLCO/VA 2.8 L 2.5 L 2.9 LPS 88% 4.9 L 3.3 (59%) (65%) (67%)
(78%) (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%

Lung Volumes:
SVC ERV FRC RV TLC 2.73 (78%) 0.42 (42%) 3.30 (116%) 2.88 (157%) 5.61 (100%)

Diffusing Capacity:
DLCO 25.6 (97%) VA 4.52 L (82%) DLCO/VA 118%

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%

Lung Volumes:
SVC ERV FRC RV TLC 3.80 (82%) 1.23 (70%) 5.24 (138%) 4.03 (197%) 7.83 (117%)

Diffusing Capacity:
DLCO 18.9 (56%) VA 6.35 L (95%) DLCO/VA 59%

A A

D B

B A

B C

B A

C
A B

D
A

C B

RA

LA LV

RV

RV
LA LV

RUL

RML RLL

LUL

LLL

Right

Left

D A

Left pulmonary artery sits higher