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Pulmonary Medicine
Basic science
Anatomy &
Development
Physiology
Pharmacology
Pathology &
Inflammation
Defense mechanism
Clinical science
Infection
Obstructive lung
Neoplasm
Pulmonary circulation
Infiltrative & Interstitial
lung
Environment and
Occupation
Pleura
Mediastinum
Control of breathing
Respiratory failure
Extrapulmonary disorders
CRITICAL
Multiple
organ failure
DEATH
Carbon dioxide
Defense mechanisms :
humidify & cool or warm inspired air
alveolar macrophage
secretory immunoglobulin
ciliary escalator : particle 2-10 m
Metabolic and endocrine functions :
surfactant, fibrinolytic system
synthesize prostaglandin, histamine
activate angiotensin I to angiotensin II
Physical examination
History taking
Symptoms
Past medical history
Cough and expectoration Personal habits
including smoking
Hemoptysis
Residence and
Chest pain
travel history
Dyspnea
Family history
Others:
Occupational history
Hoarseness
Systemic inquiry
Fever
Confusion, irrationality and coma
Halitosis
Smoking history
The leading cause of preventable death
Active smoker:
Current-, Ex-, Nonsmoker
Passive smoker (ETS)
Pack-year
= (pack/day) x (year)
Pack = cigarettes/20
Smoking cessation
Major and immediate health benefits for men
and women of all ages
Therapy: Behavioral skill Drug (nicotine
replacement therapy, bupropion, varenicline)
5 A: Ask, Advice, Assess, Assist, Arrange
5 R: Relevance, Risk, Reward, Roadblock,
Repetition
Abstinence rate at 12 months = 20-40%
(Inspection)
(Palpation)
(Percussion)
(Auscultation)
( vital signs)
Spirometry
Arterial blood gases analysis
Spirometry
Spirometer
Spirogram
pneumothorax
uncontrolled
hypertension, shock, recent myocardial infarction
Aneurysm
IC
Arterial puncture
: radial, brachial, femoral artery
radial artery : collateral
circulation ulnar artery Allen test (
radial ulnar artery
ulnar artery collateral circulation ulnar artery
6 )
radial artery
hyperextension
alcohol povidone-iodine
radial artery ()
1% xylocaine
radial pulse
2 1 .
syringe 1 mL heparin
(23-25) , radial artery
60-90o
syringe 0.5 mL
5
syringe , syringe,
heparin syringe, (
)
7.35-7.45
80-100 mmHg
35-45 mmHg
> 95%
22-26 mEq/L
-2 to +2
PaO2
Reflect the adequacy of the
transfer of oxygen from ambient
air to blood
Normal range 85-100 mmHg and
decrease slightly with age, posture
Low pH
high PaCO2
high temperature
high 2,3 DPG
PaCO2
Inversely proportional to alveolar ventilation :
PaCO2 = K V CO2
VA
Normal range 35-45 mmHg, not affected by age
PaCO2 < 35 mmHg : alveolar hyperventilation,
PaCO2 > 45 mmHg : alveolar hypoventilation
Cause of hypercapnia
Hypoventilation
Severe V/Q mismatch
pH
Normal range 7.35-7.45
pH < 7.35 : acidosis , pH > 7.45 : alkalosis
Henderson-Hasselbach equation
pH = pK + log HCO3
0.03 PaCO2
Respiratory alteration : elimination of CO2
Metabolic alteration : rapidly compensated for by
alternating CO2 eliminated by ventilation, followed by
slower elimination by kidneys of excess acid or base
Respiratory acidosis : low pH, high PaCO2
Respiratory alkalosis : high pH, low PaCO2
Metabolic acidosis : low pH, low HCO3
Metabolic alkalosis : high pH, high HCO3
ABGs
PaO2 hypoxemia
ABGs (2)
PaCO2 > 45 mmHg : hypoventilation
PaCO2 < 35 mmHg : hyperventilation
-
pH PaCO2 : ventilatory cause
pH < 7.35 , PaCO2 > 45 : respiratory
acidosis
pH > 7.45 , PaCO2 < 35 : respiratory
alkalosis
ABGs (3)
PaCO2 HCO3
PaCO2
(mmHg)
+ 10
HCO3
(mEq/L)
+1
+ 10
+4
- 10
-2
- 10
-5
ABGs (4)
pH HCO3 : metabolic cause
pH < 7.35 , HCO3 : metabolic acidosis
pH > 7.45 , HCO3 : metabolic alkalosis
HCO3 PaCO2
Metabolic acidosis : predicted PaCO2 =
(1.5 x HCO3) + 8 + 2
Metabolic alkalosis : predicted PaCO2 =
(0.7 x HCO3) + 20 + 2
pH
< 7.35
PaCO2
> 7.45
HCO3
Metabolic
acidosis
Respiratory acidosis
Acute
Chronic
PaCO2
HCO3
Metabolic
alkalosis
Respiratory alkalosis
Acute
Chronic
Acceptable spirogram
Is FEV1/FVC ratio low?
Yes
No
Is FVC low?
Obstructive defect
Yes
Is FVC low?
Yes
No
No
Restrictive defect
Pure obstruction
Normal
Hyperinflation
VS combined defect Reversible with beta agonist spirometry
results
Yes
No
Further testing
(lung volume measurements)
Asthma COPD
Normal value is
dependent on
1. Race
2. Age
3. Sex
4. Height
Normal value is
dependent on
1. Race
2. Age
3. Sex
4. Height
Emphysema
Pneumonia
Pleural effusion
Pneumothorax