Approach to

Pulmonary and Critical Care Medicine

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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 Care Medicine

Concern predominantly with the management of
patients with life-threatening conditions (the
critically ill)
Dysfunction or failure of one or more organ
systems
Multidisciplinary approach for optimal care

The moment of critical illness

RECOVERY

Single organ failure

Trauma
Sepsis
Operative
Acute MI
Chronic lung disease
Chronic renal failure

CRITICAL
Multiple
organ failure
DEATH

Approach to critically ill patients

Rapid initial assessment and intervention (focus
on real or potentially life threatening process)
Formulation of a broader and more
comprehensive diagnostic and treatment plan
Management based on understanding of
physiology and pathophysiology
Appreciation of organ system interdependence
Directed and dynamic management approach

Function of the lung

Gas exchange : External respiration, Internal respiration
Oxygen

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

Assessment of the respiratory system

History taking

Physical examination

DIAGNOSIS & MANAGEMENT

Investigation
Chest x-ray
Arterial blood gases
Pulmonary function test

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

Adverse health effects related

to smoking

Lower FEV1 and accelerated decline in FEV1

Increased respiratory symptoms
Increased airway hyperresponsiveness
COPD
Cancer: lung, oral cavity, larynx, esophagus,
bladder, kidney, pancreas, stomach, cervix
Coronary heart disease, stroke, peripheral
vascular disease
Low birth weight, intrauterine growth
retardation, etc.

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%

Occupational lung diseases

(Pneumoconiosis)
silica, asbestos, talc
Farmers lung (), Byssinosis
( ), Bagassosis ()
Occupational asthma & Reactive airway disease syndrome



(Inspection)
(Palpation)
(Percussion)
(Auscultation)
( vital signs)


Spirometry
Arterial blood gases analysis

Static lung volume

Diffusing capacity for CO
Bronchial hyper-responsiveness
Airway resistance
Respiratory center sensitivity
Cardiopulmonary exercise testing

Spirometry

Spirometer
Spirogram



pneumothorax
uncontrolled
hypertension, shock, recent myocardial infarction
Aneurysm

IC

TLC = RV+ERV+VT+IRV = IC+FRC

VC = ERV+VT+IRV = TLC-RV
FRC = RV+ERV
IC = VT+IRV

Normal value is dependent on

1. Race
2. Age
3. Sex
4. Height

Guidelines for the interpretation of

spirometry
Use FVC, FEV1 and FEV1/VC% as the primary
guides for interpretation
The primary indicator of airflow obstruction
is a reduced FEV1/VC%
Classify the severity using FEV1 expressed as
a percentage of the predicted value
Determine the response to bronchodilator
therapy (both FEV1 improvement 12% and
200 mL)

Guidelines for the interpretation of

spirometry (2)
A restrictive pattern may be cautiously diagnosed
from the spirometric examination when VC is
reduced and FEV1/VC% is normal
The definitive finding for a restrictive pattern
is a reduced TLC
The severity of restriction should be based on
TLC (or VC)
Restriction cannot be diagnosed from the
spirometric examination in the presence of
moderate-to-severe airflow obstruction

Peak expiratory flow rate

Mini Wright peak flow meter

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, (
)

 Arterial blood gases

blood gases : pH, pO2 pCO2
: HCO3, base excess

pH
pO2
pCO2
SaO2
HCO3
Base excess

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

> 60 : PaO2 = 100 - (0.25 x ())

<
Causes of hypoxemia
Hypoventilation
V/Q mismatch
Shunt
Impaired diffusion

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

D(A-a)O2 = PAO2 - PaO2

= [(713 x FiO2) - PaCO2/R] - PaO2 [R = 0.8]
D (A-a) O2 = 5-15 ; hypoventilation
low FiO2 FiO2
shunt FiO2 = 1.0
PaO2/FiO2 lung injury ( 300)

 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

Chronic respiratory acidosis

+ 10

+4

Acute respiratory alkalosis

- 10

-2

Chronic respiratory alkalosis

- 10

-5

Acute respiratory acidosis

 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

RML and RLL atelectasis

Pleural effusion

Pneumothorax