KIN 462 Section 2

Pulmonary Cases
Case 1:
Bob is a 75-year old 168 cm 65-kg ex-carpenter with a diagnosis of emphysema. He has been a
pack a day smoker for the past 50 years. He has a 35-year history of coughing and mucus
production, with frequent upper respiratory infections. He has not worked for the past 10 years
b/c he was unable to perform the demands of the job. More recently, he has been short of breath
when performing low-level activities such as walking. Bob recently started taking Symbicort.
Pulmonary Data:
Test
FVC
FEV-1
FEF- 25-75%
FRC
SaO2

Absolute Value
3.03 L
1.1 L
0.66 L/sec
6.56 L
88%

% Predicted
82%
38%
24%
198%
*****

Stress Test Results:

Progressive GXT with full monitoring of ventilatory variables including minute
ventilation, tidal volume, breathing frequency and arterial oxygen saturation and EKG
was performed.
Modified Balke protocol (speed of 2.0 mph, 2% grade increments every 2 minutes)
Maximal obtained grade was 4% (3 METS) at a HR of 121 bpm. Test terminated b/c
SaO2 decreased to 72%
Ventilation was 100% expected at rest and reaching 135% of expected at peak load which
was accomplished through an increase in breathing frequency with almost no increase in
Vt from rest to exercise.
Resting Vd/Vt was 46% (normal = 30%) and increased to > 50% at peak exercise
(normal decreases to less than 10%)
Case 2:
Molly is an 18-year old club ice hockey player. Her height and weight are: 165 cm and 59.9 kg,
respectively. As a college freshman, she began preseason conditioning with the ice hockey team.
Despite rigorous training in the off-season, the coaches are concerned with Mollys fitness level.
She has a difficult time recovering between work bouts and frequently coughs during and after
training. Molly states that she feels pressure in her chest during and after exercise which she
describes as feeling like someone is standing on my chest when I try to breathe. Her Sx are
apparent during most training sessions but those inside the ice arena cause the most trouble for
her. Her parents became concerned about her discomfort and tried to persuade her not to exercise
because it makes you feel much worse and could be dangerous. Discussion of her problems
with the teams AT led to an appt with the sports medicine clinic across town.
The physician in your clinic speculated the Molly might have asthma given her symptoms.
Spirometry was performed, which revealed an FEV1 of 3.09 L (96% of predicted), an FVC of
3.54 L (95% predicted), a peak expiratory flow rate (PEFR) of 6.97 L (95% predicted), and an
FEV1/FVC ratio of _____________. Given these results, showing normal pulmonary function,
she was told that she did not have asthma, but rather bronchitis and was told to continued her

exercise (after a course of antibiotics). She continued to exercise and noted that her symptoms
continued as they had been.
She sought the advice of another physician, this time in the clinic where you work as an exercise
specialist. An exercise test with the measurement of expired gases during progressive
incremental bike exercise was performed. Spirometry was performed at 15, 30, and 60 min
following the exercise test. Maximal oxygen consumption was 3.13 L/min (calculate relative and
evaluate). Flow rates were as follows:
FEV1 (L): pre-exercise = 3.09; 15 min post-ex = 2.87; 30 min post = 2.20; 60 min post = 2.24
FVC (L): pre-exercise = 3.54; 15 min post-ex = 3.32; 30 min post = 2.97; 60 min post = 3.03
PEFR (L/sec): pre-ex = 6.97; 15 min post = 6.00; 30 min post = 5.25; 60 min post = 5.26
Case 3:
JD is a 10 yr old Caucasian male who was diagnosed with cystic fibrosis at 6 mo of age
secondary to recurrent respiratory infections and failure to thrive. He has done relatively well
with intermittent respiratory infections that require antibiotic and hospital therapy. He regularly
takes Pulmozyme. Because of his inability to consume adequate calories, a gastrostomy tube was
placed to allow supplemental nocturnal nutrition. He is comfortable with his gastrostomy tube
and is not currently self-conscious about his appearance. His parents, however, are protective of
his gastrostomy tube and deny him activities that may cause difficulties to this area.
Diagnosis:
An exercise evaluation was performed as part of JDs medical care. An activity questionnaire
revealed that he enjoys most sports but believes that he is having increasing difficulty keeping up
with other children, especially in prolonged aerobic activities. He owns a bicycle and a
skateboard, and states that he uses them mostly in the summer when the weather is appropriate.
His parents are active and set a good example for him and his older sibling, who does not have
CF. Before exercise testing, the following pulmonary function tests were obtained:
FEV1 = 65% of predicted; FEF 25-75 = 48% of predicted
Resting Pulse/Ox = 96% on room air
Residual volume = 195% of predicted
Diffusing capacity of the lungs = 86% of predicted
Exercise Test Results:
Maximal graded ergometry test (Godfrey protocol) results:
Physical work capacity = 65W (82% of predicted)
VO2peak = 35.6 ml/kg/min (74% of predicted)
Peak end tidal CO2 = 38 mmHg
Lowest exercise oxygen saturation = 92%
Ratio of minute ventilation to maximal voluntary ventilation = 96%
Resting HR = 84 bpm
Peak HR = 200 bpm
Body composition: Wt = 23.4 kg (_____ %ile for his age); height = 129 cm (_____ %ile for age)
Percent body fat (BIA) = 12%
good posture, no muscle issues