Textbook

of
Pulmonary Medicine
 Textbook
of
Pulmonary Medicine

Jyotsna M Joshi MD

Professor and Head

Department of Respiratory Medicine
TN Medical College and BYL Nair Hospital
Mumbai, Maharashtra
India

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

New Delhi • Ahmedabad • Bengaluru • Chennai • Hyderabad
Kochi • Kolkata • Lucknow • Mumbai • Nagpur • St Louis (USA)
Published by
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
Corporate Office
4838/24 Ansari Road, Daryaganj, New Delhi - 110002, India, Phone: +91-11-43574357
Registered Office
B-3 EMCA House, 23/23B Ansari Road, Daryaganj, New Delhi - 110 002, India
Phones: +91-11-23272143, +91-11-23272703, +91-11-23282021
+91-11-23245672, Rel: +91-11-32558559, Fax: +91-11-23276490, +91-11-23245683
e-mail: jaypee@jaypeebrothers.com, Website: www.jaypeebrothers.com
Branches
 2/B, Akruti Society, Jodhpur Gam Road Satellite
Ahmedabad 380 015, Phones: +91-79-26926233, Rel: +91-79-32988717, Fax: +91-79-26927094,
e-mail: ahmedabad@jaypeebrothers.com
 202 Batavia Chambers, 8 Kumara Krupa Road, Kumara Park East
Bengaluru 560 001, Phones: +91-80-22285971, +91-80-22382956, 91-80-22372664
Rel: +91-80-32714073, Fax: +91-80-22281761 e-mail: bangalore@jaypeebrothers.com
 282 IIIrd Floor, Khaleel Shirazi Estate, Fountain Plaza, Pantheon Road
Chennai 600 008, Phones: +91-44-28193265, +91-44-28194897, Rel: +91-44-32972089, Fax: +91-44-28193231
e-mail: chennai@jaypeebrothers.com
 4-2-1067/1-3, 1st Floor, Balaji Building, Ramkote Cross Road,
Hyderabad 500 095, Phones: +91-40-66610020, +91-40-24758498
Rel:+91-40-32940929, Fax:+91-40-24758499 e-mail: hyderabad@jaypeebrothers.com
 No. 41/3098, B & B1, Kuruvi Building, St. Vincent Road
Kochi 682 018, Kerala, Phones: +91-484-4036109, +91-484-2395739, +91-484-2395740
e-mail: kochi@jaypeebrothers.com
 1-A Indian Mirror Street, Wellington Square
Kolkata 700 013, Phones: +91-33-22651926, +91-33-22276404, +91-33-22276415, Rel: +91-33-32901926,
Fax: +91-33-22656075
e-mail: kolkata@jaypeebrothers.com
 Lekhraj Market III, B-2, Sector-4, Faizabad Road, Indira Nagar
Lucknow 226 016 Phones: +91-522-3040553, +91-522-3040554
e-mail: lucknow@jaypeebrothers.com
 106 Amit Industrial Estate, 61 Dr SS Rao Road, Near MGM Hospital, Parel
Mumbai 400 012, Phones: +91-22-24124863, +91-22-24104532, Rel: +91-22-32926896, Fax: +91-22-24160828
e-mail: mumbai@jaypeebrothers.com
 “KAMALPUSHPA” 38, Reshimbag, Opp. Mohota Science College, Umred Road
Nagpur 440 009 (MS), Phone: Rel: +91-712-3245220, Fax: +91-712-2704275
e-mail: nagpur@jaypeebrothers.com

USA Office
1745, Pheasant Run Drive, Maryland Heights (Missouri), MO 63043, USA, Ph: 001-636-6279734
e-mail: jaypee@jaypeebrothers.com, anjulav@jaypeebrothers.com
Textbook of Pulmonary Medicine
© 2009, Jyotsna M Joshi
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or
by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the editor
and the publisher.
This book has been published in good faith that the material provided by contributors is original. Every effort is made to ensure
accuracy of material, but the publisher, printer and editor will not be held responsible for any inadvertent error(s). In case of
any dispute, all legal matters are to be settled under Delhi jurisdiction only.

First Edition: 2009

ISBN 978-81-8448-649-0
Typeset at JPBMP typesetting unit
Printed at Ajanta Offset & Packagings Ltd., New Delhi
 To
My mother
Smt Prema Joshi
 Contributors

A Ahuja MD Falguni S Parikh MD

Senior Registrar Associate Professor
Department of Critical Care Department of Medicine
PD Hinduja Hospital TN Medical College and
Mumbai, Maharashtra BYL Nair Hospital
India Mumbai, Maharashtra
India
Bhavin Jankharia MD
Consultant Radiologist Jyotsna M Joshi MD
Piramal Diagnostic—Jhankaria Imaging Professor and Head
Mumbai, Maharashtra Department of Respiratory Medicine
TN Medical College and BYL Nair Hospital
India
Mumbai, Maharashtra
India
Bavin M Shah MD
Consultant Chest Physician Mahadev Patil MD DNB
Purohit Hospital Senior Registrar
Mumbai, Maharashtra ICU Blacktown Hospital
India Sydney NSW, Australia

CS Pramesh MS P Sundaram MD DNB

Associate Professor Consultant
Division of Thoracic Surgery Respiratory Medicine
Department of Surgical Oncology Manipal Hospital
Tata Memorial Hospital Bengaluru, Karnataka
Mumbai, Maharashtra India
India
R Sanglikar MD
D Kudalkar MD Consultant Physician
Fellow in Rheumatology Divine Hospital
Thane, Mumbai, Maharashtra
University of Cincinnati
India
USA
Rajesh C Mistry MS
DV Shah MD Professor
Consultant Chest Physician Surgical Oncology
Ahmedabad, Gujarat Chief, Thoracic Surgical Service
India Tata Memorial Hospital
Mumbai, Maharashtra
D Gothi MD India
Associate Professor
Department of Chest Medicine S Nananware MD
LTMG Medical College and Consultant Chest Physician
Sion Hospital Saifee Hospital
Mumbai, Maharashtra Mumbai, Maharashtra
India India
 viii Textbook of Pulmonary Medicine

Sandeep Banerjee MD DNB FNB Sudhir Nair MD

(Critical Care Medicine) Consultant Chest Physician
MRCP Specialist Registrar Nanavati Hospital
Colchester General Hospital Mumbai, Maharashtra
Colchester, United Kingdom India

Sandeep Tandon MD DNB SP Bhat MD DNB

Associate Professor Resident Internal Medicine
Department of Pulmonary Medicine University of Tennessee, College of Medicine
Tata Memorial Hospital Chattanooga, Tennessee
Mumbai, Maharashtra USA
India Vinaya Karkhanis MD
Associate Professor
Shailly Saxena MD
Department of Respiratory Medicine
Associate Consultant
TN Medical College and BYL Nair Hospital
Indraprastha Apollo Hospitals
Mumbai, Maharashtra
New Delhi, India
India
Singhal Pratibha MD T Shah MD DNB
Consultant Physician Ex-Lecturer
Bombay Hospital Institute of Medical Sciences and Department of Respiratory Medicine
Research Centre TN Medical College and BYL Nair Hospital
Mumbai, Maharashtra Mumbai, Maharashtra
India India
 Preface

The past 20 odd years of my life have been spent in practicing and teaching pulmonary medicine. This has
been a vast and enriching experience. In the course of my work, I have imbibed knowledge which I have
tried to impart to my students in a form that is easy to understand and apply in practice.
This is an attempt to compile all the information in a book, so that more students and practicing
physicians have access to it. I have taken help from my associates in the department and my ex-students
who are today scattered across the globe. Some chapters have been written by experts whom I know to
be the best in their respective fields. I thank all those who have helped me in my endeavor.
I sincerely hope that this book will be useful to many. I welcome suggestions and criticisms so that I
can incorporate more in the next edition.

Jyotsna M Joshi
 Contents

1. The Respiratory System: Applied Anatomy and Physiology ......................................................................................... 1

Jyotsna M Joshi
2. Evaluation of the Respiratory System
2.1 Clinical Assessment: Clinical Decision Making in Respiratory Cases ............................................................. 12
Jyotsna M Joshi
2.2 Investigations: Chest Radiology .......................................................................................................................... 25
Bhavin Jankharia
2.3 Spirometry ............................................................................................................................................................ 46
Jyotsna M Joshi
2.4 Static Lung Volumes and Capacities .................................................................................................................. 54
Jyotsna M Joshi
2.5 Diffusion Capacity of Lung for Carbon Monoxide (DLCO) .................................................................................. 56
Jyotsna M Joshi
2.6 Cardiopulmonary Exercise (CPEX) Testing ........................................................................................................ 58
Jyotsna M Joshi
2.7 Arterial Blood Gas Analysis ................................................................................................................................. 60
Vinaya Karkhanis
2.8 Polysomnography ................................................................................................................................................ 72
Sundeep Banerjee, Jyotsna M Joshi
2.9 Bronchoscopy ...................................................................................................................................................... 76
A Ahuja, SP Tandon, CS Pramesh, RC Mistry
2.10 Thoracoscopy ....................................................................................................................................................... 82
Mahadev Patil, SP Tandon, CS Pramesh, RC Mistry
3. Respiratory Tract Infections ......................................................................................................................................... 86
P Sundaram, Jyotsna M Joshi
4. Tuberculosis (TB)
4.1 Epidemiology and Natural History of Tuberculosis .......................................................................................... 100
T Shah, Jyotsna M Joshi
4.2 Tuberculosis Prevention .................................................................................................................................... 104
P Sundaram
4.3 Anti-tuberculosis Therapy .................................................................................................................................. 111
Jyotsna M Joshi
4.4 Revised National Tuberculosis (TB) Control Program ...................................................................................... 117
D Gothi, Jyotsna M Joshi
4.5 Problems in Management of Tuberculosis ...................................................................................................... 123
Jyotsna M Joshi
4.6 Childhood Tuberculosis ..................................................................................................................................... 130
P Sundaram, Jyotsna M Joshi
4.7 Extrapulmonary Tuberculosis ........................................................................................................................... 137
R Sanglikar
4.8 Diagnosis and Management of Multidrug Resistant (MDR) TB ....................................................................... 148
DV Shah, Jyotsna M Joshi
4.9 Surgical Management of Pulmonary Tuberculosis ......................................................................................... 152
D Gothi
 xii Textbook of Pulmonary Medicine

5. HIV-related Respiratory Disorders ............................................................................................................................. 157

D Kudalkar, Jyotsna M Joshi
6. Pulmonary Collapse ..................................................................................................................................................... 170
Jyotsna M Joshi
7. Pleural Diseases
Jyotsna M Joshi
7.1 Pleural Effusion .................................................................................................................................................. 181
7.2 Pneumothorax .................................................................................................................................................... 192
8. Chronic Airway Disorders
8.1 Disorders of Airway ........................................................................................................................................... 197
Jyotsna M Joshi
8.2 Upper Airway Obstruction ................................................................................................................................. 199
SP Bhat, Jyotsna M Joshi
8.3 Pharmacotherapy of Obstructive Airway Disorders ....................................................................................... 205
D Gothi, Jyotsna M Joshi
8.4 Bronchial Asthma ............................................................................................................................................... 214
D Gothi
8.5 Chronic Obstructive Pulmonary Diseases (COPD) .......................................................................................... 228
D Gothi
8.6 Bronchiectasis ................................................................................................................................................... 239
S Nananware, D Gothi, Jyotsna M Joshi
8.7 Small Airway Obstruction .................................................................................................................................. 249
D Gothi, Jyotsna M Joshi
9. Lung Cancer ................................................................................................................................................................. 254
Sandeep Tandon, CS Pramesh, Rajesh C Mistry
10. Pulmonary Eosinophilia ............................................................................................................................................... 269
Falguni S Parikh, Jyotsna M Joshi
11. Interstitial Lung Diseases ........................................................................................................................................... 278
Jyotsna M Joshi
12. Sarcoidosis .................................................................................................................................................................. 289
Sudhir Nair
13. Air Pollution and Related Disorders ........................................................................................................................... 299
Jyotsna M Joshi
14. Pulmonary Vasculitides ............................................................................................................................................... 304
Jyotsna M Joshi
15. Pulmonary Thromboembolic Disease ........................................................................................................................ 309
Sandeep Banerjee, Jyotsna M Joshi
16. Pulmonary Hypertension and Cor Pulmonale ............................................................................................................ 317
SP Bhat, Jyotsna M Joshi
17. Disease of the Mediastinum ....................................................................................................................................... 327
Singhal Pratibha, Jyotsna M Joshi
18. Sleep-related Respiratory Disorders: Sleep Apnea Syndromes .............................................................................. 344
Jyotsna M Joshi, D Gothi
19. Drug-induced Respiratory Diseases .......................................................................................................................... 358
R Sanglikar
20. Pulmonary Hydatidosis and Pleuropulmonary Amoebiasis
20.1 Pulmonary Hydatidosis ...................................................................................................................................... 364
Shailly Saxena, Jyotsna M Joshi
20.2 Pleuropulmonary Complications of Amoebiasis ............................................................................................. 367
Bavin M Shah, Jyotsna M Joshi
 Contents xiii

21. Preoperative Pulmonary Evaluation ........................................................................................................................... 370

Jyotsna M Joshi
22. Noninvasive Ventilation ............................................................................................................................................... 375
Jyotsna M Joshi
23. Management of Advanced Chronic Respiratory Disorders: Pulmonary Rehabilitation .......................................... 384
Jyotsna M Joshi
24. Some More Case Illustrations .................................................................................................................................... 391
Jyotsna M Joshi, D Gothi
25. Chest Radiographs ...................................................................................................................................................... 404
Jyotsna M Joshi

Index .......................................................................................................................................................................... 427