A 65-year-old man with severe chronic obstructive lung disease has been admitted to the intensive care unit for treatment of broncho-pneumonia:

• Sinus tachycardia, 110/min
• Biatrial enlargement
• Right superior axis deviation

Comment: This ECG shows typical findings seen in patient with chronic lung disease:

• Tall peaked P waves in the inferior leads: right atrial enlargement
• The prominent negative component of the P in V1 (commonly seen in patients with chronic lung disease) may be due to shift of the cardiac position due the lower diaphragm, rather than to left atrial enlargement.
• Right axis deviation
• Small QRS voltage in leads 1 and aVL
• Delayed R/S transition point in the precordial leads (the R becomes taller than the S in V5)