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Diagnosis of COPD
Gamal Rabie Agmy, MD,FCCP Professor of Chest Diseases, Assiut university
GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE
(GOLD): January 2014
© 2014 Global Initiative for Chronic Obstructive Lung Disease
Diagnosis of COPD
Clinical
Spirometric
Radiological
Diagnosis of COPD
Clinical
Spirometric
Radiological
© 2014 Global Initiative for Chronic Obstructive Lung Disease
Global Strategy for Diagnosis, Management and Prevention of COPD
Diagnosis and Assessment: Key Points
A clinical diagnosis of COPD should be considered in any patient who has dyspnea, chronic cough or sputum production, and a history of exposure to risk factors for the disease.
Spirometry is required to make the diagnosis; the presence of a post-bronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow limitation and thus of COPD.
Dr.Sarma@works 7
CLINICAL FEATURES
Dr.Sarma@works 8
CHRONIC BRONCHITIS EMPHYSEMA
BLUE BLOTTER PINK PUFFER
Dr.Sarma@works 9
CHRONIC BRONCHITIS EMPHYSEMA
1. Mild dyspnea
2. Cough before dyspnea starts
3. Copious, purulent sputum
4. More frequent infections
5. Repeated resp. insufficiency
6. PaCO2 50-60 mmHg
7. PaO2 45-60 mmHg
8. Hematocrit 50-60%
9. DLCO is not that much ↓
10. Cor pulmonale common
1. Severe dyspnea
2. Cough after dyspnea
3. Scant sputum
4. Less frequent infections
5. Terminal RF
6. PaCO2 35-40 mmHg
7. PaO2 65-75 mmHg
8. Hematocrit 35-45%
9. DLCO is decreased
10. Cor pulmonale rare.
ALPHA1 ANTITRYPSIN ↓ EMPHYSEMA
Specific circumstances of Alpha 1- AT↓include.
• Emphysema in a young individual (< 35)
• Without obvious risk factors (smoking etc)
• Necrotizing panniculitis, Systemic vasculitis
• Anti-neutrophil cytoplasmic antibody (ANCA)
• Cirrhosis of liver, Hepatocellular carcinoma
• Bronchiectasis of undetermined etiology
• Otherwise unexplained liver disease, or a
• Family history of any one of these conditions
• Especially siblings of PI*ZZ individuals.
• Only 2% of COPD is alpha 1- AT ↓
© 2014 Global Initiative for Chronic Obstructive Lung Disease
Global Strategy for Diagnosis, Management and Prevention of COPD
Diagnosis of COPD
EXPOSURE TO RISK FACTORS
tobacco
occupation
indoor/outdoor pollution
SYMPTOMS
shortness of breath
chronic cough
sputum
SPIROMETRY: Required to establish diagnosis
Diagnosis of COPD
Clinical
Spirometric
Radiological
© 2014 Global Initiative for Chronic Obstructive Lung Disease
Global Strategy for Diagnosis, Management and Prevention of COPD
Diagnosis and Assessment: Key Points
Spirometry should be performed after the administration of an adequate dose of a short- acting inhaled bronchodilator to minimize variability.
A post-bronchodilator FEV1/FVC < 0.70 confirms the presence of airflow limitation.
Where possible, values should be compared to age-related normal values to avoid overdiagnosis of COPD in the elderly.
Acceptability & Repeatability
Acceptability
At least three (3) acceptable maneuvers:
• Good start to the test.
• No hesitation or coughing for the 1st second.
• FVC lasts at least 6 seconds with a plateau
of at least 1 second.
• No valsalva maneuver or obstruction of the
mouthpiece.
• FIVC shows apparent maximal effort.
Repeatability
Repeatability criteria act as guideline to
determine need for additional efforts.
– Largest and 2nd largest FVC must be within 150
mL.
– Largest and 2nd largest FEV 1 must be 150 mL.
– PEF values may be variable (within 15%).
If three acceptable reproducible maneuvers
are not recorded, up to 8 attempts may be
recorded.
Spirometry Value
• Spirometry is typically reported in both
absolute values and as a predicted
percentage of normal.
• Normal values vary and are dependent on:
– Gender,
– Race,
– Age,
– Weight and
– Height.
Reporting Standards
• Largest FVC obtained from all acceptable
efforts should be reported.
• Largest FEV1 obtained from all acceptable
trials should be reported.
• May or may not come from largest FVC
effort.
• All other flows, should come from the effort
with the largest sum of FEV 1 & FVC.
• PEF should be the largest value obtained
from at least 3 acceptable maneuvers.
Results Reporting Example
Pre & Post Bronchodilator Studies: Withholding
Medications
Reversibility
Reversibility of airways obstruction can be
assessed with the use of bronchodilators.
• > 12% increase in the FEV1 and 200
ml improvement in FEV1
OR
• > 12% increase in the FVC and 200
ml improvement in FVC.
1-First Step, Check quality of the test
1- Start:
*Good start: Extrapolated volume (EV) < 5% of FVC or 0.15 L
*Poor start: Extrapolated volume (EV) ≥5% of FVC or ≥ 0.15 L
2- Termination:
*No early termination :Tex ≥ 6 s
*Early termination : Tex < 6 s
2- Look at …………FEV1/FVC
< N(70%)
Obstructive or Mixed
≥ N(70%)
Restrictive or Normal
3- Look at FEV1 To detect degree Mild > 70% Mod 50-69 % Severe 35-49% Very severe < 35%
4- Postbronchodilator FEV1/FVC
> 70% asthma
< 70% COPD
5- Reversibility test of FEV1
> 12%, 200 ml Reversible (asthma)
< 12% ,200 ml Ireversible (COPD)
6- Look at TLC
≥ 80-120% Pure obstruction
< 80% Mixed
2- Look at …………FEV1/FVC
< N(70%)
Obstructive or Mixed
≥ N(70%)
Restrictive or Normal
3- Look at FVC
≥ N(80%) < N(80%) Normal or SAWD
4-Look at FEF25/75
> 50% Normal < 50% SAWD
Restrictive
Changes in Lung Volumes in
Various Disease States
Ruppel GL. Manual of Pulmonary Function Testing, 8th ed., Mosby 2003
Patterns of Abnormality
Restriction low FEV1 & FVC, high FEV1%FVC
Recorded Predicted SR %Pred
FEV 1 1.49 2.52 -2.0 59
FVC 1.97 3.32 -2.2 59
FEV 1 %FVC 76 74 0.3 103
PEF 8.42 7.19 1.0 117
Obstructive low FEV1 relative to FVC, low PEF, low FEV1%FVC
Recorded Predicted SR %Pred
FEV 1 0.56 3.25 -5.3 17
FVC 1.65 4.04 -3.9 41
FEV 1 %FVC 34 78 -6.1 44
PEF 2.5 8.28 -4.8 30
high PEF early ILD
low PEF late ILD
Patterns of Abnormality
Upper Airway Obstruction low PEF relative to FEV1
Recorded Predicted SR %Pred
FEV 1 2.17 2.27 -0.3 96
FVC 2.68 2.70 0.0 99
FEV 1 %FVC 81 76 0.7 106
PEF 2.95 5.99 -3.4 49
FEV 1 /PEF 12.3
Discordant PEF and FEV1
High PEF versus FEV1 = early interstitial lung disease (ILD)
Low PEF versus FEV1 = upper airway obstruction
Concordant PEF and FEV1
Both low in airflow obstruction, myopathy, late ILD
Common FVL Shapes
Volume
Flo
w
Normal Young or quitter Poor effort
Hesitation Knee Coughing
Upper Airway Obstruction
0 1 2 3 4 5 6
-6
-4
-2
0
2
4
6 Age 40 yrs
FVC 3.52 L 0.84 SR
FEV1 3.0 L 0.74 SR
PEF 4.57 L/s -2.18 SR
FEV/PEF = 10.9
Inspiratory
Expiratory
Flo
w in
L/s
Volume in Litres
FEV1 in mls
PEF in L/min > 8
Diffusing Capacity
Diffusing capacity of lungs for CO
Measures ability of lungs to transport inhaled gas
from alveoli to pulmonary capillaries
Depends on:
- alveolar—capillary membrane
- hemoglobin concentration
- cardiac output
Diffusing Capacity
Decreased DLCO
(<80% predicted)
Obstructive lung disease
Parenchymal disease
Pulmonary vascular
disease
Anemia
Increased DLCO (>120-140% predicted)
Asthma (or normal)
Pulmonary hemorrhage
Polycythemia
Left to right shunt
DLCO — Indications
Differentiate asthma from emphysema
Evaluation and severity of restrictive lung disease
Early stages of pulmonary hypertension
Diagnosis of COPD
Clinical
Spirometric
Radiological
Emphysema
histopathological definition
…..permanent abnormal enlargement of
airspaces distal to the bronchioles terminales
and
…...destruction of the walls of the involved
airspaces
And
Fibrosis is not integral part
Centrilobular Emphysema
Panlobular Emphysema
Fibrosis and Emphysema
CT findings:
• Relatively well-defined, low attenuation areas
with very thin (invisible) walls, surrounded by
normal lung parenchyma.
• As disease progresses:
– Amount of intervening normal lung decreases.
– Number and size of the pulmonary vessels
decrease.
– +/- Abnormal vessel branching angles (>90o), with
vessel bowing around the bullae.
Emphysema
•Curved arrow: area of low attenuation.
•Solid arrow: zones of vascular disruption.
•Open arrow: area of lung destruction.
Emphysematous Bullae
www.ctsnet.org/doc/6761
Quantitative CT:
• Spirometically triggered images at 10% and
90% vital capacity (VC) have been reported
to be able to distinguish patients with chronic
bronchitis from those with emphysema.
– Patients with emphysema had significantly lower
mean lung attenuation at 90% VC than normal
subjects or patients with chronic bronchitis.
– Attenuation was the same for normal subjects and
those with chronic bronchitis.
Where is the pathology ???????
in the areas with increased density meaning there is ground glass
in the areas with decreased density meaning there is air trapping
Pathology in black areas
Airtrapping: Airway Disease
Bronchiolitis obliterans (constrictive bronchiolitis) idiopathic, connective tissue diseases, drug reaction,
after transplantation, after infection
Hypersensitivity pneumonitis granulomatous inflammation of bronchiolar wall
Sarcoidosis granulomatous inflammation of bronchiolar wall
COPD/Asthma / Bronchiectasis / Airway diseases
Airway Disease
what you see……
In inspiration sharply demarcated areas of seemingly increased
density (normal) and decreased density
demarcation by interlobular septa
In expiration ‘black’ areas remain in volume and density
‘white’ areas decrease in volume and increase in
density
INCREASE IN CONTRAST
DIFFERENCES
AIRTRAPPING
Bronchiolitis
obliterans
Early Sarcoidosis
Chronic EAA
Hypersensitivity pneumonitis
Extr. Allerg. Alveolitis (EAA) HRCT Morphology
chronic: fibrosis
Intra- / interlobular septal thickening
Irregular interfaces
Traction bronchiectasis
acute - subacute
acinar (centrilobular) unsharp densities
ground glass (patchy - diffuse)
Pathology in white Areas
Alveolitis / Pneumonitis
Ground glass desquamative intertitial pneumoinia (DIP)
nonspecific interstitial pneumonia (NSIP)
organizing pneumonia
In expiration both areas (white and black) decrease in
volume and increase in density
DECREASE IN CONTRAST
DIFFERENCES
DI
P
Cellular
NSIP
Mosaic Perfusion
Chronic pulmonary embolism
LOOK FOR
Pulmonary hypertension
idiopathic, cardiac disease, pulmonary
disease
CTEPH =
Chronic thrombembolic
pulmonary hypertension
Normal lung surface
Left panel: Pleural line and A line (real-time). The pleural line is located 0.5 cm below the rib line in the adult. Its visible length between two ribs in the longitudinal scan is approximately 2 cm. The upper rib, pleural line, and lower rib (vertical arrows) outline a characteristic pattern called the bat sign.
Ultrasound profiles.
Lichtenstein D A , Mezière G A Chest 2008;134:117-125
the "seashore sign" (Fig.3).
Multiple B-lines - « comet-tails » - interstitial edema
(B1)
7 mm apart « B lines » thickened interlobular septa
D Lichtenstein et al AJRCCM 156 : 1640-1646 , 1997 JJR 25 05
2012
http://www.reapitie-
univparis6.aphp.fr http://www.reapitie-
univparis6.aphp.fr
02 09 2012