Diagnosis of COPD

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


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.

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CLINICAL FEATURES

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CHRONIC BRONCHITIS EMPHYSEMA

BLUE BLOTTER PINK PUFFER

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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 ↓



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



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


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


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.

http://radiology.rsnajnls.org/content/vol211/issue3/images/large/r99jn05g1b.jpeg

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

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

Diagnosis of COPD

Health & Medicine

Transcript of Diagnosis of COPD