The primary diagnostic tests are. Flow-volume loops: Simultaneous spirometric recordings of airflow and volume during forced maximal expiration and inspiration. Flow-volume loops show a concave pattern in the expiratory tracing see figure Flow-volume loops Flow-volume loops Airflow and lung volume measurements can be used to differentiate obstructive from restrictive pulmonary disorders, to characterize severity, and to measure responses to therapy.
With the 2nd pathway, patients have impaired lung function in early adulthood, often associated with asthma or other childhood respiratory disease. Although this 2nd pathway model is conceptually helpful, a wide range of individual trajectories is possible 1 Diagnosis references Chronic obstructive pulmonary disease COPD is airflow limitation caused by an inflammatory response to inhaled toxins, often cigarette smoke.
When the FEV1 falls below about 1 L, patients develop dyspnea during activities of daily living although dyspnea is more closely related to the degree of dynamic hyperinflation [progressive hyperinflation due to incomplete exhalation] than to the degree of airflow limitation. When the FEV1 falls below about 0. Normal reference values are determined by patient age, sex, and height. Additional pulmonary function testing is necessary only in specific circumstances, such as before lung volume reduction procedures Lung volume reduction surgery Chronic obstructive pulmonary disease COPD management involves treatment of chronic stable COPD and treatment of exacerbations.
Treatment of chronic stable COPD aims to prevent exacerbations Other test abnormalities may include. Findings of increased total lung capacity, functional residual capacity, and residual volume can help distinguish COPD from restrictive pulmonary disease, in which these measures are diminished.
Decreased DLCO is nonspecific and is reduced in other disorders that affect the pulmonary vascular bed, such as interstitial lung disease, but can help distinguish emphysema from asthma, in which DLCO is normal or elevated. Chest x-ray may have characteristic findings. Other typical findings include enlargement of the retrosternal airspace and a narrow cardiac shadow.
Emphysematous changes occurring predominantly in the lung bases suggest alpha-1 antitrypsin deficiency Alpha-1 Antitrypsin Deficiency Alpha-1 antitrypsin deficiency is congenital lack of a primary lung antiprotease, alpha-1 antitrypsin, which leads to increased protease-mediated tissue destruction and emphysema in adults The lungs may look normal or have increased lucency secondary to loss of parenchyma.
Among patients with chronic obstructive bronchitis, chest x-rays may be normal or may show a bibasilar increase in bronchovascular markings as a result of bronchial wall thickening. Chest x-ray of a patient with chronic obstructive pulmonary disease COPD. The lungs are hyperinflated, the diaphragm is flattened, vascular markings are increased, and the heart size is marginally increased.
This chest x-ray shows a large bulla in the upper right lung and 2 large bullae in the left lung. Prominent hila suggest large central pulmonary arteries that may signify pulmonary hypertension Pulmonary Hypertension Pulmonary hypertension is increased pressure in the pulmonary circulation. Right ventricular enlargement that occurs in cor pulmonale Cor Pulmonale Cor pulmonale is right ventricular enlargement secondary to a lung disorder that causes pulmonary artery hypertension.
Chest CT may reveal abnormalities that are not apparent on the chest x-ray and may also suggest coexisting or complicating disorders, such as pneumonia, pneumoconiosis, or lung cancer. CT helps assess the extent and distribution of emphysema, estimated either by visual scoring or with analysis of the distribution of lung density.
Indications for obtaining CT in patients with COPD include evaluation for lung volume reduction procedures, suspicion of coexisting or complicating disorders that are not clearly evident or excluded by chest x-ray, suspicion of lung cancer, and screening for lung cancer Screening Lung carcinoma is the leading cause of cancer-related death worldwide.
Symptoms can include cough, chest discomfort or pain, weight loss Enlargement of the pulmonary artery diameter greater than the ascending aorta diameter suggests pulmonary hypertension 3 Diagnosis references Chronic obstructive pulmonary disease COPD is airflow limitation caused by an inflammatory response to inhaled toxins, often cigarette smoke. Alpha-1 antitrypsin levels should be measured in patients 50 years with symptomatic COPD and in nonsmokers of any age with COPD to detect alpha-1 antitrypsin deficiency Alpha-1 Antitrypsin Deficiency Alpha-1 antitrypsin deficiency is congenital lack of a primary lung antiprotease, alpha-1 antitrypsin, which leads to increased protease-mediated tissue destruction and emphysema in adults Other indications of possible alpha-1 antitrypsin deficiency include a family history of premature COPD or unexplained liver disease, lower-lobe distribution of emphysema, and COPD associated with antineutrophil cytoplasmic antibody ANCA -positive vasculitis.
If levels of alpha-1 antitrypsin are low, the diagnosis should be confirmed by genetic testing to establish the alpha-1 antitrypsin phenotype. ECG Electrocardiography ECG in Pulmonary Disorders Electrocardiography ECG is a useful adjunct to other pulmonary tests because it provides information about the right side of the heart and therefore pulmonary disorders such as chronic pulmonary Multifocal atrial tachycardia Ectopic Supraventricular Rhythms Various rhythms result from supraventricular foci usually in the atria.
Diagnosis is by electrocardiography. Many are asymptomatic and require no treatment. See also Overview of Arrhythmias Echocardiography Echocardiography This photo shows a patient having echocardiography. This image shows all 4 cardiac chambers and the tricupsid and mitral valves.
Echocardiography uses ultrasound waves to produce an image of Echocardiography is most often indicated when coexistent left ventricular or valvular heart disease is suspected. Patients with anemia for reasons other than COPD have disproportionately severe dyspnea. The differential white blood cell count may be helpful.
Causes and associated disorders are myriad but often represent an allergic reaction or a parasitic infection Serum electrolytes are of little value but may show an elevated bicarbonate level if patients have chronic hypercapnia.
Venous blood gases are useful for diagnosis of acute or chronic hypercapnia. Patients with acute exacerbations usually have combinations of increased cough, sputum, dyspnea, and work of breathing, as well as low oxygen saturation on pulse oximetry, diaphoresis, tachycardia, anxiety, and cyanosis. Patients with exacerbations accompanied by retention of carbon dioxide may be lethargic or somnolent, a very different appearance. All patients requiring hospitalization for an acute exacerbation should undergo testing to quantify hypoxemia and hypercapnia.
Hypercapnia may exist without hypoxemia. It is caused by intrapulmonary shunting of blood resulting from airspace filling or However, some patients chronically manifest such levels of PaO2 and PaCO2 in the absence of acute respiratory failure. A chest x-ray Chest x-ray Chest imaging includes use of plain x-rays, computed tomography CT scanning, magnetic resonance imaging MRI , nuclear scanning, including positron emission tomography PET scanning, and Pneumonia Overview of Pneumonia Pneumonia is an infection of the small air sacs of the lungs alveoli and the tissues around them.
Pneumonia is one of the most common causes of death worldwide. Often, pneumonia is the final Infections may result in severe shortness of breath even when the person is at rest and may require hospitalization. Shortness of breath during activities of daily living, such as toileting, washing, dressing, and sexual activity, may persist after the person has recovered from the lung infection.
About one third of people with severe COPD experience severe weight loss. The cause of weight loss is not clear, and causes may differ among different people.
Possible causes include shortness of breath that makes eating difficult and increased levels in the blood of a substance called tumor necrosis factor. People with COPD may intermittently cough up blood, which is usually due to inflammation of the bronchi, but which always raises the concern of lung cancer Lung Cancer Lung cancer is the leading cause of cancer death in both men and women.
One common symptom is a persistent cough or a change in the character Morning headaches may occur because breathing decreases during sleep, which causes increased retention of carbon dioxide and decreased levels of oxygen in the blood. As COPD progresses, some people, especially those who have emphysema, develop unusual breathing patterns.
Some people breathe out through pursed lips. Others find it more comfortable to stand over a table with their arms outstretched and their weight on their palms or elbows, a maneuver that improves the function of some of the respiratory muscles. Over time, many people develop a barrel chest as the size of the lungs increases because of trapped air. Low oxygen levels in the blood can give a blue tint to the skin cyanosis.
Clubbing of the fingers Clubbing Clubbing is enlargement of the tips of the fingers or toes and a change in the angle where the nails emerge. Clubbing occurs when the amount of soft tissue beneath the nail beds increases. Fragile areas in the lungs may rupture, permitting air to leak from the lungs into the pleural space, a condition called pneumothorax Pneumothorax A pneumothorax is the presence of air between the two layers of pleura thin, transparent, two-layered membrane that covers the lungs and also lines the inside of the chest wall , resulting This condition often causes sudden pain and shortness of breath and requires immediate intervention by a doctor to remove the air from the pleural space.
A flare-up or exacerbation of COPD is a worsening of symptoms, usually cough, increased sputum, and shortness of breath. Sputum color often changes to yellow or green, and fever and body aches sometimes occur. Shortness of breath may be present when the person is at rest and may be severe enough to require hospitalization.
Severe air pollution, common allergens, and viral or bacterial infections may cause flare-ups. During severe flare-ups, people may develop a life-threatening condition called acute respiratory failure Respiratory Failure Respiratory failure is a condition in which the level of oxygen in the blood becomes dangerously low or the level of carbon dioxide in the blood becomes dangerously high.
Conditions that block Among the possible symptoms are severe shortness of breath a feeling likened to being drowned , severe anxiety, sweating, cyanosis, and confusion. If low oxygen levels are not treated with supplemental oxygen, complications can occur. Low oxygen levels in the blood, if not treated, stimulate the bone marrow to send more red blood cells into the bloodstream, a condition known as secondary polycythemia Secondary Thrombocythemia Secondary thrombocythemia is excess platelets in the bloodstream that develops as a result of another disorder and rarely leads to excessive blood clotting or bleeding.
Platelets thrombocytes The low oxygen levels in the blood also constrict the blood vessels leading from the right side of the heart to the lungs, thereby increasing the pressure in these vessels. As a result of the increased pressure, called pulmonary hypertension Pulmonary Hypertension Pulmonary hypertension is a condition in which blood pressure in the arteries of the lungs the pulmonary arteries is abnormally high.
Many disorders can cause pulmonary hypertension. Swelling Swelling Swelling is due to excess fluid in the tissues. The fluid is predominantly water. Swelling may be widespread or confined to a single limb or part of a limb.
Swelling is often in the feet and High carbon dioxide levels High carbon dioxide level hypercarbic respiratory failure Respiratory failure is a condition in which the level of oxygen in the blood becomes dangerously low or the level of carbon dioxide in the blood becomes dangerously high. People become drowsy and can go into a coma and die if the problem is not corrected. People with COPD also have an increased risk of developing heart rhythm abnormalities Overview of Abnormal Heart Rhythms Abnormal heart rhythms arrhythmias are sequences of heartbeats that are irregular, too fast, too slow, or conducted via an abnormal electrical pathway through the heart.
Heart disorders are People with COPD who smoke have a higher risk of developing lung cancer Lung Cancer Lung cancer is the leading cause of cancer death in both men and women. People with COPD seem to have an increased risk of developing osteoporosis Osteoporosis Osteoporosis is a condition in which a decrease in the density of bones weakens the bones, making breaks fractures likely. Aging, estrogen deficiency, low vitamin D or calcium intake, and The heart muscle needs a constant supply of oxygen-rich blood.
The coronary However, it is not clear whether the risk is increased because of COPD or other factors. Chronic bronchitis is diagnosed by the history of a prolonged productive cough. People with chronic obstructive bronchitis have chronic bronchitis, plus evidence of airflow obstruction on tests of lung function Pulmonary Function Testing PFT Pulmonary function tests measure the lungs' capacity to hold air, to move air in and out, and to absorb oxygen.
Pulmonary function tests are better at detecting the general type and severity Emphysema is diagnosed on the basis of findings observed during a physical examination and on pulmonary function test results. However, by the time the doctor notices these abnormalities, emphysema is moderately severe. Findings on a chest x-ray or computed tomography CT of the chest may also help in diagnosis of emphysema and sometimes chronic bronchitis. It is not important for doctors to differentiate between chronic obstructive bronchitis and emphysema, and often chronic bronchitis and emphysema occur together in the same person.
The most important determinant of how the person feels and functions is the severity of the airflow obstruction. In mild COPD, doctors may find nothing unusual during the physical examination. As the disease progresses, doctors may hear wheezing or notice a decrease in the normal sounds of breathing decreased breath sounds when they listen to the lungs with a stethoscope.
Doctors may note that it takes a long time for the person to exhale air that has been inhaled prolonged expiration. Chest movement diminishes during breathing, and the person may use the neck and shoulder muscles to breathe. In mild COPD, the chest x-ray is usually normal. As COPD worsens, the chest x-ray shows that the lungs contain excess air over-inflation of the lungs. Over-inflation, thinning of blood vessels, or the presence of cysts in the lungs called bullae suggests the presence of emphysema.
Doctors can evaluate airflow obstruction with forced expiratory spirometry tests that measure how much and how quickly air can be exhaled from the lungs—see Pulmonary Function Testing Pulmonary Function Testing PFT Pulmonary function tests measure the lungs' capacity to hold air, to move air in and out, and to absorb oxygen. Decreases in the maximum amount of air a person can exhale in one second forced expiratory volume in 1 second, or FEV1 and the ratio of the FEV1 to the amount of air that a person can force out of the lungs after taking the deepest breath possible forced vital capacity, or FVC are required to demonstrate airflow obstruction and to make the diagnosis.
Doctors may measure the amount of oxygen in the blood by using a sensor placed on a finger or an earlobe pulse oximetry or by taking a sample of blood from an artery arterial blood gas analysis Arterial Blood Gas ABG Analysis and Pulse Oximetry Both arterial blood gas testing and pulse oximetry measure the amount of oxygen in the blood, which helps determine how well the lungs are functioning. Arterial blood gas tests are invasive Oxygen levels tend to be low in people with COPD. High levels of carbon dioxide in the arteries occur late in the course of the disease.
In people who develop COPD at a young age, especially when there is a family history of COPD, the level of alpha-1 antitrypsin in the blood is measured to determine whether alpha-1 antitrypsin deficiency Alpha-1 Antitrypsin Deficiency Alpha-1 antitrypsin deficiency is a hereditary disorder in which a lack or low level of the enzyme alpha-1 antitrypsin damages the lungs and liver.
This genetic disorder is also suspected when COPD develops in people who have never smoked. This record, the electrocardiogram also known as an ECG It uses no x-rays. Ultrasonography of the heart echocardiography is one of Doctors may do other tests to detect other disorders that could be causing the person's symptoms. When people have a COPD flare-up, doctors use blood gas measurements to determine how much oxygen and carbon dioxide are in the person's blood.
Doctors may do a chest x-ray to look for evidence of a lung infection. If they suspect a lung infection, particularly if the flare-up is severe enough that the person is being treated in the hospital, doctors will do additional tests to identify the virus or bacterium causing the flare-up because treatment depends on which organism is responsible. Volume Article Contents Abstract. Author Contributions and Acknowledgments. Ethics Approval. Oxford Academic.
Google Scholar. Simone N S Ribeiro. Gustavo F Wandalsen. Fernanda C Lanza. Address all correspondence to Dr Lanza at: lanzafe gmail. Select Format Select format. Permissions Icon Permissions. Abstract Background. Issue Section:. You do not currently have access to this article. Download all slides. However, there have been no reports regarding differences in the dynamic change in Rrs between mild and moderate COPD. Therefore, the characteristic features of Rrs during the respiratory cycle in tidal breathing in mild and moderate COPD were evaluated.
First, it was studied whether the behavior of Rrs showed dynamic changes as the airway obstruction changed dynamically during the respiratory cycle in tidal breathing in COPD.
Finally, the differences in the changes in Rrs during the inspiratory and expiratory phases between mild and moderate COPD were evaluated. These findings might be helpful for distinguishing mild and moderate COPD by tidal breathing without using any forced expiratory maneuvers. All patients had smoking-related COPD without alpha-1 anti-trypsin deficiency and had a smoking history of more than 20 pack years. COPD was diagnosed based on a clinical history of exertional dyspnea and pulmonary function characterized by airflow obstruction that was not fully reversible.
This study was approved by the Ethics Committee of Tokyo University, and all subjects gave prior written informed consent. Continuous impulses consisting of multispectrum oscillation were applied to the airway four times per second, every 0. Impulse pressure was applied in two directions in accordance with the airflow direction in tidal breathing: positive in inspiration and negative in expiration. The respiratory system impedance, including Rrs and Xrs, was automatically calculated using MostGraph software version 1.
Rrs between 4 Hz and 35 Hz was depicted with three-dimensional graphics Figure 1 , and the data were plotted versus the frequency and timecourse and labeled as inspiratory phase or expiratory phase based on the spontaneous airflow direction.
The X-axis shows the frequency from 4 Hz to 35 Hz, the Y-axis shows respiratory resistance, and the Z-axis shows the timecourse. The inspiratory and expiratory phases were based on the airflow of the subjects. The image was created based on the measured results for respiratory impedance. The subjects, in the sitting position with the head in a natural position, firmly supported their cheeks using both hands to reduce the influence of the upper airway shunt effect.
The subjects wore a noseclip and closed their lips tightly around the mouthpiece to prevent air leakage. After the spontaneous volume and airflow of the subjects were monitored and stable tidal breathing was confirmed, respiratory impedance was measured during five technically acceptable periods of stable tidal breathing or 60 seconds of tidal breathing. After this editing, the mean respiratory cycle periods were tabulated, including the inspiratory and expiratory phase periods, mean Rrs, and mean Xrs at 4—35 Hz for three to four satisfactory tests.
In whole-breath analysis, the averages of the mean, maximal, and minimal Rrs values at 4—35 Hz were evaluated. For analysis of the pattern of change in Rrs, COPD subjects were tentatively classified into two patterns, based on the behavior of changes in Rrs at 4 Hz during the respiratory cycle.
One pattern was a sinusoidal pattern that consists of one peak and one valley per respiratory cycle, and the other was a bimodal pattern that consists of two peaks and two valleys per respiratory cycle. In inspiratory—expiratory breath analysis, the averages of the maximal and minimal values for inspiratory and expiratory Rrs at 4 Hz, 20 Hz, and 35 Hz were evaluated.
In this study, due to the desire to focus on the changes in Rrs in whole-breath and inspiratory—expiratory breath analysis, mainly Rrs was targeted and analyzed and Xrs excluded, even though Most-Graph can also depict Xrs.
The predicted values of spirometry were calculated in accordance with the Japanese Respiratory Society guidelines. First, the respiratory cycle during tidal breathing between mild and moderate COPD patients was compared using MostGraph The respiratory cycle in spontaneous tidal breathing was similar in both the mild and moderate groups Table 2.
The inspiratory and expiratory phases also showed no significant differences between the groups. Respiratory cycle period during tidal breathing in patients with chronic obstructive pulmonary disease.
The ratio of the inspiratory phase to the expiratory phase was calculated from the mean values for the inspiratory and expiratory phases. Since Rrs in patients with COPD appeared to change dynamically during tidal breathing in the three-dimensional graphics created by MostGraph Figure 1 , it was evaluated whether the means of the maximal and minimal values of R4, R20, and R35 differed significantly between the inspiratory and expiratory phases of tidal breathing Figure 2A.
The maximal and minimal Rrs values at 4 Hz during tidal breathing were significantly different between the inspiratory and expiratory phases in the COPD patients Figure 2B. During tidal breathing, Rrs at 4 Hz changed dynamically during the respiratory cycle, with the minimal Rrs at 4 Hz occurring at the end of the inspiratory phase and the maximal Rrs at 4 Hz occurring in the middle of the expiratory phase.
Rrs at 20 Hz and 35 Hz Figure 2C and D showed similar trends to Rrs at 4 Hz, although some of the maximal and minimal Rrs values were not significantly different.
Next, since the behavior of the dynamic Rrs change seemed to have some cyclic regularity, the pattern of Rrs changes during tidal breathing in COPD was evaluated. Based on the changes in Rrs at 4 Hz in the three-dimensional graphics, they were tentatively classified into two patterns Figure 3.
The differences in the respiratory cycle, the pulmonary function, and the severity of COPD between these two patterns were evaluated Table 3. The sinusoidal pattern group had a longer breathing period and a longer expiratory phase than the bimodal pattern group. The two pattern groups showed no significant differences in regard to the pulmonary function test parameters. Although the sinusoidal pattern was predominant in moderate COPD and the bimodal pattern was predominant in mild COPD, the numbers of patients were too small to show statistically significant differences between the groups.
Comparison of respiratory resistance between the maximal and minimal values in the inspiratory and expiratory phases in chronic obstructive pulmonary disease.
A Left panel: maximal and minimal respiratory resistance in the inspiratory and expiratory phases in a representative three-dimensional graphic image, created by MostGraph Chest MI, Inc, Tokyo, Japan , in patients with chronic obstructive pulmonary disease. Right panel: upper, middle, and lower panels show the changes in respiratory resistance at 4 Hz, 20 Hz, and 35 Hz, respectively, during the respiratory cycle.
Comparison of the maximal and minimal respiratory resistance values at B 4 Hz, C 20 Hz, and D 35 Hz during the respiratory cycle are also shown. Notes: Comparison of respiratory resistance between the inspiratory and expiratory phases was performed by one-way analysis of variance followed by multiple comparisons using the Bonferroni method.
Abbreviations: ex max, maximal value in the expiratory phase; ex min, minimal value in the expiratory phase; ins max, maximal value in the inspiratory phase; ins min, minimal value in the inspiratory phase; Rrs, respiratory resistance; R4, respiratory resistance at 4 Hz; R20, respiratory resistance at 20 Hz; R35, respiratory resistance at 35 Hz.
Patterns of change in respiratory resistance during tidal breathing in patients with chronic obstructive pulmonary disease. Respiratory resistance in three-dimensional graphics generated by MostGraph Chest MI, Inc, Tokyo, Japan for patients with chronic obstructive pulmonary disease changed dynamically.
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