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Diagnosis of COPD

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Diagnosis of COPD

  1. 1. Diagnosis of COPD Gamal Rabie Agmy, MD,FCCP Professor of Chest Diseases, Assiut university
  2. 2. GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE (GOLD): January 2014 © 2014 Global Initiative for Chronic Obstructive Lung Disease
  3. 3. Diagnosis of COPD  Clinical  Spirometric  Radiological
  4. 4. Diagnosis of COPD  Clinical  Spirometric  Radiological
  5. 5. 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. © 2014 Global Initiative for Chronic Obstructive Lung Disease
  6. 6. CLINICAL FEATURES Dr.Sarma@works 7
  7. 7. EMPHYSEMA CHRONIC BRONCHITIS PINK PUFFER BLUE BLOTTER Dr.Sarma@works 8
  8. 8. EMPHYSEMA 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Severe dyspnea Cough after dyspnea Scant sputum Less frequent infections Terminal RF PaCO2 35-40 mmHg PaO2 65-75 mmHg Hematocrit 35-45% DLCO is decreased Cor pulmonale rare. Dr.Sarma@works CHRONIC BRONCHITIS 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Mild dyspnea Cough before dyspnea starts Copious, purulent sputum More frequent infections Repeated resp. insufficiency PaCO2 50-60 mmHg PaO2 45-60 mmHg Hematocrit 50-60% DLCO is not that much ↓ Cor pulmonale common 9
  9. 9. 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 ↓
  10. 10. Global Strategy for Diagnosis, Management and Prevention of COPD Diagnosis of COPD SYMPTOMS shortness of breath chronic cough sputum EXPOSURE TO RISK FACTORS tobacco occupation indoor/outdoor pollution  SPIROMETRY: Required to establish diagnosis © 2014 Global Initiative for Chronic Obstructive Lung Disease
  11. 11. Diagnosis of COPD  Clinical  Spirometric  Radiological
  12. 12. 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 shortacting 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. © 2014 Global Initiative for Chronic Obstructive Lung Disease
  13. 13. Acceptability & Repeatability
  14. 14. 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.
  15. 15. 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.
  16. 16. 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.
  17. 17. 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.
  18. 18. Results Reporting Example
  19. 19. Pre & Post Bronchodilator Studies: Withholding Medications
  20. 20. 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.
  21. 21. 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
  22. 22. 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%
  23. 23. 4- Postbronchodilator FEV1/FVC > 70% asthma < 70% COPD
  24. 24. 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
  25. 25. 2- Look at …………FEV1/FVC < N(70%) ≥ N(70%) Obstructive or Mixed Restrictive or Normal 3- Look at FVC ≥ N(80%) Normal or SAWD 4-Look at FEF25/75 > 50% Normal < 50% SAWD < N(80%) Restrictive
  26. 26. Changes in Lung Volumes in Various Disease States Ruppel GL. Manual of Pulmonary Function Testing, 8th ed., Mosby 2003
  27. 27. Patterns of Abnormality Obstructive low FEV1 relative to FVC, low PEF, low FEV1%FVC R eco rd ed Pred icted SR % Pred 0.56 3.25 -5.3 17 1.65 4.04 -3.9 41 FEV 1 % FV C 34 78 -6.1 44 PEF 2.5 8.28 -4.8 30 FEV 1 FV C Restriction low FEV1 & FVC, high FEV1%FVC R eco rd ed FEV 1 FV C FEV 1 % FV C PEF Pred icted SR % Pred 1.49 2.52 -2.0 59 1.97 3.32 -2.2 59 76 74 0.3 103 8.42 7.19 1.0 117 high PEF early ILD low PEF late ILD
  28. 28. Patterns of Abnormality Upper Airway Obstruction low PEF relative to FEV1 R eco rd ed Pred icted SR % Pred 2.17 2.27 -0.3 96 2.68 2.70 0.0 99 81 76 0.7 106 PEF 2.95 5.99 -3.4 49 FEV 1 /PEF 12.3 FEV 1 FV C FEV 1 % FV C 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
  29. 29. Flow Common FVL Shapes Volume Normal Hesitation Young or quitter Knee Poor effort Coughing
  30. 30. Upper Airway Obstruction 6 Expiratory Age 40 yrs FVC 3.52 L FEV1 3.0 L 0.74 SR PEF 4.57 L/s 4 0.84 SR -2.18 SR FEV/PEF = 10.9 Flow in L/s 2 0 0 1 2 4 5 6 Volume in Litres -2 -4 -6 3 Inspiratory FEV1 in mls > 8 PEF in L/min
  31. 31. 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
  32. 32. Diffusing Capacity  Decreased DLCO (<80% predicted)  Increased DLCO (>120-140% predicted)  Obstructive lung disease  Asthma (or normal)  Parenchymal disease  Pulmonary hemorrhage  Pulmonary vascular disease  Polycythemia  Anemia  Left to right shunt
  33. 33. DLCO — Indications  Differentiate asthma from emphysema  Evaluation and severity of restrictive lung disease  Early stages of pulmonary hypertension
  34. 34. Diagnosis of COPD  Clinical  Spirometric  Radiological
  35. 35. 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
  36. 36. Centrilobular Emphysema
  37. 37. Panlobular Emphysema
  38. 38. Fibrosis and Emphysema
  39. 39. 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.
  40. 40. Emphysema Curved arrow: area of low attenuation. • Solid arrow: zones of vascular disruption.• Open arrow: area of lung destruction.•
  41. 41. Emphysematous Bullae www.ctsnet.org/doc/6761
  42. 42. 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.
  43. 43. 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
  44. 44. 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
  45. 45. 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
  46. 46. Bronchiolitis obliterans
  47. 47. Early Sarcoidosis
  48. 48. Chronic EAA
  49. 49. Hypersensitivity pneumonitis Extr. Allerg. Alveolitis (EAA) HRCT Morphology acute - subacute acinar (centrilobular) unsharp densities ground glass (patchy - diffuse) chronic: fibrosis Intra- / interlobular septal thickening Irregular interfaces Traction bronchiectasis
  50. 50. 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
  51. 51. DI P
  52. 52. Cellular NSIP
  53. 53. Mosaic Perfusion Chronic pulmonary embolism LOOK FOR Pulmonary hypertension idiopathic, cardiac disease, pulmonary disease
  54. 54. CTEPH = Chronic thrombembolic pulmonary hypertension
  55. 55. 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.
  56. 56. Ultrasound profiles. Lichtenstein D A , Mezière G A Chest 2008;134:117-125
  57. 57. the "seashore sign" (Fig.3).
  58. 58. Multiple B-lines - « comet-tails » - interstitial edema (B1) 7 mm apart « B lines » thickened interlobular septa http://www.reapitiehttp://www.reapitie- JJR 25 05 D Lichtenstein et al AJRCCM 156 : 1640-1646 ,09 2012 02 1997

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