5 курс / Пульмонология и фтизиатрия / Clinical_Manifestations_and_Assessment_of_Respiratory
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FIGURE 13.7 Normal spirogram and spirogram typical of patients with mild to moderate chronic obstructive pulmonary disease.
Severity Assessment of Chronic Obstructive Pulmonary Disease
According to GOLD, before an effective treatment plan for COPD can be outlined, a thorough COPD assessment must first be performed. The primary goals of COPD assessment are to (1) establish the degree of airflow limitation, (2) determine the effect of the COPD on the patient's health status, and (3) ascertain the risk for future events (e.g., exacerbations or hospital admissions).
To achieve this goal, GOLD recommends the assessment of the following features of the disease independently:
•Airflow limitation
•Symptoms
•Exacerbation risk
•Comorbidities
Assessment of Airflow Limitation
As shown in Table 13.1, GOLD has established a classification chart of airflow limitation severity in COPD. This classification chart defines the severity of the disease according to airflow limitation. The primary pulmonary functions test (PFT) measurements used to evaluate the patient's airflow limitation are the forced expiratory volume in one second (FEV1)
and the forced expiratory volume in one second (FEV1) to forced vital capacity ratio (FEV1/FVC ratio). Spirometry should be performed after the administration of a short-acting inhaled bronchodilator to minimize variability.
TABLE 13.1
Severity of Airflow Limitation in Chronic Obstructive Pulmonary Disease Based on Postbronchodilator FEV1
(Only in Patients With FEV1/FVC Ratio <0.70)
GOLD 1 |
Mild |
FEV1 |
≥80% predicted |
GOLD 2 |
Moderate |
FEV1 |
50%–79% predicted |
GOLD 3 |
Severe |
FEV1 |
30%–49% predicted |
GOLD 4 |
Very Severe |
FEV1 |
≤29% or less than predicted |
Modified from GOLD, Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Revised 2018. http://www.goldcopd.org.
It should be noted that assessing the degree of reversibility of airflow limitation before and after bronchodilator or corticosteroids is no longer recommended. The degree of reversibility has not been shown to help in the diagnosis of COPD, differentiate the COPD diagnosis from asthma, or predict the patient's possible response to long-term treatment. Because there is only a weak correlation among the patient's FEV1, symptoms, and impairment of the patient's health
status, a formal symptomatic assessment is required.
Assessment of Symptoms
There are several validated questionnaires available to assess symptoms in patients with COPD. GOLD recommends using either the Modified British Medical Research Council (mMRC) Breathlessness Scale or the COPD Assessment Test (CAT).
The mMRC questionnaire relates well to other health conditions and predicts future mortality risks. An mMRC score of less than 1 is classified as a low-risk patient; a score greater than 2 is considered a high-risk patient. Table 13.2 shows an mMRC questionnaire.
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TABLE 13.2
Modified Medical Research Council (mMRC) Dyspnea Scale
mMRC |
Check the Score Box That Best Applies to You (One Box Only) |
|
Score |
|
|
|
|
|
0 |
I only get breathless with strenuous exercise. |
□ |
1 |
I get short of breath when hurrying on level ground or walking up a slight hill. |
□ |
2 |
On level ground, I walk slower than people of the same age because of breathlessness or have to stop for |
□ |
|
breath when walking at my own pace. |
|
3 |
I stop for breath after walking about 100 meters or after a few minutes on level ground. |
□ |
4 |
I am too breathless to leave the house or I am breathless when dressing. |
□ |
The CAT is an eight-item one-dimensional assessment of health status in COPD. This questionnaire is applicable worldwide, and validated translations are available in a wide range of languages. A score less than 10 is classified as a lowrisk patient; a score greater than 10 is identified as a high-risk patient. Fig. 13.8 shows an example of the CAT assessment.
FIGURE 13.8 COPD Assessment tests. (Courtesy GlaxoSmithKline. In Jones PW, et al: Development and first validation of the COPD assessment test, European Respiratory Journal 34(3): 648-654, 2009.)
Assessment of Exacerbation Risk
According to GOLD, a COPD exacerbation is defined as “acute worsening of respiratory symptoms that result in additional therapy.” An exacerbation event is classified as either mild, moderate, or severe as follows:
•Mild exacerbation: Treated with short-acting bronchodilators (SABDs) only
•Moderate exacerbation: Treated with SABDs plus antibiotics and/or oral corticosteroids
•Severe exacerbation: Patient requires visit to emergency room and/or hospitalization
•Severe exacerbations also may be associated with acute ventilatory failure.
The best predictor for the risk for exacerbations is the patient's history of exacerbations, including hospitalizations. A history of two or more exacerbations per year is considered a high risk for more exacerbations. In addition, the risk for exacerbation is significantly higher in patients identified as GOLD 3 (severe) and GOLD 4 (very severe) (see Table 13.1).
Assessment of Comorbidities
Patients with COPD often have additional diseases that further worsen their condition. Common comorbidities associated with COPD include cardiovascular disease, skeletal muscle dysfunction, metabolic syndrome, osteoporosis, depression, anxiety, and lung cancer. Having COPD itself can also have significant extrapulmonary (systemic) effects, including weight loss and nutritional abnormalities. Comorbidities in patients with COPD should be evaluated and treated appropriately. The diagnosis, assessment of severity, and management of specific comorbidities in patients with COPD are the same as in any other patient.
To summarize, to assess the severity of the patient's COPD—and, importantly, to subsequently develop a pharmacologic treatment algorithm that is specifically designed to meet the patient's needs (discussed later in this chapter)—GOLD recommends that the patient undergo the following:
1.Spirometry to determine the severity of airflow limitation
2.An assessment of either the patient's dyspnea (using mMRC), or symptoms (using CAT)
3.A full history of the patient's exacerbations, including hospitalizations
4.Consideration of the effect of any associated comorbidities
By establishing the patient's spirometric values, current symptoms, exacerbation history, and comorbidities, the ability to diagnosis, prognosticate, and develop an effective and helpful therapeutic treatment plan for the patient is quickly and systematically secured. GOLD has developed an outstanding combined COPD Assessment Tool that can be used to quickly gather, organize, and manage all of the COPD patient's relative clinical information.
Combined COPD Assessment Tool.
A representative example of GOLD's Combined COPD Assessment Tool is shown in Fig. 13.9.
FIGURE 13.9 Combined COPD Assessment Tool. (Data from GOLD, Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. Revised 2018. Retrieved from http://www.goldcopd.org.)
•The GOLD numbers (1, 2, 3, or 4) represent the severity of the patient's airflow limitation.
•The Groups A, B, C, and D are derived from the patient's present “dyspnea,” or “symptoms,” and past history of “exacerbations” values.
The patient's GOLD score (i.e., 1, 2, 3 or 4), in conjunction with the patient's symptoms and exacerbation history values, provides the practicing clinician a consistent and simple tool to quickly assess the severity of the patient's COPD and, as discussed later in this chapter, provides the basis to develop an effective pharmacologic treatment plan. Box 13.1 provides two case examples that demonstrate the application of the Combined Assessment Tool.
Box 13.1
Combined Chronic Obstructive Pulmonary Disease Assessment Case
Examples
Case 1
A 73-year-old male COPD patient has a “symptom CAT” score of 16, an FEV1 of 55% (GOLD Grade 2) of predicted, and a
history of three exacerbations within the last 12 months. Based on this information, the symptom CAT score shows that the patient is more symptomatic (CAT ≥10) and therefore should be placed in either Group B or Group D.
Between groups B and D, the GOLD Grade of 2 (moderate airflow limitation) indicates Low Exacerbation Risk—which suggests the patient should be placed in Group B. However, because the patient had three exacerbations in the last 12 months, the correct placement is Group D—which shows High Exacerbation Risk, More Symptoms, and more than two exacerbations in the last year (see Fig. 13.9). As will be discussed later in this chapter, an effective and helpful pharmacologic treatment algorithm now can be established based on this assessment information (see Fig. 13.18).
Case 2
A 67-year-old female patient with COPD has a “dyspnea mMRC” score of 1, a “symptom CAT” score of 8, an FEV1 of
44% (GOLD Grade 3) of predicted, and a history of four exacerbations within the last 12 months. Based on this information, the symptom CAT score shows that the patient is “less symptomatic” (mMRC 1 and CAT <10) and therefore should be placed in either Group C or Group A.
Between Groups C and A, the GOLD Grade of 3 (severe airflow limitation) indicates “High Exacerbation Risk”—which suggests the patient should be placed in Group C. In addition, the fact that the patient has had four exacerbations in the last 12 months further confirms that the correct placement for this patient is Group C, which shows High Exacerbation Risk, Fewer Symptoms, and more than two Exacerbations in the last year (see Fig. 13.9). As will be discussed later in
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this chapter, an effective and helpful pharmacologic treatment algorithm now can be established based on this assessment information (see Fig. 13.18).
Additional Screening Methods Used to Diagnosis Chronic Obstructive Pulmonary Disease.
Table 13.3 provides additional diagnostic procedures that may be considered in the diagnosis and assessment of COPD.
TABLE 13.3
Additional Tests to Consider in Assessment and Diagnosis of Chronic Obstructive Pulmonary Disease
Imaging |
A chest x-ray is not helpful to establish a diagnosis of COPD |
|
However, it may be valuable in ruling out other diagnoses or establishing the presence of |
|
significant comorbidities, such as pneumonia, pulmonary fibrosis, bronchiectasis, pleural |
|
disease, kyphoscoliosis, and cardiac diseases. |
|
Radiologic changes associated with COPD include lung hyperinflation, hyperlucency of the lungs, |
|
and rapid tapering of the vascular markings. |
|
Computed tomography scanning may be helpful in the detection of bronchiectasis lung cancer in |
|
the patient with COPD |
Lung volumes and |
A complete measurement of lung volumes, capacities, and airflow limitations can provide |
diffusing |
additional information concerning the severity of the disease. |
capacity |
Measurement of the diffusing capacity (DLCO) provides further information on the functional |
|
effect of emphysema in COPD. |
|
The DLCO also may explain the breathlessness in some patients that appears out of proportion |
|
to the degree of airflow limitation. |
Oximetry and |
Oximetry is commonly used to assess the patient's arterial oxygen saturation and the need for |
arterial blood |
supplemental oxygen therapy. |
gas |
Oximetry is recommended to assess all patients with clinical signs that suggest respiratory failure |
measurement |
or right-heart failure |
|
When the peripheral arterial oxygen saturation (SpO2) is <92%, an arterial or capillary blood |
|
gases should be assessed. |
|
For example, an ABG of a patient with “stable” COPD could be pH 7.36, PaCO2 79, HCO3– 43, |
|
and PaO2 61; or |
|
An ABG example that shows the patient with COPD is in “impending ventilatory failure” (or |
|
acute alveolar hyperventilation on top of chronic ventilatory failure) could be pH 7.52, PaCO2 |
|
52, HCO3– 40, and PaO2 46 (mild or moderate acute exacerbation); or |
|
An ABG example that shows the patient with COPD is in “acute ventilatory failure” (on top of |
|
chronic ventilatory failure) could be pH 7.28, PaCO2 99, HCO3– 45, and PaO2 34 (severe acute |
|
exacerbation) (see Chapter 5 for further discussion). |
Exercise testing |
Objectively measured exercise activities, such as self-paced shuttle walk test, or the unpaced 6- |
and assessment |
minute walk test, are powerful indicators of the patient's health status. |
of physical |
Walking tests are useful in assessing the disability and risk for mortality, and are used to measure |
activity |
the effectiveness of pulmonary rehabilitation. |
|
Laboratory testing using cycle or treadmill ergometry are useful in identifying coexisting or |
|
alternative conditions (e.g., cardiac disease). |
Alpha1-antitrypsin |
When a younger patient (<45 years old) presents with a history and clinical indicators associated |
deficiency |
with COPD, an AATD screen should be considered. |
(AATD) screen |
A serum concentration below 15% to 20% of normal value is highly suggestive of emphysema |
|
caused by AATD. |
Key Distinguishing Features Between Emphysema and Chronic Bronchitis
Even though chronic bronchitis and emphysema often occur as one disease complex referred to as COPD, they can develop alone. A complete presentation of all the specific signs and symptoms associated with emphysema and chronic bronchitis are provided in the Overview of the Cardiopulmonary Clinical Manifestations section on page 199.
An abbreviated and handy overview of the key distinguishing features between emphysema and chronic bronchitis is provided as follows.
Clinically, the patient with emphysema is sometimes classified as a “pink puffer,” or a patient with type A COPD; and the patient with chronic bronchitis is sometimes classified as a “blue bloater,” or a patient with type B COPD. These general, older terms are primarily based on the clinical manifestations commonly associated with each respiratory disorder.
• Pink puffer (Type A Chronic Obstructive Pulmonary Disease): The term pink puffer is derived from the reddish complexion and the “puffing” (pursed-lip breathing) commonly seen in the patient with emphysema. The major pathophysiologic mechanisms responsible for the red complexion and puffing are the following:
•Emphysema is caused by the progressive destruction of the distal airways and pulmonary capillaries.
•The progressive elimination of the distal airways and pulmonary capillaries leads to ventilation-perfusion (V/Q) mismatches.
•To compensate for these V/Q ratio mismatches, the patient hyperventilates.
•The increased respiratory rate, in turn, works to maintain a relatively normal arterial oxygenation level and causes a ruddy or flushed skin complexion. During the advanced stage of emphysema, however, the patient's oxygenation status decreases and the carbon dioxide level increases.
•Thus the patient with emphysema, who has both a red complexion and a rapid respiratory rate, is called a pink puffer.
•In addition to the marked dyspnea and ruddy complexion, the pink puffer tends to be
thin (because of the muscle wasting and weight loss associated with the increased work of breathing), has a barrel chest (because of hyperinflated lungs), uses accessory muscles of inspiration, and exhales through pursed lips.
• Blue bloater (Type B Chronic Obstructive Pulmonary Disease): The term blue bloater is derived from the cyanosis—the bluish color of the lips and skin—commonly seen in the patient with chronic bronchitis. The bluish complexion is caused by the following:
•Unlike emphysema, the pulmonary capillaries in the patient with chronic bronchitis are not damaged. The patient with chronic bronchitis responds to the increased airway obstruction by decreasing ventilation and increasing cardiac output—that is, a decreased V/Q ratio.
•The chronic hypoventilation and increased cardiac output (decreased V/Q ratio) leads to a decreased arterial oxygen level, an increased arterial carbon dioxide level, and a compensated (normal) pH—or chronic ventilatory failure arterial blood gas (ABG) values (also called compensated respiratory acidosis). The respiratory drive is depressed in patients with chronic ventilatory failure.
•The persistent low V/Q ratio and depressed respiratory drive both contribute to a chronically reduced arterial oxygenation level and polycythemia that in turn causes cyanosis. In addition, the blue bloater tends to be stocky and overweight, has a chronic productive cough, and frequently has swollen ankles and legs and distended neck veins as a result of pulmonary hypertension and right-sided heart failure (cor pulmonale).
Table 13.4 provides an overview of the more common distinguishing features between emphysema and chronic bronchitis.
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TABLE 13.4
Key Features Distinguishing Emphysema From Chronic Bronchitis*
Clinical |
Emphysema (Type A COPD: Pink Puffer) |
Chronic Bronchitis (Type B COPD: Blue |
Manifestation |
Bloater) |
|
Inspection |
|
|
Body build |
Thin |
Stocky, overweight |
Barrel chest |
Common, classic sign |
Normal |
Respiratory |
Hyperventilation and marked dyspnea; often occurs |
Diminished respiratory drive |
pattern |
at rest |
Hypoventilation common, with resultant |
|
Late stage: Diminished respiratory drive and |
hypoxia and hypercapnia |
|
hypoventilation |
|
Pursed-lip |
Common |
Uncommon |
breathing |
|
|
Cough |
Uncommon |
Common; classic sign |
Sputum |
Uncommon |
Common; classic sign |
|
|
Copious amounts, purulent |
Cyanosis |
Uncommon (reddish skin) |
Common |
Peripheral |
Uncommon |
Common |
edema |
|
Right-sided heart failure |
Neck vein |
Uncommon |
Common |
distention |
|
Right-sided heart failure |
Use of |
Common |
Uncommon |
accessory |
|
|
muscles |
|
|
Auscultation |
Decreased breath sounds, decreased heart sounds, |
Wheezes, crackles, depending on severity of |
|
prolonged expiration |
disease |
Percussion |
Hyperresonance |
Normal |
Laboratory Tests |
|
|
Chest |
Hyperinflation, narrow mediastinum, normal or small |
Congested lung fields, densities, increased |
radiograph |
vertical heart, low flat diaphragm, presence of blebs |
bronchial vascular markings, enlarged |
|
or bullae |
horizontal heart |
Polycythemia |
Uncommon |
Common |
Infections |
Occasionally |
Common |
Pulmonary Function Study |
|
|
DLCO and |
Decreased |
Often normal |
DL/VA |
|
|
Other |
|
|
Pulmonary |
Uncommon |
Common |
hypertension |
|
|
Cor pulmonale |
Uncommon |
Common |
|
|
Right-sided heart failure |
*The clinical features of emphysema and chronic bronchitis are not always clear-cut because many patients have a combined disease process (COPD; this is especially the case during the late stages of emphysema and chronic bronchitis).
The clinical features of emphysema and chronic bronchitis are not always clear-cut because many patients have a combined disease process, COPD. This is especially the case during the late stages of emphysema and chronic bronchitis.4
Overview of the Cardiopulmonary Clinical Manifestations Associated with Chronic Bronchitis and Emphysema (Chronic Obstructive Pulmonary Disease)1
The following clinical manifestations result from the pathophysiologic mechanisms caused (or activated) by excessive bronchial secretions (see Fig. 10.11) and bronchospasm (see Fig. 10.10)—the major anatomic alterations of the lungs associated with chronic bronchitis (see Figs. 13.1 and 13.2), and the clinical manifestations activated by distal airway and alveolar weakening (see Fig. 10.12)—the major anatomic alterations of the lungs associated with emphysema (see Figs. 13.3, 13.4, and 13.5).
Clinical Data Obtained at the Patient's Bedside
|
Vital Signs |
Chronic Bronchitis and Emphysema |
|
|
Heart rate and respiratory |
Stable patients: Normal vital signs |
|
|
rate |
Exacerbations: Usually acute increase in heart rate and respiratory rate |
|
|
|
(tachypnea) |
|
|
|
Classic signs of hypoxemia |
|
|
|
|
|
|
Chest Assessment Findings |
Emphysema |
Chronic Bronchitis |
|
|
Inspection |
|
|
|
|
General body build |
Thin, underweight |
Stocky, overweight |
|
|
Altered sensorium—anxiety, irritability |
Common during |
Common during moderate and severe |
|
|
|
severe stage |
stage |
|
|
|
Classic sign of |
Classic sign of hypoxemia |
|
|
|
hypoxemia |
|
|
|
|
|
|
|
|
Barrel chest |
Classic sign |
Occasionally |
|
|
Digital clubbing |
Late stage |
Common |
|
|
Cyanosis |
Uncommon—often |
Common |
|
|
|
reddish skin |
|
|
|
Peripheral edema and venous distention |
End-stage emphysema |
Common |
|
|
|
|
Because polycythemia and cor |
|
|
|
|
pulmonale are common in chronic |
|
|
|
|
bronchitis, the following are often |
|
|
|
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seen: |
|
|
|
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• Distended neck veins |
|
|
|
|
• Pitting edema |
|
|
|
|
• Enlarged and tender liver |
|
|
Use of accessory muscles |
Common, especially |
Uncommon |
|
|
|
during exacerbations |
End stage in some chronic bronchitis |
|
|
Hoover sign: The inward movement of the |
Common—severe stage |
Uncommon |
|
|
lower lateral chest wall during each |
|
|
|
|
inspiration—indicates severe hyperinflation |
|
|
|
|
Pursed-lip breathing |
Common |
Uncommon |
|
|
Cough |
Uncommon during |
Classic sign |
|
|
|
mild and moderate |
More severe in the mornings |
|
|
|
stage |
|
|
|
|
Some coughing during |
|
|
|
|
severe stage with |
|
|
|
|
infection |
|
|
|
Sputum |
Uncommon |
Common |
|
|
|
Little, mucus |
Classic sign; copious amounts, |
|
|
|
|
purulent (see sputum examination) |
|
|
Palpation of the chest |
Decreased tactile |
Normal |
|
|
|
fremitus |
|
|
|
|
Decreased chest |
|
|
|
|
expansion |
|
|
|
|
Point of maximal |
|
|
|
|
impulse (PMI) |
|
|
|
|
often shifts to the |
|
|
|
|
epigastric area |
|
|
|
Percussion of the chest |
Hyperresonance |
Normal |
|
|
|
Decreased |
|
|
|
|
diaphragmatic |
|
|
|
|
excursion |
|
|
|
Auscultation of the chest |
Diminished breath |
Crackles |
|
|
|
sounds |
Wheezes |
|
|
|
Prolonged expirations |
|
|
|
|
Diminished heart |
|
|
|
|
sounds |
|
|
|
|
|
|
|
Clinical Data Obtained from Laboratory and Special Procedures
Pulmonary Function Test Findings
Moderate to Severe Chronic Bronchitis and Emphysema (Obstructive Lung Pathophysiology)
Pulmonary function tests are the cornerstone to the diagnostic evaluation of patients with suspected COPD. The most important values measured are the forced expiratory volume in 1 second (FEV1), the forced vital capacity (FVC), and
the FEV1/FVC ratio.
Forced Expiratory Volume and Flow Rate Findings
FVC |
FEVT |
FEV1/FVC ratio |
FEF25%–75% |
↓ |
↓ |
↓ |
↓ |
FEF50% |
FEF200–1200 |
PEFR |
MVV |
↓ |
↓ |
↓ |
↓ |
Lung Volume and Capacity Findings
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|
VT |
IRV |
ERV |
RV2 |
|
|
|
N or ↑ |
N or ↓ |
N or ↓ |
Normal or ↑ |
|
|
|
VC |
IC |
FRC2 |
TLC2 |
RV/TLC ratio2 |
|
|
↓ |
N or ↓ |
↑ |
N or ↑ |
N or ↑ |
|
2Air trapping, and a subsequent increase in the RV and FRC, is uncommon in patients with only chronic bronchitis. |
|
|
||||
|
|
|
|
|
|
|
Di usion Capacity (DLCO)3
Emphysema |
Chronic Bronchitis |
Decreased |
Normal |
A decreased DLCO is a classic diagnostic sign of emphysema |
|
3The most accurate way to express DLCO as the DLCO corrected for alveolar volume (DL/VA). This measure is always reduced in severe emphysema and reflects the loss of alveolar-capillary membrane.
Arterial Blood Gases
Chronic Bronchitis and Emphysema
Mild to Moderate Stages (GOLD 1 and 2)
Acute Alveolar Hyperventilation With Hypoxemia4 (Acute Respiratory Alkalosis)
pH |
PaCO2 |
HCO3– |
PaO2 |
SaO2 or SpO2 |
↑ |
↓ |
↓ |
↓ |
↓ |
|
|
(but normal) |
|
|
4See Fig. 5.2 and Table 5.4 and related discussions for the acute pH, PaCO2, and HCO3– changes associated with acute alveolar hyperventilation.
Severe Stages (GOLD 3 and 4)
Chronic Ventilatory Failure With Hypoxemia5 (Compensated Respiratory Acidosis)
pH |
PaCO2 |
HCO3– |
PaO2 |
SaO2 or SpO2 |
N |
↑ |
↑ |
↓ |
↓ |
|
|
(significantly) |
|
|
5See Table 5.6 and related discussion for the pH, PaCO2, and HCO3– changes associated with chronic ventilatory failure.
Acute Ventilatory Changes Superimposed on Chronic Ventilatory Failure6
Because acute ventilatory changes are frequently seen in patients with chronic ventilatory failure, the respiratory therapist must be familiar with—and alert for—the following two dangerous ABG findings:
•Acute alveolar hyperventilation superimposed on chronic ventilatory failure that should further alert the respiratory therapist to document the following important arterial blood gas assessment: possible impending acute ventilatory failure.
•Acute ventilatory failure (acute hypoventilation) superimposed on chronic ventilatory failure.
6See Table 5.7, Table 5.8, and Table 5.9 and related discussion for the pH, PaCO2, and HCO3– changes associated with acute ventilatory changes superimposed on chronic ventilatory failure.
Oxygenation Indices7 for Chronic Bronchitis and Emphysema
Moderate to Severe Stages
QS/QT |
DO28 |
VO2 |
|
O2ER |
|
|
|
|
|
|
|
↑ |
↓ |
N |
N |
↑ |
↓ |
8The DO2 may be normal in patients who have compensated to the decreased oxygenation status with (1) an increased cardiac output, (2) an increased hemoglobin level, or (3) a combination of both. When the DO2 is normal, the O2ER is usually normal.
7DO2, Total oxygen delivery; 
, arterial-venous oxygen difference; O2ER, oxygen extraction ratio; QS/QT, pulmonary shunt fraction; 
, mixed venous oxygen saturation; VO2, oxygen consumption.
Hemodynamic Indices9 for Chronic Bronchitis and Emphysema
Moderate to Severe Stages
CVP |
RAP |
|
PCWP |
CO |
SV |
|
|
|
|
|
|
↑ |
↑ |
↑ |
N |
N |
N |
SVI |
cardiac index |
RVSWI |
LVSWI |
PVR |
SVR |
N |
N |
↑ |
N |
↑ |
N |
9CO, Cardiac output; CVP, central venous pressure; LVSWI, left ventricular stroke work index; 
, mean pulmonary artery pressure; PCWP, pulmonary capillary wedge pressure; PVR, pulmonary vascular resistance; RAP, right atrial pressure; RVSWI, right ventricular stroke work index; SV, stroke volume; SVI, stroke volume index; SVR, systemic vascular resistance.
Laboratory Tests and Procedures
Test
|
Emphysema |
Chronic Bronchitis |
Hematocrit and |
Normal—mild to moderate stage |
Polycythemia common during early and late |
hemoglobin |
Elevated—late stage |
stages |
Electrolytes |
Late stage: |
Early and late stages: |
(abnormal) |
Hypochloremia (Cl−) when chronic |
Hypochloremia (Cl−) (when chronic |
|
ventilatory failure is present |
ventilatory failure is present) |
|
Hypernatremia (Na+) |
Hypernatremia (Na+) |
Sputum examination |
Normal |
Streptococcus pneumoniae |
(culture) |
|
Haemophilus influenzae |
|
|
Moraxella catarrhalis |
Radiology Findings
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Findings |
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Chronic Bronchitis |
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Chest |
Lungs may be clear if only large bronchi are affected. |
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Occasionally: |
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iog |
Translucent (dark) lung fields |
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Depressed or flattened diaphragms |
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Common: |
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Right ventricle (cor pulmonale) and/or left ventricle enlargement |
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No radiographic abnormalities may be present in chronic bronchitis if only the large bronchi are affected. |
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This often explains why the diagnosis is delayed. Although the situation is uncommon, if the more |
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peripheral bronchi are involved, air trapping may occur. This is revealed on x-ray film as areas of |
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translucency or areas that are darker in appearance. In addition, because of the increased functional |
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residual capacity, the diaphragms may be depressed or flattened and are seen as such on the radiograph |
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(Fig. 13.10). |
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Because bronchial wall thickening is common in chronic bronchitis, increased, diffuse, fibrotic-appearing |
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lung markings are often seen. This is commonly referred to as a dirty chest x-ray. |
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Finally, because right and left ventricular enlargement and failure are commonly associated with chronic |
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bronchitis, in the late stage an enlarged heart may be seen on the chest radiograph. |
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Br |
Although bronchograms are rarely done today, small spikelike protrusions (“train tracks” appearance of |
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airways) from the larger bronchi often could be seen on the bronchograms of patients with chronic |
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bronchitis. It is believed that the spikes result from pooling of the radiopaque medium in the enlarged |
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ducts of the mucous glands (Fig. 13.11). |
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Since the advent of the CT examination, bronchograms are seldom done today on patients with chronic |
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bronchitis. A “thin-section” CT examination is even more helpful. |
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to |
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p |
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( |
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C |
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T) |
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sc |
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a |
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Emphysema |
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Chest |
Common: |
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rad |
Translucent (dark) lung fields |
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iog |
Depressed or flattened diaphragms |
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rap |
Long and narrow heart (pulled downward by diaphragms) |
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h |
Increased retrosternal air space (lateral radiograph) |
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Occasionally: |
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Cor pulmonale (signs of cardiomegaly) |
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Emphysematous bullae |
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Because of the decreased lung recoil and air trapping in emphysema, the functional residual capacity |
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increases and the radiographic density of the lungs decreases. Consequently, the resistance to x-ray |
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penetration is not as great, causing areas of translucency or areas that are darker in appearance. Because |
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of the increased functional residual capacity, the diaphragm is depressed or flattened (a hallmark of lung |
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hyperinflation) and the heart often appears long and narrow (Fig. 13.12). |
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The lateral chest radiograph characteristically shows an increased retrosternal air space (more than 3.0 cm |
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from the anterior surface of the aorta to the back of the sternum measured 3.0 cm below the |
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manubriosternal junction) and flattened diaphragms (Fig. 13.13). Because right ventricular enlargement |
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and cor pulmonale sometimes develop as secondary problems during the advanced stages of emphysema, |
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an enlarged heart may be seen on the chest radiograph (Fig. 13.14). |
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Occasionally, emphysematous bulla may be seen on the chest radiograph or CT scan. Bullae appear as air- |
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containing cystic spaces whose walls are usually of hairline thickness. They can range in size from 1 to |
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2 cm in diameter up to an entire hemithorax (Fig. 13.15). These large, radiolucent, air-filled sacs are |
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generally found at the apices or at the bases of the lung. Bullae may become so large that they cause |
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respiratory insufficiency by compressing the remaining relatively normal lung. Fig. 13.16 shows a CT |
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image of emphysematous blebs. Finally, Fig. 13.17 shows a before and after chest radiograph of a 56-year- |
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old woman with severe COPD who qualified for a lung transplant. Before the surgery she was unable to |
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perform the simplest of tasks. After the surgery she was working out regularly at her neighborhood fitness |
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center. |
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