COPD Diagnosis and Management in the Physicians Office

COPD Diagnosis and Management in the Physicians Office

By Stanley J. Swierzewski, III M.D.

The diagnostic process for COPD includes a thorough medical history as well as one or more of the following diagnostic procedures. Pulmonary FunctionTests, Oximetry, Radiological Procedures, Arterial Blood Gases, Alpha-1-Antitrypsin Level.

History and Examination
Patients with COPD usually are current or past smokers over the age of 40 with a history of shortness of breath upon physical exertion and chronic productive cough. The physical examination may show a barrel chest, decreased breath sounds, and wheezing. Signs of right-sided heart failure, such as edema, tender liver, and distended abdomen (caused by fluid accumulation in the abdomen; called ascites) may be noted as well. COPD is a diagnosis of history (in the case of chronic bronchitis), or a diagnosis of anatomy (in the case of emphysema). Clubbing of the fingers rarely occurs in COPD and warrants investigation for other causes.

Pulmonary Function Tests (PFTs)
Pulmonary function tests are the primary diagnostic tools for COPD, after the medical history and physical examination. These tests demonstrate characteristic abnormalities in lung function that, in the proper clinical context (i.e., medical history, physical examination, chest x-ray) confirm or support the diagnosis of COPD and give some idea of the degree of impairment and prognosis. Lung biopsy is rarely used to diagnose emphysema.

There are four components to pulmonary function testing: spriometry, postbroncodilator spirometry, lung volumes, and diffusion capacity. In the initial evaluation, all four components are often performed. Periodically, an individual component, most commonly spirometry, is performed to assess progression of disease and to determine the effectiveness of medication.

• Spirometry
  The most reliable way to determine reversible airway obstruction is with spirometry, a procedure that measures the amount of air entering and leaving the lungs. This simple test can be performed in most physicians' offices, with the patient sitting comfortably in front of the spirometry machine. The machine measures airflow that passes through the inhalation port attached to the machine. The inhalation device is usually a disposable cardboard tube or a reusable tube that can be sterilized after use.

The patient inhales as deeply as possible and forms a seal around the tube with their mouth. Then the patient exhales, as forcefully and rapidly as they can, until they can exhale no more. To be an adequate test, the patient must exhale all the air they possibly can continue exhaling for at least another 6 seconds. Usually, three separate attempts are made and the best result is used for evaluation.

Multiple measurements are obtained from this maneuver. Those most commonly used for interpretation are (1) forced expiratory volume after 1 second [FEV1], (2) forced vital capacity [FVC], and (3) forced expiratory flow at 25%-75% of maximal lung volume [FEF25-75]. They are expressed as percentages of what is predicted for normal lung function, depending on the variables of height, age, race, and sex.

COPD produces characteristic results in this test. The amount of air exhaled (forced vital capacity, or FVC) is reduced, compared to a person with normal lung function. Futhermore, the amount of air exhaled during the initial 1 second (FEV1) is reduced and is reduced to a greater degree than the entire FVC. Therefore, the ratio of air exhaled after 1 second is low compared to the total amount of air exhaled. In healthy lungs, 70%-75% of all the air exhaled after maximum inhalation (FVC) is exhaled within the first second (FEV1), known as the FEV1/FVC ratio. In lungs with COPD, the FEV1/FVC ratio falls below 70%-75%.

The absolute value of the FEV1 is also reduced. The FEV1 can be reduced in another disease process, termed restrictive ventilatory defects. However, in restrictive ventilatory defects the FVC is reduced proportionally, preserving a normal FEV1/FVC ratio. The FEV1 is used to quantify the severity of obstruction with a FEV1 < 70% of what is predicted for age, height, weight and race considered mild; < 50% to 69%, moderate; < 35%-49%, severe; and < 35%, very severe. Sometimes the only abnormality is a reduction in the FEF25-75. Isolated reduction in the FEF25-75 is considered an early detector of very mild obstruction. It can also be a normal variant.

• Postbronchodilator Spirometry
  Spirometry is often repeated after giving the patient a bronchodilator, such as an inhaled beta-agonist. If the FEV1 (forced expiratory volume after 1 second) improves more than 12%, the obstruction may be reversible or partially reversible. This procedure provides some information on the potential responsiveness of the airways to medication. It is also useful for determining whether steroid treatment has been beneficial, a few weeks after initiating therapy.
• Peak expiratory flow rate (PEFR) also can be obtained. PEFR can be compared with readings the patient obtains at home with a peak flow meter. A peak flow meter is a portable device that consists of a small tube with a gauge that measures the maximum force with which one blows air through the tube.
• Lung Volumes
  Lung volumes are measured in two ways, gas dilution or body plethysmography. The gas dilution method is performed after the patient inhales a gas, such as nitrogen or helium. The amount of volume in which the gas is distributed is used to calculate the volume of air the lungs can hold. Body plethysmography requires the patient to sit in an airtight chamber (usually transparent to prevent claustrophobia) and inhale and exhale into a tube. The pressure changes in the plethysmograph are used to calculate the volumes of air in the lungs.

The most important measurements obtained are residual volume and total lung capacity (TLC). These measurements vary with age, height, weight, and race and are usually expressed as an absolute number and a percentage of what is predicted for a person with normal lung function. A high TLC demonstrates hyperinflation of the lungs, which is consistent with emphysema. Increased residual volume signifies air trapping. This demonstrates an obstruction to exhalation.

• Diffusion Capacity
  Diffusion capacity is a measurement of gases transfered from the alveoli to the capillary. The patient inhales a very small amount (very safe) of carbon monoxide. How much of it is taken into the blood is measured. A reduced diffusion capacity is consistent with emphysema but is seen in a many other lung diseases as well.

Oximetry
This noninvasive method determines the oxygenation of the blood (O2 sat; normal is greater than 90%) by measuring the amount of light transmitted through an area of skin. The device must be able to read pulsatile flow, so it must pick up a pulse to be accurate. Oximetry is not as accurate as the measurement of arterial blood gases. It is commonly used during exercise and sleep. Exercise oximetry can determine if a patient's oxygen decreases during activity. If so, oxygen therapy with activity may be beneficial. Overnight oximetry is done to see if oxygen concentrations decrease during sleep.

Radiology
Chest x-ray is an imprecise method of diagnosis of COPD. It is only consistently abnormal in severe cases and should be performed in the initial evaluation to exclude other lung diseases. Findings characteristic of COPD in chest x-ray are hyperinflated lungs with flattened diaphragm, hyperlucent lungs (chest film shows greater than normal film blackening from increased transmission of x-rays), and central pulmonary artery enlargement. Bullae, areas of destroyed lung tissue that create large dilated air sacs, may be seen as well.

CT scan may be used to more accurately diagnose emphysema. This is usually not necessary, however, and abnormal lung anatomy is not always detected.

Arterial Blood Gases
Arterial blood gases are measured using blood drawn from an artery, usually in the wrist. Blood is usually drawn from a vein, but venous blood is inaccurate for these measurements. Drawing blood from an artery, unfortunately, causes more discomfort.

Arterial blood gases are measured to determine the amount of oxygen dissolved in the blood (pO2), the percentage of hemoglobin saturated with oxygen (O2 sat), the amount of carbon dioxide dissolved in the blood (pCO2), and the amount of acid in the blood pH.

The oxygen measure may be used to determine whether a patient needs oxygen therapy. The carbon dioxide measure gives some idea of lung function and is especially important to know when starting oxygen therapy.

Alpha-1-Antitrypsin Level
A person suspected of having a genetic deficiency of this enzyme will undergo this test. Alpha-1-antitrypsin deficiencies can also cause liver disease in children, and the level may be measured for that as well. If the level is low, a genetic probe may be used to determine the cause.

Signs and Symptoms

Many of the signs of COPD are caused by the body's attempt to compensate for a damaged respiratory system. Symptoms develop as a direct result of disease processes.

Signs
Signs of COPD are consequences of the anatomical changes caused by the disease: barrel chest, pursed-lip breathing, productive cough, and cyanosis.

Barrel Chest
One telling sign is the change in the shape of the chest, known as barrel chest. When the lungs become enlarged, the diaphragm is displaced downward and is unable to contract efficiently. Furthermore, the chest wall is enlarged, making accessory breathing muscles (muscles in the neck, upper chest, and between the ribs) less efficient as well. These changes contribute to shortness of breath. This becomes apparent when a person with COPD tries do something with the arms raised above the head, such as changing a light bulb in a ceiling fixture, and becomes short of breath.

To compensate, a person with COPD often sits leaning forward with their arms supported on a surface in front of them or on their knees. This stabilizes the upper chest and shoulders and allows them to use accessory respiratory muscles more efficiently.

Pursed-Lip Breathing
Because airflow out of the lungs becomes limited, exhalation takes longer. Because the alveoli lose their elasticity, one tries to shorten the time needed for exhalation by forcefully exhaling. Unfortunately, forced exhalation increases pressure on the lungs and causes structurally weakened airways to collapse. To prevent airways from closing during forced exhalation, pursed-lip breathing is used: The lips are narrowed together, which slows exhalation at the mouth. This keeps positive pressure in the airways, thus preventing their collapse and allowing some forced exhalation.

Productive Cough
A productive cough is caused by inflammation and excessive amounts of mucus in the airways. Coughing becomes less effective because of obstructed airflow.

Cyanosis
People who have a poor supply of oxygen usually have a bluish tinge to their skin, lips, and nailbeds, called cyanosis.

Symptoms

Shortness of Breath (dyspnea)
Dyspnea, the most common symptom of COPD, comes on gradually and is first noticed during physical exertion or during acute exacerbations. It usually begins when patients are in their 60s and 70s and slowly becomes more prominent. It is closely associated with lung function decline and is not always associated with low oxygen in the blood.

Patients often wonder why dyspnea occurs so long after beginning to smoke, say 50 to 60 years later. Some patients have even quit smoking several years before symptoms appear. The main reason is that lung function declines slowly with age, even in a nonsmoker. At approximately age 30, people begin to lose lung function at a rate of 25 to 30 mL/year of forced expiratory volume in 1 second (FEV1; see Spirometry). People who smoke lose lung function at a more rapid rate, approximately 125 mL/year. Because the lungs have a considerable amount of reserve, a large portion must become nonfunctional before symptoms occur. It can take more than 30 years to lose enough lung function to experience symptoms.

When a person quits smoking, the loss in function slows to approximately the rate of a nonsmoker. If smoking has already destroyed a large portion of the lungs, the threshold will be reached, eventually, at a rate of decline of 30 mL/year instead of 125 mL/year. Without quitting, decline would continue at a rate of 125 mL/year. Quality of life can improve by quitting, even if lung function has already declined.

Chronic Cough
Chronic cough typically begins as a morning cough and slowly progresses to an all-day cough. The cough usually produces small amounts of sputum (less than 60 mL/day) and is clear or whitish but may be discolored. Sputum production decreases when one quits smoking.

The progression of the cough's frequency is so slow that a person usually tolerates it for a couple of years before seeing a doctor. Any change in a chronic cough or a new cough in a smoker or patient with COPD should be thoroughly evaluated by a physician.

Wheezing
Wheezing is the high-pitched sound of air passing through narrowed airways. A person with COPD may wheeze during an acute exacerbation or chronically. Sometimes the wheezing is heard only at night or with exertion. Bronchodilators can relieve wheezing quickly.

Hemoptysis
COPD is one of the more common causes of hemoptysis (coughing up blood). It usually occurs during an acute exacerbation, when there is a lot of coughing with purulent sputum (sputum containing pus). Usually, there are only very small amounts of blood streaking the sputum. Hemoptysis may be a sign of lung cancer in a patient with COPD, so any blood appearing in the sputum should be brought to a doctor's attention.

Weight Loss
Patients with severe COPD work hard and burn a lot of calories just breathing. These patients also become short of breath in the very act of eating, and so may not eat enough to replace the calories they use.

Lower Extremity Edema
In severe cases of COPD, pulmonary artery pressures increase and the right ventricle of the heart contracts less efficiently. When the heart is unable to pump enough blood to meet the needs of the kidneys and liver, edema (swelling) in the feet, ankles, and lower legs results. It can also cause the liver to become swollen and tender or fluid to accumulate in the abdomen (ascites). A distended abdomen can be a sign of ascites.