Limits...
Lung function testing in COPD: when everything is not so simple.

Barisione G, Brusasco C, Garlaschi A, Crimi E, Brusasco V - Respirol Case Rep (2014)

Bottom Line: We report the case of an elderly man, former heavy smoker, who presented with progressive exertional dyspnea for 1 year.Lung function tests showed near normal spirometry and lung volumes but marked reduction of diffusing capacity for carbon monoxide and even more nitric oxide.The arterial partial pressure of oxygen was reduced with a markedly increased alveolar-to-arterial difference.

View Article: PubMed Central - PubMed

Affiliation: U.O. Fisiopatologia Respiratoria, Dipartimento di Medicina Interna e Specialità Mediche, IRCCS Azienda Ospedaliera Universitaria San Martino - IST Genoa, Italy.

ABSTRACT
Combined pulmonary fibrosis and emphysema is a condition occurring mainly in male smokers, presenting different lung mechanics and gas exchange abnormalities than emphysema or pulmonary fibrosis alone. We report the case of an elderly man, former heavy smoker, who presented with progressive exertional dyspnea for 1 year. Lung function tests showed near normal spirometry and lung volumes but marked reduction of diffusing capacity for carbon monoxide and even more nitric oxide. The arterial partial pressure of oxygen was reduced with a markedly increased alveolar-to-arterial difference. High-resolution computed tomography of the chest showed a pattern consistent with upper lobe emphysema and lower lobe pulmonary fibrosis. In conclusion, this case report confirms the limitations of a simplistic approach to lung function in the diagnosis of symptomatic smokers.

No MeSH data available.


Related in: MedlinePlus

High-resolution computed tomography showing emphysematous areas in both upper lobes (left) and sub-pleural reticular pattern opacities with ground-glass appearance in the right lower lobe.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
getmorefigures.php?uid=PMC4263496&req=5

fig01: High-resolution computed tomography showing emphysematous areas in both upper lobes (left) and sub-pleural reticular pattern opacities with ground-glass appearance in the right lower lobe.

Mentions: In 2014, a 70-year-old Caucasian man, markedly overweight (body mass index: 29.3 kg·m−2) and with concomitant arterial hypertension and coronary artery disease, presented with dyspnea on exertion progressing over the last year. He had a 60-pack-year history of cigarette smoking, which he had quit in 2009. He was a shipping agent at a harbor with indirect exposure to asbestos for his whole occupational life. On auscultation, fine crackles were heard on mid-to-late inspiration over the lower lung zones bilaterally. Pulmonary function tests showed post-bronchodilator (salbutamol 400 μg) forced expiratory volume in one second (FEV1), its ratio to forced vital capacity (FEV1/FVC) and total lung capacity (TLC) slightly above the respective lower limits of normality (Table 1). Mean inspiratory resistance and reactance, measured by forced oscillation technique, were within the normal range at all forcing frequencies, without frequency dependence of resistance. However, using the single-breath nitric oxide (NO)-carbon monoxide (CO) method, the lung diffusing capacity for NO (DLNO) and CO (DLCO) were markedly reduced (32% and 57% of predicted values, respectively), and so were the derived values alveolar-capillary membrane conductance (DM,CO: 28.3 mL⋅min−1⋅mmHg−1) and pulmonary capillary volume (VC: 29.8 mL). Resting arterial blood gas analysis showed a mild hypoxemia (Pa,O2: 60 mmHg) associated with a widening of alveolar-to-arterial O2 tension difference (PA-a,O2: 44.5 mmHg). HRCT showed the presence of emphysema in both upper lobes and a sub-pleural reticular pattern in both lower lobes (Fig. 1), with quantitative analysis demonstrating a marked difference in lung density between lower (0.24 g⋅mL−1) and upper (0.18 g⋅mL−1) lung regions. Serum levels of α1-antitrypsin, angiotensin-1-converting enzyme, and C-reactive protein were within their normal ranges, and search for antinuclear antibodies was negative. Bronchoalveolar lavage fluid showed a reduced total cell count (6.0 × 104·mL−1), with relative T-lymphocytosis (70%) and an increased CD4/CD8 ratio of 5. The patient refused open lung biopsy and was treated with inhaled tiotropium bromide and long-term O2 supplementation (2 L·min−1, FI,O2: 0.24). After one month of treatment, his condition improved and PaO2 at rest increased to 66 mmHg on room air.


Lung function testing in COPD: when everything is not so simple.

Barisione G, Brusasco C, Garlaschi A, Crimi E, Brusasco V - Respirol Case Rep (2014)

High-resolution computed tomography showing emphysematous areas in both upper lobes (left) and sub-pleural reticular pattern opacities with ground-glass appearance in the right lower lobe.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4263496&req=5

fig01: High-resolution computed tomography showing emphysematous areas in both upper lobes (left) and sub-pleural reticular pattern opacities with ground-glass appearance in the right lower lobe.
Mentions: In 2014, a 70-year-old Caucasian man, markedly overweight (body mass index: 29.3 kg·m−2) and with concomitant arterial hypertension and coronary artery disease, presented with dyspnea on exertion progressing over the last year. He had a 60-pack-year history of cigarette smoking, which he had quit in 2009. He was a shipping agent at a harbor with indirect exposure to asbestos for his whole occupational life. On auscultation, fine crackles were heard on mid-to-late inspiration over the lower lung zones bilaterally. Pulmonary function tests showed post-bronchodilator (salbutamol 400 μg) forced expiratory volume in one second (FEV1), its ratio to forced vital capacity (FEV1/FVC) and total lung capacity (TLC) slightly above the respective lower limits of normality (Table 1). Mean inspiratory resistance and reactance, measured by forced oscillation technique, were within the normal range at all forcing frequencies, without frequency dependence of resistance. However, using the single-breath nitric oxide (NO)-carbon monoxide (CO) method, the lung diffusing capacity for NO (DLNO) and CO (DLCO) were markedly reduced (32% and 57% of predicted values, respectively), and so were the derived values alveolar-capillary membrane conductance (DM,CO: 28.3 mL⋅min−1⋅mmHg−1) and pulmonary capillary volume (VC: 29.8 mL). Resting arterial blood gas analysis showed a mild hypoxemia (Pa,O2: 60 mmHg) associated with a widening of alveolar-to-arterial O2 tension difference (PA-a,O2: 44.5 mmHg). HRCT showed the presence of emphysema in both upper lobes and a sub-pleural reticular pattern in both lower lobes (Fig. 1), with quantitative analysis demonstrating a marked difference in lung density between lower (0.24 g⋅mL−1) and upper (0.18 g⋅mL−1) lung regions. Serum levels of α1-antitrypsin, angiotensin-1-converting enzyme, and C-reactive protein were within their normal ranges, and search for antinuclear antibodies was negative. Bronchoalveolar lavage fluid showed a reduced total cell count (6.0 × 104·mL−1), with relative T-lymphocytosis (70%) and an increased CD4/CD8 ratio of 5. The patient refused open lung biopsy and was treated with inhaled tiotropium bromide and long-term O2 supplementation (2 L·min−1, FI,O2: 0.24). After one month of treatment, his condition improved and PaO2 at rest increased to 66 mmHg on room air.

Bottom Line: We report the case of an elderly man, former heavy smoker, who presented with progressive exertional dyspnea for 1 year.Lung function tests showed near normal spirometry and lung volumes but marked reduction of diffusing capacity for carbon monoxide and even more nitric oxide.The arterial partial pressure of oxygen was reduced with a markedly increased alveolar-to-arterial difference.

View Article: PubMed Central - PubMed

Affiliation: U.O. Fisiopatologia Respiratoria, Dipartimento di Medicina Interna e Specialità Mediche, IRCCS Azienda Ospedaliera Universitaria San Martino - IST Genoa, Italy.

ABSTRACT
Combined pulmonary fibrosis and emphysema is a condition occurring mainly in male smokers, presenting different lung mechanics and gas exchange abnormalities than emphysema or pulmonary fibrosis alone. We report the case of an elderly man, former heavy smoker, who presented with progressive exertional dyspnea for 1 year. Lung function tests showed near normal spirometry and lung volumes but marked reduction of diffusing capacity for carbon monoxide and even more nitric oxide. The arterial partial pressure of oxygen was reduced with a markedly increased alveolar-to-arterial difference. High-resolution computed tomography of the chest showed a pattern consistent with upper lobe emphysema and lower lobe pulmonary fibrosis. In conclusion, this case report confirms the limitations of a simplistic approach to lung function in the diagnosis of symptomatic smokers.

No MeSH data available.


Related in: MedlinePlus