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Chapter 22. Management of Chronic Obstructive Pulmonary Diseases

A 50-year-old female has worsening exertional dyspnea. For 10 years she has coughed up whitish to occasionally yellow-green phlegm most days. Two years ago, she had dyspnea while climbing stairs. Six months ago, she became dyspneic after walking 20 meters on a flat surface. Her past medical history includes childhood asthma, anxiety, and hypertension. She previously smoked two packs of cigarettes/day starting at age 18 years, but reduced that to one pack/day two years ago. Physical exam reveals an alert, thin woman. Vital signs are: BP = 150/90 mm Hg, pulse = 108/min, f = 28/min, TB = 98.2°F (36.8°C). She has a prolonged expiratory phase, bronchovesicular breath sounds, and low-pitched wheezes bilaterally. Which of the following post-bronchodilator measurements is most consistent with a presumptive diagnosis of COPD in this patient?

a. FEV1/FVC < lower limit of normal for age, gender, and height

b. FEV1/FVC <80% of predicted for age, gender, and height

c. TLC <80% of predicted for age, gender, and height

d. DLCO >120%

e. Steep downward slope of the expiratory limb of her flow-volume loop

The most correct answer is a.

FEV1/FVC imagelower limit of normal for age, gender, and height. ATS/ERS Guidelines define obstruction as an FEV1/FVC imagelower limit of normal for age, gender, and height. An alternative definition of obstruction used by the GOLD guidelines is an FEV1/FVC image70% (answer b incorrect). A TLC image80% is indicative of restriction and not obstruction (answer c) that leads to the hyperinflation (TLC >120%) that is typically found in COPD. DLCO in COPD is typically decreased due to loss of capillary-alveolar membrane surface area (answer d), particularly in emphysema. A steep downward slope of the expiratory limb of the flow-volume loop is characteristic of restriction (answer e), while the forced expiratory flow-volume curve in obstruction is upwardly concave (Chap. 6).

A 55-year-old male is referred by the emergency department (ED) physician to pulmonary clinic for evaluation of dyspnea. He has long-standing progressive dyspnea and minimal cough without sputum production for the past 10 years. He has smoked two packs per day since age 15 years. Physical exam reveals a barrel chest and decreased breath sounds on both lung fields. Spirometry shows his FEV1 = 40% of predicted with an FEV1/FVC ratio = 58% of predicted. His SaO2 by pulse oximetry is 88%. A high-resolution chest CT reveals diffuse emphysematous changes bilaterally. Which of the following is most associated with improved ...

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