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A 74-year-old woman and longtime smoker presents with fatigue and shortness of breath. She has not seen a physician for many years and says she has been basically healthy. On physical examination, she is found to be pale and mildly cachectic, and her lips are cyanotic. Her breath sounds are distant, although crackles can be heard in both lung bases. Her heart sounds are best heard in the epigastrium; a third heart sound is present. She has mild peripheral edema. Her resting pulse oximetry is 74%. Her chest X-ray (CXR) shows emphysema (Figure 58-1), and her echocardiogram confirms heart failure.


Emphysema with mild hyperinflation and increased interstitial markings. (Reproduced with permission from Miller WT: Diagnostic Thoracic Imaging. New York, NY: McGraw-Hill Education; 2006.)


Chronic obstructive pulmonary disease (COPD) is defined as a disease state characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response of the lung and airways to noxious particles or gases.1 COPD is preventable and treatable. Some patients have significant extrapulmonary effects (particularly cardiac) that may contribute to disease severity. Worldwide, tobacco smoke is the primary cause of COPD (Figure 58-2).


Gross pathology of lung showing centrilobular emphysema caused by tobacco smoking. Close-up of cut surface shows multiple cavities lined by heavy black carbon deposits. (Reproduced with permission from Centers for Disease Control and Prevention [CDC] and Dr. Edwin P. Ewing, Jr.)


Emphysema (technically refers to destruction of the alveoli).


  • Estimated prevalence of COPD in adults older than age 18 years in the United States (2014) is about 15.7 million cases, or 6.4% of the population.2 Prevalence rate varies greatly between states, from <4% in Hawaii, Colorado, and Utah to >9% in Alabama, Tennessee, Kentucky, and West Virginia.3

  • Third leading cause of death in the United States (2014).2 Mortality rates have declined for men from 1999 to 2014 (57 per 100,000 to 44.3 per 100,000) and remained fairly stable for women (35.3 per 100,000 to 35.6 per 100,000).3

  • In a study in Latin America, prevalence rates ranged from 7.8% to 19.7% of the population4; a prevalence of between 3% and 11% has been reported in never-smokers.1 This high rate among never-smokers is most likely related to indoor cooking with open wood fires.

  • In a Swedish study of COPD (birth cohorts from 1919 to 1950), the 10-year cumulative incidence rate of COPD was 13.5% using Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria (Table 58-1) based on 1109 patients with baseline respiratory symptoms (76.6% of ...

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