2. Diagnosis of COPD
Gamal Rabie Agmy, MD,FCCP
Professor of Chest Diseases, Assiut university

3. GLOBAL INITIATIVE FOR CHRONIC
OBSTRUCTIVE LUNG DISEASE
(GOLD):
January 2014
© 2014 Global Initiative for Chronic Obstructive Lung Disease

4. Diagnosis of COPD

Clinical

Spirometric

Radiological

5. Diagnosis of COPD

Clinical

Spirometric

Radiological

6. Global Strategy for Diagnosis, Management and Prevention of COPD
Diagnosis and Assessment: Key Points
A clinical diagnosis of COPD should be considered
in any patient who has dyspnea, chronic cough or
sputum production, and a history of exposure to
risk factors for the disease.
Spirometry is required to make the diagnosis; the
presence of a post-bronchodilator FEV1/FVC <
0.70 confirms the presence of persistent airflow
limitation and thus of COPD.
© 2014 Global Initiative for Chronic Obstructive Lung Disease

7. CLINICAL FEATURES
Dr.Sarma@works
7

8. EMPHYSEMA
CHRONIC BRONCHITIS
PINK PUFFER
BLUE BLOTTER
Dr.Sarma@works
8

9. EMPHYSEMA
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Severe dyspnea
Cough after dyspnea
Scant sputum
Less frequent infections
Terminal RF
PaCO2 35-40 mmHg
PaO2 65-75 mmHg
Hematocrit 35-45%
DLCO is decreased
Cor pulmonale rare.
Dr.Sarma@works
CHRONIC BRONCHITIS
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Mild dyspnea
Cough before dyspnea starts
Copious, purulent sputum
More frequent infections
Repeated resp. insufficiency
PaCO2 50-60 mmHg
PaO2 45-60 mmHg
Hematocrit 50-60%
DLCO is not that much ↓
Cor pulmonale common
9

10. ALPHA1 ANTITRYPSIN ↓
EMPHYSEMA
Specific circumstances of Alpha 1- AT↓include.
•
Emphysema in a young individual (< 35)
•
Without obvious risk factors (smoking etc)
•
Necrotizing panniculitis, Systemic vasculitis
•
Anti-neutrophil cytoplasmic antibody (ANCA)
•
Cirrhosis of liver, Hepatocellular carcinoma
•
Bronchiectasis of undetermined etiology
•
Otherwise unexplained liver disease, or a
•
Family history of any one of these conditions
•
Especially siblings of PI*ZZ individuals.
•
Only 2% of COPD is alpha 1- AT ↓

11. Global Strategy for Diagnosis, Management and Prevention of COPD
Diagnosis of COPD
SYMPTOMS
shortness of breath
chronic cough
sputum
EXPOSURE TO RISK
FACTORS
tobacco
occupation
indoor/outdoor pollution

SPIROMETRY: Required to establish diagnosis
© 2014 Global Initiative for Chronic Obstructive Lung Disease

12. Diagnosis of COPD

Clinical

Spirometric

Radiological

13. Global Strategy for Diagnosis, Management and Prevention of COPD
Diagnosis and Assessment: Key Points
 Spirometry should be performed after the
administration of an adequate dose of a shortacting inhaled bronchodilator to minimize
variability.
 A post-bronchodilator FEV1/FVC < 0.70 confirms
the presence of airflow limitation.
 Where possible, values should be compared to
age-related normal values to avoid overdiagnosis
of COPD in the elderly.
© 2014 Global Initiative for Chronic Obstructive Lung Disease

14. Acceptability & Repeatability

15. Acceptability
•
•
•
•
•
At least three (3) acceptable maneuvers:
Good start to the test.
No hesitation or coughing for the 1st second.
FVC lasts at least 6 seconds with a plateau
of at least 1 second.
No valsalva maneuver or obstruction of the
mouthpiece.
FIVC shows apparent maximal effort.

16. Repeatability
Repeatability criteria act as guideline to
determine need for additional efforts.
– Largest and 2nd largest FVC must be within 150
mL.
– Largest and 2nd largest FEV 1 must be 150 mL.
– PEF values may be variable (within 15%).
If three acceptable reproducible maneuvers
are not recorded, up to 8 attempts may be
recorded.

17. Spirometry Value
• Spirometry is typically reported in both
absolute values and as a predicted
percentage of normal.
• Normal values vary and are dependent on:
– Gender,
– Race,
– Age,
– Weight and
– Height.

18. Reporting Standards
• Largest FVC obtained from all acceptable
efforts should be reported.
• Largest FEV1 obtained from all acceptable
trials should be reported.
• May or may not come from largest FVC
effort.
• All other flows, should come from the effort
with the largest sum of FEV 1 & FVC.
• PEF should be the largest value obtained
from at least 3 acceptable maneuvers.

19. Results Reporting Example

20. Pre & Post Bronchodilator Studies: Withholding
Medications

21. Reversibility
Reversibility of airways obstruction can be
assessed with the use of bronchodilators.
•
> 12% increase in the FEV1 and 200
ml improvement in FEV1
OR
•
> 12% increase in the FVC and 200
ml improvement in FVC.

23. 1-First Step, Check quality of the
test
1- Start:
*Good start: Extrapolated volume (EV) <
5% of FVC or 0.15 L
*Poor start: Extrapolated volume (EV)
≥5% of FVC or ≥ 0.15 L
2- Termination:
*No early termination :Tex ≥ 6 s
*Early termination : Tex < 6 s

24. 2- Look at …………FEV1/FVC
< N(70%)
Obstructive or Mixed
≥ N(70%)
Restrictive or Normal
3- Look at FEV1 To detect degree
Mild > 70%
Mod 50-69 %
Severe 35-49%
Very severe < 35%

25. 4- Postbronchodilator FEV1/FVC
> 70%
asthma
< 70%
COPD

26. 5- Reversibility test of FEV1
> 12%, 200 ml
Reversible (asthma)
< 12% ,200 ml
Ireversible (COPD)
6- Look at TLC
≥ 80-120% Pure
obstruction
< 80% Mixed

27. 2- Look at …………FEV1/FVC
< N(70%)
≥ N(70%)
Obstructive or Mixed
Restrictive or Normal
3- Look at FVC
≥ N(80%)
Normal or SAWD
4-Look at FEF25/75
> 50% Normal
< 50% SAWD
< N(80%)
Restrictive

28. Changes in Lung Volumes in
Various Disease States
Ruppel GL. Manual of Pulmonary Function Testing, 8th ed., Mosby 2003

29. Patterns of Abnormality
Obstructive low FEV1 relative to FVC, low PEF, low FEV1%FVC
R eco rd ed
Pred icted
SR
% Pred
0.56
3.25
-5.3
17
1.65
4.04
-3.9
41
FEV 1 % FV C
34
78
-6.1
44
PEF
2.5
8.28
-4.8
30
FEV
1
FV C
Restriction low FEV1 & FVC, high FEV1%FVC
R eco rd ed
FEV
1
FV C
FEV 1 % FV C
PEF
Pred icted
SR
% Pred
1.49
2.52
-2.0
59
1.97
3.32
-2.2
59
76
74
0.3
103
8.42
7.19
1.0
117 high PEF early ILD
low PEF late ILD

30. Patterns of Abnormality
Upper Airway Obstruction low PEF relative to FEV1
R eco rd ed
Pred icted
SR
% Pred
2.17
2.27
-0.3
96
2.68
2.70
0.0
99
81
76
0.7
106
PEF
2.95
5.99
-3.4
49
FEV 1 /PEF
12.3
FEV
1
FV C
FEV 1 % FV C
Discordant PEF and FEV1
High PEF versus FEV1 = early interstitial lung disease (ILD)
Low PEF versus FEV1 = upper airway obstruction
Concordant PEF and FEV1
Both low in airflow obstruction, myopathy, late ILD

31. Flow
Common FVL Shapes
Volume
Normal
Hesitation
Young or quitter
Knee
Poor effort
Coughing

32. Upper Airway Obstruction
6
Expiratory
Age 40 yrs
FVC 3.52 L
FEV1 3.0
L
0.74 SR
PEF 4.57 L/s
4
0.84 SR
-2.18 SR
FEV/PEF = 10.9
Flow in L/s
2
0
0
1
2
4
5
6
Volume in Litres
-2
-4
-6
3
Inspiratory
FEV1 in mls > 8
PEF in L/min

33. Diffusing Capacity
 Diffusing capacity of lungs for CO
 Measures ability of lungs to transport inhaled gas
from alveoli to pulmonary capillaries
 Depends on:
- alveolar—capillary membrane
- hemoglobin concentration
- cardiac output

34. Diffusing Capacity
 Decreased DLCO
(<80% predicted)
 Increased DLCO
(>120-140% predicted)
 Obstructive lung disease
 Asthma (or normal)
 Parenchymal disease
 Pulmonary hemorrhage
 Pulmonary vascular
disease
 Polycythemia
 Anemia
 Left to right shunt

35. DLCO — Indications
 Differentiate asthma from emphysema
 Evaluation and severity of restrictive lung
disease
 Early stages of pulmonary hypertension

36. Diagnosis of COPD

Clinical

Spirometric

Radiological

37. Emphysema
histopathological definition
…..permanent abnormal enlargement of
airspaces distal to the bronchioles terminales
and
…...destruction of the walls of the involved
airspaces
And
Fibrosis is not integral part

41. Centrilobular Emphysema

42. Panlobular Emphysema

43. Fibrosis and Emphysema

44. CT findings:
• Relatively well-defined, low attenuation areas
with very thin (invisible) walls, surrounded by
normal lung parenchyma.
• As disease progresses:
– Amount of intervening normal lung decreases.
– Number and size of the pulmonary vessels
decrease.
– +/- Abnormal vessel branching angles (>90o), with
vessel bowing around the bullae.

45. Emphysema
Curved arrow: area of low attenuation. •
Solid arrow: zones of vascular disruption.•
Open arrow: area of lung destruction.•

46. Emphysematous Bullae
www.ctsnet.org/doc/6761

47. Quantitative CT:
• Spirometically triggered images at 10% and
90% vital capacity (VC) have been reported
to be able to distinguish patients with chronic
bronchitis from those with emphysema.
– Patients with emphysema had significantly lower
mean lung attenuation at 90% VC than normal
subjects or patients with chronic bronchitis.
– Attenuation was the same for normal subjects and
those with chronic bronchitis.

50. Where is the pathology ???????
in the areas with increased density
meaning there is ground glass
in the areas with decreased density
meaning there is air trapping

51. Pathology in black areas
Airtrapping: Airway Disease
Bronchiolitis obliterans (constrictive bronchiolitis)
idiopathic, connective tissue diseases, drug reaction,
after transplantation, after infection
Hypersensitivity pneumonitis
granulomatous inflammation of bronchiolar wall
Sarcoidosis
granulomatous inflammation of bronchiolar wall
COPD/Asthma / Bronchiectasis / Airway diseases

52. Airway Disease
what you see……
In inspiration
sharply demarcated areas of seemingly increased
density (normal) and decreased density
demarcation by interlobular septa
In expiration
‘black’ areas remain in volume and density
‘white’ areas decrease in volume and increase in
density
INCREASE IN CONTRAST
DIFFERENCES
AIRTRAPPING

53. Bronchiolitis
obliterans

54. Early Sarcoidosis

55. Chronic
EAA

56. Hypersensitivity pneumonitis
Extr. Allerg. Alveolitis (EAA) HRCT Morphology
acute - subacute
acinar (centrilobular) unsharp densities
ground glass (patchy - diffuse)
chronic: fibrosis
Intra- / interlobular septal thickening
Irregular interfaces
Traction bronchiectasis

59. Pathology in white Areas
Alveolitis / Pneumonitis
Ground glass
desquamative intertitial pneumoinia (DIP)
nonspecific interstitial pneumonia (NSIP)
organizing pneumonia
In expiration
both areas (white and black) decrease in
volume and increase in density
DECREASE IN CONTRAST
DIFFERENCES

60. DI
P

61. Cellular
NSIP

62. Mosaic Perfusion
Chronic pulmonary embolism
LOOK FOR
Pulmonary hypertension
idiopathic, cardiac disease, pulmonary
disease

63. CTEPH =
Chronic thrombembolic
pulmonary hypertension

64. Normal lung surface
Left panel: Pleural line and A line (real-time).
The pleural line is located 0.5 cm below the rib line in the adult.
Its visible length between two ribs in the longitudinal scan is approximately 2
cm. The upper rib, pleural line, and lower rib (vertical arrows) outline a
characteristic pattern called the bat sign.

65. Ultrasound profiles.
Lichtenstein D A , Mezière G A Chest 2008;134:117-125

66. the "seashore sign" (Fig.3).

69. Multiple B-lines - « comet-tails » -
interstitial edema
(B1)
7 mm apart « B lines »
thickened interlobular
septa
http://www.reapitiehttp://www.reapitie-
JJR 25 05
D Lichtenstein et al AJRCCM 156 : 1640-1646 ,09 2012
02 1997