Obstructive lung disease

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Obstructive lung disease Microchapters

Overview

Classification

Asthma
COPD
Bronchiolitis
Bronchiectasis
Heart failure
Tuberculosis
Lymphangioleiomyomatosis
Cystic fibrosis

Spirometry Findings in Various Lung Conditions

Approach to Lung Disorders

Differentiating Obstructive Lung Disease from other Diseases

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Usama Talib, BSc, MD [2], Feham Tariq, MD [3], Dildar Hussain, MBBS [4]

Overview

An obstructive lung disease is a group of diseases characterized by various deformities that result in the collapse of airways. Patients suffering from obstructive lung disease usually present with shortness of breath due to damage to the airways within the lungs. This results in an inability to exhale air completely and an abnormally high amount of air may still present in the lungs after the end of full expiration. One of the main etiology of the obstructive lung disease is long-term exposure to substances that irritate and damage the lung epithelium and lung parenchyma. This includes cigarette smoke, air pollution, chemical fumes, or dust etc. Patients are usually asymptotic during the initial phase of the disease. However, symptoms usually become more evident as the disease process gets worse. The symptoms usually include a productive cough, difficulty in breathing, wheezing, and tightness in the chest. These diseases include asthma, COPD, bronchiolitis, bronchiectasis, heart failure, tuberculosis, cystic fibrosis, and lymphangioleiomyomatosis. Obstructive lung diseases present with an obstructive pattern that is an increase in total lung capacity (TLC), increase in respiratory volume (RV), a decrease in forced vital capacity (FVC), a decreased forced expiratory volume (FEV1), and a decreased FEV1/FVC, on pulmonary function tests.

Classification

Various diseases that present with an obstructive pattern on pulmonary function tests include:

Spirometry Findings in Various Lung Conditions

Spirometry can help distinguish obstructive lung disease from restrictive lung disease. On spirometry the findings include:[1][2]


Pulmonary Function Test Obstructive Lung Disease Restrictive Lung Disease
Spirometry showing Obstructive and Restrictive Lung Disease ([Source:By CNX OpenStax [CC BY 4.0 (http://creativecommons.org/licenses/by/4.0)], via Wikimedia Commons])
Total lung capacity (TLC)
Residual volume (RV)
Forced vital capacity (FVC)
Forced expiratory volume

in 1st second

(FEV1)

↓↓
FEV1/FVC ratio N to
Maximum voluntary ventilation
RV/TLC Normal

Approach to Lung Disorders

 
 
 
 
 
 
 
 
 
 
 
 
 
Spirometry
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low FEV1/FVC ratio
 
 
 
 
 
 
 
 
 
 
 
 
 
Normal to high FEV1/FVC ratio
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Obstructive Lung Disease
 
 
 
 
 
 
 
 
 
 
 
 
 
Restrictive Lung Disease
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Bronchodilator therapy
 
 
 
 
 
 
 
 
 
 
 
 
 
DLCO
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Increased FEV1
 
 
 
 
 
 
 
No change in FEV1
 
 
 
Normal DLCO
 
 
 
 
 
 
 
Decreased DLCO
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Asthma
 
 
 
 
 
 
 
COPD
 
 
 
Chest wall disorders
 
 
 
 
 
 
 
Interstitial Lung Disease
 
 

Differentiating Obstructive Lung Disease from other Diseases

Various diseases presenting with obstructive pattern on pulmonary function tests can be differentiated from each other as follows:

Diseases Clinical manifestations Diagnosis
Symptoms Signs Lab findings PFT Imaging Gold standard Other features
Cough Dyspnea Hemoptysis Fever Weight loss Cyanosis Clubbing JVD Peripheral edema Auscultation ABGs FEV1/FVC TLC DLCO
CXR CT scan Other tests
Asthma[3] + + ± ±
  • Wheeze
  • Rhonci
  • ↑IgE
  • Normal
  • ↓FEV1

FEV1:FVC

=<0.7

  • Normal/↑
  • Pulmonary hyperinflation
  • Extensive air trapping[4]
  • Bronchoprovocation testing
  • Peak expiratory flow measurement
  • Physical Exam
  • Spirometery
Associated with:
  • Allergic rhinitis
  • GERD and obesity can mimic asthma
Chronic bronchitis[5] + + ± +
  • Wheeze
  • Rhonci
  • Egophony
  • Rales
  • ↓Bronchial breath sounds.(present in consolidation)
  • ↑Procalcitonin
  • Normal
  • ↓FEV1
  • Normal
  • Thickening of the bronchial walls in the lower lobes
  • Thickening of the bronchial walls in the lower lobes[6]
Microbiological testing is done in cases of:
  • Influenza
  • Pertusis
  • Clinical diagnosis
  • Chest radiograph
  • Secondary to URTI
Bronchiolitis[7] + + +
  • Wheeze
  • Crackles[8]
  • Normal
  • Bronchovascular markings
  • Air trapping
  • Bronchial wall thickening
  • Bronchoscopy
  • Lung biopsy
  • Thoracoscopic lung biopsy

Can be associated with:

  • Organ transplantation
Emphysema + + + + + +
  • Expiratory wheeze
  • Hyperinflation
  • ↓alpha-1 antitrypsin deficency
  • Respiratory alkalosis
  • Metabolic acidosis
  • ↓FEV1
  • Flattening of the diaphragm
  • Vertical heart
  • Small subpleural collections of gas
  • Centriacinar emphysema
  • Panacinar emphysema
  • Paraseptal emphysema
  • Pulse oximetry
  • Physical Exam
  • Spirometery
  • Barrel Chest
Bronchiectasis [9] + + + + + +
  • Rhonci
  • Wheeze
  • Crackles
  • ↑Neutrophils
  • ↓FEV1:FVC
  • Tram track opacities
  • Signet-ring sign
  • Airway dilation
  • Flexible bronchoscopy
  • Chronic productive cough
Heart failure + + + + +
  • S3 gallop
  • Wheeze
  • Rales
  • Respiratory alkalosis
  • Normal
  • Normal
  • MRI
  • Cardiac catheterization
  • Exercise testing
  • Ambulatory ECG monitoring
Tuberculosis + + + + +
  • Diminished breath sounds
  • Rhonci/wheeze
  • Upper lobe infiltrate
  • Upper lobe cavitation
  • Hilar adenopathy
  • Solitary nodules
  • Pleural effusion
  • Mediastinal lymphadenopathy
  • Fibrotic leisons
  • Distortion of the lung parenchyma
  • Centrilobular 2 to 4 mm nodules
  • Branching linear lesions
  • Patchy small lower lobe infiltrates
Lymphangioleiomyomatosis + + +(<5%) - - - +(rare) - +
  • Wheeze
  • Hyperinflation
  • Absent or ↓Breath sounds
  • ↑Vascular endothelial growth factor-D
  • Respiratory acidosis in severe disease
  • ↓FEV1:FVC
  • Normal
  • ↓DLCO
  • Ground glass appearance
  • Interstetial pulmonary edema
  • Septal thickening
  • Pulmonary cyst
  • Pnuemothorax
  • Pleural masses
  • Pleural thickening
  • Mediastianl lymphadenopathy
  • Pleural effusion
  • VQ Scan
  • PET Scan
  • Advanced lymphatic imaging
  • Surgical lung biopsy
  • Chylothorax(most common lymphatic manifestation)
  • Chyloperitonium
  • Renalangiomyolipoma
Status Asthmaticus + + - ± - - - + -
  • Wheeze
  • Absent or ↓Breath sounds
  • ↑TLC
  • ↑Glucose
  • ↑PCO2
  • ↓PO2
  • ↓FEV1:FVC
  • < 30% of predictive value
  • ↑TLC
  • ↑DLCO
  • Pulmonary hyperinflation
  • Atypical presentation
-
  • Peak expiratory flow<50% of baseline
  • Clinical diagnosis
  • Pulses paradoxus
Cystic fibrosis + + + + - + + - -
  • Crackles
  • Sweat Chloride test: >60 mEq/L
  • ↑PCO2
  • ↓PO2
  • ↓FEV1:FVC
  • ↑TLC
  • ↓ In severe lung impairment[10]

References

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  5. Mejza F, Gnatiuc L, Buist AS, Vollmer WM, Lamprecht B, Obaseki DO; et al. (2017). "Prevalence and burden of chronic bronchitis symptoms: results from the BOLD study". Eur Respir J. 50 (5). doi:10.1183/13993003.00621-2017. PMC 5699921. PMID 29167298.
  6. Park JE, Kim Y, Lee SW, Shim SS, Lee JK, Lee JH (2016). "The usefulness of low-dose CT scan in elderly patients with suspected acute lower respiratory infection in the emergency room". Br J Radiol. 89 (1060): 20150654. doi:10.1259/bjr.20150654. PMC 4846199. PMID 26861744.
  7. Allinson JP, Hardy R, Donaldson GC, Shaheen SO, Kuh D, Wedzicha JA (2016). "The Presence of Chronic Mucus Hypersecretion across Adult Life in Relation to Chronic Obstructive Pulmonary Disease Development". Am J Respir Crit Care Med. 193 (6): 662–72. doi:10.1164/rccm.201511-2210OC. PMC 4824943. PMID 26695373.
  8. Kesimer M, Ford AA, Ceppe A, Radicioni G, Cao R, Davis CW; et al. (2017). "Airway Mucin Concentration as a Marker of Chronic Bronchitis". N Engl J Med. 377 (10): 911–922. doi:10.1056/NEJMoa1701632. PMC 5706541. PMID 28877023.
  9. Dijkstra AE, de Jong K, Boezen HM, Kromhout H, Vermeulen R, Groen HJ; et al. (2014). "Risk factors for chronic mucus hypersecretion in individuals with and without COPD: influence of smoking and job exposure on CMH". Occup Environ Med. 71 (5): 346–52. doi:10.1136/oemed-2013-101654. PMID 24642640.
  10. Espiritu JD, Ruppel G, Shrestha Y, Kleinhenz ME (June 2003). "The diffusing capacity in adult cystic fibrosis". Respir Med. 97 (6): 606–11. PMID 12814143.

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