Chronic Obstructive Pulmonary Disease Workup

  • Author: Zab Mosenifar, MD; Chief Editor: Zab Mosenifar, MD   more...
 
Updated: Oct 10, 2011
 

Approach Considerations

The defining feature of COPD is irreversible airflow limitation during forced expiration. This may result from a loss of elastic recoil due to lung tissue destruction or from an increase in the resistance of the conducting airways. The formal diagnosis of COPD is made with spirometry; when the ratio of forced expiratory volume in 1 second over forced vital capacity (FEV1/FVC) is less than 70% of that predicted for a matched control, it is diagnostic for a significant obstructive defect. Other studies, including laboratory studies and imaging, are particularly important during acute exacerbations of disease.

The 2011 ICSI guidelines also emphasize the importance of spirometry in diagnosing patients.[30]

No blood-based biomarkers are accepted in COPD. However, a study by Sin et al investigated the use of serum pulmonary and activation-regulated chemokine (PARC/CCL-18) as a potential biomarker.[35] The study determined hat PARC/CCL-18 levels are elevated in COPD and track clinical outcomes.

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Arterial Blood Gas Analysis

Arterial blood gas (ABG) analysis provides the best clues as to acuteness and severity of disease exacerbation.

Patients with mild COPD have mild to moderate hypoxemia without hypercapnia. As the disease progresses, hypoxemia worsens and hypercapnia may develop, with the latter commonly being observed as the FEV1 falls below 1 L/s or 30% of the predicted value. Lung mechanics and gas exchange worsen during acute exacerbations.

In general, renal compensation occurs even in chronic CO2 retainers (ie, bronchitics); thus, pH usually is near normal. Generally, consider any pH below 7.3 to be a sign of acute respiratory compromise.

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Serum Chemistries

Patients with COPD tend to retain sodium. In addition, serum potassium should be monitored carefully, because diuretics, beta-adrenergic agonists, and theophylline act to lower potassium levels.

Beta-adrenergic agonists also increase renal excretion of serum calcium and magnesium, which may be important in the presence of hypokalemia.

Chronic respiratory acidosis leads to compensatory metabolic alkalosis. In the absence of blood gas measurements, bicarbonate levels are useful for following disease progression.

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Alpha1-Antitrypsin

Measure alpha1-antitrypsin (AAT) in all patients younger than 40 years or in those with a family history of emphysema at an early age. The diagnosis of severe AAT deficiency is confirmed when the serum level falls below the protective threshold value of 11 mmol/L (ie, in the range of 3-7 mmol/L).

Specific phenotyping is reserved for patients in whom serum levels are 7-11 mmol/L or when genetic counseling or family analysis is needed.

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Sputum Evaluation

In persons with stable chronic bronchitis, the sputum is mucoid and macrophages are the predominant cells. With an exacerbation, sputum becomes purulent because of the presence of neutrophils. Although the quality of sputum can vary between patients in chronic stable disease, an increase in the quantity of sputum production is often a sign of an acute exacerbation.

A mixture of organisms often is visible with Gram stain. The pathogens cultured most frequently during exacerbations are Streptococcus pneumoniae and Haemophilus influenzae.Moraxella catarrhalis is also a common organism, and Pseudomonas aeruginosa can be seen in patients with severe obstruction.

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B-Type Natriuretic Peptide

Human B-type natriuretic peptide (BNP) binds to particulate guanylate cyclase receptors of vascular smooth muscle and endothelial cells. Binding to the receptors causes an increase in cyclic guanosine monophosphate (GMP), which serves as a secondary messenger to dilate veins and arteries.

By measuring BNP, it was thought that the ability to differentiate between CHF and COPD exacerbations would become much easier. However, clinical observation and research have shown that in cases of mild CHF exacerbation, differentiation between CHF and COPD is still not straightforward. A mild elevation of BNP must be taken in context with the overall clinical picture.

New biomarkers such as pro-BNP peptide assays are in development and may prove helpful in differentiating COPD from CHF exacerbations in the future.

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Chest Radiography

As demonstrated in the images below, frontal and lateral chest radiographs of patients with emphysema reveal signs of hyperinflation, including flattening of the diaphragm, increased retrosternal air space, and a long, narrow heart shadow. Rapidly tapering vascular shadows accompanied by hyperlucency of the lungs are other signs of emphysema.

Chronic bronchitis is associated with increased bronchovascular markings and cardiomegaly.

With complicating pulmonary hypertension, the hilar vascular shadows are prominent, with possible right ventricular enlargement and opacity in the lower retrosternal air space.

Posteroanterior (PA) and lateral chest radiograph Posteroanterior (PA) and lateral chest radiograph in a patient with severe chronic obstructive pulmonary disease (COPD). Hyperinflation, depressed diaphragm, increased retrosternal space, and hypovascularity of lung parenchyma are demonstrated. A lung with emphysema shows increased anteroposterA lung with emphysema shows increased anteroposterior (AP) diameter, increased retrosternal airspace, and flattened diaphragm on lateral chest radiograph. A lung with emphysema shows increased anteroposterA lung with emphysema shows increased anteroposterior (AP) diameter, increased retrosternal airspace, and flattened diaphragm on posteroanterior chest radiograph.
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Computed Tomography

High-resolution CT (HRCT) scanning is more sensitive than standard chest radiography and is highly specific for diagnosing emphysema (outlined bullae are not always visible on a radiograph).

HRCT scanning may provide an adjunct means of diagnosing various forms of COPD (ie, lower lobe disease may suggest AAT deficiency) and may help the clinician to determine whether surgical intervention would benefit the patient. (See the CT images below.)

A computed tomography (CT) scan shows hyperlucencyA computed tomography (CT) scan shows hyperlucency due to diffuse hypovascularity and bullae formation, predominantly in the upper lobes. Severe bullous disease as seen on a computed tomogSevere bullous disease as seen on a computed tomography (CT) scan in a patient with chronic obstructive pulmonary disease (COPD).
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Two-Dimensional Echocardiography

Many patients with long-standing COPD develop secondary pulmonary hypertension from chronic hypoxemia and vascular remodeling. This may result in eventual right-sided heart failure (cor pulmonale). However, even with severe COPD, the degree of pulmonary hypertension is usually only mild to moderate. Findings of severe pulmonary hypertension on echocardiogram or cardiac catheterization warrant further workup.

Two-dimensional echocardiography may be helpful as a screening tool to estimate pulmonary arterial systolic pressure and right ventricular systolic function, although formal cardiac catheterization is necessary to accurately confirm the diagnosis.

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Pulmonary Function Tests

Pulmonary function tests are essential for the diagnosis and assessment of the severity of disease, and they are helpful in following its progress. (See the images below.) FEV1 is a reproducible test and is the most commonly used index of airflow obstruction.

In addition to the spirometry findings that define the disease, lung volume measurements often show an increase in total lung capacity, functional residual capacity, and residual volume. The vital capacity often decreases. Dynamic hyperinflation during exercise is now thought be a greater contributor to the sensation of dyspnea than airflow obstruction alone (as measured by FEV1).

As many as 30% of patients have an increase in FEV1 of 15% or more after inhalation of a bronchodilator. However, the absence of bronchodilator response does not justify withholding therapy.

Carbon monoxide diffusing capacity is decreased in proportion to the severity of emphysema.

Pressure volume curve comparing lungs with emphysePressure volume curve comparing lungs with emphysema, lungs with restrictive disease, and normal lungs. Flow volume curve of a patient with emphysema showFlow volume curve of a patient with emphysema shows marked decrease in expiratory flow, hyperinflation, and air trapping (patient B) compared with a patient with restrictive lung disease, who has reduced lung volumes and preserved flow (patient A). Forced expiratory volume in 1 second (FEV1) can beForced expiratory volume in 1 second (FEV1) can be used to evaluate the prognosis in patients with emphysema. The benefit of smoking cessation is shown here because the deterioration in lung function parallels that of a nonsmoker, even in late stages of the disease. Redrawn from Fletcher C, Peato R. The natural history of chronic airflow obstruction. Br Med J 1977; 1: 1645-1648.

Using lung function thresholds of 80% predicted and fixed cut points to determine whether a test result is abnormal could result in the misdiagnosis of more than 20% of patients referred for pulmonary function testing. This misclassification can be avoided by using the lower limit of normal--;based 95% confidence interval.[36]

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Six-Minute Walking Distance

The distance walked in 6 minutes (6MWD) is a good predictor of all-cause and respiratory mortality in patients with moderate COPD.[37, 38] Patients with COPD who desaturate during the 6MWD have a higher mortality rate than do those who do not desaturate.

Consequently, this test is used as a part of the BODE index (body mass index, obstruction [FEV1], dyspnea [modified Medical Research Council dyspnea scale], and exercise capacity [6MWD]),[26] which was designed to help predict mortality in COPD patients.

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Other Studies

Pulse oximetry does not offer as much information as arterial blood gas (ABG) analysis. However, when combined with clinical observation, this test can be a powerful tool for instant feedback on a patient's status.

Electrocardiography

Coexisting cardiac disease is highly likely in patients with COPD. Electrocardiography can be used in establishing that hypoxia is not resulting in cardiac ischemia and that the underlying cause of respiratory difficulty is not cardiac in nature.

Right-Sided Heart catheterization

If pulmonary hypertension is suspected based on clinical findings or on estimates from 2-dimensional echocardiography, then right-sided heart catheterization may be performed to measure pulmonary artery pressures directly and to gauge the response to vasodilators.

Hematocrit

Chronic hypoxemia may lead polycythemia. A hematocrit greater than 52% in men or 47% in women is indicative of polycythemia. Patients should be evaluated for hypoxemia at rest, with exertion, or during sleep. Correction of hypoxemia should reduce secondary polycythemia in patients who have quit smoking.

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Contributor Information and Disclosures
Author

Zab Mosenifar, MD  Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild Pulmonary Disease Institute, Professor and Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, and American Thoracic Society

Disclosure: Nothing to disclose.

Coauthor(s)

Annie Harrington, MD  Fellow in Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center

Annie Harrington, MD is a member of the following medical societies: Alpha Omega Alpha and American College of Chest Physicians

Disclosure: Nothing to disclose.

Nader Kamangar, MD, FACP, FCCP, FCCM  Associate Professor of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, Los Angeles, David Geffen School of Medicine, Olive View-UCLA Medical Center; Associate Program Director, Pulmonary and Critical Care Multi-Campus Fellowship Program, Cedars-Sinai/West Los Angeles Veterans Affairs/Los Angeles Kaiser Permanente/Olive View-UCLA Medical Center; Site Director, Pulmonary/Critical Care Fellowship Program, Olive View-UCLA Medical Center

Nader Kamangar, MD, FACP, FCCP, FCCM is a member of the following medical societies: American Academy of Sleep Medicine, American Association of Bronchology, American College of Chest Physicians, American College of Physicians, American Lung Association, American Medical Association, American Thoracic Society, California Thoracic Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Nidhi S Nikhanj, MD  Fellow, Department of Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles

Nidhi S Nikhanj, MD is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Ryland P Byrd Jr, MD  Professor, Department of Internal Medicine, Division of Pulmonary Medicine and Critical Care Medicine, Program Director of Pulmonary Diseases and Critical Care Medicine Fellowship, East Tennessee State University, James H Quillen College of Medicine; Medical Director of Respiratory Therapy, James H Quillen Veterans Affairs Medical Center

Ryland P Byrd Jr, MD is a member of the following medical societies: American College of Chest Physicians and American Thoracic Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Chief Editor

Zab Mosenifar, MD  Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild Pulmonary Disease Institute, Professor and Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, and American Thoracic Society

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Sat Sharma, MD, FRCPC, to the development and writing of a source article.

References

  1. GOLD - The Global Initiative for Chronic Obstructive Lung Disease. Available at http://www.goldcopd.com/. Accessed April 22, 2010.

  2. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. National Guideline Clearinghouse. 2008. Available at http://emedicine.medscape.com/article/807927-overview. Accessed April 20, 2010.

  3. Feghali-Bostwick CA, Gadgil AS, Otterbein LE, Pilewski JM, Stoner MW, Csizmadia E. Autoantibodies in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. Jan 15 2008;177(2):156-63.

  4. Houben JM, Mercken EM, Ketelslegers HB, Bast A, Wouters EF, Hageman GJ. Telomere shortening in chronic obstructive pulmonary disease. Respir Med. Feb 2009;103(2):230-6. [Medline].

  5. Morissette MC, Vachon-Beaudoin G, Parent J, Chakir J, Milot J. Increased p53 level, Bax/Bcl-x(L) ratio, and TRAIL receptor expression in human emphysema. Am J Respir Crit Care Med. Aug 1 2008;178(3):240-7. [Medline].

  6. Hodge S, Hodge G, Jersmann H, Matthews G, Ahern J, Holmes M, et al. Azithromycin improves macrophage phagocytic function and expression of mannose receptor in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. Jul 15 2008;178(2):139-48. [Medline].

  7. Casanova C, de Torres JP, Navarro J, Aguirre-Jaíme A, Toledo P, Cordoba E, et al. Microalbuminuria and hypoxemia in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. Oct 15 2010;182(8):1004-10. [Medline].

  8. Ofir D, Laveneziana P, Webb KA, Lam YM, O'Donnell DE. Mechanisms of dyspnea during cycle exercise in symptomatic patients with GOLD stage I chronic obstructive pulmonary disease. Am J Respir Crit Care Med. Mar 15 2008;177(6):622-9. [Medline].

  9. Belman MJ, Botnick WC, Shin JW. Inhaled bronchodilators reduce dynamic hyperinflation during exercise in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. Mar 1996;153(3):967-75. [Medline].

  10. O'Donnell DE, Lam M, Webb KA. Spirometric correlates of improvement in exercise performance after anticholinergic therapy in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. Aug 1999;160(2):542-9. [Medline].

  11. Marin JM, Carrizo SJ, Gascon M, Sanchez A, Gallego B, Celli BR. Inspiratory capacity, dynamic hyperinflation, breathlessness, and exercise performance during the 6-minute-walk test in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. May 2001;163(6):1395-9. [Medline].

  12. O'Donnell DE, Flüge T, Gerken F, Hamilton A, Webb K, Aguilaniu B. Effects of tiotropium on lung hyperinflation, dyspnoea and exercise tolerance in COPD. Eur Respir J. Jun 2004;23(6):832-40. [Medline].

  13. Martinez FJ, de Oca MM, Whyte RI, Stetz J, Gay SE, Celli BR. Lung-volume reduction improves dyspnea, dynamic hyperinflation, and respiratory muscle function. Am J Respir Crit Care Med. Jun 1997;155(6):1984-90. [Medline].

  14. Celli BR. Update on the management of COPD. Chest. Jun 2008;133(6):1451-62. [Medline].

  15. Casanova C, Cote C, de Torres JP, Aguirre-Jaime A, Marin JM, Pinto-Plata V. Inspiratory-to-total lung capacity ratio predicts mortality in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. Mar 15 2005;171(6):591-7. [Medline].

  16. Nagelmann A, Tonnov A, Laks T, Sepper R, Prikk K. Lung Dysfunction of Chronic Smokers with No Signs of COPD. COPD. Apr 22 2011;[Medline].

  17. Lamprecht B, McBurnie MA, Vollmer WM, Gudmundsson G, Welte T, Nizankowska-Mogilnicka E, et al. COPD in Never Smokers: Results From the Population-Based Burden of Obstructive Lung Disease Study. Chest. Apr 2011;139(4):752-763. [Medline].

  18. Andersen ZJ, Hvidberg M, Jensen SS, Ketzel M, Loft S, Sørensen M, et al. Chronic obstructive pulmonary disease and long-term exposure to traffic-related air pollution: a cohort study. Am J Respir Crit Care Med. Feb 15 2011;183(4):455-61. [Medline].

  19. Crothers K, Butt AA, Gibert CL, Rodriguez-Barradas MC, Crystal S, Justice AC. Increased COPD among HIV-positive compared to HIV-negative veterans. Chest. Nov 2006;130(5):1326-33. [Medline].

  20. Adams PF, Barnes PM, Vickerie JL. Summary health statistics for the U.S. population: National Health Interview Survey, 2007. Vital Health Stat 10. Nov 2008;1-104. [Medline].

  21. Buist AS, McBurnie MA, Vollmer WM, Gillespie S, Burney P, Mannino DM, et al. International variation in the prevalence of COPD (the BOLD Study): a population-based prevalence study. Lancet. Sep 1 2007;370(9589):741-50. [Medline].

  22. Halbert RJ, Natoli JL, Gano A, Badamgarav E, Buist AS, Mannino DM. Global burden of COPD: systematic review and meta-analysis. Eur Respir J. Sep 2006;28(3):523-32. [Medline].

  23. Foreman MG, Zhang L, Murphy J, et al. Early-Onset COPD is Associated with Female Gender, Maternal Factors, and African American Race in the COPDGene Study. Am J Respir Crit Care Med. May 11 2011;[Medline].

  24. Mintz ML, Yawn BP, Mannino DM, et al. Prevalence of airway obstruction assessed by lung function questionnaire. Mayo Clin Proc. May 2011;86(5):375-81. [Medline]. [Full Text].

  25. Spitzer C, Koch B, Grabe HJ, et al. Association of airflow limitation with trauma exposure and post-traumatic stress disorder. Eur Respir J. May 2011;37(5):1068-75. [Medline].

  26. Celli BR, Cote CG, Marin JM, Casanova C, Montes de Oca M, Mendez RA, et al. The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. N Engl J Med. Mar 4 2004;350(10):1005-12. [Medline].

  27. Waschki B, Kirsten A, Holz O, et al. Physical activity is the strongest predictor of all-cause mortality in patients with COPD: a prospective cohort study. Chest. Aug 2011;140(2):331-42. [Medline].

  28. Abrams TE, Vaughan-Sarrazin M, Fan VS, Kaboli PJ. Geographic isolation and the risk for chronic obstructive pulmonary disease-related mortality: a cohort study. Ann Intern Med. Jul 19 2011;155(2):80-6. [Medline].

  29. Sundh J, Stallberg B, Lisspers K, Montgomery SM, Janson C. Co-Morbidity, Body Mass Index and Quality of Life in COPD Using the Clinical COPD Questionnaire. COPD. Apr 22 2011;[Medline].

  30. Institute for Clinical Systems Improvement. Diagnosis and Management of Chronic Obstructive Pulmonary Disease (COPD). 8th Edition. March 2011. Available at http://www.icsi.org/chronic_obstructive_pulmonary_disease/chronic_obstructive_pulmonary_disease_2286.html. Accessed May 6, 2011.

  31. [Guideline] Qaseem A, Wilt TJ, Weinberger SE, et al. Diagnosis and Management of Stable Chronic Obstructive Pulmonary Disease: A Clinical Practice Guideline Update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med. Aug 2 2011;155(3):179-191. [Medline].

  32. Hurst JR, Vestbo J, Anzueto A, Locantore N, Müllerova H, Tal-Singer R, et al. Susceptibility to exacerbation in chronic obstructive pulmonary disease. N Engl J Med. Sep 16 2010;363(12):1128-38. [Medline].

  33. Hanania NA, Müllerova H, Locantore NW, Vestbo J, Watkins ML, Wouters EF, et al. Determinants of Depression in the ECLIPSE Chronic Obstructive Pulmonary Disease Cohort. Am J Respir Crit Care Med. Mar 1 2011;183(5):604-611. [Medline].

  34. Prosen G, Klemen P, Strnad M, Grmec S. Combination of lung ultrasound (a comet-tail sign) and N-terminal pro-brain natriuretic peptide in differentiating acute heart failure from chronic obstructive pulmonary disease and asthma as cause of acute dyspnea in prehospital emergency setting. Crit Care. 2011;15(2):R114. [Medline].

  35. Sin DD, Miller BE, Duvoix A, et al. Serum PARC/CCL-18 Concentrations and Health Outcomes in Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med. May 1 2011;183(9):1187-1192. [Medline].

  36. Miller MR, Quanjer PH, Swanney MP, Ruppel G, Enright PL. Interpreting lung function data using 80% predicted and fixed thresholds misclassifies more than 20% of patients. Chest. Jan 2011;139(1):52-9. [Medline].

  37. Maclay JD, Rabinovich RA, MacNee W. Update in chronic obstructive pulmonary disease 2008. Am J Respir Crit Care Med. Apr 1 2009;179(7):533-41. [Medline].

  38. Casanova C, Cote C, Marin JM, Pinto-Plata V, de Torres JP, Aguirre-Jaíme A, et al. Distance and oxygen desaturation during the 6-min walk test as predictors of long-term mortality in patients with COPD. Chest. Oct 2008;134(4):746-52. [Medline].

  39. Rice KL, Dewan N, Bloomfield HE, Grill J, Schult TM, Nelson DB, et al. Disease management program for chronic obstructive pulmonary disease: a randomized controlled trial. Am J Respir Crit Care Med. Oct 1 2010;182(7):890-6. [Medline].

  40. Dewan NA, Rice KL, Caldwell M, Hilleman DE. Economic Evaluation of a Disease Management Program for Chronic Obstructive Pulmonary Disease. COPD. Apr 22 2011;[Medline].

  41. Stephenson A, Seitz D, Bell CM, et al. Inhaled anticholinergic drug therapy and the risk of acute urinary retention in chronic obstructive pulmonary disease: a population-based study. Arch Intern Med. May 23 2011;171(10):914-20. [Medline].

  42. Casaburi R, Mahler DA, Jones PW, Wanner A, San PG, ZuWallack RL, et al. A long-term evaluation of once-daily inhaled tiotropium in chronic obstructive pulmonary disease. Eur Respir J. Feb 2002;19(2):217-24. [Medline].

  43. Donohue JF, van Noord JA, Bateman ED, Langley SJ, Lee A, Witek TJ Jr, et al. A 6-month, placebo-controlled study comparing lung function and health status changes in COPD patients treated with tiotropium or salmeterol. Chest. Jul 2002;122(1):47-55. [Medline].

  44. Vincken W, van Noord JA, Greefhorst AP, Bantje TA, Kesten S, Korducki L, et al. Improved health outcomes in patients with COPD during 1 yr's treatment with tiotropium. Eur Respir J. Feb 2002;19(2):209-16. [Medline].

  45. Tashkin DP, Celli B, Senn S, Burkhart D, Kesten S, Menjoge S, et al. A 4-year trial of tiotropium in chronic obstructive pulmonary disease. N Engl J Med. Oct 9 2008;359(15):1543-54. [Medline].

  46. Brusasco V, Hodder R, Miravitlles M, Korducki L, Towse L, Kesten S. Health outcomes following treatment for six months with once daily tiotropium compared with twice daily salmeterol in patients with COPD. Thorax. May 2003;58(5):399-404. [Medline]. [Full Text].

  47. Vogelmeier C, Hederer B, Glaab T, Schmidt H, Rutten-van Mölken MP, Beeh KM, et al. Tiotropium versus salmeterol for the prevention of exacerbations of COPD. N Engl J Med. Mar 24 2011;364(12):1093-103. [Medline].

  48. Singh S, Loke YK, Enright PL, Furberg CD. Mortality associated with tiotropium mist inhaler in patients with chronic obstructive pulmonary disease: systematic review and meta-analysis of randomised controlled trials. BMJ. Jun 14 2011;342:d3215. [Medline]. [Full Text].

  49. [Best Evidence] Calverley PM, Rabe KF, Goehring UM, Kristiansen S, Fabbri LM, Martinez FJ. Roflumilast in symptomatic chronic obstructive pulmonary disease: two randomised clinical trials. Lancet. Aug 29 2009;374(9691):685-94. [Medline].

  50. Gifford AH, Mahler DA, Waterman LA, et al. Neuromodulatory Effect of Endogenous Opioids on the Intensity and Unpleasantness of Breathlessness during Resistive Load Breathing in COPD. COPD. Apr 22 2011;[Medline].

  51. Short PM, Lipworth SI, Elder DH, Schembri S, Lipworth BJ. Effect of beta blockers in treatment of chronic obstructive pulmonary disease: a retrospective cohort study. BMJ. May 10 2011;342:d2549. [Medline]. [Full Text].

  52. [Best Evidence] Mottillo S, Filion KB, Bélisle P, Joseph L, Gervais A, O'Loughlin J. Behavioural interventions for smoking cessation: a meta-analysis of randomized controlled trials. Eur Heart J. Mar 2009;30(6):718-30. [Medline].

  53. [Guideline] US Preventive Services Task Force. Counseling and interventions to prevent tobacco use and tobacco-caused disease in adults and pregnant women: US Preventive Services Task Force Reaffirmation Recommendation Statement. Ann Int Med. Apr 21 2009;150(8):551-555. [Full Text].

  54. Wood-Baker RR, Gibson PG, Hannay M, Walters EH, Walters JA. Systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2005;(1):CD001288. [Medline].

  55. Walters JA, Walters EH, Wood-Baker R. Oral corticosteroids for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev. Jul 20 2005;CD005374. [Medline].

  56. Spencer S, Calverley PM, Burge PS, Jones PW. Impact of preventing exacerbations on deterioration of health status in COPD. Eur Respir J. May 2004;23(5):698-702. [Medline].

  57. Calverley PM, Anderson JA, Celli B, Ferguson GT, Jenkins C, Jones PW, et al. Salmeterol and fluticasone propionate and survival in chronic obstructive pulmonary disease. N Engl J Med. Feb 22 2007;356(8):775-89. [Medline].

  58. [Best Evidence] Sin DD, Tashkin D, Zhang X, Radner F, Sjöbring U, Thorén A. Budesonide and the risk of pneumonia: a meta-analysis of individual patient data. Lancet. Aug 29 2009;374(9691):712-9. [Medline].

  59. Chen D, Restrepo MI, Fine MJ, et al. Observational study of inhaled corticosteroids on outcomes for COPD patients with pneumonia. Am J Respir Crit Care Med. Aug 1 2011;184(3):312-6. [Medline].

  60. Seemungal TA, Wilkinson TM, Hurst JR, Perera WR, Sapsford RJ, Wedzicha JA. Long-term erythromycin therapy is associated with decreased chronic obstructive pulmonary disease exacerbations. Am J Respir Crit Care Med. Dec 1 2008;178(11):1139-47. [Medline].

  61. Albert RK, Connett J, Bailey WC, et al. Azithromycin for prevention of exacerbations of COPD. N Engl J Med. Aug 25 2011;365(8):689-98. [Medline].

  62. [Best Evidence] Daniels JM, Snijders D, de Graaff CS, Vlaspolder F, Jansen HM, Boersma WG. Antibiotics in addition to systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease. Am J Respir Crit Care Med. Jan 15 2010;181(2):150-7. [Medline].

  63. [Best Evidence] Sasaki T, Nakayama K, Yasuda H, Yoshida M, Asamura T, Ohrui T, et al. A randomized, single-blind study of lansoprazole for the prevention of exacerbations of chronic obstructive pulmonary disease in older patients. J Am Geriatr Soc. Aug 2009;57(8):1453-7. [Medline].

  64. Duiverman ML, Wempe JB, Bladder G, Jansen DF, Kerstjens HA, Zijlstra JG. Nocturnal non-invasive ventilation in addition to rehabilitation in hypercapnic patients with COPD. Thorax. Dec 2008;63(12):1052-7. [Medline].

  65. Crockett AJ, Moss JR, Cranston JM, Alpers JH. Domicilary oxygen for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2000;(2):CD001744. [Medline].

  66. Ringbaek TJ. Continuous oxygen therapy for hypoxic pulmonary disease: guidelines, compliance and effects. Treat Respir Med. 2005;4(6):397-408. [Medline].

  67. Sandland CJ, Morgan MD, Singh SJ. Patterns of domestic activity and ambulatory oxygen usage in COPD. Chest. Oct 2008;134(4):753-60. [Medline].

  68. Lightowler JV, Wedzicha JA, Elliott MW, Ram FS. Non-invasive positive pressure ventilation to treat respiratory failure resulting from exacerbations of chronic obstructive pulmonary disease: Cochrane systematic review and meta-analysis. BMJ. Jan 25 2003;326(7382):185. [Medline]. [Full Text].

  69. Carrera M, Marín JM, Antón A, Chiner E, Alonso ML, Masa JF, et al. A controlled trial of noninvasive ventilation for chronic obstructive pulmonary disease exacerbations. J Crit Care. Sep 2009;24(3):473.e7-14. [Medline].

  70. Keenan SP, Kernerman PD, Cook DJ, Martin CM, McCormack D, Sibbald WJ. Effect of noninvasive positive pressure ventilation on mortality in patients admitted with acute respiratory failure: a meta-analysis. Crit Care Med. Oct 1997;25(10):1685-92. [Medline].

  71. Confalonieri M, Garuti G, Cattaruzza MS, Osborn JF, Antonelli M, Conti G. A chart of failure risk for noninvasive ventilation in patients with COPD exacerbation. Eur Respir J. Feb 2005;25(2):348-55. [Medline].

  72. [Guideline] Keenan SP, Sinuff T, Burns KE, Muscedere J, Kutsogiannis J, Mehta S, et al. Clinical practice guidelines for the use of noninvasive positive-pressure ventilation and noninvasive continuous positive airway pressure in the acute care setting. CMAJ. Feb 22 2011;183(3):E195-214. [Medline]. [Full Text].

  73. Hubbard RC, Crystal RG. Augmentation therapy of alpha 1-antitrypsin deficiency. Eur Respir J Suppl. Mar 1990;9:44s-52s. [Medline].

  74. Hurst JR, Donaldson GC, Quint JK, Goldring JJ, Baghai-Ravary R, Wedzicha JA. Temporal clustering of exacerbations in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. Mar 1 2009;179(5):369-74. [Medline].

  75. Fishman A, Martinez F, Naunheim K, Piantadosi S, Wise R, Ries A, et al. A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema. N Engl J Med. May 22 2003;348(21):2059-73. [Medline].

  76. Titman A, Rogers CA, Bonser RS, Banner NR, Sharples LD. Disease-specific survival benefit of lung transplantation in adults: a national cohort study. Am J Transplant. Jul 2009;9(7):1640-9. [Medline].

  77. Burton CM, Milman N, Carlsen J, Arendrup H, Eliasen K, Andersen CB, et al. The Copenhagen National Lung Transplant Group: survival after single lung, double lung, and heart-lung transplantation. J Heart Lung Transplant. Nov 2005;24(11):1834-43. [Medline].

  78. Cote CG, Celli BR. Pulmonary rehabilitation and the BODE index in COPD. Eur Respir J. Oct 2005;26(4):630-6. [Medline].

  79. Dodd JW, Hogg L, Nolan J, et al. The COPD assessment test (CAT): response to pulmonary rehabilitation. A multicentre, prospective study. Thorax. May 2011;66(5):425-9. [Medline].

  80. Currow DC, McDonald C, Oaten S, Kenny B, Allcroft P, Frith P, et al. Once-daily opioids for chronic dyspnea: a dose increment and pharmacovigilance study. J Pain Symptom Manage. Sep 2011;42(3):388-99. [Medline].

  81. Chapman KR, Rennard SI, Dogra A, Owen R, Lassen C, Kramer B. Long-term Safety and Efficacy of Indacaterol, a Long-Acting {beta}2-Agonist, in Subjects With COPD: A Randomized, Placebo-Controlled Study. Chest. Jul 2011;140(1):68-75. [Medline].

  82. Bateman ED, Rabe KF, Calverley PM, Goehring UM, Brose M, Bredenbröker D, et al. Roflumilast with long-acting {beta}2-agonists for COPD: influence of exacerbation history. Eur Respir J. Sep 2011;38(3):553-60. [Medline].

 
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Venn diagram of chronic obstructive pulmonary disease (COPD). Chronic obstructive lung disease is a disorder in which subsets of patients may have dominant features of chronic bronchitis, emphysema, or asthma. The result is airflow obstruction that is not fully reversible.
Histopathology of chronic bronchitis showing hyperplasia of mucous glands and infiltration of the airway wall with inflammatory cells.
Histopathology of chronic bronchitis showing hyperplasia of mucous glands and infiltration of the airway wall with inflammatory cells (high-powered view).
Gross pathology of advanced emphysema. Large bullae are present on the surface of the lung.
Gross pathology of a patient with emphysema showing bullae on the surface.
At high magnification, loss of alveolar walls and dilatation of airspaces in emphysema can be seen.
Posteroanterior (PA) and lateral chest radiograph in a patient with severe chronic obstructive pulmonary disease (COPD). Hyperinflation, depressed diaphragm, increased retrosternal space, and hypovascularity of lung parenchyma are demonstrated.
A lung with emphysema shows increased anteroposterior (AP) diameter, increased retrosternal airspace, and flattened diaphragm on lateral chest radiograph.
A lung with emphysema shows increased anteroposterior (AP) diameter, increased retrosternal airspace, and flattened diaphragm on posteroanterior chest radiograph.
A computed tomography (CT) scan shows hyperlucency due to diffuse hypovascularity and bullae formation, predominantly in the upper lobes.
Severe bullous disease as seen on a computed tomography (CT) scan in a patient with chronic obstructive pulmonary disease (COPD).
Pressure volume curve comparing lungs with emphysema, lungs with restrictive disease, and normal lungs.
Flow volume curve of a patient with emphysema shows marked decrease in expiratory flow, hyperinflation, and air trapping (patient B) compared with a patient with restrictive lung disease, who has reduced lung volumes and preserved flow (patient A).
Forced expiratory volume in 1 second (FEV1) can be used to evaluate the prognosis in patients with emphysema. The benefit of smoking cessation is shown here because the deterioration in lung function parallels that of a nonsmoker, even in late stages of the disease. Redrawn from Fletcher C, Peato R. The natural history of chronic airflow obstruction. Br Med J 1977; 1: 1645-1648.
Oxygen therapy via nasal cannula.
Home supplemental oxygen.
Bilevel positive airway pressure (BiPAP).
Pulmonary rehabilitation.
Chronic obstructive pulmonary disease (COPD). Pulmonary rehabilitation.
 
 
 
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