eMedicine Specialties > Pulmonology > Obstructive Airways Diseases
Emphysema: Differential Diagnoses & Workup
Updated: Oct 26, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Differential Diagnoses
Bronchiectasis
Bronchitis
Chronic Bronchitis
Lymphangioleiomyomatosis
Other Problems to Be Considered
Common alternative diagnoses and suggestive diagnostic features
Congestive heart failure: This condition may produce wheezing and often may be difficult to differentiate from emphysema. However, a history of orthopnea and paroxysmal nocturnal dyspnea, the presence of fine basal crackles, and typical findings on chest radiographs can lead to the diagnosis of congestive heart failure.
Bronchiectasis: Patients with bronchiectasis have chronic production of copious purulent sputum, coarse crackles and clubbing upon physical examination, and abnormal findings on chest radiographs and CT scans.
Bronchiolitis obliterans: Obliterative bronchiolitis is observed in younger persons who do not smoke and in persons with collagen-vascular diseases. A CT scan characteristically shows areas of mosaic attenuation without evidence of generalized emphysema.
Chronic asthma: The delayed onset of severe asthma may be difficult to distinguish in older patients, but the important distinction is a significant bronchodilator response and normal diffusion (ie, diffusing capacity of lung for carbon monoxide [DLCO]) on pulmonary function tests.
Workup
Laboratory Studies
- Arterial blood gas analysis: Patients with mild chronic obstructive pulmonary disease (COPD) have mild-to-moderate hypoxemia without hypercapnia. As the disease progresses, hypoxemia worsens and hypercapnia develops.
- Hematocrit value: Chronic hypoxemia may lead polycythemia. A hematocrit value greater than 52% in men and greater than 47% in women is indicative of the condition. 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.
- Bicarbonate value: Chronic respiratory acidosis leads to compensatory metabolic alkalosis. In the absence of blood gas measurements, bicarbonate levels are useful for following disease progression.
- Alpha1-antitrypsin level: Of the approximately 75 different alleles for alpha1-antitrypsin (AAT) deficiency variants, 10-15 are associated with serum levels below the protective threshold of 11 mmol/L. The most common severe variant is the Z allele, which accounts for 95% of the clinically recognized cases of severe AAT deficiency. The diagnosis of severe AAT deficiency is confirmed when the serum level falls below the protective threshold value (ie, 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.
- Sputum evaluation: In patients with stable chronic bronchitis, the sputum is mucoid and the predominant cells are macrophages. With an exacerbation, the sputum becomes purulent, with excessive neutrophils and a mixture of organisms visualized through Gram staining. Streptococcus pneumoniae and Haemophilus influenzae are pathogens frequently cultured during exacerbations.
Imaging Studies
- Chest radiography
- Frontal and lateral chest radiographs reveal signs of hyperinflation, which involves flattening of diaphragms, increased retrosternal air space, and a long narrow heart shadow.
- Rapid tapering vascular shadows accompanied by hyperlucency of the lungs are signs of emphysema.
- With complicating pulmonary hypertension, the hilar vascular shadows are prominent; with right ventricular enlargement, opacity in the lower retrosternal air space may occur.
Chest radiograph shows hyperinflation, flattened diaphragms, increased retrosternal space, and hyperlucency of the lung parenchyma in emphysema.
An emphysematous lung shows increased anteroposterior (AP) diameter, increased retrosternal airspace, and flattened diaphragms on posteroanterior (PA) film.
An emphysematous lung shows increased anteroposterior (AP) diameter, increased retrosternal airspace, and flattened diaphragms on lateral chest radiograph.
The differential diagnosis of unilateral hyperlucent lung includes pulmonary arterial hypoplasia and Swyer-James syndrome. The expiratory chest radiograph exhibits evidence of air trapping and is helpful in making the diagnosis. Swyer-James syndrome is unilateral bronchiolitis obliterans, which develops during early childhood.
Lateral chest radiograph of Swyer-James syndrome may demonstrate some of the features of emphysema.
- CT scanning: High-resolution CT (HRCT) scanning is more sensitive than standard chest radiography. HRCT scanning is highly specific for diagnosing emphysema and outlines bullae that are not always observed on radiographs. A CT scan is indicated when the patient is being considered for a surgical intervention such as bullectomy or lung-volume reduction surgery. A CT scan is not indicated in the routine care of patients with COPD.
A CT scan shows emphysematous bullae in upper lobes.
Diffuse emphysema secondary to cigarette smoking.
A CT scan showing severe emphysema and bullous disease.
Other Tests
- Pulmonary function tests
- These measurements are necessary for the diagnosis of obstructive airway disease and for assessments of its severity. In addition, spirometry is helpful for assessing responses to treatment and disease progression.
- Forced expiratory volume in 1 second (FEV1) is a reproducible test and is the most common index of airflow obstruction. Lung volume measurements show an increase in total lung capacity, functional residual capacity, and residual volume. The vital capacity is decreased.
- DLCO is decreased in proportion to the severity of emphysema.
- Lung mechanics and gas exchange worsen during acute exacerbations.
- As many as 30% of patients have an increase in FEV1 of 15% or more after inhalation of a bronchodilator. The absence of bronchodilator response does not justify withholding bronchodilator therapy.
Pressure-volume curve is drawn for a patient with restrictive lung disease and obstructive disease and is compared to healthy lungs.
Flow-volume curve of lungs with emphysema shows marked decrease in expiratory flows, hyperinflation, and air trapping (patient B) compared to a patient with restrictive lung disease, who has reduced lung volumes and preserved flows (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.
Staging
The FEV1 is used to stage the severity of COPD. It is normalized as a percentage of predicted for healthy controls. The following Global Initiative for Chronic Obstructive Lung Disease staging system is widely used:
- Stage I (mild) - FEV1 greater than or equal to 80% of predicted.
- Stage II (moderate) - FEV1 less than 80% and greater than or equal to 50% of predicted
- Stage III (severe) - FEV1 less than 50% and greater than or equal to 30% of predicted
- Stage IV (very severe) - FEV1 less than 30% of predicted or FEV1 less than 50% and chronic respiratory failure
Respiratory failure is defined as a PaO2 less than 60 mm Hg (kPa 8.0) or a PaCO2 greater than 50 mm Hg (kPa 6.7).
More on Emphysema |
| Overview: Emphysema |
 Differential Diagnoses & Workup: Emphysema |
| Treatment & Medication: Emphysema |
| Follow-up: Emphysema |
| Multimedia: Emphysema |
| References |
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Further Reading
Keywords
emphysema, chronic obstructive pulmonary disease, COPD, chronic obstructive lung disease, chronic lung, chronic bronchitis, airflow obstruction, centriacinar emphysema, centrilobular emphysema, panacinar emphysema, paraseptal emphysema, distal acinar emphysema, alpha1-antitrypsin deficiency, AAT
