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      Drugs & Diseases > Pulmonology

      Emphysema Clinical Presentation

      Updated: Dec 30, 2019
      • Author: Kamran Boka, MD, MS; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
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      Presentation

      History

      COPD should be considered in any patient with dyspnea, chronic cough or sputum production or a history of exposure to risk factors. Most patients seek medical attention late in the course of their disease, usually ignoring smoldering symptoms that start gradually and progress over the course of years. Patients will adapt and modify their lifestyles in order to minimize dyspnea and ignore cough and mucus production. With questioning, a multiyear history can be elicited.

      Generally, patients present in their fifth decade of life with a productive cough or acute chest illness. This cough, commonly referred to as a "smoker's cough," typically is worse in the morning with finite production of clear-to-white sputum. The cause of this is usually undiagnosed concomitant chronic bronchitis.

      Dyspnea, emphysema's most significant symptom, does not generally occur until the sixth decade of life. By the time the forced expiratory volume in 1 second (FEV1) has fallen to 50% of predicted, the patient is breathless upon minimal exertion.

      Wheezing may occur in some patients, particularly during exertion and exacerbations. Listen to typical wheezing with the link below.

      Emphysema Wheezing (MP3)

      Auscultation of patient during exacerbation of COPD/emphysema. Courtesy of James Heilman, MD, published by Wikipedia.

      AAT-deficient patients present earlier than other COPD patients, usually in their fourth or fifth decade of life, with severe AAT deficiency mainly affecting the lungs and the liver. Liver dysfunction dominates the clinical picture in the first decade of life. Patients who are homozygous (Pi ZZ) develop emphysema with the following distinctive features: early presentation (< 45 y), predilection of emphysematous changes in the lung bases, and the panacinar morphological pattern.

      Next:

      Physical Examination

      Emphysema’s physiologic hallmark physical examination finding is the limitation of expiratory flow with relative preservation of inspiratory flow. It takes longer to exhale than it does to inhale. Measurement of the forced expiratory time maneuver is a simple bedside test; a forced expiratory time more than 6 seconds indicates severe expiratory airflow obstruction. The forced expiratory volume in one second (FEV1) and the forced vital capacity (FVC) are important in determining flows. The ratio of the two (FEV1/FVC) results as a percentage during the spirometry portion of pulmonary function testing and is the objective diagnostic means of labeling a patient with COPD.

      Although the sensitivity of the physical evaluation in mild-to-moderate disease is relatively poor, the physical signs are quite sensitive and specific in severe disease. Patients with severe disease may experience tachypnea and dyspnea with mild exertion.

      The respiratory rate increases in proportion to disease severity with the use of accessory respiratory muscles and paradoxical contraction of lower intercostal spaces becoming evident during exacerbations.

      In end-stage emphysema, cyanosis, elevated jugular venous pressure, atrophy of limb musculature, and peripheral edema due to the development of pulmonary hypertension, right-to-left shunting, and/or right heart failure can easily be observed.

      Thoracic examination reveals a 2:1 increase in anterior to posterior diameter (“barrel chest”), diffuse or focal wheezing, diffusely diminished breath sounds, hyperresonance upon percussion, prolonged expiration, and/or hyperinflation on chest radiographs.

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