Airway Diseases: COPD - Case

Prof. Dr. Müzeyyen ErkIU Cerrahpaşa Medical FacultyPulmonary Diseases Department

Symptoms 78-M Dyspnea with minimal exertion Cough Sputum

Dyspnea in exertion for 6-7 years, cough and sputum present but not severe, symptoms progressive

Dyspnea has become significant with minimal exertion for the last 3 months

The patient is treated with BD for 6 years, receives ICS for 2 years

Past medical history, family hist. Left femur fracture (15 years ago) Inguinal hernia operation (2 years ago) Mass excision from left breast: Gynecomastia (1.5

years ago) Operation for catract Glaucoma in the left eye Benign prostate hyperplasia GIS complaints Peripheral arterial disease (stent in the right femoral

artery) Coronary artery disease (3 vessels, stent in 1 vessel) Anemia

Habits

Smoking history: 90 p-y The patient does not smoke for 6

years Alcohol: rarely

Clinical findings-1 Cachectic appearence

50 kg 10 years previously, lost weight in the last 10 years, inadequate food intake for 2 years (because of dental prothesis)

BMI: 15.2 (38 kg, 1.52 m) Peripheral edema (+) Cyanosis (+) JVD (+) Decreased skin turgor

Clinical findings-2

Respiratory system RR: 20/m Hyperresonance Decrased breath sounds No adventitious sounds

Clinical findings-3

Cardiovascular HR:90/min, regular rhythm, BP:130/70

mm Hg Normal heart sounds Decreased pulse in the peripheral

arteries

Physical examination of other body systems are normal

Spirometry, arterial blood gases

Date % FVC % FEV1 FEV1/FVC

24.01.08 1460 55 690 35 0.47

Date PaO2 PaCO2 pH % sO2 SB

23.01.08 (room air)

53 36 7.42 89 24

23.01.08 (2-3 L/m O2, 4. hour)

74 45 7.38 97 26

QUESTION

What is your preliminary diagnosis?

1. Severe COPD+cor pulmonale2. Severe COPD - stabile3. Severe COPD - execarbation4. Severe COPD + CHF5. Severe COPD + PE

EKG

Blood and urineCBCLeukocyte: 9600/mm3

P: %75L: %11M: %12Eo: %1B: %1

Erythrocyte: 4.33x106

Hb: 12 g/dlHt: %36MCV: 83 fLMCH: 28 pgMCHC: 33 g/dl

PLT: 377.000/mm3

Urin analysis : normal

BiochemistryESR: 57 mm/hCRP: 64 mg/LGlucose: 70 mg/dlUrea: 44 mg/dlCreatinine: 1.4 mg/dlAST: 15 U/LALT: 13 U/LNa: 139 mEq/LK: 4.8T Protein: 6.5 g/dlAlbumin: 3.1gr/dlPSA: 0.727 ng/ml

Follow-up

Date FVC ml FEV1 ml % FEV1/FVC

03.11.06 1040 47 800 41 74

01.11.07 1200 45 740 37 62

24.01.08 1460 55 690 35 47

01.02.08 1300 49 830 42 64

The patient was given optimal treatment (BD, CS, O2, diuretics, other drugs), drug education and respiratory physical threapy was started. The treatment was not completely useful and pulmonary function test was performed again

QUESTION

What do you plan to do at this stage ?

1. Echocardiography2. V/Q sintigraphy3. HRCT4. Blood analysis5. Lung volumes, DLco

CBC and biochemistry Date RBC Hgb %Htc Fe IBC Ferri. B12 Folate OB

11.03.06 3.62 9.6 29.9

27.10.06 4.05 11.1 33.2

04.04.07 4.28 9.0 28.8 15 480 7.79 -

12.09.07 4.86 14.0 41.7

19.11.07 4.63 13.0 39.40

23.01.08 4.33 12.0 36.1

25.02.08

11.04.08

4.03

4.55

10.8

11.6

33.3

36.2

14

25

240

332

25.90

16.00

230 9.50 (-)

Endoscopy

GIS complaints: endoscopy last year (gastroscopy, colonoscopy) Hiatus hernia, sliding type Dilated cardia Erosive pangastritis Severe duodenitis Gastro-duodenal bile reflux

QuestionWhich is false for COPD and anemia?1. 10-15% of COPD patients have anemia2. Anemia is defined as a Hct level <%39 (in

M) and <%36 (in F)3. In COPD patients, HCT is an independent

and major predictor of survival4. Raised cytokines and chemokines have a

key role in ACD5. RBC life is not shortened in ACD of COPD

patients

KOAH ve anemi konusundaki ifadelerden yanlış olanı bulunuz

1. 10-15% of COPD patients have anaemia2. Anaemia is defined as a Hct level <%39(in M) and

<%36 (in F)3. In COPD patients, HCT is an independent and

major predictor of survival4. Raised cytokines and chemokines have a key role

in ACD5. There is not the shortened RBC life seen in ACD in

Similowski T, Agusti A, MacNee W, Schönhofer B. The potential impact of anaemia of chronic disease in COPD. Eur Respir J. 2006; 27: 390-396

ACD is immune driven and mainly inflammatory in nature From a pathophysiological point of view, there are three putative mechanisms that are thought to lead to ACD, namely:

Shortened RBC survivalIron homeostasis dysregulationImpaired bone marrow erythropoietic response

Shortened RBC survival is thought to occur as a result of raised IL-1 and TNF in COPD

Date RBC Hgb %Htc Fe IBC Ferritin OB

04.04.07 4.28 9.0 28.8 15 480 7.79 (-)

25.02.0811.04.08

4.034.55

10.811.6

33.336.2

1425

240332

25.9016.00

(-)

ACD Fe: ↓ IBC: N Ferritin: >10 MCV: 80 – 100

AID Fe: ↓ IBC ↑ Ferritin: <10 MCV: < 80

Bone mineral density

Lumbar spine L1-L4 T score: -5.11 Z score: -4.00

Left femoral neck T score: -2.46 Z score: -0.21

(Therapy: Ca, vit D, calcitonin)

QuestionWhich statement is wrong for osteoporosis in

COPD patients? 1. 1SD reduction in BMD increases the fracture risk by

1,5-3 fold2. PTs with COPD are at risk to develop osteoporosis

due to a reduced muscle mass and strength3. Hypogonadism and other endocrine abnormalities

can contribute to the development of osteoporosis4. For COPD pts with osteopenia those on long-term KS,

BMD should be undertaken5. For prevention, daly intake of 1000 mg Ca should be

ensured

Which statement is wrong for osteoporosis in COPD patients?

1. 1SD reduction in BMD increases the fracture risk by 1,5-3 fold

2. PTs with COPD are at risk to develop osteoporosis due to a reduced muscle mass and strength

3. Hypogonadism and other endocrine abnormalities can contribute to the development of osteoporosis

4. For COPD pts with osteopenia those on long-term KS, BMD should be undertaken

5. For prevention, the daly intake of 1000 mg Ca should be ensured

Ionescu AA, Schoon E. Osteoporosis in chronic obstructive pulmonary disease. Eur Respir J 2003; 22 (46): 64s-75s

For prevention, the daly intake of 1200-1500 mg Ca and 400 IU vitD should be ensured

Potential risk factors of osteoporosis SmokingIncreased alcohol intakeVitamin D levels Genetic factorsTreatment with corticosteroidsReduced skeletal muscle mass and strength Low BMI and changes in body composition Hypogonadism Reduced levels of insulin-like growth factors Chronic systemic inflammation

Potential risk factors of osteoporosis Bolton ,2004osteoporosis/osteopenia of COPD pts

69%: FEV1>50%89%: FEV1<50%45%: controls.

Vrieze A, de Greef MH, Wijkstra PJ, Wempe JB. Low bone mineral density in COPD patients related to worse lung function, low weight and decreased fat-free mass. Osteoporos Int 2007; 18:1197–1202.

DLco, Static volumes

Date DLco(%)

DLco/VA RV(%)

FRC TLC RV/TLC

1.2.08 4.3 (23)

1.59(46)

3.83 (152)

1.94(59)

2.79(51)

72

spiral

PE probability

D-dimer: 256 mcg/L (51-285)

Pulmonary V/Q sintigraphy: low-probability

QUESTIONPatient BMI is 15.2 kg/m2. Which one of

the following statements is false ?

1. About 25% of patients with chronic obstructive pulmonary disease (COPD) will develop cachexia

2. Incidence of cachecsia correlates with airway obstruction

3. Decrease in muscle mass increases the mortality risk

4. Increase in basal metabolic rate, tissue hypoxia, smoking, inflammation, drugs are etiopathogenetic factors

5. PR is contrindicated at this stage

Patient BMI is 15.2 kg/m2. Which one of the following statements is false ?

1. About 25% of patients with chronic obstructive pulmonary disease (COPD) will develop cachexia

2. Incidence of cachecsia correlates with airway obstruction

3. Decrease in muscle mass increases the mortality risk

4. Increase in basal metabolic rate, tissue hypoxia, smoking, inflammation, drugs are etiopathogenetic factors

5. PR is contrindicated at this stageThis must be balanced against the findings that exercise training does in fact lead to a substantial improvement in exercise capacity, even in cachectic patients.

BMI values and weight lossNomenclature BMI

Weak < 21 kg/m2

Normal 21-25 kg/m2

Overweight 25-30 kg/m2

Obese > 30 kg/m2

Wasted <15 kg/m2 (F)<16 kg/m2 (M)

ATS-ERS Pulmonary Rehabilitation 2006

Cachexia - FFMI <15 kg/m2 (F)<16 kg/m2 (M)

Cachexia - LBMI <15 kg/m2 (F)<16 kg/m2 (M)

Wagner PD. Possible mechanisms underlying thedevelopment of cachexia in COPDEur Respir J 2008; 31: 492–501

0

10

20

30

40

50

11%

27%

41%

46%

Mild COPD

(FEV1 > 50 %)

(n=37)

Moderate COPD

(FEV1 35-50 %)

(n=56)

Severe COPD

(FEV1 < 35%)

(n=112)

Resp. Failure

(PaO 2 < 55 Torr)

(n=48)

% p

ati

en

ts w

ith

lo

w b

od

y w

eig

ht

(< 9

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Schols et al. ARRD 1993; 147: 1151-6

BMI and FFMI for COPD prognosis

COPD patients: 1898 patients, 7 years follow-up (Copenhagen…)

BMI normal, low FFMI patients: %26.1 All causes of mortality: FFMI risk rate: 1.5 Mortality due to COPD: FFMI risk rate: 2.4

FFMI and BMI are mortality predictors

Vestbo J ve ark. AJRCCM 2006; 173: 79

Wagner PD. Possible mechanisms underlying thedevelopment of cachexia in COPDEur Respir J 2008; 31: 492–501

?

QUESTION

When the COPD level of the patient is considered, what is the one-year mortality risk?

1.% 52.%103.%304.%505.%100

BODE Index

ECHOCARDIOGRAPHY (31.01.08)Setum thickness :12 (7-11) mm

Peak mitral grad : 2.7 mmHg

Left v diam (diastole): 38 mm (35-56)

Aort gradient : 5.8 mmHg

Left v dia (sistole): 20 (25-41)mm

Tricuspid back flow: mild-moderate

Left v post w thickness: 12 (7-11) mm

PAPs : 50-55 mm Hg

LEFT v EF: 0.55 Right v EF: 0.45 (N:>0.50)

Aorta : 32 (20-37) mm

Left atrium dia: 27 (19-40)mm

•Degenerative changes in aorta and mitral valves, calcification

•Left ventricular hypertrophy

•Paradoxical septal movement

•Mass attached to the the right atrial free wall with a stalk, measuring 9X11 mm approximately

•Left and right ventricular diastolic disfunction

QUESTIONWhich one of the following statements is true

for the pulmonary hypertension in this patient ? (0.61x55 +2 = 35.5 mm Hg)

1. Systemic inflammation does not have a role in the etiology of PH

2. PAPm value of PH due to COPD is generally over 40 mm Hg

3. PAPm value of PH due to COPD is generally less than 40 mm Hg

4. Hypercarbia should also be present in this patient

5. At this stage pulmonary vazodilators may be useful

QUESTIONWhich of the following statements is true

for performing sleep study in this patient ?

1. It should be performed in every cor pulmonale patient 2. There is no indication, CP is the usual prognosis3. It should be performed, because ABG values do not

correlate with the functional level4. It would have been performed if the patient had mild

to moderate obstruction along with hypoxemia and PH

5. It would have been performed if the patient had daytime somnolence

A mass of 1 cm with contrast enchancement attached to the right atrial free wall

Mild thickening of mitral valves Minimal prominence at the aortic

supra valvular level

Cardiac MR

Kardiyak MR

QUESTION

What can be the pathologic mass that is seen on the echocardiogram and MRI?

1. Thrombus2. Mixoma3. Rhabdomyom4. Other cadiac tumour5. Hydatid cyst

Cardiac myxoma Autopsy series: 1/10 000 Right and left myxomas

compromise %2.5-4 of all myxomas

% 17-27 in the right atrium May grow slowly or rapidly Can be seen by TTE and

TEE Surgery indications

Emboli Hemodynamic problem Valvular obstruction

Ayan F, Koldaş L, Karpuz H. J Clin Basic Cardiol 2000; 3: 197

Clinical characteristics of right atrial myxoma

1. Systemic reactions (early stage):Anemia due tumoral degeneration, fever, weight

loss, leukocytosis, high ESR and CRP, hyperglobulinemia, local cutaneous pigmentations, acromegali, proteinuria

2. Emboli:by tumour fragments or by thrombus, micro or macro pulmonary emboli (if patent foramen ovale exists systemic embolism)

3. Hemodynamic changes: mechanical obstruction and valve destruction

Ayan F, Koldaş L, Karpuz H. J Clin Basic Cardiol 2000; 3: 197

44.9

30.6

28.3

26.5

25.5

UPLIFT Study - Associated comorbidities

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