Wednesday, November 26, 2014

You are asked to review a 72-year-old man on the post-take ward round


You are asked to review a 72-year-old man on the post-take ward round. He was admitted
last night with increasing shortness of breath. His breathing has been getting worse
for many years now, and he notices that it is especially bad in the winter. His general
practitioner (GP) has diagnosed asthma and has been managing him at home. He recalls
having several courses of antibiotics over the last few years.


His recent problems started 3 days ago with a cough productive of green sputum. He has
felt generally unwell and his breathing has deteriorated significantly. He cannot climb
the stairs at home now and slept on the sofa last night. His GP saw him this morning and
referred him to hospital as an infective exacerbation of asthma. He continues to smoke
despite advice, and has a 50 pack-year history. There is no other relevant past medical
history. He takes a salbutamol inhaler when needed but today this was of little help.


Examination
Some blood tests were performed and a chest radiograph was requested (Figur). His
white cell count is 16.3 × 109/L, neutrophil count 89 per cent and haemoglobin 14.2 g/dL.

• What does this radiograph show?
• What is the likely diagnosis and how can this be confirmed?

This is a posterior–anterior (PA) chest radiograph of an adult male. The lungs are hyperexpanded
as evidenced by visualizing more than six anterior ribs above the diaphragm.
The distance between the apex of the hemidiaphragm and a line drawn from the costophrenic
to the cardiophrenic angle is less than 1.5 cm, in keeping with diaphragmatic
flattening. The lung parenchyma demonstrates bullous emphysematous disease, most
marked in the upper zones. There is no evidence of consolidation, collapse or pneumothorax.
The cardiomediastinal borders are within normal limits, and both hila are of
normal morphology. This chest radiograph suggests a diagnosis of chronic obstructive
pulmonary disease (COPD).


COPD is a combination of increased mucus production, small airway obstruction and
emphysematous change, with a slow and progressive history of increasing shortness
of breath, usually in association with significant tobacco usage. Most commonly, the
emphysematous component is ‘centrilobular’, with irreversible destruction of normal lung
most in the apical segments of the upper lobes. On computed tomography (CT) this is
clearly seen as central black holes of destroyed lung ‘punched-out’ from normal parenchymal
architecture (Figure 1.2), although a CT is not a necessary investigation in most
cases of COPD. Sometimes the clinical symptoms of COPD are confused with asthma,
which usually starts in childhood and shows greater reversibility of airflow obstruction.
Some patients develop asthma later in life, and in practice both conditions may coexist
or be difficult to differentiate.


KEY POINTS
• Flattening of the diaphragms and lung hyperexpansion are characteristic chest
radiograph features of COPD.
• COPD is a combination of increased mucus production, small airways obstruction and
emphysematous change.
• Lung function tests are the most important investigation in a patient with COPD.



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