Updated: 10/13/2018

Emphysema

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Snapshot
  • A 23-year-old man presents to the emeCXRrgency department with severe pleuritic chest pain. He tells the resident that he is worried he might have another collapsed lung.
Introduction
  • One of two major presentations of Chronic Obstructive Pulmonary Disease (COPD)
    • including chronic bronchitis and emphysema
  • Characterized by decreased lung function in the setting of air outflow obstruction
  • Defined by alveolar wall destruction and dilation that presents in two forms
    • almost always  due to smoking (even if only secondhand)
    • panlobular is rare and caused by alpha1-antitrypsin deficiency
  • Patients identified as "pink puffers"
    • pink complexion due to hypoxic state, which is less severe than in "blue bloaters"
    • puffer describes compensatory hyperventilation necessary to normalize blood gas
Presentation
  • Symptoms 
    • mild dyspnea
    • hyperventilation
    • mild cough
    • pinkish skin coloration
    • fatigue
  • Physical exam
    • late hypercarbia/hypoxia
    • barrel chest (increased AP chest diameter)
    • thin, wasted appearance
    • pursed-lip breathing
    • decreased heart and breath sounds
    • prolonged expiratory phase
    • end-expiratory wheezing
    • scattered rhonchi
    • digital clubbing (only in the presence of other comorbidities such as lung cancer, interstitial lung disease, or bronchiectasis)
Evaluation
  • Diagnosis is based highly on clinical observations
  • ABG
    • hypoxemia
      • decreased PO2
    • acute or chronic respiratory acidosis
      • increased PCO2
  • CXR
    • decreased lung markings with flattened diaphragm
    • hyperinflated lungs with bullae and/or blebs
    • thin-appearing heart and mediastinum
    • barrel-chest
  • PFTs
    • decreased FEV1 / FVC
    • normal or decreased FVC
    • normal or increased TLC (in emphysema and asthma, specifically)
    • decreased DLCO (in emphysema, specifically)
  • Blood cultures
    • order only if patient is febrile
    • Gram stain and sputum culture order in setting of fever or productive cough
Differential
  • Chronic bronchitis, asthma, bronchiectasis
Treatment
  • Medical management 
    • O2, beta-agonists, anticholingerics, IV steroids, antibiotics
      • indicated for acute exacerbations
        • inhaled Beta-agonists
          • albuterol
        • inhaled anticholinergics
          • ipratropium, tiotropium
        • IV steroids 
        • broad-spectrum antibiotics 
          • use is controversial 
    • smoking cessation, ambulatory O2, bronchodilator, steroids, vaccines indicated for chronic disease
      • smoking cessation
      • ambulatory O2
        • resting PaO2 < 55mmHg or SaO2 <89%
      • bronchodilators
      • systemic or inhaled steroids
      • Pneumococcal and flu vaccines
    • respiratory support
      • CPAP or BiPAP if the patient's mental status is intact 
      • intubation if non-invasive measures fail or mental status is not intact
Prognosis, Prevention, and Complications
  • Prognosis
    • highly dependent of severity of disease, timing and adherence to treatment
    • disease cannot be reversed, only slowed
  • Prevention
    • alpha1-antitrypsin deficiency cannot be prevented, and should be managed accordingly
    • acute exacerbations and progression of disease secondary to smoking can be slowed with lifestyle modifications and strict adherence to treatment measures
  • Complications
    • if untreated or ignored, disease can progress rapidly leading to death
 

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Questions (3)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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