Pulmonary - Respiratory - A complete Review

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The Lancet Respiratory Medicine

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Browse All Figures Return to Figure. Previous Figure Next Figure. Email or Customer ID. Forgot password? Old Password. Another PFT maneuver is the diffusion capacity DLCO , which attempts to define diffusion characteristics of the membrane through which oxygen and carbon dioxide diffuse [8]. Diffusing capacity depends upon the rate at which gas enters the blood divided by its driving pressure and estimates the ability of the lungs to transport inhaled gas from alveoli to pulmonary capillaries.

This transport depends on the thickness of alveolar—capillary membrane, the hemoglobin concentration and the pulmonary blood flow [7].

A review of pulmonary function in Parkinson’s disease

Diffusion capacity is generally estimated using the single breath test using carbon monoxide CO [8]. CO is used due to its high affinity for hemoglobin, which is approximately times that of oxygen. At normal conditions there is a low blood concentration and pulmonary concentration. DLCO reductions occur in structural lung disease, pulmonary hypertension, congestive heart failure, reductions in effective alveolar units eg, lung resection, emphysema , and anemia [7].

A high DLCO is most frequently associated with large lung volumes, obesity and asthma, although it can also be seen in alveolar hemorrhage or when the patient valasalvas during testing [10]. The 6-min walk test has been used to assess the functional status of patients with a wide variety of pulmonary diseases, including pulmonary hypertension, COPD, and idiopathic pulmonary fibrosis. This testing is able to predict mortality for several end-stage lung diseases and has largely replaced cardiopulmonary exercise testing in the assessment of lung disease.

It is much easier to perform, with lower associated low cost and good reproducibility [11]. The majority of sarcoidosis patients will have normal PFTs [12] but may also show a restrictive or obstructive pattern 2. The most frequent PFT abnormality noted in sarcoidosis patients is a reduced diffusing capacity, which can be due to parenchymal involvement or due to the presence of pulmonary hypertension, which should be considered in sarcoidosis patients who have clinical findings consistent with right heart failure [12,13]. The presence of statistically significant differences in all PFT parameters among the patient groups with different radiographic stages of sarcoidosis has been shown [12].

Annals of Pulmonary & Respiratory Medicine

However, pulmonary function testing may show normal results even when anatomic changes documented by imaging studies are severe [14]. In one study [13], only Obstruction was noted in 9. This mild obstruction was prevalent from early stages of the disease with the tendency to coexist with restriction as the disease advanced. The DLCO was reduced in Pulmonary function testing allows the clinician to assess changes in the disease course of the individual patient through sequential measurements [2]. A common radiographic presentation of a patient with sarcoidosis is shown in Figure 1.

Figure 1. High resolution CT scan Innumerable pulmonary nodules subpleural, perifissural and peribronchovascular with bulky mediastinal and hilar lymphadenopathy. Bronchial distortion caused by pulmonary parenchymal fibrosis results in lower expiratory flow rates. Interstitial disease can cause airway distortion caused by parenchymal changes or luminal stenosis, but sarcoidosis can also involve the large and small airways, causing obstructive airways disease.

Sarcoidosis can affect the entire length of the respiratory tract, including the upper airway and the terminal bronchioles [16]. Mucosal erythema and edema and cobblestone mucosa bunching of small yellow lesions, more common in lobar and segmental bronchi can be seen. Bronchial stenosis can be seen in the lobar and segmental bronchi, but mucosal biopsy may or may not show granulomas [13,17]. Airway distortion leading to obstruction is more likely in advanced parenchymal disease.

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Supraglottic structures can also be involved. Oral, nasal, and pharyngeal mucosal changes can lead to hoarseness, dysphagia, laryngeal paralysis, airway obstruction and obstructive sleep apnea. It has been reported that 2.

The trachea and main bronchi are less frequently affected than the lobar, segmental, subsegmental, and distal airways. Sarcoid granulomas of trachea, main carina, and major bronchi by themselves seldom produce significant obstructive symptoms or airway dysfunction, this is usually seen in involvement in the smaller airways [18]. Obstructive airway disease has been noted to be more common in African-American patients with sarcoidosis, compared with much lower rates in white European and American and in Japanese patients [20].

Large airway stenosis has been described in patients with sarcoidosis, and while fixed upper airway obstruction is unusual, it has been reported [21]. Extrinsic compression of the central airways by the enlarged mediastinal and hilar lymph nodes is uncommon. Bronchoscopy can be useful in the diagnosis and management of airway sarcoidosis. However, in that study endobronchial disease was not associated with airflow obstruction.

Endobronchial occlusion by sarcoid granulomas in the submucosa or an endobronchial polyp caused by sarcoid granulomas can be seen [22]. An example of an obstructive pattern of PFTs in sarcoidosis is shown in Figure 2. Restrictive impairment is mainly caused by extensive fibrosis secondary to sarcoid granulomas or by interstitial pneumonia which coexistent with pulmonary sarcoidosis. Sarcoidosis is generally classified as a restrictive lung disease. This is due to the fact that it primarily affects the structure of the lung.


Pulmonary Disease | Internal Medicine Subspecialties | ACP

It is generally characterized by reduced compliance of the lung. Total lung capacity can be particularly helpful when a patient has severe airflow obstruction and has a reduction in FVC due to air trapping. In this case, a normal or increased total lung capacity excludes an associated restrictive process, and the reduction in FVC is actually a pseudorestriction as seen with a significant obstruction. It has been shown in the past that lung compliance correlated with vital capacity in patients with sarcoidosis [23], however, it has been also been shown that the vital capacity and the TLC do not correlate in patients with sarcoidosis.

DLCO is the most sensitive parameter to detect a loss of functional alveolar surface area and measures the forces at work in molecular movement with its concentration gradient from the alveolar surface through to the hemoglobin molecule [24]. Hemoglobin concentration is a very important measurement in interpreting reductions in DLCO. Because the hemoglobin present in the alveolar capillaries serves as a carbon monoxide sink, a DLCO may be decreased when the patient is anemic, and hematologic abnormalities are quite common in patients with sarcoidosis, with anemia due to noncaseating granulomas and absent iron stores in the bone marrow [25].

Reduction in DLCO is highly predictive of gas exchange abnormalities at exercise in patients with sarcoidosis, and DLCO and arterial desaturation at exercise have been reported to be the strongest functional parameters that correlate with the extent and the severity of sarcoidosis, assessed by either pathologic scores or high-resolution CT. Also, this reduction correlates with a loss of alveolar membrane diffusing capacity, not alterations in pulmonary capillary blood volume [26]. PH complicating sarcoidosis is associated with reduced exercise capacity. PH is more often associated with advanced sarcoidosis and reduced lung volumes, but severe PH in the absence of significant restriction is seen.

Reduced DLCO and either resting hypoxemia or exercise desaturation correlate with the presence of PH in sarcoidosis [27]. The prognostic value of PFTs in sarcoidosis is supported by a recent study by Walsh and colleagues, who found that a composite physiologic index CPI score greater than 40 was an independent predictor of mortality. An example of a restrictive defect with a markedly reduced DLCO in a sarcoidosis patient is shown in Figure 3.

Both six-minute walk distance 6MWD and desaturation during 6MWT are valuable tools for predicting functional capacity and mortality in various pulmonary and non-pulmonary diseases. Six-minute walk distance is reduced in the majority of sarcoidosis patients Several factors are associated with a reduced 6MWD, including FVC, oxygen saturation with exercise, and self-reported respiratory health The articles published in this journal are freely accessible globally and are helpful to endure the knowledge of students, researchers and academicians which helps them for further researches and increases the knowledge of common man in all the issues in Pulmonary and Respiratory Medicine.

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Pulmonary - Respiratory - A complete Review Pulmonary - Respiratory - A complete Review
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