Persistent Dyspnea in a 74-Year-Old Man With Normal Spirometry and Lung Volumes

Our plain-English summary of Persistent Dyspnea in a 74-Year-Old Man With Normal Spirometry and Lung Volumes, by W.H. Chong, B. Saha, B. Shkolnik (Chest, 2021).

The study

• Authors: W.H. Chong, B. Saha, B. Shkolnik
• Journal: Chest
• Published: 2021;159(5):e303-e307
• Type of article: Case report
• Read it: PubMed · Publisher

Abstract

A 74-year-old man was referred to a pulmonologist for evaluation of a 1-year history of nonproductive cough and progressive exertional dyspnea. He was initially evaluated by his primary care physician, where he had spirometry that was negative for any obstructive or restrictive lung disease. An echocardiogram showed a normal left ventricular ejection fraction, with no wall motion abnormality or valvular heart disease. He had an outpatient chest radiograph performed (Fig 1), and he was subsequently treated empirically for a COPD exacerbation with 5 days of oral prednisone and azithromycin. He was eventually referred to a pulmonologist because of a lack of clinical improvement. On seeing his pulmonary physician, he described the same exertional dyspnea and a nonproductive cough. A review of systems was negative for fever, chills, wheezing, angina, arthralgia, myalgia, rash, or leg swelling. He denied any medical illness and was not taking any medications. He was currently retired and had worked as a cashier his entire adult life. He had no occupational exposure to asbestos, coal dust, beryllium, silica dust, or dust from hard metal objects, such as cobalt. However, he had smoked approximately 1 to 2 packs of cigarettes per day and had done so for the past 50 years. His vital signs were unremarkable, aside from an oxygen saturation of 94% on room air. His physical examination revealed bibasilar "velcro-like" inspiratory crackles on lung examination. There was no digital clubbing, nor was there peripheral edema in his lower extremities. He had no muscle tenderness and demonstrated normal muscle strength against resistance.

Copyright © 2020 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

In plain English

This was a case report about one 74-year-old man, a retired cashier, with a year of dry cough and worsening breathlessness on exertion. He had smoked about 1 to 2 packs of cigarettes a day for 50 years. The article states he had no occupational exposure to asbestos, coal dust, beryllium, silica dust, or hard metal dust. His spirometry and lung volumes were normal. His diffusing capacity (DLCO, how well the lungs pass gas into the blood) was abnormal at 50%, and 60% when corrected for lung volume. CT showed emphysema in the upper lobes and reticulation, honeycombing and traction bronchiectasis in the lower lobes. Tests for connective tissue disease were negative. He was diagnosed with combined pulmonary fibrosis and emphysema. He received long-acting bronchodilators, eventually quit smoking, and entered lung cancer screening. A year later he was diagnosed with stage IIIA squamous cell lung cancer, and hospice care was chosen. The authors noted the condition can be missed because spirometry and lung volumes may look normal. The figures in their discussion came from other studies, not this patient.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: case report (CHEST Pearls series)
• Who was studied: One 74-year-old man, retired, who had worked as a cashier his entire adult life, with a 1-year history of nonproductive cough and progressive exertional dyspnea
• Exposure: Cigarette smoking, approximately 1 to 2 packs per day for 50 years. The article states he had no occupational exposure to asbestos, coal dust, beryllium, silica dust, or hard metal dust.
• Main results:
  • In this patient, spirometry was normal: FEV1 3.5 L (106%), FVC 4.5 L (107%), FEV1/FVC ratio 73%. Lung volumes were also normal: total lung capacity 6 L (90%), residual volume 1.5 L (75%).
  • In this patient, DLCO and DLCO corrected for lung volume (DLCO/VA) were both abnormal, at 50% and 60% respectively.
  • Chest CT showed centrilobular and paraseptal emphysema in the upper lobes. It showed reticulation, honeycombing and traction bronchiectasis mainly in the lower lobes.
  • The workup for connective tissue disease (antinuclear antibody, rheumatoid factor, anti-cyclic citrullinated peptide antibody) was negative.
  • The diagnosis was combined pulmonary fibrosis and emphysema (CPFE).
  • The patient received long-acting bronchodilators and nicotine replacement therapy, and eventually quit smoking. He was enrolled in annual low-dose CT lung cancer screening and referred for lung transplant evaluation.
  • A year later the patient was diagnosed with stage IIIA squamous cell lung cancer, and a decision was made to pursue hospice care.
• The authors' conclusion: The authors stated that CPFE can be missed in patients with breathlessness because spirometry and lung volumes may be normal or only mildly abnormal. They attributed the normal results to the opposing effects of emphysema and fibrosis, and stated that DLCO and imaging are essential for diagnosis.

Topics

Medical terms in this study, explained in our Lexicon: Dyspnea, Spirometry, Restrictive Lung Disease, Echocardiogram, Chest X-Ray, COPD, Occupational Exposure, Oxygen Saturation.

Related studies

• Abnormal wasted ventilation fraction and normal pulmonary hemodynamics during exercise in patients with exertional dyspnea — Z. Mohsenifar, H.V. Brown, et al. (1982)
• A 70-year-old woman with dyspnea and chest pain — A. Ganesh, M. Flores, et al. (2014)
• Radiographic abnormalities in asbestos insulators: effects of duration from onset of exposure and smoking. Relationships of dyspnea with parenchymal and pleural fibrosis — R. Lilis, A. Miller, et al. (1991)
• Neutrophil elastase promotes myofibroblast differentiation in lung fibrosis — A.D. Gregory, C.R. Kliment, et al. (2015)
• Combined pulmonary fibrosis and emphysema alters physiology but has similar mortality to pulmonary fibrosis without emphysema — M.D. Jankowich, S. Rounds (2010)
• Persistent effects of Libby amphibole and amosite asbestos following subchronic inhalation in rats — S.H. Gavett, C.U. Parkinson, et al. (2016)

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