Diagnosis on CT Scan vs. Spirometry

[andreajl]

Hello,

I've been treated for "moderate to severe persistent asthma" at an HMO in Northern CA for the past 10 years. My FEV1 has ranged from 44 to 58 percent of predicted, sometimes increasing quite a bit after bronchodilation. My current DLCO is 58 and DLCO/VA is 105. (I'm a 66-year-old female, 5'1", 140 lbs.) My lung volumes are normal.

A new pulmonologist suggested that I have a CT scan. It did not show any evidence of emphysema or air trapping. It does show that I have bronchiectasis in the right middle lobe and lingula, which my pulmonologist says is confined to a small area and not serious. I also have multiple small ill-defined nodules throughout my lungs, the largest of which is 6mm.

My pulmonologist told me I have "moderately severe COPD/emphysema" according to the Gold guidelines. I am very concerned and confused, as my CT scan shows no evidence of emphysema. Could I have another form of COPD w/o emphysema or just severe persistent asthma or some other respiratory condition?

Thank you in advance for your feedback.

Andrea in Northern CA

[David Tinkelman, M.D.]

You should first ask your “new pulmonologist” which of the Gold criteria, for the diagnosis of “moderately severe COPD/emphysema), have been met and how he/she can reconcile the conflicting data (cited below) with that diagnosis.  Unless you are satisfied with the response, you may want to consider requesting a second opinion.

Moderate airway obstruction (as evidenced by an FEV1 of 44-58%) that increases “quite a bit after bronchodilation” is most consistent with the diagnosis of “moderate to severe persistent asthma”, rather than COPD/emphysema, especially in the presence of a CT Scan showing “no evidence of emphysema”, normal lung volumes and what I interpret as a normal DLCO/VA of 105%.

Bronchiectasis of the right middle lobe and lingula raises the question of etiology, especially if past X-rays or CT scans show no evidence of it.  If the bronchiectasis is deemed to be a fairly recent (1-3 years) development, infection with an atypical mycobacterium (related to TB) might be considered as a cause of the new-onset bronchiectasis.  

The multiple small ill-defined nodules are another matter.  Given this description, they are probably the residual of a benign process.  Once again, comparison of your recent CT Scan and chest X-rays, with previous imaging, correlated with your clinical state (ill or in good health)  would provide guidance as to the nature of these lesions;  the most likely interpretation is that they are benign although such lesions can be seen with fungal infections of the lung and a form of TB, called miliary TB.

All of what I have described will require an experienced pulmonary specialist to synthesize the data and provide a systematic approach to diagnosis.

It is very likely that the demonstrated airflow obstruction is secondary to asthma and that the nodules and bronchiectasis will prove to be of little or no clinical significance.

Good luck

[andreajl]

Thank you so much for your very detailed answer. The information you gave me will be very helpful to me when I go for a second opinion, which I certainly will do.