Pathophysiology of COPD with Emphysema

Case Study Scenario

Chief Complaint
A.C., is a 61-year old male with complaints of shortness of breath.

History of Present Illness

A.C. was seen in the emergency room 1 week ago for an acute onset of mid-sternal chest pain. The event was preceded with complaints of fatigue and increasing dyspnea for 3 months, for which he did not seek care. He was evaluated by cardiology and underwent a successful and uneventful angioplasty prior to discharge. Despite the intervention, the shortness of breath has not improved. Since starting cardiac rehabilitation, he feels that his breathlessness is worse. The cardiologist has requested that you, his primary care provider, evaluate him for further work-up. Prior to today, his last visit with your practice was 3 years ago when he was seen for acute bronchitis and smoking cessation counseling.

Past Medical History 

  • Hypertension
  • Hyperlipidemia
  • Atherosclerotic coronary artery disease
  • Smoker

Family History

  • Father deceased of acute coronary syndrome at age 65
  • Mother deceased of breast cancer at age 58.
  • One sister, alive, who is a 5 year breast cancer survivor.
  • One son and one daughter with no significant medical history.

Social History

  • 35 pack-year smoking history; he has cut down to one cigarette at bedtime following his cardiac intervention.
  • Denies alcohol or recreational drug use

Real estate agent


  • No Known Drug Allergies


  • Rosuvastatin 20 mg once daily by mouth
  • Carvedilol 25 mg twice daily by mouth
  • Hydrochlorothiazide 12.5 mg once daily by mouth
  • Aspirin 81mg daily by mouth

Review of Systems

  • Constitutional: Denies fever, chills or weight loss. + Fatigue.
  • HEENT: Denies nasal congestion, rhinorrhea or sore throat.
  • Chest: + dyspnea with exertion. Denies productive cough or wheezing. + Dry, nonproductive cough in the AM.
  • Heart: Denies chest pain, chest pressure or palpitations.
  • Lymph: Denies lymph node swelling.

General Physical Exam  

  • Constitutional: Alert and oriented male in no apparent distress.
  • Vital Signs: BP-120/84, T-97.9 F, P-62, RR-22, SaO2: 93%
  • 180 lbs., Ht. 5’9″


  • Eyes: Pupils equal, round and reactive to light and accommodation, normal conjunctiva.
  • Ears: Tympanic membranes intact.
  • Nose: Bilateral nasal turbinates without redness or swelling. Nares patent.
  • Mouth: Oropharynx clear. No mouth lesions. Dentures well-fitting. Oral mucous membranes dry.

Neck/Lymph Nodes 

  • Neck supple without JVD.
  • No lymphadenopathy, masses or carotid bruits.


  • Bilateral breath sounds clear throughout lung fields. + Bilaterally wheezes noted with forced exhalation along with a prolonged expiratory phase. No intercostal retractions.


  • S1 and S2 regular rate and rhythm, no rubs or murmurs.

Integumentary System 

  • Skin cool, pale and dry. Nail beds pink without clubbing.

Chest X-Ray 

  • Lungs are hyper-inflated bilaterally with a flattened diaphragm. No effusions or infiltrates.


Title Predicted Pre-bronchodilator % Predicted Post-bronchodilator % Predicted Change
FVC (L) 5.64 5.23 93 5.77 102 9%
FEV1 (L) 4.57 2.92 64 3.01 66 2%
FEV1/FVC (%) 81 56 69 52 64 -5%
TLC 5.5 6.9 125 6.9 125 0%

Case Study Questions

Pathophysiology & Clinical Findings of the Disease

  1. Are the spirometry results consistent with obstructive or restrictive pulmonary disease? What is the most likely pulmonary diagnosis for this patient?
  2. Explain the pathophysiology associated with the chosen pulmonary disease.
  3. Identify at least three subjective findings from the case which support the chosen diagnosis.
  4. Identify at least three objective findings from the case which support the chosen diagnosis.

Management of the Disease

*Utilize the required Clinical Practice Guideline (CPG) to support your treatment recommendations.

  1. Classify the patient’s disease severity. Is this considered stable or unstable?
  2. Identify two (2) “Evidence A” recommended medication classes for the treatment of this condition and provide an example (drug name) for each.
  3. Describe the mechanism of action for each of the medication classes identified above.
  4. Identify two (2) “Evidence A” recommended non-pharmacological treatment options for this patient.

Pathophysiology of COPD with emphysema

Pathophysiology & Clinical Findings of the Disease:

  1. The spirometry results indicate both obstructive and restrictive features. The most likely pulmonary diagnosis for this patient is Chronic Obstructive Pulmonary Disease (COPD) with components of emphysema. The FEV1/FVC ratio is reduced (52%), suggesting obstructive disease, while the FVC and FEV1 values are both reduced, indicative of restrictive patterns.
  2. Pathophysiology of COPD with emphysema: COPD is characterized by persistent airflow limitation due to a combination of airway inflammation, bronchoconstriction, and parenchymal destruction. In emphysema, there is significant damage to the lung tissue, specifically the alveoli and their supporting structures. This leads to loss of elastic recoil in the lungs, making it difficult to exhale completely. Obstruction occurs mainly during expiration as the damaged alveoli collapse and trap air, resulting in hyperinflation and increased residual volume. The combination of these factors leads to the clinical symptoms of dyspnea, wheezing, and reduced exercise tolerance.
  3. Subjective findings supporting COPD diagnosis: a. Complaints of increasing dyspnea over three months. b. Worsening breathlessness after cardiac rehabilitation. c. 35 pack-year smoking history, with continued smoking post-cardiac intervention.
  4. Objective findings supporting COPD diagnosis: a. Spirometry results with reduced FEV1/FVC ratio (52%) and reduced FEV1 (66%). b. Bilateral wheezes noted with forced exhalation. c. Hyperinflated lungs on chest X-ray with flattened diaphragm.

Management of the Disease:

  1. Classify the patient’s disease severity: The patient’s disease severity should be classified based on the spirometry results:
    • FEV1 > 80% predicted: Mild COPD
    • FEV1 50-79% predicted: Moderate COPD
    • FEV1 30-49% predicted: Severe COPD
    • FEV1 < 30% predicted: Very severe COPD

    Since the patient’s post-bronchodilator FEV1 is 66% predicted, he would be classified as having moderate COPD.

  2. Identify two “Evidence A” recommended medication classes: a. Long-acting bronchodilators (Evidence A): Example: Tiotropium (Spiriva) – an anticholinergic bronchodilator. b. Inhaled corticosteroids (ICS) (Evidence A): Example: Fluticasone/salmeterol (Advair) – a combination inhaler containing an ICS and a long-acting beta-agonist (LABA).
  3. Mechanism of action for each medication class: a. Long-acting bronchodilators (Tiotropium): These medications relax smooth muscles in the airways, reducing bronchoconstriction and improving airflow. They work by blocking the action of acetylcholine, a neurotransmitter that causes airway constriction. b. Inhaled corticosteroids (Fluticasone/salmeterol): ICS reduce airway inflammation, preventing exacerbations and improving lung function. LABAs, like salmeterol, relax airway smooth muscles, providing bronchodilation.
  4. Identify two “Evidence A” recommended non-pharmacological treatment options: a. Pulmonary rehabilitation (Evidence A): Cardiac rehabilitation may not be sufficient for COPD management. Pulmonary rehabilitation programs offer exercise training, education, and support to improve functional capacity and quality of life. b. Smoking cessation counseling (Evidence A): Given the patient’s history of smoking, it is crucial to provide ongoing smoking cessation support to help him quit completely and prevent further lung damage.
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