History of Present Illness
A 69-year-old Caucasian man presented with concerns of breathlessness during mild efforts, such as walking on flat ground, and a cough with little sputum for several months. He had no fever, chest pain, or nighttime respiratory symptoms. As suggested by the general practitioner, he underwent chest radiography which revealed bilateral opacities suggesting pleural calcifications ( Fig. 16.1 ). Subsequently, he was referred to the outpatient pulmonology clinic.
Past Medical History
The patient was a former smoker (20–40 cigarettes a day for 30 years), but he had stopped smoking 20 years ago (approximately 45 pack-years). He had no clear recollection of any asbestos exposure, although he worked as a welder and a plumber. He had no previous history of tuberculosis, pleural infection, or effusion, but he stated that he had had pneumonia, which was treated with antibiotics at home, 15 years earlier (no imaging was available).
Moreover, he had a history of prostatic hypertrophy and discectomy for a herniated disk in the lumbar region 10 years before the current presentation.
Physical Examination and Early Clinical Findings
When the patient was at the pulmonology clinic, he was alert and cooperative; was not pale or cyanotic; and had no clubbing, jugular vein distention, or lower limb edema. Breath sounds were slightly reduced, and crackles were audible at the lung bases. Oxygen saturation (Sp O 2 ) measured by pulse oximeter was normal (97% at rest in room air). Simple spirometry showed reduction of the forced expiratory volume in 1 second (FEV1)/vital capacity (VC) ratio and lowered VC, suggesting a mixed ventilatory defect (obstructive and restrictive). However, lung volumes measured with body plethysmography revealed no reduction in total lung capacity (TLC), whereas residual volume (RV) was increased. These findings were indicative of unique airway obstruction with significant air trapping. A corresponding gas exchange disorder was found, with diffusion capacity for carbon monoxide (DLCO) decreased to 71.2% of the predicted value ( Fig. 16.2 ).
The patient was diagnosed with chronic obstructive pulmonary disease (COPD). The degree of obstruction was moderate, according to the GOLD guidelines (FEV 1 between 50% and 80% of predicted value). The patient was found to have grade 2 dyspnea, according to the Modified Medical Research Council (mMRC) questionnaire. Dual bronchodilator therapy (tiotropium bromide/olodaterol 2.5/2.5 μg, two inhalations once a day) was prescribed, with the main purpose of alleviating symptoms.
Pleural plaques (See )
Chest computed tomography (CT) was performed ( Fig. 16.3 ), and it revealed extensive bilateral calcified plaques in the parietal, diaphragmatic, and left mediastinal pleurae (adjacent to the pericardial surface). Parenchymal bands in the peripheral region of the lower zones, centrolobular emphysema in the upper lobes, and some bronchiectasis were also evident.