A 65-Year-Old Man With a Cough and Worsening Dyspnea

Joshua M. Kosowsky, MD


April 09, 2020


The ECG demonstrates a constellation of findings that suggest chronic obstructive pulmonary disease (COPD), including sinus tachycardia, a rightward axis, P pulmonale (a P-wave amplitude > 2.5 mV in the inferior leads), a low QRS voltage, and a right bundle branch block (RBBB).

In addition, the slight ST-segment depressions in the inferior leads are suggestive of prominent atrial repolarization abnormalities and are seen in COPD.

COPD is among the leading causes of death in the United States. It is defined as a disease state characterized by airflow obstruction caused by chronic bronchitis or emphysema. The airflow obstruction generally is progressive, and it may be accompanied by partially reversible airway hyperreactivity.

The condition was first described in western Europe in the early 19th century by Badham (1808) and Laennec (1827), who made the classic description of chronic bronchitis and emphysema. A British medical textbook of the 1860s described the familiar clinical picture of chronic bronchitis as an advanced disease, with repeated bronchial infections, that ended in right-heart failure. The modern definition of chronic bronchitis and emphysema that incorporated the concept of airflow obstruction was proposed by participants of the Ciba symposium of 1958.

Chronic bronchitis is defined, in clinical terms, as the presence of a chronic productive cough for 2 consecutive years, lasting for at least 3 months during each year, at the exclusion of other etiologies. Emphysema is defined, in terms of anatomical pathology, as an abnormal, permanent enlargement of the air spaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis.

The characteristic histopathology of chronic bronchitis is mucous gland hyperplasia with bronchial wall thickening, focal squamous metaplasia, ciliary abnormalities, and variable amounts of airway smooth-muscle hyperplasia and inflammation. These changes lead to luminal occlusion, causing airflow limitation by allowing airway walls to deform and narrow the airway lumen.

Emphysema has three morphologic patterns:

  1. Centriacinar emphysema, in which focal destruction is limited to the respiratory bronchioles and the central portions of acinus. It is associated with cigarette smoking.

  2. Panacinar emphysema involves the entire alveolus distal to the terminal bronchiole. It generally develops in patients with homozygous alpha-1–antitrypsin deficiency.

  3. Distal acinar emphysema or paraseptal emphysema is the least common form, involving distal airway structures, alveolar ducts, and sacs. It is localized to fibrous septa or to the pleura and leads to formation of bullae, leading to pneumothorax.

Patients with COPD are susceptible to many conditions that can rapidly lead to acute deterioration superimposed on chronic disease, including COVID-19. Quick and accurate recognition of these patients, along with aggressive and prompt intervention, may be the only action that prevents frank respiratory failure.


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