The Relationship Between Airflow Obstruction, Emphysema Extent, and Small Airways Function in COPD

Background The severities of COPD (FEV1 % predicted) and airflow obstruction (FEV1/FVC) are considered to be due to both emphysema and small airways disease. To our knowledge, this has not been previously confirmed by combined measurements of emphysema and of small airway function. We hypothesized that small airways disease and emphysema extent contribute independently to the severity of both COPD and airflow obstruction. Methods Twenty-six subjects with COPD underwent measurements with forced oscillation technique (FOT) at 6 Hz and single-breath nitrogen washout. Respiratory system resistance, respiratory system reactance (Xrs), and expiratory flow limitation (EFL) index (measured as mean inspiratory Xrs − expiratory Xrs) were derived from FOT. Closing volume/vital capacity (CV/VC) was derived from the washout. Emphysema extent was measured as low attenuation areas < −910 Hounsfield units, expressed as a percentage of CT scan lung volume from multislice CT scans taken at total lung capacity. Results Subjects were aged (mean ± SD) 69.6 ± 8.0 years. Postbronchodilator FEV1 was 64.8 ± 19.8% predicted, and diffusing capacity of lung for carbon monoxide was 50.7 ± 15.8% predicted. Emphysema extent was 22.6% ± 15.0% CT scan volume. CV/VC was 16.9% ± 7.9%; Xrs, −3.72 ± 3.03 cm H2O/L/s; and EFL index, 3.88 ± 3.93 cm H2O/L/s. In multiple regression analyses, FEV1/FVC was predicted by both emphysema and CV/VC (model r2 = 0.54, P < .0001) whereas FEV1 % predicted was predicted by emphysema and EFL index (model r2 = 0.38, P = .0014). Conclusions The severities of COPD and airflow obstruction are independently predicted by both small airways disease and emphysema extent. The severities of COPD (FEV1 % predicted) and airflow obstruction (FEV1/FVC) are considered to be due to both emphysema and small airways disease. To our knowledge, this has not been previously confirmed by combined measurements of emphysema and of small airway function. We hypothesized that small airways disease and emphysema extent contribute independently to the severity of both COPD and airflow obstruction. Twenty-six subjects with COPD underwent measurements with forced oscillation technique (FOT) at 6 Hz and single-breath nitrogen washout. Respiratory system resistance, respiratory system reactance (Xrs), and expiratory flow limitation (EFL) index (measured as mean inspiratory Xrs − expiratory Xrs) were derived from FOT. Closing volume/vital capacity (CV/VC) was derived from the washout. Emphysema extent was measured as low attenuation areas < −910 Hounsfield units, expressed as a percentage of CT scan lung volume from multislice CT scans taken at total lung capacity. Subjects were aged (mean ± SD) 69.6 ± 8.0 years. Postbronchodilator FEV1 was 64.8 ± 19.8% predicted, and diffusing capacity of lung for carbon monoxide was 50.7 ± 15.8% predicted. Emphysema extent was 22.6% ± 15.0% CT scan volume. CV/VC was 16.9% ± 7.9%; Xrs, −3.72 ± 3.03 cm H2O/L/s; and EFL index, 3.88 ± 3.93 cm H2O/L/s. In multiple regression analyses, FEV1/FVC was predicted by both emphysema and CV/VC (model r2 = 0.54, P < .0001) whereas FEV1 % predicted was predicted by emphysema and EFL index (model r2 = 0.38, P = .0014). The severities of COPD and airflow obstruction are independently predicted by both small airways disease and emphysema extent.