Author Thomas W. DeCato, M.D. Pulmonary & Critical Care Medicine Fellow University of Utah and Intermountain Medical Center
Case
A 57 year-old man with a history of renal cell carcinoma presented with subacute cough and dyspnea on exertion.
The patient had no other history of lung disease and was a lifetime
non-smoker. Vital signs and cardiopulmonary exam were normal. Spirometry
was obtained as part of his clinic visit with the flow-volume loop
prompting a further diagnostic test and definitive treatment.
Question
What is the diagnosis?
Answer
This patient has a unilateral mainstem bronchus obstruction. The
flow-volume loop shows both an end-inspiratory and end-expiratory tail
and is most commonly known as a biphasic flow-volume curve. This finding
has also been described as “two compartments.” A CT chest was obtained
which showed an obstructing right mainstem bronchus lesion.
The patient underwent interventional bronchoscopy with electrocautery
snare and cryotherapy. The lesion was found to be metastatic renal cell
carcinoma. After this intervention, the patient’s cough and dyspnea on
exertion resolved as did the biphasic pattern upon repeat spirometry.
Mild concavity was evident in the flow-volume loop post-procedure and
spirometry was consistent with mild obstruction.
The biphasic spirogram was first described by Gascoigne et al. in
1990. This characteristic pattern is the result of the asynchronous
filling and emptying of each lung. In this case, the normal left lung
has normal inspiratory and expiratory flow, which is then followed by
the abnormal right lung. The presence of the obstruction causes delayed
flows and appears as a near straight line on the inspiratory and
expiratory limbs due to the fixed resistance in effect across the
obstruction. The degree of obstruction is important with lesions
obstructing <25% or >90% of the mainstem bronchus less likely to
show a biphasic pattern. The differential diagnosis when this pattern is
present is fairly limited and shown in table 1. Tracheobronchomalacia
is a commonly named etiology, however typically only the expiratory limb
appears to show the biphasic pattern in this condition.
Common causes of biphasic flow-volume loop
Bronchial carcinoma or metastases
Macleod's syndrome (unilateral emphysema)
Single lung Transplantation
Granulation tissue at anastomosis post lung transplant
Granulomatosis with polyangiitis
Sarcoidosis
Amyloidosis
Developmental Cartilagenous Ridge
Bronchogenic cyst
(Images and spirograms are courtesy of Matthew J. Hegewald, M.D.)
References
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