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 Table of Contents  
Year : 2020  |  Volume : 9  |  Issue : 2  |  Page : 186-190

Need for pulmonary screening in rheumatoid arthritis patients: An observational study

1 Respiratory Therapist, Cosmopolitan Hospital, Thiruvananthapuram, Kerala, India
2 Consultant Pulmonologist, Department of Pulmonary and Critical Care Medicine, Renai Medicity Hospital, Cochin, Kerala, India
3 Department of Respiratory Care Therapy, Batterjee Medical College, Jeddah, Saudi Arabia

Date of Submission18-Nov-2019
Date of Decision24-Feb-2020
Date of Acceptance05-Mar-2020
Date of Web Publication07-Jul-2020

Correspondence Address:
Dr. Subin Ahamed
Renai Medicity Hospital, Cochin, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijrc.ijrc_55_19

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Background: Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease characterized by articular and extra-articular involvement. The extra-articular involvement in RA is primarily manifested in pulmonary system characterized with pleurisy, airway diseases, nodular formations, and interstitial involvement. Aim: The aim was to assess the need of pulmonary screening in RA. Patients and Methods: A cross-sectional observational study was conducted on 122 patients who presented with respiratory difficulties and suspected RA. Initial screening for pulmonary involvement was done with physical assessment and pulmonary function tests (PFTs) followed with high-resolution computerized tomography (HRCT) scan. Health-related quality of life was assessed with pre–post 6-min walk test (6MWT) followed with dyspnea assessment and pulse oximetry. Results: Of the 122 patients screened, 33 were diagnosed with RA. The mean age was 40–50 years, was more common in women, and PFT showed both restrictive and obstructive pattern. Review of HRCT pattern of all patients showed nonspecific interstitial pneumonia pattern as the most common finding. Patients had desaturation after 6MWT and worsening of dyspnea. Conclusion: The degree of pulmonary involvement in RA is related to the duration of the disease. Clinical assessment, PFT, and 6MWT used in combination are cost-effective tools in early detection. HRCT provides a better understanding of the pattern of pulmonary involvement in RA.

Keywords: Dyspnea, high-resolution computerized tomography, pulmonary function test, pulmonary manifestation, rheumatoid arthritis

How to cite this article:
Ganga B, Ahamed S, Krishna G G. Need for pulmonary screening in rheumatoid arthritis patients: An observational study. Indian J Respir Care 2020;9:186-90

How to cite this URL:
Ganga B, Ahamed S, Krishna G G. Need for pulmonary screening in rheumatoid arthritis patients: An observational study. Indian J Respir Care [serial online] 2020 [cited 2022 Dec 5];9:186-90. Available from: http://www.ijrc.in/text.asp?2020/9/2/186/289092

  Introduction Top

Rheumatoid arthritis (RA) is a chronic connective tissue disease characterized by articular and extra-articular involvement. Although the prevalence of RA in developed countries is ~1%, the data in developing countries are still unknown.[1] The main presenting feature of RA is joint disease. However, there are a number of extra-articular manifestations, in which approximately 50% of cases have lung involvement, including parenchymal, pleural, and airway diseases. The exact mechanism for this has not been elucidated but can be due to the chronic inflammation itself or secondarily to immune-modulating medications.[2] Pulmonary screening for RA, especially for interstitial lung disease (ILD) has been proposed in various studies, but there is no standard technique. Pulmonary function test (PFT), chest X-ray, and pulse oximetry are simple, cost-effective techniques, which can be used in combination or alone. More definitive techniques include high-resolution computerized tomography (HRCT), diffusion capacity of the lung for carbon monoxide, and lung biopsy (gold standard).[3],[4],[5] The screening technique may vary from institution to institution. In our center, we use the combination of PFT and clinical assessment for the preliminary screening. Due to the articular involvement, the health-related quality of life (HRQL) will already be impaired in RA patients. Studies have shown that the majority of respiratory symptoms occur within the first 5 years of disease, which further worsens the HRQL of the patients without been recognized.[6] Treating respiratory conditions begin with arriving at the right diagnosis. Respiratory therapists who work in the pulmonary function laboratory play a key role to help in tailoring individual-specific rehabilitation plans.

The present study focused on the need of early screening for pulmonary involvement and HRQL of RA patients. This can help in early identification and establishment of appropriate goals for pulmonary rehabilitation in such patients.

  Patients and Methods Top

The present cross-sectional study was done in pulmonary medicine department at a Amrita Institute of Medical Sciences and Research Center, Kochi, a southern state of India. The study was approved by the institutional ethics committee. Patients who were attending the outpatient or inpatient facilities of general and pulmonary medicine departments from August 2016 to September 2017, aged over 18 years and diagnosed with RA based on the American College of Rheumatology and European League against Rheumatism (ACR/EULAR) score of >6 (ACR/EULAR 2010) were included in the study [Figure 1].[7] Patients with overlapping diseases such as chronic obstructive pulmonary disease and asthma and who were not willing to participate were excluded from the study. Informed consent was taken from the participants.
Figure 1: Study protocol. COPD: Chronic obstructive pulmonary disease, PFT: Pulmonary function test HRCT: High-resolution computerized tomography, MMRC: Modified Medical Research Council breathlessness scale questionnaire for dyspnea, HRQL: Health-related quality of life, 6MWT: 6-min walk test, DBS: Dyspnea–Borg scale, SpO2: Pulse oximetric saturation

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The primary objective of the study was to assess the degree of pulmonary involvement in RA patients in comparison to duration of the disease and also to assess the severity of dyspnea in these patients. Secondarily, to assess the relation with predisposing factors such as age, duration of disease, gender, and smoking to the degree of pulmonary involvement in RA patients.

An initial screening was done with clinical evaluation and PFT followed with HRCT scan. Dyspnea was assessed in two ways: first using questionnaire for daily dyspnea and second by 6-min walk test (6MWT) followed with pre–post dyspnea assessment and pulse oximetry.

Tools and equipment used

PFT was performed using Vitalograph Spirotrac. HRCT was done in Philips 256-slice Brilliance iCT scanner. HRQL assessment was performed with two questionnaires: Modified Medical Research Council (MMRC) and breathlessness scale questionnaire for dyspnea. Post-6MWT dyspnea was assessed using modified Borg Dyspnea Scale.[8],[9] Pulse oximetric saturation was measured using Nellcor™M portable SpO2 patient monitoring system.

Study sample

Considering the rarity of the disease, convenient sampling technique was used. Patients with RA presented to the pulmonary medicine department during the study were enrolled based on the inclusion and exclusion criteria.

Statistical analysis

Data were analyzed using IBM (SPSS Statistic version 20, South Asia, Bangalore, India). Continuous variables were represented as a mean and standard deviation and also as median and interquartile range. Categorical variables were expressed as numbers (%). Statistical tests such as Chi-square test, Student's t-test, and Kruskal–Wallis test were used. P < 0.05 was considered statistically significant difference.

  Results Top

A total of 122 patients were screened during the study, of which 33 diagnosed with RA. Three of them were excluded from the study due to overlapping syndrome and unwillingness to participate in the study [Figure 2]. Majority of the study population were females (90%) and nonsmokers (93%). About 47% of the study population where in the age group between 40 and 50 years, and most of them (47%) had RA for 5–9 years [Table 1].
Figure 2: Patients enrollment in the study

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Table 1: Demographic data

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Initial pulmonary screening such as clinical assessment and PFT was done and compared against the duration of RA. Clinical symptoms were evidently seen in patients with RA for 5–9 years (45%), with dyspnea being the most common symptom [Figure 3]. PFT showed abnormalities in patients across all the groups. Abnormality included both obstructive and restrictive pattern. Although there was no significant difference, we found a restrictive pattern more common in patients with RA [Table 2] and [Figure 4]. HRCT findings were classified into parenchymal and pleural features, 53% had some kind of pleural or parenchymal abnormalities associated with RA, in which nonspecific interstitial pneumonia (NSIP) pattern was the most common [Table 2] and [Figure 5].
Figure 3: Clinical findings on initial examination

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Table 2: Represents the duration of rheumatoid arthritis and pulmonary involvement

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Figure 4: Pulmonary function test findings

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Figure 5: Pleural and parenchymal findings on high-resolution computerized tomography finding in rheumatoid arthritis patients. (NSIP: Nonspecific interstitial pneumonia, GGO: Ground-glass opacity)

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[Table 3] represents the severity of dyspnea in comparison with duration of RA. Participants with < 5 years of RA had Grade 1 MMRC breathlessness score and participants with diagnosed RA for >10 years had Grade 3 breathlessness. Another interesting finding was everyone in the study had some degree of breathlessness due to RA. Pre–post 6MWT showed difference in SpO2 in patients with RA for ≥10 years (97.47 ± 3.28% versus 89.41 ± 3.31%), but it was not statistically significant [Table 4].
Table 3: Modified Medical Research Council breathlessness score for dyspnea in relation to duration of rheumatoid arthritis

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Table 4: Pre-post 6-min walk test findings compared to duration of rheumatoid arthritis

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  Discussion Top

The focus of the current study was to assess the need of early pulmonary screening in RA. Based on the prevalence, studies of RA showed a higher incidence of females. Although various studies showed the relation between smoking and RA, our study could not find any significant relation. Shaw et al.[10] reviewed the pulmonary manifestation of RA stated that pulmonary symptoms occur within the first 5 years of life, and further worsening can go unrecognized due to poor functional status of the joint disease or the chronic inflammation. In our study, we observed within 5 years, 30% of the study population developed clinical symptoms, and 47% of them developed symptoms between 5 and 9 years. Dawson et al.[11] also looked for the onset of clinical symptoms and found that symptoms start within 13 months, and features are similar to ILD. PFT findings in the present study showed that 67% of the patients had abnormal findings with both restrictive and obstructive patterns which were not statistically significant. Cohort studies by Schünemannet al.[12] and Cavagna et al.[13] found that restrictive defect was the most common finding in patients of RA with pulmonary involvement, which is suggestive of ILD. Daniil et al.[14] studied the relation between the clinical, radiologic findings, and histology in RA patients and concluded that along with histopathology, chest X-ray, and HRCT are also effective tools in RA diagnosis. NSIP and usual interstitial pneumonia are the most common features associated with lung fibrosis in Remy-Jardin et al.[15] studied HRCT findings in RA and concluded that NSIP pattern had typical reticular opacities with honeycombing predominantly in parenchyma. Anaya et al.[16] studied the characteristic features of pulmonary involvement in RA. Pleuritic chest pain, parenchymal nodule formations, interstitial, and airway diseases are the common manifestations of lung disease in RA. Similarly, the present study HRCT findings showed that 53% had abnormal findings, NSIP being the most common and other findings included pleural effusion, nodules, ground-glass opacity honeycombing, and septal thickening.

Dyspnea severity was measured in the current study as a tool to measure the HRQL. MMRC breathlessness score showed everyone in the study had some degree of dyspnea. Grade 1 is more common in patients with RA <5 years and Grade 3 in patients with RA for ≥10 years. Pre-post 6MWT showed a significant difference in SpO2 in patients with RA for ≥10 years and average Borg dyspnea index post-6MWT of 0, 2, and 4 in different groups. HRQL is an important tool to assess the burden of musculoskeletal disease. The common tool for assessing HRQL is the Medical Outcomes Study Short Form 36 questionnaire with different domains. Salaffi et al.[6] study on HRQL in RA patients showed that chronic RA has a clearly detrimental effect on HRQL in both genders and in age groups, and the physical domain is more impaired than mental and social ones.


The present study is a screenshot of a particular time point, and diseases such as RA should be studied as a cohort. The smaller sample size and the convenient sampling technique were also the limitations of the study.

  Conclusion Top

Our study findings suggest that pulmonary screening can be done cost-effectively with clinical assessment, PFT, and 6MWT. HRCT provides a better understanding of the pattern of pulmonary involvement in RA. Identifying the baseline lung function of the RA patients plays a vital role in rehabilitation. Therefore, it is necessary to consider pulmonary screening at the earliest in RA.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Gibofsky A. Overview of epidemiology, pathophysiology, and diagnosis of rheumatoid arthritis. Am J Manag Care 2012;18:S295-302.  Back to cited text no. 1
Lipsky P. Rheumatoid arthritis. In: Fuci AS, Harrison TR, editors. Harrison's Principles of Internal Medicine. 14th ed. New York: McGraw-Hill; 1998. p. 1880-8.  Back to cited text no. 2
O'Dwyer DN, Armstrong ME, Cooke G, Dodd JD, Veale DJ, Donnelly SC. Rheumatoid arthritis (RA) associated interstitial lung disease (ILD). Eur J Intern Med 2013;24:597-603.  Back to cited text no. 3
Chakravarthy K, Webley M. A longitudinal study of pulmonary function in patients with rheumatoid arthritis treated with gold and D-penicillamine. Br J Rheumatol 2003;31:829-33.  Back to cited text no. 4
Lee HK, Kim DS, Yoo B, Seo JB, Rho JY, Colby TV, et al. Histopathologic pattern and clinical features of rheumatoid arthritis-associated interstitial lung disease. Chest 2005;127:2019-27.  Back to cited text no. 5
Salaffi F, Carotti M, Gasparini S, Intorcia M, Grassi W. The health-related quality of life in rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis: A comparison with a selected sample of healthy people. Health Qual Life Outcomes 2009;7:25.  Back to cited text no. 6
Aletaha D, Neogi T, Silman AJ, Funovits J, Felson DT, Bingham CO 3rd, et al. 2010 Rheumatoid arthritis classification criteria: An American College of Rheumatology/European league against rheumatism collaborative initiative. Arthritis Rheum 2010;62:2569-81.  Back to cited text no. 7
Fletcher CM, Elmes PC, Fairbairn AS, Wood CH. The significance of respiratory symptoms and the diagnosis of chronic bronchitis in a working population. Br Med J 1959; 2:257–66.  Back to cited text no. 8
Borg G. Perceived exertion as an indicator of somatic stress. Scand J Rehabil Med 1970;2:92-8.  Back to cited text no. 9
Shaw M, Collins BF, Ho LA, Raghu G. Rheumatoid arthritis-assosciated lung disease. Eur Respir Rev 2015;24:1-6.  Back to cited text no. 10
Dawson JK, Fewins HE, Desmond J, Lynch MP, Graham DR. Fibrosing alveolitis in patients with rheumatoid arthritis as assessed by high resolution computed tomography, chest radiography, and pulmonary function tests. Thora×2001;56:622-7.  Back to cited text no. 11
Schünemann HJ, Dorn J, Grant BJ, Winkelstein W Jr., Trevisan M. Pulmonary function is a long-term predictor of mortality in the general population: 29-year follow-up of the Buffalo Health Study. Chest 2000;118:656-64.  Back to cited text no. 12
Cavagna L, Monti S, Grosso V, Boffini N, Scorletti E, Crepaldi G, et al. The multifaceted aspects of interstitial lung disease in rheumatoid arthritis. Biomed Res Int 2013;2013:759-60.  Back to cited text no. 13
Daniil ZD, Gilchrist FC, Nicholson AG, Hansell DM, Harris J, Colby TV, et al. A histologic pattern of nonspecific interstitial pneumonia is associated with a better prognosis than usual interstitial pneumonia in patients with cryptogenic fibrosing alveolitis. Am J Respir Crit Care Med 1999;160:899-905.  Back to cited text no. 14
Remy-Jardin M, Remy J, Cortet B, Mauri F, Delcambre B. Lung changes in rheumatoid arthritis: CT findings. Radiology 1994;193:375-82.  Back to cited text no. 15
Anaya JM, Diethelm L, Ortiz LA, Gutierrez M, Citera G, Welsh RA, et al. Pulmonary involvement in rheumatoid arthritis. Semin Arthritis Rheum 1995;24:242-54.  Back to cited text no. 16


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1], [Table 2], [Table 3], [Table 4]


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