Chronic Obstructive Pulmonary Disease (COPD)

Chronic bronchitis: productive cough on most days for greater than 3 months (obstruction from narrowing of airway by mucosal thickening and excess mucous)

    • Cyanotic
    • Peripheral edema (RVF)
    • Crackles, wheeze
    • Increased expiratory phase
    • Obese
  • PFTs: normal TLC, Increased/normal DCO
  • CXR: AP normal, Increased bronchovascular markings, Tapering markings, Enlarged heart with cor pulmonale
  • RHF due to increased pressure in lungs

Emphysema: dilatation and destruction of air spaces distal to terminal bronchiole without obvious fibrosis (decreased elastic recoil of lung parenchyma – decreased expiratory driving pressure, airway collapse and air trapping)

    • centriacinar: bronchioles, upper lung zones, smoker
    • panacinar: bronchioles/alverolar ducts/alveolar sacs, lower zones
  • Pink
  • Pursed lip breathing
  • Accessory muscle use
  • Increased work of breathing
  • Barrel chest
  • Hyperresonant
  • PFTs: Increaased TLC, Decreased DCO
  • CXR: Increased AP, Decreased heart shadow, Increased retrosternal space, Bullae, Decreased peripheral vascular marking



 

History

  • Smoking
  • Home O2
  • How diagnosed
  • Cough
  • Function (change in SOBOE)
  • Associated symptoms
  • Triggers (infection)
  • R/O ACS
  • Occupational history
  • Lung cancer (weight loss, hemoptysis)

Physical exam

  • Inspection: cyanosis, distress (rapid shallow breathing, tripod, accessory muscle use, speaking in sentences, indrawing tracheal tug, paradoxical breathing), O2
    • Laryngeal height (< 4cm hyperinflated)
    • Barrel cheat
    • Clubbing NOT seen in COPD (CF or cancer)
  • Hyperresonance, decreased posterior chest excursion
  • Decreased breath sounds, quiet sounds, long expiratory phase (N < 6 seconds, if >9 seconds = prolonged) place stethoscope over trachea and blow out

EKG

  • Right heart strain
  • P-pulmonale (RAE)
  • Tachycardia
  • Decreased voltages

Pulmonary Function Tests

  • FEV1/FVC decreased
  • DLCO decreased (decreased SA to transfer gas)
  • FEV1 decreased
  • TLC increased

Exacerbation (infection, HF, poor compliance on Rx, bronchospasm)

  • Increased dyspnea
  • Increased sputum production
  • Change in sputum
  • Usually hypoxia corrects with a couple litres of O2 – if more required think of other diseases
    • Differential diagnosis: COPD, PE, pulmonary edema, pneumonia

Fixed obstruction (decreased/no response to bronchodilators)
ABG – wide A-a gradient; hypercarbia
2° erythrocytosis
Pulmonary HTN

Staging

  • At risk: asymptomatic smoker or ex-smoker or chronic cough/sputum production, but postbrochodilator FEV1/FVC > 0.7 and/or FEV1>80%
  • Mild: SOB from COPD with strenuous exercise or when hurrying on the level or walking up a slight hill
  • Moderate: SOB causing pt to walk slower, or stop after 100m
  • Severe: SOB resulting in patient too breathless to leave the house or after dressing/undressing or in presence of chronic respiratory failure or clinical signs of RHF

Treatment

  • Quit smoking
  • Vaccination
  • Home O2
  • Drugs
    • First-line: SA beta2 agonists (salbutamol) and anticholinergics (ipatropium bromide)
    • LA beta2 agonists (salmeterol) and anticholinergics (tiotropium)
    • Theophyline
    • Inhaled corticosteroids
    • Exacerbation: O2 to maintain sats 90-92%
    • Ventolin 2.5 mg MDI ii/hour
    • Atrovent 0.5 mg MDI q4h
    • Prednisone 40 mg PO – max. 2 weeks
    • Antibiotics (if really sick or sign of infection)
    • BiPAP – mortality benefit
    • NO inhaled steroids or theophylline

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