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