CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
Dr. Magnolia Reyes
OUTLINE
I. Case
II. Case Discussion
III. Sample Interview and Patient’s Picture
IV. Case Questions
V. Comprehension Questions
VI. Clinical Pearls
VII. References
VIII. Appendix
I. CASE
A 55-year-old male comes to the clinic because of
shortness of breath. He has experienced mild dyspnea on
exertion for a few years but more recently he has noted
worsening SOB with minimal exercise and onset of dyspnea at
rest. He has difficulty of reclining as a result, he spends the
night sitting up in a chair trying to sleep. He reports a cough
with production of yellowish-brown sputum every morning
throughout the year. He denies chest pain, fever, chills or lower
extremity edema. He has smoked about 2 packs of cigarette
per day since age 15. He does not drink alcohol.
A few months ago, he went to a clinic for evaluation of
his symptoms and received prescriptions for some inhalers
which names he cannot remember.
PE: BP 136/86, HR 96bpm, RR 28bpm, T 37℃
He is sitting in a chair, leaning forward with his arms
braced on his knees. He appears uncomfortable with labored
respirations and cyanotic lips. He is using accessory muscles
of respiration, and chest exam reveals wheezed and rhonchi
bilaterally, but no crackles. The AP diameter of the chest wall
appears increased and inward movement of the lower rib cage.
Heart is normal but with distant heart sounds. Normal jugular
venous pressure of his extremities shows no cyanosis, edema
or clubbing.
II. CASE DISCUSSION
A. WHAT ARE THE SALIENT POINTS OF THIS CASE?
 Mild dyspnea on exertion
 Shortness of breath with minimal exercise
 Onset of dyspnea at rest
 Difficulty of reclining
 Cough with production of yellowish-brown sputum
every morning throughout the year
 2 packs of cigarette per day since age 15
B. WHAT IS THE PICTURE OF THE PATIENT?
 Has a difficulty in breathing
 In “tripod position”: sitting leaning forward with hands
supported anteriorly on the knees, a posture
frequently assumed by patients in respiratory distress
 RR: 28 bmp (Normal: 12-20 bmp)
 Chest exam reveals wheezes and rhonchi bilaterally
 The AP diameter of the chest wall appears increased
and inward movement of the lower rib cage. “barrel
chest” *can be a sign of underlying condition like
COPD
o What does it denote? Emphysema
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C. WHAT ARE THE ACCESSORY MUSCLES OF
RESPIRATION?
It refers to those that assist, but do not play a primary
role, in breathing. Use of these while at rest is often interpreted
as a sign of respiratory distress.
The accessory inspiratory muscles are the
sternocleidomastoid*, the scalenus anterior, medius, and
posterior*, the pectoralis major and minor, the inferior fibres of
serratus anterior and latissimus dorsi, the serratus posterior
superior may help in inspiration, also the iliocostalis cervicis.
Technically. any muscle attached to the upper limb and the
thoracic cage can act as an accessory muscle of inspiration
through reverse muscle action (muscle work from distal to
proximal).
The accessory expiratory muscles are the abdominal
muscles: rectus abdominis, external oblique, internal oblique,
and transversus abdominis. And in the thoracolumbar region;
the lowest fibres of iliocostalis and longissimus, the serratus
posterior inferior, and quadratus lumborum.
D. WHY IS THE PATIENT USING HIS ACCESSORY
MUSCLES?
In emphysema, the alveoli are dilated, increasing their
oxygen demand. Thus, accessory muscles of respiration are
used.
E. WHAT WAS HEARD ON HIS CHEST EXAM?
“… wheezes and rhonchi bilaterally with no crackles”
 Rhonchi?
o Continuous low pitched, rattling lung sounds
that often resemble snoring. Obstruction or
secretions in larger airways are frequent
causes of rhonchi.
o Heard on expiration
 Wheezes?
o Wheezing is a high-pitched, coarse whistling
sound when you breathe. The whistling
sound happens when air moves through
narrowed airways, much like the way a
whistle or flute makes music.
o The most common causes are COPD and
asthma.
o Heard during inspiration and/or expiration,
usually louder on the latter
 Crackles? “Rales”
o Occur when airway contains fluid
o Heard on inspiration
F. WHAT IS THE PATHOPHYSIOLOGY THERE?
When emphysema develops, the alveoli and lung
tissue are destroyed. With this damage, the alveoli cannot
support the bronchial tubes. The tubes collapse and cause an
“obstruction” (a blockage), which traps air inside the lungs. Too
much air trapped in the lungs can give some patients a barrel-
chested appearance.
G. LUNG LOBES
 Right – 3; (superior) upper, middle, (inferior) lower
lobes
 Left – 2; (superior) upper, (inferior) lower lobes
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 Prelims (1st Sem) Chronic Obstructive Pulmonary DIsease
Dr. Magnolia Reyes
CLINICAL THERAPEUTICS· September 17, 2020

H. WHAT IS IN THE PATIENT’S HISTORY THAT IS VERY
IMPORTANT?
 The patient is a smoker since he was 15 years old
 How many packs per day? (in pack years)
 Formula:
time, α1-antitrypsin, a plasma protein that normally
inactivates elastase and other proteases, is itself
inhibited. The α1-antitrypsin is inactivated by oxygen
radicals, and these are released by the leukocytes.
The final result is a protease antiprotease imbalance
with increased destruction of lung tissue.

C. WHAT IS PFT? SPIROMETRY?

 Pulmonary function tests (PFTs)
o Group of tests that measure breathing and
how well the lungs are functioning. Complete
PFTs comprise respiratory tests of
 Computation: spirometry, lung volumes, and diffusion
o 1 pack of cigarette contains 20 sticks which evaluates respiratory flow volumes
o 40 sticks per day x 40 years of smoking and flow rates to assess pulmonary function.
20 (see appendices A and B)
o 1600/ 20 = 80 pack years  Spirometry
 Smoking is a risk factor of having his current condition o Method of evaluating respiratory flow
volumes and flow rates to assess pulmonary
III. SAMPLE INTERVIEW AND PATIENT’S PICTURE function. It is the most basic, inexpensive,
Doctor: Ano ho bang nangyari sa inyo? 55 years old na ho widely valuable pulmonary function test to
kayo. Ano po ba ang trabaho niyo noon? Kailan po nag- diagnose pulmonary diseases.
umpisa iyan?
D. WHAT IS FORCED VITAL CAPACITY, FORCED
Patient: Madali lang po akong mapagod pag may EXPIRATORY VOLUME IN 1 SECONDS, FEV/FVC1?
ginagawa. Pagkatapos po ngayon, kahit FVC – Forced vital capacity
naglalakad nahihirapan na po ako. Ngayon po, hindi  Total volume of air expired after full inspiration. FVC is
reduced in restrictive lung disease. Patients with
na ako makahinga kahit na wala akong ginagawa.
obstructive lung disease usually have normal FVC.
Note the progression of the disease process – from
SOB to mild dyspnea on exertion to dyspnea at rest. Try to FEV1 – Forced expiratory volume in one second
picture what is happening to the patient, not only at that  Volume of air expired in the first second during
maximal expiratory effort.
present moment.
 FEV1 is reduced in
 Where does he sleep? Sa chair kasi hindi both obstructive lung disease (increased airway
nakakahinga „pag diretso. resistance) and restrictive lung disease (low vital
capacity)
 What medicine was given? Unrecalled inhalers
 Did the patient get well with the medicine given? No, FEV1/ FVC ratio – Percentage of the vital capacity that is
because the patient returned for consultation expired during the first second
 What was noted on the heart exam? Normal heart but of maximal effort, reduced in obstructive lung disease.
with distant heart sound
 What if JVP is normal? Case might be a respiratory E. WHAT IS OBSTRUCTIVE LUNG DISEASE?
problem, not cardiac RESTRICTIVE LUNG DISEASE?
 What if JVP is high, there could be CHF Obstructive lung Restrictive lung disease
disease
 What was seen on the extremities? No cyanosis,
Increase in resistance Reduced expansion of
edema, and clubbing
to airflow due to lung parenchyma and decreased
 Findings only include the pulmonary but is the case partial or complete total lung capacity (there is
compensated? Yes, because there is no cyanosis on obstruction at any difficulty in taking air inside the
the extremities, only on the lips level from the lungs d/t loss of elasticity)
trachea and larger
IV. CASE QUESTIONS bronchi to the terminal
A. WHAT IS YOUR DIAGNOSIS? and respiratory
COPD (Emphysema) with acute exacerbations bronchioles (px
experience shortness
B. WHAT IS THE ETIOLOGY OF YOUR DIAGNOSIS? of breath d/t difficulty
 Inhalation injury like prolonged cigarette smoking in exhaling air from the
o Airflow limitation due to chronic inflammation lungs
noxious particles of cigarette  Decreased FEV  Decreased lung volumes
 The smoke causes an increase in the number of 1 <80% of  Decreased VC
pulmonary alveolar macrophages, and these predicted Decreased TLC
macrophages release a chemical substance that  FEV1/FVC <0.7  FEV1/FVC is normal
attracts leukocytes to the lungs. The leukocytes in  TLC usually
turn release proteases including elastase, which normal or
attacks the elastic tissue in the lungs. At the same increased

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 Prelims (1st Sem) Chronic Obstructive Pulmonary DIsease
Dr. Magnolia Reyes
CLINICAL THERAPEUTICS· September 17, 2020

 Diffusion capacity
decreased I. WHAT IS YOUR DIAGNOSTICS?
Bronchiectasis (ie, Extrapulmonary: Pulmonary: ABG to assess oxygenation and acid-base status.
cystic fibrosis) poor breathing poor lung
Asthma mechanics expansion J. WHAT IS YOUR TREATMENT AND RECOMMENDED
Bronchitis (chronic) Poliomyelitis Pneumonia MANAGEMENT AT THIS POINT?
Emphysema Myasthenia gravis ARDS  Ensure adequate oxygenation with target oxygenation
Scoliosis Pulmonary of 90-92% (watch out for CO2 retention), via nasal
edema cannula
Interstitial  Bronchodilators (beta-agonist and anticholinergic
fibrosis agents) administered via
 Obstructive lung disease: Chronic pulmonary disorder handheld nebulizers
that is characterized by a disproportional decrease in  Steroids for airway inflammation
maximal airflow from the lung in relation to maximal  Systemic glucocorticoids to accelerate the rate of
volume that can be displaced from the lung. Most common improvement in lung function
types of obstructive lung disease are asthma and COPD.  Antibiotics if suspicious of respiratory infection
 Restrictive lung disease: Chronic pulmonary disorder  *Consider surgical treatments like lung reduction
characterized by low lung volumes because of alterations surgery and segmentectomy/lobectomy
of either the lung parenchyma (intrinsic), or chest wall,
pleura, or respiratory muscles (extrinsic). V. COMPREHENSION QUESTIONS
1. Which of the following is the most likely physical examination
F. WHAT IS COPD? findings in a patient with COPD?
COPD is a chronic airflow obstruction caused by A. Diffuse expiratory wheezing
chronic bronchitis or emphysema characterized by persistent B. Clubbing of the fingers
airflow limitation that is usually progressive and associated with C. Bibasilar inspiratory crackles with increased jugular venous
enhanced chronic inflammatory response in the lungs to the pressure (JVP)
noxious particles and gases. D. Inspiratory stridor
 FEV1/ FVC ratio of less than 70 E. Third heart sound
 Severity on spirometry is based on FEV 1/ FEV1 ratio
vs. predicted 2. A 56-year-old woman admits to a 60-pack-year smoking
o >80% = mild disease history. She complains of fatigue and dyspnea with minimal
o 50% to 80% = moderate exertion, and a cough that is productive each morning. Which
o 30% to 50% = severe of the following is the most likely finding in this patient?
o < 30% = very severe disease A. Higher diffusing capacity of lung for carbon monoxide
(DLCO)
G. WHAT IS RESPIRATORY DISTRESS? B. Decreased residual volume
It is a clinical syndrome of progressive respiratory C. Normal to slightly increased FEV1
insufficiency caused by diffuse alveolar damage with damage D. Decreased FEV1/ FVC
to hyaline membrane lining the walls, edema, scattered E. Decreased FVC
neutrophils and macrophages, and epithelial necrosis.
This occurs when fluid builds up in the tiny, elastic air 3. Which of the following therapies is most likely to provide the
sacs (alveoli) in your lungs keeping it from filling with enough greatest benefit to a patient with chronic stable emphysema
air causing less oxygen to reach the bloodstream. and a resting oxygen saturation of 86%?
A. Inhaled tiotropium daily
H. WHAT IS YOUR EMPHYSEMA? CHRONIC B. Inhaled albuterol as needed
BRONCHITIS? C. Oral prednisone daily
Emphysema Chronic bronchitis D. Supplemental oxygen used at night
COPD component that is COPD component that is E. Supplemental oxygen used continuously
diagnosed pathologically with diagnosed clinically. It
irreversible enlargement of characterized by excessive VI. CLINICAL PEARLS
the airspaces distal to the secretion of bronchial mucus  Patients with obstructive lung disease have air flow
terminal bronchiole, and productive cough for limitation on expiration (reduced FEV1/FVC), whereas
accompanied by destruction 3 months or more in at least 2 patients with restrictive lung disease have difficulty in
of their walls without obvious consecutive years in the expanding their lung volumes in response to exercise
fibrosis. absence of any other disease (reduced TLC).
that might account for this  The mainstay for treatment of chronic obstructive
symptom pulmonary disease exacerbations includes
Smoking and inhaled Dominant pathologic features bronchodilators, oxygen, and glucocorticoids, as well
pollutants cause ongoing are mucus hypersecretion as antibiotics if infection is suspected.
accumulations of and persistent inflammation.  Controlled supplemental oxygen along with positive-
inflammatory cells, releasing pressure mask ventilation (bilevel positive airway
elastases and oxidants, which pressure) may prevent respiratory failure requiring
destroy the alveolar walls endotracheal intubation.
*most patients with emphysema also have some degree of  Smoking cessation and supplemental oxygen to treat
chronic bronchitis, which is to be expected since cigarette chronic hypoxemia are the only medical therapies
smoking is an underlying risk factor for both

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 Prelims (1st Sem) Chronic Obstructive Pulmonary DIsease
Dr. Magnolia Reyes
CLINICAL THERAPEUTICS· September 17, 2020

shown to decrease mortality among persons with

chronic obstructive pulmonary disease.
 In both obstructive and restrictive lung disease, the
FEV1 is decreased, the FEV1/FVC is decreased in
obstructive processes and normal in restrictive
processes.
 The hallmark of restrictive lung disease is decreased
lung capacities, particularly the TLC but also the VC.

References
 Case Files Ⓡ Internal Medicine (5 Edition)
th

 Doc Reyes’ ppt and lecture notes


th
Moore’s Clinically Oriented Anatomy (7 Edition)

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 Prelims (1st Sem) Chronic Obstructive Pulmonary DIsease
Dr. Magnolia Reyes
CLINICAL THERAPEUTICS· September 17, 2020

Appendix A

Appendix B

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