COPD(chronic obstructive pulmonary disease): respiratory muscles>exertional

COPD is a preventable and treatable disease that is dyspnea>symptoms at rest

characterized by persistent respiratory symptoms  Release of systemic inflammatory
mediators(IL-6,IL-8,TNF-a) and reduced
and airflow limitation that is usually progressive,
physical activity in COPD due to exertional
and associated with enhanced chronic inflammatory dyspnea.
response in the airways and lungs to noxious
particles or gases.(4th most common cause of
death). It includes- 1. Chronic Bronchitis
2. Emphysema
3. Mixed Type

 Cough is present throughout the day and night, more

Chronic Bronchitis- Presence of productive cough
(cough with sputum) for at least 3 months in two
consecutive years without any identifiable cause.
Emphysema- Abnormal permanent enlargement of
airspaces distal to the terminal bronchioles
accompanied by destruction of their walls without
obvious fibrosis.
marked in morning and exposure to cold and dust.
 Sputum is mucoid.
 Breathlessness is progressively increasing with symptoms
at exertion and relieved by taking rest at earlier stage,
while in late stage symptoms even appears at rest.
 Lip pursing occurs to minimize air trapping.
 Oedema may be due to cor-pulmonale or failure of salt
and water excretion by the hypoxic hypercapnic kidney.
 Hypercapnea may cause morning headache.
 Other systemic features includes muscular weakness,
increase prevalence of osteoporosis and weight loss.

PATHOPHYSIOLOGY-
 Increase number of goblet cells and
enlargement of mucous secreting glands-
chronic bronchitis
 Unopposed action of proteases and
oxidants or congenital alpha 1 antitrypsin
deficiency-emphysema
 Inflammation and fibrosis>loss of elastic
tissue>premature airway closure>gas
trapping>dynamic hyperinflation> flattens
the diaphragm>increased horizontal
alignment of intercostal
muscles>mechanical disadvantage of
EMPHYSEMA **GENERAL EXAMINATION ESPECIALLY IN
CHRONIC BRONCHITIS REVEALS CENTRAL
On inspection: CYANOSIS,FLAPPING TREMOR AND HIGH
 Patient is dyspnoeic with pursing of lips. BOUNDING PULSE(hypercapnoea) AND
 Chest is barrel shaped PULMONARY OEDEMA IN COR PULMONALE.
 Indrawing of lower intercostal space on
inspiration(due to low flat diaphragm) Investigations:
 Suprasternal and supraclavicular space 1. CBC- polycythemia in advanced stage
excavation 2. CXR PA view- normal in mild cases, in severe
 Prominent accessory muscles of respiration. emphysema there may be feature of
On palpation: hyperinflation: increased translucency, low flat
 Centrally placed trachea diaphragm, tubular heart, widening of
 Apex beat is not felt intercostal space
 Chest expansion is reduced 3. Lung function tests/spirometry:
 Vocal fremitus reduced  Post bronchodilator FEV1<80% of predicted
 Cricosternal distance reduced value
 Tracheal tug present  Post bronchodilator FEV1:FVC is <70% of
On percussion: predicted value
 Hyperresonance in both lung fields  Increased total lung volume and residual
 Liver dullness lowered down and cardiac volume.
dullness diminished 4. ECG- usually normal or RVH in cor pulmonale
On auscultation: 5. Blood gas analysis- p02 reduced, pco2 normal
 Breath sound diminished and is vesicular or increased
with prolonged expiration
 Vocal resonance reduced Management:
1. Avoid smoking
CHRONIC BRONCHITIS 2. Avoidance of dust,fume,smoke etc
3. Mild-avoid of risk factors+influenza
On inspection: vaccination+SABA or anticholinergic when
 Chest normal shaped needed
 Movement of chest bilaterally restricted 4. Moderate-above treatment+regular treatment
 Intercostal space appears full with 1 or more LABA or
On palpation: anticholinergic(tiotropium) when
 Centrally placed trachea needed+rehabilitation
 Apex beat palpable in left 5th intercostal 5. Severe-above treatment+inhaled
space in midclavicular line steroid(fluticasone)
 Chest expansion reduced 6. Very severe-above treatment+long term oxygen
 Vocal fremitus normal if chronic respiratory failure+surgical treatment
On percussion: if required
 Normal resonance
 Liver dullness in right 5th intercostal space Acute exacerbation of COPD:
 Area of cardial dullness impaired Usually present with cyanosis, peripheral oedema
On auscultation: or an alteration in consciousness.(after
 Breath sound vesicular with prolonged hodpitslization,bed rest and propped up)
expiration A. Oxygen therapy: controlled oxygen 24% or 28%
 Vocal resonance normal must be used
 Added sound- Plenty of rhonchi found in B. Nebulized SABA combined with anticholinergic
chronic bronchitis in both lung fields, present agent and normal saline
in both inspiration and expiration.
C. 200mg iv stat hydrocortisone followed by Oral  FEV1 at least >12% after administration of a
prednisolone 30mg for 10 days bronchodilator/trial of corticosteroids
D. Antibiotics- aminopenicillin or a macrolide or  PEFR at least>20% diurnal variation on atleast 3
Co-amoxiclav days in a week for 2 weeks
E. If, despite the above measures, the patient  FEV1at least >15% decrease after 6 minutes of
remains tachypnoeic, hypercapnic and acidotic, exercise
then *Non-invasive ventilation should be Other investigations:
commenced  Skin prick test/total and allergen specific
IgE
Bronchial Aasthma:  CXR-may show signs of hyperinflation
It is a chronic airway inflammatory disorder  Sputum eosinophil->2%
characterized by hyper-responsiveness of the
airways to various stimuli, presenting as recurrent
episode of wheezing, breathlessness, cough and
chest tightedness.(particularly at night in early
morning)
It is usually reversible while COPD is irreversible.
Symptoms-wheezing, chest tightedness,
breathlessness and cough with sputum production,
precipitated mainly by exercise,cold
weather,exposure to airborne allergens and
pollutants and viral URTIs, with symptoms being
worse on night. Occasionally it may be ‘nocturnal or
cough variant’.
Signs-
Agitation or drowsiness(in severe case)
Central cyanosis(in severe case)
Hyperinflated chest
Intercostal indrawing(children)
Rapid pulse(slow in severe asthma)
Wheeze(silent chest in severe asthma)
Rhonchi
Types of BA:
 Intermittent or episodic-occasional attack with
symptoms free between episodes
 Persistent or chronic-at least more than 2
attacks in a month
 Acute exacerbation-mild,moderate or severe
(acute severe asthma)
 Special variants-
a. Cough variant asthma
b. Exercise induced asthma
c. Occupational asthma
d. Drug induced asthma Treatment of acute severe aasthma:
e. Seasonal asthma 1.High flow 02-60%
f. Nocturnal asthma 2.Short acting bronchodilator-inhaled salbutamorl via
Investigation- metered dose inhaler(2-10puff) or administer
(Diagnosis is mainly clinical) repeated salbutamol 5mg+ipratropium bromide
Lung function tests: 500microgram by o2 driven nebulizer
3.Systemic steroids-oral prednisolone 40mg or IV
hydrocortisone 200mg
4.IV fluid to counter insensible water loss and k+ as
repeated salbutamol decreases k+
5.If patient fails to improve IV MgSo4 1.2-2g over 20
min or aminophylline.