28: 58-year-old man with shortness of breath

Question 1

Causes of dyspnea

Answer 1

• cardiac
• heme
• pulm
• psychogenic
• other: neuromu, metabolic, deconditioning

Question 2

Orthopnea Definition

Answer 2

Dyspnea which occurs when lying flat, forcing the person to have to sleep propped up in bed or sitting in a chair. It is commonly measured according to the number of pillows needed to prop the patient up to enable breathing (Example: “three pillow orthopnea”).

Question 3

Dyspnea Definition

Answer 3

Dyspnea is defined as an uncomfortable awareness of breathing.

Question 4

Paroxysmal nocturnal dyspnea (PND) - Definition, Etiology, Symptoms

Answer 4

Definition
Sudden, severe shortness of breath at night that awakens a person from sleep, often with coughing and wheezing.

Etiology
It is most closely associated with congestive heart failure.

Symptoms
PND commonly occurs several hours after a person with heart failure has fallen asleep. PND is often relieved by sitting upright, but not as quickly as simple orthopnea. Also unlike orthopnea, it does not develop immediately upon lying down.

Question 5

acute vs chronic bronchitis

Answer 5

Acute Bronchitis
Productive cough lasting 1-3 weeks

Chronic Bronchitis
Productive cough for at least three months for the past two years

Question 6

Classic Findings on Physical Exam for COPD

Answer 6

> > Increased anteroposterior (AP) diameter of the chest
Decreased diaphragmatic excursion
Wheezing (often end-expiratory)
Prolonged expiratory phase

Question 7

Four items predicted the presence of COPD:

Answer 7

> > Smoking more than 40 pack-years
Self-reported history of chronic obstructive airway disease
Maximum laryngeal height of 4 cm or less,
Age at least 45 years

Question 8

Chronic Obstructive Pulmonary Disease (COPD) - Definition, Epidemiology, Diagnosis

Answer 8

Definition
COPD encompasses both chronic bronchitis and emphysema and is characterized by airflow limitation that is progressive and not fully reversible with bronchodilators.

Epidemiology
While it is currently estimated by the World Health Organization to be the twelfth commonest cause of morbidity and the fourth commonest cause of death worldwide, COPD is set to become the fifth most common cause of morbidity and third most common cause of death by 2020. Twelve million Americans are diagnosed with COPD; yet an additional 12 million Americans may have COPD and remain undiagnosed.

Diagnosis
A clinical diagnosis of COPD should be considered in any middle-aged or older adult who has:
»dyspnea
»chronic cough or sputum production, or
»a history of tobacco use
The diagnosis should be confirmed by spirometry.

Question 9

Differences between the mechanisms underlying COPD and asthma include:

Answer 9

Cigarette smoke is more of a causal agent in COPD,

Mast cells, T helper cells, and eosinophils play more of a role in what appears to be an allergic bronchoconstrictive response in asthma

Macrophages, T killer cells, and neutrophils play a role in an inflammatory and destructive process in COPD.

As noted on the previous card, a post-bronchodilator FEV1/FVC ratio < 70% confirms the presence of airflow limitation that is not fully reversible (hence a diagnosis of COPD).

Significant reversibility is defined as an increase in FEV1 ≥ 12% after bronchodilator.

Question 10

Distinguishing COPD from Asthma

Answer 10

Air-flow obstruction in asthma is reversible, but in COPD it is not .

The major distinction between asthma and COPD is the reversible nature of asthma’s obstruction to air flow.

By definition, FEV1/FVC is decreased in COPD, but can be decreased or normal in asthma if the FEV1 and FVC are both decreased proportionally.

FVC is normal to decreased in COPD, but always decreased in asthma.

Macrophages and T killer cells play a role in COPD.

Question 11

The major benefit occurred in the first year after smoking cessation.

Answer 11

“Your lungs will work better within that first year of quitting smoking.”

“When you quit smoking, your lungs will not ‘age’ as quickly as if you continued smoking.” “Even if you quit and then start smoking again, there may be benefit to you.”

Question 12

Therapy for Moderate & Severe COPD

Answer 12

Therapy for Moderate COPD
For patients whose FEV1 is between 50 and 80% of predicted, maintenance therapy of inhaled anticholinergics (ipratroprium or tiotroprium) alone or in combination with short-acting beta agonists may be utilized.

Therapy for Severe COPD
In symptomatic COPDera whose FEV1 is < 50% of predicted and who have repeated exacerbations, it is recommended that inhaled glucocorticosteroids be added to bronchodilator tx. The combo of an inhaled glucocorticosteroid combined with a long-acting ß2-agonist is more effective than each individual component, although the addition of a gc may increase the risk of pna.

Question 13

GOLD Spirometric Criteria for COPD Severity

Answer 13

Mild
FEV1/FVC < 0.7 FEV1 ≥ 80% predicted
At this stage, the patient is probably unaware that lung function is starting to decline.

Moderate
FEV1/FVC < 0.7
50% ≤ FEV1 < 80% predicted
Symptoms during this stage progress, with shortness of breath developing upon exertion.

Severe
FEV1/FVC < 0.7
30% ≤ FEV1 < 50% predicted
Shortness of breath becomes worse at this stage, and COPD exacerbations are common.

Very Severe
FEV1/FVC < 0.7
FEV1 < 30% predicted, or
FEV1 < 50% predicted with chronic respiratory failure
Quality of life at this stage is gravely impaired. COPD exacerbations can be life threatening.

Question 14

Bronchodilators include:

Answer 14

inhaled short-acting and long-acting beta-2-agonists inhaled long-acting anticholinergics, and oral methylxanthines

Question 15

Bronchodilators are essential for symptom management in COPD. According to the Global Initiative for Chronic Obstructive Lung disease:

Answer 15

All symptomatic patients with COPD should be prescribed a short-acting bronchodilator (e.g., albuterol) on an as-needed basis.

If symptoms are still inadequately controlled, a daily dose of long-acting bronchodilator should be added.

The choice between beta-2-agonist, anticholinergic, theophylline, or combination therapy depends on availability and individual response in terms of symptom relief and side effects.

Combining bronchodilators of different pharmacological classes may improve efficacy and decrease the risk of side effects compared to increasing the dose of a single bronchodilator.

Question 16

Although COPD is usually caused by damage inflicted from long-term cigarette smoke or air pollution, it is occasionally caused by an alpha-1 antitrypsin deficiency.

Answer 16

A good clue that this may be present is when a patient younger than 45 years old is diagnosed with COPD, as they are not old enough to have developed the long-term effects from smoking. In such a case, especially if the patient is of Caucasian descent and has a strong family history of the disease, you may want to check alpha-1 antitrypsin levels – but you do not have to check this level in all adults who have COPD.

Question 17

Recommended Immunizations for Patients with COPD

Answer 17

Influenza and pneumococcal vaccines are recommended for adults with COPD. If the patient is due for a tetanus booster, then he should receive TdaP, which contains Tetanus toxoid, diphtheria, and acellular pertussis.

Question 18

Individuals with COPD are more likely to get frequent colds, bronchitis, the flu, or even pneumonia. When this happens, the symptoms of COPD may noticeably worsen. This is called a COPD exacerbation. An individual may find:

Answer 18

Difficulty catching his or her breath 
Chest tightness
Fever
Increased coughing or
A change in the cough (more productive, more mucus expelled)

Question 19

COPD Exacerbation

Answer 19

An exacerbation of COPD is defined as an event in the natural course of the disease characterized by a change in the patient’s baseline dyspnea, cough, and/or sputum that is beyond normal day-to-day variations and is acute in onset. An exacerbation may warrant a change in regular medication in a patient with underlying COPD.

Question 20

COPD Exacerbation Tx

Answer 20

Inhaled bronchodilators (particularly inhaled beta 2-agonists with or without anticholinergics) and oral glucocorticosteroids are effective treatments for exacerbations of COPD.

Antibiotics should be given to:
»Patients with exacerbations of COPD with the following three cardinal symptoms: increased dyspnea, increased sputum volume, and increased sputum purulence
»Patients with exacerbations of COPD with two of the cardinal symptoms, if increased purulence of sputum is one of the two symptoms
»Patients with a severe exacerbation of COPD that requires mechanical ventilation (invasive or noninvasive).

Question 21

COPD Hospitalization and Follow-up

Answer 21

Hospitalization:
For those patients more severely ill who might require hospitalization, noninvasive mechanical ventilation in exacerbations improves respiratory acidosis; increases pH; decreases the need for endotracheal intubation; and reduces PaCO2, respiratory rate, severity of breathlessness, the length of hospital stay, and mortality.

Follow-up:
Medications and education to help prevent future exacerbations should be considered as part of follow-up, because exacerbations affect the quality of life and prognosis of patients with COPD.

Question 22

COPD and Heart Failure

Answer 22

The proposed mechanism for COPD leading to heart failure is that chronic hypoxia (1) causes pulmonary vasoconstriction (2), which increases blood pressure in the pulmonary vessels. This elevation in blood pressure causes permanent damage to the vessel walls and leads to irreversible hypertension (3). The right heart eventually fails (4) because the pump cannot sustain flow effectively against this pressure. Right heart failure leads to an increase in preload, with peripheral edema and increased jugular venous distention.

Question 23

Pulmonary Function Test to Diagnose COPD in a symptomatic pt

Answer 23

Pulmonary function testing (PFT) is the gold standard for diagnosing COPD. In pulmonary function testing, either a FEV1/FVC ratio less than the 5th percentile, or less than 70%, confirms a diagnosis of COPD.

Question 24

When Chest X-ray is Appropriate in Setting of Dyspnea

Answer 24

The current literature doesn’t support the use of chest x-ray to rule in or out COPD, but some studies suggest that
a chest x-ray might be helpful for finding other causes of dyspnea.

Question 25

Definitions:

Answer 25

Forced Vital Capacity (FVC) = total amount of air the patient can expel from the lungs after a full inspiration

Forced Expiratory Volume - 1 second (FEV1) = amount of air the patient can expel after a full breath in one second

Question 26

Diagnosing COPD

Answer 26

COPD causes the air in the lungs to be exhaled at a slower rate and in a smaller amount compared to a normal, healthy person (obstructive defect). The amount of air in the lungs will not be readily exhaled due to either a physical obstruction (such as with mucus production) or airway narrowing caused by chronic inflammation.

FEV1 to FVC ratio (FEV1/FVC) less than 70% (or less than the 5th percentile) with compatible symptoms and history, is diagnostic of COPD.

Question 27

Differential of Shortness of Breath in Middle-Aged Man Who Smokes

Answer 27

• acute bronchitis
• asthma
• COPD
• lung ca

Question 28

COPD

Answer 28

A worsening winter cough could indicate COPD because breathing cold dry air causes constriction of the airways and obstructs air flow. In addition, shortness of breath mostly with activity, a history of heavy smoking, and the absence of orthopnea or paroxysmal nocturnal dyspnea (PND) all argue for a diagnosis of COPD. Although dyspnea is a relatively nonspecific finding, dyspnea with exertion is a cardinal symptom of COPD. COPD develops slowly over years, so most people are at least 40 years old when symptoms begin and cigarette smoking is the most commonly encountered risk factor for the development of COPD. The risk is dose-related.