Approaching Patients W/ Obstructive Respiratory Diseases

Question 1

Types of COPD

Answer 1

Emphysema

Chronic bronchitis

sometimes asthma and bronchietasis, but these are more acute

Question 2

What labs/tests do you want to get for acute cases of pulmonary dysfunction

Answer 2

ABG test

Portable imaging (x-ray/UA)

CBC, CMP

Spirometery

Question 3

Emphysema

Answer 3

“Pink puffers”

Prolonged damage to the alveolar walls and interstitum

Often older and thinner (but not always)

Causes decreased radial traction of parenchyma

• Airways tend to collapse
• more hypercapneic (more CO2) rather than hypoxemia (low O2)

Signs/symptoms

1) air-trapping
- barrel chested and usually has prolonged expiration times w/ breathing

2) dyspnea
- acute/mild = exertional only
- chronic/severe = at rest and exertional
* is prolonged in supine position and Usually takes time to show up*

3) coughing
- may or may NOT be present

4) flattened of the diaphragm w/ increased lung fields on imagining
5) increased TLC and decreased DLCO (decreased perfusion)

Question 4

Physical exam findings of emphysema

Answer 4

Wheezing
- almost always present

Diminished or distant breath sounds

Prolonged Expiratory phase
- (1:2 inspiratory/Expiratory phase time)

Coarse crackles in lungs

• may or may not be bilateral and usually in upper areas of lungs
• sign of infection most often

Tripod positioning
- arms are forward when breathing with body leaning over

Possible weight loss

Pursed-lip positioning

decreased fremitus (when saying 99, less resonance felt upon palpation of back)

Question 5

2 types of emphysema

Answer 5

1) centriacinar (centrilobular)
- most common form
- associated with heavy smoking
- upper lung zones have most destruction
- “blebs” are often present in upper lungs (imaging)

2) Panacinar (panlobular)
- associated with alpha-1 antitrypsin deficiency
- lower lung zones have most destruction
- “blebs” are often present in lower lungs (imaging)

Question 6

Chronic bronchitis

Answer 6

“Blue bloaters”

more hypoxemia (low O2) rather than hypercapneic (high CO2)

Often overweight (but not always)

Signs/symptoms

1) chronic persistent cough
- often present w/ mucus/phlegm especially in the morning
- if persistent coughing is lasting at least 3 months/year for 2 years, then chronic bronchitis is diagnostically 100%

2) hypoxia/cyanosis is more prevalent
- especially prevent in appendages

3) elevated hemoglobin
- due to increased hematopoiesis and erythropoietin due to hypoxemia

4) ronchi and wheezing are present
5) increased or normal TLC w/out decreases in DLCO (normal)

Question 7

Diagnosis and severity of COPD is determined by what PFT values?

Answer 7

Diagnosis = FEV1/FVC
- if it is <70%, COPD is clinically diagnostic

Severity = FEV1
- based on % (less than 80%)

Question 8

Gold stage and severity specific values

Answer 8

Both are used to categorize how bad COPD is currently

GOLD 1/mild = FEV1/FVC <0.7 and FEV1 >80%

GOLD 2/moderate = FEV1/FVC <0.7 and FEV1 50%-80%

GOLD 3/severe = FEV1/FVE <0.7 and FEV1 30%-50%

GOLD 4 /Very severe = FEV1/FVE <0.7 and FEV1 <30%

Question 9

Pharmacological Treatments for COPD

Answer 9

1) usually start with SABA (short acting beta agonist)
- usually albuterol

2) then go to LAMA (long acting muscarinic antagonist)
3) inhaled corticosteroids are next if 1/2 dont work
* note none of these affect mortality! Only oxygen affects this(increases long-term mortality) *

Question 10

Non-pharm treatment of COPD

Answer 10

Smoking cessation

Oxygen treatments

Flu vaccinations

Pulmonary rehabilitations

Non-invasive positive pressure ventilation (NPPV)
- end stage only

Surgery
- end stage only