• A 23-year-old man presents to the emeCXRrgency department with severe pleuritic chest pain. He tells the resident that he is worried he might have another collapsed lung.
  • One of two major presentations of Chronic Obstructive Pulmonary Disease (COPD)
    • including chronic bronchitis and emphysema
  • Characterized by decreased lung function in the setting of air outflow obstruction
  • Defined by alveolar wall destruction and dilation that presents in two forms
    • almost always  due to smoking (even if only secondhand)
    • panlobular is rare and caused by alpha1-antitrypsin deficiency
  • Patients identified as "pink puffers"
    • pink complexion due to hypoxic state, which is less severe than in "blue bloaters"
    • puffer describes compensatory hyperventilation necessary to normalize blood gas
  • Symptoms
    • mild dyspnea
    • hyperventilation
    • mild cough
    • pinkish skin coloration
    • fatigue
  • Physical exam
    • late hypercarbia/hypoxia
    • barrel chest (increased AP chest diameter)
    • thin, wasted appearance
    • pursed-lip breathing
    • decreased heart and breath sounds
    • prolonged expiratory phase
    • end-expiratory wheezing
    • scattered rhonchi
    • digital clubbing (only in the presence of other comorbidities such as lung cancer, interstitial lung disease, or bronchiectasis)
  • Diagnosis is based highly on clinical observations
  • ABG
    • hypoxemia
      • decreased PO2
    • acute or chronic respiratory acidosis
      • increased PCO2
  • CXR
    • decreased lung markings with flattened diaphragm
    • hyperinflated lungs with bullae and/or blebs
    • thin-appearing heart and mediastinum
    • barrel-chest
  • PFTs
    • decreased FEV1 / FVC
    • normal or decreased FVC
    • normal or increased TLC (in emphysema and asthma, specifically)
    • decreased DLCO (in emphysema, specifically)
  • Blood cultures
    • order only if patient is febrile
    • Gram stain and sputum culture order in setting of fever or productive cough
  • Chronic bronchitis, asthma, bronchiectasis
  • Medical management
    • O2, beta-agonists, anticholingerics, inhaled/IV steroids, antibiotics
      • indicated for acute exacerbations
        • inhaled Beta-agonists
          • albuterol
        • inhaled anticholinergics
          • ipratropium, tiotropium
        • IV and inhaled steroids
        • broad-spectrum antibiotics
          • use is controversial 
    • smoking cessation, ambulatory O2, bronchodilator, steroids, vaccines indicated for chronic disease
      • smoking cessation
      • ambulatory O2
        • resting PaO2 < 55mmHg or SaO2 <89%
      • bronchodilators
      • systemic or inhaled steroids
      • Pneumococcal and flu vaccines
Prognosis, Prevention, and Complications
  • Prognosis
    • highly dependent of severity of disease, timing and adherence to treatment
    • disease cannot be reversed, only slowed
  • Prevention
    • alpha1-antitrypsin deficiency cannot be prevented, and should be managed accordingly
    • acute exacerbations and progression of disease secondary to smoking can be slowed with lifestyle modifications and strict adherence to treatment measures
  • Complications
    • if untreated or ignored, disease can progress rapidly leading to death

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