Chronic Bronchitis - Pulmonary - Medbullets Step 2/3

Snapshot
A 46-year-old female presents to her primary care physician for follow up for a severe, unrelenting, productive cough that she has had on and off for more than 2 years. She also complains of worsening dyspnea on exertion. She has smoked 1 pack per day since she was 18. A chest radiograph is obtained.
Introduction
Clinical definition chronic obstructive pulmonary disease (COPD) is defined as persistent airflow limitation due to mixture of small airway disease and parenchymal destruction early classifications distinguished chronic bronchitis and emphysema no longer distinguished but helpful to separate for pathophysiologic understanding and clinical management chronic bronchitis is defined as a productive cough for > 3 months of the year for 2 consecutive years Epidemiology demographics males > females 4th most common cause of death globally risk factors tobacco use (most common) air pollution occupational exposure cystic fibrosis Pathogenesis chronic irritation promotes hyperplasia of mucus gland cells, mucus hypersecretion, cilia damage, and infiltration of neutrophils and CD8+ T cells
Presentation
Symptoms dyspnea, especially on exertion productive cough worse in the morning hemoptysis Physical exam "blue bloaters" cyanosis peripheral edema hypoxia coarse rhonchi end-expiratory wheezing and/or prolonged expiration pursed-lip breathing decreased breath sounds, if advanced signs of pulmonary hypertension right ventricular hypertrophy with signs of right heart failure jugular venous distension (JVD) hepatomegaly edema

Studies
Diagnostic testing imaging chest radiograph not required for routine diagnosis increased bronchial markings (due to mucus) hyperinflation/flattened diaphragm cardiomegaly studies pulmonary function tests (PFTs) best initial test decreased FEV1 / FVC (< 0.7) that is incompletely reversible obstructive pattern diagnostic FEV1 = forced expiratory volume FVC = forced vital capacity decreased % FEV1 used to categorize severity based on Global initiative for chronic Obstructive Lung Disease (GOLD) mild: > 80% moderate: 50-79% severe: 30-49% very severe: < 30% normal or decreased FVC normal or increased total lung capacity (TLC) less than with emphysema roughly normal DLCO (vs. decreased DLCO in emphysema) DLCO = diffusing capacity of the lungs for carbon monoxide arterial blood gas (ABG) indicated for O2 saturation < 92%, altered mental status, or acute exacerbation hypoxemia decreased PO2 may cause increased hemoglobin/polycythemia acute or chronic respiratory acidosis increased PCO2 (hypercapnia) due to retention
Differential
Asthma distinguishing factor obstructive pattern on PFTs are reversible after administration of inhaled bronchodilator Bronchiectasis distinguishing factor computed tomography (CT) is gold standard for diagnosis large internal bronchial diameter, thickened bronchial wall, and altered airway geometry "tram-track" and "signet-ring" signs

Treatment
First-line conservative smoking cessation greatest impact on mortality home O2 indicated if resting PaO2 < 55 mmHg or SaO2 < 89% flu and pneumococcal vaccines pharmacological step-wise depending on GOLD classification of disease severity mild short-acting inhaled bronchodilators short-acting inhaled beta-agonist (e.g., albuterol) as needed short-acting inhaled anticholinergic (e.g., ipratropium) as needed most patients will present in more advanced stages moderate long-acting inhaled bronchodilator long-acting beta-agonist (e.g., salmeterol or formoterol) long-acting anticholinergic (e.g., tiotropium) can be used in combination severe inhaled corticosteroid (e.g., budesonide or fluticasone) + long-acting bronchodilator very severe triple therapy inhaled corticosteroid + long-acting anticholinergic + long-acting beta-agonist may require roflumilast phosphodiesterase (PDE)-4 inhibitor theophylline PDE inhibitor and adenosine receptor blocker indicated for severe and refractory disease low therapeutic index Second-line lung resection or transplantation may be beneficial in severe cases refractory to medical management Other treatments mucolytics (e.g., N-acetylcysteine)
Complications
Acute exacerbation Cor pulmonale pathogenesis alveolar hypoventilation and hypoxia cause pulmonary vasoconstriction leads to pulmonary hypertension if severe can cause eventual right heart failure

Blood, Plasma, Serum	Reference Range
ALT	8-20 U/L
Amylase, serum	25-125 U/L
AST	8-20 U/L
Bilirubin, serum (adult) Total // Direct	0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca²⁺)	8.4-10.2 mg/dL
Cholesterol, serum	Rec: < 200 mg/dL
Cortisol, serum	0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h
Creatine kinase, serum	Male: 25-90 U/L Female: 10-70 U/L
Creatinine, serum	0.6-1.2 mg/dL
Electrolytes, serum
Sodium (Na⁺)	136-145 mEq/L
Chloride (Cl^-)	95-105 mEq/L
Potassium (K⁺)	3.5-5.0 mEq/L
Bicarbonate (HCO₃^-)	22-28 mEq/L
Magnesium (Mg²⁺)	1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)
24-28 wks // 32-36 wks	30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks	40-220 ng/mL // 80-350 ng/mL
Ferritin, serum	Male: 15-200 ng/mL Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma	Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250
pH	7.35-7.45
PCO₂	33-45 mmHg
PO₂	75-105 mmHg
Glucose, serum	Fasting: 70-110 mg/dL 2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation	Fasting: <5 ng/mL Provocative stimuli: > 7ng/mL
Immunoglobulins, serum
IgA	76-390 mg/dL
IgE	0-380 IU/mL
IgG	650-1500 mg/dL
IgM	40-345 mg/dL
Iron	50-170 μg/dL
Lactate dehydrogenase, serum	45-90 U/L
Luteinizing hormone, serum/plasma	Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL
Osmolality, serum	275-295 mOsmol/kd H₂O
Parathyroid hormone, serume, N-terminal	230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C)	20-70 U/L
Phosphorus (inorganic), serum	3.0-4.5 mg/dL
Prolactin, serum (hPRL)	< 20 ng/mL
Proteins, serum

Hematologic	Reference Range
Bleeding time	2-7 minutes
Erythrocyte count	Male: 4.3-5.9 million/mm³ Female: 3.5-5.5 million mm³
Erythrocyte sedimentation rate (Westergren)	Male: 0-15 mm/h Female: 0-20 mm/h
Hematocrit	Male: 41%-53% Female: 36%-46%
Hemoglobin A1c	≤ 6 %
Hemoglobin, blood	Male: 13.5-17.5 g/dL Female: 12.0-16.0 g/dL
Hemoglobin, plasma	1-4 mg/dL
Leukocyte count and differential
Leukocyte count	4,500-11,000/mm³
Segmented neutrophils	54%-62%
Bands	3%-5%
Eosinophils	1%-3%
Basophils	0%-0.75%
Lymphocytes	25%-33%
Monocytes	3%-7%
Mean corpuscular hemoglobin	25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration	31%-36% Hb/cell
Mean corpuscular volume	80-100 μm³
Partial thromboplastin time (activated)	25-40 seconds
Platelet count	150,000-400,000/mm³
Prothrombin time	11-15 seconds
Reticulocyte count	0.5%-1.5% of red cells
Thrombin time	< 2 seconds deviation from control
Volume
Plasma	Male: 25-43 mL/kg Female: 28-45 mL/kg
Red cell	Male: 20-36 mL/kg Female: 19-31 mL/kg

Cerebrospinal Fluid	Reference Range
Cell count	0-5/mm³
Chloride	118-132 mEq/L
Gamma globulin	3%-12% total proteins
Glucose	40-70 mg/dL
Pressure	70-180 mm H₂O
Proteins, total	< 40 mg/dL

Sweat	Reference Range
Chloride	0-35 mmol/L
Urine
Calcium	100-300 mg/24 h
Chloride	Varies with intake
Creatinine clearance	Male: 97-137 mL/min Female: 88-128 mL/min
Estriol, total (in pregnancy)
30 wks	6-18 mg/24 h
35 wks	9-28 mg/24 h
40 wks	13-42 mg/24 h
17-Hydroxycorticosteroids	Male: 3.0-10.0 mg/24 h Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total	Male: 8-20 mg/24 h Female: 6-15 mg/24 h
Osmolality	50-1400 mOsmol/kg H₂O
Oxalate	8-40 μg/mL
Potassium	Varies with diet
Proteins, total	< 150 mg/24 h
Sodium	Varies with diet
Uric acid	Varies with diet
Body Mass Index (BMI)	Adult: 19-25 kg/m²