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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
 

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(M2.PL.15.2) A 68-year-old, overweight gentleman with a 20-pack-year history of smoking presents to the primary care physician after noticing multiple blood-stained tissues after coughing attacks in the last month. His vital signs are within normal limits except for an O2 saturation of 93% on room air. He states that over the last 5 years his cough has continued to worsen and has never truly improved. He states that his shortness of breath has also worsened over this time period, as now he can barely make it up the flight of stairs in his home. In this patient, what is the most likely cause of his hemoptysis? Tested Concept

QID: 105819
1

Acute pulmonary edema

5%

(1/20)

2

Lung abscess

0%

(0/20)

3

Chronic bronchitis

90%

(18/20)

4

Coagulopathy

0%

(0/20)

5

Goodpasture's disease

0%

(0/20)

M 6 E

Select Answer to see Preferred Response

(M2.PL.15.6) A 62-year-old female presents with complaint of chronic productive cough for the last 4 months. She states that she has had 4-5 month periods of similar symptoms over the past several years. She has never smoked, but she reports significant exposure to second-hand smoke in her home. She denies any fevers, reporting only occasional shortness of breath and a persistent cough where she frequently expectorates thick, white sputum. Vital signs are as follows: T 37.1 C, HR 88, BP 136/88, RR 18, O2 sat 94% on room air. Physical exam is significant for bilateral end-expiratory wheezes, a blue tint to the patient's lips and mucous membranes of the mouth, and a barrel chest. Which of the following sets of results would be expected on pulmonary function testing in this patient? Tested Concept

QID: 105823
1

Decreased FEV1, Decreased FEV1/FVC ratio, Increased TLC, Decreased DLCO

52%

(11/21)

2

Decreased FEV1, Decreased FEV1/FVC ratio, Increased TLC, Normal DLCO

33%

(7/21)

3

Decreased FEV1, Normal FEV1/FVC, Decreased TLC, Decreased DLCO

10%

(2/21)

4

Decreased FEV1, Increased FEV1/FVC ratio, Decreased TLC, Normal DLCO

0%

(0/21)

5

Normal FEV1, Normal FEV1/FVC, Normal TLC, Normal DLCO

0%

(0/21)

M 6 E

Select Answer to see Preferred Response

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