THORACIC AND RESPIRATORYDISORDERS■ Chest wall hyperinflation, prolonged expiration, wheezing, and distant
breath and heart sounds may be present.
■ The patient may use accessory muscles and pursed-lip breathing (pink
puffer),and cyanosis may be present as well (blue bloater). Neck vein dis-
tention, a tender liver, and lower-extremity edema suggest cor pulmonale.
DIFFERENTIAL
Acute bronchitis, asthma, bronchiectasis, CF, CHF
DIAGNOSIS
Along with a history and physical exam, testing modalities that are useful in
diagnosing COPD and evaluating the disease progression include CXR, PFTs,
and ABG analysis.
■ CXR:Typically demonstrates ↓lung markings, ↑retrosternal airspace,
and flattened diaphragms
■ PFTs:Essential for diagnosis as well as for the evaluation of treatment and
disease progression
■ ABG analysis: Acute exacerbations show hypoxemia and hypercarbia, with
acute respiratory acidosis
■ BODE index: This is more effective than FEV 1 at predicting the risk of
death from any cause in patients with COPD. The BODEindex consists of:
■ BMI
■ Obstruction of airflow (FEV 1 )
■ Dyspnea (as measured by the modified Medical Research Council dyspnea
scale)
■ Exercise capacity (6-minute walk)
TREATMENT
■ Acute exacerbations: Where possible, the cause of the exacerbation
should be treated.
■ a 2 -adrenergicandanticholinergic agents are first-line therapy.
■ Treatment includes O 2 therapy titrated to maintain an O 2 saturation of
around 90%. ExcessiveO 2 administration may →hypercarbia from a ↓respi-
ratory drive or from ↑V/Q mismatch, but O 2 therapy must not be withheld
because of fears of hypercarbia.
■ Systemic corticosteroids in oral or IV form help ↓the length of exacerba-
tions and improve FEV 1 in hospitalized patients.
■ Antibiotics are recommended by the American Thoracic Society for
patients with acute exacerbation who have a change in sputum amount,
consistency, or color.
■ Noninvasive positive pressure ventilation is of benefit for patients with
severeacute exacerbations of COPD as it reduces in-hospital mortality, ↓
the need for intubation, and diminishes hospital length of stay.
BRONCHIECTASISDefined as the irreversible dilatation and destruction of bronchi with inade-
quate clearance of mucus in the airways. Cycles of infection and inflammation
→dilated airways and focal constrictive areas.
CAUSES
Causes of bronchiectasis include:
■ Inability to clear secretions (cilliary abnormalities, CF)
■ Severe or repeated episodes of pneumonia
O 2 therapy is the only
intervention known to ↑life
expectancy in hypoxemia
COPD patients.