PANCE Blueprint Pulmonary (10%)

Chronic obstructive pulmonary diseases (PEARLS + Lecture)

The NCCPA™ PANCE Pulmonary Content Blueprint covers two obstructive pulmonary diseases

You must be able to quickly differentiate between chronic bronchitis vs. emphysema

  • Chronic bronchitis is defined by clinical features (chronic cough) vs emphysema which is defined by structural changes (enlarged air spaces secondary to alveolar destruction)

Chronic bronchitis
Patient will present as → a 56 yo female with shortness of breath, as well as a productive cough that has occurred over the past two years for at least three months each year. She is a heavy smoker. Physical exam reveals a respiratory rate of 32, slightly labored breathing, and a temperature of 98.9FHer SpO2 is 90% while receiving oxygen via nasal cannula at 2 Lpm.

Defined as a chronic cough that is productive of phlegm occurring on most days for 3 months of the year for 2 or more consecutive years without an otherwise-defined acute cause

  • Chronic Bronchitis = Blue Bloaters (2º to chronic hypoxia)
  • Common in Smokers (80% of COPD patients)
  • Frequent cough and expectoration are typical (compared to emphysema)
  • Stocky, overweight. Occasionally a barrel chest. (compared to emphysema)


  • PFT's: FEV1/FVC ratio of less than 0.7
  • Chest radiograph: peribronchial and perivascular markings
  • ↑ HGB and HCT are common because of the chronic hypoxic state
  • Auscultation of chest: crackles and wheezes
  • Percussion of chest: Normal
  • ↑ pulmonary HTN with RVH, distended neck veins, hepatomegaly


  • Short-acting bronchodilators for mild disease
  • long-acting bronchodilators +/- inhaled corticosteroids for moderate to severe disease
  • Ipratropium bromide is the inhaler of choice for COPD
  • Smoking cessation and supplemental O2 (O2 is the single most important medication in the long term)
  • Antibiotics for acute exacerbations
  • Flu and pneumococcal vaccines are a must
Apical subpleural blebs

Apical subpleural blebs

Patient will present as → a 65-year-old male complaining of fatigue and shortness of breath with exertion. The patient reports minimal cough. On physical exam, you note a thin, barrel-chested man with decreased heart and breath soundspursed-lip breathingend-expiratory wheezing, and scattered rhonchi. Chest X-ray reveals a flattened diaphragm, hyperinflation, and a small, thin appearing heart. PFTs show a decreased FEV1 / FVC ratio.

Emphysema is a condition in which air spaces are enlarged as a consequence of the destruction of alveolar septae

  • The body's natural response to ↓ lung function is chronic hyperventilationPink PuffersCO2 Retainers - the body must increase ventilation to blow off CO2
  • Minimal cough (compared to chronic bronchitis), quite lungs, thin, barrel chest
  • Minimal sputum (compared to chronic bronchitis)
  • Thin, underweight, and barrel chest


  • Chest X-ray reveals loss of lung markings and hyperinflation, a flattened diaphragm, small thin appearing heart
    • parenchymal bullae (subpleural blebs) are pathognomonic
  • Normal hematocrit (HCT)
  • Auscultation of chest: Diminished breath sounds. Prolonged expirations. Diminished heart sounds
  • Percussion of chest: hyperresonance

Management is the same as Chronic Bronchitis

  • Ipratropium (also albuterol inhaler)
  • O2
  • Oral steroids
  • Antibiotics (see Chronic bronchitis)
Obstructive lung disease


Obstructive lung disease is characterized by airway obstruction and associated with inflammation of the airways. Air trapping as a result of airway obstruction causes an increase in the residual volume of the lungs, which means the volume of air left in the lungs after fully exhaling is increased. Forced vital capacity, the volume of air that can be forcibly blown out after one full inspiration, is decreased. FEV1, the forced expiratory volume in 1 second or the volume of air that can be forcibly blown out in 1 second, is also decreased. More importantly, the ratio of FEV1/FVC is decreased because even though FVC is decreased, the FEV1 decreases even greater resulting in an overall decrease in the FEV1/FVC ratio. This can be clearly distinguished from restrictive lung disease which has a ratio greater than 80%. Common obstructive lung diseases include chronic bronchitis, emphysema, asthma, and bronchiectasis.

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References: Merck Manual · UpToDate

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