Lecture
Patient will present as → a 60-year-old female with shortness of breath of recent onset. She has a six-year history of cough and rhonchi and is on oxygen at home. Physical exam reveals a respiratory rate of 32, slightly labored breathing, and a temperature of 98.9F. Her SpO2 is 90% while receiving oxygen via nasal cannula at 2 Lpm.
Listen to her lungs (you may need to crank up the volume)
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One of two major presentations of chronic obstructive pulmonary disease (COPD) which includes chronic bronchitis and emphysema
- Defined by clinical features of a chronic cough that is productive of phlegm occurring on most days for 3 months of the year for two or more consecutive years without an otherwise-defined acute cause
- vs emphysema which is defined by structural changes (enlarged air spaces secondary to alveolar destruction)
- Obstruction in bronchioles due to mucus (causes air trapping, wheezing, cough, and rales) and less mobile cilia
Patients with chronic bronchitis are identified as "blue bloaters"
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- Color indicative of hypoxia observed in the bluish tint of skin and mucous membranes
- Common in smokers (80% of COPD patients)
- The single best variable for predicting which adults will have airflow obstruction on spirometry is a history of more than 40 pack-years of smoking 95%
- Symptoms of bronchitis include coughing up mucus, wheezing, dyspnea, and chest discomfort
- Physical exam: wheezes, rales, decreased breath sounds, barrel-chested, pursed-lip breathing, productive cough, and rhonchi
Chest radiographs in chronic bronchitis demonstrate increased interstitial markings, particularly at the bases and thickening of the bronchial walls. Unlike in emphysema, diaphragms are NOT flattened
- Labs: ↑ HGB and HCT are common because of the chronic hypoxic state
- High CO2 in the blood (hypercapnia) and low O2 in the blood (hypoxemia)
- Respiratory acidosis (arterial PCO2> 45 mmHg, bicarbonate > 30 mEq/L)
- Lung biopsy (gold standard)- diagnosis is clinical but confirmed by postmortem biopsy ↑ Reid index (gland layer is > 50% of the total bronchial wall)
PFTs in chronic bronchitis:
FEV1/FVC ratio of < 0.7
- Airflow limitation that is irreversible or only partially reversible with a bronchodilator is the characteristic physiologic feature of COPD
- Decreased FEV1 / FVC
- Normal or decreased FVC
- Normal or increased TLC (in emphysema and asthma, specifically)
In patients with FEV1/FVC <0.70, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) system categorizes airflow limitation into stages. Determining a patient’s GOLD status requires a multidimensional assessment of a patient’s spirometry, symptom burden, and frequency of COPD exacerbations:
GOLD (spirometry)
- GOLD 1 – mild: FEV1 ≥80% predicted
- GOLD 2 – moderate: 50% ≤ FEV1 <80% predicted
- GOLD 3 – severe: 30% ≤ FEV1 <50% predicted
- GOLD 4 – very severe: FEV1 <30% predicted
Symptom burden is quantified by either the modified Medical Research Council (mMRC ) dyspnea scale (MedCalc) or COPD assessment test (CAT) score (MedCalc)
Modified Medical Research Council (mMRC) dyspnea scale
| Grade | Description of breathlessness |
| 0 | I only get breathless with strenuous exercise |
| 1 | I get short of breath when hurrying on level ground or walking up a slight hill |
| 2 | On level ground, I walk slower than people of the same age because of breathlessness, or have to stop for breath when walking at my own pace |
| 3 | I stop for breath after walking about 100 yards or after a few minutes on level ground |
| 4 | I am too breathless to leave the house or I am breathless when dressing |
GOLD status (A-D) explicitly guides therapeutic interventions
- Group A: low risk (0-1 exacerbation per year, not requiring hospitalization) and fewer symptoms (mMRC 0-1 or CAT <10)
- Group B: low risk (0-1 exacerbation per year, not requiring hospitalization) and more symptoms (mMRC ≥ 2 or CAT≥ 10)
- Group C: high risk (≥2 exacerbations per year, or one or more requiring hospitalization) and fewer symptoms (mMRC 0-1 or CAT <10)
- Group D: high risk (≥2 exacerbations per year, or one or more requiring hospitalization) and more symptoms (mMRC ≥ 2 or CAT≥ 10)
Chest radiographs in chronic bronchitis demonstrate increased interstitial markings, particularly at the bases and thickening of the bronchial walls
The most effective therapy for most patients with chronic bronchitis is smoking cessation
- Treatment depends on severity: a combination of short-acting (SABA) or long-acting (LABA) beta 2 agonist and short-acting (SAMA) or long-acting (LAMA) muscarinic agent (also known as an anticholinergic agent) +/- inhaled glucocorticoids
- Long-term oxygen therapy in all patients with COPD who have chronic hypoxemia defined as resting PaO2 < 55 mmHg or SaO2 < 89%
- Vaccination against both influenza and pneumococcal disease
- COPD exacerbations are managed with systemic glucocorticoids, antibiotics (tailored to the likelihood of specific pathogens), antiviral therapy when influenza is suspected
- Glucocorticoids: prednisone 40 mg per day for five days
- Antibiotics (examples):
- Azithromycin 500 mg x 3 days or Z-pack x 5 days
- Cefuroxime 500 mg BID x 10 days
- Doxycycline 100 mg BID x 10 days
Management of refractory chronic obstructive pulmonary disease
For patients with recurrent exacerbations (e.g., at least two per year or one requiring hospitalization per year) despite optimized inhaled therapies, we suggest either the phosphodiesterase-4 (PDE-4) inhibitor roflumilast or chronic azithromycin
Complications:
- The chronic hypoxic vasoconstriction from chronic bronchitis can lead to cor pulmonale (right-sided heart failure as a result of disease of the lungs or the pulmonary blood vessels)
Management of stable COPD
Initiation of therapy based on the GOLD ABCD assessment of symptoms and risk of exacerbation (source: UptoDate)
| Groups | Symptoms | Risk | Suggested treatment |
| All |
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| A | Less symptomatic
Mild or infrequent symptoms (ie, breathless with strenuous exercise or when hurrying on level ground or walking up a slight hill) |
Low risk
0 or 1 exacerbations in the past year without associated hospitalization |
Short-acting bronchodilator (SABA, SAMA, or combination of SABA-SAMA), as needed. |
| B | More symptomatic
Moderate to severe symptoms (ie, the patient has to walk more slowly than others of the same age due to breathlessness, has to stop to catch breath when walking on level ground at own pace, or has more severe breathlessness) |
Low risk
0 or 1 exacerbations in the past year without associated hospitalization |
Regular treatment with a long-acting bronchodilator, either LAMA or LABA, based on patient preference. Short-acting bronchodilator (usually SABA) for symptom relief as needed. |
| C | Less symptomatic
Mild or infrequent symptoms (ie, breathless with strenuous exercise or when hurrying on level ground or walking up a slight hill) |
High risk
≥2 exacerbations per year with one or more leading to hospitalization |
Regular treatment with a LAMA; SABA available for symptom relief as needed. |
| D | More symptomatic
Moderate to severe symptoms (ie, the patient has to walk slower than others of the same age due to breathlessness, has to stop to catch breath when walking on level ground at own pace, or has more severe breathlessness) |
High risk
≥2 exacerbations per year with one or more leading to hospitalization |
Regular treatment with LAMA or, if severe breathlessness (eg, CAT >20), combination LABA plus LAMA. A combination glucocorticoid-LABA inhaler may be preferred, if features of asthma/COPD overlap. SABA available for symptom relief as needed. |
 Osmosis |
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Picmonic
Chronic bronchitis
Chronic bronchitis a type of obstructive lung disease that is caused by chronic inflammation of the airway, which causes recurrent damage to the respiratory epithelium in the bronchi, resulting in hypertrophy of the mucus-secreting glands. This can be measured with a Reid index greater than 50%. Reid index measures the thickness of the gland divided by the total thickness of the bronchial wall. The clinical diagnostic criteria for chronic bronchitis are productive cough for greater than 3 months per year, for 2 plus years. There are two forms of COPD: chronic bronchitis and emphysema. Patients with chronic bronchitis are also referred to as blue bloaters, and patients with emphysema are referred to as pink puffers. This is because chronic bronchitis patients have early-onset hypoxemia and cyanosis (blue), but they have late-onset dyspnea. Common symptoms are signs that include wheezing and crackles and sputum production.
Play Video + QuizQuestion 1 |
Which of the following pathophysiological processes is associated with chronic bronchitis
Destruction of the lung parenchyma Hint: Destruction of the gas-exchanging structures in the lung is characteristic of emphysema. | |
Mucous gland enlargement and goblet cell hyperplasia | |
Smooth muscle hypertrophy in the large airways Hint: There may be smooth muscle hypertrophy in chronic bronchitis but it is not to the extent as found in asthma and is not an underlying factor in the pathology of chronic bronchitis. | |
Increased mucus adhesion secondary to reduction in the salt and water content of the mucus Hint: Abnormal absorption of sodium and a reduced rate of chloride secretion in cystic fibrosis leads to thickening of the mucus and increase in adhesion of the mucus. |
Question 1 Explanation:
Chronic bronchitis results from the enlargement of mucous glands and goblet cell hypertrophy in the large airways.
Question 2 |
A 65-year-old with COPD having received their first PPSV23 vaccination at age 63 should be revaccinated with PPSV23 in
1 year Hint: See C for explanation | |
3 years Hint: See C for explanation | |
5 years | |
10 years Hint: See C for explanation |
Question 2 Explanation:
In a patient with COPD who presents at age 65 years or older having already received PPSV23, administer 1 dose of PCV13, if not previously received, and another dose of PPSV23 at least 1 year after PCV13 and at least 5 years after PPSV23.
Review Topic: CDC Adult immnization schedules
Question 3 |
A patient with severe COPD presents to the Emergency Department with a 3 day history of increasing shortness of breath with exertion and cough productive of purulent sputum. An arterial blood gas reveals a pH of 7.25, PaCO2 of 70 mmHg and PaO2 of 50 mmHg. He is started on albuterol nebulizer, nasal oxygen at 2 liters per minute, and an IV is started. After one hour of treatment, his arterial blood gas now reveals a pH of 7.15, PaCO2 100 mmHg and PaO2 of 70 mmHg. Which of the following is the most appropriate next step in his treatment?
Decrease the oxygen flow rate. Hint: Decreasing the oxygen flow rate would be harmful as it would decrease the amount of oxygen delivered to the patient. | |
Administer oral corticosteroids. Hint: Administration of steroids is an important treatment modality but this patient is in respiratory failure and needs more immediate therapy. | |
Intubate the patient. | |
Administer salmeterol (Serevent) Hint: Long-acting beta agonist therapy such as salmeterol is not utilized for rescue therapy. |
Question 3 Explanation:
This person has increasing respiratory failure as indicated by the raising PaCO2 levels. Intubation is required at this time.
Question 4 |
A 73-year-old obese female with a 20 pack year smoking history presents complaining of chronic productive cough. She states that it has been occurring over the past 3 years more frequently November through February. Which of the following pulmonary function test values would you expect to find decreased?
tidal volume Hint: Tidal volume is usually unchanged, residual volume and total lung capacity are decreased with a restrictive disease pattern. This scenario presents with bronchitis which is an obstructive disease. | |
forced expiratory volume in 1 second/forced vital capacity | |
residual volume Hint: The residual volume, the volume of air left in the lungs following full expiration, is often increased in COPD, as is the total lung capacity | |
total lung capacity Hint: The residual volume, the volume of air left in the lungs following full expiration, is often increased in COPD, as is the total lung capacity |
Question 4 Explanation:
Forced expiratory volume in 1 second/forced vital capacity is decreased in obstructive lung diseases such as bronchitis. GOLD guidelines support using the traditional postbronchodilator FEV1/FVC ratio less than 0.7 as the threshold that indicates airflow limitation.
Question 5 |
A 75 year-old man with a long history of COPD presents with acute onset of worsening dyspnea, increased productive cough, and marked agitation. While in the emergency department he becomes lethargic and obtunded. His ABG's reveal a PaO2 40 mmHg, PaCO2 65 mmHg, and arterial pH 7.25. Which of the following is the most appropriate management at this point?
oxygen supplementation with a 100% non-rebreather mask Hint: Supplemental oxygen and positive pressure ventilation are inadequate for patients with overt respiratory failure. | |
noninvasive positive pressure ventilation (NIPPV) Hint: See A for explanation | |
endotracheal intubation and mechanical ventilation | |
emergency tracheostomy Hint: Tracheostomy is indicated for an obstructed airway. |
Question 5 Explanation:
This patient is in severe respiratory arrest with markedly impaired mental status; conventional mechanical ventilation is required.
Question 6 |
In patients with COPD, which of the following has been shown to decrease rate of malignancy and cardiovascular disease and improve survival?
bronchodilator therapy Hint: Bronchodilator therapy is used for symptomatic treatment in patients with COPD. | |
pulmonary rehabilitation Hint: Pulmonary rehabilitation improves quality of life, dyspnea and exercise capacity. It also has been shown to reduce the rate of hospitalization. | |
oral glucocorticosteroids Hint: Chronic use of oral glucocorticosteroids is not recommended because of an unfavorable benefit/risk ratio. | |
smoking cessation |
Question 6 Explanation:
Smoking cessation has been shown to provide significant improvement in decreasing the rate of decline in pulmonary function
Question 7 |
A 45 year-old male presents with complaints of a chronic cough productive of mucopurulent sputum. The cough has been present for the past 3 years, but he attributed it to a "smoker's cough". He has been coughing up a lot of sputum lasting all winter long for the past 2 years. He denies any hemoptysis, weight loss or chest pain. Physical examination reveals a moderately obese male in no acute respiratory distress. Lung fields reveal presence of scattered rhonchi and wheezes. There is 1+ peripheral edema. Which of the following is the most likely diagnosis?
Lung cancer Hint: While the respiratory complaints of lung cancer are associated with the location and type of primary tumor, anorexia and weight loss is seen in the majority of patients. Patients will also usually have a new cough or a change in a chronic cough and may complain of hemoptysis and nonspecific chest pain. | |
Bronchiectasis Hint: While bronchiectasis presents with a chronic cough productive of copious amounts of purulent sputum, these patients most commonly also have associated complaints of hemoptysis, weight loss and pleuritic chest pain. Examination of the lungs reveals persistent crackles at the bases. | |
Chronic bronchitis | |
Interstitial lung disease Hint: Interstitial lung disease is characterized by progressive exertional dyspnea and cough, however sputum production is minimal and the examination of the lungs reveals fine, late inspiratory crackles at the bases in the majority of patients. |
Question 7 Explanation:
This patient most likely has chronic bronchitis which is defined as sputum production and cough for at least 3 months of the year for 2 consecutive years which is primarily caused by cigarette smoking.
Question 8 |
A 56 year-old male with a 40 pack-year smoking history presents complaining of progressive shortness of breath. Spirometry reveals an FEV1 of 2 L (40% of predicted), an FVC of 4 L (80% of predicted) and an FEV1/FVC of 50%. These findings are most consistent with
sarcoidosis. Hint: Sarcoidosis, interstitial lung disease and congestive heart failure most commonly produce a restrictive pattern on spirometry with a reduction in forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) secondary to the decrease in total lung capacity (TLC), but the FEV1/FVC ratio is usually normal or increased, not decreased. | |
chronic bronchitis. | |
interstitial lung disease. Hint: See A for explanation. | |
congestive heart failure. Hint: See A for explanation. |
Question 8 Explanation:
The reduced FEV1 and FEV1/FVC is characteristic of an obstructive pattern that is seen in chronic obstructive pulmonary diseases, such as chronic bronchitis.
Question 9 |
A 55 year-old man with a history of chronic bronchitis presents with two days of increased dyspnea and cough with worsening purulent sputum production. He is currently using inhaled albuterol as needed. In addition to systemic corticosteroids, what pharmacologic agent is warranted at this time for treatment of this patient?
Antibiotic | |
Inhaled corticosteroid Hint: Inhaled corticosteroids are not indicated in the management of acute exacerbations of COPD. | |
Long acting beta-agonist Hint: Long acting beta-agonists are not indicated in the management of acute exacerbations of COPD. | |
Theophylline Hint: Theophylline is rarely used in the management of COPD and has no place in the management of acute exacerbations of COPD. |
Question 9 Explanation:
Empiric antibiotic treatment is indicated in the treatment of acute exacerbations of COPD if there are sputum changes suggestive of bacterial infection, such as increased quantity and purulence.
Question 10 |
A 67 year-old man presents complaining of gradually worsening fatigue and shortness of breath. He is a previous smoker with an 80 pack-year smoking history. He denies chest pain, night sweats, or hemoptysis. On physical examination, you note a very thin male who appears older than his stated age. Lung and heart sounds are barely audible to auscultation. Which of the following interventions is likely to alter the disease course?
Inhaled bronchodilator therapy Hint: Inhaled bronchodilators afford symptomatic relief for some patients with COPD but do not alter the disease course. | |
Inhaled steroid therapy Hint: Inhaled steroid therapy may reduce the number and severity of COPD exacerbations but has not been shown to alter the disease course. | |
Home oxygen | |
Theophylline Hint: Theophylline is a third-line agent for treating COPD and will not alter the natural history of the disease |
Question 10 Explanation:
Home oxygen therapy has been shown to prolong life in patients with COPD and alter the natural history of the disease.
Question 11 |
Patients with COPD have the symptoms of chronic bronchitis and emphysema. Which of the following morphologic patterns of emphysema is typically most severe in the upper lobes?
Centriacinar emphysema | |
Panacinar emphysema | |
Distal acinar emphysema | |
Paraseptal emphysema |
Question 11 Explanation:
Centriacinar emphysema is characterized by focal destruction limited to the respiratory bronchioles and the central portions of the acini. This form of emphysema is associated with cigarette smoking and is typically most severe in the upper lobes.
Question 12 |
Which of the following is independently associated with an increased risk for all-cause mortality in patients with COPD?
Asthma | |
Bronchiectasis | |
Underweight status | |
Depression |
Question 12 Explanation:
In a multicenter, prospective, observational study of 201 consecutive patients with moderate-to-severe COPD,Martinez-Garcia and colleagues reported that in addition to smoking, pulmonary hypertension, and declining lung function, all of which are known risk factors for mortality in patients with COPD, bronchiectasis, which is common in patients with moderate-to-severe COPD, is independently associated with increased risk for all-cause mortality.
In this study, those who had bronchiectasis were found to be 2.5 times more likely to die than those who did not. Bronchiectasis remained an independent risk factor after adjustment for dyspnea, partial pressure of oxygen, body mass index, presence of potentially pathogenic micro-organisms in sputum, presence of daily sputum production, number of severe exacerbations and peripheral albumin, and ultrasensitive C-reactive protein concentrations.
Question 13 |
Which of the following is generally recognized as the most significant symptom of COPD?
Productive cough | |
Pulmonary hypertension | |
Cor pulmonale | |
Breathlessness |
Question 13 Explanation:
Breathlessness is the most significant symptom, but it usually does not occur until the sixth decade of life (although it may occur much earlier). By the time the forced expiratory volume in 1 second (FEV1) has fallen to 50% of predicted, the patient is usually breathless upon minimal exertion. In fact, the FEV1 is the most common variable used to grade the severity of COPD, although it is not the best predictor of mortality.
Question 14 |
Which of the following studies provides the best clues to the acuteness and severity of disease exacerbation?
Serum chemistry evaluation | |
Alpha1-antitrypsin measurement | |
Arterial blood gas (ABG) analysis | |
Sputum evaluation |
Question 14 Explanation:
ABG analysis provides the best clues as to acuteness and severity of disease exacerbation. Patients with mild COPD have mild-to-moderate hypoxemia without hypercapnia. As the disease progresses, hypoxemia worsens, and hypercapnia may develop, with the latter commonly being observed as the FEV1 falls below 1 L/s or 30% of the predicted value. Lung mechanics and gas exchange worsen during acute exacerbations.
Question 15 |
Which of the following is accurate regarding the treatment of patients with COPD?
Pneumococcal vaccines are contraindicated in patients with COPD | |
Intravenous alpha1-antitrypsin levels should be kept at 8-10 mmol/L | |
Long-term oxygen therapy is recommended for patients with a partial pressure of oxygen in arterial blood <55 mm Hg or oxygen saturation <90% | |
Because cardiovascular disease is common in patients with COPD, beta-blockers are indicated in all patients |
Question 15 Explanation:
Long-term oxygen therapy improves survival twofold or more in hypoxemic patients with COPD, according to two landmark trials, the British Medical Research Council study and the US National Heart, Lung, and Blood Institute's Nocturnal Oxygen Therapy Trial. Hypoxemia is defined as partial pressure of oxygen in arterial blood of <55 mm Hg or oxygen saturation of <90%. Oxygen was used for 15-19 hours per day. Infections can lead to COPD exacerbations. Vaccinations are a safe and effective modality to reduce infections in susceptible COPD patients. The pneumococcal vaccine should be offered to all patients older than 65 years or to patients of any age who have an FEV1 of less than 40% of predicted. The influenza vaccine should be given annually to all COPD patients. Intravenous alpha-1 antitrypsin augmentation therapy is the only available approach that can increase serum levels to >11 mmol/L, the protective threshold. Cardiovascular disease is common in patients with COPD and is a leading cause of mortality; however, beta-blockers are not widely used in these patients due to a perceived risk for bronchospasm and concern about inhibition of beta-agonist medication, despite some studies that show efficacy.
Question 16 |
A 57-year-old man is being evaluated for shortness of breath. The following spirometric data are obtained:
VC 4.90 L (predicted), 5.15 L (observed) 105% predicted
FRC 3.99 L (predicted), 4.37 L (observed) 110% predicted
RV 2.47 L (predicted), 3.17 L (observed) 128% predicted
FEV1 3.50 L (predicted), 2.35 L (observed) 67% predicted
These findings are consistent with which of the following?
No demonstrable abnormality Hint: Spirometry findings in obstructive lung disease typically show normal or increased total lung capacity, decreased vital capacity, prolonged FEV1, and increased residual volume. | |
Restrictive lung disease Hint: Restrictive lung disease would show decreased total lung capacity, vital capacity, and normal to increased FEV1. | |
Obstructive lung disease | |
A ventilation/perfusion mismatch Hint: A ventilation/perfusion scan would be abnormal with a pulmonary embolism. |
Question 16 Explanation:
Spirometry findings in obstructive lung disease typically show normal or increased total lung capacity, decreased vital capacity, prolonged FEV1, and increased residual volume.
There are 16 questions to complete.
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References: Merck Manual · UpToDate