Respiratory Medicine Made Simple: COPD / Chronic Obstructive Airways Disease

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COPD/CHRONIC OBSTRUCTIVE PULMONARY DISEASE

COPD is a common progressive disorder characterized by airway obstruction with little or no reversibility.

It includes 2 diseases :

Chronic bronchitis and Emphysema

CHRONIC BRONCHITIS:

This is clinically defined as cough and sputum production on most days for 3 months of 2 successive years.

Symptoms improve when patients stop smoking.

EMPHYSEMA:

This is defined as enlarged air spaces distal to terminal bronchioles with destruction of alveolar walls.

COPD GENERAL CONSIDERATIONS:

FEV1 ( Forced Expiratory Volume in 1 second ) is less than 80 % predicted and FEV1/FVC is less than 0.7

COPD  is usually seen in smokers and air pollution is also an important contributory factor.

Age of onset is usually > 35 years

There is minimal day to day variation.

Patients present with Chronic Dyspnoea

SYMPTOMS:

Cough

Increased sputum production.

Dyspnoea

Wheeze

SIGNS:

Tachypnoea

Cyanosis

Use of accessory muscles of respiration.

Hyperinflation of chest

Reduced cricosternal distance < 3 cm

Reduced chest expansion.

Hyperresonant percussion note

Quiet breath sounds

INVESTIGATIONS:

FBC : Increased WCC and PCV

CXR :

Hyper inflation (> 6 anterior ribs seen above diaphragm in mid-clavicular line)

Flat hemidiaphragms

Large central pulmonary arteries

Decreased pulmonary vascular markings

Bullae

ECG:

Right axis deviation,

Right ventriucular hypertrophy/cor pulmonale.

ARTERIAL BLOOD GASES :

Low PaO2 and Increased PaCO2.

LUNG FUNCTION TESTS:

Obstructive and air trapping

FEV1 <  80 % of predicted

FEV1/FVC < 70% predicted

Raised TOTAL LUNG CAPACITY

Raised RESIDUAL VOLUME

COMPLICATIONS:

Acute exacerbations +/- Infections

Respiratory Failure

Polycythemia

Cor pulmonale

Pneumothorax

Lung carcinoma

MANAGEMENT/BTS GUIDELINES:

ASSESSMENT OF COPD:

Spirometry

Bronchodilators may improve FEV1 slightly.

Trial of steroids : Look for > 15 % increase in FEV1.

CXR : Bullae or any other pathology? Consolidation/Abnormal shadowing

SEVERITY OF COPD :

MILD: FEV1 :  50 – 80 % of predicted

MODERATE : FEV1 30 – 49 % of predicted

SEVERE : FEV1 < 30 % of predicted.

MANAGEMENT

TREATING  STABLE  COPD:

GENERAL MEASURES:

Stop smoking

Encourage exercise

Treat poor nutrition or obesity

Influenza and pneumococcal vaccinations.

Pulmonary rehabilitation/palliative care.

NIPPV : NON  INVASIVE  INTERMITTEMT POSITIVE  PRESSURE  VENTILATION

MILD COPD:

ANTIMUSCARINICS : Ipratropium or BETA 2 AGONIST inhalations :Salbutamol as per need

MODERATE: Regular anticholinergic eg Ipratropium or Tiotropium or Long acting beta 2 agonists such as salmetrol + inhaled corticosteroids esp if FEV1 < 50 % and more than or equal to 2 exacerbations / year.

SEVERE : LABA + INALED STEROIDS + ANTICHOLINERGICS AND SPECIALIST REFERRAL

PULMONARY HYPERTENSION:

Treat Oedema with Diuretics,Assess the need for LTOT

MORE ADVANCED COPD:

PULMONARY REHABILITATION

LONG TERM OXYGEN THERAPY TO MAINTAIN PAO2 > 8.0 Kpa for more than 15 hours a day.

LTOT should be used if PaO2 < 7.3 kpa

INDICATIONS FOR SURGERY:

Recurrent pneumothoraces

Isolated bullous disease

Lung volume reduction surgery

NIV in case of severe diasese

PINK PUFFERS AND BLUE BLOATERS:

These are two variants seen in COPD

PINK PUFFERS:

They have increased alveolar ventilation,a near normal PaCO2 or low PaCO2.

They are breathless but not cyanosed.

They may progress to Type 1 Respiratory failure

BLUE BLOATERS:

They have reduced Alveolar ventilation.

There is low PaO2 and high PaCO2.

They are cyanosed but not breathless and may go on to develop cor-pulmonale.Thir respiratory centres are relatively insensitive to CO2 and they rely on hypoxic drive to maintain respiratory effort.

Hence supplemental oxygen should be given with care.

Respiratory Medicine/pulmonolgy Made Simple : Asthma

Asthma:

Recurrent episodes of Dyspnoea cough and wheeze cuased by reversible airways obstruction.

PATHOPHYSIOLOGY:

Three factors contribute to airway narrowing :

Mucosal swelling/

Inflammation caused by mast cell and basophil degranulation resulting in release of inflammatory mediators.

Bronchial muscle contraction triggered by a variety of stimuli

Increased mucus production

Symptoms:

Intermittent Dyspnoea

Wheeze

Cough ( mostly at night)

Increased Sputum  production.

PRECIPITATING FACTORS:

These include:

Exercise

Cold Air

Emotional Stresses

Allergens ( house dust mite,pollens,fur)

Infection

Smoking and Passive smoking

Pollution

NSAIDS,Beta blockers

Quantification:

Exercise Tolerance

This needs to be quantified and evaluated.

Disturbed Sleep:

Quantified as nights/week : a sign of severe Asthma

ASSOCIATIONS:

ACID REFLUX:

40 – 60 % of patients with Asthma have reflux.

Treating it improves spirometry but not necessarily symptoms.

OTHER ATOPIC DISEASES:

Frequently Asthma  co-exists with other atopic diseases such as Eczema,Hay fever allergies and Family History of atopic diseases.

CHURG STRAUSS SYNDROME

POLYARTERITIS NODOSA

ABPA : ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS

OCCUPATIONAL ASTHMA/JOBS:

More common in occupations such as Paint sprayers,food processors,animal handlers and welders.

Symptoms are resolved during holidays when away from work.

Patients are advised to measure their peak flow at work and at home.

Signs:

Tachypnoea

Audible wheeze

Hyperinflated chest

Hyperresonant percussion notes.

Diminished Air Entry

Poly phonic wheeze

SEVERE ATTACK:

Inability to complete sentences

Pulse > 110 bpm

Resp Rate >25/min

PEFR 33 – 50 % of predicted

LIFE THREATENING ATTACK:

Silent Chest

Cyanosis

Bradycardia

Exhaustion

PEFR < 33% of predicted

Confusion

Feeble Respiratory Effort

Investigations:

ACUTE ATTACK:

Sputum culture & Sensitivity

PEFR

FBC

U & Es

CRP

ABGs : Normal or slightly reduced PaO2 and low PaCO2 due to hyperventilation.

If PaCO2 is raised,transfer to HDU or ITU for ventilation as this signifies failing Respiratory Effort.

Blood Cultures

CXR : To exclude pneumothorax and infection.

CHRONIC ASTHMA:

PEFR MONITORING:

This shows a diurnal variation of > 20 % on more than or equal to 3 days a week for 2 weeks,

SPIROMETRY:

This shows an obstructive defect : Reduced FEV1/FVC ratio and increased Residual volume.

Usually > 15 % improvement in FEV1following B2 agonists or steroid trial.

CXR : This shows hyperinflation.

Skin prick tests help identify allergens.

Histamine or methacholine chalenge.

MANAGEMENT:

BEHAVIOUR AND LIFE STYLE MODIFICATIONS:

Quit smoking

Avoid precipitants

Check Inhaler technique

Monitor PEFR twice a day by Peak Flow meter.

Train about a relaxed breathing technique to avoid dysfunctional breathing

Specific Management/ BTS Guideline

Start from the step most appropriate to severity.

Move up if necessary or down if control is good for > 3 months.

Rescue courses of prednisolone may be used at any time.

STEP 1 :

Occasional short acting B2 agonist as required for symptom relief.If being used more than once daily or night time symptoms,go to step 2.

STEP 2 :

Add standard dose inhaled steroid eg Beclometasone 100 -400 mcg/12 hrs or start at the dose appropriate for disease severity and titrate as appropriate.

STEP 3:

Add long acting B2 agonist eg salmeterol 50 mcg/12 hrs.If of benefit but still inadequate control,continue and increase dose of beclometasone to 400 micrograms/12 hrs.If no effect of Long Acting B2 agonist,it should be stopped.Diagnosis should be reviewed and Leukotriene receptor antagonists or oral theophylline may be tried.

STEP 4:

Consider trials of beclometasone of upto 1000 micrograms/12 hours,modified release oral theophylline,modified release oral Beta 2 agonist.

STEP 5 :

Add regular oral prednisolone 1 dose daily at lowest possible dose.

Gastroenterology Made Simple : Causes of Colonic Bleeding :

Angiodysplasia:

Also called as vascular ectasia

It occurs due to degenerative changes in walls of vessels in colon and also partly contributed by

intramuscular hypertrophy.

It occurs in old age and has association with Aortic stenosis.

Diagnosis can be made by Endoscopy and angiography.

Colon Carcinoma:

It usually causes painless bleeding.

It can involve both right and left side of colon.

Usually associated with weight loss and painless bleeding.

Can cause occult bleeding.

FOB stool test for occult blood can aid diagnosis

Haemorrhoids/Piles:

Can cause either painless or painful rectal bleeding.

They may be visible externally.

Can present with fresh blood per rectum.

Inflammatory Bowel Disease

These include Ulcerative colitis and Crohn”s disease.

It causes lower GI bleeding associated with passage of mucus and pain in abdomen and raised inflammatory

markers.

There may be systemic involvement as well including fever and systemic symptoms.

Diagnosis is made by Endoscopy with biopsy and barium enema that shows characteristic findings.

They can get complicated causing : Cancer,perforation and toxic megacolon.

Treatment is mainly with Surgery

Gastroenterology Made Simple : Causes of Colonic Bleeding : Diverticulosis

Diverticulosis:

The colonic bleeding in diverticulosis occurs due to rupture of artery at the neck of diverticulum.

This leads to a massive bleeding which is usually painless.

It usually occurs in elderly.

It mostly involves the left colon and may be accompanied by fever and pain in abdomen.

Diagnosis can be made by CT scan of abdomen.

Treatment mainly involves antibiotics.

A high fibre diet is useful in prevention of recurrence.

Colonoscopy Is contraindicated in acute state.