Approach to a patient with Obstructive Airway Disease

History Examination
Bronchial Asthma COPD Bronchial Asthma COPD
Intermittent episodes of Dyspnea Progressive dyspnea Shiners eyes Flushing
Symptom free intervals Persistent/ Continuous Symptoms Red nose Headache
Cough- while talking, eating, laughing, Nocturnal Cough no diurnal variation Turbinate hypertrophy Asterixis
symptoms Profuse sputum Inability to speak in sentences Pursed lip breathing
Thin Sputum/ mucus plugs/casts Exposure to cigarette smoke (active/passive) Pulsus Paradoxus Barrel Chest
Allergic rhinitis, conjunctivitis, eczema Exposure to biomass fuel, any noxious gas Normal Chest Decreased cricosternal distance
Wheeze Occupational history Silent Chest Accessory muscle use
Family History of allergies/asthma Past history of TB Polyphonic Expiratory wheeze Intercostal indrawing
Childhood/adolescent/young adult onset If Features of Both are present, classify as Asthma Widened intercostal spaces
Seasonal variation COPD Overlap and treat as asthma) Diminished Breath Sound Intensity
Chronic Asthma Wheeze
Reversed with inhalers Loud P2, parasternal Heave
Exercise induced Symptoms of cor pulmonale/RHF
Occupational history

Investigations: Complications: Interventions:

1.Blood Routine, Absolute Eosinophil 1. Pneumothorax Pharmacologic:
Count, S.CRP 2. Pulmonary Embolism
3. CAP 1. Nebulised beta agonist (formeterol based on FACET/SMART), Nebullised Steroid (preferably budesonide) (GOLD,
2.Radiology-CXR, HRCT Thorax 4. Pulmonary HTN
GINA), Nebulised Ipratropium bromide, salbutamol (Nebuliser and MDI are considered equivalent in mild to
5. Sleep Apnea
3. Echocardiograph 6. Cor Pulmonale moderate cases)
7. Difficult to treat 2. Oral or IV steroids(Good oral absorption, but IV preferred in hospital), no significant benefit more than 5- 14 days.
4.Spirometry
Asthma 3. Antibiotics if strong suspicion of infection in COPD patients, rarely to be used in BA
5 Special Cases: Ig E, Ig M/Ig E 4. LTRA (Monteleukast) for Maintenance therapy in BA
Aspergillus specific antigens, Sleep 5. Newer Agents: Ultra LABA, Ultra LAMA combos, Roflumilast, omalizumab, mepolizumab, benralizumab
Study, CTPA
6. No role for Low dose theophylline (TWICS,TASC), Magnesium, controversial role for high dose theophylline (Can be
tried in treatment refractory COPD patients if sustained release preparations are used)
Non Pharmacologic:

7. NIV
8. Mechanical Ventilation with I:E ratio 3 times time constant, Lung protective ventilation
9. Long term Oxygen Therapy if indicated
10. Arrange follow up, Rehabilitation for COPD, taper ics dose for BA on follow up visits
11. Lung Volume reduction surgery/ Transplant

References: Lancet, GINA 2021, GOLD 2021,NEJM