‫مقرر امراض باطنية‬

‫الدكـتـــــــور ‪:‬‬ ‫القسم ‪ :‬مسـاعــــــــد طبـيــب‬

‫ضيـــــاء عـبــداهلل الـــصــراري‬ ‫املستــــوى ‪ :‬الثاني‬

 Chronic Obstructive Pulmonary Disease
(COPD)

Definition
COPD is the name for a group of diseases that restrict air flow and
cause trouble breathing.

COPD includes emphysema and chronic bronchitis.

Chronic bronchitis
is defined clinically as the presence of a chronic productive cough for 3
months during each of 2 consecutive years (other causes of cough
being excluded).

Emphysema
is defined pathologically as an abnormal, permanent enlargement of
the air spaces distal to the terminal bronchioles, accompanied by
destruction of their walls and without obvious fibrosis.

Clinical picture
Patient typically present with a combination of signs and symptoms of
chronic bronchitis, emphysema .
Symptoms include the following:
o Cough, usually worse in the mornings and productive of a
small amount of colorless sputum
o Breathlessness: The most significant symptom, but usually
does not occur until the sixth decade of life
o Wheezing: May occur in some patients, particularly during
exertion and exacerbations

While the sensitivity of physical examination in detecting

mild-to-moderate COPD is relatively poor, the physical signs are quite
specific and sensitive for severe disease.

Findings in severe disease include the following:

o Tachypnea and respiratory distress with simple activities
o Use of accessory respiratory muscles and paradoxical
indrawing of lower intercostal spaces (Hoover sign)
o Cyanosis
o Elevated jugular venous pulse (JVP)
o Peripheral edema
o Wheezing – Frequently heard on forced and unforced
expiration
o Diffusely decreased breath sounds
o Hyperresonance on percussion
o Prolonged expiration
Certain characteristics allow differentiation between disease that is
predominantly chronic bronchitis and that which is predominantly
emphysema.

Chronic bronchitis characteristics include the following:

· Patients may be obese
· Frequent cough and expectoration are typical
· Use of accessory muscles of respiration is common
· Coarse rhonchi and wheezing may be heard on auscultation
· Patients may have signs of right heart failure (ie, cor
pulmonale), such as edema and cyanosis

Emphysema characteristics include the following:

· Patients may be very thin with a barrel chest
· Patients typically have little or no cough or expectoration
· Breathing may be assisted by pursed lips and use of
accessory respiratory muscles; patients may adopt the
tripod sitting position
· The chest may be hyperresonant, and wheezing may be
heard
· Heart sounds are very distant
Diagnosis
o Spirometry
The most effective and common method for diagnosing COPD is
spirometry. It’s also known as a pulmonary function test or PFT.
This easy, painless test measures lung function and capacity.

o Bronchodilator reversibility test

This test combines spirometry with the use of a bronchodilator,
which is medicine to help open up your airways.

o Blood tests
Blood tests can help your doctor determine whether your
symptoms are being caused by an infection or some other
medical condition.

An arterial blood gas test will measure the levels of oxygen and
carbon dioxide in your blood.

o Genetic testing
While smoking and exposure to harmful substances in the
environment are the main causes of COPD, there’s also a
hereditary risk factor for this condition. A family history of
premature COPD may signal that you have the condition.
 o Chest X-ray or CT scan
A CT scan is a type of X-ray that creates a more detailed image than a
standard X-ray. Any type of X-ray that your doctor chooses will give a
picture of the structures inside your chest, including your heart, lungs,
and blood vessels.

In patients with emphysema, frontal and lateral chest

radiographs reveal the following :
§ Flattening of the diaphragm
§ Increased retrosternal air space
§ A long, narrow heart shadow
§ Rapidly tapering vascular shadows accompanied by
hyperlucency of the lungs
§ Radiographs in patients with chronic bronchitis show
increased bronchovascular markings and cardiomegaly

o Sputum examination
The doctor may order a sputum examination, especially if you
have a productive cough. Sputum is the mucus you cough up.

o Electrocardiogram (ECG or EKG)

The doctor might request an electrocardiogram (ECG or EKG) to
determine if your shortness of breath is being caused by a heart
condition as opposed to a lung problem
Management
o Smoking cessation continues to be the most important
therapeutic intervention for COPD. Risk factor reduction (eg,
influenza vaccine) is appropriate for all stages of COPD.

Agents used include the following:

o Short-acting beta2 -agonist bronchodilators (eg, albuterol,
metaproterenol, levalbuterol, pirbuterol)
o Long-acting beta2 -agonist bronchodilators (eg, salmeterol,
formoterol, arformoterol, indacaterol, vilanterol)
o Respiratory anticholinergics (eg, ipratropium, tiotropium,
aclidinium, revefenacin)
o Xanthine derivatives (ie, theophylline)
o Phosphodiesterase-4 Inhibitors (ie, roflumilast)
o Inhaled corticosteroids (eg, fluticasone, budesonide):
Peripheral blood eosinophil counts may help stratify the
likelihood of efficacy.
o Oral corticosteroids (eg, prednisone)

Pulmonary rehabilitation programs are typically multidisciplinary

approaches that emphasize the following:
o Patient and family education
o Smoking cessation
 o Medical management (including oxygen and immunization)
o Respiratory and chest physiotherapy
o Physical therapy with bronchopulmonary hygiene, exercise,
and vocational rehabilitation
o Psychosocial support

Indications for admission for acute exacerbations include the

following:
o Failure of outpatient treatment
o Marked increase in dyspnea
o Altered mental status
o Increase in hypoxemia or hypercapnia
o Inability to tolerate oral medications such as antibiotics or
steroids
 Bronchial Asthma

Definition
It is chronic inflammatory airway disease, with hyper responsiveness
to a variety of stimuli leading to narrowing of the lower airway, the
narrowing is Reversible either spontaneously or by medication.

Clinically
the condition Episodic and characterized by the Triad of dyspnea,
cough, and wheeze.

Epidemiology
Asthma is the most common chronic disease of childhood
40% of pts. with Atopic dermatitis have asthma.

Age: more in children.

Gender :- (children its more in Boys) , ( adults : more in Females).
Race: more in Black.
Etiology
Abnormal genes [Atopic genes]+ Environment [Allergen] = ASTHMA

Triggering
1. Allergen (dust mite, pollens, pets), Aerosoles and perfumes
2. Drugs: Most important are Aspirin and B-adrenergic antagonist.
3. Occupation (symptoms are related to work).
4. Viral infections most commonly RSV and Para influenza in children &
rhinovirus & influenza in adults (NOT bacterial).
5. Exercise (exercise provokes asthma within minutes that resolves
within 1h but not swimming).
6. Emotional stress.
7. Exposure to cold air.

Classifications of asthma
Extrinsic asthma:- occurs in children, related to atopy, it is triggered
by allergens (most commonly dust mite), usually seasonal, often
remits by teenage.

Intrinsic asthma: late onset asthma related to smoking, no atopy.

May irreversible.
Asthma sub types:-
Occupational asthma:-symptoms related to work place asthma &
improve in weekend. .
Nocturnal Asthma.
Exercise induced asthma.
Aspirin sensitivity.

Clinical picture
Symptoms
Asthma = Episodes of Wheeze + Cough + Dyspnea
Diurnal variation:- Most of pt. have symptoms more at night.
Morning dipping:- symptoms are worse early in the morning.
Nocturnal asthma: symptoms prevent pt. from sleep
The pt. may have yellow or green sputum due to eosinophilia
Some pt. have only cough and called (cough-variant asthma).
Rarely pneumothorax occurs.
Aspirin-Sensitive Asthma (Samter's Triad) or (Widal's Syndrome).
More common in female.
1. Rhino sinusitis
2. Recurrent Nasal polyps (ask about them in Hx).
3. Asthma that is exacerbated by aspirin.
Mechanism: aspirin inhibition of the cyclooxygenase pathway, with
excess Leukotriene production via the lipoxygenase pathway.
Signs
Vital signs:- increased RR, increased HR.
Pulses Paradoxus: it is a poor guide for the severity of asthma.

Respiratory system examination

Signs of respiratory distress:-
1- Flaring of ala-nasi.
2- Use of accessory respiratory muscles (sternocleidomastoid).
3- Cyanosis

Investigation
CXR: normal in early or shows Hyperinflation
ABG: (respiratory failure type I)
O2 = hypoxia
C02 = reduced
PH = respiratory alkalosis
PFT: Obstructive pattern
CBC = eosinophilia. & IgE level increase in extrinsic type not intrinsic.
Sputum examination.

DDx of asthma
COPD.
GERD.
Left ventricular Heart Failure.
Treatment
Medications used in bronchial asthma Reliever medicines
1. Short acting B2 agonist
Salbutamol , Albuterol , Levalbuterol
2. Ipratropium bromide

Controller medicines
1. Steroids
a. Inhaled corticosteroids (ICS)
b. Systemic corticosteriods
2. Long Acting E2 Agonists (LABA)
3. Leukotriene receptor antagonist (LTRAs)
4. Theophylline
5. Sodium cromoglycate
 Pneumonia

Definition
Pneumonia is an infection of pulmonary parenchyma and
characterized by fever, cough, And dyspnea and new CXR
changes.

Classifications
Community-acquired Pneumonia
Hospital-acquired or Nosocomial
Aspiration pneumonia
Pneumonia in the immunocompromised individuals

Risk factors:
Smoking, Old age, alcohol, DM, URTI, corticosteroids , CRF ,
liver disease, HIV, Asplenic pt.
 Community acquired pneumonia CAP

Epidemiology :
CAP is common infection cause of death & 6th leading cause of death.

Clinical picture:-
Symptoms :-
Typical pneumonia = Fever + Productive Cough + Dyspnea
1. Constitutional symptoms (Fever, anorexia, malaise, headache).
2. Sputum is purulent (may be Rust-colored-in Streptococcus
pneumonia).
3. Hemoptysis may occur.
4. Pleuritic chest pain if pleurisy occurs.
5. Lower lobes (basal) pneumonia may cause upper abdominal pain.

Atypical pneumonia:-
Pt. has mainly constitutional symptoms and not respiratory
symptoms.

Cause: Mycoplasma (most common), Legionella, Chlamydia,

Coxiella,VIRAL.
 Sign:
Confusion (may only sign in elderly) ,cyanosis may develop in severe
cases.
Increased Resp rate ± tachycardia, hypotension.
A normal chest examination makes the diagnosis unlikely.

Investigations
CBC: Leukocytosis (Neutrophilia) (Counts of>20 or <4 indicate severe
infection).
ESR & CRP increased
Sputum culture
Sputum smears with Gram stain & Ziehl-Neelsen stain.
Blood culture.
CXR:- Radiological pneumonia may be:
Pulse oxymetry :- Normal or Hypoxia
ABG: Normal or RF type I.

Treatment
General measures:- (O, A,A,A)
(Oxygen , Antipyretic , Analgesic ,Antibiotic).
Oxygen to maintain Pa02 >/= 60 mmHg or Sa02 >/= 94%.
IV fluids → anoxia ,dehydration.
Analgesia → chest pain (Paracetamol).
Physiotherapy
 Antibiotics
Out patient :
Amoxicillin + Clarithromycin
In hospital :
3rd generation Cephalosporin + Macrolide ( Erythromycin/Clarithromycin ).

CURB 65 score = poor prognostic factors

1. Confusion.
2. Urea > 7 mmol/l.
3. Respiratory rate raised > 30/min.
4. BP Systolic BP <90 and/or diastolic BP < 60.
5. Age> 65.

Higher CURB 65 score is associated with poorer prognosis up 85%

mortality.
( 1 factor = home therapy , 2 =hospital , 3 or more ITU admission).

Complications of pneumonia
1. Respiratory failure type I, lobe collapse by sputum retention.
2. Para-pneumonic effusion (most commonly with Strep pneumonia).
3. Pneumothorax (Staph aurous).
4. Empyema • Lung abscess • ARDS • Renal failure OR multi-organ
failure.
DDx of Recurrent pneumonia
1. Diffuse obstruction (Bronchiectasis, COPD, and Asthma).
2. Localized obstruction (Foreign body ,Tumor, Lymph node).
3. Immunity (HIV, Hypogammaglobulinaemia, Multiple myeloma)
4. Recurrent aspiration pneumonia.
5. Alcoholism.

Hospital-acquired pneumonia

Definition :
A pneumonia occurring at least 2 days after admission to hospital.

Etiology :
Pseudomonas Staph. Aureus Klebsiella E.coli.

C/P & Ix as CAP

Management: Cover for gram -ve microorganisms & anti

pseudomonas penicillin (Ticarcillin) .

3rd-generation Cephalosporin+ Aminoglycoside (e.g. gentamicin). OR
Meropenem
 Aspiration pneumonia

Definition :
A pneumonia that occurs following large volume inhalation of gastric
or pharyngeal contents.

Epidemiology : Common in alcoholic

Etiology :
Anaerobes from mouth flora or gram negative organisms from gut.

CXR :
Lobar consolidation mostly right middle or lower lobe (RT bronchi is
wider & more straight).
Note:- Lung abscess may occur & hemorrhagic pneumonia in acid
aspiration.

Treatment
Amoxicillin + Metronidazole ( anaerobic) .
 Pneumonia in the immunocompromised host
(Pneumocystis -pneumonia (PCP)

Definition :
A pneumonia due to infection with Pneumocystis jiroveci (previously
termed pneumocystis carinii) It mainly infects HIV pt.

Clinical features
Symptoms: Gradual onset of dry-cough and exertional dyspnea
±Fever.

Signs:- Chest examination is typically normal Pt. may present with

pneumothorax.

Investigations
CXR: Classically a bilateral perihilar infiltrates that progress to alveolar
shadowing , CXR is normal in 10% of cases , Pleural effusions are very
rare.
CT is done if CXR is normal and may show a bilateral ground glass
pattern.
ABG: Hypoxia is common.
Lab: WBC is usually normal; Serum lactate dehydrogenase is typically
raised.
Dx is done by seeing the organism in lung or it’s Secretions induced
sputum microscopy
if -ve Bronchoscopy with BAL which is the diagnostic investigation of
choice but if –ve lung biopsy (gold standard).

Rx : co-trimoxazole ( trimethoprim + sulphamethoxazole) IV for 3 wks.

Is Rx of the choice.
High-dose steroids for pts. in respiratory failure.
Supportive therapy O2 & Fluids