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Dr.

Poliana Leru, MD, PhD


First degree specialist
Internal Medicine and Allergology
UMF Carol Davila
Definition
Diseases characterized by airways
obstruction, caused by intraluminal
mechanisms, airway wall alteration and
peribronchial tissues involvement
Normal Obstructed bronchus
bronchus
Mechanisms of
obstruction
Intraluminal mechanisms
Bronchial hypersecretion (chronic bronchitis)
Partial obstruction by foreign bodies, pulmonary
edema or post surgery
Airway wall alteration :
Bronchial
muscles contraction, glandular
hypertrophy, inflammation and edema
Peribronchial tissues involvement
Pulmonary emphysema (pulmonary tissue
destruction, resulting in loss of elastic tissue which
provides the elastic recoil)
Compression by adenopathy or tumors

Peribronchial edema
Flow-volume loops
Normal Spirometry
Ventilatory dysfunctions
1. Obstructive: FEV1 below 80% of predicted value,
FEV1/FVC ratio (Tiffneau index) below 70%.
Degrees of severity (after FEV1 values):
Mild: FEV1 > 80%
Moderate: FEV1 = 60-80%
Severe: FEV1 < 60%
1. Restrictive: FVC below 80% predicted value.
FEV1 is less decreased, and the FEV1/FVC ratio
is normal or increased
2. Mixt: FVC, FEV1 and the FEV1/FVC ratio are
decreased
Flow-volume loops in
ventilatory dysfunctions
Obstructive pulmonary diseases

Bronchial asthma
COPD
Bronchiolitis obliterans
Child viral induced asthma (post viral recurrent
wheezing)
Pulmonary emphysema
Bronchiectasis
Interrelation of the main clinical
entities
Emphysema Chronic
Bronchitis

Airflow
limitation Asthma
Bronchial asthma
Chronic airways inflammatory disease, accompanied
by hyperactive airways and recurrent episodes of
wheezing, dyspnoea, cough, and thoracic constriction,
associated usually with diffuse, variable airways
obstruction, reversible spontaneously or with
treatment.
Specific bronchial inflammation pattern Th2
lymphocytes (cytokine IL-4,Il-5,Il-13), activated
eosinophiles
Heterogeneous syndrome group
Affectes all ages, may be severe and is sometimes fatal.
The most frequent chronic disease and the most
frequent childs medical emergency
approx.10% of the nonviolent deaths in children and
young adults
Etiopathogenesis
Alergic/nonalergic
50% - sensitisation to aeroallergens (dust mites,
molds, pollens, pets, cockroaches)
- food allergens( flour, metabisulfites)
Irritant factors : vapors, gases, smoke
Outdoor pollution (ozone, sulfur dioxide)
Viral infections : rhinovirus, human respiratory
syncytial virus, influenza virus
Triggers:
1.Exercise
2.Associated diseases: GERD, sinusitis, nasal
polyposis, rhinitis
3.Concomitant medication: beta blockers si NSAID
Signs and symptoms
1. History: wheezing episodes, dyspnea, cough, chest
tightness
2. Exacerbation: nocturnal, exertion, aeroallergen
contact or irritant factors
3. Other allergic diseases association: rhinitis, atopic
dermatitis
4. Other familial cases of asthma or other allergic
diseases
5. Signs: pulmonary hyperinflation, wheezing or
prolonged expiration, sibilant rales and/or ronchus
6. Associated signs: nasal or cutaneous
Differential diagnosis in
adults
COPD
Heart failure (not all elders with dyspnea have
ischemic heart disease!)
Pulmonary embolism
Pulmonary neoplasm
Vocal cords dysfunction
Tracheal and bronchial carcinoid tumors
Foreign body aspiration
Interstitial lung disease
Differential diagnosis in
children
Foreign body aspiration
Cystic fibrosis
Tracheal and bronchial
Thoracic vascular malformations
Gastroesophageal reflux disease
Viral induced asthma (postviral wheezing)
Rhino-sino-bronchial syndrome
Classification (1)
Etiological
allergic (extrinsec)
Non-allergic (intrinsec)
(different triggers, similar inflammation
pattern)
SeverityGINA guide 2002
intermittent
persistent : mild, moderate or severe
Clinical types
acute (status astmaticus)
chronic, with fixed obstruction
Classification (2)
Particular clinical types : unstable, difficult
to control,
corticodependent/corticoresistant
Time of onset- early onset asthma
- late onset asthma (>50 years)
Degree of control (Gina 2006)
- uncontrolled
-partially controlled
-controlled
Particular clinical
patterns
Corticorezistant
Difficult to control
Brittle asthma
Cough variant
Occupational asthma
NSAID-intolerant asthma (Vidal
syndrome)
Churg Strauss vasculitis
Allergic bronchopulmonary aspergillosis
Classification of asthma severity
(Gina 2002)
Signs and symptoms

Daytime Nocturnal
symptoms FEV1 /PEF
symptoms
STEP 4 - continuous
60% predicted
persistent - restriction of frequent
severe variability > 30%
physical activity
STEP 3 - every day 60 - 80% predicted
persistent > 1 time / week variability > 30%
- crisis limits
moderate
activity
STEP 2 > 2 times / month 80% predicted
> 1 time / week.
persistent but < 1 / day variability 20-30%
mild
< 1 time / week.
STEP 1 asymptomatic and
2 times / month 80% predicted
intermittent normal FEV1 (PEF) variability < 20%
between crisis
Asthma classification
level of control (Gina 2006)
Controlled Partially controlled Uncontrolled

All below One of the criteria

Daytime None(less than More than 2/week 3 or more of the


symptoms 2/week) criteria of the
Rescue None(less than More than 2/week partially
medication 2/week) controlled
Activity none any
limitation
Nocturnal None any
symptoms
Fev1/PEF normal <80% of
predicted
Exacerbations None > 1/year > 1/week
Natural history of asthma
Onset
Usually in childhood, approx. 80% subsides in puberty
in 2/3 of cases: children (possible confusion with infant
wheezing) or young adults, in 1/3 of cases late onset (over 50 )
Risk factors for asthma development:
Infant atopic wheezing
Reduced airway caliber at birth (prematurity, low weight at
birth)
Maturity defect of the immunitary system
Maternal or perinatal exposure to sensitizing agents and
maternal smoking.
Atopy and initial disease severity.
Spirometry
Gold standard
Less than 25% of the elder pacients who come to
the emergency room for cough and/or dyspnea
undergo a spirometry!
Misdiagnosed obstruction in 8-10% pts above 65
years
Lack of obstruction at an examination does not
exclude asthma!
Reversibility: in elderly it is preffered a
combination of albuterol + ipratropium (effect
onset in 30 min)
Inhalatory devices
Asthma therapy
Relievers Controllers
Short acting beta 2 Corticosteroids
agonists Inhaled: Budesonide, Fluticasone,
Ciclesonide, Beclometasone, Mometasone
SABA Systemic
Salbutamol
Terbutaline

Anticholinergics Antileukotrienes
Ipratropium bromide
montelukast
Systemic Long acting beta 2
corticosteroids agonists
Methylxanthines Combined therapy
ICS+LABA
Dosages
recommendation
ICS side effects
Local side effect:
oral candidiasis occur in 10%. Increase risk with poor
technique, concomitant use of antibiotics and reduced by
use of spacer and rinsing mouth.
Dysphonia (30%) - in high risk professions
Osteoporosis
Bone densitometry carried out in adult asthmatic on low
and medium doses of ICS showed no signs of osteoporosis
No growth retardation in children if daily dose > 200mcg
Posterior subcapsular cataract - risk slightly increased
with high doses of ICS and use of pMDI
Risk of lung infection -no relevant risk of TB reactivation
in usual doses
Beta 2 agonists side
effects
Mild tremor (effect on skeletal muscle receptors)
Tachycardia( effect on cardiovascular receptors)
Hypokalemia ( increase K+ entry to skeletal muscle)
No evidence of increased or induced serious
arrhythmias if used less than one canister per
month and associated with controller therapy
Risk of death significantly increased (10 fold) with
two or more canisters /month. (uncontrolled
asthma)
Asthma management GINA
2006
Step 2 Sep 3 Step 4 Step 5
Choose one Choose one Add one or more Add one or more

Low dose ICS Low dose ICS Medium/large dose Oral CS


+ LABA ICS + LABA
Antileucotriene Medium/large dose Antileucotriene Anti IgE
ICS
Low dose ICS Sustained release
+ Antileucotriene Teophyline
Low dose ICS
+ Teophyline

Step down Step up

Controlled: find lowest controlling step Uncontrolled/Partialy controlled


Acute asthma (asthma
exacerbation)
Episodes of progressive increase in shortness of
breath, cough, wheezing, or chest tightness, or
some combination of these symptoms.
Characterized by decreases in expiratory airflow
that can be quantified and monitored by
measurement of PEF and FEV1
Type of onset:
Sudden onset -following allergen exposure or emotions:
higher incidence of acute respiratory failure, prompt
response to mechanical ventilation
Slow onset attack- following viral infections
Asthma exacerbation Respiratory
Symptoms Mild Moderate Severe
arrest
At rest
Walking Talking
Dyspnea Hunched
Can lie down Prefers sitting
forward
Talks in Sentences Phrases Words
Drowsy or
Alertness May be agitated Agitated Agitated
confuse
Respiratory
Increase Increase >30
Rate
Paradoxical
Accessory
Not Usually Usually thoraco-
Muscles abdominal mvm.
Moderate at end
Wheezing of expiration
Loud Loud Absent

Pulse <100 100-120 >120 Bradycardia


PEF >80 60-80 <60
PO2 Normal >60 <60
PCO2 <45 <45 >45
Treatment of
exacerbations (I)
Mild exacerbations can be treated in community
setting (outpatient), providing an individualized
approach and frequent assessment of the response
to bronchodilators
Oxygenoterapy for maintaining SaO2 > 90%
Bronchodilators: inhaled SABA (salbutamol),
anticholinergic), and methylxantine iv
(aminophyline)
Systemic corticoids : indicated in majority of
asthma exacerbations, except mild forms promptly
remitted with bronchodilators.
Treatment of
exacerbations
(II)
Mild and moderate exacerbation.
2-4 SABA puffs at 20 minutes in the first hour, max. 12
puffs
Positive response: PEF > 80% of predicted

Then: 2-4 puffs at 3-4 h(mild exacerbation) or 6-10 puffs

at 1-2h (moderate exacerbation)


Doubling dose of ICS and add of systemic CS

Severe exacerbation
Oxygenotherapy

SABA administered continuously prefferably with spacer


Add another bronchodilator inhaled or IV

Systemic CS: 300-400 mg HHC or prednisone 60-80 mg


Asthma mortality risk
History of severe asthma that required intubation
Emergency hospital admission during last year
Oral glucocorticoid treatment /recent discontinuation
excessive use of SABA (> 2 canister/month)
Psychiatric diseases or non-compliance
Intubation indication:
Confused patient
Respiratory silentium (disappearance of wheezing and rales)

Switch from tachycardia to bradycardia

Respiratory muscles exhaustion

Hypoxia, hypercapnia, respiratory acidosis


Life threatening
asthma
History of:
An episode of respiratory failure that required
intubation
Attack with respiratory acidosis, > 2
hospitalisations/year, complicated with
pneumothorax
Increased risk: - pacients with a poor perception of
bronchial obstruction (poor perceivers) ( 22% mortality
in the following 5 years after intubation)
Use of medication from more than 3 classes
Risk of SABA : marker of vital risk or cause of death
COPD: definition
COPD is a disease characterized by chronic
airflow limitation, which is not completely
reversible
The airflow limitation is usually progressive
and is associated with an abnormal
inflammatory response of the lungs to gas or
dusts
It can be prevented and treated, with some
significant extrapulmonary consequences,
which can contribute to disease severity in
some patients
COPD risk factors
Certain
smoking
Occupational exposure (dusts, vapors, smoke)

alfa-1-antitripsine deficiency

Probable
Outdoor and indoor pollution
Social and economical factors

Smoke exposure in childhood

Airways hyper reactivity

Possible
Low birth weight, family history
Respiratory diseases in childhood

Blood group A, non-secretor IgA, atopy


COPD diagnosis
History of risk factors exposure
Cigarette smoke
Occupational environment dusts and chemicals

Dyspnea
Progressive
Usually aggravated by exercise
Persistent
Described as an increased effort to breathe

Chronic cough
It can be intermittent and dry

Chronic expectoration
Any chronic expectoration points out COPD
Clinical examination
Rarely diagnostic, especially in mild or moderate
COPD
Inspection
Central cyanosis
Thoracic cage changes, such as barell chest
Palpation and percussion
Usually not useful in COPD diagnosis
Auscultation
Decreased breath sounds (this is not characteristic)
+/-Wheezing
Spirometry
Spirometry represents a reliable method for the
detection of obstruction in the airways and should
be performed to all patients suspected of COPD
Airflow decrease evaluation is very important to
confirm COPD
Gold standard to diagnose and monitor COPD
progression
The absence of significant reversibility must be
confirmed in order to exclude asthma
Severity degree classification of
COPD
Stage Predicted FEV1 Description
I Mild >80% Chronic cough and sputum production
FEV1/FVC <70% may be present

II Moderate 5080% Shortness of breath typically developing


FEV1/FVC <70% on exertion, cough and sputum production
may be present
This is the stage at which the patient seek
medical attention. Now the diagnosis is
usually established

III Severe 3050% Greater shortness of breath, reduced


exercise capacity, fatigue, repeted
FEV1/FVC <70% exacerbations.
Patients may present weight loss
Some patients do not seek medical
attention up to this moment

IV Very <30% or Respiratory failure may lead to cor


severe <50% + chronic pulmonale (right heart failure)
respiratory failure GOLD
Aims of COPD management
Symptoms improvement
Prevention of disease progression
Improvement of exercise tolerance
Health quality improvement
Prevention and treatment of complications
Prevention and treatment of exacerbations
Decrease of mortality
COPD treatment
1. Pharmacologic:
Bronhodilators
Short acting 2-agonists (SABA)(Salbutamol)
Short acting anticholinergics (Ipratropium) and long
acting anticholinergics (Tiotropium)
Sustained released theophyllines
Inhaled corticosteroids (ICS):Fluticasone, Budesonide
Combination therapy: LABA+ ICS (Seretide,
Symbicort)
Mucolytic agents
2. Non-pharmacologic: smoking cessation, O2,
rehabilitation, surgery
COPD exacerbations
Definition: event in the natural history of the disease,
characterized by a change of the initial dyspnea, cough
and/or sputum, different from the normal daily
variations, with acute onset and which can lead to
changes of the usual medication of a patient with COPD
Increase of the airways inflammatory response

Initiated by bacteria, viruses, ambient pollution

Increase of hyperinflation with air retention in the


lungs, thus dyspnea is aggravated
Important cause of morbidity and mortality
Exacerbations severity criteria
History:
Long duration oxygenotherapy
Associated diseases: left ventricle failure, alcoholism

Clinical signs:
Fever > 38,5C

Peripheral edema

Tachypnea > 25/min, tachycardia >110/min

Progressive cyanosis, use of auxiliary respiratory muscles

Confusion

Spirometry:
PEF< 100L/min

Gasometry: PaO2 <60mmHg, PaCO2>45, SaO2<90%


Home management of
exacerbations
Bronhodilators:
Increase the dose and/or frequency of short acting beta-
agonist (SABA) Ex: Salbutamol
Add an anticholinergic, if not already used (ipratropium
bromide)
corticosteroids (oral/systemic)
They shorten the recovery period, ameliorate pulmonary
function, decrease hypoxemia
To consider when baseline FEV1 is less than 50% of
predicted value (prednisolone 3040 mg/day for 710
days)
Antibiotics: macrolides, cephalosporines,
betalactamines
Indications for
hospitalisation
Increased intensity of the symptoms, like the
sudden onset of rest dyspnea
Severe underlying COPD
New clinical signs, i.e. cyanosis, peripheral oedema
Failure to answer to initial management
Significant co-morbidities
Frequent exacerbations
New onset of arythmia
Uncertain diagnosis
Elderly
Insufficient home assistance
GOLD. www.goldcopd.com
Pulmonary emphysema
Anatomic definition: permanent and abnormal enlargement
of the airways, distal to terminal bronchioles, associated
with the distruction of the alveolar walls
Types:
Diffuse: centrilobular and panlobular
Localized : paralesional (paracicatricial)
1.Diffuse centrilobular:
- constantly found in COPD, localized in the superior
lobes.
-usually men, smokers, pletoric aspect, cyanosis,
exertional dyspnea, bronchial crackles (Blue Bloater)
Pulmonary emphysema
2. Diffuse panlobular : not so frequent, primitive
degenerative disease, does not always associate
with COPD (It can evolve independently)- Pink Puffer
Predominantly basal
Etiology: exogenous (smoking), and endogenous
(alfa-1-antitripsine deficiency)
Usually young, thin male, with progressive dispnea,
without cyanosis, important hyperinflation.
Bronchiectasia
Definition: abnormal dilatation of the
subsegmental bronchiae
Diffuse or localized, idiopathic or associated with
a causative pathology
Substrate: oedema, inflammatory infiltrate,
epidermoid metaplasia, mucosal ulcerations,
distruction of the bronchial wall
Clinical signs: productive cough, abundant
sputum
Bacteria: H. influenzae, P. aeruginosa, S.
pneumoniae, S. aureus, Gram negative bacilli, M.
avium intracellular
Adult obliterans
bronchiolitis
Definition: group of diseases characterized by diffuse, non-

specific inflammation of the distal airways


BOOP type: bronchiolitis obliterans with organizing
pneumonia
Causes:
Toxicgas or mineral dust inhalation
Viruses, M. pneumoniae, L. pneumophila

Bone marrow transplantation

Collagen diseases (rheumatoid arthritis, SLE,

dermatomyositis)
Drugs: amiodarone, golden salts, Busulfan

Hypersensitivity pneumonia
Acute bronchiolitis in
children
Usually after viral infections- respiratory syncytial virus,
rhinovirus, parainfluenza virus, adhenovirus, coronavirus.
More frequent in children under 2 years during december-
february period
Risk factors:
male gender
age between 3-6 month
lack of breast feeding
maternal smoking
collectivities