Obstructive Lung Disease

OBSTRUCTIVE LUNG DISEASE
ASTHMA & COPD
By
Nabil Hanna, MD
Obstructive Lung Disease
PATHOPHYSIOLOGY
OF ASTHMA & COPD
https://www.youtube.com/watch?v=VCXVmHJ8a-U&index=1&list=PLYojB5NEEakWxqnCBgl5_5rGXEP7VYGVT
https://www.youtube.com/watchv=tusMPvA4wU&list=PLYojB5NEEakWxqnCBgl5_5rGXEP7VYGVT&nohtml5=False#t=1.369977
Age-Dependent Pathogenesis of Asthma
Extrinsic Asthma Intrinsic Asthma
Patients who initially present as Patients who initially present as
children tend to show more allergic- adults tend to show more non-allergic
type hypersensitivity to typical sensitivity to irritant inhalational
antigens exposures (e.g. cigarette smoke, air
pollution), and their illness may seem
to be triggered by an acute
pneumonia
CLINICAL PRESENTATION
OF ASTHMA & COPD
/Clubbing
(increased AP diameter)
https://www.youtube.com/watch?v=fmLZrZv10NM&list=PLYojB5NEEakWxqnCBgl5_5rGXEP7VYGVT&index=3
Presentation of Asthma
 Asthma presents: as a patient who is short of breath with expiratory wheezing*
*Not all that wheezes is asthma, and not all asthmatics wheeze
 In severe cases: the patient uses accessory muscles and cannot complete sentences
 Most important features of severe asthma exacerbation:

• Hyperventilation/increased respiratory rate
• Decrease in peak expiratory flow (corresponds to FEV1)
• Hypoxia
• Respiratory acidosis (as the hyperventilation should be causing respiratory alkalosis)
• Possible absence of wheezing (very severe bronchoconstriction with NO air entry)
Presentation of COPD
 COPD presents:
• in a long-term smoker
• with increasing shortness of breath
• and decreased exercise tolerance
DIAGNOSTIC TESTING
FOR ASTHMA & COPD
Diagnostic Testing for Asthma
Patient with acute shortness of breath:
A. Chest X-ray
B. Diffusion capacity of carbon monoxide
C. High-resolution CT scan
D. Methacholine challenge test
E. Pre- and postbronchodilation pulmonary function testing (PFT)
Asthma and reactive airway disease are confirmed with an

increase in FEV1 of > 12% post-bronchodilation (using albuterol inhalation)
Diagnostic Testing for Asthma
Asymptomatic patient:
A young man comes to the clinic for evaluation of intermittent episodes of

SOB. Currently he has NO SOB. What is the best diagnostic test for him?
Methacholine challenge test
A. Chest X-ray It’s an asthma provocation test using
B. Diffusion capacity of carbon monoxide an Ach-like substance, that will lower
C. High-resolution CT scan the FEV1 by > 20% ONLY in reactive
airway disease patients
D. Methacholine challenge test
E. Pre- and postbronchodilation pulmonary function testing (PFT)
Tests to be done for COPD patients
 Chest X-ray: Flattening of the diaphragm, elongated heart

 ABG: 50/50 ABG in moderate/severe cases: PO2 52, PCO2 49, pH 7.35, HCO3 32
 EKG: Right axis deviation, right ventricular hypertrophy
 CBC: Increased hematocrit (microcytic erythrocytosis)
 Chemistry: Increased serum bicarbonate
 PFT:
FEV1 FVC FEV1/FVC TLC Residual vol. DLCO
     
CHRONIC TREATMENT
OF ASTHMA & COPD
Drug Treatment of Asthma & COPD
Bronchodilators Antiinflammatory
Xanthine Monoclonal
Derivatives Antibodies
Theophylline Anti- Omalizumab
Leukotriene
muscarinics Antagonists
Beta- Steroids Montelukast
SAMA LAMA agonists ICS Zileuton
Ipratropium Tiotropium Fluticasone
+ For COPD
Budesonide
SABA LABA Roflumilast
Salmeterol Antibiotics
Albuterol Formoterol
Combivent® Advair Diskus®

Symbicort®
Which of the following lowers mortality in COPD?
A. Smoking cessation
B. Continuous home oxygen therapy
C. Both
D. Neither
Stepwise Approach for Managing Asthma in Youths >12 Years of Age & Adults
Intermittent Persistent Asthma: Daily Medication
Asthma Consult asthma specialist if step 4 care or higher is required.
Consider consultation at step 3
Step 6 Step up if
Step 5 needed
(first check
Step 4 Preferred adherence,
Preferred High dose ICS environmental
Step 3 High + LABA + oral control &
Preferred: Preferred: Dose ICS + comorbid
Step 2 Low-dose ICS + Medium Dose
corticosteroid conditions)
LABA
Preferred: LABA ICS + LABA AND Assess
OR – Medium control
Low dose ICS AND
dose ICS Alternative: Consider
Step 1 Alternative: Medium-dose Omalizumab Step
Cromolyn, Alternative: Consider down if
ICS + either for patients
Preferred: LTRA,
Low-dose ICS + Omalizumab possible
either LTRA, LTRA, who have
SABA Nedocromil or Theophylline,
for patients
allergies
(and asthma
PRN Theophylline Theophylline, or who have is well
Zileuton or Zileuton controlled at
allergies
least 3
Each Step: Patient Education and Environmental Control and management of comorbidities months)
Steps 2 – 4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma
•Quick-relief medication for ALL patients -SABA as needed for symptoms: up to 3 tx @ 20 minute
intervals prn. Short course of o systemic corticosteroids may be needed.
• Use of SABA >2 days a week for symptom relief (not prevention of EIB) generally indicates
inadequate control & the need to step up treatment.
Alternate asthma long-term maintenance therapy besides ICS
Cause Medication
Extrinsic allergy e.g. hay fever Cromolyn or nedocromil
Atopic disease Montelukast
Exercise-induced asthma Inhaled bronchodilator prior to exercise
High IgE levels, no control with cromolyn Omalizumab (anti-IgE antibody)
MANAGING EXACERBATIONS
OF ASTHMA & COPD
https://www.youtube.com/watch?v=4fMM6qTa7bY&list=PLYojB5NEEakWxqnCBgl5_5rGXEP7VYGVT&index=4
Symptom management of exacerbation
 ALL patients with SOB should receive the following:
 Oxygen
 Continuous oximetry
 Chest X-ray
 ABG
 Any patient with asthma + respiratory acidosis: should be placed in an ICU
 Persistent respiratory acidosis: is an indication for intubation and mechanical
ventilation
 Parenteral methyl prednisolone: used for patients in the ICU
Alpha-1 Antitrypsin Deficiency
 A genetic disorder: that presents with a combination of cirrhosis & COPD.

 Presents as: COPD in a young (< 40)/ non-smoker who might show signs of cirrhosis
 Diagnostic Testing:
• Chest X-ray: Bullae at lung bases, barrel chest, flat diaphragm
• Blood tests: low albumin and high PT& INR
• Alpha-1 antitrypsin level: low
• Genetic testing
 Treatment:
• Alpha-1 antitrypsin infusion
Case Study: Asthma
Key Features:
 A 27 y/o male presents with increasing SOB, wheezing, fatigue, cough, stuffy nose,
watery eyes, and post nasal drainage for 4 days.
 PMH:
 Diagnosed with asthma at the age of 18 months
 Moderate persistant asthma since age 19
 Perennial allergic rhinitis for 15 years
 FH:
 Father with H/O perennial allergic rhinitis and allergy to pets
Case Study: Asthma
Questions:
 Q.2: What is the most likely trigger of this patient’s asthma attack?
The most likely trigger of this patient’s asthma attack is a viral respiratory infection. Clinical
manifestations that support this assessment include the following:
a. Stuffy nose
b. Red, watery eyes
c. Postnasal drainage
d. Mildly sore throat
e. Low-grade fever
f. Production of a clear, yellow phlegm
Case Study: Asthma
Questions:
 Q.3: Identify three major factors that have likely contributed to the development of
asthma in this patient
Three major factors that have likely contributed to the development of asthma in this patient are:
a. premature birth;
b. positive family history of sensitivity to airborne allergens suggests a genetic susceptibility to asthma;
and
c. patient history of perennial allergic rhinitis.
Case Study: Chronic Obstructive Pulmonary Disease
Key Features:
 A 61 y/o man presents to the ER with a 3-day history of progressive dyspnea, cough,
and increased production of sputum
Questions:
 Q.4: Identify this patient’s most significant risk factor for COPD
• The single most significant risk factor that this patient has for chronic obstructive pulmonary
disease (COPD) is cigarette smoking—the single leading cause of COPD. The patient was a 74
pack-year smoker before his diagnosis of COPD and continues to smoke five cigarettes per day.
• A positive family history for COPD (i.e., mother also has COPD) suggests that there may also be a
contributing genetic component.
Questions:
 Q.5: Identify the clinical manifestations of chronic bronchitis in this patient
• Excessive sputum production, and Persistent cough that is more severe in the morning
• Cyanotic nail beds, Use of accessory muscles to breathe
• Dyspnea
• Jugular vein distension, Hepatomegaly, Splenomegaly
• Swelling of ankles, Swelling of abdomen (fluid wave) with tenderness and distension
• Large pulmonary vasculature observed with chest radiograph
• Scarring noted on chest radiograph
• Low PaO2 level that required oxygen therapy, High PaCO2 level
• High hematocrit and hemoglobin concentration
• Low forced expiratory volume in the first second (FEV1)
• Slightly low forced vital capacity (FVC)
• Occasional mild expiratory wheeze
Questions:
 Q.5: Identify the clinical manifestations of emphysema in this patient
• Patient is thin with significant weight loss since diagnosis
• Dyspnea at rest, Use of accessory muscles to breathe
• Barrel-shaped chest
• Few breath sounds (“quiet chest”), Prolonged expiration, Hyperresonance
• Pursed-lip breathing, Tachypnea (breathing rate of 32)
• Poor diaphragmatic excursion bilaterally
• Hyperinflation with flattened diaphragm observed with chest radiograph
• Large anteroposterior chest diameter observed with chest radiograph
• Presence of bullae observed with chest radiograph
• Low FEV1Low FVC
Questions:
 Q.5: Identify the clinical manifestations of pulmonary hypertension and cor pulmonale in
this patient
• Ankle edema (cor pulmonale)
• Mild jugular vein distension (cor pulmonale)
• Hepatomegaly (cor pulmonale)
• Splenomegaly (cor pulmonale)
• Fluid wave within abdomen with tenderness and distension (cor pulmonale)
• Prominent S3 (cor pulmonale)
• Large pulmonary vasculature observed with chest radiograph (pulmonary hypertension)
References
Katzung, B. G., Masters, S. B., & Trevor, A. J. (2012). Basic & clinical pharmacology (12th ed.). New York: McGraw-Hill Medical
Arcangelo, V. P. & Peterson, A. M. (2013). Pharmacotherapeutics for advanced practice. 3rd Ed. Lippincott Publishers.
Trevor, A. J., Katzung, B. G., & Masters, S. B. (2013) Katzung & Trevor's pharmacology: examination & board review.
(10th ed.). New York: Lange Medical Books/McGraw Hill, Medical Pub. Division.
Margaret A. Fitzgerald, (2014) Clinical Pharmacology for NPs & Advanced Practice Clinicians. Fitzgerald Health Education Associates, Inc.
McCance, K.L., Huether, S. E. (2012) Pathophysiology: The Biological Basis for Disease in Adults and Children. (6th Ed) St. Louis, MO.
Elsevier Mosby
McCance, K.L. Huether, S.E. (2009). Study Guide for Pathophysiology: The Biologic Basis for Disease in Adults and Children. (6th ed.).
Philadelphia, PA: Elsevier Science.
Porth, C. M. (2011). Essentials of Pathophysiology (3rd. ed.). Philadelphia: Lippincott Williams &Wilkins.
Huether, S. E., & McCance, K. L. (2011). Understanding pathophysiology (5th ed.). St. Louis, Mo.: Mosby/Elsevier.
Fischer, C. (2015). Master The Boards USMLE Step 3 (3rd ed.). New York, NY: Kaplan Medical
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OBSTRUCTIVE LUNG DISEASE

ASTHMA & COPD

 Most important features of severe asthma exacerbation:

Asthma and reactive airway disease are confirmed with an

A young man comes to the clinic for evaluation of intermittent episodes of

 Chest X-ray: Flattening of the diaphragm, elongated heart

Combivent® Advair Diskus®

 A genetic disorder: that presents with a combination of cirrhosis & COPD.

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