Case #1 Answers:













Answer 1
a. Chronic obstructive lung disease associated with chronic excessive mucus production and cough.
b. The diagnosis of "asthma" requires reversibility which is clinically manifested by episodic symptoms. While patients with COPD may have minor day to day fluctuations in disease severity, they are never completely symptom free. Hence, it is unlikely that this patient has asthma.
c. Emphysema: "pink puffer," thin, severe dyspnea, minimal sputum, normal pCO2, mild hypoxemia, severely reduced elastic recoil, mildly increased resistance
Chronic Bronchitis: "blue bloater," overweight, mild dyspnea, copious sputum, CO2 retainer, marked hypoxemia, normal elastic recoil, markedly increased resistance













Answer 2
Color change signifies inflammation and may imply infection.












Answer 3
Infection leads to increased airway inflammation and resistance, increasing the work of breathing, leading to fatigue. The likelihood of progression to hospitalization may be reduced by the use of early antibiotics.












Answer 4
Theories: increased work of breathing and dyspnea related to eating













Answer 5
Increased fluctuation in intrapleural pressures secondary to the elevated airways resistance.













Answer 6
Tachypnea, tachycardia, use of accessory muscles, intercostal retractions, increased A-P chest diameter, barrel chest, hyperresonance, hyperinflation, poor diaphragmatic excursion, poor air exchange, wheezing, distant heart sounds.

Hoover’s sign = inward movement of the lower rib cage during inspiration, implying a flat, but functioning, diaphragm.

Abdominal-thoraco paradox = simultaneous inward movement of the abdominal wall and outward movement of the chest during inspiration, implying a fatigued and/or non-functioning diaphragm.














Answer 7
Hyperinflation, flat diaphragms, vertical heart, hyperlucent lung fields, blebs.














Answer 8
Implies chronic hypoxia.













Answer 9
Cover H. flu. Yes.












Answer 10
Acute AND chronic respiratory acidosis.











Answer 11
VQ Mismatch. Rarely, patients with COPD may retain CO2 if their hypoxic drive to breath is blunted by over vigorous use of supplemental oxygen.











Answer 12
a. Only 10 % of patients with COPD show objective response to corticosteroids so routine use should be discouraged unless the patient is proven clinically to be a “responder:.
b. The use of corticosteroids for acute outpatient exacerbations has been shown to reduce the likelihood of subsequent hospitalization.
c. The VA cooperative trial has provided evidence supporting the long advocated use of corticosteroids for exacerbations requiring hospitalization. Nonetheless, the clinical effect, while statistically significant, was small in magnitude and the possible benefits of corticosteroids must be carefully weighed against their know side effects.










Answer 13
One expects obstruction ('d FEV1, FVC, and FEV1/FVC); hyperinflation ('d TLC) and gas trapping ('d RV); 'd DLCO.











Answer 14
Around 35cc/yr, 100cc/yr, and 35cc/yr.











Answer 15
Refer to discussion in Harrison's page 1453.











Answer 16
(1) short acting bronchodilators (albuterol, ipratropium), (2) long acting bronchodilators (long acting beta agonists or long acting anti-cholinergics), (3) adding long acting bronchodilators (long acting beta agonists and long acting anti-cholinergics), (4) consider inhaled steroid, theophylline, PDE-4 inhibitors.

Reference: Ferguson, Gary T.; Cherniack, Reuben M. Current Concepts: Management Of Chronic Obstructive Pulmonary Disease.[Review Article] The New England Journal of Medicine. Volume 328(14)Apr 8, 1993 pp 1017-1022.











Answer 17
pO2 < 55 or sat < 88% (or pO2 < 60 with cor pulmonale)











Answer 18
Young patients or those with minimal smoking histories.









Answer 19
a. Pulmonary rehabilitation

Pulmonary rehabilitation has been shown to result in improved quality of life, reduced sense of dyspnea, and increased exercise tolerance.

b. Narcotics

Narcotics, often utilized through a slow release transdermal fentanyl patch, may reduce the sense of dyspnea in patients with end stage lung disease who fail to respond satisfactorily to standard therapies.












Answer 20
Lung reduction surgery and lung transplantation.