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.