Questions for Discussion with answers:

  1. What can you say about this patient's underlying lung disease? 
    a. What are the clinical criteria for chronic bronchitis?
    b. Do you accept this patient's diagnosis of "asthma"?
    c. Compare the classic characteristics of patients suffering from emphysema and chronic bronchitis.
  2. What is the significance of the change in sputum color?  Answer
  3. What probably happened to this man to necessitate this hospitalization? Could this possibly have been prevented? Discuss the use of antibiotics on an out-patient basis in patients with COPD.  Answer

On physical examination, the patient was a cachectic, anxious male in acute respiratory distress with rapid respirations, marked supraclavicular and intercostal retractions, using his accessory muscles to breath.   T = 98 o ; P = 85; BP = 120/85; RR = 30.   Lips were cyanotic.   Neck veins were distended to the mandible but collapsed with inspiration.   Chest exam revealed limited expansion, increased A-P diameter, hyperresonance and a fixed diaphragm on percussion, marked inspiratory and expiratory wheezing, and a prolonged expiratory phase.   Heart sounds were distant with a regular rhythm.   There was no clubbing or edema.

  1. Why is this patient cachectic?  Answer
  2. What is responsible for the oscillation in neck vein distention?  Answer
  3. Discuss the expected physical examination findings in COPD. What are Hoover’s sign and abdominal-thoraco paradox and what do each signify?  Answer

Laboratory Data:

CXR:    increased A-P diameter, flat diaphragms, clear lung fields, normal heart size.
ECG:   sinus tachycardia, large P waves in II, right axis deviation.
CBC:   Hgb = 16.5; WBC = 8.4 (65% polys, 35% lymphs)
BMP:   normal.
Sputum Gram Stain: lots of polys; Culture: Pending.
ABG:    pH = 7.32; PaCO 2 = 55; PaO 2 = 55; 85% saturated

The patient was given albuterol and ipatropium bronchodilator therapy, ampicillin, solumedrol, and supplemental oxygen.

  1. Describe the typical CXR features in patients with emphysema.  Answer
  2. Do you think the hemoglobin of 16.5 is of any significance?  Answer
  3. What antibiotics should be used for an acute exacerbation of COPD? Should these be started before cultures are back?  Answer
  4. What acid-base abnormality is present?  Answer
  5. What is the primary mechanism of hypoxia in patients with COPD? Discuss the concern regarding the use of supplemental oxygen during an acute exacerbation of COPD.  Answer
  6. Discuss the data for and against the use of corticosteroids in patients with COPD.  Answer
    a. as part of chronic management
    b. for acute outpatient exacerbations
    c. for exacerbations requiring hospitalization

(Some evidence may be found in: Wood-Baker, R. Walters, EH. The role of corticosteroids in acute exacerbations of Chronic Obstructive Pulmonary Disease. [Systematic Review] Cochrane Airways Group)

The patient gradually improved and was changed to oral antibiotics, given a pneumococcal vaccine, counseled on smoking cessation, and discharged on albuterol and ipatropium MDI's as well as supplemental oxygen.   He was given a prescription for ampicillin to be used for respiratory infection prn.

The following PFT's were obtained six weeks later as an outpatient:

(% Predicted)



1.3 L (35%)

1.4 L


2.6 L (71%)

2.6 L





7.3 L   (125%)



3.5 L (150%)



12.3 (52%)



  1. Describe the characteristic changes in the following pulmonary function tests in patients with COPD: FEV1, FVC, TLC, RV, DLCO.  Answer
  2. What is the expected rate of decline in FEV1 per year in non-smokers, current smokers, and ex-smokers?  Answer
  3. Discuss the equal pressure point theory of airflow obstruction in COPD.  Answer
  4. Describe a step-wise approach to the medical management of outpatients with COPD.  Answer
  5. What is the role for long-term oxygen therapy in patients with COPD? What pO2/saturation cutoff qualifies the patient for home O2.  Answer
  6. Which patients should be screened for alpha-1 antitrypsin deficiency?  Answer
  7. Describe the role in the management of patients with COPD for:  Answer

    a. Pulmonary rehabilitation

    b. Narcotics
  8. Describe two surgical procedures that are possible options for select patients with end stage lung disease secondary to COPD?  Answer