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Case Presentation
Arpitha P
Final year MBBS
KoIMS, Madikeri
History
• Name: Mr. XYZ
• Age: 70 years
• Gender: Male
• Address: Galibeedu, Madikeri
• Occupation: currently doesn’t work, prev daily wage labourer
• Education: no formal education
• Socioeconomic status: lower middle class(modified BG Prasad’s scale)
• Informant: His wife (reliable)
Arpitha
Chief complaints:
• Breathlessness exacerbated from 6 days which is present since 10
years
• Cough with expectoration since 3 days
Arpitha
History of presenting illness:
• The patient complaints of breathlessness which has worsened from 6 days,
insidious in onset, which was initially present on doing moderate heavy
work and progressed to present stage of breathlessness on performing
daily activities. Present intermittently throughout the day.
• Aggravates in cold weather, more in the morning and slightly relieved on
bending forwards
• MMRC grade of 4.
• History of breathlessness since 10 years, some episodes were tolerable and
severe episodes required hospital admission.
• Associated with wheeze during episodes of breathlessness.
Arpitha
• Cough since 3 days, insidious onset which is gradually progressive
Associated with scanty amount of sputum, white in colour, mucoid
consistency, not blood tinged or foul smelling.
Cough aggravates in cold weather, more in the morning with no
positional variation. Cough during past were relieved over 6-7 days
with no hospital admission.
• Present symptoms subsided on admission to hospital and on receiving
treatment.
• At time of examination, patient says that breathlessness has partially
subsided and no cough.
Arpitha
No history of:
• Haemoptysis, chest pain, recurrent infections, rhinitis/sinusitis, fever,
TB contact
• Orthopnoea, swelling of legs, PND
• Sudden loss of weight, dysphagia, hoarseness of voice
• Joint pain, skin rashes, numbness of extremities
Arpitha
History of presenting illness:
• Sir, my patient is known to have episodes of breathlessness with
wheeze for last 10-15 yrs which was insidious in onset & gradually
progressive. It was associated with cough with scanty , viscid/mucoid
sputum.
• Initial few years his symptoms were mild, he was able to perform all
his duties, however he used to have more symptoms of
breathlessness, wheeze & cough in winters / early morning hrs/ on
exposures to dust/pollen..
• For the last few yrs he had more aggravation of symptoms
necessitating few hospitalization for the relief.
• His symptoms gradually progressed so that even in between the
attacks / episodes of worsening, he could do only less than moderate
work & during episodes of worsening, he was symptomatic even at
rest, preventing him to do his activity of daily living.
CR
• Currently he has sudden exacerebration of symptoms from last 6
days, Present throughout the day limiting his daily activities.
• However there is no h/o FEVER / Purulent sputum/ Hemoptysis /
Orthopnea..
• The current episode has subsided after initiatin treatment in the
hospital & At time of examination, his symptoms (---) have partially /
markedly subsided.
CR
Past history
• Similar complaints of breathless since 10 years for which he has been
admitted to hospital for around 6-7 times and treated. Previous
episodes were comparatively less severe than present episode.
• On medication for breathlessness - inhalants (particulars unknown)
• History of TB 25 years back, completely cured.
• Not a known case hypertension, diabetes, asthma, epilepsy,
pneumonia, lower respiratory infections, heart diseases, bleeding or
clotting disorders
• No history of prior surgery
• No known allergies
Arpitha
Past history / Rx history
• History of TB 25 years back, has received complete Rx.
• He is on inhalant medication for breathlessness - (particulars unknown)
• Recurrent admission to hospital for last few years – for Rx –exacerebration.
• Not a known case hypertension, diabetes, asthma, epilepsy, pneumonia,
lower respiratory infections, heart diseases, bleeding or clotting disorders
• No history of prior surgery
• No known allergies
Arpitha
Personal history
• Consumes mixed diet
• Decreased appetite
• Disturbed sleep
• Bowel and bladder movements are regular
• Chronic smoker- since 50 years, smokes 20 beedis per day.
• Alcoholic since 35 years
• No history of other substance abuse
Arpitha
Family history
• No similar complaints in
the family.
• Sister diagnosed with
diabetes mellitus 10 years
ago.
• No history tuberculosis,
pneumonia, asthma, heart
diseases, hypertension in
family.
Arpitha
Summary
• An elderly male who is a chronic smoker and alcoholic gives a history
of breathlessness since 10 years with acute exacerbation from 6 days,
more in the morning and seasonal variation, hindering his activities
with MMRC score of 4, similar complaints in the past. Also complains
of cough which was scanty, mucoid and wheeze associated with
breathlessness.
• From the history, points at lung pathology which could be
- obstructive pathology(acute exacerbation) or,
- restrictive (like ILD)
Arpitha
Summary
• Sir, This elderly male, who is a chronic smoker, alcoholic with h/o treated
pulmonary TB in remote past, is having Chronic breathlessness with wheeze
, chronic ( ?)cough with scanty expectoration for almost > 10 years with h/o
repeated hospitalisation for acute exacerbation, has now come with acute
exacerbation of symptoms - 6 days duration.
• There is no h/o fever/ Orthopnea/ Chest pain/ hemoptysis / significant DOE
• I consider him to be having chronic airway disease with acute exacerbation.
CR
• Chronic Bronchial asthma
• For- Episodic / Wheeze / Seasonal/ Allergy..
• Against: Age of onset ?
• Chronic Bronchitis
• For- ??
• Against: No EXPECTORATION / Age of onset / Episodic / Wheeze / Seasonal/ Allergy..
• Emphysema
• For- Age of onset / Significant DOE/ Mild cough/ No expectoration / No fever..
• Against: Episodic / Wheeze / Seasonal/ Allergy/ Frequent hospitalisation..
• Post Tubercular Pulmonary Fibrosis
• ILD
• CAD
CR
Examination
General physical examination
• An elderly male conscious, cooperative and well oriented to time, place
and person.
• Moderately built and poorly nourished.
Vitals
• Pulse: 102 beats per minute, regular rhythm, good volume, normal
character, no delay, palpable vessel wall, no radio-radial or radio-femoral
delay, all peripheral pulses felt
• Blood pressure : 130/80mmHg over right brachial artery in supine position
• Respiratory rate:32 breaths per minute, abdominothoracic, rhythm,
abnormal breathing pattern(pursed lip breathing)
• Afebrile at time of examination
• JVP- appears not to be raised
Arpitha
• Weight- 55kg height- 172cm
• BMI= 18.6kg/m2
• No pallor, icterus, cyanosis, clubbing, lymphadenopathy and pedal
oedema
• Using accessory muscles of respiration, flared alae nasi
• Pursed lip breathing
• External markers of TB absent
• External markers of cor pulmonale absent
Arpitha
Examination of respiratory system
• Upper respiratory tract:
Oral cavity: appears normal
Nasal cavity: appears normal
Pharynx: appears normal
Arpitha
Lower respiratory tract
Inspection:
No tracheal deviation
Apex beat: not visible
Chest: bilaterally symmetrical
barrel shaped( anteroposterior diameter is increased)
hollowness in the supraclavicular fossa
intercostal spaces are increased, no intercostal indrawing
Accessory muscles of respiration used
No dilated veins, pulsations, scars or sinuses
No spinal deformity or drooping of shoulder
Arpitha
Movements: all areas appear to move equally with respiration
Anterior:
Supraclavicular
Infraclavicular
Mammary
Decreased Decreased
Lateral:
Axillary
Infraaxillary
Decreased Decreased
Posterior:
Suprascapular
Interscapular
Infrascapular
Decreased Decreased
Arpitha
Palpation:
 All inspection findings are confirmed
 No tracheal deviation
 Apex beat- left 5th intercostal space medial to midclavicular line
 No tenderness over chest wall
 Measurements
AP diameter- 30cm
Transverse diameter- 32cm ( ratio 0.93)
Chest circumference-on expiration- 98cm
on deep inspiration-101 cm
Chest expansion- 3cm
Hemithorax-Right- 48cm ( 1cm expansion)
Left-47cm (1cm expansion)
Arpitha
Movements: all areas appear to move equally with respiration
Intensity:
Anterior:
Supraclavicular
Infraclavicular
Mammary
Decreased Decreased
Lateral:
Axillary
Infraaxillary
Decreased Decreased
Posterior:
Suprascapular
Interscapular
Infrascapular
Decreased Decreased
Arpitha
• Tactile vocal fremitus- decreased on both sides.
• No palpable rales, rhonci or rub
Percussion:
 Direct over clavicle
 Indirect
Anterior
Supraclavicular
Infraclavicular
Mammary
Resonant Resonant
Kronig’s isthmus- resonant
Liver dullness- present( 6th intercostal
space in mid clavicular line)
Hyperresonant
Kronig’s isthmus- resonant
Cardiac dullness- present(reduced)
Traube’s area- tympanic note
Hyperresonant
Arpitha
Lateral:
Axillary
Infraaxillary
Hyperresonant hyperresonant
Posterior:
Suprascapular
Interscapular
Infrascapular
Hyperresonant Hyperresonant
Arpitha
Auscultation: Vesicular breaths heard on both sided with added
sounds
Anterior:
Supraclavicular
Infra clavicular
Mammary
Decreased Decreased
Lateral:
Axillary
Infra axillary
Decreased Decreased
Posterior:
Suprascapular
Interscapular
Infra scapular
Decreased Decreased
Arpitha
• Added sounds- Rhonchi(diffuse) heard on both side
• Vocal resonance- diminished in all areas
Crepitation??
Arpitha
Impressions after respiratory system examination:
• Increased AP diameter(barrel chest) , accessory muscles used
• Movement decreased(markedly) bilaterally
• B/L Hyper resonant note on percussion, liver dullness one IC space
lower
• Vocal fremitus and vocal resonance diminished
• Bilateral diffuse rhonchi heard
Arpitha
Systemic examination
• Cardiovascular system:
S1 and S2 heard, no added sounds
• Abdominal examination
Soft, non tender and no organomegaly/mass palpable
Normal bowel sounds heard
• Central nervous system
Higher mental functions normal
Cranial nerves, motor and sensory system appear normal
Arpitha
Provisional diagnosis:
• It could be acute exacerbation of chronic obstructive pulmonary disease
• Anatomical - generalised involvement of both lungs.
• Pathology - chronic obstructive pathology of airways and alveoli
• Aetiology - hyperinflation of lungs
• Risk factors – cigarette smoking and age
Arpitha
Provisional diagnosis:
• Risk factors – cigarette smoking and age; Old PTB
• Anatomical - generalised involvement of both lungs.
• Pathology - chronic obstructive pathology of airways and alveoli & hyperinflation
Differential diagnosis
1) Chronic obstructive pulmonary disease with Ac Exacerbation
? Chr Bronchitis / ? Emphysema / ? Mixed
2) Ac Exacerbation of Chronic Bronchial Asthma / Persistent asthma
• ? Complications
CR
• ? How to confirm ? (COPD / Br asthma)
• ? How to differentiate (Ch Bronchitis / Emphysema )
• ? Acute severe asthma
• ? Mediators of Asthma
• ? Ppting factors of asthma
• ? Complications of Asthma
• ? Complications of Ch Bronchitis
• ? Complications of Emphysema
• ? Step care Rx of Asthma
• ? Rx of COPD
• ? F/o Chr Respiratory failure in COPD
CR
PFT
CR
Obstructive Restrictive
FVC ↓ ↔ ↓ ↓
FEV-1 ↓ ↓ ↓ ↔
FEV 25-75 ↓ ↓ ↓ ↔
CR
CR
Diagnosis of Asthma
• Document reversible airway obstruction
• >15% improvement in
• FEV1
• FEV1/FVC
• PEFR
after inhalation of SABA
CR
Drug delivery devises
CR
Acute Severe Asthma
 Very sever breathlessness- NOT ABLE TO SPEAK
 Tachypnoea ; RR >40/m
 Tachycardia ; PR >120/m
 Cyanosis
 Accessory muscles acting
 Pulses paradoxus
 Chest wall movement markedly reduced – NIL
 Hyper-resonent on percussion
 Very minimal / No breath sounds
 No ronchi SILENT CHEST
 SPO2 < 85%
 PFER & FEV1 < 50% of predicted
CR
COPD:
• Progressive, largely irreversible lung diseases
• Debilitating
• Death rate is 20 folds higher than asthama.
• CHRONIC, SLOWELY PROGRESSIVE DISEASE characterized by airflow
obstruction ( FEV1 <80% & FEV1 /FVC <70% of predicted) which does not
change markedly over several months.
CR
COPD
• Emphysema ( Pink puffer)
• Chronic bronchitis ( Blue bloater)
 Refractory (irreversible) asthma / Chr Asthmatic bronchitis
 Severe bronchiectasis
CR
• Chronic Bronchitis is defined as a chronic airway inflammation
with excessive tracheobronchial secretions causing cough and
expectoration on most days of at least 3 consecutive months for
more than 2 consecutive years.
• Emphysema is defined as pathological process of irreversible
damage and dilatation of the airspaces distal to terminal
bronchioles .
CR
Emphysema Chr Bronchitis
Age 50+ 35-40
Mechnism Abnormal/ reduced Elastic recoil Increased Airway resistance
Dyspnoea Marked, early Late, mild
Cough Minimal Marked
Sputum Scanty Large, Purulent
Mucopurulent relapse / RTI Rare Frequent
Cyanosis NO YES
Pul HTn Late Early
CHF & Resp failure Late, terminal Early, frequent
PCV High --
Pao2 Normal Low
PaCO2 Normal- Low High
FEV1 Low Low
DCLO Reduced Normal
CXR Hyperinflation, Bullae, tubular heart Increased BVM, CE
CR
CR
• Chr Hypoxemia  Pulmonary vascular remodeling  Pul
Hypertension RVH
CR
Spirometry Classification for COPD
Stage FEV1:FVC FEV1
1: Mild
<0.70
≥80% of predicted value
2: Moderate 50% to 79% of predicted value
3: Severe 30% to 49% of predicted value
4: Very severe
<30% of predicted value
OR
<50% of predicted value with chronic
respiratory failure
Adapted from GOLD, 2009
CR
CASE PRESENTATION-COPD.ppt
Diagnostic Criteria
Key Indicators
• Dyspnea
• Progressive, usually worse with exercise, persistent, described as increased effort to breathe
• Chronic cough
• May be intermittent, may be nonproductive
• Chronic sputum production
• Any pattern
• History of exposure to risk factors
• Tobacco smoke, occupational dust, chemicals, fumes or smoke from cooking or heating fuels
Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2009
Treatment
• SMOKING CESSATION!
• Inhaled bronchodilators – Salbutamol , Salmeterol..
• Combination of anti-cholinergic and -agonist bronchodilator
• Ipratropium + Salbutamol
• Tiotropium
• Methylxanthines (Theophylline)
• Inhaled corticosteroids
• Fluticasone, Budesonide
• Combination of Inhaled corticosteroid and long-acting -agonist
• Fluticasone + salmeterol
• Oral Corticosteroids
• Home Oxygen Rx
C/f COPD Asthma
Age >35 years Any age
Cough Persistent, productive Intermittent, nonproductive
Smoking ++++ Variable
Dyspnea Persistent Progressive Episodic / Variable
Nocturnal
symptoms
Breathlessness, late in disease Coughing, wheezing ++
Family history Less common More common
Atopy Less common More common
Diurnal symptoms Less common More common
Spirometry Irreversible obstructive pattern Reversible pattern
Complications
• Bullae
• Pnemothorax
• Recurrent RTI
• Chr Respiratory failure
• Pul HT  Chr Cor pulmonale
CR
• CO2 Narcosis  Hypercapnic encephalopathy
• Confusion  Drowsiness Coma?
• Warm extremities
• Cyanosis
• Bounding pulse
• Flapping tremors
CR
• ? How to confirm ? (COPD / Br asthma)
• ? How to differentiate (Ch Bronchitis / Emphysema )
• ? Acute severe asthma
• ? Mediators of Asthma
• ? Ppting factors of asthma
• ? Complications of Asthma
• ? Complications of Ch Bronchitis
• ? Complications of Emphysema
• ? Step care Rx of Asthma
• ? Rx of COPD
• ? F/o Chr Respiratory failure in COPD
CR

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CASE PRESENTATION-COPD.ppt

  • 1. Case Presentation Arpitha P Final year MBBS KoIMS, Madikeri
  • 2. History • Name: Mr. XYZ • Age: 70 years • Gender: Male • Address: Galibeedu, Madikeri • Occupation: currently doesn’t work, prev daily wage labourer • Education: no formal education • Socioeconomic status: lower middle class(modified BG Prasad’s scale) • Informant: His wife (reliable) Arpitha
  • 3. Chief complaints: • Breathlessness exacerbated from 6 days which is present since 10 years • Cough with expectoration since 3 days Arpitha
  • 4. History of presenting illness: • The patient complaints of breathlessness which has worsened from 6 days, insidious in onset, which was initially present on doing moderate heavy work and progressed to present stage of breathlessness on performing daily activities. Present intermittently throughout the day. • Aggravates in cold weather, more in the morning and slightly relieved on bending forwards • MMRC grade of 4. • History of breathlessness since 10 years, some episodes were tolerable and severe episodes required hospital admission. • Associated with wheeze during episodes of breathlessness. Arpitha
  • 5. • Cough since 3 days, insidious onset which is gradually progressive Associated with scanty amount of sputum, white in colour, mucoid consistency, not blood tinged or foul smelling. Cough aggravates in cold weather, more in the morning with no positional variation. Cough during past were relieved over 6-7 days with no hospital admission. • Present symptoms subsided on admission to hospital and on receiving treatment. • At time of examination, patient says that breathlessness has partially subsided and no cough. Arpitha
  • 6. No history of: • Haemoptysis, chest pain, recurrent infections, rhinitis/sinusitis, fever, TB contact • Orthopnoea, swelling of legs, PND • Sudden loss of weight, dysphagia, hoarseness of voice • Joint pain, skin rashes, numbness of extremities Arpitha
  • 7. History of presenting illness: • Sir, my patient is known to have episodes of breathlessness with wheeze for last 10-15 yrs which was insidious in onset & gradually progressive. It was associated with cough with scanty , viscid/mucoid sputum. • Initial few years his symptoms were mild, he was able to perform all his duties, however he used to have more symptoms of breathlessness, wheeze & cough in winters / early morning hrs/ on exposures to dust/pollen.. • For the last few yrs he had more aggravation of symptoms necessitating few hospitalization for the relief. • His symptoms gradually progressed so that even in between the attacks / episodes of worsening, he could do only less than moderate work & during episodes of worsening, he was symptomatic even at rest, preventing him to do his activity of daily living. CR
  • 8. • Currently he has sudden exacerebration of symptoms from last 6 days, Present throughout the day limiting his daily activities. • However there is no h/o FEVER / Purulent sputum/ Hemoptysis / Orthopnea.. • The current episode has subsided after initiatin treatment in the hospital & At time of examination, his symptoms (---) have partially / markedly subsided. CR
  • 9. Past history • Similar complaints of breathless since 10 years for which he has been admitted to hospital for around 6-7 times and treated. Previous episodes were comparatively less severe than present episode. • On medication for breathlessness - inhalants (particulars unknown) • History of TB 25 years back, completely cured. • Not a known case hypertension, diabetes, asthma, epilepsy, pneumonia, lower respiratory infections, heart diseases, bleeding or clotting disorders • No history of prior surgery • No known allergies Arpitha
  • 10. Past history / Rx history • History of TB 25 years back, has received complete Rx. • He is on inhalant medication for breathlessness - (particulars unknown) • Recurrent admission to hospital for last few years – for Rx –exacerebration. • Not a known case hypertension, diabetes, asthma, epilepsy, pneumonia, lower respiratory infections, heart diseases, bleeding or clotting disorders • No history of prior surgery • No known allergies Arpitha
  • 11. Personal history • Consumes mixed diet • Decreased appetite • Disturbed sleep • Bowel and bladder movements are regular • Chronic smoker- since 50 years, smokes 20 beedis per day. • Alcoholic since 35 years • No history of other substance abuse Arpitha
  • 12. Family history • No similar complaints in the family. • Sister diagnosed with diabetes mellitus 10 years ago. • No history tuberculosis, pneumonia, asthma, heart diseases, hypertension in family. Arpitha
  • 13. Summary • An elderly male who is a chronic smoker and alcoholic gives a history of breathlessness since 10 years with acute exacerbation from 6 days, more in the morning and seasonal variation, hindering his activities with MMRC score of 4, similar complaints in the past. Also complains of cough which was scanty, mucoid and wheeze associated with breathlessness. • From the history, points at lung pathology which could be - obstructive pathology(acute exacerbation) or, - restrictive (like ILD) Arpitha
  • 14. Summary • Sir, This elderly male, who is a chronic smoker, alcoholic with h/o treated pulmonary TB in remote past, is having Chronic breathlessness with wheeze , chronic ( ?)cough with scanty expectoration for almost > 10 years with h/o repeated hospitalisation for acute exacerbation, has now come with acute exacerbation of symptoms - 6 days duration. • There is no h/o fever/ Orthopnea/ Chest pain/ hemoptysis / significant DOE • I consider him to be having chronic airway disease with acute exacerbation. CR
  • 15. • Chronic Bronchial asthma • For- Episodic / Wheeze / Seasonal/ Allergy.. • Against: Age of onset ? • Chronic Bronchitis • For- ?? • Against: No EXPECTORATION / Age of onset / Episodic / Wheeze / Seasonal/ Allergy.. • Emphysema • For- Age of onset / Significant DOE/ Mild cough/ No expectoration / No fever.. • Against: Episodic / Wheeze / Seasonal/ Allergy/ Frequent hospitalisation.. • Post Tubercular Pulmonary Fibrosis • ILD • CAD CR
  • 17. General physical examination • An elderly male conscious, cooperative and well oriented to time, place and person. • Moderately built and poorly nourished. Vitals • Pulse: 102 beats per minute, regular rhythm, good volume, normal character, no delay, palpable vessel wall, no radio-radial or radio-femoral delay, all peripheral pulses felt • Blood pressure : 130/80mmHg over right brachial artery in supine position • Respiratory rate:32 breaths per minute, abdominothoracic, rhythm, abnormal breathing pattern(pursed lip breathing) • Afebrile at time of examination • JVP- appears not to be raised Arpitha
  • 18. • Weight- 55kg height- 172cm • BMI= 18.6kg/m2 • No pallor, icterus, cyanosis, clubbing, lymphadenopathy and pedal oedema • Using accessory muscles of respiration, flared alae nasi • Pursed lip breathing • External markers of TB absent • External markers of cor pulmonale absent Arpitha
  • 19. Examination of respiratory system • Upper respiratory tract: Oral cavity: appears normal Nasal cavity: appears normal Pharynx: appears normal Arpitha
  • 20. Lower respiratory tract Inspection: No tracheal deviation Apex beat: not visible Chest: bilaterally symmetrical barrel shaped( anteroposterior diameter is increased) hollowness in the supraclavicular fossa intercostal spaces are increased, no intercostal indrawing Accessory muscles of respiration used No dilated veins, pulsations, scars or sinuses No spinal deformity or drooping of shoulder Arpitha
  • 21. Movements: all areas appear to move equally with respiration Anterior: Supraclavicular Infraclavicular Mammary Decreased Decreased Lateral: Axillary Infraaxillary Decreased Decreased Posterior: Suprascapular Interscapular Infrascapular Decreased Decreased Arpitha
  • 22. Palpation:  All inspection findings are confirmed  No tracheal deviation  Apex beat- left 5th intercostal space medial to midclavicular line  No tenderness over chest wall  Measurements AP diameter- 30cm Transverse diameter- 32cm ( ratio 0.93) Chest circumference-on expiration- 98cm on deep inspiration-101 cm Chest expansion- 3cm Hemithorax-Right- 48cm ( 1cm expansion) Left-47cm (1cm expansion) Arpitha
  • 23. Movements: all areas appear to move equally with respiration Intensity: Anterior: Supraclavicular Infraclavicular Mammary Decreased Decreased Lateral: Axillary Infraaxillary Decreased Decreased Posterior: Suprascapular Interscapular Infrascapular Decreased Decreased Arpitha
  • 24. • Tactile vocal fremitus- decreased on both sides. • No palpable rales, rhonci or rub Percussion:  Direct over clavicle  Indirect Anterior Supraclavicular Infraclavicular Mammary Resonant Resonant Kronig’s isthmus- resonant Liver dullness- present( 6th intercostal space in mid clavicular line) Hyperresonant Kronig’s isthmus- resonant Cardiac dullness- present(reduced) Traube’s area- tympanic note Hyperresonant Arpitha
  • 26. Auscultation: Vesicular breaths heard on both sided with added sounds Anterior: Supraclavicular Infra clavicular Mammary Decreased Decreased Lateral: Axillary Infra axillary Decreased Decreased Posterior: Suprascapular Interscapular Infra scapular Decreased Decreased Arpitha
  • 27. • Added sounds- Rhonchi(diffuse) heard on both side • Vocal resonance- diminished in all areas Crepitation?? Arpitha
  • 28. Impressions after respiratory system examination: • Increased AP diameter(barrel chest) , accessory muscles used • Movement decreased(markedly) bilaterally • B/L Hyper resonant note on percussion, liver dullness one IC space lower • Vocal fremitus and vocal resonance diminished • Bilateral diffuse rhonchi heard Arpitha
  • 29. Systemic examination • Cardiovascular system: S1 and S2 heard, no added sounds • Abdominal examination Soft, non tender and no organomegaly/mass palpable Normal bowel sounds heard • Central nervous system Higher mental functions normal Cranial nerves, motor and sensory system appear normal Arpitha
  • 30. Provisional diagnosis: • It could be acute exacerbation of chronic obstructive pulmonary disease • Anatomical - generalised involvement of both lungs. • Pathology - chronic obstructive pathology of airways and alveoli • Aetiology - hyperinflation of lungs • Risk factors – cigarette smoking and age Arpitha
  • 31. Provisional diagnosis: • Risk factors – cigarette smoking and age; Old PTB • Anatomical - generalised involvement of both lungs. • Pathology - chronic obstructive pathology of airways and alveoli & hyperinflation Differential diagnosis 1) Chronic obstructive pulmonary disease with Ac Exacerbation ? Chr Bronchitis / ? Emphysema / ? Mixed 2) Ac Exacerbation of Chronic Bronchial Asthma / Persistent asthma • ? Complications CR
  • 32. • ? How to confirm ? (COPD / Br asthma) • ? How to differentiate (Ch Bronchitis / Emphysema ) • ? Acute severe asthma • ? Mediators of Asthma • ? Ppting factors of asthma • ? Complications of Asthma • ? Complications of Ch Bronchitis • ? Complications of Emphysema • ? Step care Rx of Asthma • ? Rx of COPD • ? F/o Chr Respiratory failure in COPD CR
  • 34. Obstructive Restrictive FVC ↓ ↔ ↓ ↓ FEV-1 ↓ ↓ ↓ ↔ FEV 25-75 ↓ ↓ ↓ ↔ CR
  • 35. CR
  • 36. Diagnosis of Asthma • Document reversible airway obstruction • >15% improvement in • FEV1 • FEV1/FVC • PEFR after inhalation of SABA CR
  • 38. Acute Severe Asthma  Very sever breathlessness- NOT ABLE TO SPEAK  Tachypnoea ; RR >40/m  Tachycardia ; PR >120/m  Cyanosis  Accessory muscles acting  Pulses paradoxus  Chest wall movement markedly reduced – NIL  Hyper-resonent on percussion  Very minimal / No breath sounds  No ronchi SILENT CHEST  SPO2 < 85%  PFER & FEV1 < 50% of predicted CR
  • 39. COPD: • Progressive, largely irreversible lung diseases • Debilitating • Death rate is 20 folds higher than asthama. • CHRONIC, SLOWELY PROGRESSIVE DISEASE characterized by airflow obstruction ( FEV1 <80% & FEV1 /FVC <70% of predicted) which does not change markedly over several months. CR
  • 40. COPD • Emphysema ( Pink puffer) • Chronic bronchitis ( Blue bloater)  Refractory (irreversible) asthma / Chr Asthmatic bronchitis  Severe bronchiectasis CR
  • 41. • Chronic Bronchitis is defined as a chronic airway inflammation with excessive tracheobronchial secretions causing cough and expectoration on most days of at least 3 consecutive months for more than 2 consecutive years. • Emphysema is defined as pathological process of irreversible damage and dilatation of the airspaces distal to terminal bronchioles . CR
  • 42. Emphysema Chr Bronchitis Age 50+ 35-40 Mechnism Abnormal/ reduced Elastic recoil Increased Airway resistance Dyspnoea Marked, early Late, mild Cough Minimal Marked Sputum Scanty Large, Purulent Mucopurulent relapse / RTI Rare Frequent Cyanosis NO YES Pul HTn Late Early CHF & Resp failure Late, terminal Early, frequent PCV High -- Pao2 Normal Low PaCO2 Normal- Low High FEV1 Low Low DCLO Reduced Normal CXR Hyperinflation, Bullae, tubular heart Increased BVM, CE CR
  • 43. CR
  • 44. • Chr Hypoxemia  Pulmonary vascular remodeling  Pul Hypertension RVH CR
  • 45. Spirometry Classification for COPD Stage FEV1:FVC FEV1 1: Mild <0.70 ≥80% of predicted value 2: Moderate 50% to 79% of predicted value 3: Severe 30% to 49% of predicted value 4: Very severe <30% of predicted value OR <50% of predicted value with chronic respiratory failure Adapted from GOLD, 2009 CR
  • 47. Diagnostic Criteria Key Indicators • Dyspnea • Progressive, usually worse with exercise, persistent, described as increased effort to breathe • Chronic cough • May be intermittent, may be nonproductive • Chronic sputum production • Any pattern • History of exposure to risk factors • Tobacco smoke, occupational dust, chemicals, fumes or smoke from cooking or heating fuels Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2009
  • 48. Treatment • SMOKING CESSATION! • Inhaled bronchodilators – Salbutamol , Salmeterol.. • Combination of anti-cholinergic and -agonist bronchodilator • Ipratropium + Salbutamol • Tiotropium • Methylxanthines (Theophylline) • Inhaled corticosteroids • Fluticasone, Budesonide • Combination of Inhaled corticosteroid and long-acting -agonist • Fluticasone + salmeterol • Oral Corticosteroids • Home Oxygen Rx
  • 49. C/f COPD Asthma Age >35 years Any age Cough Persistent, productive Intermittent, nonproductive Smoking ++++ Variable Dyspnea Persistent Progressive Episodic / Variable Nocturnal symptoms Breathlessness, late in disease Coughing, wheezing ++ Family history Less common More common Atopy Less common More common Diurnal symptoms Less common More common Spirometry Irreversible obstructive pattern Reversible pattern
  • 50. Complications • Bullae • Pnemothorax • Recurrent RTI • Chr Respiratory failure • Pul HT  Chr Cor pulmonale CR
  • 51. • CO2 Narcosis  Hypercapnic encephalopathy • Confusion  Drowsiness Coma? • Warm extremities • Cyanosis • Bounding pulse • Flapping tremors CR
  • 52. • ? How to confirm ? (COPD / Br asthma) • ? How to differentiate (Ch Bronchitis / Emphysema ) • ? Acute severe asthma • ? Mediators of Asthma • ? Ppting factors of asthma • ? Complications of Asthma • ? Complications of Ch Bronchitis • ? Complications of Emphysema • ? Step care Rx of Asthma • ? Rx of COPD • ? F/o Chr Respiratory failure in COPD CR