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Clinical Presentation
Patients with COPD will usually present with a history of cigarette smoking and
symptoms of chronic cough, expectoration, and exertional dyspnea. The intensity of
each symptom varies from patient to patient. Cough and expectoration appear
slowly and insidiously. Dyspnea is first evidenced during exertion. As the disease
progresses, symptoms worsen. Dyspnea occurs at progressively lower activity
levels. Severely involved patients may feel dyspneic even at rest. On physical
examination, the thorax appears enlarged owing to loss of lung elastic recoil and
hyperinflation. The anterior-posterior diameter of the chest increases and a dorsal
kyphosis results. These anatomical changes give the patient a barrel-chest
appearance (Fig. 12.4).
As the resting position of the thorax is now held in a more inspiratory mode,
the available range of thoracic motion is limited, that is, decreased thoracic
excursion. There are morphologic changes to the ventilatory muscles due to a
greater demand, both in frequency and in power needed for this altered thorax. The
muscles of ventilation hypertrophy as a result. Figure 12.5 shows many of the
accessory muscles of ventilation that may be recruited for breathing. In severe
disease, these muscles are recruited even at rest to aid in the work of breathing.
The lengthtension relationship of muscles of ventilation is altered as the thorax
increases in size with chronic hyperinflation. There are changes in the alignment of
fibers, especially the fibers of the diaphragm, with hyperinflation. The diaphragm
becomes flatter, or less domed. In severe disease, the diaphragm fiber alignment
may become more horizontal than vertical, resulting in an inward motion of the
lower ribs during a diaphragm muscle contraction of inhalation (Fig. 12.6).
Breath sounds and heart sounds may be distant and difficult to hear. Partially
obstructed bronchi and bronchioles may result in an expiratory wheeze, a musical,
whistling sound. Crackles, an intermittent bubbling or popping sound, may also be
Asthma
Asthma is a common chronic pulmonary disease, affecting 300 million people
worldwide.16 The disease is characterized by chronic airway inflammation
associated with airway hyperresponsiveness (hyperreactivity) resulting in
bronchospasm. Wheezing, breathlessness, and coughing with sputum production
that is at least partially reversible in nature are characteristic symptoms of asthma.
Asthma exacerbations may improve spontaneously or with medical intervention and
are interspersed with symptom-free intervals.
Diagnosis
The diagnosis of asthma is clinically based on a history of episodic wheezing,
shortness of breath (SOB), tightness in the chest, and/or coughing, which may be
worse at night in the absence of any other obvious cause. The FEV1 during
exacerbations will be less than 80% of the predicted value. With the use of a rescue
drug (used to quickly relieve acute symptoms, e.g., inhaled short-acting beta-2
agonist), an improvement of at least 12% (or 200 mL) in FEV1 indicates reversibility
of the airway limitation consistent with a diagnosis of asthma. An improvement of
PEF of 60 L/min (or greater than 20%) following the use of a beta-2 agonist would
also suggest the diagnosis of asthma.
Etiology
The etiology of asthma is not completely understood. Historically, two types of
asthma have been described. Allergic (or extrinsic) asthma has an immunologic
(immunoglobulin E [IgE]mediated) response to certain environmental triggers (dust
mites, pollen, mold, animal dander). The resulting eosinophilic inflammatory
response (an increased number of eosinophils found in the airway mucosa)
produces the common symptoms and pathophysiological findings of asthma. Atopy,
or allergic sensitivity, is the strongest factor for the development of allergic asthma.
Nonallergic (or intrinsic) asthma is a less common form of asthma. There are no
clinical findings of atopy in nonallergic asthma; however, an inflammatory response
does result from exposure to an irritant such as smoke, fumes, infections, or cold air.
Literature in asthma has begun to consider that the two types of asthma are not all
that different: one has a known and widespread allergic response (extrinsic)
whereas the other has a more local inflammatory response (intrinsic).18 The Global
Initiative for Asthma (GINA) does not differentiate allergic from nonallergic asthma
in its guide to management and prevention.16 Viral infections have been suggested
to play a role in both the development and exacerbation of asthma.19 Symptoms of
asthma may begin at any age.
Pathophysiology
The major physiological manifestation of asthma is narrowing of the airways in
response to a trigger. The airway narrowing occurs as a result of eosinophilic
inflammation of the bronchial mucosa, bronchospasm, and increased bronchial
secretions. The narrowed airways increase the resistance to airflow and cause air
trapping, leading to hyperinflation. These narrowed airways provide an abnormal
distribution of ventilation to the alveoli. Even during periods of remission, some
degree of airway inflammation is present (Fig. 12.8).
Clinical Presentation
Clinical Course By the time adulthood is reached, many children with asthma
no longer have symptoms of the disease.19-21 When the onset of asthma
symptoms begins later in life, the clinical course is usually more progressive,
showing changes in pulmonary function tests even during periods of remission.
Airway remodeling in response to the chronic airway inflammation is thought to be
responsible for the progressive nature of the disease.