BRONCHIAL ASTHMA

It is a chronic inflammatory disorder of airways in

which many cellular elements lymphocyte,
neutrophil, mast cell, and macrophages are
involved .It results in exaggerated airway hyper
responsiveness which leads to reversible airway
obstruction and intermittent symptoms of Wheeze,
cough, SOB and tightness of chest.
Airflow limitation is due to
a. Bronchial smooth muscle constriction
b. Swelling of bronchial mucosa
c. Mucus plug
d. Airway remodeling

When exposed to allergen,At

mucosa
1. Immediate reaction allergen (Ag) bind with
IGE AB in the mast cell and eosiniphil and release
Leukotriene, Histamine, PG
Platelet activating factor.
.2. Late reaction Allergen activate the
Maccrophages, B lymphocytes,
CD4 Ly, Thymocyte, Eosinophil
All these cells release same mediators and IL4 & IL5

Effects of these mediators

1. Contraction of the smooth muscle
2. Increase in microvascular leakage secretions
increasess
3. Activate different neurones constricti
4. mucosal oedema
All these leads to bronchoconstriction
When this inflamation is chronic
1. Hypertrophy and hyperplasia of airway smooth
muscle
2. Increase in number of goblet cells

3. Enlargement of submucus glands

4. Activation of fibroblasts
5. Remodelling of airway connective tissue fibrosis
will lead to some componant of permanent
obstruction.
What is Hyperresponsiveness?- (Infamed airway)
Instability of the airways due to an exagerated
bronchoconstrictor response to endohenous +
Exogenous stimuli
Why? Due to air way inflammation. Once the airway
is inflamed lot of inflammation cells will be there
at mucosa for few weeks

Eg: Mast cells, Eosinophilia CD4 cells

Macrophages recurrited to mucosa
Secret
Mediators
*Cytokines, Interleukins
*Histamine, seratonin *PAF, Pro-GF
All these Stimulate smooth muscle directly
And Stimulate nerve
Rapid + Brisk airway constriction

Br. Asthma is common in Atopic people

10-30% people suffer from wheeze at one stage of their
life
Risk factors and triger factors for Asthma
1. Host factors: Genetic, Atopy, Gender, Hyperresponsiveness
Gender M>F (childhood) IgE, Race
2. Environmental
- In door allergens- mite, animal allergens, cockroach,
fungi, molds, yeasts, tobacco/ wood/ mosquito coil smok
Food
- Out door allergens Pollens, fungi, molds, yeast,
passive smooke

- Air pollution gases, fumes, dust

- 3.Respiratory tract infections=>
viral/bacterial/RSV/influenxa fungal infections,
parasitic
- 4.Socioeconomic
Developed > Developing countries
- 5.Family size few> large members
- 6. Drugs + diet NSAID, beta blockers, cocaine,
heroin IL2, Vinblastin, Dipridamole,
- 7.Obesity
More in BMI > Less MBI

8. Exercise + hyperventilation dry & cold air

9.Weather changes cold, high humidity
10.Sinusitis, nasal polyp, gastro eosophagal reflux
All triger factors will not cause symtoms in all pt
How to diagnose Bronchial Asthma
Symptoms for 2-3 weeks
1. Wheeze with or without difficulty in breathing
2. Chest tightness
3. Cough cough variant asthma
All these symptomes are worse at night , after exercise,
exposture to dust, allergen or other trigers.
These symtomes gets better with or without treatment.
4. H/o eczema/ rhinitis/ Hay fever in the past or family

2.Signs in Br. Asthma

May be normal
Tachypnoea,
wheeze(rhonchi) is the important sign.
Evidence of hyperinflation of lungImpaired cardiac + liver dullness
In severe cases
Cyanosis, drowsiness, difficult to talk, tachycardia,
use of accessory muscle, intercostal + subcostal
recession All evedence of repiratory distress

3.Investigations in a stable patient

1. Bedside test PEFR through PEFM
Highest of three value is taken
Effort dependent,
Affected by airway narrowing, respira Muscle weakness
Easily learned
Reduced In Asthma, COPD, tracheal / broncheal
obstruction
Expiratory muscle weakness
Poor effort
PEF variability: PEFR in the morning and evening
Usually morning dips

If the patient is having symptoms

1.Morning and evening PFR measurements to show the
variability > 20% atleast on 3occations or
PEFR before and after nebuliser with beta 2 agonist(15mt)
Demonstrate 15-20 % improvement in PFR
If the patient is not having the symptoms
PEFR before and after provocation
- physical exercise for 6 mts
- Pharmacological methacholin/ histamin
Demonstrate 15-20% decrement in PFR
2.FEVI/ VC Ratio with exercise or B2 agonist

3.Chest x ray
4.Full blood count
To find out eosinophilic conditions 5-7 % eosinophils
in asthmatics
In tropical pulmonary eosinophilia 10-70%
PAN, Eosinophilic vasculitis also high
5.ESR To detect any infections, vasculitis
6. Skin prick tests to detect allergens
Positive test just indicate the allery to particullary Ag
7. Diffusing capacity of the lung is normal

Differential Diagnosis
1.Tropical pulmonary Eosinophilia
Noct cough & wheeze
Eosinophil count > 3.000 cu mm3
Respond to Diethylcarbamazepine 100mg tds
for two weeks
2.COPD : Present with cough progressive SOB
Need exclusion in old + wheeze patients with
h/o smoking
FEV1 or FEV1/FVC or PER does not improve
Significantly with beta 2 agonist or short course of
steroids

3. Bronchiectasis
Cough with purrulent sputum
They can have bronchospasm
4. Gastro-oesophageal reflux
Mimic nocturnal asthma / or worse existing
asthma h/o hart burn, symptoms related to
posture
5. Upper airway obstruction
Inspiratory wheeze & stridor
6. Left ventricular failure / Pulmonary oedema
In old people need exclusion
Commonly they will have crepts but may have
wheeze alone

Classification of Asthma according to overall disease

severity ( in stable stage)
1. Mild Intermittent Asthma:
step 1 Rx
Brief exacerbations only
Asymptomatic between attacks
Daytime symptoms < once/week
Nocturnal symptoms twice / month
FEV1 or PEF > 80% predicted
PEF or FEV1 variability < 20%
highest Lowest reading * 100
PFR variability =
Highest PRF

2. Mild Persistant Asthma:

Step II Rx
Exacerbations may affect activity & sleep
Day time symptoms > once/week But < daily
Night symptoms > twice / month
FEV1 or PEF > 80% predicted
PEF or FEV1 variability 20 30%
3. Moderate Persistant Asthma:
Step III Rx
Daily symptoms (daily use of salbutamol inhaler)
Exacerbations afect activities & sleep
Nocturnal symptoms > once/week
FEV1 or PEF 60-80% predicted
PEF or FEV! Variability greater than 30%

4. Severe Persistant Asthma

Step IV
Continuous symptoms
Frequent exacerbations/frequent nebulization or
hospitalisations
Frequent nocturnal symptoms
Limitation of physical activities
FEV1 or PEF 60% of predicted
Variability > 30%
The patient should be considered to the most severe
grade in which any feature occurs
Eg: Noct sym 3 times/months
Day sym once / 2 weeks mild persistant

Primary prevention * Breast feeding

*Fish oil & Vit C in diet
*Avoidance of maternal and
paternal smoking during
pregnancy
Secondary Prevention:
1. Avoiding triger factors and optimum Rx
2. Regular physical activity
3. Weight reduction in obese
4. Early Rx of respiratory tract infection and gastro
oesophageal reflux,sinusitis.

Relievers
Preventors
Relieve acute symptoms
Prevent symptoms
1.2 adreno recepto
1. Corticosteroid
stimulant(short acting)
2. Cromoglycates
rapid action last 4h
mild acting
Symptoms controler
Long acting 2 agonist/long act theophillin
2. Theophyllines
3. Anti-muscarinic agents
- Ipratropium
Oxitropium
4. MgSO4

Other drugs
1. Ketotifen Non selective antihistamine with
mast cell stabilizing action. Useful in children
2. Leukotrien modifier -> Zileuton or receptor
antagonst Montelekast
Zafirlukast
( Bronchodilator + antiinflammatory)
Useful in aspirin induced and exercise induced
asthma

Goals of Rx
1. Good control of symptoms at all times
2. Maximize lung function
3. Identify triger factors
4. Minimize side effects of medication
5. Prevention of Exacerbations
Management targets
1. Assess the severity
2. Establish appropriate step Mx
3. Health education including inhaler technique
4. Maintaining good lung function
5. Plans for managing exacerbation
6. Providing regular follow up

Appropriate step management

1. Mild intermittent asthma - step 1
as needed short acting beta 2 agonist
Inhaler / oral
2. Mild persistant asthma - Step 2
as needed short acting beta 2 agonist and
low dose regular inhaled steroid
Beclamethasone 100-400 g bd
Budesonide 100 - 400g bd
Fluticazone 50 200 g bd
one of these

Moderate persistant Asthma: step III

As needed inhaled short acting beta 2 agonist
AND- Regular moderate dose of inhaled steroids
Beclamethazone 250-500g bd
Fluticazone 125 250 g bd
one of these
AND- Long acting beta 2 agonist salmeterol 50 g
bd regularly
can try slow release theophyllin inspite of long acting
beta 2 agonists
OR

As needed short acting beta 2 agonist +

AND High dose regular steroids
Beclamethasone 800 1000 g bd
Fluticazone 200 500 g bd

one of these

Severe persistant Asthma:

step 4
As needed short acting beta 2 agonist
AND
Regular high dose steroids
AND
Regular long acting beta 2 agonist salmeterole 50g bd
Or oral salmeterole / orl slow release theophyllin
If still symptomatic Step 5
With other drugs
add oral steroids morning dose 5-7.5 mg

When higher doses of inhaled steroids are prescribed

It should be prescribed with spacer
As the inhaled steroids take time (1-3/52) to show the
benefit. May need to give short course of oral
steroids for 2/52
Education on these aspects
1. What is asthma
2. What are the triger factors, how to prevent
3. Methods of inhaler medication
4. How to monitor asthma with PEFR
5. How to treat acute wheeze at home with first aid
6. Written action plan

Maintaining good lung function

Once it is controlled maintain the same Medication at least for
3-6/12
Monitor lung function with PFR/ FEV1/ VC
If good x 3/12
step down the treatment
Regular follow up care at clinic
1. Look at PEFR chart, also do at clinic
2. Examin inhaler technique and look for side effects of Rx
3. Check the compliance of Rx
4. Find new triger factors and whether they can recognise
exacerbation

Management of Acute Asthma

Initial
Assessment History brief
Physical examination rapidly
Treatment should be started immediately while the
initial assesement is going on
Once the patient is better detail history & examination
Acute asthma should be classified according to its
severity
This classification is important to decide whether
patient need treatment at outdoor or ward Rx or
ICU/EU

mild-moderate
1.Physical
No
Exhaustion

severe
+

lifethreatening
+ also have
paradoxical chest
movement
2. Talk
in sentense
in words
cant talk- agitated
3.Pulse rate
<120
>120
Bradyccardia BP
4.Pulsus para Not present
present
present
- doxus
5.Cyanosis
No
May +ve
present
6.Wheeze
+
+
silent chest
PEF/FEV1
>50%
<50%
cannot perform
SPO2
> 92%
<92%
very low
drowsy&confused
ABG To do not necessary Yes
Yes

Features

Acute severe
. Cant complete a sentense
. RR>= 25/mt
. Pulse >120

Life threatening
1. Cant talk
2. Cyanosed
3. silent chest with poor
respiratory effort
. PEF < 50% of predided
4. Hypotension,bradycardia
. Pulse paradoxus
5. Exhausted, confused
comatouse
Blood gas makers of life threatening Asthma
. PaO2 < 8kPa or 60 mmHg irrespective of O2 Rx
. Normal or high PaCO2 > 45 mmHg
. Low PH

In acute asthma they will have type I failure

PaO2
PaCO2
But
When they are having life threatening asthma they
will develop type II failure PaO2
But PaCO2

Management of Acute Asthma

1. Mild Acute Asthma
1. Rxed at OPD
2. Ventolin nebuliser 5mg stat
+
Oral prednisolone 30-60 mg stat 2/52 tailoff
Inhalers introduced or double the dose of
inhalers
Once PEFR > 70% D

Moderate acute Asthma

a. Rx at ward
b. O2 40-60% prop up
c. Salbutamole 5 mg nebuliser + 4 hourly
d. Oral prednisolone 30-60 mg and
e. If poor response do CXR
continue inhaler
PEFR > 70% D

Management of acute severe / life threatening asthma

1. Prop up, O2 via face mask (exclude COPD)
40 60%(connect pulse oxymeter)
2. Salbutamole 5 mg / Terbutaline 10 mg via O2
driven nebuliser
can repeat every 15 minutes 3-4 times if needed
3. If pt can take oral Prednisolone 30-60 mg stat
daily
If cannot take oral Hydrocortisone 200mg
stat 6 hrly

Insert IV canula and take blood for investigations

FBC, BU,SC,ESR,RBS
If Patient is not improving
do chest Xray pneumothorax
pneumonia
Monitor SPO2, pulse, RR,BP
If SPO2 92% ABG from femoral artery

*Not to give sedation*

Hydrate the patient
If Hypokalaemia treat it
If evidense of infection, give broad spectram of AB

If improving
Send to ward
Steroid inhaler
Regular ventolin
Nebuliser
+ oral steroid 2/52
PEFR > 70%
D
+ Plan

If not improving

ICU Mx
1. Ipratropium bromide
2 hourly 500 g + Salbutamol
Also try
a. Salbutamol 250 g
IV bolus infusion
5 g/kg
OR

2. IV Aminophylline 250 mg bolus

0.5 mg/kg/hr
OR
c. MgSO4 2 gm in 100ml N. saline in 20 mts
If deteriorating any life threatening
signs or low PaO2, high PcO2
(Repeat blood gas analysis)
Ventilate the patient if PCO2 high
or acidosis or low O2

Once they are improving

Regular salbutamole 5 mg 4 hrly nebuliser
+
Inhaled steroids appropriate for their severity
+
Oral steroids 30 mg daily x 2/52
+
Inhaled salbutamole sos
Once PEFR > 70%
Plan for D

1.
2.
3.
4.

Re-examin the inhaler technique

Advice about triger factors + disease
Advice to buy peak flow meter
Give written action plan
Know best PEF best/predicted eg: 500l/mt
If low 400 l/mt - double steroid
If low 300l/mt start oral steroids
If very low 200l/mt - need hospital admission
If acute exacerbation at home 10 puffs of
salbutamole through spacer + oral prednisolone 30
mg on stat
If mild attacks respond well

Tell about side effects of oral steroids

Advice to take inhalers regularly
Inhaled drug delivery devices:
Types Metered dose inhaler MDI
Dry powder inhaler
Nebuliser
MDI Delivers given dose of drug as aerosol
How Remove the cap, shake canister
Hold canister upright
Breath out until the end of normal breath
Keep the mouth piece into the mouth,
close lips tightly around

As you start to take a slow deep breath in through

the mouth sqeeze once to actuate (press canister)
Hold the breath for 10 seconds
Repeat the inhalations as needed
Wash mouth and gargle with water and spit out
15 20 % of the drug only deposits in the bronchial
system
Balance is wasted or deposit in the throat
Disadvantage
Need good cordination with hand + breathe

If large doses of steroid is prescribed

Prescribe with spacer
How
1. Select compatible MDI
2. Shake the MDI well & insert to the mouth piece
into socket of spacer

3. Hold the spacer mouth piece into mouth and close

lips tightly
4. Actuate the inhaler and breath in and out normally
through the mouth peice 3-4 times
repeat same if large dose is taken
Advantages with Spacer
1. Increases lung deposition of drug up to 30%
2. Cordination of actuation and breathing not
necessary
3. No need to have good breathing effort- tidal
breathing is enough

Who need spacer

1. People with difficulty in coordinating , old,
children < 5 yrs( with faces mask).
2. Who need steroid > 800 g Beclamethasone x 24
hours

Spacer should be cleaned once in 2-4 days

Washed with soap water, drip dried
Should not be wiped with other materials
Change every year

Dry powder inhalers

Release drug as powder in capsules or in blister
(dischaler)
Ex: Cyclohaler, D-P haler Dipihaler, Rota haler
Disk haler, Accuhaler and
Turbuhaler low inspiratory effort enough
(preloaded dry powder)
Deposition rate 20 30%
For optimum use of dry powder
1. Load the capsule or card and break it accordingly
2. Breathout until the end
3. Keep the mouth piece & close lips tightly
4. Breath in as fast as and as deep as possible

5. Hold breath for 10 seconds

6. Patient should not breathout through the mouth
piece of DPI
For most of these drypowder inhalers good inspiratory
effort is needed
Exceptions are Turbuhaler x accuhaler
While on Inhaler
Poor control of Asthma may be due to
1. Poor compliance 2. Improper technique
3. Inadequate dosage 4. Inappropriate Rx
5. Poor environmental control

Local side effects of steroids with inhaler

1. Oral candidiasis
2. Steroid induced pharyngeal myopathy voice change which is reversible

Asthma & Surgery

1. Life threatening bronchospasm can occur during and
after Sx and during anaesthesia.
specially if the asthma was poorly controlled at the time
of Sx
It is due to
Severe Bronchospasm occurs with intubation, induction
drugs, + maintenance drugs and extubation

2. So, careful pre-op control of symptom of asthma is important before

the elective surgery
3. Make sure, there was no lung infection
Or asthmatic exacerbation during last 2-3/52,
Do PEFR or FEV1 > 70% of predicted
If there was post pone Sx by 2-3 /52 x Rx it
Repeat PEFR or FEV1
4. Continue inhaled drugs until be the time and after Sx
5. If they are on systemic steroids continue it until Sx and give
parenteral steroid during Sx then ct oral.
6. Pre op give prednisolone 10mg noct, day before
ventolin nebuliser just before Sx
7.Continue the same RX after surgery on which she was on
before surgery.
8. If connot take inhaler or oral,- cover that time with paranteral steroid.

If possible do Sx under local

If GA do intubation + extubation under deep
anaesthesia
Post OP
1. Good pain control with Fentanyl / Pethedine
Dont give morphine
2. Avoid NSAID
3. Good Hydration

Drying
Cooling

Exercise induced Asthma

Exercise
Sympathetic Activity
1-2 mnt
Catacholamine

Mast cells
1 2 Hours

short act broncho

constriction
2-6mt
mediater destruction in 20 mt

Depleted mast cells

Dilate bronchi

constrict

1. Any one with poorly controled asthma can get

wheeze after exercise
2. In some people it occurs only after exercise
3. Symptoms starts 5-10 mts after stopping the Ex
Exercise:
During exercise both
Dilators + constriction together
So usually no symptoms
But * after exercise when catachalamine is
reduced wheeze

4. Once the released mediater is destroyed they will

be free of symptoms and there is a refractory
period( 2-6 hours) during which they will not
develop wheeze even if they exercise due to PG
which cause Bronchodilatation.
How to RX
1. Short acting beta 2 agonist just before exercise
OR
Na cromoglycate just before exercise
2. Long acting beta 2 agonist 2 hr before exercise
3. Warming up exercise within last 30 mts.

Brittle Asthma
Unusual variant, patients are at risk of sudden
severe unexpected acute attacks over minutes
hours
Emergency drugs should be with the patient all the
time , Nebuliser at home and work place and
Self injectable epinephrine Epi pens 0.3 0.5mg
pre loaded in syringe x 2 with patient.
Prednisolone 60 mg with patient
Medical alert brakelet

Pregnancy & Asthma

- 1/3 gets better
- 1/3 same
- 1/3 gets bad during pregnancy
Should be monitored carefuly
Severe asthmatics usually get worse
Non of the drugs including steroids are
contraindicated except leakotrine modifferes
Theophyllin may cause foetal tackycardia

Hypoxia during acute attacks of asthma cause

damage to mother & foetus then drugs so priority
is to control asthma
Optimum medication is given with inhaled steroids
and beta agonists long + short
Avoid oral salbutamol
Treatment is same like other patients
Even if they get acute attacks, Rx is as like others
patients with foetal monitoring + O2
They can continue same medication during
pregnancy & lactation
During Labour
All drugs continued

If they were on oral steroids > 7.5 mg/d need to give

hydrocortisone 6 hourly
No special indication for LSCS other than Obs indication
If anaesthesia is needed, local anaesthesia better specially if
they are symptomatic
Prostaglandin F2 alpha should be avided, if necessary used
with extreme caution.
Anaphylaxis
If Acute Bronchospasm is due to Anaphylaxis
Adrenalin 0.5 mg should be used instead of selective beta 2
agonists

Other drugs that could be used as steroid sparing

drugs in Asthma
1. Methotrixate
2. Cyclosporins
3. Gold
4. IV Immunoglobulin
5. Anti IgE monoclonal antibody Omalizumab

If you see a patient with Asthma with Acute

exacerbation
1. Find out what was the precipitatory factor this time
2. Find out the severity prior to this
* How many attacks
* Functional state dependant/nondepedant
* How often taking salbutamol
* How often absent from work / school
3. No. of hospital admission
Last admission
Any life threatening asthma- need of ventilation.

4. Other precipitating factor

5. allergy history, drug allergy, eczema, rhinitis
6. If already on medication
- compliance, side effcts of drugs Ex prednisol.
7. Drug compliance and technique of inhaler
8. Detail occupational history -

COPD

Chronic Obstructive Pulmonary Disease

Clinical syndromes that leads to destruction of lung
and irreversible airway obstruction
Airway obstruction is progressive and associated with
abnormal inflammatory response to noxious agents
Following conditions are included:
a. Mainly Emphysema and chronic bronchitis
usually both co- exist together
b. Other diseases
- bronchiectasis
- Cystic fibrosis
- Persistant chronic uncontrolled asthma
- Bronchiolitis obliterans

It is characterized by following
a. Inflammatory narrowing of respiratory
bronchioles
b. Proteolytic destruction of connective tissue of lung
c. Loss of alveolar surface area and vascular bed
d. Lung hyperinflation with loss of Elastic recoil
e. Increased vascular resistance
Risk Factors
1. Smoking active + passive proportionate to number
of cigarette, cigar, house-hold smoke
Increased with number of pack per year

2. Environmental factors
Air pollution
Occupational exposure to toxic gas
3. Genetic
1 Antitrypsin deficiency(proteolytic enzme inhibitor
4. Old age, F/H of COPD, Male sex
5. Low birth weight and recurrent childhood
infection or at infant stage
Emphysema Pathological defiition
Dilatation & Destruction of air spaces distal to the
terminal bronchole without obvious fibrosis

There is reduction of elastic recoil of lung

Collapse of airways in early Expiration Air
traping

expiration +ve p

Normal recoil
pressure

pleural
pressure

recoil pressure is less

Chronic bronchitis
Clinical Diagnosis
Def: Chronic cough and sputum production on most of the
days for at least 3 consecutive months of succesive 2 years
Here obstruction is due to narrowing of airways by mucosal
thickening excess mucus & structural narrowing
Exacerbations are due to
- Respiratory tract infection
- Bronchospasm
- Mucus plugging

Presentation
Chronic Bronchitis
Blue Bloated
Symptoms
Signs
* cough with
*cyanosis
sputum
* peripheral
oedema
* SOB usually
mild
* wheeze
+
cracles

Complications
* Iiry polycythe
* pul. HT
cor pulmonale
Ix: PO2
PCO2

Emphysema pink & puffing

Symptoms
SOB

signs
complications
Tachypnoeic
pneumothorax
Pink
weight loss
Cough
pursed lip breathing
mild
accessory muscle use
Cackectic
PO2
Barrel chest
PCO2 or
Breath sounds
Usually both components will be there together in
patients. Main symptoms and signs depends on the
predominant component

Ix:
1. Chest Xray
Laterl - Increased AP diameter.
Increased Retrosternal space.
PA - flat hemidiaphragm on PA.
Elongated Cardiac shadow.
prominent Pu A.
Reduced Peripheral marking .
When cor- pulmonalae Cardiomegaly with
prominent PA

2. PEFR very low not improved with Bronchodilators or

steroids x 2/52 30 mg oral daily
3. FEV1
VC
FEV1 / VC ratio

RV & TLC both are increased

FEV1/VC
5
VC
normal 4.5/5 = > 90%
4.5
3.5
VC of PT
2.5
1.5/3 = 50%
1.5
FEV1

COPD 1.5/3 = 50%

COPD Gold criteria with FEV1
1.mild - FEV1 > 80% variable SOB
2.moderate - FEV1= 50-70% SOB on mild exertion
3.Severe - FEV1= 30 49 % SOB ++
4. Very severe EFV1= < 30% limitd all activities

4. Flow volume Loop

Normal & early COPD

Late COPD

7l
Fl
Ow second
4.5l
recidual volume
Increased Recidual volume
PFR
75 50 25% of lung volume
In early COPD PEFR may be normal But rate at 50%,
25% of lung volume is very low
5.Diffusing capacity of lung is low but in early
Bronchitis may be normal

Management of COPD
Usually they present to us with exacerbations
infections or CCF
By the time when they present with SOB, their lung
function is badly affected
I. Etablish the diagnosis with history / Ix &
examinations
after 30 y, in normal people FEV1 decreases by
20 ml/year but in COPD 50 ml/year
II. Once diagnosis is made
1. Stop smokiong

2.7
FEV1

stoped smoking
contined to smoking

a. Set up a date for stoping

b. Make group discussion & councelling
c. If they are dependant nicotine patches
Nicotine chuingum

2. Rx of Exacerbations:Treatmetn is as like as exacerbation of bronchial Asthma

2.1 Prop up, monitor, SPO2, pulse, BP
If SPO2 < 85% - arterial blood gas analysis
2.2 O2- 24 28 % Just to maintain SaO2 88-90%
If we over treat with more O2 patient will develop CO2
Narcosis
2.3 Bronchodilators SALBUTAMOL / Terbutalin
& Anticholinergics (Iprotropium) 4 hourly
Although bronchodilatation is very minimal
*High in crosectional area
* in resistance to air flow
Helps Symptomatically (lung function not much improved)

2.4 IV cannula
- Take blood samples BU, Se, FBC, RBS
- Sputum DS
- Culture & ABST
- Do chest Xray, ECG.
- In young patients 1 Antitrypsin level
2.5 Give IV Hydrocortisone 200 mg / 6 hourly or
oral prednisolone to reduce mucosal oedema
2.6 If still symptomatic
Aminophyllin 250mg bolus followed with
infusion

Aminophillin act as
-Resp. stimulant, Bronchodilator,mild diuretic
& mild positive Ionotrope
2.7 If poor response Try with Doxopram
(Resp.stimulant)
2.8 If precipitant is infection start broad spectrum
antibiotics Ampicillin / Cefuroxine
Need to repeat arterial Blood gas after 1-2hours
2.9 If arterial blood gas shows severe hypoxia
PO2 < 55 mm Hg
PCO2 > 55 mm Hg
pH < 7.26(acidosis)

If the patients living status prior to this acute problem is OK.

(at least the patient was able to look after themselves)
ET tube & Ventilation Artificial
Ventilation
Noninvasive with continuous positive
airway pressure is prefered
-No ET tube
- tightly fitting Mask that covers the nose
or
nose and mouth, is used
Invasive ET tube with + ve pressure ventilation
Clinical judgement is very important before ventilation
Rationalae for ventilation giving time for the acute
problem to settle, so the pt can get back to previous stage

3. Once the patient is recovered follow up

3.1 Regular bronchodilators
inhaled salbutamol 200 microgram 6 hourly
MILD (FEV1 > 80%)
or
COPD
Salmeterole 50 microgram bd
AND
MODERATE Anticholinergic
FEV1 50-70 % Ipratropium Bromide 40micro.g6hly
Oral slow release theophyllin 150-250 mg Bd

 SEVERE COPD PFR < 50%, FEV1< 30%

Together with other Rx
Optional Inhaled steroids- with spacer higher
dose only in severe cases. Ex
If there is improvement in FEV1 / PEFR
After Rx with oral prednisolone 30-60 mg/daily for 2
weeks
Very SEVERE COPD FEV1, PEFR < 30%
Add Oral steroid 5- 7.5 mg daily together
3.2 Mucolytics- if difficult to cough out sputum
3.3 If Right heart failure due to cor-Pulmonalae
Diuretics, ACEI, Digoxin, theophyllin

3.4
3.5
3.6
3.7

Avoid Sedatives
Good nutrition, Calori intake
Regular limb exercise
Regular vaccination Pneumococcus
Haemophilus
Influenza virus
3.8 Home O2 treatment
3.9 Surgical options
3.10 If treatable eg: Antitrypsin replace it
3.11 Cor-pulmonalae with polycythemia regular
venesection

Home O2 Rx (Domicilliary O2)

Indicationsshould not smoke at present(COHb <3%)
PaO2 < 55 mm Hg
When the patient is
PaCO2 > 38 mm Hg
stable after 6/52
Previous Corpulmonalae
of Exacerbation
FEV1 < 1.5 L
O2 could be delivered with O2 concentrator or O2
cylinders
It is given for 15 hours / day
Given through nasal catheter

Step Rx in COPD
Lung reducing surgery

FEV1

Home O2
Pulmonary rehabilitation
combination of

steroid inhaler

long act beta 2 agonist

long acting theophyllin

Symptoms

combination of Ipratropium inhalar with

beta2 agonist

Long acting bronchodilator regularly

short acting bronchodilators

vaccination
Stop smoking
Regular lung function

The rate of O2 should be titrated at hospital usually

1.5 2 L / mt
When they are going out they could be given with O2
cylinder on wheel
*If they have severe hypoxia at night CPAP with mask
continuous positive airway pressure
(Durig REM sleep all muscles are relaxedmore weak)
Surgical Options:
1. Bullectomy
2. Lung reduction surgery
3. Single Lung transplantation

Complications of COPD
1. Low effort tolerance
2. Type II respiratory failure
- Hypoxia
- High CO2
3. Pulmonary hypertension loud P2
4. Right heart failure cor pulmonalae
5. Polycythemia
6. Severe hypoxic cachexia
Cor pulmonalae Heart disease2ry to disease of Lung

Bronchiectasis

Bronchiectasis

Destructive lung disease associated with

chronic localised dilatation of bronchi
persistant but variable inflamation of the lung
Should suspect, when there is chronic productive
cough
Pathollogy: any part of lung is affected, commonly lower lobes
Dilatation of the bronchi
Ulceration of the Mucosa
Squamous metaplasia
Inflammatory infiltration & excess
Mucus secretion due to high Goblet cells

Conditions associated with bronchiectasis

1. Host defects
a. Immunodeficiency IgG , IgM
abnormal phagocytic function
Reduced complement levels
Leucocyte adhereace defect
b. Mucociliary clearance defect
Immotile cilia syndrome
Young syndrome, cystic fibrosis
Katageners syndrome

2. After infection: -Aspiration pneumonia

or TB, Measles, whooping cough, poorly
treated pneumonia, septic emboli, HIV, Allergic
aspergilosis
3. Post Inflammatory aspiration, neurological
weakness-achalasia
Gastric reflex aspiration
IV heroin, Rheumatoid arthritis
Fibrosing alveolitis
4. Others: 1, Antitrypsin deficiency
Yellow nail syndrome
5. 2ry to obstruction by LN, adenoma, Foreign body

Clinical features
Usually present with acute exacerbations,
Chronic cough with purulent sputum,fever
Haemoptysis with pleuritic chest pain
Sputum production is continuous or intermitent
Sputum production, cough is changed with position
H/O post nasal drip, infertility, chronic ear discharge
Chronic sisusitis& frequent chest infections
H/O - HIV, RA, Reflux disease
F/H cystic fibrosis
p/h TB, pneumonia

Exacerbation
1. Large amount of sputum production
2. Fever and worsening cough
3. Change is colour of sputum
O/E
Clubbing + Halitosis
Coarse crepts & rhonchi
Signs of consolidation

Investigations:
1. Chest Xray: Tram line shadow
Cystic shadow
Areas of minor collapse
and fibrotic changes
2. Sputum examination is necessary during
excerbation: Direct smear, culture, ABST &
fungal study
3.FBC high N
4.ESR - High

3. High resolution CT Chest Non invasive

Diagnostic investigation
Demonstrate the dilated bronchi & distribution
4. Bronchogram
1. Invasive
2. But confirm the diagnosis
5. Lung function test
To asses the lung damage & degree of obstruction
- Spirometry
- flow volume loop

6. To find out underlying cause for bronchiectasis

1. Xray sinus
2. Aspergilus test
3. BA swallow
4. IgG, IgM complement
level
5.Cilliary function, Neutrophil function test,
sweat Na+, 1 antitrypsin level
Management
When they come with acute exacerbation
General 1.Bronchodilator inhaled beta 2 agonist

2. chest physiotherapy postural drinage(Important

- 3. Mucolytic agents
- 4. O2 If needed

2. Antibiotics If not very ill

short courses of
Amox 500 mg tds/cotrim 2 bd
Or erythromycin 500 mg 6h / cephalexin 500 mg
10 14 days
If severe infection
IV 2nd or 3rd generation cephalosporin
or Augmentin
If sputum is offensive Metronidazole is added
Once sputum culture, ABSt is available change
accordingly

Follow up Rx
Very important
1. Continue chest physio regularly Bd at home
2. Ct Bronchodilators,
3. Good nutritionVitamin A & D
4. If cor pulmonalae diuretics
5. If needed Antibiotic prophylaxix / Rx
< 2/52

every 2/12

continuous purulent sputum

Give antibiotic Rx
frequent excerbation Amox 3g Bd
Only for Exacerbation Rx Exacerbation
Rx with high dose antibiotics
Prophylaxix
Continuous Rx
Amox 500mg D
500 mg tds
Cotrim 960mg D
If pseudomonas ceftazidine or Cipro.
or Inhaled antibiotics

5. If needed Antibiotic prophylaxix / Rx

Over 2 months disability
< 2/52

> 2/52

continuous purulent sputum

SOS Rx
Prophylaxic Rx
Continuous Rx
Give antibiotic Rx
frequent excerbation Amox 3g Bd
Only for Exacerbation Rx Exacerbation
Rx with high dose
antibiotics
Prophylaxix
Continuous Rx
Amox 500mg D
500 mg tds
Cotrim 960mg D
If pseudomonas
ceftazidine or Cipro.
or Inhaled antibiotics

6. Surgical Rx
If Bronchiectasis is Localised - lobectomy
7. Steroids may be useful in some patients-Optional
Complications:
1. Pneumonia
2. Pneumothorax
3. Empyema
4. Metastatic abscess, Amyloidosis

1. Severe life threatening haemoptysis usually from

bronchial artery
- Rest
- Antibiotics
- Blood transfusion
If still not improved Embolise, surgical
resection