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Blue

Bloaters
And

Pink
Puffers

Dr Ng Kian Seng
IMU Kluang
2014

Blue
Bloaters
And
Pink
Puffers

Pink Puffers & Blue Bloaters

Pink Puffers
Emphysema

Blue Bloaters
Chronic Bronchitis

Low paO2>Cyanosis
=Blue
Retention Of Fluid
=Bloater

PaO2 Maintained
At Normal Levels
=Pink
Hyperventilate
=Puffer

Chronic
obstructive
pulmonary
disease
(COPD)

Chronic obstructive pulmonary disease (COPD) is


characterized by *airflow
limitation that is usually progressive and associated with an
*enhanced chronic
inflammatory response in the airways and the lung to noxious
particles or
gases.

Chronic
Bronchitis

Emphysema

Asthma

Chronic bronchitis is defined as a chronic productive cough


for three months in each of two successive years in a patient
in whom other causes of chronic cough (eg, bronchiectasis)
have been excluded . It may precede or follow development
of airflow limitation.

Emphysema is defined by abnormal and permanent


enlargement of the airspaces distal to the terminal
bronchioles that is accompanied by destruction of the
airspace walls, without obvious fibrosis

Asthma is a chronic inflammatory disorder of the airways in which many cells


and cellular elements play a role. The chronic inflammation is associated
with airway responsiveness that leads to recurrent episodes of wheezing,
breathlessness, chest tightness, and coughing, particularly at night or in the
early morning. These episodes are usually associated with widespread, but
variable, airflow obstruction within the lung that is often reversible either
spontaneously or with treatment.

Venn
Diagram
In
COPD

Venn Diagram In COPD


These Conditions Are Not
COPD

1,2,11 Persons with chronic bronchitis or


emphysema without airflow obstruction
are not classified as having COPD.
9 Patients with asthma whose
airflow
obstruction is completely
reversible
are not considered to have COPD
10 Patients with airway obstruction due
to diseases with known etiology or
specific pathology, such as cystic fibrosis
or obliterative bronchiolitis (10), are not
included in the definition of COPD.
Gray: The subsets defined as COPD
are shaded gray.

Venn Diagram In COPD

These Conditions Are


COPD

6, 7, 8. In many cases it is virtually


impossible to differentiate patients
with asthma whose airflow
obstruction does not remit
completely from persons with
chronic bronchitis and emphysema
who have partially reversible airflow
obstruction with airway hyperreactivity.
Thus, patients with unremitting
asthma are classified as
having COPD

Venn Diagram In COPD

These Conditions Are


COPD

5 Chronic bronchitis and emphysema


with airflow obstruction usually occur
together (5).

3, 4. Chronic Bronchitis & Emphysema with


Airflow Obstruction, COPD

8 Some patients may have


asthma
associated with these two
disorders
(8).
6 Individuals with asthma
exposed to
chronic irritation, as from
cigarette
smoke, may develop chronic
productive cough, a feature of
chronic bronchitis (6). Such
patients
are often referred to as having
asthmatic bronchitis or the
asthmatic form of COPD.

Ottawa
COPD
Risk
Scale

COPD Risk Scale

Clinical characteristics associated with adverse events in


patients with exacerbation of chronic obstructive
pulmonary disease: a prospective cohort study, Ian G.
Stiell MD MSc, February 18 2014

Schematic representation of the chief prognostic dimensions


in COPD. Airflow limitation is one of the mechanisms with the
greatest influence on survival. This central mechanism is
surrounded by various disease components that have
prognostic implications, many of which are interrelated.
Inflammation, both local and systemic, may be the pathogenic
substrate that links these different dimensions. PHT indicates
pulmonary hypertension

Cigarettes & COPD

Calculate the number of pack years smoked


(packs of cigarettes per day multiplied by
the number of years), as the majority (80 %)
of patients with COPD have a history of
cigarette smoking .

Ardi Rizal, a 2 yo Indonesian boy


who
developed a 2-pack-a-day cigarette
habit.

Smoking less than 10 to 15 pack


years of
cigarettes is unlikely to result in
COPD.
On the other hand, the single best
variable
for predicting which adults will have
airflow
obstruction on spirometry is a
history of
more than 40 pack years of
smoking .

Risk Factors In COPD

Cigarette smoking
Most important risk factor. It causes
90% of cases of COPD. Elicits an
inflammatory response and causes
cilia dysfunction and oxidative injury.
Advanced age
The effect of age may be related to a
longer period of cigarette smoking as
well as the normal age-related loss o
FEV1.
Genetic factors
Airway responsiveness to inhaled
insults depends on genetic factors.
Alpha-1 antitrypsin deficiency is a
genetic disorder, mostly encountered
in Northern Europeans, which causes
panacinar emphysema in lower lobes
in young people.

Modes of Presentation
Relatively Asymptomatic

Classic Triad of Cough,


Dyspnoea
& Copious Sputum
Production
COPD Sucks The Breath Out
of
Their mornings
Background of Triad +Episodes of
increased cough, Purulent Sputum,
Dyspnoea (Wheeze) + Fever

This Is The Day I Long For

Spirometry

Spirometry is the first test for diagnosis of COPD and for monitoring disease
progress. Patients with COPD have a distinctive pattern seen on spirometry,
with a reduced FEV1 and FEV1/FVC ratio. The presence of airflow limitation
is defined by the Global Initiative for Chronic Obstructive Lung Disease
(GOLD) criteria as a post-bronchodilator FEV1/FVC <0.70.

Stage I (mild): FEV180% or greater of predicted


Stage II (moderate): FEV150-79% of predicted
Stage III (severe): FEV130-49% of predicted
Stage IV (very severe): FEV1less than 30% of predicted
or FEV1less than 50% and chronic respiratory failure

7 radiological
features
of
COPD

7 radiological features of COPD


1 Dark lung fields.
2 Low set diaphragm in
11th or 12th posterior rib.
3 Heart is vertical & narrow.
This is the result of
downward push of
diaphragm by lungs.
4 Flattened diaphragms
in lateral chest.
5 Infra cardiac air: Left
diaphragm is seen in
its entirety.
6 Retrosternal air is
increased.
7 Increased AP diameter.

*Lungs are large and hyper inflated.


*Signs of hyperinflation are:
Low set diaphragm
Flat diaphragm best determined
by lateral chest
Hyper lucent lung fields
Increased AP diameter
Increased retrosternal air
Vertical heart
*Signs of hyperinflation can be
seen in emphysema, chronic
bronchitis and asthma.
We can call it emphysema only
when hyperinflation is associated
with blebs and paucity of
vascular markings in the outer
third of the film.

Lateral chest is best to


evaluate flattening of
diaphragm, AP diameter
and retrosternal air.
This lateral chest shows:
Increased AP diameter
Low set flat diaphragms
Hyper lucent lung fields
Increased retrosternal air
encroaching on heart density
Multiple blebs: Avascular zones
surrounded by thin wall

Schamroths Sign In COLD

Isoelectric P wave in lead I combined with a very small QRS complex


< 1.5 mm total deflection and a T wave of less than 0.5 mm in lead I.