Chronic Obstructive Pulmonary Disease (COPD)

Chronic obstructive pulmonary disease (COPD) is a lung disease characterized by progressive, largely irreversible airflow obstruction. The condition usually presents in middle-aged or elderly persons with a history of cigarette smoking. Symptoms include progressive dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea and chronic cough. Prolonged expiration, wheezing Wheezing Wheezing is an abnormal breath sound characterized by a whistling noise that can be relatively high-pitched and shrill (more common) or coarse. Wheezing is produced by the movement of air through narrowed or compressed small (intrathoracic) airways. Wheezing, and/or diminished breath sounds may be noted on physical exam. The diagnosis is confirmed with a pulmonary function test. Management includes smoking cessation, pulmonary rehabilitation, and pharmacotherapy.

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Overview

Definition

Chronic obstructive pulmonary disease (COPD) is a lung disease characterized by airflow limitation resulting from airway disease and/or parenchymal destruction.

Types

The subtypes may have differing presentations and response to therapy. Patients may have any combination of both.

  • Chronic bronchitis: 
    • Clinically defined
    • Productive cough > 3 months per year for at least 2 consecutive years 
    • Must be in the absence of other causes of chronic cough
  • Emphysema: 
    • Pathologically or radiologically defined 
    • Destruction and permanent dilation of alveolar sacs

Epidemiology

  • Worldwide: 
    • Prevalence: 11.7% (expected to rise)
    • Annual deaths: 3 million 
    • 4th leading cause of death (soon to be 3rd)
  • In the United States:
    • Prevalence: 16 million people
    • Annual deaths: > 140,000
    • 3rd leading cause of death
  • Age:
    • Prevalence peaks around 50–60 years of age 
    • Age of onset is lower for heavy smokers.
  • Sex:
    • More prevalent in men
    • Rates in women are rising.
    • Mortality rate equal among men and women

Etiology

  • Cigarette smoking (90% of cases)
  • 2nd- hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand smoke
  • Air pollution 
  • Occupational exposure to toxins 
  • Alpha-1 antitrypsin (AAT) deficiency Alpha-1 Antitrypsin (AAT) Deficiency Alpha-1 antitrypsin deficiency is a genetic disorder caused by inherited genetic mutations of the SERPINA1 gene, causing the defective production of the protease inhibitor alpha-1 antitrypsin (AAT). These mutations can lead to deficiency of the enzyme causing lung disease, production of an abnormal form of the enzyme leading to liver dysfunction, or both. Alpha-1 Antitrypsin (AAT) Deficiency

Risk factors

  • Premature birth
  • Low body weight
  • Lower socioeconomic status
  • Poor nutrition
  • Childhood respiratory disorders
  • Preexisting airway reactivity

Pathophysiology

Chronic bronchitis

Inhaled agents cause chronic inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation in the airways, which lead to progressive airway obstruction Airway obstruction Airway obstruction is a partial or complete blockage of the airways that impedes airflow. An airway obstruction can be classified as upper, central, or lower depending on location. Lower airway obstruction (LAO) is usually a manifestation of chronic disease, such as asthma or chronic obstructive pulmonary disease (COPD). Airway Obstruction through:

  • Damage to endothelial cells → ↓ mucocilliary clearance
  • Mucous gland hyperplasia → mucous hypersecretion and plugging
  • Airway edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema and smooth muscle hyperplasia → luminal narrowing
  • Peribronchial fibrosis → bronchial distortion
Chronic bronchitis pathophysiology

Chronic bronchitis pathophysiology:
Inflammation, smooth muscle hypertrophy, and excess mucus production lead to progressive airway obstruction Airway obstruction Airway obstruction is a partial or complete blockage of the airways that impedes airflow. An airway obstruction can be classified as upper, central, or lower depending on location. Lower airway obstruction (LAO) is usually a manifestation of chronic disease, such as asthma or chronic obstructive pulmonary disease (COPD). Airway Obstruction.

Image by Lecturio.

Emphysema

In normal lungs Lungs Lungs are the main organs of the respiratory system. Lungs are paired viscera located in the thoracic cavity and are composed of spongy tissue. The primary function of the lungs is to oxygenate blood and eliminate CO2. Lungs, there is a balance between:

  • Proteases → break down elastin and connective tissue Connective tissue Connective tissues originate from embryonic mesenchyme and are present throughout the body except inside the brain and spinal cord. The main function of connective tissues is to provide structural support to organs. Connective tissues consist of cells and an extracellular matrix. Connective Tissue as part of normal tissue repair:
    • Neutrophil elastase
    • Matrix metalloproteinase (MMP)
    • Cathepsins
  • Antiproteases → balance protease activity:
    • AAT
    • Secretory leukoprotease inhibitor derived from airway epithelium Epithelium The epithelium is a complex of specialized cellular organizations arranged into sheets and lining cavities and covering the surfaces of the body. The cells exhibit polarity, having an apical and a basal pole. Structures important for the epithelial integrity and function involve the basement membrane, the semipermeable sheet on which the cells rest, and interdigitations, as well as cellular junctions. Surface Epithelium
    • Elafin
    • MMP tissue inhibitor

In emphysema:

  • Inflammatory response → activated neutrophils release proteases
  • Protease activity exceeds antiprotease activity → tissue destruction
  • Alveolar destruction leads to:
    • Enlarged alveoli
    • ↓ Elastic recoil
    • ↑ Compliance
  • Consequences:
    • Airway closure during expiration → obstruction
    • Air trapping → lung hyperinflation

Morphologic patterns:

  • Centriacinar emphysema (associated with cigarette smoking):
    • Destruction of the respiratory bronchioles and a central portion of the acini
    • More severe in the apical lung fields
  • Panacinar emphysema (associated with AAT deficiency):
    • Destruction of all parts of the acinus
    • More severe in the basal lung fields

Effects of the pulmonary vasculature

  • Tissue destruction → ↓ ability to oxygenate blood
  • Hypoxemia → vasoconstriction in small pulmonary arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries → ↑ vascular resistance
  • Chronic hypoxemia → vascular remodeling → irreversible pulmonary hypertension Pulmonary Hypertension Pulmonary hypertension (PH) or pulmonary arterial hypertension (PAH) is characterized by elevated pulmonary arterial pressure, which can lead to chronic progressive right heart failure. Pulmonary hypertension is grouped into 5 categories based on etiology, which include primary PAH, and PH due to cardiac disease, lung or hypoxic disease, chronic thromboembolic disease, and multifactorial or unclear etiologies. Pulmonary Hypertension

Clinical Presentation

Symptoms

Patients suffer from chronic, progressive symptoms with acute exacerbations.

General:

  • Progressive dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea (particularly with exertion)
  • Chronic cough
  • Sputum production
  • Chest tightness
  • Weight gain or loss
  • Fatigue

Acute exacerbation:

  • Worsening dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea
  • Increased cough 
  • Purulent sputum production
  • Wheezing
  • Fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever may or may not be present.

Physical examination

When examining a patient with possible COPD, look for the following findings:

Vitals:

  • Tachypnea
  • Hypoxia

General:

  • Muscle wasting
  • Barrel chest: increased anteroposterior chest wall Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. Chest Wall diameter from hyperinflation

Pulmonary:

  • Visual:
    • Respiratory distress (acute exacerbations)
    • Accessory muscle use
    • Pursed lip breathing
  • Auscultation:
    • Prolonged expiration
    • Wheezing
    • Diminished breath sounds
  • Palpation and percussion:
    • Hyperresonance on percussion
    • Reduced chest wall Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. Chest Wall expansion

Extremities:

  • Digital clubbing
  • Cyanosis

Findings suggestive of cor pulmonale Cor Pulmonale Cor pulmonale is right ventricular (RV) dysfunction caused by lung disease that results in pulmonary artery hypertension. The most common cause of cor pulmonale is chronic obstructive pulmonary disease. Dyspnea is the usual presenting symptom. Cor Pulmonale:

  • Jugular venous distension
  • Peripheral edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema

Clinical phenotypes

Signs and symptoms are associated more frequently with either chronic bronchitis or emphysema. However, patients often present with a mixture of features.

Chronic bronchitis (“blue bloater”):

  • Patients are generally overweight.
  • Frequent, productive cough
  • Peripheral edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema
  • Cyanosis

Emphysema (“pink puffer”):

  • Patients are generally thin.
  • Barrel chest
  • Infrequent cough
  • Pursed lip breathing
  • Accessory muscle use
  • Tripod positioning
  • Hyperresonant chest

Diagnosis

Pulmonary function tests

Pulmonary function tests are used to confirm COPD diagnosis. Testing is indicative of obstruction, which is largely irreversible.

Spirometry:

  • ↓ Forced expiratory volume in 1 second (FEV1): maximum volume of air forcefully expired 1 second after maximal inspiration
  • ↓ Forced vital capacity (FVC): maximum volume of air forcefully expired after maximal inspiration
  • Greater loss of FEV1 than FVC → ↓ FEV1/FVC ratio:
    • FEV1/FVC: < 70%
    • FEV1/FVC: < 50% indicates severe disease.
  • ↑ Residual volume and total lung capacity (air trapping)
  • Emphysema:
    • ↓ Diffusing capacity for CO: 
      • Also known as transfer factor
      • Due to loss of surface area for gas exchange Gas exchange Human cells are primarily reliant on aerobic metabolism. The respiratory system is involved in pulmonary ventilation and external respiration, while the circulatory system is responsible for transport and internal respiration. Pulmonary ventilation (breathing) represents movement of air into and out of the lungs. External respiration, or gas exchange, is represented by the O2 and CO2 exchange between the lungs and the blood. Gas Exchange
    • Rapid fall in expiratory flow (dynamic airway collapse) → produces a concave pattern

Post-bronchodilator test: 

  • Used to assess the reversibility of the obstructive condition
  • Minimal reversibility in COPD
Flow-volume-curve-in-obstructive-lung-disease emphysema

Flow-volume curve in obstructive lung disease:
Both flows are reduced due to obstruction; dynamic airway collapse causes a rapid fall in expiratory flow, which leads to a concave contour.

Image by Lecturio.

Staging Staging Cancer is the 2nd leading cause of death in the US after cardiovascular disease. Many malignancies are treatable or curable, but some may recur. Thus, all malignancies must be assigned a grade and stage in order to guide management and determine prognosis. Grading, Staging, and Metastasis

In addition to COPD diagnosis, spirometry results may be used in conjunction with symptoms to help stage severity. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria are as follows:

Table: The Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria
GOLD class Severity of COPD Symptoms Spirometry results
GOLD I Mild None or mild
  • FEV1: ≥ 80%
  • FEV1/FVC: < 70%
GOLD II Moderate On exertion
  • FEV1: 50%–79%
  • FEV1/FVC: < 70%
GOLD III Severe On minimal exertion
  • FEV1: 30%–49%
  • FEV1/FVC: < 70%
GOLD IV Very severe At rest
  • FEV1: < 30%
  • FEV1/FVC: < 70%
FEV1: forced expiratory volume in 1 second
FVC: forced vital capacity

Supporting evaluation

Laboratory studies:

  • Arterial blood gas (ABG):
    • Hypoxemia:
      • Progressive
      • Often worse during acute exacerbation
    • Hypercapnia:
      • Develops as FEV1 falls
      • pH is usually near normal due to renal compensation (↑ serum HCO3)
  • ↑ BNP in cor pulmonale Cor Pulmonale Cor pulmonale is right ventricular (RV) dysfunction caused by lung disease that results in pulmonary artery hypertension. The most common cause of cor pulmonale is chronic obstructive pulmonary disease. Dyspnea is the usual presenting symptom. Cor Pulmonale
  • AAT testing: Consider if COPD symptoms are present (not in typical demographic):
    • Younger
    • Nonsmoker
    • Concomitant, unexplained liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver disease

Chest X-ray:

  • Barrel-shaped chest 
  • Wide intercostal spaces
  • Horizontal ribs 
  • Flattened, low diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm 
  • Hyperlucency
  • Attenuated peripheral vascular markings (due to parenchymal destruction)

Management and Complications

Principles

  • Improve symptoms.
  • Decrease exacerbations.
  • Improve patient function.
  • Improve quality of life.

General management

  • Smoking cessation (critical in slowing lung function decline)
  • Vaccinations for:
    • Pneumococcal pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia
    • Influenza Influenza Influenza viruses are members of the Orthomyxoviridae family and the causative organisms of influenza, a highly contagious febrile respiratory disease. There are 3 primary influenza viruses (A, B, and C) and various subtypes, which are classified based on their virulent surface antigens, hemagglutinin (HA) and neuraminidase (NA). Influenza typically presents with a fever, myalgia, headache, and symptoms of an upper respiratory infection. Influenza Viruses/Influenza
  • Pulmonary rehabilitation:
    • Guided exercise and behavioral interventions
    • Goal is to improve functional capacity.
  • O2 therapy:
    • If O2 saturation is < 88% in a stable patient (PO₂ < 55 mm Hg)
    • If concurrent pulmonary hypertension Pulmonary Hypertension Pulmonary hypertension (PH) or pulmonary arterial hypertension (PAH) is characterized by elevated pulmonary arterial pressure, which can lead to chronic progressive right heart failure. Pulmonary hypertension is grouped into 5 categories based on etiology, which include primary PAH, and PH due to cardiac disease, lung or hypoxic disease, chronic thromboembolic disease, and multifactorial or unclear etiologies. Pulmonary Hypertension, right-sided heart failure, or polycythemia

Medical therapy

  • Bronchodilators: 
    • Short acting (used as needed for rescue):
      • Beta-2 adrenergic agonists (e.g., albuterol)
      • Anticholinergics (e.g., ipratropium bromide)
    • Long acting:
      • Beta-2 adrenergic agonists (e.g., salmeterol, formoterol, indacaterol)
      • Anticholinergics (e.g., tiotropium, aclidinium, umeclidinium)
  • Phosphodiesterase-4 inhibitors: 
    • Option: roflumilast
    • Reduces inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation
    • Can increase FEV1 and reduce exacerbations
  • Inhaled corticosteroids: 
    • Options: budesonide, fluticasone
    • Can produce both marginal improvements and adverse effects
  • Theophylline (oral bronchodilator)
  • Mucolytics

Surgical intervention

Surgery is reserved for severe cases not controlled with medical therapy to improve quality of life.

  • Bullectomy: removal of giant bullae to relieve local compression
  • Lung volume reduction: resection of the most diseased parts of the lung to decrease hyperinflation
  • Lung transplant: indicated in end-stage lung disease

Management of acute exacerbations

  • Outpatient or inpatient therapy depending upon severity
  • Short-acting bronchodilators:
    • Scheduled every 4–6 hours
    • Continuous nebulization may be needed for severe bronchospasm.
  • Systemic steroids
  • Antibiotics are indicated for:
    • Purulent sputum
    • Evidence of pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia
    • Patients requiring hospitalization
  • Controlled O2 therapy for acute respiratory failure Respiratory failure Respiratory failure is a syndrome that develops when the respiratory system is unable to maintain oxygenation and/or ventilation. Respiratory failure may be acute or chronic and is classified as hypoxemic, hypercapnic, or a combination of the two. Respiratory Failure:
    • Nasal cannula
    • Noninvasive ventilation:
      • Hypercapnia and hypoxemia
      • Significant effort to breathe
    • Invasive ventilation:
      • Severe respiratory failure Respiratory failure Respiratory failure is a syndrome that develops when the respiratory system is unable to maintain oxygenation and/or ventilation. Respiratory failure may be acute or chronic and is classified as hypoxemic, hypercapnic, or a combination of the two. Respiratory Failure
      • May be difficult to wean patients with severe COPD

Complications

  • Respiratory failure
  • Respiratory infections ( pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia)
  • Pulmonary hypertension → cor pulmonale Cor Pulmonale Cor pulmonale is right ventricular (RV) dysfunction caused by lung disease that results in pulmonary artery hypertension. The most common cause of cor pulmonale is chronic obstructive pulmonary disease. Dyspnea is the usual presenting symptom. Cor Pulmonale
  • Long-term complications of steroids → osteoporosis Osteoporosis Osteoporosis refers to a decrease in bone mass and density leading to an increased number of fractures. There are 2 forms of osteoporosis: primary, which is commonly postmenopausal or senile; and secondary, which is a manifestation of immobilization, underlying medical disorders, or long-term use of certain medications. Osteoporosis
  • Weight loss or cachexia
  • Bullae rupture → secondary spontaneous pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax
Chest/abdomen x-ray showing right pneumothorax chronic obstructive pulmonary disease (copd)

X-ray showing a right-sided pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax in a patient with chronic obstructive pulmonary disease (COPD):
Pneumoperitoneum (arrow points to air under the diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm) is noted due to a diaphragmatic defect, which allows air from the pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax to escape into the abdominal cavity.

Image:“Chest/abdomen X-ray showing right pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax and also air under diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm suggesting perforated viscus Perforated Viscus Perforated viscus or GI perforation represents a condition in which the integrity of the GI wall is lost with subsequent leakage of enteric contents into the peritoneal cavity, resulting in peritonitis. The causes of perforated viscus include trauma, bowel ischemia, infections, or ulcerative conditions, all of which ultimately lead to a full-thickness disruption of the intestinal wall. Perforated Viscus.” by Fernanda Duarte et al. License: CC BY 4.0

Differential Diagnosis

  • Asthma: a chronic, inflammatory condition characterized by reversible airflow obstruction in the lower airways. Patients present with intermittent or persistent wheezing Wheezing Wheezing is an abnormal breath sound characterized by a whistling noise that can be relatively high-pitched and shrill (more common) or coarse. Wheezing is produced by the movement of air through narrowed or compressed small (intrathoracic) airways. Wheezing, cough, and dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea. Diagnosis is usually confirmed with a pulmonary function test showing a reversible, obstructive pattern. Management varies based on severity and includes bronchodilators and inhaled corticosteroids for inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation control.
  • Bronchiectasis Bronchiectasis Bronchiectasis is a chronic disease of the airways that results from permanent bronchial distortion. This results from a continuous cycle of inflammation, bronchial damage and dilation, impaired clearance of secretions, and recurrent infections. Bronchiectasis: a chronic condition with bronchial dilation and destruction as a result of inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation and infection. Symptoms include dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea, chronic cough, and purulent sputum. The diagnosis is made with imaging (X-ray and CT). Management includes bronchodilators and antibiotics for acute exacerbations.
  • Bronchiolitis obliterans Bronchiolitis obliterans Bronchiolitis obliterans is an obstructive lung disease triggered by a bronchiolar injury, which leads to inflammatory fibrosis and narrowing of the distal bronchioles. The triggering bronchiolar injury is often due to inhalation of a noxious substance, infection, or drug toxicity. Bronchiolitis Obliterans: a chronic, obstructive disease of the small airways usually caused by repeated cycles of inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation and scarring. Patients present with cough and persistent, progressive dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea. Pulmonary function tests are used for diagnosis. Management includes steroids and bronchodilators.
  • Heart failure: an inability to produce normal cardiac output to meet metabolic needs. Patients present with dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea, hypoxia, and peripheral edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema. BNP will be elevated and pulmonary edema Pulmonary edema Pulmonary edema is a condition caused by excess fluid within the lung parenchyma and alveoli as a consequence of a disease process. Based on etiology, pulmonary edema is classified as cardiogenic or noncardiogenic. Patients may present with progressive dyspnea, orthopnea, cough, or respiratory failure. Pulmonary Edema may be seen on X-ray. Echocardiography confirms the diagnosis. Management relies on diuresis and medical optimization of cardiac function with beta blockers and ACE inhibitors.
  • Cystic fibrosis Cystic fibrosis Cystic fibrosis is an autosomal recessive disorder caused by mutations in the gene CFTR. The mutations lead to dysfunction of chloride channels, which results in hyperviscous mucus and the accumulation of secretions. Common presentations include chronic respiratory infections, failure to thrive, and pancreatic insufficiency. Cystic Fibrosis: an autosomal recessive Autosomal recessive Autosomal inheritance, both dominant and recessive, refers to the transmission of genes from the 22 autosomal chromosomes. Autosomal recessive diseases are only expressed when 2 copies of the recessive allele are inherited. Autosomal Recessive and Autosomal Dominant Inheritancedisorder leading to dysfunction of chloride channels, which results in hyperviscous mucus and the accumulation of secretions. Patients often have chronic respiratory infections, failure to thrive Failure to Thrive Failure to thrive (FTT), or faltering growth, describes suboptimal weight gain and growth in children. The majority of cases are due to inadequate caloric intake; however, genetic, infectious, and oncological etiologies are also common. Failure to Thrive, and pancreatic insufficiency. The gold standard for diagnosis is the sweat chloride test, which can be complemented by genetic testing. Management includes cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy and system-specific strategies for supportive care. 
  • Pulmonary embolism Pulmonary Embolism Pulmonary embolism (PE) is a potentially fatal condition that occurs as a result of intraluminal obstruction of the main pulmonary artery or its branches. The causative factors include thrombi, air, amniotic fluid, and fat. In PE, gas exchange is impaired due to the decreased return of deoxygenated blood to the lungs. Pulmonary Embolism: obstruction of the pulmonary arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries most often due to thrombus migration from the deep venous system. Signs and symptoms include pleuritic chest pain Chest Pain Chest pain is one of the most common and challenging complaints that may present in an inpatient and outpatient setting. The differential diagnosis of chest pain is large and includes cardiac, gastrointestinal, pulmonary, musculoskeletal, and psychiatric etiologies. Chest Pain, dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea, tachypnea, and tachycardia. Severe cases can result in hemodynamic instability or cardiopulmonary arrest. Chest CTA is the primary method of diagnosis. Management includes oxygenation, anticoagulation, and thrombolytic therapy for unstable patients.

References

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