Good. Inspiration. That has been compromised.
Then finally, what we talked about
extrathoracic, well, intrathoracic, meaning
to say an obstruction and therefore you have
problems with your expiration-exhalation
Now, let’s take a look at smoking.
So that was review, make sure you’re
clear about that. Let’s take a look at smoking.
It’s never too late to stop smoking is the
point of this graph. Never. On your Y-axis
represents your FEV1 and that’s your percentage
of air as you know that you are exhaling
in one second. Now, on the X-axis
represents your age.
Let’s go to worst case scenario. Let’s
go to worst case scenario where we have death
at the bottom line. That’s pretty final,
isn’t it? Death. So, with the death occurring,
I want you to now come to, please, the earliest
age that we see here. The earliest age, the
dark green solid line, in which your patient
has died before the age of 75. That is a patient
who is continuously and regularly smoking
and therefore, susceptible to all kinds of
issues including chronic bronchitis, including
your emphysema. If the patient had asthma,
then it could be all kinds of mixtures. Or,
my goodness gracious, what about those lung
cancers? Any of them. But, more likely, squamous
or small. You’ll notice there that
the average age is below 75 with the patient
continuously susceptible to damage due to
smoking. It’s never too late.
Your patient now, now let’s move over
one to the right where it says “Stopped
at 65”. Even stopping at 65, the patient
might have potentially gained 5-10 years of
life. It’s never too late to stop smoking.
Let’s go further proximal, shall we? I want
you to take a look at the title where it says “Stopped
at 45”. You stopped at 45, you have then
prolonged your life so much more. It’s never
too late to stop smoking.
If the patient has never smoked, obviously,
Take a look at disabilities. Disability will
always take a little bit, will take place
a little bit younger in your patient who’s
smoking and death will always take place a
little bit younger in your patient. I hope
that’s clear, your point to your patient.
You’re a clinician, you’re doctor, I don’t
have to tell you anything. At least do this
for me and do this for the field of medicine,
tell your patients “It’s never too late
to stop smoking”.
Let’s take a look at multistep approach
in pulmonary function test, a diagnostic test
of choice. Reveals your classic obstructive
pattern. What’s that mean to you? A decreased
FEV1 to FVC ratio. Tell me about your total
lung capacity. It is increased and residual
volume as well. Tell me about your DLCO, especially,
let’s say, for example, if it’s emphysema.
You can then expect that you’ve lost your
surface area and therefore, your DLCO in fact
is decreased. What does that mean, DLCO? Good.
Your oxygen from the alveoli to your pulmonary
capillary is not moving quick enough. Why
in this case with emphysema? Loss of surface
Now, preventive medicine. How big is this?
Huge. These individuals might be susceptible,
all COPD patients are susceptible to? Pneumonia.
Vaccine is a very good idea. Yearly influenza
vaccine is a good idea. Ultimately, tobacco
cessation. You do this, you slowly progress
the disease process, that’s amazing.
Now, home oxygen therapy to correct hypoxemia,
if PaO2 is less than 59 or saturation is less
than 89. Are we clear? Remember, PaO2 on the
arterial side normally should be, how many
times have we talked about this? 95-100. If
it drops below 60, not good. Home oxygen.
You're worried about your saturation of oxygen clinically
even if it drops below 90%. Keep that in mind.
Management, treatment of acute flares.
Steroids, oxygen, antibiotics, especially
for Strep. pneumo and the big one here, Hemophilus
influenza may require non-invasive ventilatory
support. Which one would be a better choice?
BiPAP, CPAP, intubation or synchronised
intermittent mandatory ventilation? All the
discussions that we had before. First, you
want to try to remain non-invasive. Therefore
now you’re left with two answer choices.
Either have CPAP or BiPAP. Which one’s better,
if your patient has hypercapnia? Good. BiPAP.
Why? Bi-level. What’s Bi-level mean to you?
Inspiration, positive airway pressure.
It’s also going to help you with, Bi-level,
exhalation. What’s my problem in a patient
that might have acute flare? Retention of
your carbon dioxide. Wouldn’t you like to
facilitate some of that carbon dioxide efflux?
Sure, welcome to BiPAP. Bi-level, representing
both of the breathing patterns. Much more
comfortable for the patient, much more effective,
and as far as costs, becoming much more reasonable.