Chronic Bronchitis: Multistep Approach

by Carlo Raj, MD

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    00:00 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 loop.

    00:10 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.

    00:33 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.

    01:35 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.

    01:51 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.

    02:06 If the patient has never smoked, obviously, natural.

    02:10 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.

    02:24 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”.

    02:38 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.

    03:02 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 area, good.

    03:23 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.

    03:47 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.

    04:07 You're worried about your saturation of oxygen clinically even if it drops below 90%. Keep that in mind.

    04:15 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.

    04:52 Either have CPAP or BiPAP. Which one’s better, if your patient has hypercapnia? Good. BiPAP.

    05:00 Why? Bi-level. What’s Bi-level mean to you? Inspiration, positive airway pressure.

    05:07 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.

    About the Lecture

    The lecture Chronic Bronchitis: Multistep Approach by Carlo Raj, MD is from the course Obstructive Lung Disease.

    Author of lecture Chronic Bronchitis: Multistep Approach

     Carlo Raj, MD

    Carlo Raj, MD

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