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dr. Irbab Hawari

Symptoms and Signs
• Cough, usually worse in the mornings and
productive of a small amount of colorless
• Breathlessness: The most significant symptom,
but usually does not occur until the sixth
decade of life
• Wheezing: May occur in some patients,
particularly during exertion and exacerbations
• Hyperinflation (barrel chest)
• Wheezing – Frequently heard on forced and
unforced expiration
• Diffusely decreased breath sounds
• Hyperresonance on percussion
• Prolonged expiration
(in severe disease)
• Tachypnea and respiratory distress with
simple activities
• Use of accessory respiratory muscles and
paradoxical indrawing of lower intercostal
spaces (Hoover sign)
• Cyanosis
• Elevated jugular venous pulse (JVP)
• Peripheral edema
Certain characteristic :
Chronic Bronchitis
• Patients may be obese
• Frequent cough and expectoration are typical
• Use of accessory muscles of respiration is
• Coarse rhonchi and wheezing may be heard
on auscultation
• Patients may have signs of right heart failure
(ie, cor pulmonale), such as edema and
Certaim characteristics:
• Patients may be very thin with a barrel chest
• Patients typically have little or no cough or
• Breathing may be assisted by pursed lips and
use of accessory respiratory muscles; patients
may adopt the tripod sitting position
• The chest may be hyperresonant, and
wheezing may be heard
• Heart sounds are very distant
• The formal diagnosis of COPD is made with
spirometry; when the ratio of forced
expiratory volume in 1 second over forced
vital capacity (FEV1/FVC) is less than 70%
• Severity
– Stage I (mild): FEV1 80% or greater of predicted
– Stage II (moderate): FEV1 50-79% of predicted
– Stage III (severe): FEV1 30-49% of predicted
– Stage IV (very severe): FEV1 less than 30% of
predicted or FEV1 less than 50% and chronic
respiratory failu
• Chest radiograph : Emphysema
– Flattening of the diaphragm
– Increased retrosternal air space
– A long, narrow heart shadow
– Rapidly tapering vascular shadows accompanied
by hyperlucency of the lungs
– Radiographs in patients with chronic bronchitis
show increased bronchovascular markings and
• Chest Radiograph : Bronchitis
– Chronic bronchitis is associated with increased
bronchovascular markings and cardiomegaly.
Differential Diagnosis
• Chronic asthma
• The goal of COPD management is to improve a
patient’s functional status and quality of life
by preserving optimal lung function,
improving symptoms, and preventing the
recurrence of exacerbations.
• Diet
Inadequate nutritional status associated with low
body weight in patients with COPD is associated
with impaired pulmonary status, reduced
diaphragmatic mass, lower exercise capacity, and
higher mortality rates.
• Smoking Cessation
• Bronchodilator
Bronchodilators are the backbone of any COPD
treatment regimen. They work by dilating airways,
thereby decreasing airflow resistance. This
increases airflow and decreases dynamic
• Beta 2-agonist and cholinergic antagonist
– Beta2-agonist bronchodilators activate specific B2-
adrenergic receptors on the surface of smooth
muscle cells, which increases intracellular cyclic
adenosine monophosphate (cAMP) and smooth
muscle relaxation.
– Anticholinergic drugs compete with acetylcholine
for postganglionic muscarinic receptors, thereby
inhibiting cholinergically mediated bronchomotor
tone, resulting in bronchodilation
• Management of Inflammation
– Steroid is effective in acute exacerbation
– the use of oral steroids in persons with chronic
stable COPD is widely discouraged,
– inhaled corticosteroids should be used only in
conjunction with a long-acting beta agonist.
• Management of infection
– In patients with COPD, chronic infection or
colonization of the lower airways is common from S
pneumoniae, H influenzae, and M catarrhalis. In
patients with chronic severe airway obstruction, P
aeruginosa infection may also be prevalent.
– Empiric antimicrobial therapy is recommended in
patients with an acute exacerbation
– In a study by Daniels et al, the addition to doxycycline
to corticosteroids was found to somewhat improve
treatment for acute exacerbation of COPD (AECOPD).
• Oxygen Therapy and Hypoxemia
Thank You