Clinical vignette 3obstructive and

restrictive lung disease

Ghaida Al-Rashed

ObjectivesDescribe the treatment of acute exacerbation of

asthma and COPD ??

How can lung volumes be used to differentiate between obstructive and restrictive lung disease ?

What are the emergent investigations are to be performed on an emergency basis to reach the diagnosis ?

Objectives:

Describe the treatment of acute exacerbation of asthma and COPD ??

ACUTE EXACERBATION OF ASTHMA

Treatment

Oxygen 40-60% High doses of inhaled bronchodilators . Systemic corticosteroids. Intravenous fluids. Subsequent management.

OXYGEN

The patient should supply by High concentrations of oxygen:

Goal: SaO2 > 92% Failure to achieve appropriate oxygenation assisted

ventilation.

INHALED BRONCHODILATORS o Short-acting β2 agonist agent (SABA) : (Salbutamol 5 mg/hr) or (terbutaline 10mg/hr)via nebulizer driven by oxygen via metered dose inhaler through a spacer device o Inhaled anti-cholinergics (SAMA)(Ipratropium bromide 0.5 mg):

SYSTEMIC CORTICOSTEROIDS • Hydrocortisone sodium succinate: Dose: 200 mg 4 hourly Rote: intravenous in patients who are unable to swallow or vomiting.

ARTERIAL BLOOD GASES

We should correct ABG especially If patients ..o Initial PaCO2 measurement was raised ( >7 kPa)o PaO2 was < 8 kPa (60 mmHg) o the patient deteriorates.

SUBSEQUENT MANAGEMENT If patients fail to improve:

o Intravenous magnesium sulphate (1.2–2 g over 20 min) o Intravenous β2 agonists (e.g. Salbutamol)o Intravenous aminophylline (5mg/kg loading dose over 20

minutes)

Chest x-ray To exclude pneumothorax

MANAGEMENT OF COPD

The goals of effective COPD management are to:

1. Prevent disease progression2. Relieve symptoms3. Improve exercise tolerance4. Improve health status5. Prevent and treat complication

OXYGENATION AND VENTILATION• Oxygen therapy:the oxygen saturation level should be at least 90%. • Respiratory support:Non-invasive positive pressure ventilation (NIPPV) BiPAP improves blood gases. indicated if adequate ventilation cannot be achieved using a

high-flow mask.

Nasal oxygen therapy Non- invasive mechanical ventilation invasive mechanical ventilation

Con..• SHORT-ACTING BRONCHODILATORS (nebulization)

1. Inhaled short-acting β2 agonist agent (SABA).2. Inhaled anti-muscarinic (SAMA).

• CORTICOSTEROIDS:Short courses of systemic corticosteroids.

• ANTIBIOTICSwith bacterial infection

PREVENTING FUTURE EXACERBATIONS

Appropriate use of

inhaled corticosteroid

+inhaled

bronchodilators

Smoking cessation

vaccination

Objectives:

How can lung volumes be used to differentiate between obstructive and restrictive lung disease ?

OBSTRUCTIVE VS. RESTRICTIVE Obstructive disorders

• Characterized by: reduction in airflow.

• So, shortness of breath in exhaling air.

( the air will remain inside the lung after full expiration )

1. COPD2. Asthma3. Bronchiectasis

Restrictive disorders

• Characterized by a reduction in lung volume.

• So, Difficulty in taking air inside the lung.

( DUE TO stiffness inside the lung tissue or chest wall cavity )

1. Interstitial lung disease.2. Scoliosis3. Neuromuscular cause 4. Marked obesity

SPIROMETRY measures the rate of lung volume changes during forced breathing maneuvers

The diagnosis and distinguished between obstructive and restrictive

lung diseases.

Confirmed by Spirometry

DIFFERENT BETWEEN OBSTRUCTIVE VS. RESTRICTIVE  

Obstructive disorders• Decrease in both FEV1 and

FEV1/FVC ratio .

Restrictive disorder • Normal FEV1/FVC ratio .

Forced vital capacity (FVC):The maximum volume of air forcibly exhaling from the point of maximal inhalation.

Forced expiratory volume in 1 second (FEV1):Forced expiratory volume in 1 second during FVC maneuver.

Ratio of FEV1 and FVC (FEV1/FVC):Expressed as percentage

Objectives:

What are the emergent investigations are to be performed on an emergency basis to reach the diagnosis ?

Emergent Investigations1- ECG- ABNORMAL:

In 70% patients with PE:

- Sinus tachycardia- Nonspecific ST-T wave abnormalities

- RBBB

2- ARTERIAL BLOOD GASES:o hypoxemia, hypocapnia, and respiratory alkalosis due to

hyperventilation.PO2 and A-a gradient most often abnormal Profound hypoxia with normal chest X-ray in the absence of preexisting lung disease is highly suspicious of pulmonary embolism.

3- D-DIMER • D-dimer: A degradation product of fibrin.• is a substance in the blood that is often increased in people

with PE.D-dimer levels are abnormal in patients with PE; a person with a normal D-dimer level is unlikely to have a PE. Positive D-dimer indicate abnormal high level of fibrin degradation product ( indicate significant blood clut)

Summary

References

• http://www.who.int/respiratory/copd/management/en/

• http://www.aafp.org/afp/2010/0301/p607.html

• http://emedicine.medscape.com/article/300901-workup#c9

Thank you