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Symptoms and Diagnosis of COPD

Jun 06, 2021
Alright, so let's start with the signs and

symptoms

of a patient with chronic obstructive pulmonary disease. Now sometimes it could be. If you've actually been exposed to these things you may have heard the term blue bloater and pink puffer these are common types of terms we use for COPD patients now that blue bloater is going to be common for someone who has chronic bronchitis okay then what I'm going to do is write blue bloaters and again just remember that the blue balloons are more particularly for chronic bronchitis patients, the other one is your pink balloons and the pink balloons are going to be those patients who they have more particular emphysema now realizing again that they often co-occur but one of them might be a little more severe than the other now patients with blue swelling what do you mean by that?
symptoms and diagnosis of copd
Let's leave out the big big term why do they mean blue pumps why do they mean pink pumps well the easy one is th pumps they are thick they are a little big ok so commonly seen to have an um obesity , okay, it looks like they have a high BMI, the other one with the blue goes back to that hypercapnia, I was talking to you. guys remember chronic bronchitis one of the biggest things i told you was hypoxemia which was low oxygen and what else hypercapnia high co2 build up because of that over time it can lead to cyanosis ok cyanosis , which will be that bluish discoloration that's why they're known as blue balloons we'll go over more again I'm just explaining why they're referring to this and how we can try to separate them where it's easier to remember the pink balloons now the pink balloons , these are usually because they breathe out through pursed lips okay so they breathe out through pursed lips and the reason they breathe out through pursed lips is it helps them prolong the breath out okay so it helps them to prolong the expiration and another thing is that they are pink because remember what I told you.
symptoms and diagnosis of copd

More Interesting Facts About,

symptoms and diagnosis of copd...

These patients have hypercapnia again because the airway is collapsed, but their hypoxemia is not as severe. Remember why I told you that because they can get air in, that's not always the problem? It's trying to get air out, so usually in the early stages, they're able to oxygenate properly, okay, but again, every time you get to the more serious later stages, they lose that ability to oxygenate properly and , again, it can lead to that severe hypoxemia which can then progress to central pulmonary, remember pulmonary hypertension, right? ventricular hypertrophy right ventricular failure and then again that can lead to the signs we can see from that ok what are some other things that help us tell the difference between someone who is a blue bloater or a bloater pink again with these chronic bronchitis? of the hallmark signs i cant stress this enough again remember what i told you about structural changes emphysema to chronobronchitis mucus production plugging these guys in one of the hallmark signs is a chronic productive cough this is the biggest i want you to remember and again that is the productive cough which is rich in a lot of sputum why remember you have so much mucus buildup? get rid of it somehow and one of the big ways they do that is by hacking it okay another thing with chronic bronchitis is we already check for hypoxemia we check that but another thing we can see with these patients is they have wheezing ok so that's another sign so every time we do the auscultation we listen to the chest we hear wheezing but particularly on the exhale and you can remember why again as you exhale the airways are so clogged with mucus that that it's having a hard time getting air out and that's the sound we're hearing is wheezing another thing is you can even hear creaking creaking it's rails ok but these are inspiring so sometimes it can be or what's called crackles inspiratory now it's not too hard to understand this this is what you have to remember with these inspiratory crackles remember me that airway was so clogged good with mucus that every time we breathe out again the actual airway gets a little smaller and clogs the air out causing air to get trapped but every time we breathe in remember what can happen is that the actual airway are so clogged up that sometimes what can happen is whenever you're really trying to breathe you can open up those airways okay so whenever you're really trying to make it take a breath it opens up those airways and makes that crackling sound that we can hear when breathing in, they also call it rails, another thing that we can see in these two patients is that they usually also have a kind of increased anterior posterior diameter and may also have, so they could have increased ap diameter and because they have so much air in their lungs when we try to hit the royal thorax.
symptoms and diagnosis of copd
The chest can produce hyperresonance okay for percussion okay so hyperresonance after percussion so these are things we want to keep in mind we're talking about chronic bronchitis but again I can't stress this productive cough enough chronic because here it is Why can we make a clinical

diagnosis

of chronic bronchitis? We'll talk about what it is, but usually if they've been coughing constantly with a productive cough for at least three months in a year for two years in a row, that's one of the criteria. that we can go on to say that this person probably has chronic bronchitis ok those are the things we're going with for this one now the pink balloons we talked about they exhale they have a long exhale they do it through pursed lips the reason why doing that helps to be able to maintain positive airway pressure and prevent them from collapsing remember bernoulli's principle if we breathe slowly what's going to happen to do is going to keep some air in those actual airways to keeping them open a little bit, that's fine, and it's also going to create some resistance again, think of that Bernoulli principle, but because you're breathing through pursed lips and long exhalation you use a lot of accessory muscles for breathing, so a Sometimes these patients will lose weight so it can be a common thing that we see another oh and I can't forget another one here for blue bloating and I'm going to writing this right here is that they have what's called exertional dyspnea, in other words, they're short of breath moving, walking, getting up, anything that requires a lot of effort is going to cause severe shortness of breath, okay ? that's another very, very big one for blue bloats but again weight loss is common and again come back to these other things it can cause wheezing okay it can cause wheezing on expiration again because those air waves they're getting so narrow and they're collapsing, you don't usually hear inspiratory crackles in these patients, but again, they have an increased ap diameter and it's more common for these patients to have an increased ap diameter because of that significant air. entrapment and they're also going to have hyperresonance to percussion okay now with these patients it's not always clear but again the ones I really want you to remember here is that for blue bloated it's a chronic productive cough and Disney in effort to pink puffers i want you to remember purse lip breathers to prolong your exhalation because long exhalation helps to keep your airways try to keep them open but it can cause weight loss they can get oxygenated usually in the early stages but in chronic periods of time it can lead to chronic hypoxemia and it can lead to chronic hypercapnia which can lead to right ventricular heart failure but again that is more common n with the blue bloaters again a significant increase in heart rate is also common ap diameter, but again both can have that and both can have hyperresonance to percussion and both can You can't have those inspiratory crackles because the buildup of mucus every time you inhale can actually try to open up the airway, so those are some of the common things that we're going to see in patients. having the signs and

symptoms

of chronic abstract or lung disorder blue swelling chronic bronchitis pink swelling emphysema The next thing we're going to do is get into the

diagnosis

here okay the hallmark here actually let me do the first one the first What I really want you to remember is that you can do these kinds of sometimes it's based on clinical diagnosis okay in other words their history is taken into account so you look at whether they smoke, you look at whether they work in situations where those who are exposed to t or a lot of contaminants dust or silica try to take and see if they have a family history of COPD.
symptoms and diagnosis of copd
Look to see if they have any underlying liver disorders because again, remember alpha antitrypsin one sometimes when situations don't get done. that alpha one in trypsin can cause liver destruction so they may have liver destruction so you can check their feet but again you can just go by history and physical especially if someone has chronic bronchitis, if someone has chronic bronchitis, remember I told you one of the big things that might make you think about this is if you have three months out of the year, two years of productive coughing, this is one of the big things that leads us to believe oh man this could definitely be chronic bronchitis emphysema obviously we could try to look for you know some of the signs there one of the biggest things is you could do it's not always the best it's not really the which we do but you can do a chest x-ray and what a chest x-ray showed I'll put it down here it can show hyperinflation of the lungs so you can see they're really big you can see that as well because the lungs are so big the diaphragm is really flat and they have a lot of what are called transparent dark spots on the chest x-ray that's okay too but that's one of the big ones we can go with we can build on in the history and physical but the gold standard here would be the best the best possible here would be to do pulmonary function tests pulmonary function tests and again we talk about this in physiology and we go through the charts and we go through a lot of the things with the four spirometry we went over, inspiratory reserve volume and expiratory reserve volume total lung capacity so we have videos on our physiology and respiratory playlist if you want to see more of that we're going to go right to though and talk about abo ut what kinds of things we see that are abnormal is ok so what we look at is we do a spirometry on them we make them take like a device or we have them take in as much air as they can and exhale as much air as possible and what we're looking at with this is we're looking to see two particular numbers first so the first thing we're looking at is we look at their fev1 and this is basically their expiratory volume forced in a second and we look at his fvc his forced vital capacity in patients who have chronic obstructive pulmonary disorders both are low but this is even lower so the fev1 is more significantly lower or markedly lower in someone with COPD and the fvc is also low now the next thing we can do is do the ratio so if you imagine here you can take the fev1 and you can divide it by the fvc and if it's less than 75 percent that's a positive sign that it's usually of obstructive lung disease. disorder so this is usually a positive sign of some type of COPD and again it could be COPD or it could be any obstructive lung disease, it could be asthma, it could be bronchiectasis, it could be cystic fibrosis, so those are some of the things we would look at but this is what we would go to we would take their actual pulmonary function test their fev1 and their fvc we would give them a bronchodilator and a bronchodilator is something like saba so it's basically albuterol and that's basically a beta adrenergic, a beta-2 adrenergic agonist in other words binds to a beta-2 receptor and causes smooth muscle relaxation to open up the airways dilates the airways which will help them get more air however with COPD it is irreversible unfortunately so they will have a small increase in their fev1 after you take it again, but it's not going to be big enough, so what we do is put the bronchodilator on, we'll do these p you test we'll do the bronchodilator and remeasure later and usually after the bronchodilator the fev1 is still less than 12 there's less than a 12 percent increase and that's usually a sign of COPD ok , if it's higher than 12 percent then it could be asthma but what we do is again take your pulmonary function tests we take your fev1we take their fec both are low fev1 lower we do the ratio usually if it's less than 75 percent then we say this is obstructive pulmonary disease the next thing we do is try to monitor so we do a bronchodilator like an albuterol saba then having done that, we ask them to do the pulmonary function test again, they will still be low, but what we are looking for is looking specifically at that fev1, how much did it change if the change was a 12? rise or more it's more likely asthma if it's less than a 12 rise it's most likely an irreversible situation and you're probably fine that's how we do this test and again this is the gold standard for this so this is the you defined.
I'd like to try to get it right. Other things we might do is look at your pulse oximeter to get your pulse oximetry up again. What did I do? I tell you with these situations here with patients who have chronic obstructive pulmonary disease they can develop hypoxemia so what you can find with these patients sitting is that they can have low O2 saturation and that is what you are going to have to look at ' we're going to want to see how significantly low it is so what we're looking for is if your O2 saturation is below 88 that usually means we have to start you on supplemental oxygen ok not a good sign ok , we might have to put in a nasal cannula or if their O2 saturation is less than 90 percent, but they have predisposing factors, maybe they have right heart failure or, in general, some heart failure and have a high hematocrit, maybe they have polycythemia , so again, we'll probably want to start on supplemental oxygen, so we generally have two thresholds, one is if it's less than 88 percent, we can have them start on supplemental oxygen or if it's less than 90 we can increase Lower the threshold if they have heart failure or an elevated hematocrit but we'll also base it on something else then the other thing we do is do an arterial blood gas and an arterial blood gas, what it does is it gives us a pair. different things it gives us bicarbonate it gives us the partial pressure of co2 it gives us the partial pressure of oxygen and it can give us the ph now you have to think about this if a patient has

copd

what we said was one of the big things we would find remember that they can't get the co2 out so most likely there is elevated co2.
What is this thing called hypercapnia? What I want you to remember is in patients who have elevated co2. Remember that co2 plus water physiology equation. produces carbonic acid carbonic acid can dissociate into protons and bicarbonate so if you have a lot of CO2 you have a shift to the right and that accumulates a lot of protons. What can protons do with real blood plasma? as in the ph remember what i told you it can also decrease oxygen and cause hypoxemia usually because someone is in their respiratory acidosis they might have a compensatory change in bicarbonate but we're not going to talk about this ok that's more specifically for metabolic acidosis or alkalosis but these are some of the things that might make us believe that they might have respiratory acidosis okay and one other thing I remember I told them we'll talk about that later but when we start people on supplemental oxygen it we do based on your O2 stats but if we do an abg we can also base on your oxygen usually we set it to less than 55 so anything less than 55 we say ok let's select supplemental oxygen and again 55 millimeters of mercury or if it's uh less than 60 because they have right sided heart failure and elevated hematocrit again we can start on the ox supplemental muscle oxygen but that's what we're going to do for arterial blood gas so the next test is What we could do here and it's really good just to rule out cardiac disorders is we can do an EKG and really everything What we're doing the EKG is to rule out, you know, maybe a myocardial infarction or congestive heart failure and sometimes, what you have, especially in someone who has a

copd

exacerbation, it can happen, it can produce this thing called multifocal atrial tachycardia, i also call it matting all it is is it causes these irregular qrs complexes but they have three clearly different p waves one after the other and the reason is they have two thoughts one is because in situations where there is hypoxemia the cells of the actual atria may try to set their own rhythm and therefore there may be multiple areas of the atria that are firing at the same time time another is if someone is actually on blood pressure medication sometimes on blood pressure medication that can also cause it but again with the EKG what we're trying to see is that we're trying to look for errors to rule out something like that and we're also looking to see congestive heart failure, especially one thing we can do is see if there's cardiac stress on the right ventricle.
Cardiac stress Right ventricular stress You can look at the EKG and sometimes you can see inverted T waves, so some things can sometimes happen as well. someone has this exacerbation of COPD sometimes due to hypoxemia which can cause this multifocal atrial tachycardia with three distinctly different p waves with irregular qrs complexes and if you want to see if a patient might have signs of cardiac stress in the right ventricle you have something of inverted t waves but again looking for a right sided heart failure EKG won't cut it for that you may have to do a bmp and echo and swan god catheter ok last th on what which we're going to talk about in general it's not that great but it can do it can do chest x-rays it can also do high res ct scans those are a little bit better chest x-rays not as good but high Resolution cts can also be used and what they will show is we will put hrct if it can show air trapping so it will usually show air trapping so hyperinflation of the lungs can even show a flat diaphragm if you get an x-ray of chest so again on the chest x-ray you'll see some trapped air you might see a flat diaphragm again you can still see that increased anterior posterior diameter as well you might have some transparency and like the anterior chest wall like well for emphysema you might see a bulla remember you can see a blue bulla and remember what was distal acid or emphysema one of those you can see bulla commonly because it can rupture and a torus is basically a bag of air is fine, just an air pocket that could easily rupture because of that.
Over time, it can distend in emphysema, there can also be a decrease in the mas vascular markings, whereas with chronic bronchitis you may have increased vascular markings as well because, again, think about pulmonary hypertension perhaps in the later stages of emphysema might have increased. vascular markings but it's usually not that great so those are things that would come off the chest x-ray or high resolution CT so again to check it out very quick clinical diagnosis especially with chronic bronchitis three months of productive cough for a year for two years in a row your pfts can't stress enough this is the gold standard so don't remember any of the others at least remember this one is fine and again what we're looking for is a low fev1 and a low fvc but plus fev less than 75 percent tells us obstructive bronchodilator will show less than 12 percent increase in pulse rate ox is looking for low o2 stats usually cutoff is less than 88 to start on supplemental oxygen, gas on arterial blood or an abg to see if they have respiratory acidosis, an electrocardiogram to rule out any cardiac conditions such as heart failure mi, pa rticularly to see if there is cardiac tension in the right ventricle by seeing that reversed. t waves and if they are in an exacerbation sometimes they have multifocal atrial tachycardia due to hypoxemia and again you can do a chest x-ray or high resolution CT scan it can usually show these common signs which is air trapped in a flat diaphragm an increase in diameter ap again emphysema usually decrease in vascular markings in later stage could show increase in vascular markings but chronic bronchitis will be more specific to show you this increase in vascular markings because of the cost that has on pulmonary hypertension and heart so one more thing you could do but you don't have to it's a cbc the only reason I mentioned is I want you to think about that pt physiology concept again if you have hypoxia what would that really do to your kidneys?
It would stimulate the kidneys to produce erythropoietin. Erythropoietin is a hormone that stimulates the red bone marrow to make more red blood cells. cell count, polycythemia, elevated hematocrit, but again, that's not diagnostically specific, okay, so again that's going to be the most important thing in being able to diagnose COPD, and specifically trying to see if it's chronic bronchitis or emphysema, so one other thing I wanted to bring up with the pulmonary function test is to remember again that a COPD patient's lungs are going to be very compatible and the reason why they're going to have that elastic tissue damage again so there will be a lot of trapped air as we have said. many times because of that the volume of air in the lungs generally ok will generally increase so our patient total lung capacity will increase easily and even if we exhale remember the problem is exhaling air always they're going to have a lot of air trapped in their lungs afterwards, what's the volume of air left in their lungs after a forceful scan called the residual volume? there's going to be an increase in residual volume one of the things they really do to test it is they can actually do what's called diffusing lung capacity with carbon monoxide they can give a little bit of carbon monoxide and they look to see how much diffuses across the respiratory membrane in these patients they have decreased dlco okay so they have decreased their diffusion sorry carbon monoxide diffusion so their actual carbon monoxide diffusion in the lungs are going to decrease so they give out a little bit of carbon monoxide, but because of the decrease in surface area or because of the clogging again, it will cause a decrease in diffusion of the actual carbon monoxide through the lungs. t hat membrane these are things we can see on the pulmonary function test okay ninja in this video we talk about the symptoms we talk about the diagnosis of COPD I hope you had teni make sense, I hope you enjoyed it, please. hit the like button comment in the comment section subscribe if you want to go in our description box we have links to our facebook, instagram, our patreon or even our gofundme page if you want to go there keep in touch with us too if you you guys can donate we would really appreciate it as always you ninja nerds see you next time.

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