Symptoms and Diagnosis of COPD

Alright, let's start with the signs and

symptoms

of a patient with chronic obstructive pulmonary disease. Sometimes if you've been exposed to these things you may have heard the term blue bloat and pink balloon these are common terms we use for COPD patients now blue bloat will be common for someone who has chronic bronchitis. Well, what I'm going to do is write blue swelling and again, just remember that the blue swellings are more particularly for patients with chronic bronchitis, the other one is the pink balloons and the pink balloons will be those patients who have more particularly emphysema.

Now I realize again that they often coexist, but one of them might be a bit. more severe than the other now patients with blue swellings what do you mean by this? let's get the big term out of the way why do they mean blue swellings why do they mean pink swellings well the easiest one is swellings they are thick they are a little big okay so they are commonly seen with obesity okay , then you see that they have a high BMI, the other one with the blue goes back to that hypercapnia that I was talking about, remember chronic bronchitis, one of the important things that I told you was hypoxemia, which was a low level of oxygen, and what else, hypercapnia, the high accumulation of CO2 due to that, over time, can cause cyanosis, okay, cyanosis, which will be that bluish discoloration, that's why they are known as blue swellings.

We will go over more again. I'm just explaining why they mean this and how we can try to separate them where it's easier to remember the pink balloons. Now, pink balloons are usually due to exhaling through pursed lips. Okay, so exhale through them. pursed lips and the reason they exhale through pursed lips is that it helps them prolong the exhale, okay, so it helps them prolong the exhale and another thing is that they're pink because remember what I told you, these Patients have hypercapnia again due to the airways collapsing, 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, they're trying to get air out, so because of this, usually in the early stages they can oxygenate themselves adequately, but again. it's when it gets to the more severe later stages that they lose that ability to oxygenate themselves adequately and again it can lead to that severe hypoxemia which can then progress to the pulmonary core, remember pulmonary hypertension right ventricular hypertrophy right ventricular failure and then again that can lead to the signs What can we see from that, okay? What are some other things that help us determine the difference between someone who is a blue bloat or a pink bloat again with these, chronic bronchitis, one of the hallmark signs that I can't emphasize.

Enough, remember what I told you for emphysema, structural changes for chronobronchitis, mucus production, obstruction, so these guys, one of the hallmark signs is a chronic productive cough, this is the big one I want you to remember. and again, that's that productive cough that's delicious. in a lot of sputum, why remember you have so much mucus buildup that you have to get rid of it somehow and one of the most important ways you do that is by cutting through that. Well, another thing with chronic bronchitis is that we already went over hypoxemia. We go over those things, but another thing we can see with these patients is that they are wheezing, so that's another sign.

Every time we do auscultation, we listen to the chest, we listen to wheezing, but particularly on expiration, and you can remember. Why, again, as you exhale are your airways so clogged with mucus that it's hard for air to come out and that's the sound we hear is wheezing? Another thing is that you can even hear crackles, crackles, rails, okay, but these are inspiratory, so sometimes you can hear what are called inspiratory crackles. Now it is not very difficult to understand this. This is what you need to remember with these inspiratory crackles. Remember that in me the airways were so clogged with mucus that every time we exhale again, the airways become a little bit smaller and it obstructs the exit of the air causing the air to get trapped, but every time we inhale, remember that what can happen is that the actual airways are so clogged, sometimes what can happen is that when you actually try to breathe, it can open up those airways, okay? you are actually trying to take in air, that opens those airways and produces that crackling sound that we can hear when we breathe in.

They also call it rails. Another thing we can see in both patients is that they usually have some sort of enlargement as well. posterior anterior diameter and they can also have an increased ap diameter and because they have a lot of air in their lungs when we try to percuss the actual chest, the thorax, it can produce hyperresonance. Okay, percussion is okay, so hyperresonance. percussion, so these are things we want to keep in mind, we're talking about chronic bronchitis, but again, I can't emphasize this chronic productive cough enough because here's why we can make a clinical

diagnosis

of chronic bronchitis, we'll actually talk about. about what it is, but generally, if they have been coughing consistently with a productive cough for at least three months of the year for two consecutive years, that is one of the criteria we can follow in saying that this person probably has chronic bronchitis. are things that we choose for this now, the pink balloons that we already talked about, that exhale, they have a long expiration, they do it through pursed lips, the reason they do it is that it helps to be able to maintain a positive airway pressure. and to prevent them from collapsing, remember Bernoulli's principle, if we breathe slowly, what it will do is keep some air in those actual airways to keep them slightly open and it will also create some resistance, think again. on that Bernoulli principle, but because they breathe through pursed lips and prolonged expiration, a lot of accessory muscles are used to breathe, which is why sometimes these patients lose weight, so it may be a common thing that we see in others . one, and I can't forget another one here for the blue swellings and I'm going to write this right here.

They have what is called exertional dyspnea, in other words, they are short of breath when moving, walking and getting up. anything that requires a lot of effort will cause serious shortness of breath, well that's another really big problem for blue bloats, but again, weight loss is common and again, let's get back to these other things, it can cause wheezing, can you? OK? They cause wheezing again when you exhale because those air waves become very narrow and collapse. Typically, you don't hear inspiratory crackles in these patients, but again, they have that increased ap diameter and it's more common for these patients to have that increased ap. diameter due to that significant air trapping and will also have hyperresonance to percussion.

Well, now with these patients it's not always clear, but again, what I really want you to remember here is that for blue swelling it is a chronic disease. productive cough and disney about straining for pink balloons i want you to remember to breathe with pursed lips to prolong your exhalation because prolonged exhalation helps keep the airways they try to keep them open but it can cause weight loss they can usually oxygenate themselves In the early stages, but during chronic periods, it can cause chronic hypoxemia and chronic hypercapnia, which can lead to right ventricular heart failure, but again, that is more common with blue swellings.

A significant increase in the diameter of the ap is also common, but again. you both can have that and you both can have hyperresonance to percussion and you both can have wheezing when you breathe out chronic bronchitis you can't have those inspiratory crackles because the buildup of mucus every time you inhale can try to open your airways so those are some of the common things we'll see in patients who have the signs and

symptoms

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

diagnosis

here okay the distinctive thing here well actually let me do the first one, the first one I really want you to remember is that you can do this sometimes based on the clinical diagnosis, okay, in other words, you take into consideration his history so you can Look to see if he's a smoker, look to see if they work on situations where you are exposed to a lot of dust or silica contaminants, try taking and see if you have a family history of COPD, look to see if you have any underlying liver disorders because, again, remember alpha one antitrypsin, sometimes in situations where that if that alpha one in trypsin is not produced, it can cause liver destruction, so they may have liver destruction, so you can monitor their livers, but again, you can do that based solely on medical history and physical exam, especially if someone has chronic bronchitis.

Remember I told you that one of the most important things that can make you think about this is if you have three months to the day. year multiplied by two years of productive cough, this is one of the important 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 that are there , one of the important things. What could you do? It's not always the best. It's not really what we do, but you can do a chest x-ray and what a chest x-ray showed.

I'll put it here. May show hyperinflation of the lungs. you can see that they are really very big. You can also see that because the lungs are so big, the diaphragm is very flat and they have a lot of spots, what are called bright dark spots on the chest x-ray, that's okay too, but that's one of the big ones that we can choose we can rely on the history and the physical exam, but the gold standard here, which would be 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 over the charts and we go over a lot of things with the four spirometries, we go over the inspiratory reserve volume and the expiratory reserve volume, the total lung capacity, so we have videos in our physiology and respiratory playlist if you guys want to see more of that, but we're going to get right into that and talk about what kinds of things we see that are abnormal.

Well, what we see is that we make them do spirometry, we make them drink like a device. we make them take in as much air as they can and exhale as much air as they can 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 for is We look at their fev1 and this is basically their forced expiratory volume in a second and we look at their f v c their forced vital capacity in patients who have chronic obstructive pulmonary disorders. Both are low, but this one is even lower, so the fev1 is more significantly low 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 divide it by fvc and if it's less than 75 percent, that's a positive sign that it's usually an obstructive pulmonary disorder, so it's 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 consider, but this is what we would do: we would take an actual lung function test, their fev1 and their fvc, we would give them a bronchodilator and A bronchodilator is kind of like saba, so it's basically albuterol and it's basically a beta adrenergic, a beta-2 adrenergic agonist, in other words, it binds to a beta-2 receptor and causes the smooth muscle to relax to open the airways, it dilates the airways which is going to help them get more air in, however with COPD it is irreversible, unfortunately, so they will have a small increase in their fev1 after taking it again, but it won't be big enough , so what we do is we apply the bronchodilator and we will take these. tests, we will do the bronchodilator and we will measure again afterwards and usually after the bronchodilator the fev1 is still less than 12, there is an increase of less than 12 percent and that is usually a sign of COPD.

Okay, if it's over 12 percent, then that could be asthma, but what we do again is we take their lung function tests, we take their fev1, we take their fec, they both have low fev1, lower, we usually do the ratio if is less than 75 percent, then we say it is an obstruction.lung disease, the next thing we do is try to monitor, so we apply a bronchodilator like saba albuterol and after we have done that, we ask them to do the pulmonary function test again, they will still be low, but what we look for If we look specifically at that fev1 , how much did it change if the change was an increase of 12 or more?

That's most likely asthma, if it's less than a rise of 12 it's most likely an irreversible situation and you're probably fine, that's how we proceed. this test and again this is the gold standard for this one so this is the one you definitely want to try to do. Other things we could do is look at your pulse oximeter to get your pulse oximetry back up. i"I tell you these situations here with patients who have chronic obstructive pulmonary disease and may develop hypoxemia, so what you might find with these patients sitting up is that they might have low O2 saturation and that's what you'll have to look at." We're going to want to see how low it is, so what we're looking for is to see if his O2 saturation is less than 88, which usually means we should start him on supplemental oxygen.

Well, it's not a good sign. Well, we could. they have to be put on a nasal cannula or if their satellite oxygen level is less than 90 percent but they have predisposing factors, maybe they have right-sided heart failure or just some heart failure in general and they have an elevated 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 start on supplemental oxygen or if it's less than 90, we can increase the threshold if they have insufficiency. heart rate or an elevated hematocrit, but we'll also base it on something else, so the other thing we do is we do an arterial blood gas and an arterial blood gas, what it does is it gives us a couple of 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 did we say were some of the important things that we would find?

Remember they cannot remove CO2, so there is most likely elevated CO2. What is called hypercapnia? What I want you to remember is in patients who have elevated CO2. Remember that the physiology equation CO2 plus water produces carbonic acid. Carbonic acid can dissociate into protons and bicarbonate, so if it has a lot of CO2, it shifts to the right and that accumulates many protons. What can protons do to real blood plasma? Make it acidic, so you might notice a decrease in pH. Remember what I told you that it can actually also decrease oxygen and cause hypoxemia, usually because someone has respiratory acidosis and may have a compensatory change in bicarbonate, but we're not going to talk about this, okay, it's more specific to metabolic acidosis or alkalosis, but These are some of the things that might lead us to believe that they might have respiratory acidosis.

And another thing I remember. I told them we'll talk about it later, but when we start giving people supplemental oxygen, we do it based on their O2. statistics, but if we do an abg we can also base it on your oxygen, we usually set it to less than 55, so anything less than 55 we say, okay, let's select the supplemental oxygen and again 55 millimeters of mercury or if it is less than 60 because they have right sided heart failure and elevated hematocrit again, we can start muscle supplemental oxygen, but that's where we go for arterial blood gases, so the next test we could do here and it's really good to rule out heart disease. disorders is that we can do an EKG and really all we do 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. can produce this thing called multifocal atrial tachycardia, I also call it mats, all it is is that it causes these irregular qrs complexes, but they have three distinctly different p waves, one after the other, and the reason is that they have two thoughts, one is because in Situations where there is hypoxemia, the cells in the actual atria may try to set their own rhythm and therefore there may be multiple areas of the atria that become active at the same time, another is if someone is sometimes taking antihypertensive medications. blood pressure. on blood pressure medications that can also cause it, but again with the EKG what we're trying to look at is 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 really do is see if there is any right ventricular cardiac strain. Sometimes you can see if there is right ventricular cardiac tension. That can happen as well, so again, the reason I would do an EKG is to really rule out any heart problems, but again, if someone has this COPD exacerbation, sometimes due to hypoxemia, it can cause this multifocal atrial tachycardia. with three clearly different p waves. with irregular qrs complexes and if you want to see if a patient maybe has signs of right ventricular cardiac strain, has some inverted t waves, but again, looking for right heart failure, the EKG won't be enough for that, you may have to do that. a bmp and an echo and a swan god catheter, okay, the last one we're going to talk about is usually not that good, but you can do it, you can do chest x-rays, you can also do high resolution ct scans, those are a slightly better chest x-rays are not as good but you can also use high resolution CT scans and what they will show is we will put in hrtct if it can show trapped air so it will usually show trapped air so hyperinflation of lungs properly, it might even show a flat diaphragm if you do a chest x-ray, so again on the chest x-ray you will see some trapped air, you may see a flat diaphragm again, you can still see that increase in diameter anteroposterior like Well, you might have some clarity and you might also like the anterior chest wall, for emphysema, you might see a bulla.

Remember that you can see a blue bulla and remember which was the distal acid or emphysema in which you can commonly see the bulla. because it can rupture and a torus is basically an air sac, well, just an air sac that could easily rupture because of its uh, over time, it can become distended in emphysema, it can also have diminished vascular markings, whereas with the Chronic bronchitis can have increased vascular markings as well because again think about it, that pulmonary hypertension maybe in the later stages of emphysema you may have increased vascular markings, but overall it's not that good, so that those are things that we would get off our chest.

X-ray or high-resolution CT scan, so again, to do it very quickly, clinical diagnosis, especially with chronic bronchitis, three months of productive cough for a year for two consecutive years. Can't your pfts get stressed enough? This is the gold standard, so I don't remember any of the others, at least remember this one, okay, and again what we're looking for is a low fev1 and a low fvc, but more so, the fev less than 75 percent tells us that the obstructive bronchodilator will show a pulse increase of less than 12 percent. ox, you are looking for low O2 stats, usually the limit is less than 88 to start supplemental oxygen, arterial blood gases or an abg to see if they have respiratory acidosis, an EKG to rule out any cardiac situation like a my heart. particularly fails to see if there is strain on the right ventricle by looking at inverted t waves and if they are in an exacerbation they sometimes have multifocal atrial tachycardia due to hypoxemia and again may have a chest x-ray or high resolution computed tomography .

It can usually show you these common signs, which are trapped air, a flat diaphragm, an increase in PA diameter, again, emphysema, usually decreased vascular markings in the later stage, it can show increased vascular markings, but chronic bronchitis will be more specific to show you this increase. vascular marks because of the toll that pulmonary hypertension and the heart take, so one additional thing you could do, but is not necessary, is a complete blood count. The only reason I mentioned is I want you to think back to that concept of physiology if you have hypoxia, what would that actually do to your kidneys?

It would stimulate the kidneys to produce erythropoietin. Erythropoietin is a hormone that stimulates the red bone marrow to produce more red blood cells, so you might suspect that you have a high red blood cell count. Polycythemia and a high level. hematocrit, but again, that's not specific from a diagnostic standpoint, okay, again, that's going to be the most important thing to be able to diagnose COPD and specifically try to see if it's chronic bronchitis or emphysema, so one other thing I wanted mention with the pulmonary function test is again. Remember that the lungs of a COPD patient are going to be super docile and the reason is that they are going to have that damage to the elastic tissue again, so there will be a lot of trapped air, as we have said many times, because the volume of air that is in the lungs is generally fine, it will generally increase, so our patient's total lung capacity will increase and even if we exhale, remember the problem is exhaling air, they will always have plenty of air. air trapped in the lungs after, what is that called? the volume of air that remains in the lungs after a vigorous scan is called residual volume, so there will be an increase in residual volume, one of the things they actually do to test this is In fact, they can do what is called pulmonary diffusion capacity with carbon monoxide.

They can administer a little bit of carbon monoxide and see how much of it diffuses across the respiratory membrane. In these patients, they have a decrease in dlco. Well, then they have a decrease. in your diffuse diffusion, sorry, carbon monoxide diffusion, so your actual lung diffusion of carbon monoxide is going to decrease, so you give some carbon monoxide, but because of the decrease in the area of surface or because of the obstruction again, it's going to cause a decrease in the diffusion of the actual carbon monoxide through that membrane, so these are things that we can see on the pulmonary function test, okay, ninja, so in this video we talk about the symptoms, we talk about the diagnosis of COPD, I hope so. makes sense, I hope you enjoyed it, if you did, hit the like button, comment in the comments section, subscribe if you want go to our description box, we have links to our Facebook, our Instagram, our Patreon or even our Gofundme page.

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