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For further information, see CMDT Part 9-06: Chronic Obstructive Pulmonary Disease

Key Features

Essentials of Diagnosis

  • History of cigarette smoking or other chronic inhalational exposure

  • Chronic cough, dyspnea, and sputum production

  • Rhonchi, decreased intensity of breath sounds, and prolonged expiration on physical examination

  • Airflow limitation on pulmonary function testing

General Considerations

  • Airflow obstruction due to chronic bronchitis or emphysema; most patients have features of both

  • Obstruction

    • Is progressive

    • May be accompanied by airway hyperreactivity

    • May be partially reversible

  • Chronic bronchitis is characterized by excessive mucous secretions with productive cough for 3 months or more in at least 2 consecutive years

  • Emphysema is abnormal enlargement of air spaces distal to terminal bronchiole, with destruction of bronchial walls without fibrosis

  • Cigarette smoking is the most important cause

    • About 80% of patients have had a significant exposure to tobacco smoke

  • Air pollution, airway infection, environmental factors, and allergy have been implicated in chronic bronchitis

  • α1-Antiprotease deficiency has been implicated in emphysema

Clinical Findings

Symptoms and Signs

  • Presentation

    • Usually at 40–50 years of age

    • Cough

    • Sputum production

    • Shortness of breath

  • Dyspnea initially occurs only with heavy exertion, progressing to symptoms at rest in severe disease

  • Exacerbation of symptoms beyond normal day-to-day variation, often including increased dyspnea, an increased frequency or severity of cough, increased sputum volume, or change in sputum character

  • Infections (viral more commonly than bacterial) precede exacerbations in most patients

  • Late-stage COPD characterized by

    • Hypoxemia

    • Pneumonia

    • Pulmonary hypertension

    • Cor pulmonale

    • Respiratory failure

  • Clinical findings may be absent early

  • Patients are often dichotomized as "pink puffers" or "blue bloaters" depending on whether emphysema or chronic bronchitis predominates (Table 9–6)

Table 9–6.Patterns of disease in advanced COPD.

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