- General term encompassing a spectrum of conditions including chronic bronchitis and emphysema.
- Characterised by chronic resistance to expiratory airflow from infection, mucosal oedema, bronchospasm and bronchoconstriction, due to reduced lung elasticity.
- Causative factors include smoking, chronic asthma, alpha-1 antitrypsin deficiency and chronic infection.
- Exacerbations commonly precipitated by infection.
- Cough, wheeze and exertional dyspnoea.
- Tachypnoea, wheeze, lip pursing (a form of PEEP), use of accessory muscles.
- Cyanosis, plethora and signs of right heart failure suggest severe disease and cor pulmonale.
- Signs of hypercarbia include coarse tremor, bounding pulse, peripheral vasodilatation, drowsiness, confusion or an obtunded patient.
- CXR – only moderately sensitive (40–60%), but highly specific in appearance. Is an easily accessible method of assessing the extent and degree of structural parenchymal damage.
- Assessment for complications such as pneumonia, lobar collapse/ atelectasis, pneumothorax or mimics of COPD.
- CXR features include hyper-expanded lungs with associated flattening of both hemi-diaphragms, ‘barrel-shaped chest’, lung bullae, coarse irregular lung markings (thickened dilated bronchi) and enlargement of the central pulmonary arteries in keeping with pulmonary arterial hypertension.
- REMEMBER to look for lung malignancy/nodules; a common association.
- CT – quantifies the extent, type and location of emphysema and bronchial wall thickening. It may also identify occult malignancy.
- Lymphangioleiomyomatosis (LAM) and Langerhan’s cell histiocytosis (LCH) can have a similar CXR and CT appearance. The clinical history and imaging together are diagnostic.
- Asthma _ superimposed infection.
- Extrinsic allergic alveolitis.
- Viral infections.
- Supplemental oxygen tailored to keep pO2 >7.5 kPa. Beware high concentrations of supplemental pO2, as patients fail to expel the CO2 and develop high pCO2 levels.
- Nebulised bronchodilators (oxygen or air driven where appropriate). Adding nebulised ipratropium bromide may help.
- Consider an aminophylline or salbutamol infusion.
- Corticosteroids unless contraindicated.
- Appropriate antibiotics should be given if infection suspected.
- Ventilation or BiPAP can be considered.
- Long-term management may include
- Long-term home oxygen.
- Lung reduction surgery.