COPD | Clinical Features

[Music] all right so we're going to start off with the signs and the symptoms of a patient with chronic obstructive pulmonary disease now sometimes you might be if you've actually kind of been exposed to this stuff you might have heard the term blue bloater and pink puffer these are common kind of terms that we utilize for patients with copd now that blue bloater is going to be common for someone who has chronic bronchitis okay so what i'm going to do is i'm going to write down blue bloaters and again just remember that blue bloaters are more particularly for patients with chronic bronchitis the other one is your pink puffers and pink puffers are going to be those patients who have more particularly emphysema now realize again they often coexist but one of them might be a little bit more severe than the other now patients with blue bloaters what do they mean by this let's get the big big term out of the way why they mean blue bloaters why they mean pink puffers well the easy one is bloaters they're chunky they're a little bit big all right so they are commonly seen to have a um obesity okay so they're seen to have a high bmi the other one with the blue goes back to that hypercapny i was talking to you guys about remember chronic bronchitis one of the big things that i told you was hypoxemia which was low oxygen and what else hypercapnia high buildup of co2 because of that over time it can lead to cyanosis okay cyanosis which is going to be that bluish discoloration that's why they're referred to as blue bloaters we'll go over more again i'm just giving you why they refer to this and how we can try to separate these where it's easier to remember pink puffers now pink puffers these are generally because they exhale through pursed lips okay so they exhale through pursed lips and the reason why they exhale through purse lips is it helps them to prolong the expiration okay so it helps them to prolong the expiration and another thing is they're pink because remember what i told you these patients have hypercapnia again because of the airways kind of collapsing but their hypoxemia is not as bad 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 because of these usually in the early stages they can properly oxygenate okay but again it's whenever it gets to the more severe later stages that they lose that ability for them to oxygenate properly and again it can lead to that uh severe hypoxemia which can then progress to core pulmonal remember pulmonary hypertension right ventricular hypertrophy right ventricular failure and then again that can lead to the signs that we can see from that okay what are some other things that help us to determine the difference between someone who's a blue bloater or a pink puffer again with these ones chronic bronchitis one of the hallmark signs i can't stress it enough again remember what i told you for emphysema structural changes for chronobronchitis mucus production plugging so these guys one of the hallmark signs is a chronic productive cough this is the big one that i i want you guys to remember and again that's that productive cough that's rich in a lot of sputum why remember they have so much mucus buildup they got to get rid of it somehow and one of the big ways that they do that is by hacking that up okay another thing with chronic bronchitis is again we already went over the hypoxemia we went over that stuff but another thing that we can see with these patients is that they have wheezing okay so that's another sign so whenever we're doing auscultation we're listening to the chest we hear wheezing but particularly on expiration and you can remember why again as you're exhaling the airways are actually so mucus plugged so that it's having a hard time for the air getting out and that's that sound that we hear is wheezing another thing is you might even hear crackles crackles are rails okay but these are inspiratory so sometimes you might hear what's called inspiratory crackles now it's not too hard to understand this here's what you gotta remember with this inspiratory crackles remember that me that airway was so plugged up okay with mucus that whenever we exhale again the actual airway gets a little bit smaller and obstructs the air getting out causing air trapping but whenever we inhale remember what can happen is that that actual airway is so plugged up sometimes what can happen is whenever you're really trying to breathe it can pop those airways open okay so whenever you actually are trying to take air in it pops those airways open and produces that crackling sound that we can hear upon inspiration they also call it rails another thing that we can actually see with both of these patients is usually they also have kind of an increased anterior posterior diameter and they can also have so they might have an increased ap diameter and because they have so much air in their lungs when we try to percuss the actual chest the thorax it can produce hyper resonance okay to percussion all right so hyper resonance upon percussion so these are things that we want to take into consideration we're talking about chronic bronchitis but again i can't stress enough this one chronic productive cough because here's why we can make a clinical diagnosis of actually um chronic bronchitis we'll talk about what it is but usually if they've been coughing consistently with a productive cough for at least three months in a year for two consecutive years that's one of the criteria that we can go about by saying this person probably has chronic bronchitis okay so those are things that we go with for this one now pink puffers we already talked about that they breathe out they have prolonged expiration they do it through purse lips the reason why they do that is it helps to be able to keep a positive pressure in the airways and to keep them from collapsing remember that bernoulli principle if we breathe slowly what it's going to do is going to keep some air in those actual respiratory airways to keep them kind of slightly opened okay and it's also going to kind of create some resistance again think about that bernoulli principle but because they're kind of breathing through purse lips and prolonged expiration that you utilize a lot of accessory muscles for breathing so because of that sometimes these patients will have weight loss so that can be a common thing that we see another one oh and i can't forget another one here for blue bloaters and i'm going to write this down right here is they have what's called dyspnea on exertion so in other words they get short of breath based upon moving upon walking upon getting up anything that requires a lot of effort is going to cause a severe shortness of breath okay so that's another really really big one for blue bloaters but again weight loss is a common one and again go back to these other things it can cause wheezing okay it can cause wheezing up on expiration again because those airwaves are getting so narrow and they're collapsing you generally don't hear inspiratory crackles for these patients but again they do have that increased ap diameter and it's more common for these patients to have that increased ap diameter because of that significant air trapping and they're also going to have hyper resonance to percussion okay now with these patients it's not always clear-cut but again the ones that i really want you to remember here is that for blue bloaters it's a chronic productive cough and disney on exertion for pink puffers i want you to remember that they breathe through pursed lips to prolong their expiration because of that prolonged expiration helps to keep the airways try to keep it open but it can cause weight loss they can oxygenate usually in the early stages but over chronic periods of time it can lead to chronic hypoxemia and can lead to chronic hypercapnia which can lead to right ventricular heart failure but again that's more common with blue bloaters again a significant increase in ap diameter is also common but again they both can have that and they both can have hyper resonance to percussion and they both can have wheezing on expiration chronic bronchitis you can't have those inspiratory crackles because the mucous buildup whenever you inhale it can actually try to pop the airway open so those are some of the common things that we're going to see in patients who have the signs and symptoms of the chronic abstract or pulmonary disorder blue bloaters chronic bronchitis pink puffers emphysema next thing we're going to do is we're going to go into the diagnostics here okay the hallmark thing here well actually let me do the first one the first one that i really want you to remember is you can do these kind of sometimes based upon clinical diagnosis okay in other words you take into consideration their history so you look to see if they're a smoker you look to see if they work in situations where they're exposed to a lot of dust pollutants or silica you try to take and see if they have a family history of copd you look to see if they have some underlying liver disorder because again remember the alpha one anti-trypsin sometimes when situations if you don't make that alpha one at the trypsin it can cause destruction of the liver so they might have liver destruction so you can check their lfts but again you can go just based upon the history and physical examination particularly if someone has chronic bronchitis if someone has chronic bronchitis remember i told you one of the big things that can kind of tip you to think about this one is if they have three months per year times two years of productive cough this is one of the big things that kind of leads us to believe oh man this definitely could be chronic bronchitis emphysema obviously we could try to look for the you know some of the signs there one of the big things is you could do it's not always the best it's not really what we go with but you can do a chest x-ray and what a chest x-ray was showing i'll put that down here is it can show hyperinflation of the lungs so you can see that they're really really big you can also see that because the lungs are so big the diaphragm is really flat and they have lots of spots of what's called lucency dark spots on the chest x-ray too okay but that's one of the big ones that we can go with we can kind of just go based off history and physical examination but the gold standard here that would be the best best possible thing here would be to do pulmonary function tests so pulmonary function tests and again we talked about this in physiology and we went over the graphs and we went over a lot of the stuff with the four spirometry we went over uh the the inspiratory reserve volume and expiratory reserve volume total lung capacity so we have videos on our physiology playlist and respiratory if you guys want to watch more of that we're going to kind of go right into it though and talk about what kind of things we see that are abnormal okay so what we look at is we have them do spirometry we have them take like an apparatus we have them take as much air as they can in and breathe out as much air as they possibly can and what we're looking at with this is we're looking to see two particular numbers first so the first thing that we look for is we looked at their fev1 and this is just basically their forced expiratory volume in one second and we look at their f v c their forced vital capacity in patients who have chronic obstructive pulmonary disorders both of these are low but this one is even more significantly low so the fev1 is more significantly low or markedly lower in someone with copd and the fvc is also low as well now the next thing we can do is we can do the ratio so if you imagine here you can take the fev1 and you can divide it by the fvc and if it is less than 75 percent that is a positive sign that usually this is an obstructive pulmonary disorder so this is usually a positive sign of some type of copd and again that could be copd or it could be any obstructive lung disease it could be asthma it could be bronchiectasis could be cystic fibrosis so those are some of the things that we would look at but here's 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 just something like saba so it's basically albuterol and that's basically a beta adrenergic a beta-2 adrenergic agonist in other words it binds onto a beta-2 receptor and causes smooth muscle relaxation to open up the airway it dilates the airway that's going to help them to get more air in however with copd it's irreversible unfortunately so they'll have a small increase in their fev1 after you retake it but it's not going to be big enough so what we do is we do the bronchodilator we'll take these tests we'll do the bronchodilator and we'll re-measure afterwards and usually after the bronchodilator the fev1 is still less than 12 there's a less than 12 percent increase and that is usually a sign of copd okay if it's greater than 12 percent then that might be asthma but what we do is again we take their pulmonary function tests we take their fev1 we take their fec they're both low fev1 more low we do the ratio usually if it's less than 75 percent then we say this is an obstructive pulmonary disease the next thing we do is we try to monitor so we do a bronchodilator like a saba albuterol then after we've done that we have them do the pulmonary function test again they're still going to be low but what we look for is we look specifically at that fev1 how much did it change if the change was a 12 increase or above that's more likely asthma if it's less than a 12 increase that's most likely an irreversible situation and it's probably copd okay so that's how we go about with this test and again this is the gold standard for this one so this is the one that you definitely want to try to do okay other things that we could do is we could look at their pulse ox so their pulse oximetry is another one again what did i tell you with these situations here with patients who have chronic obstructive pulmonary disease they can develop hypoxemia so what you might find with these sits patients is that they might have a low o2 saturation and that's what you're going to have to look at you're going to want to look to see how significantly low is it so what we look for is we look to see if their o2 saturation is less than 88 that usually means that we got to start supplemental oxygen okay it's not a good sign okay we might have to put them on a nasal cannula or if their o2 sat is less than 90 percent but they have you know predisposed factors maybe they have right side heart failure or just in general some heart failure and they have an elevated hematocrit maybe they have polycythemia then again we're probably going to want to start them on supplemental oxygen so we usually have two thresholds one is if it's less than 88 percent we can get them started on supplemental oxygen or if it's less than 90 we can increase the threshold if they have heart failure or an elevated hematocrit but we'll also base it on another thing so the other thing that we do is we do an arterial blood gas and an arterial blood gas what it does is it gives us a couple 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 got to think about this if a patient has copd what did we say was some of the big things that we would find remember they're not able to get co2 out so there would be most likely elevated co2 what is that called hypercapnia what i want you to remember is in patients who have elevated co2 remember that equation back from physiology co2 plus water yields carbonic acid carbonic acid can disassociate into protons and bicarbonate so if you have a lot of co2 you have a right shift and that builds up a lot of protons what can protons do to the actual blood plasma make it acidic so you might notice a decrease in the ph remember what i told you that it also can actually decrease the oxygen and cause hypoxemia usually because someone is in his respiratory acidosis they might have a compensatory change in bicarbonate but we're not going to talk about this one okay that's more specifically for metabolic acidosis or alkalosis but these are some of the things that might lead us to believe that they might have respiratory acidosis okay and another thing i remember i told you that we'll talk about it later but when we start people on supplemental oxygen we do it based on their o2 stats but if we do an abg we can also base it on their oxygen usually we set it at 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's uh less than 60 because they have right side heart failure and elevated hematocrit again we can start the muscle supplemental oxygen but that's what we go to for the arterial blood gas so the next test that we could do here and and it's really good just to kind of uh rule out cardiac disorders is we can do an ekg and really all we're doing the ekg for is to rule out you know maybe a myocardial infarction or congestive heart failure and sometimes what you kind of have especially in someone who has a copd exacerbation it can happen it can produce this thing called a multi-focal atrial tachycardia i also call it mats all it is is is it causes these irregular qrs complexes but they have three distinctly different p waves one after another and the reason why is that they have two thoughts one is because in situations where there's hypoxemia the uh cells of the actual atria can try to actually set their own rhythm and so there can be multiple areas of the atria that are firing at the same time another one is if someone is actually taking blood pressure medications sometimes in blood pressure medications that can also cause it as well but again with ekg what we're trying to look at is we're trying to look for mis to rule out anything like that and we're also looking to see congestive heart failure especially one thing we can actually do is we want to see if there's any right ventricular heart strain sometimes you can see if there is right ventricular heart strain right ventricular strain you can look at the ekg and sometimes you might see inverted t waves so some things sometimes that can come about as well so again the reason why you would do an ekg is to really rule out any cardiac issue but again if somebody has this copd exacerbation sometimes because of the hypoxemia it 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 is maybe having signs of right ventricular heart strain they have some inverted t waves but again looking for right side heart failure ekg is not going to be enough for that you might have to do a bmp and echo and a swan god's catheter okay the last one that we're going to talk about generally it's not that great but you can do it you can do chest x-rays you can also do high-resolution cts those are a little bit better chest x-rays aren't as great but high-resolution cts can be also utilized and what they'll show is so we'll put hrtct is it can show air trapping so it'll generally show air trapping so hyperinflation of the lungs right it might even show a flat diaphragm if you get a chest x-ray so again on the chest x-ray you'll see some air trapping you might see a flat diaphragm again you can still see that increased anterior posterior diameter as well you might have some lucency and like the anterior chest wall as well um for emphysema you might see bula remember that you can see blue bulla and remember which one that distal acid or emphysema was one of the ones that you can see the bula commonly in because it can rupture and a bull is just basically an air pocket okay just an air pocket that could as easily can rupture because of its uh over time it can be distended in emphysema you can also have decreased vascular markings whereas with chronic bronchitis you might have increased vascular markings as well because of the again think about it that pulmonary hypertension maybe in the later stages of emphysema you might have increased vascular markings but generally it doesn't have that much okay so those are things that we would go off of the chest x-ray or the high resolution ct scan so again to go through it really quickly clinical diagnosis especially with chronic bronchitis three months of productive cough for a year for two consecutive years do your pfts can't stress enough this is the gold standard so you don't remember any of the other ones at least remember this one okay and again what we look for is a low fev1 and a low fvc but more the fev less than 75 percent tells us obstructive bronchodilator will show less than a 12 percent increase pulse ox you're looking for low o2 stats generally the cutoff is less than 88 to start them on supplemental oxygen arterial blood gas or an abg to look to see if they have any respiratory acidosis an ekg to rule out any cardiac situation like an mi heart failure particularly to see if there's any right ventricular heart strain seeing that inverted t waves and if they're in an exacerbation sometimes they have multifocal atrial tachycardia because of the hypoxemia and again you can do a chest x-ray or a high-res ct it can generally show you these common signs which is air trapping a flat diaphragm an increased ap diameter again emphysema usually decreased vascular markings in the later stage it might show increased vascular markings but chronic bronchitis will be more of the specific one to show you this increased vascular markings because of the toll that it takes on the pulmonary hypertension and the heart so one more additional thing you could do but it's not necessary is a cbc only reason i mentioned is i want you to think back to that physiology concept again if you have hypoxia what would that actually do to your kidneys it would stimulate the kidneys to make erythropoietin erythropoietin is a hormone that stimulates your red bone marrow to make more red blood cells erythropoies so you might suspect them to have an elevated red blood cell count polycythemia an elevated hematocrit but again that's not diagnostically specific okay so again that's going to be the big thing for being able to diagnose copd and specifically trying to see if it's chronic bronchitis or emphysema so one other thing that i wanted to mention with the pulmonary function test is again remember that the lungs of a copd patient is going to be super compliant and the reason why is they're going to have again that elastic tissue damage so there's going to be a lot of air trapping as we've said many times so because of that the volume of air that's in the lungs in general okay in general is going to increase so our total lung capacity of the patient's going to increase and even if we exhale remember the problem is exhaling air they're always going to have a lot of air trapped in the lungs afterwards what's that called the volume of air that remains in the lungs after a forceful exploration that's called a residual volume so there's going to be an increase in the residual volume one of the things that they actually do to test it is they can actually do what's called um diffusion lung capacity with carbon monoxide they can give a little bit of carbon monoxide and they look to see how much of it diffuses across the respiratory membrane in these patients they have a decreased dlco okay so they have a decrease in their diffuse i'm sorry the diffusion of carbon monoxide so their actual lung diffusion of carbon monoxide is going to decrease so they give a little bit of carbon monoxide but because of the decrease in the surface area or because of the obstruction again it's going to cause a decrease in the diffusion of the actual carbon monoxide across that membrane so these are things that we can see upon the pulmonary function test all right ninja so in this video we talked about the symptoms we talked about the diagnosis of copd i hope it made sense i hope you guys enjoyed it if you guys did please hit that like button comment down in the comment section please subscribe if you guys want to go in our description box we got links to our facebook our instagram our patreon or even our gofundme page if you guys want to go there keep in contact with us also if you guys can donate we would truly appreciate it as always ninja nerds until next time [Music] you

Channel: Ninja Nerd

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Keywords: Ninja Nerd Lectures, Ninja Nerd, Ninja Nerd Science, Chronic Obstructive Pulmonary Disease, emphysema, COPD, chronic bronchitis, pulmonary medicine, clinical features, respiratory disease, Lung, lungs, Lectures

Id: a_hjeb4dzuc

Length: 28min 3sec (1683 seconds)

Published: Mon Nov 23 2020