Snapshot A 46-year-old female presents to her primary care physician for follow-up for a severe, unrelenting, productive cough that she had had on and off for more than two years Introduction One of two major presentations of Chronic Obstructive Pulmonary Disease (COPD) including chronic bronchitis and emphysema Characterized by decreased lung function in the setting of airflow obstruction Defined by productive cough for >3 months per year for two consecutive years Patients identified as "blue bloaters" color indicative of hypoxia observed in bluish tint of skin and mucous membranes barrel-chested secondary to hyperinflation of the lungs due to outflow obstruction Presentation Symptoms minimal and non-specific until advanced disease productive cough cyanosis mild dyspnea hyperventilation swollen feet/ankles hemoptysis Physical exam hypercarbia/hypoxia decreased breath sounds ronchi end-expiratory wheezing barrel-chested pursed-lip breathing signs of pulmonary hypertension RVH JVD hepatomegaly peripheral edema Evaluation ABG hypoxemia decreased PO2 acute or chronic respiratory acidosis increased PCO2 CXR decreased lung markings with flattened diaphragm hyperinflated lungs with bullae and/or blebs thin-appearing heart and mediastinum barrel-chest Lung biopsy diagnostic gold standard increased Reid index ( gland layer > 50% of total bronchial wall) PFTs decreased FEV1 / FVC normal or decreased FVC normal or increased TLC (in emphysema and asthma, specifically) roughly normal DLCO vs. decreased DLCO in emphysema Blood cultures order only if patient is febrile Gram stain and sputum culture order in setting of fever or productive cough Differential Chronic bronchitis, asthma, emphysema, bronchiectasis Treatment Medical management O2, beta-agonists, anticholingerics, inhaled/IV steroids, antibiotics indicated for acute exacerbations inhaled Beta-agonists albuterol inhaled anticholinergics ipratropium, tiotropium IV and inhaled steroids broad-spectrum antibiotics use is controversial smoking cessation, ambulatory O2, bronchodilator, steroids, vaccines indicated for chronic disease smoking cessation best intervention for lowering mortality ambulatory O2 resting PaO2 < 55mmHg or SaO2 <89% bronchodilators systemic or inhaled steroids Pneumococcal and flu vaccines Prognosis, Prevention, and Complications Prognosis highly dependent of severity of disease, timing and adherence to treatment monitored via FEV1 results (higher FEV1 indicates better disease status, lower FEV1 indicates worsening disease) Prevention acute exacerbations and progression of disease can be slowed with lifestyle modifications (i.e. smoking cessation) and strict adherence to treatment measures Complications if untreated or ignored, disease can progress rapidly leading to death