Snapshot A 23-year-old man presents to the emergency department with severe pleuritic chest pain. He tells the resident that he is worried he might have another collapsed lung. 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 air outflow obstruction Defined by alveolar wall destruction and dilation that presents in two forms almost always due to smoking (even if only secondhand) panlobular is rare and caused by alpha1-antitrypsin deficiency Patients identified as "pink puffers" pink complexion due to hypoxic state, which is less severe than in "blue bloaters" puffer describes compensatory hyperventilation necessary to normalize blood gas Presentation Symptoms mild dyspnea hyperventilation mild cough pinkish skin coloration fatigue Physical exam late hypercarbia/hypoxia barrel chest (increased AP chest diameter) thin, wasted appearance pursed-lip breathing decreased heart and breath sounds prolonged expiratory phase end-expiratory wheezing scattered rhonchi digital clubbing (only in the presence of other comorbidities such as lung cancer, interstitial lung disease, or bronchiectasis) Evaluation Diagnosis is based highly on clinical observations 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 PFTs decreased FEV1 / FVC normal or decreased FVC normal or increased TLC (in emphysema and asthma, specifically) decreased DLCO (in emphysema, specifically) 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, 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 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 disease cannot be reversed, only slowed Prevention alpha1-antitrypsin deficiency cannot be prevented, and should be managed accordingly acute exacerbations and progression of disease secondary to smoking can be slowed with lifestyle modifications and strict adherence to treatment measures Complications if untreated or ignored, disease can progress rapidly leading to death