This document discusses the treatment of acute exacerbations of asthma and COPD. For asthma, treatment involves high doses of inhaled bronchodilators, systemic corticosteroids, oxygen therapy, and intravenous fluids. For COPD, treatment focuses on oxygenation, ventilation support using non-invasive ventilation if needed, nebulized short-acting bronchodilators, corticosteroids, and antibiotics for bacterial infections. Lung volumes measured via spirometry can differentiate obstructive disorders like COPD and asthma from restrictive disorders. Obstructive disorders show reduced airflow and FEV1/FVC ratio, while restrictive disorders have normal ratio but reduced lung volumes. Emergent tests for diagnosis include ECG, arterial blood gases,

1. Clinical vignette 3
obstructive and
restrictive lung disease
Ghaida Al-Rashed

2. Objectives
Describe the treatment of acute exacerbation of
asthma and COPD ??
How can lung volumes be used to differentiate
between obstructive and restrictive lung
disease ?
 What are the emergent investigations are to be
performed on an emergency basis to reach the
diagnosis ?

3. Objectives:
Describe the treatment of acute exacerbation of
asthma and COPD ??

4. ACUTE EXACERBATION OF ASTHMA
Treatment
 Oxygen 40-60%
 High doses of inhaled bronchodilators .
 Systemic corticosteroids.
 Intravenous fluids.
 Subsequent management.

5. OXYGEN
The patient should supply by High concentrations
of oxygen:
Goal: SaO2 > 92%
Failure to achieve appropriate oxygenation  assisted
ventilation.

6. INHALED BRONCHODILATORS
o Short-acting β2 agonist agent (SABA) :
(Salbutamol 5 mg/hr) or (terbutaline 10mg/hr)
via nebulizer driven by oxygen
via metered dose inhaler through a spacer device
o Inhaled anti-cholinergics (SAMA)
(Ipratropium bromide 0.5 mg):

7. SYSTEMIC CORTICOSTEROIDS
• Hydrocortisone sodium succinate:
 Dose: 200 mg 4 hourly
 Rote: intravenous
 in patients who are unable to swallow or vomiting.

8. ARTERIAL BLOOD GASES
We should correct ABG especially If patients ..
o Initial PaCO2 measurement was raised ( >7 kPa)
o PaO2 was < 8 kPa (60 mmHg)
o the patient deteriorates.

9. SUBSEQUENT MANAGEMENT
If patients fail to improve:
o Intravenous magnesium sulphate (1.2–2 g over 20 min)
o Intravenous β2 agonists (e.g. Salbutamol)
o Intravenous aminophylline (5mg/kg loading dose over 20
minutes)
Chest x-ray
To exclude
pneumothorax

10. MANAGEMENT OF COPD
The goals of effective COPD management are to:
1. Prevent disease progression
2. Relieve symptoms
3. Improve exercise tolerance
4. Improve health status
5. Prevent and treat complication

11. OXYGENATION AND VENTILATION
• Oxygen therapy:
the oxygen saturation level should be at least 90%.
• Respiratory support:
Non-invasive positive pressure ventilation (NIPPV) BiPAP
 improves blood gases.
 indicated if adequate ventilation cannot be achieved using a
high-flow mask.
Nasal oxygen therapy  Non- invasive mechanical ventilation 
invasive mechanical ventilation

12. Con..
• SHORT-ACTING BRONCHODILATORS (nebulization)
1. Inhaled short-acting β2 agonist agent (SABA).
2. Inhaled anti-muscarinic (SAMA).
• CORTICOSTEROIDS:
Short courses of systemic corticosteroids.
• ANTIBIOTICS
with bacterial infection

13. PREVENTING FUTURE EXACERBATIONS
Appropriate
use of
inhaled
corticosteroid
+
inhaled
bronchodilator
s
Smoking
cessation
vaccination

14. Objectives:
How can lung volumes be used to differentiate
between obstructive and restrictive lung disease ?

15. OBSTRUCTIVE VS. RESTRICTIVE
Obstructive disorders
• Characterized by: reduction in
airflow.
• So, shortness of breath  in
exhaling air.
( the air will remain inside the
lung after full expiration )
1. COPD
2. Asthma
3. Bronchiectasis
Restrictive disorders
• Characterized by a reduction
in lung volume.
• So, Difficulty in taking air
inside the lung.
( DUE TO stiffness inside the lung tissue
or chest wall cavity )
1. Interstitial lung disease.
2. Scoliosis
3. Neuromuscular cause
4. Marked obesity

16. SPIROMETRY measures the rate of lung volume changes
during forced breathing maneuvers
The diagnosis and distinguished between
obstructive and restrictive lung diseases.
Confirmed by  Spirometry

17. DIFFERENT BETWEEN OBSTRUCTIVE
VS. RESTRICTIVE
Obstructive disorders
• Decrease in both FEV1 and
FEV1/FVC ratio .
Restrictive disorder
• Normal FEV1/FVC ratio .
Forced vital capacity (FVC):
The maximum volume of air forcibly exhaling from the point of
maximal inhalation.
Forced expiratory volume in 1 second (FEV1):
Forced expiratory volume in 1 second during FVC maneuver.
Ratio of FEV1 and FVC (FEV1/FVC):
Expressed as percentage

20. Objectives:
 What are the emergent investigations
are to be performed on an emergency basis
to reach the diagnosis ?

21. Emergent Investigations
1- ECG- ABNORMAL:
In 70% patients with PE:
- Sinus tachycardia
- Nonspecific ST-T wave abnormalities
- RBBB

22. 2- ARTERIAL BLOOD GASES:
o hypoxemia, hypocapnia, and respiratory alkalosis due to
hyperventilation.
PO2 and A-a gradient
most often abnormal Profound hypoxia with normal chest X-ray
in the absence of preexisting lung disease is highly suspicious of
pulmonary embolism.

23. 3- D-DIMER
• D-dimer: A degradation product of fibrin.
• is a substance in the blood that is often increased in people
with PE.
D-dimer levels are abnormal in patients with PE; a person
with a normal D-dimer level is unlikely to have a PE.
 Positive D-dimer indicate abnormal high level of fibrin
degradation product ( indicate significant blood clut)

24. Summary

25. References
• http://www.who.int/respiratory/copd/manag
ement/en/
• http://www.aafp.org/afp/2010/0301/p607.ht
ml
• http://emedicine.medscape.com/article/3009
01-workup#c9