Chronic obstructive pulmonary disease (COPD) should be suspected in patients over 40 with respiratory symptoms like cough or breathlessness, especially smokers. The diagnosis is confirmed by spirometry showing airflow limitation. Differential diagnoses need excluding through history, examination, chest x-ray and additional tests. Severity is classified based on lung function, but symptoms, exercise capacity and body composition also provide important information for characterizing COPD patients.
Pulmonary rehabilitation is a comprehensive intervention based on a thorough patient assessment followed by patient tailored therapies that include, but are not limited to, exercise training, education, and behavior change, designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence to health-enhancing behaviors”
Pulmonary rehabilitation is a comprehensive intervention based on a thorough patient assessment followed by patient tailored therapies that include, but are not limited to, exercise training, education, and behavior change, designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence to health-enhancing behaviors”
Cardiac Rehabilitation has been defined as:
Coordinated, multifaceted interventions designed to optimize a cardiac patient’s physical, psychological, and social functioning so that they may, by their own efforts, resume and maintain as normal a place as possible in the community
Analysis of arterial blood sample provides precise measurement of acid-base balance in the body and of the lungs ability to oxygenate the blood and remove excess carbon dioxide
Assessment of a patient with respiratory dysfunction is incomplete without an ABG report
What does cardiac rehab involve? Cardiac rehabilitation doesn't change your past, but it can help you improve your heart's future. Cardiac rehab is a medically supervised program designed to improve your cardiovascular health if you have experienced heart attack, heart failure, angioplasty or heart surgery.
The 6-minute walk test (6MWT) is an easy to perform and practical test that has been used in the assessment of patients with a variety of cardiopulmonary diseases including pulmonary arterial hypertension (PAH). It simply measures the distance that a patient can walk on a flat, hard surface in a period of 6 minutes.
Cardiac Rehabilitation has been defined as:
Coordinated, multifaceted interventions designed to optimize a cardiac patient’s physical, psychological, and social functioning so that they may, by their own efforts, resume and maintain as normal a place as possible in the community
Analysis of arterial blood sample provides precise measurement of acid-base balance in the body and of the lungs ability to oxygenate the blood and remove excess carbon dioxide
Assessment of a patient with respiratory dysfunction is incomplete without an ABG report
What does cardiac rehab involve? Cardiac rehabilitation doesn't change your past, but it can help you improve your heart's future. Cardiac rehab is a medically supervised program designed to improve your cardiovascular health if you have experienced heart attack, heart failure, angioplasty or heart surgery.
The 6-minute walk test (6MWT) is an easy to perform and practical test that has been used in the assessment of patients with a variety of cardiopulmonary diseases including pulmonary arterial hypertension (PAH). It simply measures the distance that a patient can walk on a flat, hard surface in a period of 6 minutes.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
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We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
2. 22 J. Vestbo
The most difficult clinical problem will often be distinguishing COPD from per-
sistent poorly reversible asthma, especially in older patients. In general, it is easy
to distinguish asthma from COPD, in particular in young and middle-aged patients
where history will often suffice and where demonstration of a significant bron-
chodilator response is diagnostic of asthma. However, in older patients with signifi-
cant previous cigarette exposure and only modest reversibility to a bronchodilator,
the diagnosis can be difficult. In specialist clinics, measurements of NO in exhaled
air, cell differentials and mediators in induced sputum, and typical features such
as fragmented surface epithelium, presence of eosinophils and thickened basement
membrane in mucosal biopsies can all be used, but most often a more pragmatic
approach is needed. Treatment response to inhaled corticosteroids will often be the
indicator of the presence of asthma or COPD to the clinician but the evaluation by
treatment has never really been examined properly in prospective studies.
For most of the other differential diagnoses, the combination of a good clinical
assessment together with simple investigations will usually resolve any uncertainty;
often a chest radiograph will be helpful.
Table 2.1 Risk factors for chronic obstructive
pulmonary disease (COPD)*.
External
Smoking*
Socioeconomic status*
Occupation*
Biomass fuel exposure*
Internal
Genetic factors*
Gender
Chronic mucus hypersecretion
Other
Airway hyper-responsiveness*
Elevated IgE
Asthma*
Environmental pollution
Perinatal events and childhood respiratory illness
Recurrent bronchopulmonary infections
Diet
IgE immunoglobulin E
In an attempted descending order, *risk factors with strongest
evidence to support
Table 2.2 Most important differential diagnoses to
chronic obstructive pulmonary disease (COPD).
Respiratory
Chronis asthma
Bronchiectasis
Obliterative bronchiolitis
Diffuse panbronchiolitis
Tuberculosis
Non-respiratory
Congestive heart failure
Recurrent pulmonary embolism
3. 2 Clinical Assessment 23
In the middle-aged and elderly, congestive heart failure is an important differential
diagnosis. In many text books, fine basilar inspiratory crackles on auscultation is
referred to as a good sign of heart failure but often minor abnormalities can be found
in COPD as well. In this case, a chest radiograph is often helpful showing a dilated
heart and flow shift indicating heart failure. Spirometry will more often show volume
restriction than airflow restriction but particularly in more severe cases airflow limitation
secondary to heart failure can be seen.
A diagnosis of bronchiectasis is often helped by a history of large volumes of sputum.
It can sometimes be seen on a plain chest radiograph but often a diagnostic high-
resolution computed tomography (HRCT) scan is required for diagnosis. Caution in
interpreting bronchiectasis on an HRCT scan as absence of regular COPD is warranted
as the two diseases often coexist.
Tuberculosis is an important differential diagnosis in high-prevalence countries and
a chest radiograph is important. Obstructive bronchiolitis is seen much less frequently
than COPD, is more frequent in younger patients and is often associated with rheu-
matoid arthritis or extensive fume exposure but smoking may be causative as well. An
HRCT scan, preferably with expiration scans, is needed. Diffuse panbronchiolitis is
rare and not smoking-related; HRCT is needed for diagnosis.
When differential diagnoses have been excluded, a post-bronchodilator FEV1
/FVC
ratio <0.7 confirms the diagnosis of COPD. Again, caution is required when using this
fixed cut-off value. The normal value for the FEV1
/FVC ratio is age-dependent and
whereas a ratio <0.7 is clearly abnormal in a 40-year old it is close to the expected
value for an 80-year old. Thus, COPD is likely to be under-diagnosed in younger
adults and “over-diagnosed” in the elderly; whether this is truly over-diagnosis or
actually abnormality associated with excess risk (like arterial hypertension associated
with age) is currently unknown. If spirometry is requested on the basis of breathless-
ness this dilemma is usually trivial. However, an increasing number of more affluent
patients are being diagnosed in health programmes or as a result of screening and have
no symptoms. In this case, liberal use of the diagnostic label of COPD is unlikely to
be very helpful in those with borderline abnormal spirometry.
Once a diagnosis of COPD is established it is recommended that staging takes place.
According to guidelines, classification of the severity of the disease is based on FEV1
expressed in per cent of predicted value as shown in Table 2.3. In addition to problems
arising from the use of different reference values, or lack of locally derived reference
values in certain ethnic population groups, it is well-known that composite scores
including lung function, symptoms, body weight and exercise tolerance have better
Table 2.3 Severity grading of chronic obstructive pulmonary disease (COPD)
according to GOLD [1].
Stage I: Mild
FEV1
/FVC < 0.70 FEV1
³ 80% predicted
Stage II: Moderate
FEV1
/FVC < 0.70 50% £ FEV1
< 80% predicted
Stage III: Severe
FEV1
/FVC < 0.70 30% £ FEV1
< 50% predicted
Stage IV: Very severe
FEV1
/FVC < 0.70 FEV1
30% predicted or FEV1
50% predicted
plus chronic respiratory failure
4. 24 J. Vestbo
predictive value than FEV1
alone; a good example of such a score is the BODE index [6].
If such a score is not used in its suggested form, several of the variables should never-
theless be registered, see later.
Symptoms in COPD
The most common symptoms seen in COPD are breathlessness, cough and fatigue.
There is no good correlation between lung function and symptoms of COPD, not even
the standardized scoring of breathlessness correlates well with FEV1
; the important
message being that a simple physiological measure can never substitute a symptom
history.
Breathlessness
Breathlessness is the most significant symptom in COPD and it is associated with
significant disability, poor quality-of-life and poor prognosis.
Although the degree of breathlessness in a single patient can be difficult to under-
stand – let alone explain, properly – we understand a lot about the mechanisms
underlying the sensation of breathlessness in COPD [7]. Breathlessness is defined as
an awareness of increased or inappropriate respiratory effort and is assumed to relate
to an awareness of the motor command to breathe. The terms used to describe breath-
lessness may vary with the stimulus used to provoke it and despite the increased time
for expiration many COPD patients describe the sensation of breathlessness as one
of inspiratory difficulty [8]. The intensity of breathlessness is best related to changes
in end-expiratory lung volumes during exercise and this fact probably explains the
need to look at changes in measurements other than FEV1
and FVC for characterizing
COPD patients’ disability or for assessing effects of treatment. For this purpose, meas-
urements of inspiratory capacity (IC) may be better suited (see Chap. 3).
In early stages of COPD, patients often modify their behaviour in order to cope with
the sensation of breathlessness. Patients avoid climbing stairs, get help with cleaning and
shopping, and to the author it has always been a mystery how otherwise well-functioning
subjects can ascribe increasing breathlessness associated with ordinary tasks as being
merely the results of “age.” However, with increasing severity of COPD, breathlessness
becomes an unavoidable symptom and in severe and very severe COPD there is rarely any
time when patients are asymptomatic. In very severe COPD, the patient is usually breath-
less on minimal exertion but due to the poor correlation between FEV1
and breathlessness
some patients may have surprisingly high levels of activity, even in late-stage COPD.
The degree of breathlessness can be measured using a number of different scales
and questionnaires. The simple MRC dyspnoea scale [9] is a useful tool but as it was
originally developed for assessing breathlessness in epidemiological surveys in the
workplace, it is relatively insensitive to changes. However, a slightly modified version
of the MRC Questionnaire, as shown in Table 2.4, has been translated into numerous
languages, is easy and quick to use and it relates well to measures of health status and
has additional predictive value to that of FEV1
when it comes to predicting resource
utilization and mortality [10].
The baseline and transitional dyspnoea indices of Mahler et al. [11] are much more
specific and more susceptible to change but in addition they are much more time-
consuming to use for clinicians; its main role lies in evaluating interventions with a
supposed effect on breathlessness. The Borg category scale, as shown in Table 2.5, is
5. 2 Clinical Assessment 25
often used in the exercise laboratory as it measures short-term changes in perceived
intensity during a particular task, e.g., during shuttle walk testing. It is simple and easy
to explain. As an alternative, visual analogue scales can be used; however, like the
Borg scale, this approach is for use in task-specific situations and cannot be used for
assessing the degree of breathlessness associated with usual daily tasks.
Although there is an increasing focus on systemic manifestations of COPD (see later),
breathlessness is a major cause of deconditioning and subsequent muscle wasting in
COPD. This has profound effects on the life of COPD patients as illustrated in Fig. 2.1.
Table 2.4 The Medical Research Council dyspnoea scale (Modified).
Grade Description
0 Not troubled with breathlessness except with strenuous exercise
1 Troubled by shortness of breath when hurrying or walking up a slight hill
2 Walks slower than people of the same age due to breathlessness or has to stop for
breath when walking at own pace on the level
3 Stops for breath after walking 100 m or after a few minutes on the level
4 Too breathless to leave the house or breathless when dressing or undressing
Table 2.5 The Borg scale.
0 Nothing at all
0.5 Very, very slight (just noticeable)
1 Very slight
2 Slight (light)
3 Moderate
4 Somewhat severe
5 Severe (heavy)
6
7 Very severe
8
9
10 Very, very severe (almost maximal)
Maximal
Immobilization
DepressionDeconditioning
Social isolationBreathlessness
COPD
Fig. 2.1. The impact of breathlessness in chronic obstructive pulmonary disease (COPD)
6. 26 J. Vestbo
Cough and Sputum Production
Cough is a respiratory defence mechanism protecting the airways and cough is the
major method of clearing excess mucus production [12]. In COPD patients, cough as
a symptom is almost as common as breathlessness and may actually precede the onset
of breathlessness [8]. Cough is usually worse in the morning but seldom disturbs the
patient’s sleep; it can, nevertheless, be disabling because of the embarrassment felt
by many patients when they have bursts of productive cough on social occasions and
may contribute to the isolation often imposed on patients due to breathlessness (see
Fig. 2.1). The actual role of cough and phlegm on the natural history of COPD has
been debated for decades. Currently, most epidemiological studies seem to show that
the symptoms of chronic bronchitis do not increase the risk of developing COPD in
smokers with normal lung function [13]. However, the presence of these same symp-
toms in patients with severe and very severe COPD predict both a more rapid decline
in lung function and more frequent acute exacerbations of COPD [14, 15].
In patients with more severe COPD, cough syncopy is frequent. It arises from the
acute increase in intrathoracic pressure during cough, producing a transient reduction
in venous return and cardiac output. A similar mechanism is thought to be the explanation
for cough fractures.
Cough is difficult to measure. Questionnaires exist but their validity is questionable
and devices for direct measurement of cough are still in the development stage.
Wheezing
Wheezing is generally seen as an asthma symptom but frequently occurs in COPD as
well. However, nocturnal wheeze is uncommon in COPD and suggests the presence of
asthma and/or heart failure [2, 3].
Fatigue
Fatigue is frequently reported by COPD patients. It is a ubiquitous and multifactorial
symptom not to be confused with simple physical exhaustion due to breathlessness but
is more an awareness of a decreased capacity for physical and mental activity due to
lack of resources needed to perform the activity in question. Fatigue has been identi-
fied as a serious consequence in a number of chronic conditions and will undoubtedly
be a focus of attention in the future characterization of COPD. No standardized meas-
urement scales for fatigue in COPD exist.
Other Symptoms
Chest pain is a common complaint in COPD, mostly secondary to muscle pain.
However, it should be noted that ischaemic heart disease is frequent in any population
of heavy smokers and COPD patients may be at particular risk. Acid reflux occurrence
is also frequent in COPD.
Ankle swelling may result from immobility secondary to breathlessness or as a result
of right heart failure. Anorexia and weight loss often occur as the disease advances and
should be mirrored by measurements of body mass index (BMI) and body composition
(see later). Psychiatric morbidity is high in COPD, reflecting the social isolation, the
neurological effects of hypoxaemia and possibly the effects of systemic inflammation;
this is described in more detail in Chap. 17. Sleep quality is impaired in advanced
disease [16] and this may contribute to neuropsychiatric comorbidity.
7. 2 Clinical Assessment 27
Assessment of the Patient Suspected of COPD
History
An accurate history, not least for the purpose of excluding differential diagnoses,
should include family history of heart and lung diseases, childhood diseases (atopic
and infectious), environment in which the subject grew up including exposures to
fumes gas and dust, education and occupational experiences.
Most patients are, or have been, smokers with cigarette smoking dominating.
Depending on the environment, patients may underestimate their tobacco use when
confronted with questions on life-time smoking habits. Calculation of pack-years of
smoking provides a useful estimate of smoking intensity (1 pack-year is equivalent to
20 cigarettes smoked per day for 1 year – or ten cigarettes smoked per day for 2 years)
but additional information is needed on debut of smoking and inhalation habits.
Objective verification of smoking status can be helpful and is often used in smoking
cessation programmes, most often using exhaled breath carbon monoxide or urinary
nicotine measurement.
Occupational exposures to organic dust and fumes contribute to the accelerated
decline in the lung function characteristic of COPD [4, 5]. The evidence for outdoor
as well as indoor pollution is much weaker except for areas where indoor burning of
biomass fuel has lead to more extensive exposure.
Finally, a social history is needed in most COPD patients. Often the carer for the
patient will have the same age and possibly other chronic diseases and the need for
social support may depend on this. Also, the smoking habits of the family may deter-
mine the outcome of smoking cessation intervention.
Physical Signs
Not surprisingly, it is difficult to come up with standardized guidance for a disease that
spans from almost normal health to terminal disease. The physical signs in patients
with COPD will invariably depend on the severity of disease. A physical examination
will in general be a poor tool for detecting mild or moderate COPD, and the repro-
ducibility of physical signs have been shown to be very variable. In contrast, physical
signs are more specific and sensitive for severe COPD.
Patients with mild and moderate disease appear normal in clinic and usually have
done little to reduce their normal daily activities. Patients with severe COPD, and
indeed very severe COPD, will appear breathless just from entering the clinic room,
and even a short history will often be sufficient to realize that they are distressed.
These patients will often appear to have a “barrel chest.” This used to be ascribed to
emphysema, but more likely it represents the visible component of hyperinflation,
where patients, in order to meet the ventilatory demands, increase their end-expiratory
lung volume. Patients will often sit leaning forward with their arms resting on a table in
front of them or on some other stationary object in order to use the ribcage and larger
muscles to function as inspiratory muscles. Often, these patients often use pursed-lips
breathing, presumably to avoid small airways collapse during tidal breathing.
The general stature of the patients should be observed. Weight loss, especially
when there is clear muscle atrophy, can be a sign of severe disease, emphysema-
tous-type COPD and likely a systemic effect of COPD, possibly due to systemic
inflammation.
The patient’s breathing should also be observed. Use of accessory muscles indicates
severe disease. Percussion of the chest is of little, if any, use in patients with COPD.
8. 28 J. Vestbo
A tympanic percussion note is not specific for pulmonary hyperinflation and it is dubious
if clinicians can use percussion for estimation of diaphragmatic motion.
On auscultation, patients with COPD generally have a noisy chest although patients
with significant emphysema in a stable state can have remarkably few chest sounds.
Although significant research has been carried out on chest sounds, it is unclear to this
author if it should have any impact on the daily management of patients with COPD
where the value of auscultation is generally limited – except in cases where comorbidi-
ties or complications may be detected this way; e.g., as unilateral wheeze in cases of
endobronchial tumour, or decreased chest sounds on one side due to pneumothorax.
Auscultation of the heart is an essential part in the physical examination of COPD
patients. Severe COPD is associated with tachycardia at rest and with increasing
severity of disease the risk of atrial fibrillation increases. Ventricular gallop rhythm,
increases in the pulmonary second heart sound and murmurs of pulmonary or tricuspid
insufficiency can all be signs of cor pulmonale.
A raised JVP, hepatomegaly and peripheral oedema have all been considered as
signs of pulmonary hypertension and cor pulmonale. However, these signs are not
specific for cor pulmonale as a raised JVP may result from increased intrathoracic
pressure secondary to dynamic hyperinflation and hepatomegaly may be illusive due
to downward displacement of the liver by the diaphragm in the hyperinflated chest.
Finally, peripheral oedema can be the result of both altered renal function as a result
of hypoxaemia and the result of simple inactivity.
Body Habitus
Weight, or rather BMI, has been shown to be a very strong predictor of prognosis with
rapidly increasing risk of dying when BMI falls, even within the normal range [17, 18].
Some studies indicate that measures of fat-free mass can add further information [19];
the easiest and cheapest way of measuring body composition is by using measure-
ments of body impedance. Measures of skin-fold thickness or mid-thigh diameter may
also be useful but currently these methodologies have not been validated to the extent
of body impedance. A BMI 20 kg/m2
will denote a subject at risk as will a fat-free
mass index 15 kg/m2
in women and 17 kg/m2
in men.
Lung Function Tests
The role of lung function tests COPD is crucial for diagnosis, assessment of severity,
prognosis and for monitoring the course of the disease. The physiologic assessment of
the COPD patient is described in detail in Chap. 3.
Arterial Blood Gases
In stable state, there is a general relationship between reductions in FEV1
and arte-
rial oxygen tension (Pa
O2
), whereas arterial carbon dioxide tension (Pa
CO2
) usually
remains within the normal range until FEV1
falls below 1.0–1.2 l (30% of predicted)
and even then large variations are found. Measurement of arterial blood gases with
the patient breathing room air is recommended for assessing patients with moderate
or severe COPD. Often, a practical approach is to initially measure arterial oxygen
saturation (SatO2
) by means of pulse oximetry. If SatO2
is 92%, arterial gases should
be measured.
9. 2 Clinical Assessment 29
Exercise Testing
Exercise capacity can be assessed in different ways, but outside the physiology labo-
ratorium; either a 6 min walk test or incremental shuttle walk testing is used. The cor-
relation between lung function and exercise capacity is poor in the individual patient
but in groups there are clear correlations, particularly with measures that reflect hyper-
inflation such as IC. As mentioned earlier, breathlessness during exercise can be meas-
ured easily using either a Borg scale (Table 2.5) or a visual analogue scale. During
exercise, the severity of breathlessness is closely related to ventilation and to the severity
of dynamic hyperinflation. Many, but not all, patients will desaturate during exercise and
the extent of arterial desaturation is related to both TLCO
and resting blood gases.
Assessing exercise capacity is of particular value in patients whose breathlessness
appears to be out of proportion to simple spirometric measures; it can also provide infor-
mation of value for assessing cardiac disease through aligning the exercise test with a
cardiac exercise test used for assessing ischaemic heart disease. Exercise testing is also
usually done before and after pulmonary rehabilitation and is increasingly being used to
assess the value of other interventions, including pharmacological treatments, see Chap. 3.
In parallel with exercise testing, tests of muscle strength may be applied. Simple meas-
ures, e.g., quadriceps muscle strength, have been shown to be of value in COPD [20].
Blood Tests
Blood tests are often of little use in COPD but can be used for identifying polycythaemia
in patients with severe COPD as this is associated with risk of subsequent vascular
events, and there is some evidence to suggest that venesection may improve exercise
tolerance as well as mental capacity. As in other chronic diseases, anaemia can occur
as a systemic consequence and is generally a marker of poor prognosis; anaemia
associated with COPD is usually normochromic and normocytic, characteristic of the
anaemia of chronic disease. There is no indication for assessing blood biochemistry
routinely in COPD patients and although there is a growing research interest in markers
of systemic inflammation in COPD, data so far available are difficult to implement in
clinical practice.
a1
-Antitrypsin levels should be measured in all patients aged 50 years, and in those
with a family history of emphysema at an early age.
Radiology
There are no specific features of COPD on a plain chest radiograph. A radiologi-
cal diagnosis of “emphysema” on a plain chest radiograph is usually based on lung
overinflation and should be reported as such. Overinflation of the lungs results in low
diaphragms, an increase in the retrosternal airspace and an obtuse costophrenic angle
on the postero-anterior or lateral chest radiograph. The vascular changes associated
with emphysema can often be seen on a plain chest radiograph by a reduction in the
size and number of pulmonary vessels, particularly at the periphery of the lung, vessel
distortion and areas of transradiancy; however, assessment of vascular loss in emphy-
sema is very dependent on the quality of the radiograph.
Computed tomography (CT) can be used for the detection and quantification of
emphysema, either using semiquantitative visual assessment of low-density areas on
the CT scan or by using measures of lung density to quantify areas of low x-ray attenu-
ation. Several studies have shown that visual evaluation of the CT scan can locate areas
10. 30 J. Vestbo
of macroscopic emphysema in post mortem or resected lungs. The use of HRCT with
thin slices does not improve the detection of mild emphysema; however, HRCT can be
used to distinguish between the various types of emphysema.
More quantitative approaches to assessing macroscopic emphysema have been
employed [21, 22]. They use the original virtue of the CT-scanner as a densitometer.
As emphysema develops, alveolar wall mass decreases and this leads to a decreased
CT lung density. Initial experiences suggest that this can be used to measure progression
of emphysema, although the radiation involved precludes its use as a frequent measure
of disease progression.
Magnetic resonance (MR) scanning using hyperpolarised gases such as Helium is
still in its pioneering phase.
Electrocardiography and Echocardiography
Routine electrocardiography is not required in the assessment of patients with COPD
unless cardiac comorbidities are suspected, including atrial fibrillation. ECG is an
insensitive technique in the diagnosis of cor pulmonale.
Echocardiography can be used to assess the right ventricle and for the detection of
pulmonary hypertension. In addition, it provides an opportunity to check for cardiac
comorbidity, particularly in patients with breathlessness out of proportion to the findings
on general examination and from pulmonary function testing.
Assessment of the Patient with Acute Exacerbation of COPD
This issue is dealt with in detail in Chap. 12 and has been reviewed recently [23].
Summary
COPD should be suspected in any patient aged 40 years or more with symptoms
of cough, sputum production, or breathlessness and/or a history of exposure to risk
factors, in particular smoking. Spirometry is needed for both diagnosis and staging,
although other parameters such as breathlessness, exercise tolerance and body mass
and/or body composition should be included in the staging procedure.
In the assessment of patients suspected of COPD, several differential diagnoses
should be considered. Assessment can usually be done using fairly simple clinical
tools, although advanced imaging seems to be a promising tool for the near future.
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