Introduction Defined as expectoration for > 3 months for > 2 consecutive years Pathophysiology overproduction of mucus due to inflammation central and peripheral airways involved results in hyperplasia of bronchiolar mucus glands and fibrosis of terminal bronchioles ciliary dysfunction Causes smoking chronic irritation promotes hyperplasia of mucus glands and increases mucus production toxicity of smoke destroys ciliated epithelium and reduces mucus clearance cystic fibrosis loss of CFTR function results in increased viscosity of mucus and decreased mucus clearance Presentation Symptoms dyspnea productive cough Physical exam wheezing and crackles on auscultation prolonged expiration classic pursed lip breathing "blue bloater" (end-stage) chronic alveolar hypoxia leads to pulmonary hypertension edematous due to right heart failure (end-stage) cyanosis of skin Evaluation Labs ABG during exacerbation shows hypoxemia and may show acute respiratory acidosis hypoxemia can stimulate increased erythropoetin production by the kidneys can see polycythemia with prolonged hypoxemia chronic respiratory acidosis Chest radiograph cardiomegaly (horizontally oriented) increased bronchial markings (due to mucus) Clinical diagnosis confirmed by lung biopsy (rarely indicated) ↑ Reid index gland layer > 50% of total diameter of bronchial wall bronchial wall measured from the surface epithelium to the beginning (but not including) the cartilaginous rings patch squamous metaplasia neutrophil infiltration Pulmonary function tests hallmark is obstruction ↓ FEV / FVC similar to emphysema ↑ TLC (less than emphysema) Treatment Conservative smoking cessation home oxygen Pharmacological bronchodilators and inhaled steroids for long-term maintenance systemic steroids and antibiotics for acute exacerbations roflumilast for severe disease Complications Pulmonary hypertension chronic alveolar hypoxia results in pulmonary vasoconstriction right side ventricular hypertrophy and failure (cor pulmonale) distended neck veins hepatomegaly
QUESTIONS 1 of 7 1 2 3 4 5 6 7 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M1.PL.138) A 70-year-old male with a 10-year history of COPD visits his pulmonologist for a checkup. Physical examination reveals cyanosis, digital clubbing, and bilateral lung wheezes are heard upon auscultation. The patient has a cough productive of thick yellow sputum. Which of the following findings is most likely present in this patient? Review Topic QID: 100941 1 Decreased arterial carbon dioxide content 0% (0/9) 2 Increased pulmonary arterial resistance 78% (7/9) 3 Increased pH of the arterial blood 22% (2/9) 4 Increased cerebral vascular resistance 0% (0/9) 5 Increased right ventricle compliance 0% (0/9) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (M1.PL.133) A 65-year-old male presents to the emergency department from his home complaining of dyspnea. He is alert and oriented. The following arterial blood gas readings are drawn: pH: 7.33 (Normal: 7.35-7.45), pCO2: 70 mmHg (Normal: 35-45 mmHg), HCO3 33 (Normal: 21-26 mEq/L) Which of the following is most likely to have produced this patient’s condition? Review Topic QID: 100936 1 Panic attack 0% (0/13) 2 Mechanical ventilation 8% (1/13) 3 Diabetic ketoacidosis 8% (1/13) 4 Pulmonary embolus 8% (1/13) 5 Chronic obstructive bronchitis 69% (9/13) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 5 (M1.PL.84) A 45-year-old man presents with a chronic productive cough that he has had for the past few years. He admits to having smoked 1 pack of cigarettes a day for the past 25 years. A chest radiograph reveals an enlarged heart. The patient's pulmonary function tests would be similar to that seen in a patient with: Review Topic QID: 100887 1 Asymptomatic asthma 0% (0/16) 2 Silicosis 6% (1/16) 3 Emphysema 88% (14/16) 4 Coal worker's pneumonitis 6% (1/16) 5 Prior lung radiation 0% (0/16) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (M1.PL.76) A post-mortem lung examination of a 68-year-old male overweight male with evidence of chronic lower extremity edema, a 60 pack-year smoking history and daily productive cough would be most likely to reveal: Review Topic QID: 100879 1 Hypereosinophilia 0% (0/12) 2 Reid Index > 50% 83% (10/12) 3 Non-caseating granulomas 0% (0/12) 4 Evidence of a necrotizing infection 0% (0/12) 5 Keratin pearls 8% (1/12) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (M1.PL.65) A 68-year-old male smoker dies suddenly in a car accident. He had smoked 2 packs per day for 40 years. His past medical history is notable for a frequent, very productive cough, recurrent respiratory infections and occasional wheezing. He had no other medical problems. At autopsy, which of the following is most likely to be found in this patient? Review Topic QID: 100868 1 Interstitial fibrosis of the lung 9% (1/11) 2 Pleural plaques 0% (0/11) 3 Increased number and activity of goblet cells 82% (9/11) 4 Ferruginous bodies 0% (0/11) 5 Mucous gland atrophy 9% (1/11) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (M1.PL.46) A 65-year-old male presents to your office complaining of worsening shortness of breath. He has experienced shortness of breath on and off for several years, but is noticing that it is increasingly more difficult. Upon examination, you note wheezing and cyanosis. You conduct pulmonary function tests, and find that the patient's FEV1/FVC ratio is markedly decreased. What is the most likely additional finding in this patient? Review Topic QID: 100849 1 Decreased bicarbonate 5% (5/101) 2 Increased erythropoietin 62% (63/101) 3 Nasal polyps 5% (5/101) 4 Increased IgE 17% (17/101) 5 Pleural effusion 9% (9/101) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 2
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