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 replaces with squamous cells which ultimately 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