74 PART II: PRIMARY CARE DISORDERS
specicorganisms.
2
Indicationsforthepneumococcalvac-
cinationincludepatientsaged65yearsorolderandsmok-
ersaged65yearsor younger with an FEV
1
lessthan40
percent of the predicted value. All patients, regardless of
age, should receive the annual inuenza vaccination.
5
Mucolyticagentsmaybeused,buttheoverallbenetfrom
theiruseisprobablyminimal.
2
Oxygentherapy(>15h/d)isrecommendedforpatients
withaPaO
2
<55mmHg,SpO
2
88%,orPaO
2
between
55–60 mm Hgwith polycythemia,pulmonary hyperten-
sion,orcongestiveheartfailure.Oxygenistheonlycur-
rently available agent that reduces mortality in patients
withadvancedCOPD.
2,5
Alpha
1
-antitrypsin augmentation is available and rec-
ommendedonlyinselectcases.
1
Surgicalprocedures,such
as bullectomy, lung-volume reduction surgery, and lung
transplantation, are reserved for select patients.
2
Acute exacerbations of COPD can occur at any time
throughoutthecourseofthediseaseandarecharacterized
byepisodesofworseningsymptoms.
3,6
Although they can
be triggered by noninfectious irritants, they are generally
caused by an infectious organism, usually a bacteria or
virus.Themostcommonbacterialpathogensencountered
include Streptococcus pneumoniae, Haemophilus influenzae,
and Moraxella catarrhalis.Atypicalorganismsmayalsobe
responsible to a lesser degree.
2,3,9
Recurrent respiratory
infectionsworsendyspneaandpulmonaryfunctionbecause
inammation-induced bronchial wall brosis causes fur-
therairwaynarrowing.Othercausesofacuteexacerbation
mayincludeallergicresponsetoaspecicallergen,most
oftencigarettesmoke.Inthesecases,patientsexperience
an eosinophilic inammatory response in the bronchial
airways that is typical to asthma and partially reversible
with pharmacologic agents.
3
Exacerbations of COPD can
betreatedwithoxygen,inhaledbronchodilators,inhaled
anticholinergics, oral corticosteroids, and, in the case of
bacterial infection, appropriate antibiotic therapy.
2,9
Asthma
General Characteristics
Asthmaisamultifactorialdiseasethatischaracterizedby
airway hyperresponsiveness, inammation, and varying
degrees of reversible and nonreversible airow obstruc-
tion, depending on the chronicity of the disease.
Asthma is a very common chronic disease, affecting
approximately5percentofthepopulation.
3,8,16
Itisnon-
discriminatory,affectingallraces,ethnicgroups,genders,
andages,withapredilectiontomales(2:1)inchildhood
16,17
and slightly higher in females after age 14 years.
8,17
Althoughasthmacanaffectallagegroups,inthemajority
of cases it begins before the age of 10 years with a peak
incidence at age 3 years.
3,16
Although the prevalence for
asthma remains high, the proposed widespread use of
inhaledcorticosteroidsinpersistentasthmaappearstobe
relatedtoadownwardtrendofhospitalizationsforasth-
matic attacks and associated mortality.
16,17
Today deaths
resultinpatientswithpoorcontroloftheirasthma,which
maybeattributedtoseveralfactorssuchassocioeconomic
status, previous life-threatening asthma attacks, and
improper use of or lack of proper medications.
16,17
The
keystopreventionofmorbidityandmortalitycontinueto
includehealtheducationandpromotion.
3
Inammation,asaresultoftheairway’sresponsetotrig-
gers, is the basis of physiologic changes within the airway
bothintheacuteandchronicstages.Physiologicchanges
intheairwaysleadtoairowrestrictionthroughbroncho-
constriction, airway edema, airway hyperresponsiveness,
andairwayremodeling.Bronchoconstrictionresultsfroma
Lifestyle Changes: Practical Tips for Your
Patients
Lifestylechangescanbedividedintogroupsofslow-
ing disease progression; preventing infections; and
improving breathing, exercise tolerance, nutrition,
and mood. The most important lifestyle change a
patient with COPD can make is to abstain from
smoking.Inthosewhoquit,evidenceshowsthatlung
function decline slows. Another lifestyle change
includes the prevention of infections and other air-
borneirritantsbymaintaininggoodhandhygieneand
obtaining vaccinations that prevent respiratory disease,
as previously described.
15
Improvements in respiration can be attained by
learning breathing techniques, such as pursed lip
breathingandincentivespirometry breathtraining.
Those with excessive sputum production should
maintain adequate hydration through drinking u-
ids and home humidication. Chest therapy that
includesrhythmicbreathingwithcoughingmayalso
be beneficial.
15
Physical exercise improves whole body health
and strength. Pulmonary rehabilitation is a great
option for patients because it incorporates not only
physicalactivity,butalsobehavioraltherapy.Ifpul-
monary rehabilitation is not an option, walking,
strengthtraining,yoga,orotherexercisethatincor-
poratesdeepbreathingandmeditationtechniquesis
recommended.
15
Maintenance of good nutrition is important in
patientswithCOPD.Inpatientswhoareunderweight,
a high-fat protein diet with fewer carbohydrates is
recommended. Good nutrition in obese patients is
importantbecauseweightlossmayimprovesleeping
and overall health. Foods rich in antioxidants have
beenshowntobebenecial.Forexample,N-acetyl-
cysteine,anantioxidant,maybehelpfulinpreventing
exacerbations.
15
Social and emotional support should be encour-
aged because patients who cope with this lifelong
progressivediseaseareatriskformooddisorders.
15
Chapter 8: Pulmonary Disorders 75
contractionofthebronchialsmoothmuscletoirritantsand
allergens,resultinginaninammatoryresponse.Thepres-
enceofpersistentinammationofthebronchiolesleadsto
airwayedemacharacterizedbyaugmentedsmoothmuscle,
excess mucus production, and small airway mucus plug-
ging. In response to persistent inammation, changes in
airwaycompositionandproblemswithneuroregulationto
avarietyofirritantsandallergensoccur.Theairwaybecomes
hyperresponsive or more vulnerable to bronchospasm,
whichinturnworsensbronchoconstriction.Overtimeair-
wayremodelingoccurs,resultinginpermanentchangesto
thecompositionoftheairwaysthatarenolongerreversible
withtreatmentandleadtosomedegreeofpermanentair-
owobstruction(Figure 8–4).
18
No one specific etiology is thought to be the cause of
asthma;ratheracombinationofbothgeneticandenviron-
mentalcomponentsappeartoberesponsible.Atopy,one
genetic factor, shows the strongest relationship for risk of
developingasthma.Itisattributedtoageneticallydeter-
mined production of specic IgE antibody and is best
revealedwiththepresenceofatopicdermatitisandaller-
gicrhinitisinmanypatientswithasthma.
16
Otherpoten-
tial etiologies include other genetic factors, infections,
diet,allergens,airpollution,occupationalexposures,and
thehygienehypothesis.Althoughtheactualroleofmany
oftheseproposedetiologiesisuncertain,severalofthem
areresponsiblefortriggeringasthmasymptoms.
16
Allergens
Immunologicasthmaistheresultofanantigen–antibody
reactionthatresultsintheIgE-mediatedallergicresponse.
Allergensproducestericchangesinamastcell,leadingto
theproductionofchemicalmediators(i.e.,histamineand
bradykinin).Theclinicalresultis(1)localizededemain
thewallsofthesmallbronchioles,(2)secretionofthick
mucusintothebronchiolarlumens,and(3)spasmofthe
bronchiolarsmoothmuscle.
3
Someofthecommonprecipitatingfactorsforimmuno-
logicasthmaincludepollens,pollutants,smoke,irritating
fumesandodors,changeinhumidityandairtemperature,
and dust.
3
Infections
Nonallergic asthma may be associated with a history of
recurrentrespiratorytractinfections.Infact,viralinfections
arethemostcommontriggerinexacerbationsofasthma
symptoms.
16
Withinfection,aninammatoryresponseis
initiated,resultinginairwayhyperresponsivenessthatmay
persist for days or weeks after the viral infection has
resolved.
3
Exercise
Exercise-inducedasthmaisdenedasadecreaseinFEV
1
of 15%ofbaselinevalue.
19
Symptomsofwheezingand
coughingusuallydevelopafter5–10minutesofstrenuous
activity or shortly after it ends and resolve within 30
minutes.Vigorousexerciseincold,dryairismorelikely
tocauseanattackthanexerciseinwarm,humidair.
3
Emotions
Psychologicalfactors,suchasemotionalstress,canoften
makeanattackworsethroughbronchoconstriction,medi-
atedthroughtheparasympatheticnervoussystem.
3
Medications
All beta-blockers can induce bronchoconstriction, wors-
eningexistingasthma.Theuseofthismedicationinasth-
maticsmayleadtodeathandshouldbeavoided.Aspirin
andallnonselectiveCOXinhibitorsshouldbeavoidedin
asthmaticsbecausetheycaninducewheezing.
16
Other Triggers
Cold air, laughter, air pollution, occupational pollutants,
hormonalchanges,andgastroesophagealreuxdiseasecan
alsotriggerasthmaattacks.Althoughthestimulithattrig-
ger episodes vary from one person to another, the end
resultisusuallyinammation,airwayhyperresponsiveness,
bronchoconstriction,andexcessmucusproduction,result-
inginvariabledegreesofdyspnea,wheezing,andcough.
3
Signs, Symptoms, and Diagnosis
Clinically,thesignsandsymptomsofasthmavaryforeach
individualandtheseverityofthedisease. Because ofthe
reversiblenature ofasthma,signsandsymptomsmaybe
presentorabsentatvaryingtimesthroughoutthecourse
of the disease, and a thorough history is key for evaluation.
Classic symptoms, often found in asthma with varying
degreesofseverity,includewheezing,shortnessofbreath,
chest tightness, and a cough that can either be productive
or nonproductive.
8,20
Associated symptoms may include
nighttimeawakenings,oftenduetocough,aswellassome
degree of chest discomfort or pressure.
8,16,20
In a patient
withstableasthmawhoisasymptomaticorisexperiencing
onlyminorsymptoms,thepulmonaryportionofthephysi-
cal examination may be unremarkable.
10
However, an
examinationoftheskinforahyperpigmented,scalingrash
thatissuggestiveofeczema,especiallyintheantecubital
and popliteal fossas, and an examination of the nasal
mucosaforerythema,edema,andacleartowhitedrainage
that is suggestive of rhinitis should be conducted for evalu-
ationofapotentialallergiccomponent.
Asthma attacks are episodic in nature and often pro-
vokedbyapredictabletrigger.Frequentlyattacksdevelop
insidiouslyoveraperiodoftime,buttheycanoccuracutely
in response to a trigger.
3
An acute asthmatic episode or
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Figure 8–4 Asthma.

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