..

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