THE BRONCHOBSTRUCTIVE SYNDROME IN THE PRACTICE of the DISTRICT DOCTOR.

DIFFERENTIAL

DIAGNOSTICS

The Bronchobstructive syndrome (BOS) is a symptomocomplex, developing as a result of airflow obstruction of the bronchi due to narrowing or occlusion of airways. The most common clinical manifestations are expiratory breathlessness, dry whistling rales, prolonged expiration and decreased forced expiratory volume per 1 sec (FEV1) at spirometry.

Causes of BOS
1. Respiratory organ diseases : Infectious and inflammatory diseases ( such as chronic obstructive pulmonary disease (COPD), pneumonia, multiple bronchiectasis, bronchiolitis, mycotic lung lesions) Allergic diseases (e.g. bronchial asthma). Tumours of the trachea and bronchi. Postnasal syndrome (that is disease of the nose and paranasal sinuses): such as allergic rhinitis, infectious rhinitis, sinusitis, hypertrophy of tonsils) Bronchopulmonary dysplasia; tracheobronchial dyskinesia Bronchopulmonary malformations . Mucoviscidosis; Pulmonary vasculitis Hyperventilation syndrome ; Sleep-apnea and sleep-hypopnae syndrome;

Causes of BOS
2. Aspiration diseases (or aspiration obstructive bronchitis). They include the following disease Gastroesophageal reflux disease, tracheoesophageal fistula, gastroentestinal malformations diaphragmatic hernia. 3. Foreign bodies in the trachea, bronchi, esophagus 4. Cardiovascular diseases associated with left ventricular failure. 5. Diseases of the central and peripheral nervous system. 6. Congenital and acquired immunodeficiecy diseases 7. Some other conditions, such as: Traumas and burns. Poisonings. Exposure to various physical and chemical factors of the environment. Compression of the trachea and bronchi of the extrapulmonary origin.

DIAGNOSTICS FINDINGS
1. Clinical data, the anamnesis (medical case history). 2. Laboratory studies (including virologic and microbiological) 3. Examination of the patient by otorhinolaryngologist (ENT-specialist). 4. Respiratory function tests 5. Examination of the patient by allergologist 6. Chest X-Ray and X-Ray examination of the sinuses of the nose. 7. Bronchoscopy and bronchography 8. Fibre-optic gastroduodenoscopy 9. Electrocardiography (ECG)

Definition of BA and COPD

BA is a hronic inflammatory disorder of the airways in which many cells and cellular elements play a role. The chronic inflammation is associated with airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning. These episodes are usually associated with widespread, but variable, airflow obstruction within the lung that is often reversible either spontaneously or with treatment. COPD is a Chronic inflammatory disease of the respiratory system with primary involvement of peripheral airways and pulmonary parenchyma resulting in the development of emphysema. It is considered that ecology plays an impotent role in the development of COPD. The clinical manifestations often include partly reversible bronchial obstruction and progressing and chronic respiratory failure

Key issues in detection of bronchial asthma

1. Bronchial asthma is a chronic persistent inflammatory disease of the airways. It doesnt matter from degree of severity 2. BA is an inflammatory process resulting in airway hyperresponsiveness to a wide range of stimuli, obstruction and development of respiratory symptoms. 3. Obstruction of airways may be four forms: Acute bronchoconstriction due to a spasm of smooth muscles; Subacute - due to hypostasis of the mucosa of the airways; Obturational - due to formation of mucosa plugs; Sclerotic which is manifested by sclerosis of the bronchi in a prolonged and severe course of the disease. 4. Atopy, genetic predisposition to production immunoglobulin E (IgE).

Key issues in detection of COPD:

Affection of the bronchial tree and the pulmonary parenchyma Presence of partly irreversible bronchial obstruction. It is - a distinctive feature of COPD from BA because in the latter obstruction is quite reversible Steadily progressing character of the disease leading to increased respiratory insufficiency. Reduction of FEV1 by more than 50 ml testifies to progression of bronchial obstruction

ASTHMA
Allergens

COPD
Cigarette smoke

Ep cells

Mast cell

Alv macrophage Ep cells

CD4+ cell (Th2)

Eosinophil

CD8+ cell (Tc1)

Neutrophil

Bronchoconstriction AHR

Small airway narrowing Alveolar destruction

Reversible

Airflow Limitation

Irreversible
Source: Peter J. Barnes, MD

Changes in Lung Parenchyma in COPD

Alveolar wall destruction

Loss of elasticity

Destruction of pulmonary capillary bed

Inflammatory cells macrophages, CD8+ lymphocytes
Source: Peter J. Barnes, MD

Basic criteria of differential diagnostics of BA from COPD

Features (Signs) BA COPD

Anamnesis data The onset in the Typically develops in (Medical history first half of life people over 35 findings) Presence of atopy, Risk factors play a burdened heredity major role in the initiation of the disease Extrapulmonary Present None manifestations of allergy

Risk Factors for COPD

Nutrition
Infections Socio-economic status

Aging Populations
12

Basic criteria of differential diagnostics of BA from COPD

Features Extent of involvement BA Inflammatory process only in bronchi It reverts spontaneously or with the help of treatment COPD Inflammatory process begins in bronchi, and spreads over the pulmonary parenchyma The obstruction cannot revert spontaneously and partly reversible with the help of treatment

Obstruction

Basic criteria of differential diagnostics of BA from COPD

Features Symptoms (cough, breathlessness) BA Wave-like character of the disease, absence of progression in an uncomplicated forms of BA Paroxysmal (attack-like) at night or in the morning Poor glass-like sputum COPD Symptoms are constant and progress steadily

Cough Sputum

Constant or periodic, mainly in the afternoon Poor viscous sputum

Breathlessness

Paroxysmal, it typicaly subsides Constant, slowly progressing spontaneously or with the help of treatment
It is decreased in exacerbations It is decreased and is of the disease and it is constantly getting worse restored in remission

Tolerance to physical exertion

Basic criteria of differential diagnostics of BA from COPD

Features
FEV1 and FEV1/FVC Change of FEV1 after 2-agonists test The airway hyperresponsiveness

BA
Respiratory function tests Are reduced and restored according to disease severity Gain by more than 15%

COPD
Are steadily decreasing according to the stage of the disease Gain by less than 15 %

PEF variability > 20 %. Positive Histamine or methacholine bronchial provocation test Increased IgE in blood Eosinophilia of blood and sputum

PEF variability < 10 %

Additional tests

Basic criteria of differential diagnostics of BA from COPD

Features BA Presence of cor Not typical pulmonale Hypoxia, hypercapnia Type of inflammation Efficiency of glucocorticoid therapy COPD Typical in a severe course of the disease

Uncommon, only in a Common in patients severe exacerbations with III-IV stage of the of the disease disease Eosinophils prevailing Neutrophils prevailing High Low

Diagnostics BA and COPD

Sings of BOS (Cough, dyspnea, dry whistling rales ) Anamneses Presence of atopy, Risk factors of COPD

Respiratory function tests

Signs of bronchial obstruction Determination of reversibility of bronchial obstruction

Reversible obstruction BA

Irreversible obstruction COPD

Difference in classifications of BA and COPD

BA Classification by the degree of severity is based mainly on intensity of respiratory symptoms Daily fluctuations of PEFR and changes of FEV1 appropriate to a certain degree of severity, are an addition to clinical parameters COPD Stages of the disease manifest clearly. Thus a mild stage cannot follow a severe stage The basic functional parameter determining the stage of disease - the degree of decrease of FEV1 and FEV1/FVC

Reduction of a degree of Clinical manifestations are severity of BA is a usual secondary to FEV1 changes. phenomenon which is necessary to achieve on carrying out of adequate therapy

Classification of BA According to the degree of severity

Intermitting BA Symptoms less than 1 time a week. Brief exacerbations Nocturnal symptoms not more then tvice a month. PEF or FEV1 > 80 % predicted; PEF or FEV1 variability less than 20 %. Mild persisting BA Symptoms more then once a week but less than once a day. Exacerbations may affect activity and sleep. Nocturnal symptoms more then tvice a month PEF or FEV1 > 80 % predicted; PEF or FEV1 variability < 20-30 %

Classification of BA According to the degree of severity

Moderate BA Symptoms daily Exacerbations may affect activity and sleep Nocturnal symptoms more then once a week. PEF or FEV1 60-80 % predicted; PEF or FEV1 variability >30 % Severe BA Symptoms daily Frequent exacerbations Frequent nocturnal symptoms. Limitation physical activities. PEF or FEV1 < 60 % predicted; PEF or FEV1 variability >30 %

Levels of Asthma Control

Characteristic
Daytime symptoms Nocturnal symptoms/ awakening Need for reliever/ rescue treatment Limitations of activities Lung function (PEF or FEV1) Exacerbations of BA

Controlled
None (twice or less/week) None

Partly controlled
More than twice/week

Uncontrolled

None (twice or less/week) None

Three or more features of Any partly controlled asthma More than twice/week present in any week Any

Normal

< 80% predicted or personal best (if known) One or more/year One or any week

None

Classification of COPD Severity by Spirometry

Stage I: Mild FEV1/FVC < 0.70 FEV1 > 80% predicted FEV1/FVC < 0.70 50% < FEV1 < 80% predicted FEV1/FVC < 0.70 30% < FEV1 < 50% predicted FEV1/FVC < 0.70 FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure

Stage II: Moderate Stage III: Severe Stage IV: Very Severe

Basic therapy BA and COPD

Bronchial asthma
I. Elimination of trigger factors II. Anti-inflammatory therapy: 1 Inhaled corticosteroids 2. Leukotriene Modifiers 3. Systemic corticosteroids 4. Anti-IgE III. Long-acting bronchodilators 1. Long-acting 2 -agonists 2. Long-acting preparations of theophylline

COPD
I. Elimination of risk factors II. Bronchodilators 1. Anticholinergic agents 2. 2- agonists 3. Long-acting preparations of theophylline III. Inhaled corticosteroids (only if indicated) Indications: *Decreased FEV1 (less than 50%) and repeated exacerbations. The proved clinical effect IV. Rehabilitation

Management Approach Based On Control of asthma

Treatment Steps

As needed rapidacting 2-agonists

Control options

None

Select one Select one Low-dose ICS

Add one or more

Add one or both Oral CS (lowest dose)

Low-dose ICS Medium-or +LABA high-dose ICS +LABA

Leukotrien Medium-or Leukotriene e high-dose ICS modifier modifier

Low-dose ICS +leukotriene modifier Low-dose ICS +sustained rele-

Anti-IgE treatment

Sustained release theophylline

Management Approach Based On Control of Asthma

Level of Control Controlled Partly controlled Treatment Action Maintain and find lowest controlling step Consider stepping up to gain control

Uncrontrolled
Exacerbation

Step up until controlled

Treat as exacerbation

Therapy at Each Stage of COPD

I: Mild II: Moderate III: Severe IV: Very Severe

FEV1/FVC < 70% FEV1/FVC < 70% 30% < FEV1 < 50% predicted FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure

FEV1/FVC < 70% FEV1 > 80% predicted

FEV1/FVC < 70% 50% < FEV1 < 80% predicted

Active reduction of risk factor(s); influenza vaccination Add short-acting bronchodilator (when needed)

Add regular treatment with one or more long-acting bronchodilators (when needed); Add rehabilitation Add inhaled glucocorticosteroids if
repeated exacerbations
Add long term
oxygen if chronic respiratory failure. Consider surgical treatments

Estimated Equipotent daily doses of inhaled corticosteroids

Preparation Low doses Daily doses, g Medium doses High doses

Beclometasone 200-500 dipropionat

Budesonid (pulmicort) Fltuticasone propionat 200-400 100-250

500-1000
400-800 250-500

> 1000
> 800 > 500

Signs of disease Exacerbation

Bronchial asthma COPD

1. Symptoms become severe and 1. Severe cough appear frequently 2. Increased amount of sputum 2. Increased need for and change of its character bronchodilators 3. Dyspnea 3. Decrease of FEV1 and PEFR

Management of Exacerbation
Bronchial asthma COPD

1.Short acting bronchodilators: increase of the dose and frequency of drug intake; 2.various combinations of drugs are administered; 3.used nebulaser

2. System corticosteroids: prednisolone 0,5-1 mg / kg orally (40-60 mg)

2. Systemic corticosteroids: prednisolone 30-40 mg a day orally for 10-14 days

3. Aminophylline
4. Oxygen-therapy. 5. Antibiotics are administered if any signs of an infection are present

Antibacterial therapy of COPD exacerbation

Antibiotics are administered if any signs of an infection are present. Evaluation criteria: clinical manifestations (increased amount of sputum, severe cough, breathlessness,, decompensation of a concomitant disease); decreased FEV1; laboratory data (leukocytosis, increased ESR);

Stratification of patients with COPD exacerbated for antibiotic treatment

Group Main causative agents Antibiotics

Group A Mild exacerbation: No risk factors for poor outcome

H. influenzae S. pneumoniae M. catarrhalis Chlamydia pneumoniae

-lactam Tetracycline -lactam/ lactamase inhibitor (Co-amoxiclav) Macrolides Cephalosporins 2nd or 3rd generation

Stratification of patients with COPD exacerbated for antibiotic treatment

Group
Group B Moderate exacerbation with risk factor(s) for poor outcome

Main causative agents

Group A plus, presence of resistant organisms Enterobacteriaceae (K.pneumoniae, E. coli, Proteus, Enterobacter, etc)

Antibiotics
-lactam/ lactamase inhibitor (Co-amoxiclav) Fluoroquinolones Cephalosporins 2nd or 3rd generation