Identifying COPD

Chronic obstructive pulmonary disease commonly called as COPD is a dreadful disease of the respiratory system. It is a combination of four lung diseases which includes chronic bronchitis, emphysema, bronchiectasis and asthma. It is not a communicable disease but it is an irreversible disease. It is said to be the fourth most common cause of deaths in United States and it affects over 25% of adult population.

SIGNS AND SYMPTOMS OF COPD: The clinical manifestation ranges from pink puffers to blue bloaters. The pink puffer is due to emphysema and the blue bloater is due to chronic bronchitis. The pink puffer state is due to redder complexion and the blue bloater state is due to cyanosis of the lips, nail and skin caused by increased carbon dioxide and decreased oxygenation to the lungs.

SIGN: The signs of COPD include,
1. On inspection, a typical COPD patient will
a. have a barrel chest (due to emphysema),
b. use their accessory muscles for breathing (sternocleidomastoid),
c. cyanosis,
d. Clubbing of fingers,
e. dyspnea,
f. shortness of breath,
g. tachypnea,
h. pursed lip breathing,
i. muscle wasting,
j. distended neck veins.
2. On percussion, the lung will sound dull or hyper-resonance instead of being resonant due to excessive mucus production and collection in the lungs.
3. On palpation, there can be,
a. palpable cervical lymph nodes (chronic bronchitis)
b. deviation of trachea (rarely)
c. asymmetrical chest wall movements (due to obstruction)
d. decreases tactile fremitus (emphysema)
4. On auscultation, you can identify a number of things like,
a. Wheezing and crackles (asthma)
b. cardiac dysrhythmias
c. tachycardia (due to increased effort to breath)
d. rales and rhonchi (due to congestion)
e. diminished breath sounds
f. prolonged expiration

X-rays show hyperinflation and congestion.

Arterial blood gas (ABG) will indicate respiratory acidosis and hypoxemia.

Pulmonary function test (PFT) will indicate decreased vital capacity, increased residual volume and slightly increased total lung capacity.

SYMPTOMS: A symptom is what the patient experiences and complaints due to a particular disease. The common symptoms are,
a. chronic cough
b. presence of sputum in cough
c. exertional dypnea
d. orthopnea
e. wheezing
f. tachypnea
g. shortness of breath
h. weight loss
i. fatigue
j. anorexia

Above are the classical signs and symptoms of COPD which are exhibited slowly as age increases. Avoid smoking, air pollution and occupational exposure to radiations/chemicals and avoid COPD!

Asthma

Asthma is a reversible obstructive airway disease that affects 17% of the American population. Although asthma can be fatal, more often it is just disruptive and affects day to day activities. Asthma can begin at any age, but in most cases it develops in childhood. Children usually develop allergic asthma which they outgrow by adolescence.

The common symptoms of asthma are cough, dyspnea and wheezing. These symptoms are manifested because of the narrowing of the airways. The symptoms and treatment of asthma depend upon the degree of airway narrowing. Asthma attacks frequently occur at night. The cause is not completely understood, but may be related to circardian variations, which influence the airway receptor thresholds. An asthmatic attack usually starts suddenly with coughing and a tight sensation in the chest. These symptoms are followed by slow, laborious, wheezy breathing. Generally expiration is always much more strenuous and prolonged than inspiration. This makes the asthmatics to sit upright and use every accessory muscle of respiration.

Obstructed air flow causes dyspnea. The cough at first is dry but soon it becomes forceful. Sputum, consisting of thin mucus containing small, round, gelatinous masses is coughed up with much difficulty. Later signs may include cyanosis (bluish discoloration) secondary to severe hypoxia, and symptoms of carbon dioxide retention, including sweating, tachycardia, and a widened pulse pressure. The symptoms of asthma may last from 30 minutes to several hours.

Other possible reactions that may accompany asthma include eczema, rashes, and temporary edema. The symptoms may occur periodically after exposure to a specific allergen, some medications, physical exertion, and emotional excitement.

Asthma symptoms can be reversed either spontaneously or by medical therapy. They can be effectively treated or controlled by medication therapy. There are five categories of medications that are used to treat asthma namely beta agonists, methylxanthines, anticholinergics, corticosteroids and mast cell inhibitors.

Beta Agonists:
Beta agonists are the initial medications used in the treatment of asthma because they dilate bronchial smooth muscles. They can also increase the ciliary movements and decrease the chemical mediators of anaphylaxis. The most commonly used beta adrenergic agents are epinephrine, albuterol, isoproterenol, metaproterenol and terbutaline. These medications are administered parenterally or by inhalation. Inhalation route is the best route of choice because it directly acts on the bronchioles and has only a few side effects.

Methylxanthines:
Methylxanthines, like aminophylline and theophylline are used in the treatment of asthme because of their bronchodilating effects. They relax the bronchial smooth muscles, increase movement of mucus in the airways and increase the contraction of diaphragm. Aminophylline is the IV form of theophylline and is administered intravenously. Theophylline is given orally.

Methylxanthines are not used in acute attacks because they are slow acting compared to beta agonists. There are several factors like tobacco smoking, heart failure, chronic liver disease, oral contraceptives, erythromycin and cimetidine which interfere with the metabolism of methylxanthines, particularly theophylline. Physician should be notified if any of the above mentioned condition exists before taking theophylline. Aminophylline should be administered very slowly, because giving them rapidly may cause tachycardia or cardiac dysrhythmias.

Anticholinergics:
Anticholinergic like atropine is not used in the routine treatment of asthma because of their systemic side effects such as dryness of the mouth, urinary hesitancy, blurred vision, palpitation and flushing. Atropine methylnitrate and ipratropium bromide have shown excellent bronchodilator effects with minimal side effects.They are administered by inhalation. Anticholinergics are particularly beneficial to asthmatics who are not candidates for beta agonists and methylxanthines because of underlying cardiac disease.

Corticosteroids: Corticosteroids are widely used in the treatment of asthma. These medicines can be administered intravenously (hydrocortisone), orally (prednisone), or by inhalation (dexamethasone, beclomethasone). The mechanism of action is not clear but they are thought to reduce inflammation and bronchoconstriction. Prolonged use of corticosteroids can result in serious side effects like peptic ulcers, osteoporosis, adrenal suppression, steroid myopathy and cataracts.

Inhaled corticosteroids are effective in the treatment of asthmatics with steroid dependent asthma. The advantage of this method of administration is the reduced side effects on other body systems. Throat irritation, coughing, dry mouth, hoarseness, and fungal infection of the mouth and pharynx may occur. Rinsing and gargling the mouth immediately after using inhaled corticosteroids will decrease the incidence of fungal infection. Any redness or presence of white patches in the mouth should be reported.

Mast cell inhibitors: Cromolyn sodium, a mast cell inhibitor is an integral part of the treatment of asthma. It is administered by inhalation. It prevents the release of chemical mediators of anaphylaxis, thereby resulting in bronchodilation and a decrease in airway inflammation. Cromolyn sodium is the most beneficial between attacks or while the asthma is in remission. It may result in the reduction of use of other medications and overall improvement in symptoms.

Status asthmaticus (severe and persistent asthma) is a medical emergency. The treatment is usually on an emergency room setting, and the person will be treated initially with beta agonists and corticosteroids. Oxygen therapy may be initiated for those who have dyspnea, cyanosis and hypoxemia.

These are the symptoms and treatment available for asthma. Identifying the early symptom and taking appropriate action will prevent emergencies.

Antihistamines

Any histamine antagonist is generally termed as Antihistamine. They are mostly used in the treatment for allergies. An allergy is caused due to excessive release of histamines by the body and so Antihistamines are major class of medications generally prescribed for allergies. Before going into how antihistamines work, let us understand the action of histamines in our body. Histamines play an important role in regulating the immune response.

Physiologic effects of histamines on major organs include

1. Contraction of bronchial smooth muscles resulting in wheezing and bronchospasm.
2. Dilatation of small venules and constricting of larger vessels, causing erythema, edema and urticaria
3. Increase in secretion of gastric and mucosal cells resulting in diarrhea.

Histamines act on organs through two types of receptors: H1 and H2 receptors. H1 receptors are predominantly found on bronchiolar and vascular smooth muscle cells. H2 receptors are found on gastric parietal cells. Antihistamines are categorized by these receptors.

Antihistamines are now classified as H1 receptor antagonist and H2 receptor antagonist. H1 antagonists have no effects on H2 receptors. The H1-receptor antagonists or H1-blockers are used in the management of mild allergic disorders. H1-blockers binds selectively to H1 receptors and prevent the action of histamine to these sites. Benadryl is a good example of an antihistamine medication which displays an affinity for H1 receptors. The H2-receptor antagonists are used to treat gastric and duodenal ulcers. Cimentidine targets H2 receptors to inhibit gastric secretions in peptic ulcer disease.

Oral antihistamines are readily absorbed. They are most effective when they are given at the first occurrence of symptoms because they prevent the development of new symptoms by blocking the actions of histamine at the H1 receptors. They are found to be very effective in patients with hay fever, vasomotor rhinitis, hives and mild asthma. The major side effect of all antihistamines is sedation.

Newer antihistamines are called second-generation or non-sedative H1 receptor antagonists. They do not cross blood brain barrier and do not bind to cholenergic, serotonin or alpha adrenergic receptors. They bind to peripheral rather than central nervous system H1 receptors, causing less sedation. They are more costlier than the traditional antihistamines and are not more potent than their predecessors.

Apart from sedation, there are additional side effects for both traditional and second generation antihistamines which includes nervousness, tremors, headache, dizziness, dryness of mouth, palpitations, cardiac dysrhythmias, anorexia, nausea and vomiting. Hence, all antihistamines should be taken under medical supervision.