INTERNAL MEDICINE BOARDS - PART 9 ppt

■ Adjustment disorder: Patients have stress, anxiety, depression, or behav-ioral changes that are related to a specific trigger but do not have all three 1° symptoms: reexperiencing, avo

■ Obsessions: Recurrent or persistent thoughts that cause anxiety.

■ Compulsions: Behaviors or rituals that temporarily relieve anxiety.

■ Patients must recognize that their symptoms are unreasonable and that

their obsessions are their own thoughts

D IFFERENTIAL

■ Delusional disorder: Patients do not find the thoughts unreasonable.

■ Schizophrenia: Patients have psychotic symptoms along with affective

flat-tening, asociality, and avolition

■ Generalized anxiety disorder: Patients have anxiety in several different

ar-eas of their lives that are generally not relieved by compulsive acts

T REATMENT

■ Behavioral: Exposure-response prevention therapy; cognitive-behavioral

therapy (teaches patients how to diminish their cognitive distortions of thestressor and how to change their behavioral response)

■ Medication: Clomipramine, SSRIs (e.g., paroxetine, sertraline, ine) Higher doses than those used for depression are usually required.

fluvoxam-C OMPLICATIONS

Often leads to depression if left untreated

Post-traumatic Stress Disorder (PTSD)

Reaction to a traumatic event characterized by reexperiencing, avoidance,and↑ arousal Age of onset is variable; the male-to-female ratio is 1:2 Preva-

lence is up to 3%, but 30% of Vietnam veterans are affected

S YMPTOMS

Patients must have a perceived life-threatening trauma and all three of the

fol-lowing:

1 Reexperiencing (flashbacks, nightmares, etc.)

2 Avoidance (places, thoughts, feelings, people related to the trauma)

3 ↑ arousal (insomnia, hyperstartle, poor concentration, anger outbursts).Patients must have all symptoms for a minimum of one month

D IFFERENTIAL

■ Depression: Patients do not have flashbacks to a traumatic event.

■ Generalized anxiety disorder: Patients do not have a history of a

trau-matic event or flashbacks

■ Adjustment disorder: Patients have stress, anxiety, depression, or

behav-ioral changes that are related to a specific trigger but do not have all three

1° symptoms: reexperiencing, avoidance, and ↑ arousal

T REATMENT

■ Behavioral: Various forms of individual and group psychotherapy

■ Medication: SSRIs, sleep agents (e.g., trazodone), long-acting

benzodi-azepines (e.g., clonazepam) Prazosin is sometimes given for nightmares

Obsessions cause ↑ anxiety

that is temporarily relieved by

compulsions.

Some research suggests that reducing autonomic activation (with β-blockers)

shortly after the trauma may ↓ the likelihood of developing PTSD

C OMPLICATIONS

■ Long-term use of benzodiazepines can lead to psychological dependence

Prescribe with caution/selectivity

■ Avoidance of stimuli associated with the trauma can generalize to

avoid-ance of wide-ranging things (which become secondarily associated with

the trauma in the patient’s mind) This leads to a far greater negative

im-pact on the patient’s life

M O O D D I S O R D E R S

Major Depressive Disorder

Age of onset is variable; the male-to-female ratio is 1:2 Lifetime prevalence in

men is 10% and in women 20% Risk is higher if there is a family history

Un-treated episodes usually last four or more months.

S YMPTOMS

■ Patients must have depressed mood or loss of interest/pleasure

(anhedo-nia) and five of the SIG E CAPS symptoms (see mnemonic).

■ Symptoms must represent a change from baseline; cause functional

im-pairment (e.g., work, school, or social activities); and last at least two

weeks continuously.

D IFFERENTIAL

■ Adjustment disorder: Patients have a known stressor that causes a reaction

similar to a depressive episode, but the reaction is less severe and is

trig-gered specifically by that stressor

■ Dysthymic disorder: Patients have “low-level depression” (i.e., depression

involving fewer than five SIG E CAPS symptoms) that lasts at least two

years.

■ Anxiety disorders: Generalized anxiety disorder, PTSD, OCD.

■ Medical “masqueraders”: Hypothyroidism, anemia, pancreatic cancer,

Parkinson’s disease

■ Substance-induced mood disorder: Illicit drugs, thiazide diuretics,

digoxin, glucocorticoids, benzodiazepines, cimetidine, ranitidine,

cy-closporine, sulfonamides, metoclopramide

D IAGNOSIS

Eliminate potential medical etiologies (e.g., check TSH and CBC)

T REATMENT

■ Behavioral: Various forms of individual and group psychotherapies.

■ Medication: SSRIs; other classes of antidepressants Choose medication

on the basis of the symptom profile and anticipated side effect tolerability

■ Electroconvulsive therapy (ECT): Often reserved for medication-resistant

depression; especially useful in the elderly.

Symptoms of major depressive disor- der—

worthlessness or inappropriate guilt)

audi-■ Suicidality: One of the major comorbidities of untreated depression is

Bipolar Affective Disorder

Extreme mood swings between mania and depression Age of onset is mostcommonly in the 20s and the 30s; the male-to-female ratio is 1:1 Prevalence

is 1% Risk is higher if there is a family history There are two types: type I, which alternates between mania and depression, and type II, which alternates

between depression and hypomania (i.e., fewer symptoms for a shorter tion)

dura-S YMPTOMS

■ The symptoms of bipolar affective disorder are described by the mnemonic

DIG FAST.

■ Manic episodes must last at least four days or lead to hospitalization in

order to be called mania Anything less is considered hypomania

■ See the entry on depression for symptoms of the depressive episodes of

bipolar disorder; remember the mnemonic SIG E CAPS.

D IFFERENTIAL

■ Major depressive disorder: Patients have no history of a manic episode.

■ Schizoaffective disorder: Patients have both psychotic symptoms and mood symptoms Psychotic symptoms occur in the absence of mood

symptoms

■ Schizophrenia: Patients do not have mood symptoms.

T REATMENT

■ Acute manic episode: Hospitalize; consider antipsychotic agents (e.g.,

haloperidol, olanzapine, risperidone) ↑ doses of mood stabilizers (lithiumcarbonate, valproic acid, carbamazepine)

■ Maintenance treatment: Give mood stabilizers such as those listed above.

Titrate to the lowest effective dose to maintain mood stability

■ Depressive episodes: Antidepressants alone may trigger mania, so use

care-fully; consider individual and group psychotherapies

more effective for depression

than either treatment alone.

■ Left untreated, many patients have progressively more rapid cycling

(more frequent and shorter-duration episodes)

P SYC H OT I C D I S O R D E R S

Schizophrenia

A history of severe and persistent psychotic symptoms (≥ 1 month) in the

con-text of chronic impairment in function (> 6 months) There are several

sub-types Age of onset is mostly in the late teens or 20s for men and in the

20s–30s for women; the male-to-female ratio is 1:1 Prevalence is 0.5–1.0%;

risk is higher if there is a family history

S YMPTOMS

Patients must have two or more of the following:

■ Delusions: Fixed false beliefs.

■ Hallucinations: Most often auditory, but can be visual, olfactory,

gusta-tory, or tactile

■ Disorganized speech or thoughts.

■ Grossly disorganized or catatonic behavior.

■ Negative symptoms: Affective flattening, avolition, alogia (poverty of

speech), asociality

D IFFERENTIAL

■ Bipolar affective disorder: Patients have psychotic symptoms only during

extreme manic or depressive episodes

■ Schizoaffective disorder: Patients have psychotic symptoms but also have

prominent mood symptoms (either depression or mania).

■ Delusional disorder: Patients have one fixed false belief that is nonbizarre

and that does not necessarily have a broad impact on functioning

■ Developmental delay (mental retardation): Patients do not have overtly

psychotic symptoms and have not deteriorated from a

higher-function-ing baseline.

■ OCD: Patients are aware that their obsessions (recurring repetitive

thoughts) are their own thoughts

■ Depression with psychotic features: Patients have psychotic symptoms

that occur only during depressive episodes, and the depressive symptoms

can occur without psychotic symptoms.

■ Generalized anxiety disorder: Patients have severe and chronic anxiety

but no psychotic symptoms

■ Substance-induced psychosis: Especially associated with amphetamine or

cocaine, both of which can cause paranoia and hallucinations Patients

have other signs/symptoms of substance use

■ Medical “masqueraders”: Examples include neurosyphilis, herpes

en-cephalitis, dementia, and delirium

■ Neurologic “masqueraders”: Include complex partial seizures and

Diagnose by history Neuropsychological testing can be helpful in clarifying

the diagnosis but often is not indicated

T REATMENT

■ Choose an antipsychotic agent that minimizes both symptoms and side fect profile

ef-■ First-line agents are now the atypical antipsychotics (e.g., olanzapine,

risperidone, quetiapine, ziprasidone, aripiprazole) because they have fewermotor side effects than do typical antipsychotics (e.g., haloperidol) How-ever, atypicals are much more expensive and can cause significant weightgain

■ Acute psychotic episodes: Hospitalize; ↑ the dose of antipsychotic agentand consider the use of anxiolytic agents (e.g., alprazolam, clonazepam).Group therapy can provide a forum for reality checks if patients can toler-ate them

■ Maintenance treatment: Titrate to the lowest effective dose of chotic agent to maintain stability Group therapy and structured day pro-

antipsy-grams provide safety, socialization skills, and reality checks

C OMPLICATIONS

■ Left untreated, will lead to a “downward drift” in socioeconomic class.

■ Long-term use of typical antipsychotics (e.g., haloperidol) can lead to dive dyskinesias—i.e., involuntary choreoathetoid movements of the face,

tar-lips, tongue, and trunk

■ Tardive dyskinesias should be treated by minimizing doses of tics or by switching to an atypical neuroleptic (e.g., olanzapine, risperi-done, quetiapine)

neurolep-■ Can also be treated with a benzodiazepine (e.g., alprazolam, azepam) or a β-blocker (e.g., propranolol)

pa-■ There is usually a relative lack of other symptoms, and patients often main high functioning otherwise

re-D IFFERENTIAL

■ Schizophrenia: Patients often have a history of auditory hallucinations or

other psychotic symptoms, such as prominent negative symptoms tive flattening, avolition, alogia, asociality) Frequently, there is greaterfunctional impairment

(affec-■ Substance-induced delusions: Particularly associated with amphetamine

and cannabis

There is often a prodromal

phase of schizophrenia

involving negative symptoms

without the positive symptoms

■ Medical conditions: Hyper-/hypothyroidism, Parkinson’s, Huntington’s,

Alzheimer’s, CVAs, metabolic causes (hypercalcemia, uremia, hepatic

en-cephalopathy), other causes of delirium

T REATMENT

■ Patients are often likely to refuse treatment and/or medications Low-dose

atypical antipsychotics may be helpful,

■ Do not pretend that the delusion is true, but do not argue with patients to

prove it false Instead, gently remind them of your goal of maximizing

functionality

C OMPLICATIONS

Many patients do not seek treatment, leading to progressive isolation and a ↓

in productivity and/or functional status

S U B STA N C E A B U S E D I S O R D E R S

Chronic Abuse/Dependence

Substance abuse is a maladaptive pattern of use that occurs despite adverse

consequences Dependence is abuse and physiologic tolerance

T REATMENT

All the dependencies are characterized by relapsing and remitting patterns.

Optimal treatment varies from patient to patient but usually involves

combi-nations of the following:

■ Pharmacologic substitutes: Replace the substance of abuse with a

longer-acting and less addictive pharmacologic equivalent Examples include

methadone for heroin, chlordiazepoxide (Librium) for alcohol, and

clon-azepam for short-acting benzodiazepines Can be used either in a

detoxifi-cation program (e.g., 21 days) or as maintenance therapy (e.g., methadone

maintenance)

■ Pharmacologic antagonists: ↓ the pleasurable response associated with

the substance of abuse Examples include the following:

■ Antabuse (disulfiram) for alcohol: Blocks the efficacy of alcohol

dehy-drogenase, causing buildup of acetaldehyde

■ Naltrexone: Thought to ↓ alcohol craving

■ Therapeutic communities: Provide a safe, structured environment in

which to boost attempts at maintaining early sobriety Can be inpatient

(residential) or outpatient, brief or long-term

■ Self-help organizations: Provide a regular and ongoing community of

peers to maintain ongoing sobriety Examples include Alcoholics

Anony-mous (AA) and Narcotics AnonyAnony-mous (NA)

■ Family support/education: Provide support to family members; offer an

environment in which to learn from and commiserate with others An

ex-ample is Al-Anon

■ Individual counseling/therapy: Various techniques focus on the following:

■ Understanding and eliminating triggers for relapse

■ Harm reduction approach: Minimizing use of the substance, which

minimizes its functional impact on patients’ lives

■ Abstinence model: Getting patients to accept that they cannot

mini-mize use but must abstain in order to improve their functional quality

of life

Delusional disorder is far less common than schizophrenia and is less responsive to medications.

■ Psychoeducation: Educating patients regarding issues such as the

cy-cle of relapses and remissions; the chronic nature of the illness; andavailable resources

For information on the treatment of acute intoxication or withdrawal dromes, see the Hospital Medicine chapter

syn-C OMPLICATIONS

Chronic substance dependence leads to significant loss of productivity, tionality, and quality of life

func-OT H E R D I S O R D E R S Somatoform Disorders

A group of disorders in which patients complain of physical symptoms thathave no clear medical etiologies Affect 15% of all psychiatric patients and20% of medical inpatients Certain subtypes are more common in women(e.g., conversion disorder, pain disorder); others are more common in men(e.g., factitious disorder, malingering) All generally occur more often in thosewith lower socioeconomic status and education

■ Somatization disorder: Complaints are in at least two organ systems.

■ Conversion disorder: Complaints are in the neurologic system.

■ Pain disorder: Complaints are of pain (predominantly).

■ Hypochondriasis: Complaints and fear are of serious diseases.

■ Body dysmorphic disorder: Complaints are about a perceived defective

body or body part

■ Factitious disorder: Complaints are consciously simulated by the patient

■ Psychiatric consultation can help clarify specific diagnoses and thereforepotential treatment options that could be most helpful

T REATMENT

■ Minimize the number of different providers involved in the care of the

pa-tient

■ Establish and maintain a long-term, trusting doctor-patient relationship;

schedule regular outpatient visits and routinely inquire about psychosocialstressors

■ On each visit, perform at least a partial physical exam directed at the organ

system of complaint, and gradually change the agenda to inquire about

psychosocial issues in an empathic manner

■ Refer patients to a mental health professional to help them express their

feelings, thereby minimizing physical symptoms as a proxy for those

feel-ings

■ Treat any 2 ° depression (i.e., depression 2° to the sense of hopelessness

as-sociated with having the somatoform disorder)

■ Some patients may benefit from the use of an anxiolytic agent (e.g.,

alpra-zolam)

■ Be aware that some patients will develop psychological dependence on

medications, so prescribe selectively

Attention-Deficit Hyperactivity Disorder (ADHD)

Persistent (> 6 months) problems with inattention and/or hyperactivity and

impulsivity Prevalence is 3–5%; the male-to-female ratio is 3–5:1.

D IAGNOSIS

■ Inattention, including at least six of the following:

1 Poor attention to tasks, play activities, or schoolwork

2 Poor listening skills

3 Poor follow-through on instructions

4 Poor organizational skills

5 Avoidance of tasks requiring sustained mental effort

6 Frequent loss of things

7 Easy distractibility and forgetfulness

8 Frequent careless mistakes

■ Hyperactivity-impulsivity, including at least six of the following:

1 Fidgetiness

2 Leaves rooms where sitting is expected

3 Excessive running/climbing

4 Subjective thoughts of restlessness

5 Difficulties with leisure activities

6 Acts as if “driven by a motor.”

7 Talks excessively

8 Interrupts others often

D IFFERENTIAL

■ Med-seeking behavior: Patients often present with a history of substance

abuse (especially amphetamine abuse)

■ Bipolar affective disorder: Inattention/racing thoughts occur only during

manic episodes; are accompanied by a lack of need for sleep and by

grandiosity/euphoria; and are cyclical in nature

■ Substance-induced symptoms: Especially amphetamine intoxication.

Look for associated signs/symptoms of substance abuse

T REATMENT

■ Stimulants (methylphenidate, others): ↑ the dose as needed

■ Antidepressants: If there is a risk of abuse/dependence, bupropion

(Well-butrin) is a nonaddictive and reasonable first-line agent

■ Behavioral therapy: Focus on changing maladaptive behaviors and on

learning more effective ones

Informal “curbside” consults

of colleagues can be quite helpful and are preferable to the formal introduction of yet another medical provider.

In order for an adult to be diagnosed with ADHD, symptoms must have been present in childhood and must cause functional impairment.

Adults tend to have less hyperactivity than do children.

Patients with ADHD describe stimulants as slowing them down rather than making them “high.”

■ Anorexia nervosa: Patients have misperceptions of body weight, generally

weigh < 85% of their ideal body weight, and self-impose severe dietary itations Affects 0.5–1.0% of adolescent girls; the male-to-female ratio is1:10–20 More common in developed/Western societies and in more afflu-ent socioeconomic strata

lim-■ Bulimia nervosa: Episodic uncontrolled binges of food consumption

fol-lowed by compensatory weight loss strategies (e.g., self-imposed vomiting,laxative and diuretic abuse, excessive exercise) Affects 1–3% of youngwomen; the male-to-female ratio is 1:10

S YMPTOMS

■ Both anorexia and bulimia involve a marked misperception of body imageand poor self-esteem

■ Anorexia only: Actual body weight must be < 85% of ideal body weight

(for height and age) Also presents with lanugo, dry skin, lethargy,

brady-cardia, hypotension, cold intolerance, hypothermia, and hypocarotenemia

■ Bulimia only: Patients must have at least three months of binge-purging activity that occur at least twice a week They must also have a sense of loss of control during food consumption binges Patients often have signs

of frequent vomiting (e.g., low chloride levels, pharyngeal lesions, tooth enamel decay, scratches on the dorsal surfaces of the fingers) and en- larged parotid glands.

S YMPTOMS

There are several types, most often subdivided into clusters:

■ Cluster A (aka the “weird” personality disorders):

Without a significant amount of collateral information, it is difficult to

diag-nose patients with personality disorders on a single visit Because there must

be a persistent pattern of behavior, patients should ideally be observed over

time to ensure accurate diagnosis and referral

T REATMENT

■ Personality disorders are both longstanding and pervasive and are thus

re-sistant to treatment.

■ Dialectical behavioral therapy has been shown to be an effective

treat-ment of borderline personality disorder Brief cognitive-behavioral

ther-apy groups may also maximize effective coping strategies and minimize

functional impact on patients’ lives

■ Mood stabilizers (e.g., valproic acid, lithium, carbamazepine) may be of

use in antisocial and borderline personality disorders SSRIs (e.g.,

fluox-etine, sertraline, paroxetine) may be useful in treating borderline,

depen-dent, and avoidant personality disorders.

PAT I E N T C O M P E T E N C E A N D D E C I S I O N - M A K I N G C A PAC I T Y

Patient competence refers to a patient’s ability to regularly make medical

de-cisions on his/her own behalf It involves a legal assessment and is generally a

long-term decision made outside the hospital or clinic setting Patient

capac-ity refers to the abilcapac-ity of a person to make an informed decision about a

par-ticular clinical decision (e.g., to operate or not) and always occurs in the

con-text of a specific treatment encounter Therefore, the fundamental question

with regard to patient decision-making capacity is “Does the patient have

the ability to make the decision in question on his/her own behalf, or should

you (or someone else; see the discussion of medical ethics in the Ambulatory

Medicine chapter) make decisions for him/her?” The answer depends on the

context of care:

■ Patients with acute/emergent medical issues (e.g., massive hemorrhage,

delirium): In most states, doctors have the right to perform emergent

med-ical care Although not explicitly defined, “emergent” is generally thought

of as “when there is an imminent loss of life or limb.” Technically, without

explicit patient or representative consent, you must confine your care to

the treatment of emergent conditions

■ Patients with acute psychiatric issues (e.g., actively psychotic, floridly

manic, dangerously suicidal): Again, laws vary from state to state, but most

states allow for emergent psychiatric treatment This may include

medica-tions (IM or IV if necessary), locked hospitalization, locked seclusion, or

physical restraints

People with Cluster B personality disorders will sometimes “split” medical personnel—i.e., they will give

incompatible impressions to

different providers about their emotional state and motivation for treatment.

■ Patients with subacute medical conditions (e.g., nonemergent medical

or surgical procedures): Patients have the right to refuse recommendedtreatment as long as they:

■ Know and can repeat the nature of the medical condition.

■ Know and can repeat the benefits/risks of and alternatives to the

rec-ommended treatment

■ Consistently express their rationale for their decision.

■ Patients with subacute psychiatric conditions (e.g., schizophrenia but

not actively psychotic; depression but not currently actively suicidal; lar but not floridly manic): Recommended medical treatment should beoffered just as if there were no psychiatric condition (see above)

bipo-■ Laws regarding recommended psychiatric care vary significantly acrossstates Some states allow doctors significant power in forcing unwantedtreatment, while others give patients significant rights to refuse, whichcan be overturned only in a court of law

■ Remember that if/when the condition becomes acute/emergent, moststates allow psychiatric treatment

■ Patients with advance directives: By definition, patients may sign advance

directives only when they have the mental capacity to do so

■ As long as the advance directive explicitly addresses the mended/anticipated treatment, doctors must adhere to the patient’sprestated wishes even if those wishes will lead to a worse outcome (in-cluding death)

recom-■ When the directive does not explicitly address an emergent or subacutemedical condition (and the patient cannot respond), staff and/or thepatient’s family/friends must attempt to infer what the patient’s wisheswould be and treat accordingly

C O N F I D E N T I A L I T Y I N P SYC H I AT RY

The following are some exceptions to confidentiality in psychiatric practice:

■ If the patient is suicidal or homicidal, protective steps may have to betaken that breach confidentiality

■ Child abuse must be reported to protective services

■ If the plaintiff in a lawsuit has made his or her medical or psychiatric dition an issue, the defendant has the right to know about and to obtainthe records of the plantiff’s evaluation and treatment

con-■ A court may order a physician to disclose confidential information

■ The results of a court-ordered pretrial evaluation may be available to thedefense attorney, the prosecuting attorney, and the judge

■ The results of a disability evaluation will be available to the attorney oragency that requested the evaluation

S P E C I A L P O P U L AT I O N S I N P SYC H I AT RY Geriatric Patients

Psychotic and anxiety disorders (with the exception of relationship or related disorders) tend not to present initially late in life, but late-life onset ofdepression is common

trauma-■ Medication side effects: Geriatric patients are more sensitive to

medica-tions that cause orthostasis or cognitive impairment

■ Depression: In general, depression that first presents in late life is more

difficult to treat than depression that first presents in early or midlife

Early dementia can often

present as depression.

■ Dementia: In many cases, depression can be the first clinical sign of mild

cognitive impairment or early dementia, especially Alzheimer’s disease

Adolescent Patients

Mid- to late adolescence is the most common time for early signs of

schizo-phrenia or bipolar disorder to begin, with significant impairments in

function-ing tendfunction-ing to occur in the late teens to early 20s

■ Depression: In adolescents (and children), irritability can often be more

prominent than sadness or anhedonia when diagnosing depression

■ Suicidality: Adolescents are more prone to impulsive acts, so close

moni-toring when beginning antidepressant medications (which can sometimes

cause anxiety or agitation as side effects) is crucial

Patients with HIV/AIDS

Psychomotor slowing and personality change can sometimes be seen in

HIV-associated cognitive impairment Some antiretroviral medications (e.g.,

efavirenz) can have significant psychiatric side effects

T H E R A P E U T I C D R U G S I N P SYC H I AT RY

Adverse Effects

Table 15.2 outlines both common and potentially serious adverse effects

asso-ciated with psychiatric drugs

Important Drug-Drug Interactions

■ Carbamazepine:

■ An autoinducer of cytochrome P-450 isoenzyme, so the level needs to

be rechecked and the dose often ↑ after several weeks of use

■ ↓ serum level of OCPs

■ Erythromycin, INH, and H2blockers all ↑ carbamazepine levels

■ Valproic acid: Levels are ↑ by aspirin and anticoagulants

Nonpsychiatric Medication Classes with Psychiatric Side Effects

■ Antiretrovirals (e.g., efavirenz): Delirium, mania, irritability, cognitive

T A B L E 1 5 2 Adverse Effects of Commonly Administered Psychiatric Drugs

CLASS EXAMPLES COMMON SIDE EFFECTS MEDICALLY SERIOUS SIDE EFFECTS

fluvoxamine (Luvox)

nausea, diarrhea, T-wave flattening.

rash.

long-term use).

constipation, urinary retention, tachycardia).

(in long-term use).

antipsychotics (when used in high doses).

F I G U R E 1 6 2 Flow volume loops.

(A) Normal pattern (B) Variable extrathoracic obstruction (e.g., vocal cord paralysis or

dysfunc-tion) (C) Variable intrathoracic obstruction (e.g., bronchogenic cysts) (D) Fixed obstruction

(e.g., prolonged intubation and resultant tracheal stenosis).

A.

Volume (L)

Inhalation Exhalation

T A B L E 1 6 7 Differential Diagnosis of Wheezing

UPPER AIRWAY OBSTRUCTION LOWER AIRWAY OBSTRUCTION

EXTRATHORACIC INTRATHORACIC

COPD CHF Parasitic infections PE

■ The most important risk factor for developing COPD is cigarette smoking.

α1-antitrypsin (AAT) deficiency is also a well-characterized genetic

abnor-mality that predisposes individuals to the development of early-onset

COPD

S YMPTOMS /E XAM

■ Symptoms are usually not present until the individual has smoked > 1 pack

of cigarettes per day for 20 years

■ Typically presents with chronic cough in the fourth or fifth decade of life

Dyspnea usually occurs only with moderate exercise, and not until the

sixth or seventh decade of life

■ Chest wall hyperinflation, prolonged expiration, wheezing, and distant

breath and heart sounds may be present

■ The patient may use accessory muscles and pursed-lip breathing (“pink

puffer”), and cyanosis may be present as well (“blue bloater”) Neck vein

distention, a tender liver, and lower extremity edema suggest cor

pul-monale

D IFFERENTIAL

Acute bronchitis, asthma, bronchiectasis, CF, CHF

D IAGNOSIS

Along with a history and physical exam, testing modalities that are useful for

diagnosing COPD and for evaluating the progression of disease include CXR,

PFTs, ABG analysis, and AAT screening

■ CXR: Typically demonstrates ↓ lung markings, ↑ retrosternal airspace, and

flattened diaphragms

■ PFTs: Essential for diagnosis as well as for the evaluation of treatment and

disease progression

■ ABG analysis: Acute exacerbations show hypoxemia and hypercarbia with

acute respiratory acidosis

■ AAT screening: AAT deficiency accounts for < 1% of COPD cases Low

levels of AAT lead to basilar emphysema CXR may show ↓ lung

mark-ings, predominantly in the bases (usually in the apices with COPD from

tobacco use)

■ BODE index: More effective than FEV1 at predicting the risk of death

from any cause in patients with COPD The BODE index consists of:

BMI, Obstruction of airflow (FEV1), Dyspnea (as measured by the

modi-fied Medical Research Council dyspnea scale), and Exercise capacity

(six-minute walk)

T REATMENT

■ Acute exacerbations: Where possible, the cause of the exacerbation

should be treated

■ β2-adrenergic and anticholinergic agents are first-line therapy.

■ O 2 therapy is often necessary to treat hypoxemia Hypercarbia can

re-sult either from a ↓ respiratory drive with ↑ PaO2 or from ↑ V/Q

mis-match with hyperoxia, but O2 therapy must not be withheld owing to

fears of hypercarbia

■ Systemic corticosteroids in oral or IV form help ↓ the length of

exac-erbations and improve FEV1in hospitalized patients