UKRAINIAN MINISTRY OF PUBLIC HEALTH

Vinnytsya National Medical University n.A. M.I. Pyrogov

«APPROVED»

At the methodological meeting of the internal medicine propedeutics department

Chief of the department

____________ prof. Mostovoy Y.M.

«______»_______________ 200 ___ y.

Guidelines for Third-year Students of the Medical Department

Subgect	Propedeutics of the internal medicine
Modul №	1
Enclosure module №	2
Topic	Clinical presentation of chronic obstructive pulmonary diseases, bronchial asthma
Course	3
Faculty	Medical № 1

Methodical recommendations are made in accordance with educationally-qualifying descriptions and educationally-professional programs of preparation of the specialists ratified by Order MES of Ukraine from 16.05 2003 years № 239 and experimentally - curriculum, that is developed on principles of the European credit-transfer system (ECTS) and Ukraine ratified by the order of MPH of Ukraine from 31.01.2005 year № 52.

Vinnytsya- 2007

1. Importance of the topic

Bronchial asthma and chronic obstructive pulmonary disease (COPD) are widely spread internal diseases. They produce serious problems with health. Prevalence of COPD a-is increasing from year to year and now it is one from frequent cause of death in the world. Ability to recognizing COPD and bronchial asthma is very important for every doctor or student, because sometimes these diseases appear with emergency life-threatened condition that should be resolved immediately.

2. Concrete aims:

• Study main symptoms and signs of the bronchial asthma

• Learn main instrumental methods that can help to establish bronchial asthma

• Learn classification of bronchial asthma

• Study main symptoms and signs of COPD

• Learn instrumental and functional exanimation patients with COPD

3. Basic training level

Previous subject	Obtained skill
Normal anatomy	Anatomy of the airways and lungs, their blood supply and innervation
Normal physiology	Mechanics of breathing, gas exchange in the lung and tissues of system organs
Histology	Ontogenesis of the respiratory tract, histological structure of the respiratory tract and alveoli
Propedeutics to internal medicine	Subjective, objective and instrumental examinations of the respiratory patients

4. Task for self-depending preparation to practical training

4.1. List of the main terms that should know student preparing practical training

Term	Term
Bronchial obstruction	Hyperinflation
Reversibility of obstruction	Respiratory failure
Emphysema	Asthma attack

4.2. Theoretical questions:

1. Definition of bronchial asthma

2. Causes of bronchial asthma and its classification

3. Symptoms of bronchial asthma

4. Signs of bronchial asthma

5. Instrumental and laboratory methods of examination of patients with bronchial asthma

6. Definition of COPD

7. Symptoms and signs of COPD

8. Data of additional methods of examination of patients with COPD.

9. . Classification of COPD.

4.3. Practical task that should be performed during practical training

1. Revealing and assessment of symptoms and signs of bronchial asthma

2. Revealing and assessment of symptoms and signs of COPD

3. Revealing and assessment of functional data at patients with bronchial asthma and COPD

Topic content

Bronchial asthma is a chronic inflammatory disease of the airways resulting in airflow obstruction secondary to airway edema, increased mucus production, bronchospasm and infiltration of the airway with leukocytes (eosinophils, lymphocytes and neutrophiles). It is usually reversible either spontaneously or with treatment. May be allergic and non-allergic and genetic burden.

Clinical presentation:

Episodic dyspnea

Wheezing

Cough dry and nocturnal or morning or episodic as asthma attack equivalent

Episodic chest tightness

Signs of reversible bronchial obstructive syndrome

Visual examination:

The patient sits upright and leans on the edge of the table or chair with hands. This position mobilizes accessory respiratory muscles, does exhalation active and facilitates breathing. There is cyanosis, tachypnea and lengthened exhalation. Auxiliary muscles take part in breathing. If patient is sick during 5 or more year his chest has barrel shape.

Palpation of the chest

Vocal fremitus is diminished. Potenzher symptom is negative and pleural points are painless. Chest has increased resistance.

Percussion of the chest

Comparative percussion: There is resonant percussion sound over chest. Because account of air in lung increases due to dysfunction of breathing.

Topographic percussion: The lower borders of the lungs descend down and apexes of lungs lift up. There is dimension of lower lung border excursion.

Auscultation of the lung

There is diminished rough vesicular breathing with prolonged exhalation, polyphonic wheezes due to narrowing of airways of differing caliber.

Investigations:

Lung function tests: pre- and post-bronchodilator test – FEV1 is increased by> 12% and > 200 ml.

Peak expiratory flow rate: difference of > 20% between morning and afternoon PEF may suggest asthma

Bronchoprovocation test: test for airway hyperreactivity. Test positive if FEV1 drop to 20%.

Classification of bronchial asthma:

I step – Intermittent symptoms rare than 1 a week and night symptoms less than 1 a 2 week (PEF, FEV1> 80%)

II step – mild persistent - symptoms rare than 1 a day and night symptoms less than 1 a 2 week (PEF, FEV1> 80%)

III step – moderate persistent – daily symptoms and night symptoms one a week (PEF, FEV1 80-60%)

IV step – severe persistent – continua day symptoms and frequent night symptoms

(PEF, FEV1<60%)

Chronic obstructive pulmonary disease (COPD) is a disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases.

Risk factors: smoking, occupational dust and chemicals, air pollution and chronic recurrent respiratory infections, hereditary α-1 antitrypsin deficiency.

Symptoms of COPD:

Cough is productive, slowly progressive dyspnoe with difficulty during expiration, wheeze, decreased exercise tolerance.

Significant airflow obstruction may be present before the patient is aware of it.

Signs of bronchial obstruction:

Visual examination:

The patient sits upright and leans on the edge of the table or chair with hands. This position mobilizes accessory respiratory muscles, does exhalation active and facilitates breathing. There is cyanosis, tachypnea and lengthened exhalation. Auxiliary muscles take part in breathing. The chest has barrel shape.

Palpation of the chest

Vocal fremitus is diminished. Potenzher symptom is negative and pleural points are painless. Chest has increased resistance.

Percussion of the chest

Comparative percussion: There is resonant percussion sound over chest. Topographic percussion: The lower borders of the lungs descend down and apexes of lungs lift up. There is dimension of lower lung border excursion.

Auscultation of the lung

There is quiet breath sounds with prolonged exhalation, wheezes, quiet heart sounds (due to overlying hyperinflated lung)

Signs of Cor pulmonale and CO₂ retention (ankle oedema, raised jugular vein pulse, warm peripheries, plethoric conjunctivae, bounding pulse, polycythaemia. Flapping tremor if CO₂ acutely raised).