Table of Contents
Clinical features
- Symptoms
- Exertional dyspnoea
- Chronic productive cough
- Wheeze
- Signs
- Accessory muscle use
- Tar-stained fingers
- Bounding pulse
- CO2 retention asterixis
- Lip pursing
- Central cyanosis
- Tracheal tug
- Hyperexpanded chest
- Quiet breath sounds/wheeze/prolonged expiratory phase
Expiratory wheeze
Investigations
- Spirometry
- Obstructive pattern: ↓FEV1 (<80%), normal FVC (>80%), ↓FEV1/FVC ratio (<0.7)
- FEV1 grades severity
- Chest X-ray
- Hyperinflation (>8 anterior ribs visible)
- Flat hemi-diaphragms
- Decreased lung markings
- Black lesions (bullae)
- Prominent hila
Severity grading
Mild | FEV1 >80% |
Moderate | FEV1 50-80% |
Severe | FEV1 30-50% |
Very severe | FEV1 <30% |
Management
Inhaled therapy
Abbreviations: SABA = short-acting β2 agonist; SAMA = short-acting muscarinic antagonist; LABA = long-acting β2 agonist; LAMA = long-acting muscarinic antagonist; ICS = inhaled corticosteroid

Common inhalers
SABA
Ventolin (salbutamol)
SAMA
Atrovent (ipratropium)
LABA + LAMA
Anoro = Vilanterol + Umeclidinium
Ultibro = Indacaterol + Glycopyrronium
Duaklir = Formoterol + Aclidinium
Spiolto = Olodaterol + Tiotropium
LABA + ICS
Fostair = formoterol + beclomethasone
Seretide = salmeterol + fluticasone
Symbicort = formoterol + budesonide
LABA + LAMA + ICS
Trimbow = formoterol + glycopyrronium + beclomethasone
Trelegy Ellipta = vilanterol + umeclidinium + Fluticasone
Tablets
- Mucolytics, e.g. carbocisteine
- Theophylline
Non-pharmacological
- Smoking cessation
- Pulmonary rehabilitation
- Pneumococcal/influenza vaccines
- Lung transplant
Oxygen therapy
- Long-term oxygen therapy: considered in chronic hypoxaemia if PaO2<7.3kPa (or <8kPa in presence of pulmonary hypertension or secondary polycythaemia)
- Ambulatory home oxygen therapy: considered if hypoxaemic on exertion/activity
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What are the different inhaler devices available?
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