There is currently an epidemic of cholera in Haiti. Should all patients with cholera be treated with antibiotics? International guidelines recommend that patients with moderately severe and severe cholera be treated promptly with antibiotics. How do we differentiate between a mild case, a moderately severe case and a severe case of cholera? We can do that by looking at the degree of dehyration. A severe case of cholera is one where the dehyration amounts to 10 percent or more of the body weight. A moderately severe case is one where the dehydration amounts to 5 to 10 percent of the body weight. And a mild case will be one where the dehyration is minimal, less than 5 percent of body weight.
So, what are the antibiotics that can be used for cholera? Doxycycline, Azithromycin or Ciprofloxacin can be used.
Should contacts of cholera patients be given prophylactic antibiotics? The answer is No. Finally, when should a doctor suspect cholera? Cholera should be suspected in any diarrhoeal illness of short duration (less than 24 hours) which is associated with dehydration. Vomiting often accompanies the diarrhoea and there is no fever.
This site has the WHO guidelines for cholera treatment and a good write-up on the antibiotics of choice for the disease.
(NB: Only a single dose of an antibiotic is needed for treatment of cholera. Either 300mg OD Doxycycline or 1gram OD Azithromycin or 1gram OD Ciprofloxacin)
Sunday, December 12, 2010
Friday, December 3, 2010
Monday, November 15, 2010
Sunday, November 7, 2010
Re: Jason Chan
Dear Jason Chan,
In response to :"hi there, i saw some article explains that rehydration therapy is divded into phases: phase 1 - 20ml/kg bolus NS or HM for the 1st hr, phase 2 - 2nd-8th hr, give 1/2 of deficit and maintenance then phase 3 give the remaining 50% in the remaining 16 hrs. my question is how can we decide what type of fluid to be introduced into the patient in phase 2 and 3 and when is necessary to give additional KCl? thx"
Yes, well said Jason. The formula that you mentioned is ABSOLUTELY right and is used. However, I have so far seen Neonatologist use that formula more for neonates. I believe it is a very cautious formula and in general peadiatrics, it is a good rule to follow. So, YES. I would encourage you to use the formula.
As for the type, it depends on the purpose of the fluids being used for. To come to an accurate choice requires a good understanding of the contents of each fluids i.e. Normal saline and Hartmann's solution. (which is not explained further here unless requested...:))
Having said that, the use of which type of fluids also varies from hospital to hospital and doctor to doctor. It is personal. In your reading, research & working experience, you'll have to come to a choice of your own. However, generally Normal saline is used for administration of intravenous drugs & quick fluid resuscitation (but there are also doctors who use Hartmann's). Hartmann's is regarded as the solution that most resembles the human plasma electrolyte contents, therefore it is best used to replace any fluids lost i.e. maintenance fluids and (since it has a considerable amount of electrolyte) for raising/maintaining the blood pressure.
As for KCl, it is ultimately given as both the patients' requirements (too sick to eat, losing too much fluids, etc) and either fluids (NS or HM) aren't sufficient. However, it is always wise to take a renal profile to assess the potassium level (as patients with chronic renal failure would have high potassium levels) and proceed as necessary. (the formula to how much KCl to give is not discussed here unless requested. :) )
Does this answer your questions? I hope so. :)
In response to :"hi there, i saw some article explains that rehydration therapy is divded into phases: phase 1 - 20ml/kg bolus NS or HM for the 1st hr, phase 2 - 2nd-8th hr, give 1/2 of deficit and maintenance then phase 3 give the remaining 50% in the remaining 16 hrs. my question is how can we decide what type of fluid to be introduced into the patient in phase 2 and 3 and when is necessary to give additional KCl? thx"
Yes, well said Jason. The formula that you mentioned is ABSOLUTELY right and is used. However, I have so far seen Neonatologist use that formula more for neonates. I believe it is a very cautious formula and in general peadiatrics, it is a good rule to follow. So, YES. I would encourage you to use the formula.
As for the type, it depends on the purpose of the fluids being used for. To come to an accurate choice requires a good understanding of the contents of each fluids i.e. Normal saline and Hartmann's solution. (which is not explained further here unless requested...:))
Having said that, the use of which type of fluids also varies from hospital to hospital and doctor to doctor. It is personal. In your reading, research & working experience, you'll have to come to a choice of your own. However, generally Normal saline is used for administration of intravenous drugs & quick fluid resuscitation (but there are also doctors who use Hartmann's). Hartmann's is regarded as the solution that most resembles the human plasma electrolyte contents, therefore it is best used to replace any fluids lost i.e. maintenance fluids and (since it has a considerable amount of electrolyte) for raising/maintaining the blood pressure.
As for KCl, it is ultimately given as both the patients' requirements (too sick to eat, losing too much fluids, etc) and either fluids (NS or HM) aren't sufficient. However, it is always wise to take a renal profile to assess the potassium level (as patients with chronic renal failure would have high potassium levels) and proceed as necessary. (the formula to how much KCl to give is not discussed here unless requested. :) )
Does this answer your questions? I hope so. :)
Wednesday, November 3, 2010
Re: Mark Lee
Dear Mark Lee,
Basically, the fluid management for children (& elderly) is MORE tedious as compared to an adults'. Having said that, its' not wrong (in fact, it is better) to actually use the formula used for management of fluids in a child on an adult.
However, since adults have a better tolerance of fluids imbalance as compared to a child, they are able to take (slightly) more/less of fluids than the body needs if given by any physician.
Therefore:
1) The clinical manifestations of dehydration can still be used in an adult (the table in my previous pdf file.)
2) However, the initial resuscitation steps for an adult during the ABC need NOT use the 20ml/kg body weight formula. Just run a pint (500ml) of Hartmann's solution or Normal Saline and check for the patients' haemodynamic status after each pint. Repeat this until the patient is stable. (you don't need to count to the exact amount of fluids needed as compared to a child.)
[NB: For extreme ages (children & elderly), the imbalance of fluid tolerance levels are less. This means that for this age groups, it’ll be VERY wise to provide the amount of fluids that is loss or needed, no more or less. So, you'll have to calculate the fluids needed in this age group.]
3) The formula to estimate maintenance requirements still remain the same for an adult as for a child.
[NB: For young adults who you decide to be less accurate in the management of fluids, do LOOK OUT for signs & symptoms of fluid overload, most notably-pleural oedema.]
Basically, the fluid management for children (& elderly) is MORE tedious as compared to an adults'. Having said that, its' not wrong (in fact, it is better) to actually use the formula used for management of fluids in a child on an adult.
However, since adults have a better tolerance of fluids imbalance as compared to a child, they are able to take (slightly) more/less of fluids than the body needs if given by any physician.
Therefore:
1) The clinical manifestations of dehydration can still be used in an adult (the table in my previous pdf file.)
2) However, the initial resuscitation steps for an adult during the ABC need NOT use the 20ml/kg body weight formula. Just run a pint (500ml) of Hartmann's solution or Normal Saline and check for the patients' haemodynamic status after each pint. Repeat this until the patient is stable. (you don't need to count to the exact amount of fluids needed as compared to a child.)
[NB: For extreme ages (children & elderly), the imbalance of fluid tolerance levels are less. This means that for this age groups, it’ll be VERY wise to provide the amount of fluids that is loss or needed, no more or less. So, you'll have to calculate the fluids needed in this age group.]
3) The formula to estimate maintenance requirements still remain the same for an adult as for a child.
[NB: For young adults who you decide to be less accurate in the management of fluids, do LOOK OUT for signs & symptoms of fluid overload, most notably-pleural oedema.]
Sunday, October 24, 2010
Re: Rachel
- All pregnant women should be screened for gestational diabetes unless they are in a low-risk group. (at 28th week)
- Women at high risk for gestational diabetes are those
- >25 years of age;
- those with a body mass index > 25 kg/m2,
- maternal history of macrosomia or gestational diabetes,
- positive diabetes in a first-degree relative;
- high-risk ethnic group (African American, Hispanic, Native American).
- two-step strategy for establishing the diagnosis of gestational diabetes involves
- administration of a 50-g oral glucose challenge with a single serum glucose
measurement at 60 min.
- <7.8 mmol/L (<140 mg/dL) = normal.
- > 7.8 mmol/L (>140 mg/dL) = administration of a 100-g oral glucose challenge
with serum glucose measurements obtained in the
fasting state, and at 1, 2, and 3 h.
- Normal = <5.8 mmol/L (<105 mg/dL), 10.5 mmol/L
(190 mg/dL), 9.1 mmol/L (165 mg/dL), and 8.0
mmol/L (145 mg/dL), respectively.
- Pregnant women with gestational diabetes are at increased risk of:
- preeclampsia,
- delivering infants who are large for their gestational age,
- birth lacerations.
- (after birth) fetuses are at risk of hypoglycemia and birth trauma (brachial
plexus) injury.
--> Treatment of gestational diabetes with a two-step strategy of dietary intervention followed by insulin injections if diet alone does not adequately control blood sugar [fasting glucose < 5.6 mmol/L (<100 mg/dL) and 2-h post-prandial <7.0 mmol/L (<126 mg/dL)] is associated with a decreased risk of birth trauma for the fetus. (Usuaully, most pregnant mothers' glucose levels are controlled by diet modification alone. Compliance to these diet restrictions are usually the culprit for high blood sugar.)
- For women with gestational diabetes, within the 10 years after the index pregnancy there is a 80% (Malaysia) risk of being diagnosed with diabetes. All women with a history of gestational diabetes should be counseled about prevention strategies and have an annual screening for diabetes (according to Malaysian CPG).
- In general, during the first trimester, the initial insulin requirement is 0.7 units/kg per d. By late pregnancy, patients generally require 1 unit/kg per d.
--> Generally, 2/3 of the total insulin dose is given in the morning and 1/3 in the evening. Usually, 2/3 of the morning dose consists of NPH (NPH = Humulin N: intermediate type)and 1/3 of regular insulin. The evening dose consists of half NPH and half regular insulin. Determination of the exact amount of insulin for each pregnant woman is done on a case-by-case basis. Start with the safe amount of insulin units by using the formula above (Usually 1 unit/kg per day), and slowly increase/decrease by 4 units if the blood sugar level results are high/low respectively.
--> Usage of metformin:
- Recent evidence suggests that glyburide or metformin are safe and effective
alternatives. However...
- Fetal, neonatal, and maternal outcomes have been evaluated following maternal
use of metformin for the treatment of GDM and type 2 diabetes. Available
information suggests that metformin use during pregnancy may be safe as long as
good glycemic control is maintained; however, many studies used metformin
during the second or third trimester only.
- Therefore, until further research is done (on the 1st trimesters), treatment
with oral hypoglycemics in Malaysia (and many other countries) is NOT advocated
as the routine 1st line treatment(as it increases the risk of congenital
malformations. ), as Insulin is the drug of choice for the control of diabetes
mellitus during pregnancy.
- Women at high risk for gestational diabetes are those
- >25 years of age;
- those with a body mass index > 25 kg/m2,
- maternal history of macrosomia or gestational diabetes,
- positive diabetes in a first-degree relative;
- high-risk ethnic group (African American, Hispanic, Native American).
- two-step strategy for establishing the diagnosis of gestational diabetes involves
- administration of a 50-g oral glucose challenge with a single serum glucose
measurement at 60 min.
- <7.8 mmol/L (<140 mg/dL) = normal.
- > 7.8 mmol/L (>140 mg/dL) = administration of a 100-g oral glucose challenge
with serum glucose measurements obtained in the
fasting state, and at 1, 2, and 3 h.
- Normal = <5.8 mmol/L (<105 mg/dL), 10.5 mmol/L
(190 mg/dL), 9.1 mmol/L (165 mg/dL), and 8.0
mmol/L (145 mg/dL), respectively.
- Pregnant women with gestational diabetes are at increased risk of:
- preeclampsia,
- delivering infants who are large for their gestational age,
- birth lacerations.
- (after birth) fetuses are at risk of hypoglycemia and birth trauma (brachial
plexus) injury.
--> Treatment of gestational diabetes with a two-step strategy of dietary intervention followed by insulin injections if diet alone does not adequately control blood sugar [fasting glucose < 5.6 mmol/L (<100 mg/dL) and 2-h post-prandial <7.0 mmol/L (<126 mg/dL)] is associated with a decreased risk of birth trauma for the fetus. (Usuaully, most pregnant mothers' glucose levels are controlled by diet modification alone. Compliance to these diet restrictions are usually the culprit for high blood sugar.)
- For women with gestational diabetes, within the 10 years after the index pregnancy there is a 80% (Malaysia) risk of being diagnosed with diabetes. All women with a history of gestational diabetes should be counseled about prevention strategies and have an annual screening for diabetes (according to Malaysian CPG).
- In general, during the first trimester, the initial insulin requirement is 0.7 units/kg per d. By late pregnancy, patients generally require 1 unit/kg per d.
--> Generally, 2/3 of the total insulin dose is given in the morning and 1/3 in the evening. Usually, 2/3 of the morning dose consists of NPH (NPH = Humulin N: intermediate type)and 1/3 of regular insulin. The evening dose consists of half NPH and half regular insulin. Determination of the exact amount of insulin for each pregnant woman is done on a case-by-case basis. Start with the safe amount of insulin units by using the formula above (Usually 1 unit/kg per day), and slowly increase/decrease by 4 units if the blood sugar level results are high/low respectively.
--> Usage of metformin:
- Recent evidence suggests that glyburide or metformin are safe and effective
alternatives. However...
- Fetal, neonatal, and maternal outcomes have been evaluated following maternal
use of metformin for the treatment of GDM and type 2 diabetes. Available
information suggests that metformin use during pregnancy may be safe as long as
good glycemic control is maintained; however, many studies used metformin
during the second or third trimester only.
- Therefore, until further research is done (on the 1st trimesters), treatment
with oral hypoglycemics in Malaysia (and many other countries) is NOT advocated
as the routine 1st line treatment(as it increases the risk of congenital
malformations. ), as Insulin is the drug of choice for the control of diabetes
mellitus during pregnancy.
Monday, September 20, 2010
Shock! A brief overview.
Prof: What is the first line therapeutic strategy for those in shock?
Student: Administration of intravenous fluids.
Prof: That is right. But what if the blood pressure remains low in spite of fluid resuscitation?
Student: Give vasoconstrictors.
Prof: Right again. What are the vasoconstrictors commonly used for shock?
Student: Dopamine, Dobutamine and Norepinephrine.
Prof: Which is better - dopamine or norepinephrine?
Student: I am not sure.
Prof: Vasoconstrictors differ in their degree of alpha adrenergic, beta adrenergic and dopaminergic effects. Dopamine and norepinephrine (noradrenaline) both have alpha and beta adrenergic effects but norepinephrine stimulates alpha adrenergic receptors more than beta adrenergic receptors. Stimulation of alpha receptors will bring up the blood pressure more effectively but at the cost of reduced splanchnic and renal blood flow. Dopamine also stimulates dopaminergic receptors which norepinephrine does not. Stimulation of dopaminergic receptors helps to improve blood flow to the internal organs and kidney but has a deleterious effect on the hypothalamic pituitary axis because it results in reduced prolactin and growth hormone levels. So you can see that there are good and bad points for both norepinephrine and dopamine. A study was published in the March 2010 issue of the New England Journal of Medicine which compared the effect of these two vasoconstrictor agents in shock. You can read the article HERE. You can see from it that both these agents are good as initial therapy for shock. But based on this study it would be preferable to use norepinephrine rather than dopamine for cardiogenic shock.
Student: Administration of intravenous fluids.
Prof: That is right. But what if the blood pressure remains low in spite of fluid resuscitation?
Student: Give vasoconstrictors.
Prof: Right again. What are the vasoconstrictors commonly used for shock?
Student: Dopamine, Dobutamine and Norepinephrine.
Prof: Which is better - dopamine or norepinephrine?
Student: I am not sure.
Prof: Vasoconstrictors differ in their degree of alpha adrenergic, beta adrenergic and dopaminergic effects. Dopamine and norepinephrine (noradrenaline) both have alpha and beta adrenergic effects but norepinephrine stimulates alpha adrenergic receptors more than beta adrenergic receptors. Stimulation of alpha receptors will bring up the blood pressure more effectively but at the cost of reduced splanchnic and renal blood flow. Dopamine also stimulates dopaminergic receptors which norepinephrine does not. Stimulation of dopaminergic receptors helps to improve blood flow to the internal organs and kidney but has a deleterious effect on the hypothalamic pituitary axis because it results in reduced prolactin and growth hormone levels. So you can see that there are good and bad points for both norepinephrine and dopamine. A study was published in the March 2010 issue of the New England Journal of Medicine which compared the effect of these two vasoconstrictor agents in shock. You can read the article HERE. You can see from it that both these agents are good as initial therapy for shock. But based on this study it would be preferable to use norepinephrine rather than dopamine for cardiogenic shock.
Monday, August 16, 2010
2 better than 1?
There is enough evidence to suggest that lowering LDL cholesterol helps decrease the incidence of coronary artery disease. It is a bit of a surprise therefore to learn from the ENHANCE trial that a greater degree of LDL cholesterol lowering with the combination of Ezetimibe and Simvastatin, when compared to Simvastatin alone, did not have any significant impact on the carotid intima-media thickness.
The IMPROVE IT trial is now underway to study if this combination of Ezetimibe and Simvastatin will be better than Simvastatin alone in reducing cardiovascular events.
For now, there is no evidence to recommend that the combination of ezetimibe plus simvastatin is better than a statin alone for patients with elevated LDL cholesterol levels.
Note:
Exetimibe is a drug that lowers LDL cholesterol by reducing intestinal absorption of cholesterol.
Simvastatin is a drug that lowers LDL cholesterol by affecting a key enzyme in the liver.
Carotid intima-media thickness is a marker of atherosclerosis in the carotid artery.
Monday, August 9, 2010
Rosiglitazone, from Hero to Zero.
In the years that followed the launch of rosiglitazone, there were many papers on its usefulness for patients with diabetes. There were papers that showed the drug’s effectiveness in reducing blood sugar when used alone example and also when used in combination with sulphonylureas example or metformin example . Some other notable trials that showed beneficial effects of rosiglitazone were the DREAM trial and the ADOPT trial. In the DREAM trial investigators showed that rosiglitazone could reduce the development of diabetes in those who had impaired fasting glucose or impaired glucose tolerance while the ADOPT trial showed that rosiglitazone was better than metformin or a sulphonylurea in maintaining glycemic control as monotherapy.
Problems with the drug began to surface in 2007. In early 2007, the first reports that rosiglitazone was associated with osteoporosis and an increased fracture risk appeared - See here. Then, in June 2007 a meta analysis published in the New England Journal of Medicine showed that patients on rosiglitazone had a greater risk of suffering a myocardial infarction - (Read the article).
Tuesday, July 27, 2010
Saturday, May 8, 2010
Lung cancer (teratment)
- The treatment of lung cancer is dependent on the type and stage of cancer.
- The treatment explained here is only a summary:
1) Non-small cell lung cancer
* Stages IA, IB, IIA, IIB & some IIIA :
- basically the tumour is resected with / without removal of the lymph nodes in the mediastinum.
- post-operative radiotherapy is only advocated for selective patients.(with N2 disease if no neoadjuvant chemotherapy)
* Stage IIIA & IIIB
- The treatment for this stage of lung cancer is a little more complicated in that it depends also on the nature of the tumour i.e. bulky, with/without chest wall invasion,etc.
- It is suffice to say that resection of tumour is followed up with chemotherapy or radiotherapy.
* Stage IV & more advanced IIIB
- For this stage, radiotherapy to site of the involved area for relieve of symptoms.
- Chemotherapy for ambulatory patients.
- Resection of primary tumour and tumour spread (metastases) will be considered.
2) Small cell lung cancer
- limited stage (good performance status) : chemotherapy + chest radiotherapy
- Extensive stage (good performance status) : combination chemotherapy
- complete tumour responders (all stages) : consider prophylactic cranial radiotherapy
- Poor-performanc-status patients (all stages) :modified-dose combination, palliative care.
3) All patients
- radiotherapy for brain metastases, spinal cord compression, weight bearing lytic bony lesions, symptomatic local lesions.
- encourage to stop smoking.
- supportive care during chemotherapy.
- The treatment explained here is only a summary:
1) Non-small cell lung cancer
* Stages IA, IB, IIA, IIB & some IIIA :
- basically the tumour is resected with / without removal of the lymph nodes in the mediastinum.
- post-operative radiotherapy is only advocated for selective patients.(with N2 disease if no neoadjuvant chemotherapy)
* Stage IIIA & IIIB
- The treatment for this stage of lung cancer is a little more complicated in that it depends also on the nature of the tumour i.e. bulky, with/without chest wall invasion,etc.
- It is suffice to say that resection of tumour is followed up with chemotherapy or radiotherapy.
* Stage IV & more advanced IIIB
- For this stage, radiotherapy to site of the involved area for relieve of symptoms.
- Chemotherapy for ambulatory patients.
- Resection of primary tumour and tumour spread (metastases) will be considered.
2) Small cell lung cancer
- limited stage (good performance status) : chemotherapy + chest radiotherapy
- Extensive stage (good performance status) : combination chemotherapy
- complete tumour responders (all stages) : consider prophylactic cranial radiotherapy
- Poor-performanc-status patients (all stages) :modified-dose combination, palliative care.
3) All patients
- radiotherapy for brain metastases, spinal cord compression, weight bearing lytic bony lesions, symptomatic local lesions.
- encourage to stop smoking.
- supportive care during chemotherapy.
Tuesday, April 6, 2010
Tuesday, March 23, 2010
Monday, March 15, 2010
Tuesday, March 9, 2010
Lung cancer (Histological classification)
Bronchogenic carcinomas of primary lung cancers can be classified as follows:
o Non small cell lung carcinomas (NSCLC) : This accounts for 70 -75% of bronchogenic carcinomas and can be further subdivided into:
§ Squamous cell carcinoma (25-30%)
§ Adenocarcinoma (30-35%)
§ Large cell carcinoma (10-15%)
o Small cell lung carcinoma (SCLC) : This chalks up 20 – 25% of bronchogenic carcinomas and comprises mainly of a group of cancers called oat cell carcinomas.
o Combined patterns : this consists of the various types of combinations of NSCLC and SCLC e.g. combined squamous & adenocarcinomas and combined squamous cell carcinomas & SCLC.
Friday, February 19, 2010
Monday, February 8, 2010
Lung cancer (Incidents and risk factors)
- Lung cancer accounts for around 19% of all cancers and 27% of cancer deaths.
- The incidence is increasing in women (due to the increase in women smokers).
- The major risk factor for lung cancer is cigarette smoking.
- Other risk factors:
o Passive smoking - being near smokers and inhaling the smoke which is being exhaled by smokers increases the risk to twice that of non-smokers.
o Heavy metal exposure - exposure / working with heavy metals e.g. nickel, chromium, vinyl chloride, arsenic for prolonged periods of time.
o Asbestos exposure - increases the risk of non-smokers by 5 fold & 55 times greater in smokers.
o Chronic Obstructive Pulmonary Disease (COPD) (check out my writings on COPD)
o Industrial carcinogens - products from factories that cause cancer e.g. chloromethyl ether.
o Lung scars - e.g. post-tuberculosis infection
o Air pollution - prolonged exposure
o Hereditary - genetic factors
Tuesday, January 19, 2010
Re: rachel
Hi rachel, I can't read your lecturer's mind but maybe this is what he's thinking...both asthma and COPD present clinically with breathlessness or acute exacerbations.
However, asthma usually presents with reversible symptoms and interference with normal activity of various degrees i.e. acute exacerbations of breathlessness +/- wheezing and after medication (short acting beta-2 agonist)will be normal.
COPD on the other hand is generally a partially reversible condition (this is a controversial issue for some doctors if you just mention it. You'll have to specify that the improvement of this disease can only be partially achieved if put on long term medication) thus their symptoms are persistent. But what I think your lecturer wants to hear (maybe) is the salient clinical feature of COPD which is the chronic bronchitis of blue bloaters and the emphysematous pink puffers.
A typical blue bloaters (not always seen) have CO2 retention, the picwickian syndrome (obesity, somnolence, hypoventilate, plethoric/red face), short neck, doesn't look breathless, an abnormal ABG (hypercapnic, hypoxic) & shallow breathing.
The pink puffer does not retain CO2, is usually thin, has a long neck, look really breathless, has a normal/ near normal ABG & pursed lips breathing.
That makes all the difference in my opinion for these 2 conditions.
However, asthma usually presents with reversible symptoms and interference with normal activity of various degrees i.e. acute exacerbations of breathlessness +/- wheezing and after medication (short acting beta-2 agonist)will be normal.
COPD on the other hand is generally a partially reversible condition (this is a controversial issue for some doctors if you just mention it. You'll have to specify that the improvement of this disease can only be partially achieved if put on long term medication) thus their symptoms are persistent. But what I think your lecturer wants to hear (maybe) is the salient clinical feature of COPD which is the chronic bronchitis of blue bloaters and the emphysematous pink puffers.
A typical blue bloaters (not always seen) have CO2 retention, the picwickian syndrome (obesity, somnolence, hypoventilate, plethoric/red face), short neck, doesn't look breathless, an abnormal ABG (hypercapnic, hypoxic) & shallow breathing.
The pink puffer does not retain CO2, is usually thin, has a long neck, look really breathless, has a normal/ near normal ABG & pursed lips breathing.
That makes all the difference in my opinion for these 2 conditions.
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