top of page
Search

The Pink Puffer and the Blue Bloater

The Classic Dichotomy. COPD- an attempt to differentiate the patient with moderate to severe emphysema (pink puffer) from the patient with chronic bronchitis (blue bloater).

Pulmonology Term

FibonacciMD Compendium

In Short


by Adele Shenoy, MD

Edited by Charles L. Fishman, MD

Contributor – Rich Strongwater, MD


The Pink Puffer

Although these terms may seem out of date and politically incorrect they were an attempt to differentiate the patient with moderate to severe emphysema from the patient with chronic bronchitis.


The term “pink puffer” is colloquially used to describe the “typical” presentation of a patient with emphysema, in contrast to the “typical” patient with chronic bronchitis, who has been described as a “blue bloater.” Patients with predominant emphysema will respond to dyspnea by hyperventilating, and will for a time be able to maintain oxygenation and remain “pink.”


Causes and Risk Factors

In emphysema, alveoli are lost, and the airways lose elasticity, leading to air trapping within the respiratory units, making exhalation more difficult. Oxygenation can be maintained by increasing minute volume. Pursed lip breathing will help to increase the pressure within the airways and prevent collapse.


Signs and Symptoms

Pink puffers have a thin body habitus, pursed lips with breathing, barrel chest, increased work of breathing, and rarely have cyanosis. They have prolonged expiration time, and may speak in short sentences. As emphysema and respiratory failure worsen, hypoxemia and loss of “pink” color can result.


The Blue Bloater

The term “blue bloater” is colloquially used to describe the “typical” presentation of a patient with chronic bronchitis, in contrast to the “typical” patient with emphysema, who has been described as a “pink puffer.” Patients with moderate chronic bronchitis are more likely to have hypoxemia compared to patients with moderate emphysema, and thus can have cyanosis and appear “blue.”


Causes and Risk Factors

In chronic bronchitis, there is increased mucous production, along with damage to airway epithelium. Gas exchange is disturbed, leading to a mismatch between ventilation and perfusion, and hypoxemia, hypercapnia and respiratory acidosis. This eventually leads to pulmonary vasoconstriction and right heart failure. It should be noted that severe emphysema can also cause respiratory failure, and that emphysema and chronic bronchitis are often found in the same patient.


Signs and Symptoms

Blue bloaters have chronic productive cough, cyanosis, and peripheral edema (due to right heart failure). They will often appear plethoric and obese.


The Classic Dichotomy

Emphysema vs Chronic Bronchitis

Table 1: Comparison between emphysema and chronic bronchitis


Emphysema

Chronic bronchitis

Definition

Pathological: alveolar parenchymal destruction and irreversible airspace dilatation

Clinical: Productive cough on most days for > 3 months a year for > 2 years.

Pathogenesis

Imbalance between proteases and anti-proteases leads to destruction of lung parenchyma

Airway irritation leading to mucus gland hypertrophy/hyperplasia, mucus overproduction, and small airway clogging

Pathophysiology

  • Destruction of alveolar walls causes loss of elastic recoil, leading to increased compliance, air trapping, and hyperinflation.

  • Hypoxemia is a late feature since there is no V/Q mismatch

  • Airway plugging leads to expiratory airflow obstruction and air trapping

  • Obstruction impairs alveolar ventilation, causing V/Q mismatch and hypoxemia with CO2 retention

  • Chronic hypoxemia causes pulmonary hypoxic vasoconstriction, leading to pulmonary hypertension and eventually cor pulmonale

Clinical features

"Pink puffer"

  • Progressive dyspnea

  • Pursed-lip breathing, accessory muscle use

  • "Barrel chest" configuration

  • Cachexia

"Blue bloater"

  • Productive cough, wheezing

  • Early cyanosis

  • Signs of cor pulmonale (peripheral edema, jugular venous distension, hepatomegaly)

  • Associated with obesity and metabolic syndrome

Adapted from Ni, A, ed. "Block B: Respiration" from "Osler Notes". McGill Medical Students Society, 2019.


Conclusion

Chronic Obstructive Pulmonary Disease (COPD)

The blue bloater vs pink puffer distinction may be less useful given the overlap of chronic bronchitis in both groups (emphysema vs non-emphysema) and the non-distinct timeline of hypoxia in both groups.

Chest CT scan along with formal pulmonary function testing may be the best way to differentiate and characterize your COPD patient. Changes on CT scan in pulmonary emphysema results from dilatation of airspaces and destruction of airspace walls distal to terminal bronchioles. This is seen as low attenuation areas on the CT with vascular distortion and thinning.


High resolution computed tomography (HRCT) may discover abnormal findings associated with emphysema earlier and may also give a better view of pathology progression.

Chronic bronchitis exists in both groups thereby explaining why patients with “asthma-overlap” exist in both groups. Nevertheless, COPD-asthma overlap is more common in non-emphysematous COPD, as is bronchodilator responsiveness.


One third of patients with COPD may have eosinophilic airway inflammation and treatment directed at eosinophilia may be warranted. More studies regarding eosinophila as a potentially useful biomarker in the treatment of COPD are needed.


BMI does seem to be low in the emphysema group. BMI is higher in the chronic bronchitis group. This along with chronic inflammation may explain the association with non-emphysema COPD and diabetes or metabolic syndrome.

 

Pink Puffier - in FibonacciCOMPENDIUM

Blue Bloater - in FibonacciCOMPENDIUM

#Puliminary


 

References

  • Petty, T. COPD: Clinical phenotypes. Pulmonary Pharmacology & Therapeutics. 2002;15(4):341-351.

  • Mirza S, Clay RD, Koslow MA, Scanlon PD. COPD Guidelines: A Review of the 2018 GOLD Report. Mayo Clin Proc. 2018 Oct. 93 (10):1488-1502.

  • Petty, T. COPD: Clinical phenotypes. Pulmonary Pharmacology & Therapeutics. 2002;15(4):341-351.

  • Mirza S, Clay RD, Koslow MA, Scanlon PD. COPD Guidelines: A Review of the 2018 GOLD Report. Mayo Clin Proc. 2018 Oct. 93 (10):1488-1502.

  • Hersh C, Make B, Lynch D, et al. Non-emphysematous chronic obstructive pulmonary disease is associated with diabetes mellitus. BMC Pulm Med. 2014; 14: 164. Published online 2014 Oct 24. doi: 10.1186/1471-2466-14-164

  • Balachandran, J. Chronic Obstructive Pulmonary Disease and Eosinophils. Editorial. Pulmon. 24(2):p57-58. May-Aug 2022. Doi: 10.4103/pulmon.pulmon_4_22

  • Ni A. An Approach To Chronic obstructive pulmonary disease (COPD) Published online: 19 October 2020 Faculty of Medicine, McGill University, Montreal, QC, Canada.

  • Grenier P. Emphysema at CT in Smokers with Normal Spirometry: Why It Is Clinically Significant. Editorial. Radiology. Published Online:Jul 7 2020 https://doi.org/10.1148/radiol.2020202576

  • David B, Bafadhel M, Koenderman L, De Soyza A. Eosinophilic inflammation in COPD: from an inflammatory marker to a treatable trait. BMJ. Thorax. 2021. Volume 76, Issue 2. https://thorax.bmj.com


IMIT takes pride in its work, and the information published on the IMIT Platform is believed to be accurate and reliable. The IMIT Platform is provided strictly for informational purposes, and IMIT recommends that any medical, diagnostic, or other advice be obtained from a medical professional. Read full disclaimer.

bottom of page