Chronic Obstructive Pulmonary Disease

Dr .Mohammad Kharraz MD InternistArab-Jordanian-Palestinian Board

Definition of COPD

Chronic Obstructive Pulmonary Disease is a preventable and treatable disease with some significant extrapulmonary effects.

The pulmonary component is characterized by airflow limitation that is not fully reversible.

Healthy Alveolus

COPD

Chronic Obstructive Pulmonary Disease (COPD)

The airflow limitation in COPD is usually progressive and associated with an abnormal inflammatory response of the lungs to noxious particles and gases

Severe COPD leads to respiratory failure, hospitalization and eventually death from suffocation

1990 2020Ischaemic heart diseaseCerebrovascular diseaseLower resp infectionDiarrhoeal diseasePerinatal disordersCOPDTuberculosisMeaslesRoad Traffic AccidentsLung Cancer

Stomach CancerHIVSuicide

6th

3rd

COPD Mortality Worldwide

Source: Murray & Lopez. Lancet 1997

COPD Mortality increased 22% over the last decade.

COPD is the third most common cause of death for both men and women worldwide.

About 13.9% of the U.S. adult population (25+ years) have been diagnosed with COPD*

An estimated 15-19% of COPD cases are work-related**

24 million other adults have evidence of troubled breathing, indicating COPD is under diagnosed by up to 60%***

*Braman, S. Update on the ATS Guidelines for COPD. Medscape Pulmonary Medicine. 2005;9(1):1. **CDC programs in Brief– Workplace Health and Safety-Work-related Lung Diseases.

www.cdc.gov/programs/workpl18.htm ***COPD Fact Sheet. Oct 2003. www/lungusa.org

Obstructive Lung Disease

EMPHYSEMACHRONIC BRONCHITIS

ASTHMABRONCHECTASISCYSTIC FIBROSIS

BULLOUS LUNG DISEASE

Causes Most cases of COPD occur as a result of long-term exposure to lung

irritants that damage the lungs and the airways

 The most common irritant that causes COPD is cigarette smoke

In rare cases, a genetic condition called alpha-1 antitrypsin deficiency may play a role in causing COPD

Risk Factors for COPD

Nutrition

Infections

Socio-economic status

Aging Populations

Other risk factors

About 20% or more of all COPD in USA occur in never-smokers.

Childhood recurrent viral infections and childhood Asthma contribute to increase risk of developing COPD in the future.

Tuberculosis can result in airflow obstruction secondary to destruction of lung tissue.

Hereditary factors

Data show that relatives of patients with COPD have a higher prevalence of the disease ,that cannot be attributed to environmental factors.

Best documented genetic influence is hereditary deficiency of alfa-1-antitrypsin :

-COPD at age <45.-non-smoker.

-basilar lung disease.-concurrent liver disease.

Pathology Central airways shows mucous gland hypertrophy and goblet

cell metaplasia.

Peripheral airway shows smooth muscle hypertrophy, peribronchial fibrosis, luminal occlusion by mucus and enlarged lymphoid follicles.

Alveoli enlarged by loss of the alveolar walls with evidence of persistent inflammation with neutrophils in the airway lumen and macrophage in the airway wall.

Normal versus Diseased Bronchi

Comorbid conditions commonly observed in PTs with COPD

CVD, AF,CHF,MIHigh cholesterol

GERDDepression

OsteoporosisDM

Glaucoma Erectile dysfunction

High blood pressureArthritis

CataractsSleep apnea

StrokeCancer

Diagnosis of COPD

Guidelines from both American College of Physicians and GOLD define airflow obstruction as postbrochodilator FEV1/FEV ratio less than 70%.

Spirometry is essential for diagnosis of COPD.

Testing should not be performed in asymptomatic peoples as screening intervention.

Classification of COPD Severity by Spirometry

Stage I: Mild FEV1/FVC < 0.70 GOLD 1 FEV1 > 80% predicted

Stage II: Moderate FEV1/FVC < 0.70 GOLD 2 50% < FEV1 < 80% predicted

Stage III: Severe FEV1/FVC < 0.70GOLD 3 30% < FEV1 < 50% predicted

Stage IV: Very Severe FEV1/FVC < 0.70GOLD 4 FEV1 < 30% predicted or

FEV1 < 50% predicted plus chronic respiratory failure

Physiology Reduced forced expiratory flow ( FEV1) FEV1/Forced vital capacity ( FVC) ratio less than 0.7 Lung compliance is increased in emphysema. Loss of elastic recoil in emphysema which result in alteration

in lung compliance.

Changes in end expiratory lung volume and increase residual volume result in a lower, flatter diaphragm and more horizontal rib cage which will impair the inspiratory muscles ability to develop pressure and increase the overall work of breathing.

Flattening of the diaphragm redirects the axis of shortening of skeletal muscle and produce paradoxical in drawing of the lower rib cage

Gas exchange Arterial Hypoxemia which become clinically significant when

the PO2 fall below 60 mmHg Arterial Hypercapnia due to increase dead space and reduce

alveolar ventilation

Pulmonary circulation Hypoxic vasoconstriction with increase in the pulmonary

artery pressure Treatment with oxygen prevents disease progression and

reduce pulmonary artery pressure

SYMPTOMScough

sputum shortness of breath

EXPOSURE TO RISKFACTORS tobacco

occupationindoor/outdoor pollution

SPIROMETRY

Diagnosis of COPD

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Volume Measuring Spirometer

Flow Measuring Spirometer

Desktop Electronic Spirometers

Small Hand-held Spirometers

Spirometry

Predicted Normal Values

Predicted Normal Values

Age Height Sex Ethnic Origin

Affected by :

Criteria for Normal Post-bronchodilator Spirometry

FEV1: % predicted > 80%

FVC: % predicted > 80%

FEV1/FVC: > 0.7 - 0.8, depending on age

Spirometric Diagnosis of COPD COPD is confirmed by post–bronchodilator FEV1/FVC < 0.7

Post-bronchodilator FEV1/FVC measured 15 minutes after 400µg salbutamol or equivalent

Bronchodilator Reversibility Testing

Provides the best achievable FEV1 (and FVC)

Helps to differentiate COPD from asthma

Must be interpreted with clinical history - neither asthma nor COPD are diagnosed on spirometry alone

When to refer to PulmonologistDisease onset before 40 years age .

Rapidly progressive course of diseaseSevere COPD despite optimal treatment

Need for oxygen therapyDiagnostic uncertainty

Confirmed or suspected alpha 1 antitrypsin deficiency

Management

Reduce symptomsPrevent exacerbationsEnhance quality of life

Reduce disease morbidity and mortality

Medications Bronchodilators:

Inhaled short acting anticholinergicInhaled short acting B2 –agonists

Inhaled long acting anticholinergics

Methylxanthine

Oral phosphodiesterase -4 inhibitor Roflumilast

Anti -inflamatory agentsInhaled and oral steroids

Recently FDA approved an inhaled long acting B2- agonist Indacaterol (arcapta) for once daily maintenance treatment of airflow obstruction in pt with COPD.

Roflumilast is indicated to reduce the risk and frequency of exacerbations or to improve symptoms with severe COPD.Its not indicated for the relief of acute bronchospasm or rescue therapy.

Not indicated in the treatment of emphysema.

Antibiotics Indicated to treat exacerbations ;

Increased dyspneaSputum volume

Sputum purulenceSevere exacerbation of COPD requiring

mechanical ventilation

Respiratory fluoroquinolones or Third generation cephalosporin plus macrolide

Influenza and pneumococcal vaccine are recommended for pts with COPD.

Smoking cessation

Pulmonary rehabilitation;Can be considered in all pts with

FEV1<50%.Involves education,nutritional counseling,

excersize training.

Oxygen therapy

Indicated for pts who have resting hypoxia , defined as arterial Po2 of 55 mmHg or lower arterial oxygen saturation of 88%.

Duration of oxygen therapy not less than 15 hours daily.

Oxygen therapy improves survival, hemodynamics, excersize capacity and mental status

Noninvasive positive pressure ventilation in pts with COPD exacerbation

Improve respiratory acidosisIncrease pH

Decrease the need for endotracheal intubation

Reduce arterial Pco2 ,respiratory rate, length of hospital stay and mortality.

Lung volume reduction surgery

Resecting up to 30% of diseased or non functioning parynchyma to reduce hyperinflation and allow the remaining lung to function more efficiently.

LVRS indicated in pts with advanced COPD FEV1<45% and >20% and Dlco> 20%.

Lung trasplantation

For patients with very advanced COPD.The leading cause of long term morbidity at 5

years posttransplant is chronic allograft rejection ( bronchiolitis obliterance).