COPD
COPD
COPD
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Introduction
06/28/2023
COPD by Meaza R( MD Internist)
Defined as disease state characterized by persistent respiratory symptoms and
airflow obstruction(GOLD)
The classic definition of COPD requires the presence of
chronic airflow obstruction by spirometry
250 million people live with COPD world wide and
is the 4th leading cause of death in US
Which one is to be considered symptom Vs air flow limitation? 3
06/28/2023
COPD by Meaza R( MD Internist)
COPD
Is based only on airflow obstruction determined by spirometric thresholds of
normality.
Respiratory symptoms and other features of COPD can occur in subjects who do not
meet a definition of COPD
Chronic bronchitis with out air flow limitation is not COPD
What are the mechanism of obstruction? 4
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COPD by Meaza R( MD Internist)
Small airway disease
Air way inflammation
Is there any significant airway hyperresponsive ness and smooth musles contraction?
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COPD by Meaza R( MD Internist)
Emphysema: an abnormal and permanent distension of air spaces distal to the
terminal bronchiole with destruction of the alveoli
Classification
Centrilobular
Limited to the reparatory bronchiole and alveoli related to them, spare the periphery
Upper lobe and superior segments of lower lobe
Frequently associated with smoking , coal miners in some case
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COPD by Meaza R( MD Internist)
Panacinar
Both peripheral and central acini are involved
Predominantly the lower half of the the lung is affected
Associate to α1 AT deficiency
Paraseptal (distal acinar)
may occur alone or in association with the above two.
When it occurs alone, the usual association is a spontaneous pneumothorax in a young
adult.
COPD by Meaza R( MD Internist)
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COPD by Meaza R( MD Internist)
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COPD by Meaza R( MD Internist)
chronic Bronchitis:
Excess tracheobronchial mucus secretion thus cause productive chronic cough (3
month of a yr for more than two consecutive years), Goblet cells
There is hypertrophied and hyperplastic mucus gland
Is inflammation of the airways with reduced caliber
06/28/2023
COPD by Meaza R( MD Internist)
Environmental
Smoking: dose response relationship
Occupational exposure(mining, textile, dust exposure)
Air pollution
Respiratory infection(exacerbation)
Genetics
Alpha 1 antitrypsin deficiency
Abnormal lung development
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Pathogenesis
06/28/2023
COPD by Meaza R( MD Internist)
The physiologic marker is Airflow obstruction which results from airway disease
and /or emphysema
Lead to inflammatory cell recruitment within the
terminal air spaces of the lung 12
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COPD by Meaza R( MD Internist)
These inflammatory cells release elastolytic proteinases
that damage the extracellular matrix of the lung.
pathophysiology
06/28/2023
COPD by Meaza R( MD Internist)
Airflow obstruction determined by spirometry (FEV1/FVC)
Hyperinflation : air trapping with increased residual volume
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Clinical presentation
06/28/2023
COPD by Meaza R( MD Internist)
Chronic bronchitis Emphysema
Ongoing productive cough Minimal cough with exacerbation
Copious purulent sputum Breathlessness, insidious in
onset( initially exertional then at rest)
Breathlessness( late )
Generalized weakness, lethargy
Wheeze
Chest tightness
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Approach
06/28/2023
COPD by Meaza R( MD Internist)
History( symptoms, smoking, occupation, family Hx, Hx medication)
Physical examination
Signs of smoking ( odor , stained finger),
Barrel chest
Accessory muscle use
Tripod position
Cyanosis, clubbing
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COPD by Meaza R( MD Internist)
Posture
Pink puffers (thin, noncyanotic at rest and prominent use of accessory muscles):
Emphysema
In chronic bronchitis: cyanotic and heavy(blue bloaters)
Sign of right HF?
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COPD by Meaza R( MD Internist)
Poor diaphragmatic excursion
Hyper resonant
Decreased breath sound to silent chest
Wheeze, prolonged expiratory phase
Crepitation
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COPD by Meaza R( MD Internist)
investigation
CBC--- anemia/ polycythemia, exacerbation
ABG and oximetry
• Demonstrate resting or exertional hypoxemia.
• Alveolar ventilation and acid-base status by measuring arterial P CO2 and pH.
• The change in pH with PCO2 is 0.08 units/10 mmHg acutely and 0.03 units/10
mmHg in the chronic state.
• Arterial pH -ventilatory failure( PCO2 >45 mmHg) - acute or chronic
• Indications for ABG --- when to do ABG?
• Low FEV1( < 50%)
• SaO2 < 92%
• Depressed LOC
• Acute exacerbation
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COPD by Meaza R( MD Internist)
Spirometry
FEV1/ FVC ratio < 0.7 ---- airflow limitation
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Is imaging important to Dx COPD?
06/28/2023
COPD by Meaza R( MD Internist)
Not required to diagnose COPD
CXR
Used to exclude other diagnosis like kiynphosis
Sensitivity for moderate cases(50%)
Inc. radiolucency, flat diaphragm, long and narrow heart shadow
Inc. retrosternal airspace on lateral x- ray
Bullae
Prominent hilar vascular shadows – in advanced disease with pulmonary HTN and cor
pulmonale
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COPD by Meaza R( MD Internist)
Indicated if
Lung cancer is considered in the presence of emphysema
To asses the presence of bronchiectasis
Preoperative assesment for LVRS
Centriacinar – upper lobe and holes in center of SPL
Panacinar – lung bases and entire SPL
Paraseptal – periphery
Lung transplantation
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COPD by Meaza R( MD Internist)
How to assess level of air flow limitation ? 26
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COPD by Meaza R( MD Internist)
Spirometry should be done after adequate does of SABA
After 15 minute
How to assess symptom? 27
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COPD by Meaza R( MD Internist)
COPD is beyond dyspnea so what to do?
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COPD by Meaza R( MD Internist)
Based on GOLD stage and grouping
Less symptom, low exacerbation?
More symptom, less exacerbation?
Less symptom, frequent exacerbation?
More symptom, frequent exacerbation?
ABCD
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COPD by Meaza R( MD Internist)
Acute exacerbation Vs stable COPD
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COPD by Meaza R( MD Internist)
Stable phase
Goal: provide symptom relieve and reduce future risk
survival is improved by:
Quit smoking,
oxygenation,
lung volume reduction(emphysematous)
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pharmacotherapy
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COPD by Meaza R( MD Internist)
Medical therapy
symptomatic and decrease exacerbation( bronchodilators, steroid)
Smoking cessation
Oxygen
Decrease mortality
Indicated with person with resting SPo2<= 88%, history of pulmonary hypertension or
corplumonale or erythrocytosis
`α 1 AT Augmentation Therapy
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Non pharmacotherapy
06/28/2023
COPD by Meaza R( MD Internist)
Vaccination (influenza, pneumococcal, Bordetella pertussis)
Lung rehabilitation ( pt education, exercise, psychosocial and nutritional)
Improve QOL, dyspnea , exercise tolerance
Reduce rate of hospitalization
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COPD by Meaza R( MD Internist)
Surgical volume reduction
In emphysematous lung
Improve lung function, exercise capacity
Candidates: upper lobe predominant emphysema and pts with low post rehabilitation
exercise capacity
Lung transplant
Pts with very sever airflow obstruction
COPD is 2nd leading cause for lung transplant
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COPD by Meaza R( MD Internist)
Acute exacerbation
Bronchodilators
Systemic glucocorticoid
Antibiotics
Oxygen supplement keep saturation above 90%
Ventilatory support: invasive vs non invasive
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COPD by Meaza R( MD Internist)
COPD hospitalization
20% rehospitalized in next 30 days
45% in the next yr
20% hospitalized pts die in the following yr after discharge
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COPD by Meaza R( MD Internist)
It has been shown that a multifactorial index (BODE), incorporating airflow
obstruction, exercise performance, dyspnea, and body mass index, is a better
predictor of mortality. Recently, GOLD added additional elements to their COPD
classification system incorporating respiratory symptoms and exacerbation history
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COPD by Meaza R( MD Internist)
Reference
Harrison 21st ed
UpToDate
ATS
GOLD 2020