Lec 8 COPD Chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease

1. Chronic obstructive pulmonry disease

2. DEFINITION Progressive, non-reversible, obstructive airway disease leading to damaged alveolar walls and inflammation of the conducting airways Some part of the airway becomes obstructed or no longer functions efficiently

3. Chronic Bronchitis Emphysema Asthma (?) Although not strictly a COPD disorder ASTHMA is often linked with being a COPD disorder. COPD DISORDERS

4. CHRONIC OBSTRUCTIVE PULMONARY DISEASE:

5. Differential Diagnosis: COPD and Asthma COPD ASTHMA Onset in mid-life Symptoms slowly progressive Long smoking history Dyspnea during exercise Largely irreversible airflow limitation Onset early in life (often childhood) Symptoms vary from day to day Symptoms at night/early morning Allergy, rhinitis, and/or eczema also present Family history of asthma Largely reversible airflow limitation

6. Epidemiology of COPD 30% of smokers develop COPD 20% of adult males have COPD 15% of COPD patients are severely symptomatic Mortality rate still rising prevalence in low birth weight and low socioeconomic status Tuberculosis in smokers predisposes to COPD

7. Excessive tracheobronchial mucus production sufficient to cause cough with expectoration for most days of at least 3 months of the year for 2 consecutive years. Def: Chronic Bronchitis

8. Permanent abnormal distention of air spaces distal to the terminal bronchiole with destruction of alveolar septa (containing alveolar capillaries) and attachments to the bronchial walls. Def: Emphysema

9. 9 Risk Factors for COPD Nutrition Infections Socio-economic status Aging Populations Alpha-1 antitrypsin deficiency

10. Pathophysiology of COPD Chronic inflammation, bronchial wall edema, mucous secretion, hyperinflation and air trapping Increase in proteinases compared to antiproteinases and in free radicals leading to parenchymal destruction Changes in pulmonary vasculature leading to ventilation-perfusion mismatching, pulmonary hypertension, cor pulmonale

11. COPD

12. Smokers lung Normal Lung

13. Chronic hypoxia Pulmonary vasoconstriction Muscularization Intimal hyperplasia Fibrosis Obliteration Pulmonary hypertension Cor pulmonale Death Edema Pulmonary Hypertension in COPD

14. Complications of COPD: Cor Pulmonale syncope, hypoxia, pedal edema, passive hepatic congestion, and death. Acute Exacerbations. End-stage lung disease . Polycythemia – hypoxia. Pneumothorax, Infections, Bronchectasis.

15. COPD – Signs and Symptoms Cough – usually chronic Excess sputum production thick, sticky yellow, green, bloody Wheezing Shortness of breath with exertion Shortness of breath soon after lying down

16. COPD – Signs and Symptoms Increased “work of breathing” Fatigue – lack of energy Muscle wasting Difficulty sleeping

17. Physical signs Large barrel shaped chest (hyperinflation) Prominent accessory respiratory muscles in neck and use of accessory muscle in respiration Low, flat diaphragm Diminished breath sound Limitation of air flow on breathing test – Spirometry

18. Emphysema = Pink Puffer ! Gross Pathological Changes of Emphysema

19. Emphysema = pink puffer Chronic Bronchitis = blue bloater Age (Dx) 60 + y 50 ± y Rest dyspnea mild-mod none Exer dyspnea severe moderate Cough ± prominent Sputum scanty, mucoid large volume, purulent Resp infect less often often Resp failure terminal repeatedly Cor pulmonale terminal common Emphysema : ChronicBronchitis

20. Emphysema = pink puffer Chronic Bronchitis = blue bloater PHT (rest) 0-mild Mild-moderate PHT (exertion) moderate severe Build Asthenic, cachectic obese, cyanosed Hematocrit 35-45 50-55 Breath pattern use accessory muscles of respiration do not use accessory muscles of respiration Sleep pattern Normal sleep apnea XRC Hyperinflation Bullae bronchovascular markings Emphysema : ChronicBronchitis

21. Emphysema = pink puffer Chronic Bronchitis = blue bloater PaO 2 ± 65 mm Hg 45-60 PaCO 2 35-40 50-60 Elastic recoil  Normal FEV1    Bronchodilator response Poor Better but < 12% and 200ml Emphysema : ChronicBronchitis

22. Lab investigations Imaging tecniques Pulmonry function test CBC ABG Alpha-1 antitrypsin levels Echo. & ECG

23. Spirometry Diagnosis Assessing severity Assessing prognosis Monitoring progression

24. COPD classification based on spirometry SPIROMETRY is not to substitute for clinical judgment in the evaluation of the severity of disease in individual patients. Severity Postbronchodilator FEV 1 /FVC Postbronchodilator FEV 1 % predicted At risk >0.7 > 80 Mild COPD < 0.7 > 80 Moderate COPD < 0.7 50-80 Severe COPD < 0.7 30-50 Very severe COPD < 0.7 <30

25. Spirometry FEV 1 – Forced expired volume in the first second FVC – Total volume of air that can be exhaled from maximal inhalation to maximal exhalation FEV 1 /FVC% - The ratio of FEV 1 to FVC, expressed as a percentage.

26. Spirometry: Normal and Patients with COPD

27. 29 Goals : Relieve symptoms Prevent disease progression Improve exercise tolerance Improve health status Prevent and treat complications Prevent and treat exacerbations Reduce mortality COPD MANAGEMENT GOALS

28. Risk Factor Reduction Smoking cessation (prolongs survival) Avoid exposure to second hand cigarette smoke Reduction of exposure to indoor and outdoor pollution Influenza vaccine Pneumococcal vaccines

29. Post-bronchodilator FEV1 (% predicted) Management based on GOLD

30. 33 Bronchodilators Bronchodilator medications are central to the symptomatic management of COPD They are given on an as-needed basis or on a regular basis to prevent or reduce symptoms and exacerbations The principal bronchodilator treatments are ß 2 - agonists and anticholinergics used singly or in combination Regular treatment with long-acting bronchodilators is more effective and convenient than treatment with short-acting bronchodilators

31. 34 Inhaled Glucocorticoids Consider adding regular treatment with inhaled glucocorticosteroids to bronchodilator treatment is for symptomatic COPD patients with an FEV1 < 50% predicted ( Stage III and IV) and repeated exacerbations An inhaled glucocorticosteroid combined with a long-acting ß2-agonist is more effective than the individual components

32. Other Medications Chronic oral Prednisone Use in chronic COPD is controversial. No effect on survival. May improve symptoms and reduce hospitalizations in some patients already at maximum treatment Mucolytics & Expectorants Relives symptoms from copious, viscous secretions Oral Theophylline If inhalers not sufficient Side effects common

33. Home Oxygen Therapy > 15 hours/day reduces mortality Criteria for O2 therapy Pa O2 < 55 mm Hg (O2 saturation < 88%) at rest or during exercise or sleep or Pa O2 < 60 mm Hg and hematocrit >52% Bipap (non-invasive ventilation) when sleeping may provide additional improvement

34. Typically includes exercise, education and psychological support Shown to improve symptoms, exercise capacity, reduce use of medical care, reduce anxiety and depression Pulmonary Rehabilitation and Patient Education

35. Surgery Primarily for patients with emphysema Bullectomy and lung volume reduction surgery  may result in improved spirometry, lung volume, exercise capacity, dyspnoea, health-related quality of life and possibly survival in highly selected patients. Lung transplantation  results in improved pulmonary function, exercise capacity, quality of life and possibly survival in highly selected patients.

36. Prognosis Disease Trajectory of a Patients with COPD Symptoms Exacerbations Exacerbations Exacerbations Deterioration End of Life

37. Quality of life: compromised