Chronic Obstructive Pulmonary Disease ICD-9M Code 496 : COPD 492.8 Emphysema 1. Definition: a.

COPD Requires Significant Irreversible Airflow Obstruction b. It Includes Chronic Bronchitis and Emphysema. c. The Two Conditions Often Coexist. 2. Comparison: A. The Definition of Emphysema Is A Morphologic Definition. B. The Definition of Chronic Bronchitis Is Clinically Based on the Presence of Chronic & Recurrent Cough With Excess Mucus Production. C. The Anatomic Patterns Of The Two Diseases Are Different. 1. Chronic Bronchitis Affects The Large & Small Airways Viz. The Bronchi & The Bronchioles. 2. Emphysema Affects The Acinus Of The Lung: The Structures Distal To The Terminal Bronchioles. 3. Types of Emphysema Emphysema Is Not Only Defined By The Acinar Structure But Also By The Dstribution In The Lobule & Acinus Of The Lung. A. Centroacinar (Centrilobular) Emphysema A. It Involves The Central Or Proximal Part Of Acinus Formed By The Respiratory Bronchioles B. The Distal Alveoli Are Spared C. The Lesion is More Severe In The Upper Lobes Particularly The Apical Segments B. Panacinar (Panlobular) Emphysema A. Here The Acini Are Uniformly Affected From The Respiratory Bronchiole Through The Alveoli B. The Lesion Is More Severe In The Lower Lung Zones.

C. Distal Acinar (Paraseptal) Emphysema A. The Distal Part Of Acinus Is Primarily Involved Viz The Alveoli B. The Lesion Is More Strikingly Adjacent To The Pleura, Adjacent To The Septa & At The Margins Of The Lobules. C. It Occurs In Areas Of Fibrosis, Scarring Or Atelectasis D. It Is More Severe In The Upper Half Of The Lungs. 4. Incidence: A. Becomes Disabling In The 5th to 8th Decades Of Life. B. There Is A Clear Association Between Cigarette Smoking & Emphysema. 5. Pathogenesis: There Are 2 Critical Imbalances: A. Protease-Antiprotease Imbalance B. Oxidant-Anti-Oxidant Imbalance A. Protease-Antiprotease Imbalance Theory: 1. Neutrophils Are The Principal Source Of Cellular Proteases 2. Any Stimulus Which Increases the Number Of Leukocytes Or The Release Of Protease Granules Of The Leukocytes Increases Proteolytic Activity. 3. With Low Levels Of Serum Alpha-Anti-Trypsin, Elastic Tissue Is Destroyed & Emphysema Occurs 4. This Is What Occurs In Alpha-Antitrypsin Deficiency Disease Thus Emphysema Is Seen To Result From The Destructive Effect Of High Protease Activity In Subjects With Low Antiprotease Levels 1. This Hypothesis Explains The Effects Of Cigarette Smoking On Emphysema: In Smokers, Neutrophils and Macrophages Accumulate In The Alveoli.

2. This Mechanism Possibly Involves The Direct Chemoattractant Effects Of Nicotine. These Activate Transcription Of Nuclear Factors NF-kb Which Switches On Genes For TNF & IL8.TNF & IL-8 In Turn Attract & Activate More Neutrophils. 3. Accumulated Neutrophils Release Their Granules Rich In Cell Proteases Such As Neutrophil Elastase, Proteinase 3 & Cathepsin G Resulting In Tissue Damage 4. Smoking Also Increases Macrophage Elastase Activity Which Is Not Inhibited By Alpha-Antitrypsin. B. Oxidant-Anti-Oxidant Theory Tobacco Smoke Contains An Abundance Of Free Radicals Which Deplete The Anti-Oxidant Concentration In The Lungs (Superoxide Dismutase, Glutathione) Predisposing The Lungs To Damage 6. Clinical Signs: A. Progresive Dyspnea B. Weight Loss C. Pulmonary Function Tests : Reduced FEV-1 & Reduced FEV-1/FVC Ratio A. Classic Pink Puffer: Emphysematous Patient A. The Patient Is Barrel Chested B. They Are Usually Sitting Forward In A Hunched Over Position C. The Patient Has Dyspnea With Prolonged Expiration D. The Patient Attempts To Squeeze The Air Out Of His Lungs With Each Expiratory Effort

B. Classic Blue Bloater: Chronic Bronchitic Patient: A. Has A History Of Recurrent Infections With Purulent Sputum. B. Has Less Prominent Dyspnea & Less Prominent Respiratory Drive & Retain CO2 C. Usually Are Hypoxic & Cyanotic D. Tend To Be Obese & Their Condition Progresses to CHF. C. Most COPD Patients Tend To Be In Between These Two Extremes Of Clinical Forms Of The Disease. 6. Treatment: A. Non Pharmacologic Treatment 1. Weight Loss In Patients With Chronic Bronchitis. 2. Avoidance of Tobacco & Elimination Of Air Pollutants 3. Supplemental Oxygen A. Ensure Oxygen Saturation >90% Measured By Pulse Oximetry 4. Pulmonary Toilet A. Careful Nasotracheal Suction B. General Treatment: 1. Bronchodilators 2. Short Acting Beta-2 Agonists A. Albuterol MDI 1-2 Puffs Q4-6H PRN 3. Long Acting Inhaled Agents: A. Patients With Mild To Moderate Symptoms Or Continuous Symptoms: 1. Salmeterol or Formoterol 1-2 Puffs BID 4. Anticholinergics: A. Ipatropium (Atrovent) Inhaler 2 Puffs QID B. Tiotropium (Spiriva): Long Term/ Once A Day

5. Antibiotics Are Indicated If Suspected Respiratory Infections: A. Antibiotics Of Choice: 1. Azithromycin 2. Levofloxacin 3. Amoxicillin/Clavalanate 4. Cefuroxime 6. Inhaled Steroids: If Unresponsive 7. Theophylline: If Unresponsive 7. Pulmonary Rehabilitation: A. Home Oxygen B. Combination Therapy Including: 1. Beta-2 Agonists Or. Ipatropium Bromide (Atrovent) 2. Antibiotics 3.. Prednisolone 40 Mg/ For 10 Days Has Been Shown To Reduce Relapse Rates At 30 Days/ 8. Comments: A. All Patients With COPD Should Receive: 1. Pneumococcal Vaccine 2. Yearly Influenza Vaccine 9. Complications and Causes Of Death: A. Secondary Pulmonary Hypertension : 1. Hypoxia From Loss Of The Pulmonary Capillary Surface Area Due To Alveolar Destruction B. Death Results From: 1. Pulmonary Failure With A. Respiratory Acidosis B. Hypoxia C. Coma Or 2. Right Sided Heart Failure (Cor Pulmonale)

10. Differential Diagnosis: A. CHF B. Asthma C. Respiratory Infections D. Bronchiectasis E. Cystic Fibrosis F. Neoplasm G. Pulmonary Embolism H. Obstructive Sleep Apnea I Hypothyroidism 11. Conditions Related To Emphysema; A. Compensatory Emphysema: Involves Compensatory Dilation Of Alveoli In Response To Loss Of Lung Substance Eg Post-Lobectomy B. Senile Emphysema: Is Due To Age Related Effects Of Larger Alveolar Ducts & Smaller Alveoli. Perhaps A Better Term Is Senile Hyperinflation. C. Obstructive Overinflation: The Lungs Expand Because Air Is Trapped Within It Example : Subtotal Obstruction Due To A Tumor Or Foreign Body. D. Mediastiinal (Interstitial ) Emphysema: Dissection Of Air Into The Interstitium Where Air Enters The Connective Tissue Of The Lungs, Mediastinum & Subcutaneous Tissue. Patient Literally Blows Up Like A Balloon With Marked Swelling Of The Head & Neck & Crackling Crepitations All Over the Chest. When The Tear Is Sealed The Swelling Subsides.