COPD

DEFINITION
• A disease state characterized by the presence
of airflow obstruction due to chronic
bronchitis or emphysema.
• The airflow obstruction is generally
progressive, may be accompanied by airflow
hyperactivity, and may be viewed as partially
reversible.
• Includes emphysema and chronic bronchitis
 INCIDENCE
• COPD occurs in 4-6% of white males, and 1-3%
of adult white females
• The 4th most common cause of death in the
United States
 EMPHYSEMA

• Permanent and destructive enlargement of

airspaces distal to the terminal bronchioles
without obvious fibrosis and with loss of normal
architecture
• Always involves clinically significant airflow
limitation.
• “pink puffer”
 CHRONIC BRONCHITIS
• Presence of productive cough not attributable
to other causes on most days for at least 3
months over 2 consecutive years
• May be present in the absence of airflow
limitation.
• “blue bloater”
 PATHOGENESIS
• Increased number of activated polymorpho
nuclear cells and macrophages produce
elastases (such as human leukocyte elastase),
resulting in lung destruction.
• Increased oxidative stress caused by free
radicals in cigarette smoke, the oxidants
released by phagocytes, and
polymorphonuclear leukocytes all may lead to
apoptosis or necrosis of exposed cells
 CHRONIC BRONCHITIS
• Is a condition associated with excessive
tracheobronchial mucus production sufficient
to cause cough with expectoration on most
days for atleast 3 months a year for more than
two consecutive years .
 CHRONIC BRONCHITIS
– Mucus gland enlargement

– Airway atrophy, focal squamous metaplasia,

ciliary abnormalities, variable amounts of
airway smooth muscle hyperplasia,
inflammation, and bronchial wall thickening
– Respiratory bronchioles display a
mononuclear inflammatory process, lumen
occlusion by mucous plugging, goblet cell
metaplasia, smooth muscle hyperplasia,
and distortion due to fibrosis
• Airway walls to deform and narrow the airway
lumen
 REID INDEX
• The ratio of thickness of the submucosal
glands to ratio of the bronchial wall .
• Normal – 0.44 + 0.09
• Chronic bronchitis -0.52 + 0.08
 EMPHYSEMA
• Centriacinar:

–focal destruction limited to the respiratory

bronchioles and the central portions of acinus

–associated with cigarette smoking

–most severe in the upper lobes

• Panacinar:
–involves the entire alveolus distal to the terminal
bronchiole

–develops in patients with homozygous alpha1-

antitrypsin (AAT) deficiency

–most severe in the lower lung zones

• Distal acinar:
– Also called paraseptal
– least common form
– involves distal airway structures, alveolar ducts, and
sacs
– localized to fibrous septa or to the pleura and leads to
formation of bullae (can result in pneumothorax)
 RISK FACTORS
• SMOKING
• Impairs ciliary movement
• Inhibit function of alveolar macrophages
• Causes hypertrophy and hyperplasia of mucus
secreting glands
• Causes obstruction of small airways
• Stimulates vagus – bronchoconstriction
• Occupational Exposures :

• Dusts, gases, fumes

• Atmospheric pollution: More incidence in

industrilaised area

• Sulphur dioxide, NO2, toxic fumes, particulate

dust
• Alpha1-antitrypsin deficiency

• Alpha1-antitrypsin is an important protease

inhibitor that usually prevents elastases from
causing lung destruction
 Contributory factors:
• Occupation
• Infection
• Familial & genetic factors
 CLINICAL FEATURES
• Dyspnea
• Cough (usually worse in morning, sputum
production)
 SIGNS
• RR, HR, O2 saturation
• Cyanosis
• Barrel chest
• Use of accessory muscles of inspiration
• Hyper resonance on percussion
• Decreased breath sounds
• Enlarged thoracic volume
• Signs of cor pulmonale +
 INVESTIGATIONS
• CBC:  Hgb/Hct
• ABG: pH, pCO2
• Chemistry: HCO3
CHEST X RAY
 Diagnosis of COPD – Pulmonary Function
Tests
•  Forced Expiratory Volume for 1 second
(FEV1)
• FEV1/FVC (Forced Vital Capacity) ratio
•  Total Lung Capacity (TLC)
•  Forced Residual Capacity (FRC)
•  Residual Volume (RV)
•  Vital Capacity (VC)
GOLD CLASSIFICATION OF COPD
 TREATMENT
• MILD COPD :
• Short acting beta 2 agonist
• Salbutamol , Fenoterol , Terbutaline
• MODERATE :
• Long acting bronchodilators
• Formoterol , Salmeterol
• If needed add
• Anticholinergics
• Short – Ipratropium , Oxitropium
• Long - Tiotropium
• SEVERE :
• Inhaled steroids
• Beclomethasone , Triamcinolone , Fluticasone
• Not satisfactory
• Add systemic steroids
• Prednisolone , methyl prednisolone
• VERY SEVERE :
• Long term O2 therapy
• Maintain a PaO2 > 60 mm hg , SaO2 > 90 %
• Ventilatory support
 NIPPV INDICATIONS
• Non invasive positive pressure ventilation :
• Severe dyspnea with the use of accesssory
muscles ,
• Acidosis PH < 7.35 ,
• Hypercapnea PaCO2 > 45 mm hg,
• Respiratory rate > 25 / min
 MECHANICAL VENTILATION
• INDICATIONS :
• Respiratory rate > 35 / min
• PaO2 < 40 mm hg
• Severe acidosis PH < 7.25
• Hypercapnea PaCo2 > 60 mm hg
• Respiratory arrest
• Altered sensorium
• NIPPV failure
 Surgery
• Bullectomy
• Resection of damaged portion of lung