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GAO Bao-an MD
Respiratory Department,
The First College of Clinical Medical Science,
Three Gorges University
E-mail: 222xiaozhao@163.com
The learner will…
● Master clinical manifestation, diagnosis, and
principal protocols of prophylaxis and treatment
of COPD.
● Be familiar with the pathophysiology of COPD.
● Understand COPD is common and frequently-
occurring disease. Incidence is high, and
complication is serious.
World’s Top Ten Killers (WHO)
World’s Top Ten Killers (WHO)
Why COPD is Important ?
• COPD is the only chronic disease that is
showing progressive upward trend in both
mortality and morbidity.
• It is expected to be the third leading
cause of death by 2020
ⅠDefinition
Chronic obstructive pulmonary
disease is defined as
--‘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 airway hyper-
reactivity, and may be partially reversible’
American Thoracic Society 1995/ATS
New Definition
• Chronic obstructive pulmonary disease (COPD) is
a preventable and treatable disease state
characterized by airflow limitation that is not fully
reversible.
• The airflow limitation is usually progressive and
is associated with an abnormal inflammatory
response of the lungs to noxious particles or
gases, primarily caused by cigarette smoking.
• Although COPD affects the lungs, it also
produces significant systemic consequences.
1.5
1.0
0.5
14 12.7 12.4
12.1
12
10 8.8 8.2
7.8
8
4.9 5.4 5.1 #
6
4
2
0
Male Female * Total
cilia
Nonsmoker COPD
A B
A Hypertrophy of airway
smooth muscles
B Squamous metaplasia
replace columnar epithelium
focally
C Enlarged submucosal
C glands
Ⅴ Pathogenesis of COPD
3 Imbalance of protease-antiprotease
AIRWAY INFLAMMATION OF COPD
? Alveolar macrophage
CD8
+
lymphocyte
Neutrophil chemotactic factors
Cytokines (IL-8, interleukin)
Mediators
Neutrophil
Proteolysis
IL-8 TNF-
a
O2-, H202 α
Neutrophil
OH., ONOO-
recruitment
Mucus secretion
Isoprostanes Plasma leak Bronchoconstriction
PROTEASE-ANTIPROTEASE IMBALANCE IN COPD
α 1-Antitrypsin
SLPI
Neutrophil elastase
Elafin
Cathepsins
TIMPs
MMP-1, MMP-9,
MMP12
Granzymes, perforins
Others……..
Ⅵ Pathophysiology of COPD
▲ Increased mucus production and reduced mucociliary
clearance
– cough and sputum production
▲ Loss of elastic recoil, Increase smooth muscle tone,
Pulmonary hyperinflation
– airway collapse (emphysema)
▲ Gas exchange abnormalities
– hypoxemia and/or hypercapnia (dyspnea, cyanosis)
▲ Pulmonary hypertension: hypoxemia, decreasing capillary
bed
– chronic cor pulmonale (systemic edema)
Ⅶ Diagnosis of COPD
1 Symptoms
• Cough and mucoid sputum
• Dyspnea-slowly
progressive
• Wheeze
• Edema (If cor pulmonale)
• Winter exacerbations
Key indicators for COPD diagnosis
Chronic cough Present intermittently or every day
often present throughout the day;
seldom only nocturnal
Normal
Pulmonary function testing
Spirometry
• Diagnosis
• Assessing severity
• Assessing prognosis
• Monitoring progression
• FEV1 – Forced expired volume in the
first second
• FVC – Total volume of air that can be
exhaled from maximal inhalation to
maximal exhalation
• FEV1/FVC% – The ratio of FEV1 to
FVC, expressed as a percentage.
Arterial blood gas analysis
In the early stages, mild or moderate hypoxemia (PaO2
﹤60mmHg) without hypercapnia.
As the disease progresses, hypoxemia becomes more
severe and hypercapnia (PaCO2﹥50mmHg) happens.
Hypercapnia occurs with increasing frequency as the
FEV1 falls below 1 L.
Blood gas abnormalities worsen during acute
exacerbations and may worsen during exercise and
sleep.
4 COPD classification based on Spirometry
Severity Post bronchodilator Post bronchodilator
FEV1/FVC % FEV1% predicted
Bronchitis
Asthma
COPD
Emphysema
Ⅷ Differential diagnosis
COPD Smoking (occupational ) history. Onset after middle age.
chronic cough, sputum, dyspnea. Symptoms develop
slowly. Airflow obstruction is not reversible fully.
Exacerbations
Exacerbations
Deterioration
Exacerbation
s
End of Life
4
FEV1 (liters)
3
smoking
2
1
Stop
0
10 15 20 25 30 35 40 45 50 55 60 65 70 75 80
Age (Years)
Smoking cessation
• Stops accelerated decline in FEV1
• Improves possibility of oxygen therapy benefits
• 3-6 months after quitting: end of cough/phlegm
production
• 1 year: lung function increased 30mls
• 1 year: risk of Small Cell Lung Cancer halved
• 5 years: risk of any lung cancer halved
– No progression of COPD
– Sporting performance enhanced
• Methods of smoking cessation
– Counseling; Nicotine replacement; Behavior
modification
Physical activity
● Walk, jogging
(30 minutes for at least twice a week )
● pursed-lip breathing
● Abdominal breathing
● Qi gong, or Indian yoga
Nutrition
Low BMI, high mortality
BMI (body mass index) = weight (kg)/high2(m2)
BMI﹤21 kg/m2, mortality rise