Chronic obstructive pulmonary disease (COPD)

1. General characteristics
a. COPD is a clinical and pathophysiologic syndrome that includes emphysema and
chronic bronchitis. These disorders have overlapping features, and because patients often
have characteristics of more than one disorder, both are classified together as COPD
(Table 2-7).

(1) Emphysema is a condition in which the air spaces are enlarged as a consequence of
destruction of alveolar septae.
(2) Chronic bronchitis is a disease characterized by a chronic cough that is productive of
phlegm occurring on most days for 3 months of the year for 2 or more consecutive years
without an otherwise-defined acute cause.
b. Smoking is the most important cause of COPD. Other causes include environmental
pollutants, recurrent upper respiratory infections, eosinophilia, bronchial
hyperresponsiveness, and 1-antitrypsin deficiency.

2. Clinical features
a. Patients present with a history of progressive shortness of breath, excessive cough,
and sputum production. Patients with predominantly emphysematous COPD may have
dry cough and weight loss.
b. The physical examination of a patient with advanced COPD may reveal asthenia,
dyspnea, pursed-lip breathing, and grunting expirations.
c. Chest examination
(1) Signs of hyperinflation with increase in the anteroposterior dimension are noted.
(2) Percussion yields increased resonance.
(3) Auscultation reveals decreased breath sounds and early inspiratory crackles.
(4) Wheezing may not be present at rest but can be evoked with forced expiration or
exertion.
(5) The duration of expiration is prolonged.
d. In patients with chronic bronchitis, rhonchi reflect secretions in the airways, and
breathing typically is raspy and loud.
3. Laboratory findings
a. Chest radiography
(1) CXR may show hyperinflation of the lungs and flat diaphragms; however, a CXR is
not sensitive or specific enough to serve as a diagnostic or screening tool.
(2) If emphysema is the main clinical feature, parenchymal bullae or subpleural blebs are
pathognomonic.
(3) In chronic bronchitis, nonspecific peribronchial and perivascular markings maybe
present.
b. Pulmonary function testing
(1) Air flow obstruction demonstrated on forced expiratory spirometry is suggestive.
(2) The FEV1/FVC ratio is decreased.

c. The CBC may show polycythemia caused by chronic hypoxemia.

4. Treatment
a. In symptomatic patients, the goal of treatment is to improve functional state and relieve
symptoms.
b. Smoking cessation is the single most important intervention.
c. Anticholinergic inhalers (ipratropium or tiotropium) are superior to -adrenergic agonists
in achieving bronchodilation.
d. Short-acting bronchodilators should be prescribed for acute exacerbations of dyspnea.
e. These patients are at high risk for acute infections; therefore, oral antibiotics frequently
are necessary.
f. Supplemental oxygen is the only therapy that may alter the course of COPD in patients
with resting hypoxemia (PaO2 < 55mm Hg or SaO2 < 88%).
g. Graded aerobic physical exercise should be encouraged.
h. Steroids are effective but should be used with caution.
i. Human 1-antitrypsin replacement may be recommended for patients who are deficient.
j. Patients should receive the pneumococcal vaccine and yearly influenza vaccine.

Bronchodilators

Beta agonists and Anticholinergics

Improve FEV1 and provide symptomatic relief

May reduce the frequency of exacerbation

Long-acting anticholinergics better than long-acting beta-agonists in moderate to

severe COPD

Does not alter the decline in pulmonary function in COPD

Side effects-few systemic adverse events since inhaled

Beta Agonists: Palpitations, tachycardia, hypokalemia, tremor, sleep disturbance.

Avoid excessive use of SABA while using LABAs

Anticholinergics: Dry mouth(MC), metallic taste, constipation, tachycardia,

blurred vision, rare precipitation of glaucoma, urinary retention

Inhaled Corticosteroids

Consider in patients with features of asthma or

Use for stage 3 or 4 COPD patients with frequent exacerbations

Reduce frequency of exacerbations in severe COPD

Use in combination with LABA(more effective) rather than monotherapy

Breo: fluticasone furoate 100 mcg/vilanterol trifenatate 25 mcg once daily inhalation

Symbicort: budesonide/formoterol 160/4.5 mcg/inhalation - 2 inhalations twice daily

Advair: fluticasone/salmeterol DPI 250/50 mcg/inhalation - 1 inhalation twice daily

Side effects

Oropharyngeal candidiasis (MC-rinse mouth and use spacer for MDIs)

Hoarseness

Cataracts

Osteopenia

Increased bruising

Paradoxical association with increased rate of pneumonia

Theophylline

For severe COPD, symptomatic despite maximal inhaled bronchodilators and steroids

400-600 mg/day PO divided every 6-24 hrs based on formulation

Must monitor serum levels (5 to 15 mg/dL, narrow therapeutic index)

Side effects

Heartburn, restlessness, insomnia, irritability, tachycardia, tremor,

Dose-related: Supraventricular arrhythmias, nausea, vomiting, seizures

Smoking decreases the plasma level

Roflumilast

Phosphodiesterase-4 inhibitor

Reduces COPD exacerbation frequency

Role not yet determined, but is an option for patients refractory to LABAs, LA cholinergics, and
inhaled steroids

500 mcg PO daily

Side effects

Nausea

Diarrhea

Weight loss, decreased appetite

Headache

Insomnia

Abdominal pain

Anxiety & depression (less common)