COPD

COPD is characterized by
Persistent respiratory symptoms and air flow limitation due to airway
and alveolar abnormalities usually caused by significant exposure to
noxious agents or gasses.

Two main varieties

Emphysema
Chronic bronchitis
Chronic bronchitis
Excessive secretion of bronchial mucus characterized by daily productive
cough for 3 months in at least 2 consecutive years

Emphysema
Pathological diagnosis
Abnormal permanent enlargement of air spaces distal to terminal
bronchioles with destruction of alveolar walls and without obvious
fibrosis
Etiology
80 % Cigarette smoking
20% environmental tobacco
occupational dusts
chemicals and
indoor air pollution (biomass fuel used for cooking in poorly
ventilated homes
outdoor air pollution
airway infection
atopy ..allergy
hereditary factor ..alpha 1 anti trypsin deficiency
Clinical features

Type A (Pink Puffer )Emphysema predominant

Major complaint is dyspnea often severe

Presenting age is 50
Thin with h/o recent weight loss
Cough is rare
Sputum scant ,mucoid and clear
Appear uncomfortable using accessory muscles of respiration
Chest quiet
No peripheral edema
Clinical features

Type B (Blue bloater ) Bronchitis predominant

Chronic cough
Mucopurulent sputum with frequent exacerbations due to chest infections
Presenting age is 30s and 40s
Dyspnea is mild but there's limitation to exercise
overweight
Cyanosis
Edema
Wheezes are common
Laboratory findings
Emphysema
SaO2 is normal at rest
Hb is normal (12-15 g/dl)
Arterial blood gases PaO2 normal to slightly reduced (65-75mmhg )
PaCO2 normal to slighty reduced (35-40 mmHg
X ray Chest hyperinflation with flattened diaphragm
Vascular markings are reduced at apices
High resolution CT Scan confirmation
Pulmonary function tests Total lung capacity increased
Dlco reduced
Echocardiography pulmonary artery pressure
Ventilation –perfusion test increased ventilation to high V/Q areas
high dead space ventilation
Nocturnal ventilation mild to moderate degrees of oxygen desaturation not
usually associated with obstructive sleep apnea
Laboratory findings
Chronic bronchitis
Hb is elevated (15-18g/dl
Arterial blood gases PaO2 reduced (45-60mmhg )
PaCO2 slightly to markedly elevated (50 to 60 mmHg
X ray Chest Increased interstial markings (dirty lungs )
Diaphragms not flattened
High resolution CT scan confirmation
Pulmonary function tests Total lung capacity is normal
Dlco normal
Echocardiography pulmonary artery pressure
Ventilation –perfusion test increased perfusion to low V/Q areas

Nocturnal ventilation severe degree of oxygen desaturation

usually associated with obstructive sleep apnea
Complications

Acute bronchitis
Pneumonia
Pulmonary thromboembolism
Atrial arrhythmias (atrial fibrillation ,atrial flutter ,multifocal atrial
tachycardia)
Pulmonary hypertension
Cor pulmonale
Chronic respiratory failure
Spontaneous pneumothorax
Bronchogenic carcinoma …hemoptysis
Differential diagnosis

Bronchial asthma( complete or near complete reversibility )

Bronchiectasis (recurrent pneumonia and hemoptysis ,digital clubbing
and specific imaging abnormalities )
Cystic fibrosis(occurs in children ,young adults )
Bronchopulmonary mycosis (eosinophilia ,elevated IgE levels and
recurrent fleeting pneumonias )
Central airway obstruction by mass
Prevention

Prevent exposure to
tobacco smoke ,
combustion of biomass fuel
and other inhaled toxins

Smoking cessation
Yearly influenza vaccination
5 yearly pneumococcal vaccination
Treatment
Smoking cessation
Oxygen therapy with resting hypoxemia (Pao2 <56mmHg)
Inhaled bronchodilators improve symptoms and exercise tolerance
Short acting …anticholinergic-ipratropium bromide
Short acting…. beta agonists –albuterol
Long acting.... Anticholinergics- tiotropium
Long acting ….beta agonists –formeterol ,salmeterol
Corticosteroids reduce the frequency of exacerbations given in combination
with LABAs or anti cholinergic drugs
oral corticosteroids can be used
Theophylline(xanthines) fourth line agent improves Hb saturation ,dyspnea
exercise performance and pulmonary function
Antibiotics ….to treat acute exacerbations
Phosphdiasterase inhibitors …roflumilast to reduce exacerbation
frequency
Pulmonary rehabilitation
aerobic physical exercise
Training of inspiratory muscles
Surgery
Lung transplantation
Lung volume Reduction surgery .bilateral 20-30% lung volume reduction
leads to modest improvement
Bullectomy
Management of hospitalized patient with acute exacerbation
1.Oxygen to maintain O2 saturation between 90 to 94% and PaO2 between 60 -70
mmhg
2.Inhaled ipratropium bromide 500mcg by nebulizer plus beta 2 agonist albuterol 2.5
mg every 1 to 4 hours as needed
3.Corticosteroids ..prednisone 30-40mg daily for 7 days
4.Antibiotics floroquinolones combined with third generation cephalosporins
Levofloxacin/moxifloxacin +ceftrioxone
For pseudomonas piperacillin-tazobactam ,ceftazidime or cefipime
salt restriction
diuretics
5.Dc cardioversion for arrhythmias
6NON Invasive positive pressure ventilation delivered via face mask
7Chest intubation
Prognosis

BODE index
B Body mass index
O Airway Obstruction FEV1
D Dyspnea (MRC dyspnea scale)
E Exercise capacity
Indications of home oxygen
• Room air arterial partial pressure of oxygen ≤ 55 mm Hg, or 56 to 59
mm Hg with cor pulmonale or signs of tissue hypoxia
• Room air oxygen saturation ≤ 88%, or ≤ 89% with cor pulmonale or
signs of tissue hypoxia
• Nocturnal oxygen saturation ≤ 88% (use oxygen only at night)
• Exercise hypoxemia with arterial partial pressure of oxygen ≤ 55 mm
Hg, or oxygen saturation ≤ 88% (use oxygen only with exertion)
THANKYOU