CHRONIC OBSTRUCTIVE

PULMONARY DISEASE
(COPD)
• COPD is a preventable and treatable disease
• persistent airflow limitation progressive
• associated with an enhanced chronic inflammatory response in the airways and the
lung to noxious particles or gases.
• Chronic bronchitis (cough and sputum on most days for at least 3 months, in each of
2 consecutive years)
• Emphysema (abnormal permanent enlargement of the airspaces distal to the
terminal bronchioles, accompanied by destruction of their walls and without obvious
fibrosis).
• The prevalence of COPD is directly related to the prevalence of tobacco smoking
• In low- and middle income countries, the use of biomass fuels.
• COPD relates to both the amount and the duration of smoking.
• unusual to develop COPD with less than 10 pack years (1 pack year = 20
cigarettes/day/year)
• The presence of airflow limitation, combined with premature airway closure

gas trapping and hyperinflation, reducing pulmonary and chest wall compliance.
• Pulmonary hyperinflation also flattens the diaphragmatic muscles
• leads to an increasingly horizontal alignment of the intercostal muscles, placing the
respiratory muscles at a mechanical disadvantage.
• Clinical features
• over the age of 40 years who presents with symptoms of chronic bronchitis and/or
breathlessness.
• ( Differential diagnoses include chronic asthma, tuberculosis, bronchiectasis and
congestive cardiac failure.)
• Cough and associated sputum production are usually the first symptoms, often
referred to as a ‘smoker’s cough’.
• Hemoptysis may complicate exacerbations of COPD
• In advanced disease, the presence of oedema, which may be seen for the first time
during an exacerbation, and morning headaches, which may suggest hypercapnia.
• Physical signs are non-specific, correlate poorly with lung function.
• Crackles may accompany infection but, if persistent, raise the possibility of
bronchiectasis.
• Finger clubbing is not a feature of COPD and should trigger further investigation for lung
cancer or fibrosis.
• Pitting oedema should be sought but the frequently used term ‘cor pulmonale and the
occurrence of oedema usually relates to failure of salt and water excretion by the hypoxic
hypercapnic kidney.
• The body mass index is of prognostic significance.
• Two classical phenotypes have been described: ‘pink puffers’ and ‘blue bloaters’.
• The former are typically thin and breathless, and maintain a normal PaCO2 until the
late stage of disease. ( Type I Respiratory Failure)
• The latter develop (or tolerate) hypercapnia earlier and may develop oedema and
secondary polycythaemia. ( Type II Respiratory Failure)
• In practice, these phenotype often overlap.
• Investigations
• FBC: PCV .
• CXR: Hyperinflation (>6 anterior ribs seen above diaphragm in midclavicular line); flat
hemi diaphragms; large central pulmonary arteries; peripheral vascular markings;
bullae.
• ECG: Right atrial and ventricular hyper trophy (cor pulmonale).
• ABG: PaO2 ± hypercapnia.
• Lung function : obstructive + air trapping (FEV1 <80% of predicted, FEV1 : FVC ratio
<70%.
• The diagnosis requires objective demonstration of airflow obstruction by spirometry
and is established when the post-bronchodilator FEV1/FVC is less than 70%.
• Management

• It is usually possible to help breathlessness, reduce the frequency and severity of

exacerbations, enhance the health status, and improve the prognosis.
• ‘Sustained smoking cessation in mild to moderate COPD is accompanied by a
reduced decline in FEV1 compared to persistent smokers.’
• Bronchodilator therapy is central to the management of breathlessness.
• The inhaled route is preferred and a number of different agents, delivered by a variety of
devices, are available.
• Short-acting bronchodilators the β2-agonists salbutamol and terbutaline
• Anticholinergic ipratropium bromide for patients with mild disease,
• Longer acting bronchodilators the β2-agonists salmeterol, formoterol and indacaterol,
or the anticholinergic tiotropium bromide, are more appropriate for patients with
moderate to severe disease.
• Significant improvements in breathlessness may be reported, despite minimal changes
in FEV1.
• Oral bronchodilator therapy may be used in patients who cannot use inhaled
devices efficiently.
• Theophylline preparations improve breathlessness and quality of life, but their use
is limited by side-effects, unpredictable metabolism and drug interactions.
• Corticosteroids
• Inhaled corticosteroids (ICS) reduce the frequency and severity of exacerbations,
and are currently recommended in patients with severe disease (FEV1 < 50%)
• Regular use is associated with a small improvement in FEV1, but ICS do not alter the
natural history of the FEV1 decline.
• It is more usual to prescribe a fixed combination of an ICS and a LABA.
• Oral corticosteroids are useful during exacerbations but maintenance therapy
contributes to osteoporosis and impaired skeletal muscle function and should be
avoided.
• Use oxygen for a minimum of 15 hours per day; greater benefits are seen in
patients who receive more than 20 hours per day.
• The aim of therapy is to increase the PaO2 to at least 8 kPa (60 mmHg) or SaO2 to at
least 90%.
• Patients with COPD should be offered an annual influenza vaccination and, as
appropriate, pneumococcal vaccination.
• Obesity, poor nutrition, depression and social isolation should be addressed
• Mucolytic therapy or antioxidant agents are occasionally used but with limited
evidence.
 ACUTE EXACERBATIONS OF COPD

• A common medical emergency especially in winter.

• triggered by viral or bacterial infections.
• Presentation Increasing cough, breathlessness, or wheeze,Decreased exercise
capacity.
• Differential diagnosis Asthma, pulmonary oedema, upper respiratory tract
obstruction, pulmonary embolus, anaphylaxis.
• Investigations
• • Arterial blood gases .
• • CXR to exclude pneumothorax and infection.
• • FBC; U&E; CRP. Theophylline level if patient on therapy at home.
• • ECG.
• • Send sputum for culture if purulent.
• • Blood cultures if pyrexial.
• More advanced COPD
• Pulmonary rehabilitation is greatly valued by patients.
• Consider LTOT if PaO2 <7.3kPa.
• Indications for surgery: recurrent pneumothoraces; isolated bullous disease; lung
volume reduction surgery (selected patients).
• NIV may be appropraite if hypercapnic on LTOT.
• Air travel is risky if FEV1 <50% or PaO2 <6.7kPa.
• Assess home set-up and support needed. Treat depression
 Steroid trial
• 30mg prednisolone/24h PO for 2wks.
• If FEV1 rises by >15%, the COPD is ‘steroid responsive’ and benefit may be had by
using long-term inhaled corticosteroids
• The followings are true for COPD
• (a) In between attacks COPD patients are free of symptoms.
• (b) Emphysema is defined histologically as enlarged air spaces distal to terminal
• bronchioles, with destruction of alveolar walls.
• (c) smoking cessation and long term oxygen therapy can increase survival in COPD
patients
• (d) long term oral steroid therapy is no longer recommended
• (e ) no role of antibiotic in acute exacerbation of COPD
• Systemic manifestations of COPD are
• (a) Muscular weakness and deconditioning and cellular changes in skeletal muscles
• (b) Increased circulating inflammatory markers
• (c) Impaired salt and water excretion leading to peripheral oedem
• (d) Altered fat metabolism contributing to weight loss
• (e ) Increase prevalence of osteoporosis
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