COPD

DR AMBREEN SHAMS
NEPHROLOGIST
 INTRODUCTION
 Chronic obstructive pulmonary disease is the
progressive and partially reversible disease of
the airway comprises primarily of two related
disease- chronic bronchitis and Emphysema .
Chronic obstruction of the flow of air through
the airway and out of the lungs causes
permanent and progressive obstruction over
time.
 COPD is also known as chronic obstructive
lung disease (COLD), chronic obstructive
airway disease (COAD), chronic airflow
limitation (CAL) and chronic obstructive
respiratory disease (CORD)
 DEFINITION
 COPD is a common, preventable and treatable
disease that is characterized by persistent
respiratory symptoms and airflow limitation
that is due to airway and/or alveolar
abnormalities usually caused by significant
exposure to noxious particles or gases.
 INCIDENCE
 It affects more than 5 percent of the population
and is associated with high morbidity and
mortality , It is the third-ranked cause of death
in the United States, killing more than 120,000
individuals each year.

 Men have prevalance of 11% and womwn

8.5%.
 TYPES
 COPD includes 1) Chronic Bronchitis 2)
Emphysema
 CHRONIC BRONCHITIS
 Defined as a chronic productive cough for
three months in each of two successive years in
a patient in whom other causes of chronic
cough have been excluded
 It involves inflammation and swelling of the
lining of the air way that leads to narrowing
and obstruction of the air way. The
inflammation also stimulate production of
mucus which can cause further obstruction of
the airway.
 EMPHYSEMA
 It is permanent enlargement of the alveoli due
to destruction of the wall between alveoli
which leads to reduce elasticity of the lungs
over all.Loss of elasticity leads to collapse of
the bronchioles, obstructing air flow out of the
alveoli. Air become trapped In the alveoli and
reduce the ability of the lungs to shrink during
exhalation . As a result, less air for the
exchange of gasses gets into the lungs . This
trapped air also can compress adjacent less
damage lung tissue.
 SUB TYPES OF EMPHYSEMA
 1.Centrilobular emphysema (Proximal acinar)
Abnormal dilation or destruction of the respiratory
bronchiole, the central portion of the acinus. It is
commonly associated with cigarette smoking,
 2.Panacinar emphysema

Refers to enlargement or destruction of all parts of

the acinus. Seen in alpha-1 antitrypsin deficiency
and in smokers
 3.Paraseptal emphysema
Distal acinar - the alveolar ducts are
predominantly affected.
ETIOLOGY AND RISK FACTORS
 The specific causes of COPD are not clearly
understood. Some risk factors are :
 1.Cigarette smoking. The primary cause is
exposure to tobacco smoke. cigarette smokers
will develops COPD in 15% . Overall, tobacco
smoking accounts for as much as 90% of the
risk of COPD .
 2.Secondhand smoke or environmental tobacco
smoke, increases the risks of COPD
RISK FACTORS
 3 .Air Pollution outdoor air pollution
contributes to the development of COPD. Most
common cause is indoor stoves for cooking .
Some occupational pollutants such as cadmium
and silica can be the cause.
 4.low socioeconomic class
 5.Aging
 6.Genetic :Alpha-1 Antitrypsin (AAT)
deficiency- enzyme is produced by liver and
present in normal lungs. Block the damaging
effects of elastase and trypsin on lungs which
are released due to exposure to smoke In
body.So if genetically deficient increases the
risk for COPD.
 7. Chronic Respiratory Infections
 8. Alcohol Ingestion
 PATHOPHYSIOLOGY
 Chronic inflammation Increase number of
goblet cell and mucus secreation --Increase size
and number of submucus gland in bronchi and
mucus production-- Decrease ciliary function
reduce mucus clearance (deposit )-IgEmucus
Allergic reaction-- IgE stimulation --IgE
attached to the mast cell-- Mast cell release
histamine and prostagladin --Mucus secretion
and bronchospasm-- Obstructive air way.
 SYMPTOMS:
 1.Cough with or without mucus
 2.Shortness of breath (dyspnea) that gets worse
with mild activity .
 3.Fatigue
 4.Chest tightness
 5.weight loss
 SIGNS:
Common signs are:
1 .INSPECTION:
 Tachypnea a rapid breathing rate .

 Breathing through pursed lips.

 Using accessoray muscles for respiration.

Enlargement of the chest, particularly the front-

to-back distance (hyperaeration) on inspection
 Paradoxical retraction of the lower interspaces
during inspiration (ie, hoover's sign) in Tripod
Position
(Tripod Position Patients with end-stage COPD
may adopt positions that relieve dyspnea, such as
leaning forward with arms outstretched and
weight supported on the palms or elbows.)
 2.PALPATION:
 Increased anteroposterior to lateral ratio of the
chest (i.e. barrel chest) on palpation measured
with inch tape
 3.decrease vocal fremitus
3.PERCUSSION:
 Hyperresonant percussion note

 Dimination of the area of absolute cardiac

dullness.
4.AUSCULTATION:
 Wheezing sounds mostly, crackles heard if

chest infecton
 Expiration longer than inspiration.

 Reduced breath sounds

 COMORBID CONDITIONS:
Take history of :
Cardiovascular diseases
Osteoporosis,
Respiratory infections
Anxiety and Depression
Diabetes
Lung cancer
Bronchiectasis
These comorbid conditions may influence mortality
and need to be seen.
 LAB INVESTIGATIONS:
 1. Blood CP. A hematocrit value of more than
52% in males and more than 47% in female
indicates COPD,High TLC count suggestive of
infection.
 2. Measure the alpha1-antitrypsin (AAT),the
AAT level is low.
 3. Sputum for culture and microscopy .The
pathogens Streptococcus pneumoniae and
Haemophilus influenzae common
 CHEST XRAY
 FINDINGS OF CXR are:
 Hyperinflated lungs
 flat diaphragm ,
 Tubular heart ,
 REDUCED broncho vascular markings
 intercoastal spaces widening,
 horizontal ribs
 Sometimes lung opacity seen if infection
 CT scan chest
 High Resolution CT scanning(HRCT): is highly
specific for diagnosing emphysema, and the
outlined bullae are not always visible on a
radiograph
 Decrease in lung volume as shown in CT
CHEST
 ECHO
 ECHO may be useful to see pulmonary arterial
systolic pressure and right ventricular systolic
function.
 PULMONARY FUNCTION TESTS
 COPD is diagnosed using a medical device
called a spirometer, which measures air
volume and flow the main components of
common clinical breathing tests (pulmonary
function tests). The measurement of the forced
expired volume of air in one second (FEV
1)and total amount of air that can be forcefully
exhaled (forced vital capacity or FVC) Is the
main functional way of defining COPD
PULMONARY FUNCTION TEST
 Forced expiratory volume in 1 second (FEV1) is
a reproducible test and is the most commonly
used index of airflow obstruction.
 Mild= FEV1 >80% predicted
 Moderate= FEV1 80-50% predicted
 Severe= FEV1 50-30% predicted
 Very severe = FEV1 <30% predicted
 An FEV1/FVC ratio less than 0.70 after a
patient is given a bronchodilator usually
indicates that he or she has COPD
 ARTERIAL BLOOD GAS
 Arterial blood gas analysis: As the disease
progresses, severe hypoxemia PaO2 < 80
mmHg with or without PaCO2 > 60 mmHg
indicates respiratory failure.
 COMPLICATIONS
 Respiratory Infections
 Acute Respiratory Failure
 Spontaneous Pneumothorax due to rupture of
emphysematous bleb/Bullae
 Ventilation Perfusion Mismatch
 Hypoxemia
 Corpulmonale (right heart failure due to lung
pathology)
 DIFFERENTIAL DIAGNOSIS
 TB
 Congestive cardiac failure
 Bronchiectasis
 Asthma
 Bronchogenic carcinoma
 bronchiolitis
 MANAGEMENT
 1-MEDICAL MANAGEMENT
 2-SURGICAL MANAGEMENT
 3-NURSING MANAGEMENT
 4-IMPROVE
VENTILLATION(REHABILITATION)
 5-IMPROVED NUTRITION
 -MEDICAL MANAGEMENT
 1.BRONCHODILATORS
 2.ANTICHOLINERGICS
 3.METHYLXANTHINES
 4. CORTICOSTEROIDS
 5. OXYGEN ADMINISTRATION
 BRONCHODILATORS
 Three major classes of bronchodilators: β2 -
agonists:
 Short acting: salbutamol & terbutaline
 Long acting :Salmeterol & formoterol
 Anticholinergic agents: Ipratropium,tiotropium
 Theophylline (a weak bronchodilator, which
may have some anti-inflammatory properties)
 GLUCOCORTICOIDS
 Regular treatment with inhaled glucocorticoids
is appropriate for symptomatic patients with
an FEV1<50% and repeated exacerbations.
Chronic treatment with systemic
glucocorticoids is given in severe cases but
should be avoided because of an unfavorable
benefit-to-risk ratio.
 COMBINATION THERAPY
 long acting ß2-agonists and inhaled
corticosteroids show a significant additional
effect on pulmonary function and a reduction
in symptoms. Mainly in patients with an
FEV1<50%predicted
 OXYGEN THERPY:
 >15 h /Day Long-term oxygen therapy
(LTOT) improves survival,exercise,sleep and
cognitive performance in patients with
respiratory failure. The therapeutic goal is to
maintain SaO2 ≥ 90% and PaO2 ≥ 60mmHg at
sea level and rest .
 OTHERS:

 1-ANTIBIOTICS :
In cases of evidence of infections
 2-MUCOLYTICS:

 3-PHOSPHODIESTERASE INHIBITORS:
 4-VACCINATIONS:
 Influenza vaccines can reduce serious illness.
 Pneumococcal polysaccharide vaccine is
recommended for COPD patients 65 years and
older and for COPD patients younger than age
65 with an FEV1 < 40% predicted.
 SURGICAL
 Bullectomy
Lung volume reduction surgery
 Lung transplantation
 NURSING
Nursing assessment:
 1. Determine smoking history, exposure history

,+ve family history of respiratory disease ,onset

of dyspnea.
2. Note amount , color &consistency of sputum. 3.
Inspect for use of accessory muscles of respiration
& use of abdominal muscles during expiration ;
Note increase of anteroposterior diameter of chest.
with both asthma and COPD."
 PULMONARY REHABILITATION
 Smoking Cessation
 Nicotine replacement therapy (nicotine gum,
inhaler, nasal spray, transdermal patch,
sublingual tablet, or lozenge) as well as
pharmacotherapy with varenicline, bupropion,
and nortriptyline reliably increases long-term
smoking abstinence rates and are significantly
more effective .
 Supervise training exercise to strengthen
diaphragm & muscles of expiration . Discuss &
demonstrate relaxation exercises to reduce
stress , tension & anxiety. Encourage patient to
assume position of comfort to decrease
dyspnea.
 Encourage patient to carryout regular exercise
program 3-7 days per week to increase physical
endurance. Train patient in energy
conservation techniques
 Patient education. Avoid exposure to
respiratory irritant
 NUTRITION
 Take nutritional history , weight &
anthropometric measurements. Encourage
frequent small meals if patient is dyspneic .
Encourage snaking on high-calorie , high
protein snacks. Offer liquid nutritional
supplements to improve calorie intake &
counteract weight loss.
 ASSIGNMENT
 ENLIST THE CASUES /CONDITIONS
EXACERBATING COPD:
THANK YOU