Chronic Obstructive

Pulmonary Disease
Medical Clinical Clerk
Samson, Caesar Anthony
Definition

● Disease state characterized by persistent respiratory symptoms and airflow

limitations that is not fully reversible.
● Present only if chronic airflow obstruction occurs
● Includes Emphysema, Chronic Bronchitis, and Small Airway Disease
● Preventable and treatable disease characterized by persistent respiratory
symptoms and airflow limitations.
● Caused by exposure to noxious particles or gases.
Risk Factors

● Cigarette smoking
○ 20-pack years
● Respiratory Infections
○ Viral - Influenza
○ Bacterial - S. pneumoniae, M. catarrhalis, H. influenzae
● Environmental exposures
● Asthma and airway hyperreactivity
● Genetic: alpha1-antitrypsin deficiency
Pathogenesis
Hypothesis in COPD

● Dutch Hypothesis
○ Asthma and COPD are variations of the same basic disease
● British Hypothesis
○ Asthma and COPD are fundamentally different diseases
● American Hypothesis
○ COPD is due to direct toxic effect of cigarette smoke
● Protease-Antiprotease Hypothesis
○ Imbalance in the regulation of a protease particularly elastase due to loss of
alpha1-antitrypsin
Forms of COPD

● Emphysema
○ Anatomically defined condition
● Chronic Bronchitis
○ Clinically defined condition
● Small airway disease
○ Bronchioles and smaller airways are narrowed
EMPHYSEMA
EMPHYSEMA
CHRONIC BRONCHITIS

Cough with sputum expectoration for at least 3 months a year during a period of 2
consecutive years.
CHRONIC BRONCHITIS

REID INDEX RATIO

● Ratio of thickness of the mucous
gland and the thickness of the wall
between the epithelium and
cartilage of trachea and bronchi.
○ <0.4 - normal
○ >0.4 - chronic bornchitis
EMPHYSEMA VS CHRONIC BRONCHITIS
EMPHYSEMA VS CHRONIC BRONCHITIS
DIAGNOSIS (GOLD): Approach to Classification of COPD

1. Confirm Diagnosis
2. Assess airflow limitation by
spirometry
3. Assess symptoms and risk
for exacerbations
DIAGNOSIS (GOLD): Approach to Classification of COPD

1. Confirm Diagnosis
2. Assess airflow limitation by
spirometry
3. Assess symptoms and risk
for exacerbations
DIAGNOSIS (GOLD): Approach to Classification of COPD

1. Confirm Diagnosis
2. Assess airflow limitation by
spirometry
3. Assess symptoms and risk
for exacerbations
● Confirmed diagnosis.
○ COPD
● Assess airflow limitation by spirometry
○ 0.35 - Grade 3
● Assess for symptoms and risk of
exacerbation
○ mMRC 2, with 3 hospitalization this year due
to non compliant with medications
○ Group E

FINAL DIAGNOSIS

COPD Grade 3 Group E

MANAGEMENT
Non Pharmacologic Management
Pharmacologic Treatment
Pharmacologic Therapy
Pharmacologic Therapy
Pharmacologic Treatment
SLEEP APNEA
Medical Clinical Clerk
Samson, Caesar Anthony
Sleep Related Breathing Disorders
● Obstructive Sleep Apnea/Hypopnea Syndrome (OSAHS)
● Central Sleep Apnea

→ Both share some risk factors and physiological bases but also have unique features→
Both of them are associated with impaired ventilation during sleep and disruption of sleep.

→ It is always important to take a careful history taking, physical examination and

physiological testing .

→ Sleep-disordered breathing is a very common clinical problem.

→ Pathologic changes in breathing during sleep may take the form of discrete episodes of
absent (apnea) or reduced (hypopnea) breathing or of more sustained reductions in
breathing during sleep compared with wakefulness (hypoventilation).
OBSTRUCTIVE SLEEP
APNEA/HYPOPNEA SYNDROME
(OSAHS)
● More common disorder
● Daytime sleepiness which impairs daily function
● Major contributor to cardiovascular disease in adults and
behavioral problems in children.
Diagnosis

● Either symptoms of nocturnal breathing disturbances or daytime sleepiness or

fatigue that occurs despite sufficient opportunities to sleep and is unexplained by
other medical problems;
● Five or more episodes of obstructive apnea or hypopnea per hour of sleep ( the
apnea-hypopnea index (AHI), calculated as the number of episodes divided by the
number of hours of sleep) documented during a sleep study.
Diagnosis

● OSAHS also may be diagnosed in the absence of symptoms if the AHI is >15
episodes per hour.
● Each episode of apnea or hypopnea represents a reduction in breathing for at least
10 seconds and commonly results in a greater than or equal to 3% drop in oxygen
saturation and/or a brain cortical arousal
Diagnosis
OSAHS SEVERITY IS BASED ON:

● The frequency of breathing disturbances (AHI).

● The amount of oxyhemoglobin desaturation with respiratory events.
● The durations of apneas and hypopneas
● The degree of sleep fragmentation.
● The level of daytime sleepiness or functional impairment.
FACTORS AFFECTING UPPER AIRWAY PATENCY
PATHOPHYSIOLOGIC CYCLE
RISK FACTORS

● Obesity - 40-60%
● Male sex - 2-4x higher vs women
● Mandibular retrognathia and micrognathia - reduces size of posterior airway space
(when you lie down, it makes it more narrow)
● Positive family history of OSAHS - strong genetic basis; 2x higher in first degree
relatives
● Down Syndrome, Treacher-Collins syndrome
● Adenotonsillar hypertrophy (in children) - 3-8 years old due to lymphoid hypertrophy
● Menopause (women) - lower sex hormones
● Endocrine Syndromes (acromegaly, hypothyroidism); Diabetes
● Hypertension
SYMPTOMATOLOGY

● Sleep history should be obtained with assistance from a bed partner/household

member
● Snoring - most common complaint
● Gasping or snorting during sleep
● Frequent awakening or sleep disruption
● Excessive sleepiness - most common daytime symptom
● Fatigue
● Dry mouth
● Nocturnal heartburn
SYMPTOMATOLOGY

● Diaphoresis of the chest and neck

● Nocturia
● Morning headaches
● Trouble concentrating
● Irritability
● Mood disturbances
SYMPTOMATOLOGY
PHYSICAL FINDINGS

● Hypertension
● Obese(large waist and neck circumference);
● BMI >30; Neck >40cm
● Small orifice of oropharynx with bulk uvula, large tonsils, high arched palate and/or
micro retrognathia
● Inspect for nasal polyps and nasal deviation
● Careful cardiac and neurological examination
PHYSICAL FINDINGS
PHYSICAL FINDINGS
DIAGNOSIS

Overnight Polysomnogram (PSG)/Sleep-Study Gold Standard

● Measurement of breathing (changes in airflow, respiratory excursion), oxygenation
(hemoglobin oxygen saturation), body position and cardiac rhythm.
● Measure sleep continuity and sleep stages (by electroencephalography, chin
electromyography, electro-oculography, and actigraphy), limb movements (by leg
sensors) and snoring intensity
DIAGNOSIS
DIAGNOSIS
DIAGNOSIS
TREATMENT

● Optimize sleep duration (7-9 hours)

● Regulate sleep schedules with similar bedtimes and wake times across the week
● Encourage the patient to avoid sleeping in the supine position
● Treat nasal allergies
● Increase physical activities
● Eliminate alcohol ingestion which impairs pharyngeal muscle activity within 3
hours of bedtime
● Minimize use of sedating medications
● Patients should be counseled to avoid drowsy driving
CPAP

● Continuous Positive Airway Pressure is the highest level of evidence for efficacy
● Delivered through a nasal or nasal-oral mask, CPAP works as a mechanical splint to
hold the airway open thus maintaining airway patency during sleep
● Beneficial effect on blood pressure, alertness, mood, quality of life and insulin
sensitivity
SURGERY

● Upper airway surgery for OSAHS is less effective than CPAP and its mostly
reserved for the treatment of patients who snore, have mild OSAHS or cannot
tolerate CPAP
● Uvulopalatopharyngoplasty (removal of the uvula and the margin of the soft palate)
is the most common surgery and although results vary greatly is generally less
successful than treatment with oral appliances
OXYGEN SUPPORT

● Supplemental oxygen can improve saturation but there is little evidence that it
improves OSAHS symptoms or the AHI in unselected patients
CENTRAL SLEEP APNEA (CSA)
● Less common.
● Transient loss of respiratory drive output from central respiratory
control.
● May occur in combination with OSA or secondary to medical
conditions.
● Frequents awakening and daytime fatigue.
● Increased risk for heart failure and atrial fibrillation.
CLASSIFICATION OF CENTRAL SLEEP APNEA
Clinical Manifestations

● Patients with CSA may report symptoms of frequent awakenings as well as daytime
fatigue
● Full overnight PSG
● Treatment of CSA is difficult and depends on the underlying cause
● Limited data suggest that supplemental oxygen can reduce the frequency of central
apneas, particularly in patients with hypoxemia
● No good evidence that CPAP including adaptive servo ventilation (a from of
ventilatory support that attempts to regularize the breathing pattern) improves
health outcomes in patients with Cheyne-Stokes respiration without OSAHS
Clinical Manifestations
Clinical Manifestations
THANK YOU!!!!