COPD

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Chronic obstructive pulmonary disease

Definition of COPD

. The not fully reversible a disease state characterized by airflow limitation that is “
abnormal and associated with an progressive airflow limitation is usually both
of the lungs to noxious particles or gases”. inflammatory response

COPD is an umbrella term encompassing: ( Look: Venn diagram)

- Chronic bronchitis
- Emphysema
- Chronic severe asthma

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Global burden of COPD

COPD is one of the few major causes of death that increases in prevalence. It is
estimated that by 2020, COPD will be the fifth leading cause of death
internationally .
Further, epidemiological data show tha t COPD is rapidly increasin g in prevalence
in women, and mortality data reflect this trend.

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Internationally, the World Heath Organization (WHO) estimates that in 2001, 4.6%
of all deaths among men (1,355,000 total), and 4.9% of all deaths among women
(1,317,000 total) were directly attributable to COPD.

and recognized not usually The burden of COPD is underestimated because it is

diagnosed until it is clinically apparent and moderately advanced.
but in all countries vary across countries Prevalence, morbidity, and mortality
where data are available, COPD is a significant health problem in both men and
women.
30% of s mokers develop COPD
20% of adult males have COPD
15% of COPD patients are severely symptomatic
Mortality rate still rising

How common is COPD?

About 13.9% of the U.S. adult population (25+ years) have been diagnosed with
COPD*
An estimated 15 -19% of COPD cases are work -related**

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24 million other adults have evidence of troubled breathing, indicating COPD is
under diagnosed by up to 60%***

Economic Impact of COPD

economic costs of COPD are significant because hospital admissions and direct The
economic costs of COPD are indirect expensive treatments are often needed. The
also significant and include lost years of life, disability, loss of working capacity,
and reduction in q uality of life.
The economic costs of COPD are high and will continue to rise in direct relation to
the ever -aging population, the increasing prevalence of the disease, and the cost
of new and existing medical and public health interventions.

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Pathogenesi s and Pathophysiology

Pathogenesis

Tobacco smoking is the main risk factor for COPD, although other inhaled noxious
particles and gases may contribute.
In addition to inflammation, an imbalance of proteinases and antiproteinases in
the lungs, and oxidati ve stress are also important in the pathogenesis of COPD.

Pathophysiology

The different pathogenic mechanisms produce the pathological changes which, in
turn, give rise to the physiological abnormalities in COPD:
mucous hypersecretion and ciliary dysfunction,
airflow limitation and hyperinflation,
gas exchange abnormalities,
pulmonary hypertension,
systemic effects.

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Smoking & COPD
It is not fully understood how tobacco smoke and other inhaled particles damage
the lungs to cause COPD. The most important processes causing lung damage are:
in tobacco free radicals produced by the high concentrations of 1. Oxidative stress
smoke
as the body responds to irritant particles inflammation release due to 2. Cytokine
such as tobacco smoke in the airway
3-Tobacco smoke and free radicals impair the activity of antiprotease enzymes
enzymes to damage the lung protease , allowing antitrypsin- alpha 1 such as
4- levels of myeloperoxidase and eosinophilic cationic protein  broncho -
constriction

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Schematic view of ciliotoxic damage and mucus hypersecretion in early -stage

COPD
Normal airway mucosa
Early COPD

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“Moth -eaten” appearance of autopsied lung from smoker with advanced COPD
emphysema

Risk Factors for COPD

Host factors:
- Genetic factors (e.g. alpha1 -antitrypsin deficiency)
- Sex
- Airway hyperreactivity
- IgE and asthma
Exposures :
- Smoking : primary cause in 80 -90% of cases
- Socioeconomic status
- Occupation
- Environmental pollution
- Perinatal events and childhood illness
- Recurrent bronchopulmonary infection
- Diet

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Diagnosis of COPD

Diagnosis of COPD should be considered in any patient who has the following:
symptoms of cough
sputum production
dyspnoea
history of exposure to risk factors for the disease

Spirometry : Decreased FEV1/FVC

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Spirometry: Normal and COPD

Radiology

Chest X -ray

Bullae, often bilateral upper lobes in smokers
Flat diaphragms (best seen on lateral) and retrosternal airspace can indicate air
trapping

High Resolution CT of Chest

Most sensitive to detect above changes
No role in routine care of COPD patients
Can be useful for giant bullous disease surgeries or lung vol ume reduction surgery
planning 0
5
1
4
2
3Liter
1 6 5 4 3 2
FVC
FVC
FEV 1
FEV 1
Normal
COPD
3.9005.200 2.3504.150 80 %60 % NormalCOPD
FVC FEV 1 FVC FEV 1/
Seconds

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GOLD Staging Criteria
Stage 0: Normal spirometry; chronic symptoms
Stage 1 (Mild):
FEV1/FVC < 70%; FEV1 > 80% predicted
Stage 2 (Moderate):
FEV1/FVC < 70%; FEV1 30 -80% predicted
2A: FEV1 50 -80% predicted
2B: FEV1 30 -50% predicted
Stage 3 (severe):
FEV1/FVC < 70% AND:
FEV1 < 30% predicted OR:
FEV1 < 50% predicted and clinical evidence of Right heart failure

Patterns of spirometry

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Other Diagnostic tests
Full pulmonary function tests : Lung volumes: Increased TLC, RV, RV/TLC
Alpha -1 antitrypsin level & phenotype
Arterial blood gas (ABG): Measurement of arterial blood gas tension should be
< 40% predicted or clinical signs suggestive of 1 considered in all patients with FEV
respiratory failure or right heart failure.
Sputum gram stain/culture

Prevention & control

Avoidance of noxious agents
- Smoking cessation
- Reduction of indoor pollution
- Reduction of occupational exposure
Influenza vaccination

Management of COPD

Ph armacological therapy
Long -term oxygen therapy
Pulmonary rehabilitation
Nutrition: Nutritional therapy may only be effective if combined with exercise or
other anabolic stimuli. Weight loss and a depletion of fat -free mass (FFM) may be
observed in stable C OPD patients.
Surgery in and for COPD: Bullectomy and lung volume reduction surgery &Lung
transplantation

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Exercise and Nutrition
COPD makes the lungs and heart work harder to carry oxygen to all parts of the
body. Because of this, weight control is a must to reduce heart and lung strain.
Special exercises to strengthen chest muscles can improve breathing
Eat several small meals
Avoid gas -producing foods, this can cause the stomach to swell and press against
the diaphragm.
Sleep: Management of sleep pro blems in COPD should particularly focus on
minimising sleep disturbance by measures to limit cough and dyspnoea, and
nocturnal oxygen therapy is rarely indicated for isolated nocturnal hypoxaemia.
Hypnotics should be avoided, if possible, in patients with severe COPD.
Air travel: Patients with COPD can exhibit falls in arterial O2 tension ( Pa,O2).

Distinguishing asthma and COPD clinically

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Distinguishing asthma and COPD
Spirometry needs to be interpreted in the light of clinical history
Spirometry in a sthma may be normal
Spirometry in COPD is never normal
There is overlap – some patients have both

Lung volumes