COPD in 2009 Perspective of Respiratory Physicians Ramesh Kaul, MD M. Surgery FCCP
Presently Speaker for Astra Zeneca( Symbicort)
Previous speaker for GlaxoSmithKline (Advair)
Previous speaker for Boeringer Inghelheim
(Spiriva , Atrovent)
No funding was received from any Organization for this lecture at 36th Annual Western PSRC Seminar in Respiratory Care and Sleep Medicine.
Information presented mostly from reading Chest, GOLD and AJRCCM
WHY A NEW NAME COPD
Classical picture is no more seen of Pink Puffer of Emphysema
Blue Bloater Of Chronic Bronchitis
Early awareness by Providers of care
Avoidance of Precipitating factors
Epidemiology of COPD
COPD is the 4th leading cause of death, and the 2nd leading cause of disability in the U.S. And yet, COPD is under-diagnosed and under-treated:
About 24 million U.S. adults have evidence of impaired lung function
12 million people have been diagnosed with COPD
5.8 million COPD patients are untreated
The COPD death rate among women is increasing
REFERENCES GOLD 2008 and American Thoracic Society
Socioeconomic factors in COPD
Congested Living space
Lack of Education
Use of Biomass fuels, wood stoves
Inner City population has more prevalence
Stress of environment
Lack of funds for treatment in exacerbations
Pollution in COPD
Second hand tobacco smoke
Wood, leaves and coal burning
Plastic and paper burning
Spraying of crops
Unclean air ducts with dust
Farming with exposure to animal excreta
Exposure to moldy hay, and gases in silos.
Animal fur, cat and dog dander
Gas fumes, diesel fumes and the list goes on and on
Definition of COPD
COPD: Definition World Health Organization
Chronic obstructive pulmonary disease (COPD) is a lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible. The more familiar terms 'chronic bronchitis' and 'emphysema' are no longer used, but are now included within the COPD diagnosis. COPD is not simply a "smoker's cough" but an under-diagnosed, life-threatening lung disease.
A COPD diagnosis is confirmed by a simple test called Spirometry, which measures how deeply a person can breathe and how fast air can move into and out of the lungs. Such a diagnosis should be considered in any patient who has symptoms of cough, sputum production, or dyspnea (difficult or labored breathing), and/or a history of exposure to risk factors for the disease. Where Spirometry is unavailable, the diagnosis of COPD should be made using all available tools. Clinical symptoms and signs, such as abnormal shortness of breath and increased forced expiratory time, can be used to help with the diagnosis. A low peak flow is consistent with COPD, but may not be specific to COPD because it can be caused by other lung diseases and by poor performance during testing. Chronic cough and sputum production often precede the development of airflow limitation by many years, although not all individuals with cough and sputum production go on to develop COPD.
Classification of Severity of COPD
Stage 0: At Risk • normal Spirometry • chronic symptoms (cough, sputum production)
Nasal flaring, septum , turbinate, uvula, oral space
Accessory muscle use, AP diameter
Thoracic-abdominal breathing assessment
Auscultation wheeze, rhonchi, Rales, air movement and trapping
palpation and percussion
Heart sounds with augmented right heart sounds
Jugular veins and distension
Evaluate Tremors , muscle strength
Occupational Exposure in COPD
Genetics in COPD
Alpha -1 Anti Trypsin deficiency
ZZ type require treatment, testing available without charge by squeezing a drop of blood on a paper and mailing to lab.
Genetic counseling done
Our office we test every new patient and at least once in established patient
We follow levels in below normal patients
Once established significantly deficient Home IV therapy is given weekly.
Alpha-1 Antitrypsin Deficiency (A1AD) is a hereditary disorder characterized by low levels of a protein called alpha-1 antitrypsin (A1AT) which is found in the blood. This deficiency may predispose an individual to several illnesses but most commonly appears as emphysema , less commonly as liver disease , or more rarely, as a skin condition called panniculitis .
A deficiency of A1AT allows substances that break down protein (proteolytic enzymes) to attack various tissues of the body. This results in destructive changes in the lungs (emphysema) and may also affect the liver and skin. Alpha-1 Antitrypsin is ordinarily released by specialized, granular white blood cells (neutrophils) in response to infection or inflammation. A deficiency of Alpha-1 Antitrypsin results in unbalanced (relatively unopposed) rapid breakdown of proteins (protease activity), especially in the supporting elastic structures of the lungs. This destruction over many years leads to emphysema and is accelerated by smoking and some occupational exposures.
Testing in COPD
PFT: Pulmonary function tests TLC, FEV1/FVC, Diffusion, MVV.
ABG: Arterial Blood Gas PO2 PCO2 PH
Exercise Test: Good test for overall pulmonary efficiency