Chronic obstructive pulmonary disease(copd)

1. CHRONIC OBSTRUCTIVE PULMONARY
DISEASE(COPD)
Rana Shankor Roy

2. DEFINITION
 Chronic obstructive pulmonary disease
(COPD) is a preventable and treatable
disease characterized by persistent airflow
limitation that is usually progressive, and
associated with an enhanced chronic
inflammatory response in the airways and
the lung to noxious particles or gases.

3. IT INCLUDES------------
 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).

4. CLINICALLY TWO TYPES--------
 Blue bloaters:
--Patients having predominantly bronchitis.
--Cyanosis present(Blue)
--Edematous(bloaters)
-- ↑PCO2 & ↓PO2
--Cor-pulmonale common.
 Pink puffer:
--Patients having predominantly emphysema.
--Pursed-lip breathing(puffer)
--Absence of cyanosis i.e. pink
--lean & thin body.
-- PCO2 & PO2 normal.

5. WHAT ARE THE OBSTRUCTIVE PULMONARY
DISEASE?
 COPD
 Asthma

6. RISK FACTORS FOR COPD
 Environmental
• Tobacco smoking
• Indoor air pollution; cooking with biomass fuels
• Occupational exposures, such as coal dust, silica
• Infections: recurrent infection
persistence of adenovirus in lung tissue.
HIV infection
• Low socioeconomic status
 Host factors
• α1-antiproteinase deficiency; other COPD
• Airway hyper-reactivity

7. SYMPTOMS
 Cough(Productive, frothy, persist throughout
the day)
 Sputum production
 Breathlessness( Exertional breathlessness)
 Hemoptysis
 Morning headache(indication of hypercapnia)
 Features of complications

8. SIGNS
 Increased respiratory rate
 Pursed lip breathing
 Intercostal recession
 Bilaterally reduced chest expansion
 Edema, if heart failure develop

9. WHAT YOU EXPECT IN PHYSICAL EXAMINATION?
 Inspection:
--RR increased.
--Intercostal recession
 Palpation:
--Bilaterally reduced chest expansion.
 Percussion:
--Hyperresonant.
 Auscultation:
--Breath sound is vesicular with prolonged
expiration
--Ronchi may found.

10. IMPORTANT NEGATIVE HISTORY:
 No history of nocturnal dyspnea/ orthopnoea.
 No family history of same type of disease.
 No dust/cold allergy.
 Any skin disease

11. INVESTIGATIONS
 General:
i)CBC—
Hb% : polycythemia (If anemia, then any
associated disease such as TB,
carcinoma)
ii) Electrolyte: Hypokalemia
iii) Blood glucose
iv) Serum creatinine

12.  Specific:
i) Chest X-ray: X-ray is essential to identify
alternative diagnoses, such as cardiac failure,
other complications of smoking such as lung
cancer, and the presence of bullae.
In emphysema-----
--Hyper translucent lung fields due to trapping of
air.
--Low flat diaphragm.
--Long tubular heart shadow.
--widening of rib space
--Emphysematous bulla.

13. ii) Spirometry:
--Post bronchodilator FEV1<80% of predictive
value.
--FEV1/FVC<70%
iii) In younger patients with predominantly
basal emphysema,α1-antiproteinase should be
assayed.

14. SPIROMETRIC CLASSIFICATION OF COPD SEVERITY BASED ON
POST-BRONCHODILATOR FEV1
Stage Severity FEV1
I Mild FEV1/FVC < 0.70
FEV1 ≥ 80% predicted
II Moderate FEV1/FVC < 0.70
FEV1 50–79% predicted
III Severe FEV1/FVC < 0.70
FEV1 30–49% predicted
IV Very severe FEV1/FVC < 0.70
FEV1 < 30% predicted or FEV1 < 50%
predicted if respiratory failure present

15. D/D
 Chronic asthma
 Tuberculosis
 Bronchiectasis
 Congestive cardiac failure.(Orthopnea
present)
 In COPD patients can lie but in Heart failure
patients cant lie.

16. CORPULMONALE
 It is defined as Pulmonary HTN with right
ventricular hypertrophy with or without HF
due to COPD or any respiratory cause.

17. MANAGEMENT
 Reducing exposure to noxious particles and gases:
Smoking should be stopped
 Bronchodilators:
---Short-acting bronchodilators, such as the β2-
agonists salbutamol and terbutaline, or the
anticholinergic ipratropium bromide, may be used for
patients with mild disease,
--Longer acting bronchodilators, such as the β2-
agonists salmeterol, formoterol and indacaterol, or
the anticholinergic tiotropium bromide, are more
appropriate for patients with moderate to severe
disease.
--Thioxanthene derivatives such as Theophylline.

18.  Corticosteroids: both for maintenance & acute attack.
-- Oral prednisolone 30 mg for 10 days. Or
--Inj. Hydrocortisone.
--Inhaler Fluticasone, Beclomethasone
 Leukotriene antagonist( No role but given)
--Montelukast.
 Oxygen therapy: Long-term domiciliary oxygen therapy
(LTOT) has been shown to be of significant benefit in
selected patients
 Non-invasive ventilation.
 Surgery:
--Bullectomy or
--lung volume reduction surgery (LVRS) to improve
symptoms.

19. HOW WILL YOU MANAGE A ACUTE CASE?
 Propped up position.
 Oxygen inhalation: 1-2 L/min
Low flow oxygen at 24% or 28% should be
used with the aim of maintaining a PaO2
above 8 kPa (60 mmHg).(In patients with an
exacerbation of severe COPD, high
concentrations of oxygen may cause
respiratory depression and worsening
acidosis)

20.  Nebulization: Nebulized short-acting β2-
agonists, combined with an anticholinergic
agent (e.g. salbutamol and
ipratropium),should be administered.
3ml solution
-----1ml normal solution+1ml ipratropium+1ml
Salbutamol in adults
-----1.5ml normal solution+1ml ipratropium
+0.5ml Salbutamol in children
Given for 10 minutes.

21.  Oral prednisolone 30 mg for 10 days
 Antibiotic: Amino penicillin or macrolides.
 If, despite the above measures, the patient
remains tachypnoeic, hypercapnic and
acidotic (PaCO2 > 6 kPa, H+ ≥ 45 (pH <
7.35)), then NIV(Non-invasive ventilation)
should be commenced

22. PRESCRIPTION OF LONG-TERM OXYGEN
THERAPY IN COPD
 Arterial blood gases measured in clinically stable
patients on optimal medical therapy on at least two
occasions 3 weeks apart:
• PaO2 < 7.3 kPa (55 mmHg) irrespective of PaCO2
and FEV1< 1.5 L
• PaO2 7.3–8 kPa (55–60 mmHg) plus pulmonary
hypertension, peripheral oedema or nocturnal
hypoxaemia
• the patient has stopped smoking.
Use at least 15 hrs/day at 2–4 L/min to achieve a PaO2
> 8 kPa (60 mmHg) without unacceptable rise in
PaCO2.

23. DIFFERENCE BETWEEN ASTHMA & COPD
Traits Bronchial asthma COPD
Age incidence Child & younger Old age(>50 years)
Main symptom Respiratory distress Cough & sputum
Diurnal variation Occurs Not occurs
History of allergy Present Usually Absent
Smoking history Not so important Important
Chest X-ray Usually normal Abnormal
Eosinophil count Increase Normal
IgE level Raised Normal