2. DefinitionDefinition
COPDCOPD ((Chronic obstructive pulmonary diseaseChronic obstructive pulmonary disease))
is a preventable and treatable disease stateis a preventable and treatable disease state
characterized by airflow limitation that ischaracterized by airflow limitation that is notnot
fully reversiblefully reversible..
The airflow limitation is usuallyThe airflow limitation is usually progressiveprogressive andand
is associated with an abnormal inflammatoryis associated with an abnormal inflammatory
response of the lungs, primarily caused byresponse of the lungs, primarily caused by
cigarette smoking.cigarette smoking.
Although COPD affects the lungs, it alsoAlthough COPD affects the lungs, it also
producesproduces significant systemic consequencessignificant systemic consequences.. 2222
4. ➢Major cause of death and disabilityMajor cause of death and disability
➢4th4th leading cause of deathleading cause of death
➢COPD is the only chronic disease that isCOPD is the only chronic disease that is
showing progressive upward trend in bothshowing progressive upward trend in both
mortality and morbiditymortality and morbidity
➢It is expected to be the third leading cause ofIt is expected to be the third leading cause of
death bydeath by 20202020
COPDCOPD
GENERAL FACTSGENERAL FACTS
4444
5. % Change in Age Adjusted Death Rate% Change in Age Adjusted Death Rate
5555
7. ➢ COPD should be suspected in any patientCOPD should be suspected in any patient
over the age ofover the age of 3535 years who presents withyears who presents with
symptoms of persistent cough and sputumsymptoms of persistent cough and sputum
production and/or breathlessness.production and/or breathlessness.
➢ Depending on the presentation importantDepending on the presentation important
differential diagnoses include asthma,differential diagnoses include asthma,
tuberculosis, bronchiectasis and congestivetuberculosis, bronchiectasis and congestive
cardiac failure.cardiac failure.
7777
8. ➢ BreathlessnessBreathlessness usually heralds the first presentation tousually heralds the first presentation to
the health professional.the health professional.
➢ In advanced disease, the presence ofIn advanced disease, the presence of edemaedema andand
morning headachesmorning headaches indicative ofindicative of hypercapniahypercapnia..
➢ CracklesCrackles may accompany infection but if persistent raisemay accompany infection but if persistent raise
the possibility of bronchiectasis.the possibility of bronchiectasis.
➢ Finger clubbingFinger clubbing isis not consistentnot consistent with COPD and shouldwith COPD and should
alert the physician to potentially more serious pathologyalert the physician to potentially more serious pathology
((CA LungCA Lung).).
8888
9. ➢ Some patients with severe COPD maySome patients with severe COPD may
demonstrate signs consistent withdemonstrate signs consistent with corpulmonalecorpulmonale
(raised jugular venous pressure, loud P(raised jugular venous pressure, loud P22 due todue to
pulmonary hypertension, tricuspid regurgitation,pulmonary hypertension, tricuspid regurgitation,
pitting peripheral edema and hepatomegaly) andpitting peripheral edema and hepatomegaly) and
its presence usually indicates a poor prognosis.its presence usually indicates a poor prognosis.
9999
10. Skeletal muscle wasting and cachexia maySkeletal muscle wasting and cachexia may
occur in advanced disease, while someoccur in advanced disease, while some
patients may also be overweight.patients may also be overweight.
The body mass index (BMI; weight/height²)The body mass index (BMI; weight/height²)
should be calculated during the initialshould be calculated during the initial
examination.examination.
10101010
16. Pink PuffersPink Puffers
➢Thin and dyspnic ,Thin and dyspnic ,
and maintain Paand maintain Pa COCO22
until the late stage ofuntil the late stage of
disease.disease.
➢EMPHESEMAEMPHESEMA
16161616
17. PPursed liursed lipp breathing occur inbreathing occur in
emempphysemahysema not in chronic bronchitisnot in chronic bronchitis
17171717
22. Clinical FeaturesClinical Features
➢No cyanosisNo cyanosis ((pinkpink))
➢Presents withPresents with severe dyspneasevere dyspnea (puffer(puffer))
➢Have aHave a barrel chestbarrel chest..
➢X-ray showsX-ray shows large volume lung, Heartlarge volume lung, Heart isis
seems buried and diaphragm pushed down.seems buried and diaphragm pushed down.
Alveoli can ruptureAlveoli can rupture pneumothorax.pneumothorax.
➢Don’t usually have cough or expectorationDon’t usually have cough or expectoration
PINK PUFFERPINK PUFFER
22222222
23. BLUE BLOATERBLUE BLOATER
Develop andDevelop and
toleratetolerate
hypercapniahypercapnia
earlier and mayearlier and may
develop edemadevelop edema
andand 22‘‘
polycythemia.polycythemia.
CHRONICCHRONIC
BRONCHITICBRONCHITIC
23232323
24. CHRONIC BRONCHITISCHRONIC BRONCHITIS
➢DefinedDefined clinicallyclinically
Persistent cough with sputumPersistent cough with sputum
production forproduction for at leastat least 33 monthsmonths inin
at leastat least 22 consecutiveconsecutive yearsyears, with, with
exclusion of other causes likeexclusion of other causes like
Bronchiectasis .Bronchiectasis .
24242424
25. PATHOGENESISPATHOGENESIS
SMOKINGSMOKING
4-104-10 times more common in heavy smokerstimes more common in heavy smokers
✓ a smoking history of more thana smoking history of more than 2020 pack yearspack years
➢ Smoke and other irritants causeSmoke and other irritants cause
Hypertrophy of submucosal glands--- hypersecretionHypertrophy of submucosal glands--- hypersecretion
of mucusof mucus
Increase in goblet cellsIncrease in goblet cells
↑↑predisposition to infectionpredisposition to infection
25252525
26. Clinical FeaturesClinical Features
➢CyanosedCyanosed ((BlueBlue))
➢EdematousEdematous ((BloaterBloater))
➢Productive CoughProductive Cough
➢CorPulmonale – heart failureCorPulmonale – heart failure
➢Usually dyspnea triggered by infectionUsually dyspnea triggered by infection
➢Respiratory acidosisRespiratory acidosis
Blue bloaterBlue bloater
26262626
31. DLCO: Transfer FactorDLCO: Transfer Factor
• AsthmaAsthma highhigh
• Chronic bronchitisChronic bronchitis normalnormal
• EmphysemaEmphysema lowlow
31313131
32. Other testsOther tests
➢ HemoglobinHemoglobin andand PCVPCV can be elevated as a result ofcan be elevated as a result of
persistent hypoxemia causing secondarypersistent hypoxemia causing secondary
polycythemia.polycythemia.
➢ Arterial blood gases (ABGs)Arterial blood gases (ABGs) determine the degree ofdetermine the degree of
hypoxia and hypercapnia.hypoxia and hypercapnia.
➢ CXRCXR can be normal or show hyper-expanded lungcan be normal or show hyper-expanded lung
fields with low flattened diaphragms and the presencefields with low flattened diaphragms and the presence
of bullae (emphysemaof bullae (emphysema))..
➢ ECGECG can show advanced cor pulmonalecan show advanced cor pulmonale
➢ Alpha-antitrypsin level and phenotypeAlpha-antitrypsin level and phenotype may be helpfulmay be helpful
(young non smokers, lower lobe emphysema, a family(young non smokers, lower lobe emphysema, a family
history of chest problemshistory of chest problems).). 32323232
34. Disease Progression of a Patients withDisease Progression of a Patients with
COPDCOPD
Symptoms
Exacerbations
Exacerbations
Exacerbations
Deterioration
End of Life
34343434
39. Smoking cessationSmoking cessation
➢The onlyThe only
interventionintervention
proven toproven to
decelerate thedecelerate the
decline indecline in
FEVFEV11.. 39393939
42. BronchodilatorsBronchodilators
Short Acting BetaShort Acting Beta22 Agonist (SABAAgonist (SABA))
➢e.g. Salbutamole.g. Salbutamol
➢Improve pulmonary function/SOB/exerciseImprove pulmonary function/SOB/exercise
performanceperformance
➢Combination SABA’s and anticholinergicsCombination SABA’s and anticholinergics
produce better bronchodilationproduce better bronchodilation
➢For patients with MILD symptomsFor patients with MILD symptoms
●
SOB on exertionSOB on exertion
42424242
43. BronchodilatorsBronchodilators
Long Acting BetaLong Acting Beta22 Agonist (LABAAgonist (LABA))
➢e.g.– Formoterol, Salmeterole.g.– Formoterol, Salmeterol
➢For patients who still have symptoms onFor patients who still have symptoms on
SABA’sSABA’s ((MODERATE diseaseMODERATE disease))
➢More sustained effect on PFT’s, chronic SOBMore sustained effect on PFT’s, chronic SOB
➢Early evidence these may prolong timeEarly evidence these may prolong time
between exacerbationsbetween exacerbations
43434343
44. Inhaled anticholinergicsInhaled anticholinergics
inhaled ipratropium bromide is preferred over
beta-2 agonists by many as the bronchodilator of
choice in COPD for the following reasons:
➢Its minimal cardiac stimulatory effects compared
to those of beta agonists
➢Its greater effectiveness than either beta agonist
or methylxanthine bronchodilators in most studies
of patients with COPD
44444444
46. SteroidsSteroids
Inhaled steroidInhaled steroid
➢ Not recommended as first line therapyNot recommended as first line therapy
➢ No consistent effect on decreasing inflammationNo consistent effect on decreasing inflammation
➢ Consider inhaled form in those with mod-severeConsider inhaled form in those with mod-severe
diseasedisease
➢ Consider in those who have maximalConsider in those who have maximal
bronchodilator therapybronchodilator therapy
➢ Inhaled corticosteroids are currentlyInhaled corticosteroids are currently
recommended inrecommended in severe disease( FEVsevere disease( FEV1<50%1<50% whowho
report two or more exacerbations requiringreport two or more exacerbations requiring
antibiotics or oral steroids per yearantibiotics or oral steroids per year .. 46464646
49. Additional measuresAdditional measures
➢ Vaccines. Patients with COPD should receive a singleVaccines. Patients with COPD should receive a single
ddose of the polyvalent pneumococcal polysaccharideose of the polyvalent pneumococcal polysaccharide
vaccine and yearly influenza vaccinations.vaccine and yearly influenza vaccinations.
➢ aa11-Antitrypsin replacement. Weekly or monthly-Antitrypsin replacement. Weekly or monthly
Infusions of aInfusions of a11-antitrypsin have been recommended for-antitrypsin have been recommended for
patients withpatients with lowlow serum levels and abnormal lungserum levels and abnormal lung
function.function.
➢ Heart failure should be treated with diuretics .Heart failure should be treated with diuretics .
➢ Secondary polycythemia requires venesection if theSecondary polycythemia requires venesection if the
PCV is >PCV is >5555%%
49494949
50. SURGERYSURGERY
➢ BullectomyBullectomy : young with emphysema: young with emphysema
➢ Lung Volume reduction surgery (LVRS)Lung Volume reduction surgery (LVRS)::
emphysemaemphysema
➢ Lung transplantLung transplant
Have been used for severe COPDHave been used for severe COPD
50505050
51. 5151
Emergency treatment
Emergency treatment
Exacerbations of COPD are characterized by an acute
worsening of symptoms, with
increased breathlessness,
sputum volume and
sputum purulence.
They may occur spontaneously or as a result of infections.
Mild exacerbations can be managed at home but patients with
severe exacerbations require admission to hospital.
key adverse features that indicate a severe
exacerbation : (confusion, cyanosis, severe
respiratory distress) 5151
52. 5252
Patients admitted to hospital should have
• Chest X-ray,
• Arterial blood gas measurement,
• ECG (to exclude comorbidities)
• Full blood count and
• Urea and electrolyte measurements.
• Culture of sputum
• Blood cultures should be taken if the patient is
pyrexial and
• Theophylline level should be measured in patients
on theophylline therapy.
5252
54. ORAL STEROIDSORAL STEROIDS
ORAL STEROIDS are useful during exacerbationsORAL STEROIDS are useful during exacerbations
(rule of(rule of 15)15)
PREDINSOLONPREDINSOLON 1515 mgmg TWICE DAILY GIVENTWICE DAILY GIVEN FORFOR 1515
DAYSDAYS MAY BENEFITMAY BENEFIT 1515%% OF PATIENTS WITHOF PATIENTS WITH
COPD EXACERBATIONCOPD EXACERBATION
54545454
55. 5555
Antibiotics
Common bacteria associated with COPD exacerbation
include
Haemophilus inluenzae,
Streptococcus pneumoniae and
Moraxella catarrhalis.
Treatment
Augmentin(amoxicillin and clavulanic acid),
or doxycycline, or ciprofloxacin or clarithromycin.
5555
56. 5656
Emergency oxygen
treatment should be commenced using controlled oxygen (e.g.
28% Venturi mask in pre-hospital care or 24% Venturi mask in
hospital settings), with an initial target saturation of 88–92%
pending urgent blood gas assessment to determine the patient’s
ventilatory status (pH and PCO2) .
5656
57. 5757
Ventilatory support
if the pH is below the normal range (<7.3) then
noninvasive ventilation (NIV) should be employed
5757
58. BRONCHIECTASISBRONCHIECTASIS
A destructive lung disease characterized by:A destructive lung disease characterized by:
●
Abnormal & permanent dilatation of medium sizedAbnormal & permanent dilatation of medium sized
bronchibronchi
●
An associated, persistent and variable inflammatoryAn associated, persistent and variable inflammatory
process producing damage to bronchial elastic andprocess producing damage to bronchial elastic and
muscular elementsmuscular elements
58585858
61. Physical signsPhysical signs
➢ 11-normal chest exam-normal chest exam. If bronchiectatic airways. If bronchiectatic airways
do not contain secretions and there is nodo not contain secretions and there is no
associated lobar collapse .associated lobar collapse .
➢ 22-coarse crackles-coarse crackles if there is secretions .if there is secretions .
➢ 33- deviated trachea toward side of lesion ,- deviated trachea toward side of lesion ,
dullness ,↓breath sounddullness ,↓breath sound if there is collapse .if there is collapse .
➢ 44- bronchial breathing- bronchial breathing : advanced scarring .: advanced scarring .
61616161
62. INVESTIGATIONSINVESTIGATIONS
11-Sputum culture-Sputum culture
For pseudomonas aeruginosa , fungi , andFor pseudomonas aeruginosa , fungi , and
mycobacteria .mycobacteria .
22- Radiology- Radiology
CXR : early stage normalCXR : early stage normal
Advanced thickened airway walls , cystic spaces ,Advanced thickened airway walls , cystic spaces ,
pneumonic consolidation or collapse .pneumonic consolidation or collapse .
SPIRAL CT SCAN of chest is much moreSPIRAL CT SCAN of chest is much more sensitive .sensitive .
33-Assessment of ciliary function-Assessment of ciliary function
62626262
64. managementmanagement
➢ 11-airway obstruction-airway obstruction :: inhaled bronchodilators andinhaled bronchodilators and
corticosteroids .corticosteroids .
➢ 22-- physiotherapyphysiotherapy
Patients should adopt a position in which the lobePatients should adopt a position in which the lobe
to be drained is uppermost.to be drained is uppermost.
Deep breathing followed by forced expiratoryDeep breathing followed by forced expiratory
maneuvers (the 'active cycle of breathing'maneuvers (the 'active cycle of breathing'
technique) is of help in allowing secretions in thetechnique) is of help in allowing secretions in the
dilated bronchi to gravitate towards the trachea,dilated bronchi to gravitate towards the trachea,
from which they can be cleared by vigorousfrom which they can be cleared by vigorous
coughing.coughing.
64646464
65. 'Percussion' of the chest wall with cupped'Percussion' of the chest wall with cupped
hands may help to dislodge sputum, and ahands may help to dislodge sputum, and a
number of mechanical devices are availablenumber of mechanical devices are available
which cause the chest wall to oscillate, thuswhich cause the chest wall to oscillate, thus
achieving the same effect.achieving the same effect.
The optimum duration and frequency ofThe optimum duration and frequency of
physiotherapy depends on the amount ofphysiotherapy depends on the amount of
sputum butsputum but 55--1010 minutes once or twice dailyminutes once or twice daily
is a minimum for most patients.is a minimum for most patients.
65656565
67. 33- antibiotics- antibiotics
Oral ciprofloxacinOral ciprofloxacin 500500--750750 mg bidmg bid
Or ceftazidime by IV inj. Or infusionOr ceftazidime by IV inj. Or infusion 11--22 gmgm 88--
hourly.hourly.
44- surgery- surgery
Only in unilateral , single lobe in young patientOnly in unilateral , single lobe in young patient
67676767
Diagnosis of COPD is based on a history of exposure to risk factors and the presence of airflow limitation that is not fully reversible, with or without the presence of symptoms.
Patients who have chronic cough and sputum production with a history of exposure to risk factors should be tested for airflow limitation, even if they do not have dyspnea.
For the diagnosis and assessment of COPD, spirometry is the gold standard.
Health care workers involved in the diagnosis and management of COPD patients should have access to spirometry.
