2. Key points
It is a preventable and treatable disease characterized by
persistent respiratory symptoms and airflow limitation that is
not fully reversible.
It is the third leading cause of death worldwide, according to
the world health organization.
Most (86%) COPD deaths occur among those age 65 years or
older.
Emphysema and chronic bronchitis are the most well-known
conditions that compose COPD and they frequently coexist.
3. Risk factors
Most COPD cases are caused by cigarette smoking.
Genetic abnormalities, including a deficiency of alpha1-antitrypsin enzyme.
Passive smoking
Occupational exposure
Ambient air pollution
12. Long term oxygen therapy
Criteria:
Resting PaO2 ≤ 55 mmHg
SPO2 ≤ 88% on RA
With evidence of cor pulmonale:
Resting PaO2 ≤ 59 mmHg or SPO2 ≤ 89%
13. Chronic bronchitis
Chronic productive cough for at least three months for two
consecutive years
Other causes of symptoms, such as tuberculosis or other lung
diseases, must be ruled out.
Is one of the principal manifestations of chronic obstructive
pulmonary disease (COPD
Also called blue bloaters
14. Emphysema
Destruction of lung parenchyma leading to loss of elastic recoil
of the alveoli.
Can develop Pneumothorax from ruptured bullae
Types: Centrilobular, Panacinar and Paraseptal
17. A 72-year-old woman is evaluated during a routine examination. She has very severe COPD
with multiple exacerbations. She has dyspnea at all times with decreased exercise capacity.
She does not have cough or any change in baseline sputum production. She is adherent to
her medication regimen, and she completed pulmonary rehabilitation 1 year ago. She quit
smoking 1 year ago. Her medications are a budesonide/formoterol inhaler, tiotropium, and an
albuterol inhaler as needed. Following a physical and pulmonary exam, what is the most
appropriate next step in management?
On physical examination, pulse rate is 94/min, and respiration rate is 26/min. Pulmonary
examination reveals distant breath sounds and no wheezing. Oxygen saturation is 86%
breathing ambient air. Pulmonary function testing reveals an FEV1 of 26% of predicted and an
FEV1/FVC ratio of 41%.
Which of the following is the most appropriate next step in management?
A. Oral antibiotics
B. Oxygen therapy
C. Prednisone taper
D. Repeat pulmonary rehabilitation
18. A 72-year-old woman is evaluated during a routine examination. She has very severe COPD
with multiple exacerbations. She has dyspnea at all times with decreased exercise capacity.
She does not have cough or any change in baseline sputum production. She is adherent to
her medication regimen, and she completed pulmonary rehabilitation 1 year ago. She quit
smoking 1 year ago. Her medications are a budesonide/formoterol inhaler, tiotropium, and an
albuterol inhaler as needed. Following a physical and pulmonary exam, what is the most
appropriate next step in management?
On physical examination, pulse rate is 94/min, and respiration rate is 26/min. Pulmonary
examination reveals distant breath sounds and no wheezing. Oxygen saturation is 86%
breathing ambient air. Pulmonary function testing reveals an FEV1 of 26% of predicted and an
FEV1/FVC ratio of 41%.
Which of the following is the most appropriate next step in management?
A. Oral antibiotics
B. Oxygen therapy
C. Prednisone taper
D. Repeat pulmonary rehabilitation
19. The most appropriate next step in management is long-term oxygen
therapy (LTOT). This patient's oxygen saturation is 86% breathing ambient
air, patient is already on max therapy with 3 inhalers and still having
symptom.
Indications for LTOT are an arterial PO2 of less than or equal to 55 mm Hg
(7.3 kPa) or an oxygen saturation of less than or equal to 88% when
breathing ambient air.
20. A 55-year-old man with a 7- year history of severe chronic obstructive pulmonary disease is
evaluated after being discharged from the hospital following an acute exacerbation; he has
had three exacerbations over the previous 8 months. He is a long-term smoker who stopped
smoking 3 years ago. He adheres to therapy with albuterol as needed, inhaled salmeterol
and tiotropium and has demonstrated proper inhaler technique.
On physical examination, vital signs are normal. Breath sounds are decreased bilaterally;
there is no edema or cyanosis. Oxygen saturation after exertion is 92% on ambient air.
Spirometry shows an FEV1 of 32% of predicted and an FEV1/FVC ratio of 40 % Chest
radiograph done in the hospital 3 weeks ago showed no active disease.
Which of the following should be added to this patients therapeutic regimen:
A) An inhaled corticosteroid
B) N –acetylcysteine
C) Oral prednisone
D) Oxygen therapy
21. A 55-year-old man with a 7- year history of severe chronic obstructive pulmonary disease is
evaluated after being discharged from the hospital following an acute exacerbation; he has
had three exacerbations over the previous 8 months. He is a long-term smoker who stopped
smoking 3 years ago. He adheres to therapy with albuterol as needed, inhaled salmeterol
and tiotropium and has demonstrated proper inhaler technique.
On physical examination, vital signs are normal. Breath sounds are decreased bilaterally;
there is no edema or cyanosis. Oxygen saturation after exertion is 92% on ambient air.
Spirometry shows an FEV1 of 32% of predicted and an FEV1/FVC ratio of 40 % Chest
radiograph done in the hospital 3 weeks ago showed no active disease.
Which of the following should be added to this patients therapeutic regimen:
A) An inhaled corticosteroid
B) N –acetylcysteine
C) Oral prednisone
D) Oxygen therapy
22. Inhaled corticosteroids may offer significant benefit in patients with severe
COPD, with the benefit generally greater when an inhaled corticosteroid is
combined with a long-acting.
Regular use of inhaled corticosteroids in patients with chronic obstructive
pulmonary disease are also associated with a reduction in the rate of
exacerbation. Therefore, the GOLD guidelines recommend consideration
of inhaled corticosteroids in patients whose lung function is less than 50%
and those who have exacerbations.
23. A 61-year-old woman is evaluated in a follow-up examination for dyspnea, chronic
cough, and mucoid sputum; she was diagnosed with COPD 7 years ago. The patient has
a 40 pack-year history of cigarette smoking, but quit 1 year ago. She is otherwise healthy
and her only medication is inhaled albuterol as needed.
On physical examination, vital signs are normal. Breath sounds are decreased, but there
is no edema or jugular venous distention. Spirometry shows an FEV1 of 62% of predicted
and FEV1/FVC ratio of 65 %. CXR shows mild hyperinflation.
Which of the following is the most appropriate therapy for this patient:
A) Add a long-acting β-agonist
B) Add an inhaled corticosteroid
C) Add an oral corticosteroid
D) Add theophylline and montelulast
E) Continue current albuterol therapy
24. A 61-year-old woman is evaluated in a follow-up examination for dyspnea, chronic
cough, and mucoid sputum; she was diagnosed with COPD 7 years ago. The patient has
a 40 pack-year history of cigarette smoking, but 1 year ago. She is otherwise healthy and
her only medication is inhaled albuterol as needed.
On physical examination, vital signs are normal. Breath sounds are decreased, but there
is no edema or jugular venous distention. Spirometry shows an FEV1 of 62% of predicted
and FEV1/FVC ratio of 65 %. CXR shows mild hyperinflation.
Which of the following is the most appropriate therapy for this patient:
A) Add a long-acting β-agonist
B) Add an inhaled corticosteroid
C) Add an oral corticosteroid
D) Add theophylline and montelulast
E) Continue current albuterol therapy
25. This patient has stage 2 COPD with moderate airflow obstruction as defined by the
guidelines of the Global initiative for obstructive lung disease (GOLD).
Maintenance treatment for these patients include long-acting bronchodilator such
as LABA ( Salmeterol or formoterol) or a LAMA( long-acting muscarinic antagonist )
along with as-needed albuterol.
Editor's Notes
It is a common respiratory condition preventable and treatable, characterized by persistent respiratory symptoms and airflow limitation that is not fully reversible.
There are many risk factors that lead to COPD. Exposure to tobacco smoke accounts for an estimated 80% to 90% of COPD cases.
Although smoking is definitely a cause of COPD, not all cigarette smokers develop COPD-with disease expression mediated by additional factors such as genetics and environment.
Occupational exposure to dusts, fumes or chemicals;
indoor air pollution: biomass fuel (wood, animal dung, crop residue) or coal is frequently used for cooking and heating in low- and middle-income countries with high levels of smoke exposure;
early life events such as poor growth in utero, prematurity, and frequent or severe respiratory infections in childhood that prevent maximum lung growth;
The cause of COPD is usually long-term exposure to irritants that damage your lungs and airways. Inhalation of cigarette smoke or other nauseous particles, such as occupational exposure, Inhaled noxious particles and gases cause lung inflammation, induce tissue destruction, impair the defense mechanisms that serve to limit the destruction, and disrupt the repair mechanisms that may be able to restore tissue structure in the face of some injuries.
The inflammatory response that results from the chronic exposure to an inflammatory stimulus may induce tissue destruction like we see in emphysema, and disruption of the normal repair and defense mechanism resulting in a small airways fibrosis. These pathological changes lead to gas trapping and progressive airflow limitation. Over time, inflammation damages the lungs and leads to the pathologic changes characteristic of COPD.
· In addition to inflammation, two other processes thought to be important in the pathogenesis of COPD are an imbalance of proteinases and anti-proteinases in the lung, and oxidative stress.
patients typically present with a combination of signs and symptoms of chronic bronchitis, emphysema, and reactive airway disease. These include cough, worsening dyspnea, progressive exercise intolerance, sputum production, and alteration in mental status.
Dyspnea may be severe and often interferes with the patient’s activities. Weight loss is common because dyspnea interferes with eating.
Less common symptoms of COPD include:
weight loss, fatigue, LE edema, chest pain, hemoptysis,
Diagnosis is suggested by history, physical examination, and is confirmed by pulmonary function tests.
The presence of symptoms compatible with COPD (eg, dyspnea at rest or on exertion, cough with or without sputum production, progressive limitation of activity) are suggestive of the diagnosis, especially if there is a history of exposure to triggers of COPD (eg, tobacco smoke, occupational dust, indoor biomass smoke), a family history of chronic lung disease, or presence of associated comorbidities
Suspect COPD in any patient who presents with complaints of dyspnea and productive cough-whether they smoke or not.
The diagnosis can be confirmed by spirometry with a [FEV1/FVC] ratio less than 0.7
After confirming the presence of COPD, the next step is to consider the cause. For the majority of patients, the etiology is long-term cigarette smoking. However, it is important to review with the patient whether underlying asthma, workplace exposures, indoor use of biomass fuel, a prior history of tuberculosis, or familial predisposition is contributory, because mitigation of ongoing exposures may reduce disease progression.
It is appropriate to screen all patients with COPD for alpha-1 antitrypsin
Determine the airflow limitation severity is your pretty we use the gold guidelines, that stands for The Global Initiative for Chronic Obstructive Lung Disease (GOLD) for recommendations for first-line treatment
Once we confirmed that the pt has COPD the goal is to determine the level of airflow limitation and risk of future events such as exacerbation, hospital admissions or death in order to guide therapy. For this, we use the ABCD' Assessment Tool which will assess the airflow limitation using the FEV1 and the stage of the COPD using the numbers of exacerbation and symptoms reported by the patient using the CAT score,
CAT- iThe COPD Assessment Test (CAT) is a questionnaire for people with COPD.
Risk reduction: is the most effective intervention to prevent COPD or slow its progression.. Especially Smoking cessation is the single most effective intervention.
Treatment is based
According to the severity and stage of the COPD we can use these guideline to determine which is the best treatment for the patient.
In patients with severe COPD long-term oxygen therapy has been shown to improve the patient’s quality of life and survival.
Chronic bronchitis- chronic bronchitis is defined as a chronic productive cough for at least three months for two consecutive years in a patient in whom other causes of chronic cough (eg, bronchiectasis) have been excluded [1].
Chronic bronchitis is one of the principal manifestations of chronic obstructive pulmonary disease (COPD),
is caused by overproduction and hypersecretion of mucus by goblet cells, which leads to worsening airflow obstruction by luminal obstruction of small airways, epithelial remodeling, and alteration of airway surface tension predisposing to collapse.
Blue bloaters- because of the presence of cyanosis due to hypoxemia early in the disease. They also tend to be obese especially because of the air trapping.
destruction of lung parenchyma leading to loss of elastic recoil of the alveoli, which increases the tendency for airway collapse
Patients with emphysema have symptoms such as a barrel chest, enlarged lungs, shortness of breath, and weight loss.
Centrilobular (proximal acinar) is the most common type and is commonly associated with smoking. It can also be seen in coal workers' pneumoconiosis.
Panacinar is most commonly seen with alpha one antitrypsin deficiency.
Paraseptal (distal acinar) may occur alone or in association with the above two. When it occurs alone, the usual association is a spontaneous pneumothorax in a young adult.
