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Jongsiriyunyong K. EP rj
 Progressive        and Non fully reversible airflow    limitation   COPD is a disorder in which subsets have dominant  ...
   The Global Initiative for Chronic Obstructive    Lung Disease (GOLD) guidelines define COPD as a    disease state char...
1          1           2                       5                4         3                       8              6        ...
Histopathology of chronic bronchitis showing hyperplasia of mucous glandsand infiltration of the airway wall with inflamma...
Gross pathology of advanced emphysema. Large bullae are present on thesurface of the lung.
At high magnification, loss of alveolar walls and dilatation of airspaces inemphysema can be seen.
This phenomenon is called                      dynamic hyperinflationPathophysiological
   Cigarette smoking- 90%   Environmental factors     Biomass fuels with indoor cooking and heating     Traffic-relate...
   Immunodeficiency syndromes       Independent risk   Vasculitis syndrome       Hypocomplementemic vasculitis urticar...
   For assess an individual’s risk of death or    hospitalization   History   Multifactorial with       Individual lif...
4-year survival     0-2 points = 80%     3-4 points = 67%     5-6 points = 57%     7-10 points = 18%
   Typically combination of signs and symptoms of    chronic bronchitis, emphysema, and reactive    airway disease.   Co...
   Hx of more than 40 pack-yrs of smoking was the    best single predictor of airflow obstruction   If all 3 signs are a...
   Hyperinflation (barrel chest)   Wheezing – Frequently heard on forced and    unforced expiration   Diffusely decreas...
   obese                             thin with a barrel chest   Frequent cough and                little or no cough  ...
 Alpha1-Antitrypsin     def Bronchitis Emphysema Nicotine   Addiction Pulmonary    Embolism
   Pulmonary Function Tests       For diagnosis       Assessment of severity       Following its progress   ABG     ...
   CBC       Secondary polycythemia           Hct>52% in men or 47% in women   Alpha1-Antitrypsin       all patients ...
COPD: Hyperinflation, depressed diaphragm, increased retrosternal space,and hypovascularity of lung parenchyma are demonst...
Emphysema : increased AP diameter, increased retrosternal airspace, andflattened diaphragm on lateral chest radiograph.
A lung with emphysema shows increased anteroposterior (AP) diameter,increased retrosternal airspace, and flattened diaphra...
A computed tomography (CT) scan shows hyperlucency due to diffusehypovascularity and bullae formation, predominantly in th...
Severe bullous disease as seen on a computed tomography (CT) scan in apatient with chronic obstructive pulmonary disease (...
 Acute    exacerbation Stable   COPD    Rx base on severity of disease
Acute exacerbation Severity         evaluate    Mild to moderate             Hemodynamic stable                      ...
 Indication     for admit    Severe exarcerbation    Severe stage of COPD    New onset of : cyanosis, peripheral edema...
treatment
Acute exacerbation : 1-3 wk onset   Bronchodilator       Beta2-agonist       Anticholinergic       Methylxantine   Co...
Acute exacerbation : 1-3 wk onset   Short acting Beta2-agonist is first line but    recommended combine of SABA and    An...
Medication       type      Onset (min)     duration   Route            drug                                             (h...
Acute exacerbation : 1-3 wk onset Systemic         corticosteroid     Limited systemic inflammation and airway      infl...
Acute exacerbation : 1-3 wk onset   Oxygen       All pt with SpO2 < 90% keep SpO2 90-94%   Limited S/E of Oxygen supple...
Acute exacerbation : 1-3 wk onset   Machanical ventilation       Indication of NIPPV                            accesso...
Acute exacerbation : 1-3 wk onset Machanical  ventilation   Indication of Invasive mechanical    ventilation       Resp...
treatment
Stable COPD : base on severity   Bronchodilator       Beta2-agonist       Anticholinergic       Methylxantine   Corti...
Stable COPD : at ALL stage Avoidance   of risk factor(s) Influenza   vaccination Pneumococcal     vaccination
Stable COPD : Mild COPD   Short-acting bronchodilator when needed
Stable COPD : Moderate COPD   Short-acting bronchodilator when needed   Regular treatment with one or more long-acting  ...
Stable COPD : Severe COPD   Short-acting bronchodilator when needed   Regular treatment with one or more long-acting    ...
Combination            Dose(ug/dy)      Trade nameFluticasone/Salmeterol    500/100-1000/100   Seretide®Budesonide / Forme...
Medication       type      Onset (min)     duration   Route            drug                                             (h...
Stable COPD : Very severe COPD   Short-acting bronchodilator when needed   Regular treatment with one or more long-actin...
       3       Short-term therapy       Long-term continuous therapy       During exercise                     PaO2  ...
 Indication   for STOT     Recent Exacerbation with new hypoxemia Re-evaluate     at wk 4     Continue STOT if still h...
 Continue       Oxygen supplement > 15 hr/dy        mortality         exercise tolerance     Quality of life: psychoth...
Oxygen therapy via nasal cannula   Home supplemental oxygen
Bilevel positive airway pressure (BiPAP)
 Hemodynamic    stable Bronchodilator   supply less than every 4 hr SpO2   >90% w/o O2 supplement at least 24 hr
COPD review
COPD review
COPD review
COPD review
COPD review
COPD review
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COPD review

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COPD review

  1. 1. Jongsiriyunyong K. EP rj
  2. 2.  Progressive and Non fully reversible airflow limitation COPD is a disorder in which subsets have dominant features of  chronic bronchitis  chronic productive cough for 3 months during each of 2 consecutive years  emphysema, or asthma  permanent enlargement of the air spaces distal to the terminal bronchioles, without obvious fibrosis
  3. 3.  The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines define COPD as a disease state characterized by  Airflow limitation that is not fully reversible, is usually progressive, and  Associated with an abnormal inflammatory response of the lungs to inhaled noxious particles or gases
  4. 4. 1 1 2 5 4 3 8 6 7 9 10Venn diagram of chronic obstructive pulmonary disease (COPD).
  5. 5. Histopathology of chronic bronchitis showing hyperplasia of mucous glandsand infiltration of the airway wall with inflammatory cells
  6. 6. Gross pathology of advanced emphysema. Large bullae are present on thesurface of the lung.
  7. 7. At high magnification, loss of alveolar walls and dilatation of airspaces inemphysema can be seen.
  8. 8. This phenomenon is called dynamic hyperinflationPathophysiological
  9. 9.  Cigarette smoking- 90% Environmental factors  Biomass fuels with indoor cooking and heating  Traffic-related air pollution Airway hyperresponsiveness Alpha1-antitrypsin deficiency  Panacinar emphysema  Premature emphysema at an average age of 53 years for nonsmokers and 40 years for smokers Intravenous drug use  Pulmonary vascular damage  Insoluble filler (eg, cornstarch, cotton fibers, cellulose, talc) contained in methadone or methylphenidate  Cocaine or heroin
  10. 10.  Immunodeficiency syndromes  Independent risk Vasculitis syndrome  Hypocomplementemic vasculitis urticaria syndrome (HVUS) Connective tissue disorders  Cutis laxa is a disorder of elastin , various forms of inheritance  Marfan syndrome is an autosomal dominant inherited disease of type I collagen  Ehlers-Danlos syndrome Salla disease  Autosomal recessive storage disorder , sialic acid
  11. 11.  For assess an individual’s risk of death or hospitalization History Multifactorial with  Individual lifestyle  Socioeconomic factors  Education / Knowledge
  12. 12. 4-year survival  0-2 points = 80%  3-4 points = 67%  5-6 points = 57%  7-10 points = 18%
  13. 13.  Typically combination of signs and symptoms of chronic bronchitis, emphysema, and reactive airway disease. Cough  Systemic manifestations worsening dyspnea  decreased fat-free mass progressive exercise  impaired systemic muscle intolerance function  Osteoporosis sputum production  Anemia alteration in mental status  Depression Productive cough or acute  pulmonary hypertension chest illness  cor pulmonale Breathlessness  left-sided heart failure Wheezing
  14. 14.  Hx of more than 40 pack-yrs of smoking was the best single predictor of airflow obstruction If all 3 signs are absent, airflow obstruction can be nearly ruled out  Self-reported smoking Hx of > 55 pack-yrs  Wheezing on auscultation  Self-reported wheezing
  15. 15.  Hyperinflation (barrel chest) Wheezing – Frequently heard on forced and unforced expiration Diffusely decreased breath sounds Hyperresonance on percussion Prolonged expiration phase
  16. 16.  obese  thin with a barrel chest Frequent cough and  little or no cough expectoration  Breathing may be assisted Use of accessory muscles by pursed lips of respiration is common  patients may adopt the Coarse rhonchi and tripod sitting position wheezing may be heard on  hyperresonant, and auscultation wheezing may be heard signs of right heart failure  Distant Heart sounds  Cor pulmonale  edema and cyanosis Chronic bronchitis Emphysema
  17. 17.  Alpha1-Antitrypsin def Bronchitis Emphysema Nicotine Addiction Pulmonary Embolism
  18. 18.  Pulmonary Function Tests  For diagnosis  Assessment of severity  Following its progress ABG  Hypoxemia / hypercapnia  Acidosis Serum Chemistries  Retain sodium /Lower potassium levels /bicarbonate  Chronic respiratory acidosis leads to compensatory metabolic alkalosis
  19. 19.  CBC  Secondary polycythemia  Hct>52% in men or 47% in women Alpha1-Antitrypsin  all patients < 40 yrs or Fm Hx of emphysema at early age Sputum Evaluation  Streptococcus pneumoniae  Haemophilus influenzae  Moraxella catarrhalis  Pseudomonas aeruginosa Chest Radiography +/- CT scan
  20. 20. COPD: Hyperinflation, depressed diaphragm, increased retrosternal space,and hypovascularity of lung parenchyma are demonstrated.
  21. 21. Emphysema : increased AP diameter, increased retrosternal airspace, andflattened diaphragm on lateral chest radiograph.
  22. 22. A lung with emphysema shows increased anteroposterior (AP) diameter,increased retrosternal airspace, and flattened diaphragm on posteroanteriorchest radiograph
  23. 23. A computed tomography (CT) scan shows hyperlucency due to diffusehypovascularity and bullae formation, predominantly in the upper lobes.
  24. 24. Severe bullous disease as seen on a computed tomography (CT) scan in apatient with chronic obstructive pulmonary disease (COPD).
  25. 25.  Acute exacerbation Stable COPD  Rx base on severity of disease
  26. 26. Acute exacerbation Severity evaluate  Mild to moderate   Hemodynamic stable  bronchodilator  Pred 30-40 mg/dy for 7dy  Moderate to severe  Risk for respiratory failure  AOC  Accessory muscle used: paradoxical chest/abd motion  SpO2 < 90% or PaO2 < 60 mmHg  PaCO2 > 45 mmHg or pH < 7.35
  27. 27.  Indication for admit  Severe exarcerbation  Severe stage of COPD  New onset of : cyanosis, peripheral edema  Unimprove after appropriated Tx  Multi-Comorbit : CAD, DM, HT  New onset Arrhythmia  Undefinite Diagnosis  Old age or Homeless
  28. 28. treatment
  29. 29. Acute exacerbation : 1-3 wk onset Bronchodilator  Beta2-agonist  Anticholinergic  Methylxantine Corticosteroid  Systemic corticosteroids Oxygen  All pt with SpO2 < 90% keep SpO2 90-94% Antibiotic  Cover Streptococcus pneumoniae, Hemophilus influenza, Morexella catarrhalis, Klebsiella pneumoniae ; Pseudomonas aeruginosa Machanical ventilation  Non-invasive positive pressure ventilation: NIPPV  Invasive mechanical ventilation
  30. 30. Acute exacerbation : 1-3 wk onset Short acting Beta2-agonist is first line but recommended combine of SABA and Anticholinergic for limited S/E (palpitation, tachycardia, tremor)  Fenoterol/Ipratropium bromide  Every 15-20 min in 1st hour then 4-6 hr interval  Addition SABA every 1-2 hr
  31. 31. Medication type Onset (min) duration Route drug (hour) Beta2agonist Short 3-5 4-6 Inhale Salbutamol(ventolin®) Oral Terbutaline IV Fenoterol 8-12 Inhale Procaterol Oral Long 30-45 > 12 Inhale Salmeterol FormoterolAnticholinergic Short 10-15 6-8 Inhale Ipratopium bromide Long 5 >24 Inhale Tiotropium (Spiriva®)Methylxanthine Uncertained in sustained release Oral Theophylline IV Aminophylline
  32. 32. Acute exacerbation : 1-3 wk onset Systemic corticosteroid  Limited systemic inflammation and airway inflammation  Decrease sputum eosinophil  Decrease serum CRP  Improve FEV1 and PaO2  Minimize treatment failure / Length of stay in Hospital/ Exacerbation  No improve of mortality  Prednisoline 30-40 mg/dy for 7-14 dy or  Dexamethasone 5- 10 mg q 6 hr or  Hydrocortisone 100-200 mg q 6 hr
  33. 33. Acute exacerbation : 1-3 wk onset Oxygen  All pt with SpO2 < 90% keep SpO2 90-94% Limited S/E of Oxygen supplement  hypoxic drive hypoventilation  ventilation / perfusion mismatch deadspace  Haldane effect  rightward displacement of the CO2-hemoglobin dissociation curve in the presence of increased oxygen saturation, increasing the amount of CO2 dissolved in blood
  34. 34. Acute exacerbation : 1-3 wk onset Machanical ventilation  Indication of NIPPV  accessory muscle with abd paradox  Acidosis pH 7.25-7.35 and/or PaCO2 > 45 mmHg  RR > 24 / min  C/I of NIPPV  Uncooperation    Cardiovascular instability  Life-threatening hypoxemia  Severe acidosis : pH < 7.25
  35. 35. Acute exacerbation : 1-3 wk onset Machanical ventilation  Indication of Invasive mechanical ventilation  Respiratory failure  Severe acidosis : pH < 7.25  RR > 35/min  Accessory muscle used  with  C/I for NIPPV  Fail NIPPV
  36. 36. treatment
  37. 37. Stable COPD : base on severity Bronchodilator  Beta2-agonist  Anticholinergic  Methylxantine Corticosteroid  inhaled corticosteroids Vaccination  Annual influenza vaccine  Pneumococcal vaccination Pulmonary rehabilitation  Improve quality of life Oxygen therapy  Short term  Long term sugery
  38. 38. Stable COPD : at ALL stage Avoidance of risk factor(s) Influenza vaccination Pneumococcal vaccination
  39. 39. Stable COPD : Mild COPD Short-acting bronchodilator when needed
  40. 40. Stable COPD : Moderate COPD Short-acting bronchodilator when needed Regular treatment with one or more long-acting bronchodilators Rehabilitation
  41. 41. Stable COPD : Severe COPD Short-acting bronchodilator when needed Regular treatment with one or more long-acting bronchodilators Rehabilitation Inhaled glucocorticoids if significant symptoms, lung function response, or if repeated exacerbations
  42. 42. Combination Dose(ug/dy) Trade nameFluticasone/Salmeterol 500/100-1000/100 Seretide®Budesonide / Formeterol 320/9-640/18 Symbicort®
  43. 43. Medication type Onset (min) duration Route drug (hour) Beta2agonist Short 3-5 4-6 Inhale Salbutamol(ventolin®) Oral Terbutaline IV Fenoterol 8-12 Inhale Procaterol Oral Long 30-45 > 12 Inhale Salmeterol FormoterolAnticholinergic Short 10-15 6-8 Inhale Ipratopium bromide Long 5 >24 Inhale Tiotropium (Spiriva®)Methylxanthine Uncertained in sustained release Oral Theophylline IV Aminophylline
  44. 44. Stable COPD : Very severe COPD Short-acting bronchodilator when needed Regular treatment with one or more long-acting bronchodilators Inhaled glucocorticoids if significant symptoms, lung function response, or if repeated exacerbations Treatment of complications : CHF, infection, nutrition Rehabilitation Long-term oxygen therapy if chronic respiratory failure Consider surgical treatment
  45. 45.  3  Short-term therapy  Long-term continuous therapy  During exercise PaO2 60 mmHg SaO2 90% O2
  46. 46.  Indication for STOT  Recent Exacerbation with new hypoxemia Re-evaluate at wk 4  Continue STOT if still hypoxemia Re-evaluate at Mo 3  Treat as LTOT
  47. 47.  Continue Oxygen supplement > 15 hr/dy  mortality  exercise tolerance  Quality of life: psychotherypy  Prevent pulmonary HT Ind for LTOT  PaO2 < 55 mmHg or SaO2 < 88%  PaO2 < 56-59 mmHg or SaO2 < 89% with sign of chronic hypoxemia  Pul HT  Peripheral edema CHF  Polycythemia (Hct > 55%)  Failed STOT
  48. 48. Oxygen therapy via nasal cannula Home supplemental oxygen
  49. 49. Bilevel positive airway pressure (BiPAP)
  50. 50.  Hemodynamic stable Bronchodilator supply less than every 4 hr SpO2 >90% w/o O2 supplement at least 24 hr

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