Chronic obstructive pulmonary disease (COPD) is characterized by partially reversible airflow limitation and minimal airway hyperresponsiveness. It is strongly linked to chronic tobacco smoke exposure and causes progressive shortness of breath. Patients admitted for COPD exacerbations receive antibiotics, steroids, inhaled bronchodilators and oxygen. If intubated, ventilator settings must carefully avoid hyperinflation. At discharge, patients are prescribed a prednisone taper, inhaled bronchodilators and follow-up to support smoking cessation which is the primary treatment.

1. Chronic Obstructive
Pulmonary Disease
Josh Solomon, MD

2. COPD
• Definition
• Epidemiology
• Clinical Disease and Diagnosis
• Exacerbations
– Definition
– Treatment
• Ventilation
• Outpatient Treatment

3. Definition
• A clinical syndrome characterized by:
– Partially reversible airflow limitation
– Slow clinical progression
– Minimal airway hyperresponsiveness vs.
asthma
• Strongly linked to chronic exposure to
tobacco smoke
• An inflammatory airway disease

4. Epidemiology
• Fourth leading cause of death in the
United States
• Seen in 10% of adults over the age of
40 globally
– Higher in smokers
– Higher in men

5. Clinical Disease
• Slow onset of progressive shortness
of breath
• Inability to tolerate physical activity
• Increasing frequency of
exacerbations
• Cough and sputum production

6. Diagnosis
Airflow obstruction

8. TIME
1 2 3 4 5 6
V
O
L
U
M
E
FVC
FEV1
FEV1 FEV1/FVC >70%

9. Spirometric Criteria for COPD
• Forced expiratory volume in one
second (FEV1) < 80% predicted
• FEV1/FVC ratio < 70%
• Airflow does not improve ≥ 12% and
200mL with albuterol
Pauwels RA, et al. AJRCCM 2001; 163.
Fabbri LM and Hurd SS. Eur Respir J 2003; 22.

10. 0
20
40
60
80
100
20 30 40 50 60 70 80 90
FEV1
(%)
Age (years)
Death
Disability
Symptoms
Fletcher C, Peto R. Br Med J. 1977; 1.
Natural History: FEV1 Decline
Never-smoker
Smoker

11. COPD - Pathology
• Irreversible changes:
– Airway fibrosis and narrowing
– Loss of airways elastic recoil
– Alveoli destruction
• Reversible changes:
– Smooth muscle contraction/hypertrophy
– Airway accumulation of cells, mucus

14. COPD
Toxic Inhaled Agent
(tobacco smoke, air pollution, occupational)
Occupation
Respiratory infection
Airway responsiveness
Socioeconomics
COPD
Susceptibility
Genetics

15. Patient X
• 65 years old
• Smoke 1 pack/day for 30 years
• Complains of morning cough
with a lot of sputum and
worsening shortness of breath
over last 5 years

16. Chest X-ray

17. Chest X-ray

18. Chest CT

19. Spirometry
• FEV1 45%
• FEV1/FVC 50%
V
O
L
U
M
E
TIME
PATIENT X

20. Exacerbation

21. Definition
• Abrupt increase in symptoms
• Shortness of breath
• Amount of sputum
• Color of sputum
• Requires change in medication
• Increase in frequency as disease
gets more severe

22. Exacerbation
•infection account for 80% of
exacerbations
•Strep Pneumonia, Hemophilus influenza,
Moraxella catarrhalis most common
•Other causes include pulmonary
embolism, heart failure, pneumothorax
Sethi et al. CHEST 2001; 115.

23. Workup
• History/physical exam
• Chest Xray - 20% abnormal
• Arterial Blood Gas
– Degree of hypoxemia (O2) and hypercarbia
(CO2)

24. Treatment
•Oxygen
•keep SaO2 > 90% but avoid high SaO2
(>97%)
•B agonists(albuterol/terbutaline/salbuterol)
•Nebulized or MDI have same delivery
•inhaled better than intravenous (FEV1)
Mcrory et at. CHEST 2001; 119.
•anticholinergics (ipratropium)
•use with beta agonists in inhaled form

25. Treatment
•Methylxanthines (aminophylline)
•No good data that they work in COPD
•Minimal if any improvement in FEV1
•Only use if no access to B- agonists or
anticholinergics
Barr et al. Cochrane Review 2001

26. Treatment
•Antibiotics
•All ICU and ventilated patients
Saint et al. JAMA 1995, 273.
•Inpatient – mild
•macrolide, fluoroquinolone, 3rd generation
cephalosporin, antipseudomonal penicillin
•Inpatient – sick (ICU)
•3rd generation ceph/antipseudomonal PCN
+ fluoroquinolone or aminoglycoside

27. Treatment
•Steroids
•studies show shorter hospital stay and faster
improvement in FEV1
Niewoehner et al. NEJM 1999, 340.
•Severe disease
•methylprednisolone 0.5 to 1 mg/kg every 6
hrs for 3 days, then prednisone 40 mg for 2
weeks
•slow taper in severe disease

28. COPD and respiratory failure
•Non-invasive ventilation
•studied in COPD – prevents intubation and
improves outcome in respiratory failure
Brochard et al. NEJM 1995, 333.
•Contraindications : altered mental status,
increased secretions, CV instability

29. COPD and respiratory failure
•Ventilation Goals
•rest muscles of breathing
•allow time for exhalation
•prevent hyperinflation

30. COPD and respiratory failure
•Ventilation
•Volume Control
•Vt – 8 – 10 cc/kg body weight
•RR – use to target normal or patients CO2
•PEEP 5 mm H2O
•I:E 1:3 to 1:5 (**important long expiratory
time)
•#1 risk is HYPERINFLATION

31. Hyperinflation
• Increased volume of lung at end -
expiration
• Causes - expiratory airflow obstruction +
inadequate expiratory time
• Signs - hypotension, high airway
pressures, hypoxemia, pneumothorax

32. Hyperinflation
• Measure - breath hold at end expiration
(iPEEP, autoPEEP)

33. Hyperinflation Treatment
• Increase expiratory time
– Decrease respiratory rate
– Decrease tidal volume
– Increased flow rate/change I:E ratio
– Tolerate higher CO2 levels
• Decrease airflow obstruction
– Aggressive use of bronchodilators
– Sedation/paralysis if necessary

34. COPD and respiratory failure
•Ventilation
•Extubate as soon as patient tolerates a 30
minute wean
•Target patients baseline CO2
•Can extubate early to noninvasive
Ferrer et al. AJRCCM 2006; 173.

35. Discharge
•Smoking cessation #1
•inhaled albuterol/salbuterol + ipratropium
•slow prednisone taper(2 weeks
minimum)
•oxygen if SaO2 <88% on room air
(improves survival)
NOTT. Ann Int Med 1980; 93(3).

36. Summary
•patients admitted for COPD get antibiotics,
steroids, inhaled albuterol/ipratropium and O2
•if intubated, careful to avoid hyperinflation by
altering RR, I:E time
•at discharge, all go home with prednisone taper,
inhaled albuterol/ipratropium and follow-up

37. References
• www.goldcopd.com
• www.copd-international.com
• Evidence Based Review of COPD management
Soto et al. Curr Opin Pulm Med 2003, 9: 117-124.