This document provides information on chronic obstructive pulmonary disease (COPD) including its definition, pathophysiology, diagnosis, and pre-operative optimization. It defines COPD as a common lung disease characterized by persistent airflow limitation associated with an enhanced inflammatory response in the airways. The document discusses the types and features of COPD including chronic bronchitis and emphysema. It covers the risk factors, pathogenesis, pathology, and pathophysiology of COPD. Details are provided on pre-operative patient assessment including history, physical exam, investigations like chest x-ray, spirometry, ABG and optimization measures such as smoking cessation and bronchodilation therapy.

1. Dr PRASHANTH
Dr GANESH
Dr KARAN
Dr KIRAN

2.  DEFINITION
 PATHOPHYSIOLOGY
 DIAGNOSIS
 PRE OPERATIVE OPTIMISATION

3. www.goldcopd.com, Updated 2006
INTRODUCTION
 “A common preventable and treatable disease
characterised 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’’
 3rd Leading cause of morbidity & mortality

4. COPD INCLUDES..
 CHRONIC BRONCHITIS: (clinical definition)
Chronic productive cough for 3 months in each of 2
successive years
 EMPHYSEMA: (anatomical definition)
Permanent enlargement of the airspaces distal to the terminal
bronchioles
 SMALL AIRWAY DISEASE:
Narrowing of small bronchioles due to hyperplasia, mucus
and fibrosis

5. Comparative features of COPD
Feature Chronic Bronchitis Emphysema
Mech of Airway Obstruction Decreased Lumen d/t
mucus & inflammation
Loss of elastic recoil
Dyspnoea Moderate Severe
FEV1 Decreased Decreased
PaO2 Marked Decrease (Blue
Bloater)
Moderate Decrease (Pink
Puffer)
PaCO2 Increased Normal or Decreased
Diffusing capacity Normal Decreased
Hematocrit Increased Normal
Cor Pulmonale Marked Mild
Prognosis Poor Good

6. Differences Between COPD and Asthma
Parameters COPD Asthma
Onset Middle age Early in life (often
childhood)
Symptoms Slowly progressive Diurnal and seasonal
variation
History Long smoking history or
exposure to smoking and
bio-mass fuel
History of allergy,
rhinitis and/or eczema.
Inflammatory cells Neutrophils Eosinophils
Airway
hyperresponsivene
ss
++ ++++
Airflow limitation Largely irreversible
usually < 15% or 200 ml
change
Largely reversible
usually > 15% or 200 ml
change. (irreversible in
later stages)

7. Risk factors
 SMOKE:
CIGARETTE smoking
passive smoking
environmental
occupational
 Genetic factors: α1 anti trypsin deficiency

8. PATHOGENESIS

9. PATOGENESIS contd..
 Elastase & antielastase hypothesis
Imbalance between elastin and elastase
Deficiency of α 1 antitrypsin which is elastase
inhibitor
 Autoimmune contribution
 Cigarette smoke induced loss of cilia & impaired
macrophage phagocytosis

10. PATOGENESIS contd..

11. PATHOLOGY contd..
Types of emphysema

12. PATHOPHYSILOGY :PULMONARY
PULMONARY
AIRWAY OBSTUCTION HYPERRESPONSIVENESS
ALVEOLAR
DESTRUCTIONSECRETIONS
HYPERINFATION

13. PATHOPHYSIOLOGY contd..:EXTRA PULMONARY
IL6,TNF a, CRP, OXIDANTS,
HYPOXEMIA
RT HEART
DISEASE,IHD
SKELETAL MUSCLE
WEAKNESS
OSTEOPOROSISDM, DEPRESSION

14. PATHOPHYSIOLOGY contd..:EXTRA PULMONARY

16. Pre-operative assessment:
History:
 Smoking
 Cough: Type, Progression, Recent RTI
 Sputum: Quantity, color, blood
 Dyspnea
 Exercise intolerance
 Occupation, Allergies
 Symptoms of cardiac or respiratory failure

17. Physical findings
 Early stage: signs of smoking
 Advanced stage:
 prolonged expiratory phase with wheeze
 Signs of hyperinflation: barrel chest
 Use of accessory muscles
 Tripod position
 Cyanosis
 Cachexia, bitemporal wasting & diffuse loss of subcutaneous
adipose tissue
 Clubbing : ?? carcinoma

18. PHYSICAL FINDINGS contd..
 Pink puffers
emphysema
Thin patients
Non cyanotic at rest
Use of accessory muscles
Good prognosis
 Blue bloaters
Chronic bronchitis
Heavy patients
Cyanotic at rest
Bad prognosis

19. Investigations:
Routine blood investigations
Chest Radiograph: To exclude other
diseases
•Emphysematous changes
Spirometry
•Diagnosis
•Assessment of severity
•Following progress
Bronchodilator Reversibility
•Exclude Bronchial Asthma
•<20%
Diagnosis

20. Investigations: Chest X-Ray
 Overinflation
 Depression or flattening of
diaphragm
 Increase in length of lung
 ↑ size of retrosternal airspace
 ↑ lung markings- dirty lung
 Bullae +/-
 Vertical Cardiac silhouette
 ↑ transverse diameter of chest,
ribs horizontal, square chest
 Enlarged pulmonary artery with
rapid tapering in MZ
Diagnosis contd

21. Indications for PFT
(American College of Physicians consensus statement)
 Cardiac, thoracic or upper abdominal surgery with
a history of dyspnea, smoking
 Lower abdominal surgery with a history of
dyspnea, smoking and anticipated prolonged
surgery
 All patients undergoing lung resection
 Morbid obesity
 Any pulmonary disease
 Age > 70 years

22. Bed side PFT
 Sabrasez breath holding test:
 >25 sec- normal cardio pulmonary reserve (CPR)
 15-25 sec- limited CPR
 <15 sec-very poor CPR (contra indication for elective
surgery)
25-30 sec -3500ml VC
20-25 sec -3000ml VC
15-20 sec -2500 ml VC
10-15 sec-2000 ml VC
5-10 sec- 1500 ml VC

23. Bed side PFT contd..
 Schneider’s match blowing test: measures maximum
breathing capacity
Ask to blow a match stick from a distance of 15 cm
 Mouth wide open
 Chin rested/supported
 No pursing of lips
 No head movement
 No air movement in the room
 Mouth and match at same level

24. Bed side PFT contd..
 Can not blow the match
-MBC<60L/min
-FEV1<1.6L
 Able to blow out a match
-MBC>60 L/min
-FEV>1.6L
 Modified match test
Distance MBC
9’’ >150L/min
6’’ >60 L/min
3’’ >40L/min
Match blowing test

25. Bed side PFT contd..
 Cough test: deep breath followed by cough
Ability to cough
Strength
Effectiveness
Inadequate cough : FVC <20 ml/kg
FEV1<15ml/kg
PEFR<200L/min
A wet productive cough /self propagated paraxysms of
coughing –patient susceptible for pulmonary
complication

26. Bed side PFT contd..
 Forced expiratory time:
A deep breath, exhale maximally and forcefully & keep
stethoscope over trachea &listen
normal:3-5 sec
obstr. Lung disease: >6sec
restr. Lung disease : <3 sec

27. Bed side PFT contd..
 Wright peak flow meter : measures peak expiratory flow
rate
Normal: Males 450-700L/min
Females 350-500L/min
 DE-BONO whistle blowing test: measure PEFR
Patient blows down a wide bore tube at the end of
which is a whistle ,on the side is hole with adjustable knob.
As patient blows whistle blows, leak hole is gradually
increased till intensity of whistle disappears
Last position at which the whistle can be blown, the PEFR
can be read off the scale

28. Bed side PFT contd..
 MIROSPIROMETERS: measures vital capacity
 BED SIDE PULSE OXYMETRY
 ABG

29. Pulmonary Function Tests: spirometry
Measure Normal Obstructive Restrictive
FVC (L) 80% of TLC
(4800)
  
FEV1 (L) 80% of FVC  
FEV1/FVC(%) 75- 85% N to  N to 
FEV25%-
75%(L/sec)
4-5 L/ sec  N to 
PEF(L/sec) 450- 700 L/min  N to 
Slope of FV
curve
 
MVV(L/min) 160-180 L/min  N to 
TLC 6000 ml N to  
RV 1500 mL  
RV/TLC(%) 0.25  N

30. FEV1
FEV1
FVC
seconds
21 3 4 5
0
1
2
3
4
Litres
5
COPD
NORMAL
60%39002350COPD
80%52004150Normal
FEV1/FVCFVCFEV1
FVC
Spirometric tracing in COPD patients
Spirometry contd

31. FLOW VOLUME LOOP
Spirometry contd

32. GOLD Classification (severity of disease)
Stage Characteristics
I: Mild FEV1/FVC < 70%
FEV1 ≤ 80% predicted, with/without chronic symptoms
II: Moderate FEV1/FVC < 70%
50% ≤ FEV1 ≤ 80% predicted, with/without chronic
symptoms
III: Severe FEV1/FVC < 70%
30% ≤ FEV1 ≤ 50% predicted, with/without chronic
symptoms
IV: Very
severe
FEV1/FVC < 70%
FEV1 < 30% predicted or < 50% predicted plus chronic
respiratory failure (PaO2 < 60mm Hg &/or PaCO2 > 50mm
Hg)

33. Preoperative Assessment: Investigations contd.
ECG
 May be normal
 Signs of RVH:
 RAD
 p Pulmonale in Lead II,III,avF
 Predominant R wave in V1-3
 Supraventricular arrhythmias common in exacerbations

34. Preoperative Assessment: Investigations
contd.
 ABG
Not done routinely
Indicated
 Severe pulmonary disease : FEV1/FVC <50%
Good predictor of post op pulmonary complication
PaCO2>50mm Hg  need for post op mechanical
ventilation

35.  Exercise testing:
-expensive, cumbersome
-Not validated in nonthoracic surgery
-Parameter with greatest utility is decreased
maximum O2 consumption

36. Pre-operative optimization
 Cessation of smoking
 Dilation of airways
 Loosening & Removal of secretions
 Eradication of infection
 Recognition of Cor Pulmonale and treatment
 Improve strength of skeletal muscles – nutrition,
exercise
 Correct electrolyte imbalance
 Familiarization with respiratory therapy, education,
motivation & facilitation of patient care

37. Pre operative optimization : Smoking
Cessation
 Motivation, Counseling
& behavioral support
 Nicotine replacement
 Patches
 chewing gum
 Inhaler
 nasal spray
 lozenges
 Bupriopion

38. Smoking cessation and time course of beneficial Effects
Time after smoking Physiological Effects
12-24 Hrs Fall in CO & Nicotine levels
48-72 Hrs COHb levels normalise
Airway function improves
1-2 Weeks Decreased sputum production
4-6 Weeks PFTs improve
6-8 Weeks Normalisation of Immune function
8-12 Weeks Decreased overall post operative morbidity

39. Effect of smoking and smoking
cessation on Lung Function:
Loss of lung function over 11 yrs in the Lung Health Study for continuous smokers
(–––), intermittent quitters (–––) and sustained quitters (–––). FEV1: forced expiratory
volume in one second.
Smoking and lung function of Lung Health Study participants after 11 years. Am J
Respir Crit
Care Med 2002; 166: 675–679.

40. Pre operative optimization: Dilatation of
Airways:
 Bronchodilators:
 Only small increase in FEV1
 Alleviate symptoms by decreasing hyperinflation & dyspnoea
 Improve exercise tolerance
Anticholinergics
Beta Agonists
Methylxanthines

41. Pre operative optimization:Anticholinergics:
 Block muscarinic receptors
 Onset of action within 30 Min
 Ipratropium –
 40-80 μg by inhalation
 20 μg/ puff – 2 puffs X 3-4 times
 250 μg / ml respirator soln. 0.4- 2 ml X 4 times daily
 Tiotropium - long lasting
 Side Effects:
 Dry Mouth, metallic taste
 Caution in Prostatism& Glaucoma

42. Pre operative optimisation:Beta agonists:
 Act by increasing cAMP
 Specific β2 agonist –
 Salbutamol :
 oral 2-4 mg/ 0.25 – 0.5 mg i.m /s.c ,100-200 μg inhalation
 muscle tremors, palpitations, throat irritation
 Terbutaline :
 oral 5 mg/ 0.25 mg s.c./ 250 μg inhalation
 Salmeterol :
 Long acting (12 hrs)
 50 μg BD- 200 μg BD
 Formeterol, Bambuterol

43. Pre operative optimisation:Methylxathines:
 Mode of Action
– inhibition of phospodiesterase,↑ cAMP, cGMP –
Bronchodilatation
 Adenosine receptor antagonism
 ↑ Ca release from SR
 Oral(Theophyllin) & Intravenous (Aminophylline,
Theophyllin)
 loading – 5-6 mg/kg
 Previous use – 3 mg/kg
 Maintenace –
 1.0mg/kg h for smokers
 0.5mg/kg/h for nonsmokers
 0.3 mg/kg/h for severely ill patients.

44. Pre operative optimisation: Inhaled
Corticosteroids:
 Anti-inflammatory
 Restore responsiveness to β2 agonist
 Reduce severity and frequency of exacerbations
 Do not alter rate of decline of FEV1
 Beclomethasone, Budesonide, Fluticasone
 Dose: 200 μg BD ↑ upto 400 μg QID

45.  Loosen secretions
-Hydration: systemic, jet/USG nebulizer
-Mucolytics (acetylcysteine) not of much use
 Remove secretions
-Postural drainage
-Purcussion(chest physiotherapy)
-Coughing
-Breathing exercises
Pre operative optimisation contd..

46.  History of smoking (current or >40 pack-years)
 ASA-PS > 2
 Age >70 years
 Neck, thoracic, upper abdominal, aortic, or neurologic surgery
 Anticipated prolonged procedures (>2 hours)
 General anesthesia (especially with endotracheal intubation
 Albumin less than 3 g/dL
 Exercise capacity of less than two blocks or one flight of stairs
 BMI greater than 30
Arozullah AM, Ann Surg 232:242-253,2000.
Risk factors for post op pulmonary complications

47. To be contd.....
Thank you