1. Chronic obstructive pulmonary disease (COPD) is a preventable and treatable lung disease characterized by airflow limitation caused by cigarette smoking. 2. COPD symptoms include cough, sputum production, and breathlessness. It is a major cause of death and disability worldwide and is expected to be the third leading cause of death by 2020. 3. COPD is diagnosed based on symptoms and spirometry showing airflow limitation that is not fully reversible. The two main phenotypes are chronic bronchitis and emphysema.

1. DR.Bilal Natiq Nuaman,MDDR.Bilal Natiq Nuaman,MD
C.A.B.M.,F.I.B.M.S.,D.I.M.C.A.B.M.,F.I.B.M.S.,D.I.M.
20182018
Chronic obstructiveChronic obstructive
pulmonary diseasepulmonary disease
11

2. DefinitionDefinition
Chronic obstructive pulmonary disease (COPD) isChronic obstructive pulmonary disease (COPD) is
a preventable and treatable disease statea 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..
22

3. 33

4. ➢Major cause of death and disabilityMajor cause of death and disability
➢44thth
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
mortalitymortality andand morbiditymorbidity
➢It is expected to be theIt is expected to be the thirdthird leading cause ofleading cause of
death by 2020death by 2020
COPDCOPD
GENERAL FACTSGENERAL FACTS
44

5. % Change in Age Adjusted Death Rate% Change in Age Adjusted Death Rate
55

6. 66

7. ➢ COPD should be suspected in any patientCOPD should be suspected in any patient
over the age of 35 years who presents withover the age of 35 years 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.
77

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 pathology.alert the physician to potentially more serious pathology.
(CA Lung)(CA Lung)
88

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 P2 due to(raised jugular venous pressure, loud P2 due 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.
99

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.
1010

11. 1111

12. 1212

13. 1313

14. COPD clinical phenotypesCOPD clinical phenotypes
Chronic Bronchitis
(Blue Bloaters)
EmPhysema
(Pink Puffers)
1414

15. 1515

16. Pink PuffersPink Puffers
➢Thin andThin and
dyspnic , anddyspnic , and
maintain PaCO2maintain PaCO2
until the lateuntil the late
stage ofstage of
disease.disease.
➢EMPHESEMAEMPHESEMA
1616

17. PPursed liursed lipp breathing occur inbreathing occur in
emempphysemahysema not in chronic bronchitisnot in chronic bronchitis
1717

18. EMPHYSEMAEMPHYSEMA
Pathological definitionPathological definition
permanent dilatation of air spacespermanent dilatation of air spaces
distal to terminal bronchioles,distal to terminal bronchioles,
accompanied by destruction ofaccompanied by destruction of
their wallstheir walls
1818

19. 1919

20. 1.1. CCENTRIACINAR (Centrilobular):ENTRIACINAR (Centrilobular):
CentralCentral part of the acinus (respiratory bronchioles)part of the acinus (respiratory bronchioles)
is affected, while distal alveoli is spared.is affected, while distal alveoli is spared. UpperUpper
lobeslobes, particularly apical segments are involved, particularly apical segments are involved
Cause:Cause: CCigarette smokingigarette smoking
2)2) PPANACINAR (Panlobular):ANACINAR (Panlobular):
EntireEntire aacinuscinus (from respiratory bronchiole to distal(from respiratory bronchiole to distal
alveoli affected) , Affectsalveoli affected) , Affects lower lobeslower lobes
Cause:Cause: αα-1 antitry-1 antitryPPsin deficiencysin deficiency
Types of emphysema
2020

21. Pathogenesis of EmphysemaPathogenesis of Emphysema
2121

22. Clinical FeaturesClinical Features
➢No cyanosisNo cyanosis (pink)(pink)
➢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
2222

23. BLUE BLOATERBLUE BLOATER
Develop andDevelop and
toleratetolerate
hypercapniahypercapnia
earlier and mayearlier and may
develop edemadevelop edema
and 2‘and 2‘
polycythemia.polycythemia.
CHRONICCHRONIC
BRONCHITICBRONCHITIC
2323

24. CHRONIC BRONCHITISCHRONIC BRONCHITIS
➢DefinedDefined clinicallyclinically
Persistent cough with sputumPersistent cough with sputum
production forproduction for at least 3 monthsat least 3 months inin
at leastat least 2 consecutive2 consecutive yearsyears, with, with
exclusion of other causes likeexclusion of other causes like
Bronchiectasis .Bronchiectasis .
2424

25. PATHOGENESISPATHOGENESIS
SMOKINGSMOKING
4-10 times more common in heavy smokers4-10 times more common in heavy smokers
✓ a smoking history of more than 20 pack yearsa smoking history of more than 20 pack 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
2525

26. Clinical FeaturesClinical Features
➢CyanosedCyanosed ((Blue)Blue)
➢EdematousEdematous ((Bloater)Bloater)
➢Productive CoughProductive Cough
➢CorPulmonale – heart failureCorPulmonale – heart failure
➢Usually dyspnea triggered by infectionUsually dyspnea triggered by infection
➢Respiratory acidosisRespiratory acidosis
Blue bloaterBlue bloater
2626

27. 2727

28. Diagnosis of COPD
SYMPTOMS
cough
sputum
dyspnea
RISK
FACTORS
tobacco
SPIROMETRYEXAMINATION

29. Criteria of DxCriteria of Dx
1-1-PFTPFT :: OBSTRUCTIVE LUNG PATTERNOBSTRUCTIVE LUNG PATTERN
➢FEV1FEV1 ↓↓ <80 %<80 %
➢FVCFVC low-normal 70-80%low-normal 70-80%
➢FEV1/ FVCFEV1/ FVC ↓ <70%↓ <70%
2929

30. 2-Negative reversibility test2-Negative reversibility test (Post-(Post-
bronchodilator FEV1 <15%bronchodilator FEV1 <15% (200ML)(200ML)
increase following administration ofincrease following administration of
bronchodilator or trial ofbronchodilator or trial of
corticosteroids) .corticosteroids) .
3030

31. DLCO: Transfer FactorDLCO: Transfer Factor
• AsthmaAsthma highhigh
• Chronic bronchitisChronic bronchitis normalnormal
• EmphysemaEmphysema lowlow
3131

32. Other testsOther tests
➢ Hemoglobin level and packed cell volume (PCV)Hemoglobin level and packed cell volume (PCV) cancan
be elevated as a result of persistent hypoxemiabe elevated as a result of persistent hypoxemia
causing secondary polycythemia.causing secondary 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 (emphysema).of 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 problems).history of chest problems). 3232

33. 3333

34. Disease Progression of a Patients withDisease Progression of a Patients with
COPDCOPD
Symptoms
Exacerbations
Exacerbations
Exacerbations
Deterioration
End of Life
3434

35. 3535

36. Management ofManagement of
COPDCOPD
3636

37. 3737

38. 3838

39. Smoking cessationSmoking cessation
➢The onlyThe only
interventionintervention
proven toproven to
decelerate thedecelerate the
decline indecline in
FEV1.FEV1. 3939

40. PharmacotherapyPharmacotherapy
BRONCHODILATORSBRONCHODILATORS
➢Decrease airway muscle toneDecrease airway muscle tone
➢Three types (short & long acting):Three types (short & long acting):
●
Anticholinergics (inhaled)Anticholinergics (inhaled)
●
Beta-2 agonists (inhaled)Beta-2 agonists (inhaled)
●
Methylxanthines (po)Methylxanthines (po)
4040

41. BronchodilatorsBronchodilators
Short Acting BetaShort Acting Beta22 Agonist (SABA)Agonist (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
4141

42. BronchodilatorsBronchodilators
Long Acting BetaLong Acting Beta22 Agonist (LABA)Agonist (LABA)
➢e.g.– Formoterol, Salmeterole.g.– Formoterol, Salmeterol
➢For patients who still have symptomsFor patients who still have symptoms
on SABA’s (MODERATE disease)on SABA’s (MODERATE disease)
➢More sustained effect on PFT’s, chronicMore sustained effect on PFT’s, chronic
SOBSOB
➢Early evidence these may prolong timeEarly evidence these may prolong time
between exacerbationsbetween exacerbations
4242

43. 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
4343

44. 4444

45. 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( FEV1 <50%) whosevere disease( FEV1 <50%) who
report two or more exacerbations requiringreport two or more exacerbations requiring
antibiotics or oral steroids per yearantibiotics or oral steroids per year .. 4545

46. 4646

47. 4747

48. 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.
➢ a1-Antitrypsin replacement. Weekly or monthlya1-Antitrypsin replacement. Weekly or monthly
Infusions of a1-antitrypsin have been recommended forInfusions of a1-antitrypsin have been recommended for
patients with serum levels below 310mg/L andpatients with serum levels below 310mg/L and
abnormal lung function. 1abnormal lung function. 1
➢ 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 >55%.PCV is >55%.
4848

49. 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
4949

50. 5050
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).

51. 5151
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.

52. 5252
Bronchodilator therapy
is usually given by nebulizer, using a
combination of salbutamol 2.5 – 5.0 mg and
ipratropium 500 mcg

53. ORAL STEROIDSORAL STEROIDS
ORAL STEROIDS are useful during exacerbationsORAL STEROIDS are useful during exacerbations
(rule of 15)(rule of 15)
PREDINSOLONPREDINSOLON 1515 mgmg TWICE DAILY GIVENTWICE DAILY GIVEN FORFOR 1515
DAYSDAYS MAY BENEFITMAY BENEFIT 1515%% OF PATIENTS WITHOF PATIENTS WITH
COPD EXACERBATIONCOPD EXACERBATION
5353

54. 5454
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.

55. 5555
Emergency oxygen
pre-hospital care or 24% Venturi mask in hospital settings), with an i

56. 5656
Ventilatory support
if the pH is below the normal range (<7.35) then
noninvasive ventilation (NIV) should be employed

57. 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
5757

58. PATHOLOGYPATHOLOGY
Neutrophil proteasesNeutrophil proteases
(acute infection in a normal or compromised host)(acute infection in a normal or compromised host)
⇩⇩
Epithelial injuryEpithelial injury
++
Structural protein damageStructural protein damage
⇩⇩
Damaged, dilated airwayDamaged, dilated airway
⇩⇩
Mucous retention / chronic, recurrent infectionMucous retention / chronic, recurrent infection
⇩⇩
Ongoing inflammation / tissue damage / repairOngoing inflammation / tissue damage / repair
5858

59. 5959

60. 6060

61. 6161

62. Physical signsPhysical signs
➢ 1-normal chest exam1-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 .
➢ 2-coarse crackles2-coarse crackles if there is secretions .if there is secretions .
➢ 3- deviated trachea toward side of lesion ,3- deviated trachea toward side of lesion ,
dullness ,↓breath sounddullness ,↓breath sound if there is collapse .if there is collapse .
➢ 4- bronchial breathing4- bronchial breathing : advanced scarring .: advanced scarring .
6262

63. INVESTIGATIONSINVESTIGATIONS
1-Sputum culture1-Sputum culture
For pseudomonas aeruginosa , fungi , andFor pseudomonas aeruginosa , fungi , and
mycobacteria .mycobacteria .
2- Radiology2- Radiology
CXR : early stage normalCXR : early stage normal
Advanced thickened airway walls , cysticAdvanced thickened airway walls , cystic
spaces , pneumonic consolidation or collapse .spaces , pneumonic consolidation or collapse .
SPIRAL CT SCAN of chest is much more sensitiveSPIRAL CT SCAN of chest is much more sensitive
..
3-Assessment of ciliary function3-Assessment of ciliary function
6363

64. managementmanagement
➢ 1-airway obstruction1-airway obstruction :: inhaled bronchodilators andinhaled bronchodilators and
corticosteroids .corticosteroids .
➢ 2-2- 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.
6464

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 but 5-10 minutes once or twice dailysputum but 5-10 minutes once or twice daily
is a minimum for most patients.is a minimum for most patients.
6565

66. 6666

67. 3- antibiotics3- antibiotics
Oral ciprofloxacin 500-750 mg bidOral ciprofloxacin 500-750 mg bid
Or ceftazidime by IV inj. Or infusion 1-2 gm 8-Or ceftazidime by IV inj. Or infusion 1-2 gm 8-
hourly.hourly.
4- surgery4- surgery
Only in unilateral , single lobe in young patientOnly in unilateral , single lobe in young patient
6767

68. THANK YOUTHANK YOU
6868