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COPD

Michele Ritter, M.D.


Argy Teaching Resident, Feb. 2007
Definition

A disease state characterized by the


presence of airflow obstruction due to
chronic bronchitis or emphysema; the
airflow obstruction is generally
progressive, may be accompanied by
airflow hyperactivity, and may be viewed
as partially reversible.
Includes emphysema and chronic
bronchitis
Prevalence

COPD occurs in 4-6% of white males,


and 1-3% of adult white females
The 4th most common cause of death in
the United States
14.2 million people in U.S. have COPD
Highest mortality rate is in white men,
and the lowest is in hispanic women.
Types of COPD
Emphysema
Permanent and destructive enlargement of airspaces
distal to the terminal bronchioles without obvious fibrosis
and with loss of normal architecture
Always involves clinically significant airflow limitation.
pink puffer
Chronic Bronchitis
Presence of a cough productive of sputum not attributable
to other causes on most days for at least 3 months over 2
consecutive years
May be present in the absence of airflow limitation.
blue bloater
COPD
Pathogenesis of COPD

Increased number of activated


polymorphonuclear cells and macrophages
produce elastases (such as human leukocyte
elastase), resulting in lung destruction.
Increased oxidative stress caused by free
radicals in cigarette smoke, the oxidants
released by phagocytes, and
polymorphonuclear leukocytes all may lead to
apoptosis or necrosis of exposed cells
Pathogenesis of COPD (cont.)
Emphysema Chronic Bronchitis
3 morphologic patterns: Mucus gland enlargement
Centricacinar: Airway atrophy, focal
focal destruction limited to the
respiratory bronchioles and the
squamous metaplasia, ciliary
central portions of acinus abnormalities, variable
associated with cigarette amounts of airway smooth
smoking muscle hyperplasia,
most severe in the upper lobes inflammation, and bronchial
Panacinar: wall thickening
involves the entire alveolus
distal to the terminal bronchiole Respiratory bronchioles
develops in patients with display a mononuclear
homozygous alpha1-antitrypsin inflammatory process, lumen
(AAT) deficiency
most severe in the lower lung occlusion by mucous plugging,
zones goblet cell metaplasia, smooth
Distal acinar: muscle hyperplasia, and
Also called paraseptal distortion due to fibrosis
least common form
involves distal airway
Airway walls to deform and
structures, alveolar ducts, and narrow the airway lumen
sacs
localized to fibrous septa or to
the pleura and leads to
formation of bullae (can result
in pneumothorax)
Risk Factors
SMOKING!
48 million smokers in the U.S.
3000 new people take up smoking daily
Nearly all patients with symptomatic
COPD are current or former smokers
10-20% of smokers will develop
symptomatic COPD.
In men who smoke one pack/day, the
drop in FEV1 per year was 9 mL more
than in non-smokers
Occupational Exposures
Dusts, gases, fumes
Alpha1-antitrypsin deficiency
Alpha1-antitrypsin is an important
protease inhibitor that usually presents
elastases from causing lung
destruction
Symptoms

Dyspnea
Cough (usually worse in morning,
sputum production)
Wheezing
Cyanosis
Right heart failure
Weight loss, anorexia
Physical Exam

RR, HR, O2 saturation


Gen: Barrel-chest, accessory muscle
use
CV: Quiet heart sounds
Resp: Decreased breath sounds,
wheezing, rhonchi, crackles
Labs

CBC: Hgb/Hct
ABG: pH, pCO2
Chemistry: HCO3
Emphysema
Diagnosis of COPD

Look for secondary polycythemia:


Hct >52% in males, Hct>47% in females

Measure alpha1-antitrypsin levels in all


patients 40 years or younger, or in those
with family history.
Hyperinflation see on chest x-ray
Bullae seen on Chest x-ray or CT scan
Pulmonary Function Tests
Diagnosis of COPD Pulmonary
Function Tests
Forced Expiratory Volume for 1 second
(FEV1)
FEV1/FVC (Forced Vital Capacity) ratio
Total Lung Capacity (TLC)
Forced Residual Capacity (FRC)
Residual Volume (RV)
Vital Capacity (VC)
Pulmonary Function Tests
COPD Exacerbation
Typically manifest as increased sputum production, more purulent
sputum and worsening of dyspnea.
Although infectious etiologies account for most exacerbations, exposure
to allergens, pollutants or inhaled irritants may also play a role.
Bacterial infection is a factor in 70 to 75 percent of exacerbations, with
up to 60 percent caused by
Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis
Antibiotic therapy has a small but important effect on clinical recovery and
outcome.
Respiratory fluoroquinolone (Levofloxacin, Moxifloxacin)
Ceftriaxone + azithromycin
Short courses of systemic corticosteroids may provide important benefits
in patients with exacerbations of COPD.
Oxygen therapy to keep saturation Between 90-93%
Non-invasive ventilation such as BiPAP can be helpful in avoiding
intubation/mechanical ventilation.
Treatment of COPD
SMOKING CESSATION!
Short-acting bronchodilators
albuterol
Long-acting bronchodilator
salmeterol
Combination of anti-cholinergic and -agonist bronchodilator
Ipratropium + albuterol (combivent)
Tiotropium (spiriva)
Methylxanthines (Theophylline)
Has anti-inflammatory affect, and improves respiratory muscle function, stimulates
the respiratory center, and promotes bronchodilation
Adverse effects include anxiety, tremors, insomnia, nausea, cardiac arrhythmia, and
seizures
Inhaled corticosteroids
Fluticasone (Flovent), budesonide (Pulmicort)
Combination of Inhaled corticosteroid and long-acting -agonist
Fluticasone + salmeterol (Advair)
Oral Corticosteroids
Treatment of COPD (cont.)
Oxygen Therapy
Continous oxygen has been shown to cut mortality in half or
decrease morbidity when compared with non-continous
oxygen
Continuous (24 hours/day)
Resting Pa02 of 55 mm HG, or Resting oxygen saturation < 88%
Resting Pa02 of 56-59 mmHg or Oxygen Sat. <89% in presence of
dependent edema (suggestive of CHF), P pulmonale on ECG (P
wave more than 3 mm in inferior leads) or cor pulmonale, or
erythrocytosis (Hct > 56)
Noncontinuous
During exercise when PaO2 is < 55 mmHg or Oxygen sat. < 88%
with low level of exercise.
During sleep if Pa02 is < 55 mmHg or Sa02 less than 88% with
associated complications such as pulmonary hypertension, daytime
somnolence, cardiac arrythmias.
Treatment of COPD (cont.)

Pulmonary Rehabilitation
Aimed at keeping patient conditioned with exercise,
perception of dyspnea, quality of life and self-efficacy.
Surgery
Bullectomy
Resection of large bullae compressing normal lung
Lung volume reduction surgery
Pneumonectomy of nonuniform emphysematous lung
Double lung transplantation
Can be life-saving, but is costly, can be lack of donor
availability and requires lifelong immunosuppression.
Treatment of COPD
Stages of COPD
Stage FEV1/FV FEV1 Clinical Findings
C Ratio %
At Risk >0.7 Patients who smoke, patients exposed to
high pollutants, and patients with recurrent
respiratory symptoms/infections. Give
influenza and pneumonia vaccines.
Mild < 0.7 >80 Add short-acting bronchodilator as needed

Moderate <0.7 50-80 Add regular treatment with one or more


long-acting bronchodilator and add
Pulmonary rehabilitation
Severe <0.7 30-50 Add inhaled corticosteroids if repeated
exacerbations
Very < 0.7 <30 Add long-term oxygen if chronic respiratory
Severe failure; Consider surgical treatments
Take Home Points

Smoking is the number one cause of


COPD!
If smoking is stopped once COPD
diagnosed, the progression of disease
can slow down.
Treat COPD exacerbations with
antibiotics and possibly with steroids.
Continuous oxygen is shown to decrease
morbidity and mortality in COPD

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