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COPD

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Title: COPD


1
COPD
2
Chronic Obstructive pulmonary Disease
  • Two distinct processes are involved, most often
    in combination.
  • Chronic Bronchitis dx on history
  • Emphysema dx previously on histology, nowadays
    clinically (good clinical-pathologic-radiologic
    correlation)

3
Def Chronic Bronchitis
  • Excessive tracheobronchial mucus production
    sufficient to cause cough with expectoration for
    most days of at least 3 months of the year for 2
    consecutive years.
  • Classification
  • Simple chronic bronchitis
  • Chronic mucopurulent bronchitis
  • Chronic bronchitis with obstruction
  • Chronic bronchitis with obstruction and airway
    hyperreactivity.

4
Def Emphysema
  • Permanent abnormal distention of air spaces
    distal to the terminal bronchiole with
    destruction of alveolar septa (containing
    alveolar capillaries) and attachments to the
    bronchial walls.
  • Classification
  • Centriacinar ( centrilobular) emphysema
  • Panacinar emphysema
  • Paraseptal emphysema
  • Senile emphysema

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Def COPD
  • Chronic obstruction to airflow due to chronic
    bronchitis and/or emphysema.
  • Degree of obstruction may be less when the
    patient is free from respiratory infection and
    may improve with bronchodilator drugs
  • Significant obstruction is always present

7
Epidemiology of COPD
  • 30 of smokers develop COPD
  • 20 of adult males have COPD
  • 15 of COPD patients are severely symptomatic
  • 4 th leading cause of death (USA)
  • Mortality rate still rising
  • ?prevalence in low birth weight and low
    socioeconomic status
  • Tuberculosis in smokers predisposes to COPD

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PathogenesisEffects of Smoking -1
  • Oxidative stress O2-, OH-,H2O2, HOCl source of
    Fe2 ? catalizes production of OH- by
    neutrophils, eosinophils, alveolar macrophages
    tar (cigarettes) contains NO and induces
    iNOS?toxic peroxynitrites
  • Elastin breakdown- activated neutrophils
    ?neutrophil elastases and oxidants ?-1-AT and
    metalloproteinase inhibitors (lung defenses)
    inactivated by smoke
  • Chemoattractant, upregulation of adhesion
    molecules ? neutrophil sequestration in lungs
  • ?expression of pro-inflammatory mediators IL-8,
    NF-?B ?recruitment of N, B, E and T lymphocytes

10
Effects of smoking -2
  • ? levels of myeloperoxidase and eosinophilic
    cationic protein ? bronchoconstriction
  • ? levels of TGF-? (transforming growth factor)
    ?fibrogenesis
  • Lipid peroxidation and DNA damage ?point
    mutations 0f the p53 gene locus ?epithelial
    dysplasia and lung cancer
  • ? ciliary function ? retained secretions ?
    airway resistance ?vagal-mediated smooth muscle
    contraction
  • Hypertrophy and hyperplasia of mucus secreting
    glands ??secretions

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12
Pathogenesis-3
  • Air pollution ?exacerbations of CB related to
    heavy pollution with SO2 and NO2
  • Occupation ? exposure to organic and inorganic
    dust or noxious gases ?accelerated decline in
    lung function
  • Infection ? even mild viral respiratory
    infections ( rhino virus) may be a major factor
    associated with etiology as well as progression
    of disease severe viral pneumonia early in life
    may lead to COPD
  • Genetic factors - ?-1-antitrypsin deficiency
    PIZZ, PISZ, PI00 (PI null null), ? susceptibility
    to effects of smoking

13
Pathophysiology
  • Air trapping- RV and FRC elevated
  • Hyperinflation TLC elevated
  • ? elastic recoil pressure ? dynamic collapse of
    airways during expiration ?ineffective cough
    mechanism and pursed lips breathing (emphysema)
  • ? compliance (emphysema)
  • ? airway resistance
  • Prolonged forced expiratory time (Nlt6 seconds)

14
Pathology CB
  • Hypertrophy of mucus-producing glands in
    submucosa of large cartilaginous airways
  • Goblet cell hyperplasia, mucosal and submucosal
    inflammatory cell infiltrate, oedema,
    peribronchial fibrosis, intraluminal mucus plugs
    and increased smooth muscle in small airways
  • The major site of airflow obstruction is in the
    small airways and the inflammatory infiltrate
    consists of neutrophils (in asthma eosinophils)

15
Pathology Emphysema
  • ?in number and size of alveolar fenestrae
    ?eventual destruction of alveolar septa and their
    attachments to terminal and respiratory
    bronchioles ?distention of alveolar spaces
  • Centriacinar E- respiratory bronchioles (central)
    affected
  • Panacinar E- central and peripheral portions of
    acinus affected
  • Senile E- alveoli and alveolar ducts enlarge (gt
    50 Y)
  • Periacinar/paraseptal E- distention of alveolar
    spaces adjacent to septal and pleural surfaces

16
Physical signs of COPD
  • Ronchi- in early disease present on forced
    expiration, later present in inspiration and
    expiration
  • Prolonged forced expiratory time (gt 6 seconds)
  • Hyperinflation ? cardiac dullness, liver
    dullness displaced downwards, ? A-P chest
    diameter, ? heart and breath sounds, Hoover sign
  • Inspiratory crepitations (lung bases)
  • Pursed lips breathing (?? dynamic airway
    collapse)
  • Use accessory respiratory muscles
  • Signs of cor pulmonale and PHT

17
EmphysemaChronicBronchitis
  • Emphysema pink puffer
  • Age (Dx) 60 y
  • Rest dyspnea mild-mod
  • Exer dyspnea severe
  • Cough
  • Sputum scanty, mucoid
  • Resp infect less often
  • Resp failure terminal
  • Cor pulmonale terminal
  • Chronic Bronchitis blue
  • bloater
  • 50 y
  • none
  • moderate
  • prominent
  • large volume, purulent
  • often
  • repeatedly
  • common

18
EmphysemaChronic Bronchitis
  • PHT (rest) 0-mild
  • (exertion) moderate
  • Build Asthenic, cachectic
  • Hematocrit 35-45
  • Breath pattern use accessory muscles of
    respiration
  • Sleep pattern Normal
  • XRC Hyperinflation
  • Bullae
  • Mild-moderate
  • severe
  • obese, cyanosed
  • 50-55
  • do not use accessory muscles of respiration
  • sleep apnea
  • bronchovascular markings

19
EmphysemaChronic Bronchitis
  • Blood gas
  • PaO2 65 mm Hg
  • PaCO2 35-40
  • Elastic recoil ?
  • AW resistance N-?
  • Diffusion Cap ?
  • FEV1 ? ?
  • Bronchodilator
  • response Poor
  • 45-60
  • 50-60
  • Normal
  • ?
  • N- ?
  • ?
  • Better but lt 12 and 200ml

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27
Spirometric classification of COPD severity using
post-bronchodilator FeV1
  • Stage I (Mild) FeV1/FVC lt0.7 FeV1 80 of
    predicted
  • Stage II (Moderate) FeV1/FVC lt0.7 FeV1 50- lt80
    of predicted
  • Stage III (Severe) FeV1/FVC lt0.7 FeV1 30-lt50
  • Stage IV (Very severe) FeV1/FVC lt0.7 FeV1 lt30
    or lt50 but chronic respiratory failure is
    present. (GOLD 2007)

28
Treatment Goals of management -1
  • Recognition of disease (early Diagnosis and
    staging)
  • Smoking cessation (secondary prevention) nicotine
    replacement and Zyban
  • Improvement of breathlessness (Rx of airflow
    obstruction- bronchodilator drugs)
  • 1.Methylxanthines
  • 2.Short and long-acting B2adrenergic agonists (?
    incidence of pneumonia with ICS and LABA
    combinations)
  • 3.Short and long-acting Anticholinergics- BD of
    choice in COPD

29
Treatment -2
  • Respiratory infections AB when ?sputum volume
    and/or purulence (exacerbation of COPD)
    Influenza and Streptococcus pneumoniae
    vaccination
  • Bronchopulmonary drainage and postural drainage
    (physiotherapy) for patients with CB
  • Oxygen therapy for patients with hypoxia (PaO2lt55
    mmHg, SaO2 lt88 ) and erythrocytosis
    (Hematocritgt55)
  • Pulmonary rehabilitation and education (
    improving quality of life)- exercise program and
    improved nutrition
  • Prevention and treatment of complications (cor
    pulmonale) and limitation of disease progression

30
Treatment -3
  • Glucocorticoids only 10 of COPD patients show
    subjective benefit and improved lung function
    (FeV1 increase of 20 or more) on systemic GCs
    with COPD exacerbation a course of prednisone 40
    mg/d for 2 weeks are usually prescribed
  • Inhaled GCs may ? severity of exacerbations and
    need for hospitalisation. Benefit of 10-14 day
    trial of 30-40mg prednisone for Stage III COPD
    patients remains to be proven.
  • Lung volume reduction surgery
  • Transplantation

31
Airway Diseases - COPD
  • Smoking
  • Hyperinflation
  • Airway collapse
  • Respiratory infection
  • Bronchospasm
  • Allergy
  • Inflammation

32
Airway Diseases Asthma
  • Allergy
  • Inflammation
  • Bronchospasm
  • Hyperinflation
  • Respiratory infection

33
AirwayDiseasesBronchiectasis
  • Respiratory infection
  • Hyperinflation
  • Bronchospasm
  • Inflammation
  • Allergy
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