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PULMONARY DISEASE
Martha Burk, MD
COPD
Airflow obstruction caused by irreversible damage to
distal airways
Often has partially reversible components
Hyperreactivity of airways
Airway secretions
Includes
Chronic Bronchitis
Excessive bronchial secretions
Daily cough for at least 3 months for at least 2 consecutive years
Emphysema
Destruction of airway walls causing permanent dilation of air spaces
with resulting loss of lung surface area for gaseous exchange
Martha Burk, MD
Who Is Affected?
14 million Americans
14 million more thought to be affected but undiagnosed
CDC Data
Nearly 8 million diagnosed with Chronic Bronchitis 2007
13% of Nursing Home residents had COPD as a diagnosis 2004
Martha Burk, MD
Leading Causes
of Death Heart Disease
Cancer
Cerebrovascular
Disease
Chronic
Lung Diabetes Mellitus
Disease
Infectious
Unintentional Diseases
Injuries
Martha Burk, MD
Adapted from American Council on Science and Health riskometer.org
Mortality Rates
Deaths due to
COPD
continue to
increase while
deaths from
other causes
decrease
Martha Burk, MD
Anatomy of the Distal Airways
Elastic fibers
provide
support to
alveoli and
bronchioles
Capillaries
surround each
alveolus for
gas exchange
Martha Burk, MD
Alveolar Structure
Electron microscopy
reveals a cork-like
structure to the alveoli
Destruction of alveoli
results in alveolar and
bronchiolar collapse,
especially during
exhalation when
intrathoracic pressures
are increased
Martha Burk, MD
Electron Microscopy Images from Imglib.lbl.gov
Anatomy of Disease
Media-2.web.britannica.com
Martha Burk, MD
Keys to Diagnosis
History of smoking
Still the primary cause of COPD!
Additional risk factors include
Inhalational drug use – cocaine, marijuana, methamphetamine
Second hand smoke
Occupational dusts and chemicals
Persistent or progressive
Dyspnea – usually worse with exercise
Cough – may or may not be productive
Sputum production
Martha Burk, MD
Exam Findings
Martha Burk, MD
Hypoxemia
Stages of COPD
Stage Symptoms FEV1/FVC FEV1
At Risk Asymptomatic with usual activity ≥ 70% > 80%
Increased cough
Mild Symptomatic with usual activity < 70% > 79%
Increased dyspnea or wheeze
Moderate Symptomatic with minimal activity <70% 50-79%
Increased sputum production
Severe Symptomatic at rest <70% 30-49%
Change in sputum color and quality
Very Severe <70% <30%
Global Initiative for Chronic Obstructive Lung Disease 2008
Martha Burk, MD
Timeline Estimate of Disease Progression
Martha Burk, MD
Diagnostic Tests
Pulmonary Function Testing
Arterial Blood Gas Analysis
Chest X-ray
Computed Tomography of Chest
Alpha-1 Antitrypsin
Patients 45 years or less with COPD
Patients with strong family history of COPD
Martha Burk, MD
Global Initiative for Chronic Obstructive Lung Disease 2008
Pulmonary Function Testing
FVC Forced Vital Capacity
SVC Slow Vital Capacity
FEV1 Forced Expiratory Volume in 1 second
FEF 25-75 Forced Expiratory Flow Rate (mid 50%)
MVV Maximal Voluntary Ventilation
TLC Total Lung Capacity
RV Residual Volume
DLCO Diffusion Capacity for Carbon Monoxide
Martha Burk, MD
Lung Volumes Illustrated
Inspiratory or Expiratory
Reserve Volume
Residual Volume
Lose this and your lungs collapse!
Tidal Volume
at rest
Martha Burk, MD
Static Lung Volumes
Martha Burk, MD
Flow-Volume Loop
Forced (or Slow) Vital Capacity
Flow
Exhale
Normal Tidal Volume +
Expiratory Reserve
Volume
Nothing left but . . .
Inhale Residual Volume!
Normal Tidal Volume +
Inspiratory Reserve
Martha Burk, MD
Airway Obstruction on Spirometry
Airway
obstruction
decreases
airflow rates
and appears
as a “scooped
out” portion
of the flow-
volume curve
on spirometry
Flow
Volume
Normal
Chronic Obstructive Disease
Martha Burk, MD
Forced Vital Capacity
in Restrictive Lung Disease
(i.e., Pulmonary Fibrosis, Neuromuscular Weakness or Chest Wall Defects)
Note
Sharp peak in outflow
Flow Left shift in volume •FVC decreased
•FEV1 decreased
•Residual Volume decreased
Volume •Tidal Volume decreased
•DLCO decreased
Martha Burk, MD
Forced Vital Capacity
In Mixed Obstructive and Restrictive Defects
Note
obstructive
Flow “dipping” •FEV1 > FVC
•Residual Volume
•Tidal Volume
Volume FEV1 is reduced more than FVC, however,
FEV1/FVC ratio may still appear within normal
range!
DLCO is reduced
Martha Burk, MD
Patterns of Impairment in Spirometry
Measurement Obstructive Restrictive
FVC (L)
FEV1
FEV1 /FVC Normal or Normal or
Slope of FV curve
MVV Normal or
TLC Normal or
RV
RV/TLC Normal
Adapted from
Interpretation of Pulmonary Function Tests A Practical Guide
Hyatt, Scanlon, Nakamura Lippincott Williams & Wilkins 2003
Martha Burk, MD
Measuring Oxygen and Carbon Dioxide
Oximetry
Problems
Noninvasively measures oxygen saturation
More costly Co-oximetry
Invasive Noninvasively measures oxygen & carbon dioxide
saturations
Accuracy Arterial Blood Gas
affected by
how sample is
Invasive measurements
obtained and Partial pressure Oxygen
handled Partial pressure Carbon dioxide
during pH
transport Can also measure
Carbon Monoxide
Methemoglobin
Martha Burk, MD
Arterial Blood Gas Analysis
Disorder Primary Defect Compensatory Magnitude of
Acidosis versus Response Compensation
Alkalosis
Respiratory ↑HCO3
Respiratory Acidosis
versus Acute ↑PCO2 ↑HCO3 1 per 10↑PCO2
Metabolic
Chronic ↑PCO2 ↑HCO3 3.5 per 10↑PCO2
Anion Gap Respiratory ↓HCO3 ↓HCO3
Alkalosis
Compensation
present, and Acute ↓PCO2 ↓HCO3 2 per 10 ↓PCO2
if so is it Chronic ↓PCO2 ↓HCO3 5 per 10 ↓PCO2
appropriate
Oxygen repleted
UpToDate
Martha Burk, MD
PaO2 to FIO2 Ratio
Arterial oxygen as percent of FIO2
300-500mm Hg = Within Normal Limits
200-300 indicates Acute Lung Injury
<201 indicates severe hypoxemia (as in ARDS)
Martha Burk, MD
A-a oxygen ratio PaO2 / PAO2
Helps predict PaO2 changes with changing FIO2
Normal lower limits of 0.77-0.82
Most accurate with FIO2 <55%
Martha Burk, MD
Normal A-a Variation Based on FiO2
FiO2 A-a
Higher than expected
values indicate one of 21% 10-15
the following
30% 89
1. V/Q mismatch
40% 160
2. Right to Left Shunt
50% 232
3. Diffusion defect 60% 303
70% 374
80% 445
90% 517
100% 588
Martha Burk, MD
Influences on A-a Gradient
Anything that
interferes with
Ventilation
Diffusion
Perfusion
will increase
the A-a
gradient.
Hyperlucent lungs
Vascular displacement
Martha Burk, MD
Image from meddean.luc.edu
CT
Appearance
Panacinar
emphysema
Subpleural
blebs
Bronchiectasis
indicates
chronic
endobronchial
infection
Martha Burk, MD
Knol.google.com
Not This Emphysema
Not to be
confused with
subcutaneous
emphysema
Indicates
intrathoracic air
leak
Muscle striations
are
pathognomonic
Be sure to rule
out
Pneumothorax
paramediastinal
pneumothorax with subcutaneous emphysema
Consider addition of inhaled corticosteroids [TORCH trial] Tiotropium + Long Acting Beta
Fewer moderate and severe exacerbations in patients taking inhaled steroids Agonist +/- Methylxanthines
compared with those taking only long acting bronchodilators Supplemental Oxygen as needed
No change in number of hospitalizations for severe exacerbations or change in
Lung Volume
mortality UpToDate
Reduction
The Role of Long Acting Bronchodilators in the Management of Stable COPD Chest 2004; 125:249-259 Surgery
Martha Burk, MD
Treatment Options Acute Exacerbations
Supplemental oxygen
Cough
increases in Goal 90-94%
frequency or Short acting bronchodilators
severity Albuterol and Ipratropium combined have a greater
effect than either individually
Sputum
Steroids
increases in
volume or IV administration for those intolerant of oral intake
character Oral steroids are as effective as IV
Dosed as 1mg/kg IBW (Ideal Body Weight)
Dyspnea 60mg orally for 7 days
increases
Antibiotics, if appropriate
50-60% due No Benefit
to infection Mucolytics, methylxanthines or chest physiotherapy
Martha Burk, MD
Ventilatory Support
Martha Burk, MD
UpToDate
Nocturnal NIPPV
Martha Burk, MD
UpToDate
Evaluating Need For Long Term Oxygen
Duration
SLEEP
Activity PaO2 <55 or Sats <89%
PaO2 falls >10mm Hg and/or Sats drop >5%
Delivery
vehicle
EXERCISE
Portable or PaO2 <55 or Sats <89%
Ambulatory OR in presence of significant dyspnea that may limit activity
Martha Burk, MD
UpToDate
Survival Benefit Nocturnal Oxygen Therapy Trial
Improved
survival seen
with wearing
oxygen
Survival
benefit seen
with at least
18 hours of
daily use
Martha Burk, MD
UpToDate
How Much Oxygen?
Martha Burk, MD
Oxygen Conserving Devices
Martha Burk, MD
Summary
History of chronic or progressive Additional therapy
Dyspnea Pulmonary rehab
Cough Supplemental oxygen therapy
Sputum Nocturnal BiPap
Smoking Severe exacerbations
Evaluate pulmonary function Supplemental oxygen
Diagnosis NIPPV versus intubation
Severity Antibiotics
Initiate treatment Bronchodilators
Bronchodilators Steroids
Inhaled steroids
Annual influenza vaccine
Pneumococcal vaccine
Martha Burk, MD