Chronic Obstructive Pulmonary Disease - Wikipedia

11/10/2016
ChronicobstructivepulmonarydiseaseWikipedia
Chronicobstructivepulmonarydisease
FromWikipedia,thefreeencyclopedia
Chronicobstructivepulmonarydisease(COPD)isatypeofobstructivelungdiseasecharacterizedbylong
termpoorairflow.Themainsymptomsincludeshortnessofbreathandcoughwithsputumproduction.COPD
typicallyworsensovertime.[1]Eventuallywalkingupstairsorcarryingthingswillbedifficult.[2]Chronic
bronchitisandemphysemaareoldertermsusedfordifferenttypesofCOPD.[2][3]Theterm"chronic
bronchitis"isstillusedtodefineaproductivecoughthatispresentforatleastthreemonthseachyearfortwo
years.[4]
Chronicobstructivepulmonarydisease
chronicobstructivelungdisease(COLD),
chronicobstructiveairwaydisease(COAD),
chronicbronchitis,emphysema,pulmonary
emphysema,others
TobaccosmokingisthemostcommoncauseofCOPD,withanumberofotherfactorssuchasairpollutionand
geneticsplayingasmallerrole.[5]Inthedevelopingworld,oneofthecommonsourcesofairpollutionispoorly
ventedheatingandcookingfires.[2]Longtermexposuretotheseirritantscausesaninflammatoryresponsein
thelungsresultinginnarrowingofthesmallairwaysandbreakdownoflungtissue.[6]Thediagnosisisbasedon
poorairflowasmeasuredbylungfunctiontests.[7]Incontrasttoasthma,theairflowreductiondoesnotimprove
muchwiththeuseofabronchodilator.[2]
MostcasesofCOPDcanbepreventedbyreducingexposuretoriskfactors.[8]Thisincludesdecreasingratesof
smokingandimprovingindoorandoutdoorairquality.Whiletreatmentcanslowworsening,thereisnocure.[2]
COPDtreatmentsincludestoppingsmoking,vaccinations,respiratoryrehabilitation,andofteninhaled
bronchodilatorsandsteroids.[5]Somepeoplemaybenefitfromlongtermoxygentherapyorlung
transplantation.[6]Inthosewhohaveperiodsofacuteworsening,increaseduseofmedicationsand
hospitalizationmaybeneeded.[5]
Asof2013COPDaffects329millionpeopleornearly5percentoftheglobalpopulation.[9][10]Ittypically
occursinpeopleovertheageof40.Malesandfemalesareaffectedequallycommonly.[2]In2013itresultedin
2.9milliondeaths,upfrom2.4milliondeathsin1990.[11]Morethan90%ofthesedeathsoccurinthe
developingworld.[2]Thenumberofdeathsisprojectedtoincreasefurtherbecauseofhighersmokingratesin
thedevelopingworld,andanagingpopulationinmanycountries.[12]Itresultedinanestimatedeconomiccost
of$2.1trillionin2010.[13]
Contents
https://en.wikipedia.org/wiki/Chronic_obstructive_pulmonary_disease
Grosspathologyofalungshowingcentrilobular
typeemphysemacharacteristicofsmoking.This
closeupofthefixed,cutlungsurfaceshows
multiplecavitiesfilledwithheavyblackcarbon
deposits.
Classificationandexternalresources
Specialty
Pulmonology
ICD10
J40(http://apps.who.int/classification
s/icd10/browse/2016/en#/J40)J44(ht
tp://apps.who.int/classifications/icd1
0/browse/2016/en#/J44),J47(http://a
pps.who.int/classifications/icd10/bro
wse/2016/en#/J47)
ICD9CM
490(http://www.icd9data.com/getIC
1/24
11/10/2016
Contents
1 Signsandsymptoms
1.1 Cough
1.2 Shortnessofbreath
1.3 Otherfeatures
1.4 Exacerbation
2 Cause
2.1 Smoking
2.2 Airpollution
2.3 Occupationalexposures
2.4 Genetics
2.5 Other
2.6 Exacerbations
3 Pathophysiology
4 Diagnosis
4.1 Spirometry
4.2 Severity
4.3 Othertests
4.4 Differentialdiagnosis
5 Prevention
5.1 Smokingcessation
5.2 Occupationalhealth
5.3 Airpollution
6 Management
6.1 Exercise
6.2 Bronchodilators
6.3 Corticosteroids
6.4 Othermedication
6.5 Oxygen
6.6 Surgery
6.7 Exacerbations
7 Prognosis
8 Epidemiology
9 History
10 Societyandculture
10.1 Economics
11 Research
12 Otheranimals
13 References
D9Code.ashx?icd9=490)492(http://
www.icd9data.com/getICD9Code.ash
x?icd9=492),494(http://www.icd9da
ta.com/getICD9Code.ashx?
icd9=494)496(http://www.icd9data.
com/getICD9Code.ashx?icd9=496)
OMIM
606963(http://omim.org/entry/60696
3)
DiseasesDB 2672(http://www.diseasesdatabase.co
m/ddb2672.htm)
MedlinePlus 000091(http://www.nlm.nih.gov/me
dlineplus/ency/article/000091.htm)
eMedicine
med/373(http://www.emedicine.com/
med/topic373.htm)emerg/99(http://
www.emedicine.com/emerg/topic99.h
tm#)
PatientUK Chronicobstructivepulmonary
disease(http://patient.info/doctor/chr
onicobstructivepulmonarydiseasep
ro)
MeSH
C08.381.495.389(https://www.nlm.ni
h.gov/cgi/mesh/2016/MB_cgi?mode=
&term=COPD&field=entry#TreeC0
8.381.495.389)
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11/10/2016
13 References
14 Furtherreading
15 Externallinks
Signsandsymptoms
ThemostcommonsymptomsofCOPDaresputumproduction,shortnessofbreath,andaproductivecough.[14]
Thesesymptomsarepresentforaprolongedperiodoftime[15]andtypicallyworsenovertime.[6]Itisunclearif
differenttypesofCOPDexist.[5]Whilepreviouslydividedintoemphysemaandchronicbronchitis,emphysema
isonlyadescriptionoflungchangesratherthanadiseaseitself,andchronicbronchitisissimplyadescriptorof
symptomsthatmayormaynotoccurwithCOPD.[1]
Videoexplanation
Wheezing
0:00
Cough
MENU
Thesoundofwheezingasheardwitha
stethoscope.
Achroniccoughisoftenthefirstsymptomtodevelop.Whenitpersistsformorethanthreemonthseachyear
Problemsplayingthisfile?Seemediahelp.
foratleasttwoyears,incombinationwithsputumproductionandwithoutanotherexplanation,thereisby
definitionchronicbronchitis.ThisconditioncanoccurbeforeCOPDfullydevelops.Theamountofsputum
producedcanchangeoverhourstodays.Insomecases,thecoughmaynotbepresentormayonlyoccuroccasionallyandmaynotbeproductive.Somepeople
withCOPDattributethesymptomstoa"smoker'scough".Sputummaybeswallowedorspatout,dependingoftenonsocialandculturalfactors.Vigorous
coughingmayleadtoribfracturesorabrieflossofconsciousness.ThosewithCOPDoftenhaveahistoryof"commoncolds"thatlastalongtime.[14]
Shortnessofbreath
Shortnessofbreathisoftenthesymptomthatmostbotherspeople.[16]Itiscommonlydescribedas:"mybreathingrequireseffort,""Ifeeloutofbreath,"or"Ican't
getenoughairin".[17]Differentterms,however,maybeusedindifferentcultures.[14]Typicallytheshortnessofbreathisworseonexertionofaprolongedduration
andworsensovertime.[14]Intheadvancedstages,itoccursduringrestandmaybealwayspresent.[18][19]Itisasourceofbothanxietyandapoorqualityoflifein
thosewithCOPD.[14]ManypeoplewithmoreadvancedCOPDbreathethroughpursedlipsandthisactioncanimproveshortnessofbreathinsome.[20][21]
Otherfeatures
InCOPD,itmaytakelongertobreatheoutthantobreathein.[22]Chesttightnessmayoccur[14]butisnotcommonandmaybecausedbyanotherproblem.[16]
Thosewithobstructedairflowmayhavewheezingordecreasedsoundswithairentryonexaminationofthechestwithastethoscope.[22]Abarrelchestisa
characteristicsignofCOPD,butisrelativelyuncommon.[22]Tripodpositioningmayoccurasthediseaseworsens.[15]
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AdvancedCOPDleadstohighpressureonthelungarteries,whichstrainstherightventricleoftheheart.[6][23][24]Thissituationisreferredtoascorpulmonale,
andleadstosymptomsoflegswelling[14]andbulgingneckveins.[6]COPDismorecommonthananyotherlungdiseaseasacauseofcorpulmonale.[23]Cor
pulmonalehasbecomelesscommonsincetheuseofsupplementaloxygen.[15]
COPDoftenoccursalongwithanumberofotherconditions,dueinparttosharedriskfactors.[5]Theseconditionsincludeischemicheartdisease,highblood
pressure,diabetesmellitus,musclewasting,osteoporosis,lungcancer,anxietydisorderanddepression.[5]Inthosewithseveredisease,afeelingofalwaysbeing
tirediscommon.[14]FingernailclubbingisnotspecifictoCOPDandshouldpromptinvestigationsforanunderlyinglungcancer.[25]
Exacerbation
AnacuteexacerbationofCOPDisdefinedasincreasedshortnessofbreath,increasedsputumproduction,achangeinthecolorofthesputumfromcleartogreen
oryellow,oranincreaseincoughinsomeonewithCOPD.[22]Thismaypresentwithsignsofincreasedworkofbreathingsuchasfastbreathing,afastheartrate,
sweating,activeuseofmusclesintheneck,abluishtingetotheskin,andconfusionorcombativebehaviorinverysevereexacerbations.[22][26]Cracklesmayalso
beheardoverthelungsonexaminationwithastethoscope.[27]
Cause
TheprimarycauseofCOPDistobaccosmoke,withoccupationalexposureandpollutionfromindoorfiresbeingsignificantcausesinsomecountries.[1]Typically
theseexposuresmustoccuroverseveraldecadesbeforesymptomsdevelop.[1]Aperson'sgeneticmakeupalsoaffectstherisk.[1]
Smoking
TheprimaryriskfactorforCOPDgloballyistobaccosmoking.[1]Ofthosewhosmokeabout20%willgetCOPD,[29]andofthosewhoarelifelongsmokersabout
halfwillgetCOPD.[30]IntheUnitedStatesandUnitedKingdom,ofthosewithCOPD,8095%areeithercurrentsmokersorpreviouslysmoked.[29][31][32]The
likelihoodofdevelopingCOPDincreaseswiththetotalsmokeexposure.[33]Additionally,womenaremoresusceptibletotheharmfuleffectsofsmokethan
men.[32]Innonsmokers,secondhandsmokeisthecauseofabout20%ofcases.[31]Othertypesofsmoke,suchasmarijuana,cigar,andwaterpipesmoke,also
conferarisk.[1]Waterpipesmokeappearstobeasharmfulassmokingcigarettes.[34]Problemsfrommarijuanasmokemayonlybewithheavyuse.[35]Women
whosmokeduringpregnancymayincreasetheriskofCOPDintheirchild.[1]
Airpollution
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Poorlyventilatedcookingfires,oftenfueledbycoalorbiomassfuelssuchaswoodandanimal
dung,leadtoindoorairpollutionandareoneofthemostcommoncausesofCOPDin
developingcountries.[36]Thesefiresareamethodofcookingandheatingfornearly3billion
peoplewiththeirhealtheffectsbeinggreateramongwomenduetomoreexposure.[1][36]They
areusedasthemainsourceofenergyin80%ofhomesinIndia,ChinaandsubSaharan
Africa.[8]
PeoplewholiveinlargecitieshaveahigherrateofCOPDcomparedtopeoplewholiveinrural
areas.[37]Whileurbanairpollutionisacontributingfactorinexacerbations,itsoverallroleasa
causeofCOPDisunclear.[1]Areaswithpooroutdoorairquality,includingthatfromexhaust
gas,generallyhavehigherratesofCOPD.[8]Theoveralleffectinrelationtosmoking,however,
isbelievedtobesmall.[1]
Percentageoffemalessmokingtobaccoasofthelate1990searly
2000s
Occupationalexposures
Intenseandprolongedexposuretoworkplacedusts,chemicalsandfumesincreasetheriskof
COPDinbothsmokersandnonsmokers.[38]Workplaceexposuresarebelievedtobethecausein
1020%ofcases.[39]IntheUnitedStatestheyarebelievedtoberelatedtomorethan30%of
casesamongthosewhohaveneversmokedandprobablyrepresentagreaterriskincountries
withoutsufficientregulations.[1]
Percentageofmalessmokingtobaccoasofthelate1990sandearly
Anumberofindustriesandsourceshavebeenimplicated,including[8]highlevelsofdustincoal
2000s.Notethescalesusedforfemalesandmalesdiffer. [28]
mining,goldmining,andthecottontextileindustry,occupationsinvolvingcadmiumand
isocyanates,andfumesfromwelding.[38]Workinginagricultureisalsoarisk.[8]Insome
professionstheriskshavebeenestimatedasequivalenttothatofonehalftotwopacksofcigarettesaday.[40]SilicadustexposurecanalsoleadtoCOPD,withthe
riskunrelatedtothatforsilicosis.[41]Thenegativeeffectsofdustexposureandcigarettesmokeexposureappeartobeadditiveorpossiblymorethanadditive.[40]
Genetics
GeneticsplayaroleinthedevelopmentofCOPD.[1]ItismorecommonamongrelativesofthosewithCOPDwhosmokethanunrelatedsmokers.[1]Currently,the
onlyclearlyinheritedriskfactorisalpha1antitrypsindeficiency(AAT).[42]Thisriskisparticularlyhighifsomeonedeficientinalpha1antitrypsinalso
smokes.[42]Itisresponsibleforabout15%ofcases[42][43]andtheconditionispresentinabout34in10,000people.[15]Othergeneticfactorsarebeing
investigated,[42]ofwhichtherearelikelytobemany.[8]
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Other
AnumberofotherfactorsarelesscloselylinkedtoCOPD.Theriskisgreaterinthosewhoarepoor,althoughitisnotclearifthisisduetopovertyitselforother
riskfactorsassociatedwithpoverty,suchasairpollutionandmalnutrition.[1]Thereistentativeevidencethatthosewithasthmaandairwayhyperreactivityareat
increasedriskofCOPD.[1]BirthfactorssuchaslowbirthweightmayalsoplayaroleasdoanumberofinfectiousdiseasesincludingHIV/AIDSand
tuberculosis.[1]RespiratoryinfectionssuchaspneumoniadonotappeartoincreasetheriskofCOPD,atleastinadults.[15]
Exacerbations
Anacuteexacerbation(asuddenworseningofsymptoms)[44]iscommonlytriggeredbyinfectionorenvironmentalpollutants,orsometimesbyotherfactorssuch
asimproperuseofmedications.[45]Infectionsappeartobethecauseof50to75%ofcases,[45][46]withbacteriain25%,virusesin25%,andbothin25%.[47]
Environmentalpollutantsincludebothpoorindoorandoutdoorairquality.[45]Exposuretopersonalsmokeandsecondhandsmokeincreasestherisk.[8]Cold
temperaturemayalsoplayarole,withexacerbationsoccurringmorecommonlyinwinter.[48]Thosewithmoresevereunderlyingdiseasehavemorefrequent
exacerbations:inmilddisease1.8peryear,moderate2to3peryear,andsevere3.4peryear.[49]Thosewithmanyexacerbationshaveafasterrateofdeterioration
oftheirlungfunction.[50]Pulmonaryemboli(bloodclotsinthelungs)canworsensymptomsinthosewithpreexistingCOPD.[5]SignsofPEinCOPDinclude
pleuriticchestpainandheartfailurewithoutsignsofinfection.[51]
Pathophysiology
COPDisatypeofobstructivelungdiseaseinwhichchronicincompletely
reversiblepoorairflow(airflowlimitation)andinabilitytobreatheoutfully(air
trapping)exist.[5]Thepoorairflowistheresultofbreakdownoflungtissue
(knownasemphysema)andsmallairwaysdisease(knownasobstructive
bronchiolitis).Therelativecontributionsofthesetwofactorsvarybetween
people.[1]Severedestructionofsmallairwayscanleadtotheformationoflargeair
pocketsknownasbullaethatreplacelungtissue.Thisformofdiseaseiscalled
bullousemphysema.[52]
COPDdevelopsasasignificantandchronicinflammatoryresponsetoinhaled
Ontheleftisadiagramofthelungsandairwayswithaninsetshowingadetailed
irritants.[1]Chronicbacterialinfectionsmayalsoaddtothisinflammatorystate.[50]
crosssectionofnormalbronchiolesandalveoli.Ontherightarelungsdamagedby
Theinflammatorycellsinvolvedincludeneutrophilgranulocytesand
COPDwithaninsetshowingacrosssectionofdamagedbronchiolesandalveoli.
macrophages,twotypesofwhitebloodcell.Thosewhosmokeadditionallyhave
Tc1lymphocyteinvolvementandsomepeoplewithCOPDhaveeosinophil
involvementsimilartothatinasthma.Partofthiscellresponseisbroughtonbyinflammatorymediatorssuchaschemotacticfactors.Otherprocessesinvolved
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withlungdamageincludeoxidativestressproducedbyhighconcentrationsoffreeradicalsintobaccosmoke
andreleasedbyinflammatorycells,andbreakdownoftheconnectivetissueofthelungsbyproteasesthatare
insufficientlyinhibitedbyproteaseinhibitors.Thedestructionoftheconnectivetissueofthelungsiswhat
leadstoemphysema,whichthencontributestothepoorairflowand,finally,poorabsorptionandreleaseof
respiratorygases.[1]GeneralmusclewastingthatoftenoccursinCOPDmaybepartlyduetoinflammatory
mediatorsreleasedbythelungsintotheblood.[1]
Micrographshowingemphysema(leftlargeempty
spaces)andlungtissuewithrelativepreservationof
thealveoli(right)
Narrowingoftheairwaysoccursduetoinflammationandscarringwithinthem.Thiscontributestothe
inabilitytobreatheoutfully.Thegreatestreductioninairflowoccurswhenbreathingout,asthepressurein
thechestiscompressingtheairwaysatthistime.[53]Thiscanresultinmoreairfromthepreviousbreath
remainingwithinthelungswhenthenextbreathisstarted,resultinginanincreaseinthetotalvolumeofair
inthelungsatanygiventime,aprocesscalledhyperinflationorairtrapping.[53][54]Hyperinflationfrom
exerciseislinkedtoshortnessofbreathinCOPD,asitislesscomfortabletobreatheinwhenthelungsare
alreadypartlyfull.[55]Hyperinflationmayalsoworsenduringanexacerbation.[56]
Somealsohaveadegreeofairwayhyperresponsivenesstoirritantssimilartothosefoundinasthma.[15]
Lowoxygenlevelsand,eventually,highcarbondioxidelevelsinthebloodcanoccurfrompoorgasexchangeduetodecreasedventilationfromairway
obstruction,hyperinflationandareduceddesiretobreathe.[1]Duringexacerbations,airwayinflammationisalsoincreased,resultinginincreasedhyperinflation,
reducedexpiratoryairflowandworseningofgastransfer.Thiscanalsoleadtoinsufficientventilationand,eventually,lowbloodoxygenlevels.[6]Lowoxygen
levels,ifpresentforaprolongedperiod,canresultinnarrowingofthearteriesinthelungs,whileemphysemaleadstobreakdownofcapillariesinthelungs.Both
thesechangesresultinincreasedbloodpressureinthepulmonaryarteries,whichmaycausecorpulmonale.[1]
Diagnosis
ThediagnosisofCOPDshouldbeconsideredinanyoneovertheageof35to40whohasshortnessofbreath,achroniccough,sputumproduction,orfrequent
wintercoldsandahistoryofexposuretoriskfactorsforthedisease.[14][16]Spirometryisthenusedtoconfirmthediagnosis.[14][57]Screeningthosewithout
symptomsisnotrecommended.[58]
Spirometry
Spirometrymeasurestheamountofairflowobstructionpresentandisgenerallycarriedoutaftertheuseofabronchodilator,amedicationtoopenupthe
airways.[57]Twomaincomponentsaremeasuredtomakethediagnosis:theforcedexpiratoryvolumeinonesecond(FEV1),whichisthegreatestvolumeofair
thatcanbebreathedoutinthefirstsecondofabreath,andtheforcedvitalcapacity(FVC),whichisthegreatestvolumeofairthatcanbebreathedoutinasingle
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largebreath.[59]Normally,7580%oftheFVCcomesoutinthefirstsecond[59]andaFEV1/FVCratioofless
than70%insomeonewithsymptomsofCOPDdefinesapersonashavingthedisease.[57]Basedonthese
measurements,spirometrywouldleadtooverdiagnosisofCOPDintheelderly.[57]TheNationalInstitutefor
HealthandCareExcellencecriteriaadditionallyrequireaFEV1oflessthan80%ofpredicted.[16]
Evidenceforusingspirometryamongthosewithoutsymptomsinanefforttodiagnosetheconditionearlieris
ofuncertaineffectandisthereforecurrentlynotrecommended.[14][57]Apeakexpiratoryflow(themaximum
speedofexpiration),commonlyusedinasthma,isnotsufficientforthediagnosisofCOPD.[16]
Severity
Apersonblowingintoaspirometer.Smaller
Therearea
[14]
[16]
handhelddevicesareavailableforofficeuse.
GOLDgrade
MRCshortnessofbreathscale
numberofmethods
todeterminehow
FEV1%predicted Grade
Activityaffected
Severity
muchCOPDis
1
Onlystrenuousactivity
Mild(GOLD1)
80
affectingagiven
2
Vigorouswalking
Moderate(GOLD2)
5079
individual.[14]The
3
Withnormalwalking
modifiedBritish
Severe(GOLD3)
3049
MedicalResearch
4
Afterafewminutesofwalking
Verysevere(GOLD4)
<30
Council
5
Withchangingclothing
questionnaire
(mMRC)ortheCOPDassessmenttest(CAT)aresimple
questionnairesthatmaybeusedtodeterminetheseverityofsymptoms.[14]ScoresonCATrangefrom040withthehigherthescore,themoreseverethe
disease.[60]Spirometrymayhelptodeterminetheseverityofairflowlimitation.[14]ThisistypicallybasedontheFEV1expressedasapercentageofthepredicted
"normal"fortheperson'sage,gender,heightandweight.[14]BoththeAmericanandEuropeanguidelinesrecommendedpartlybasingtreatmentrecommendations
ontheFEV1.[57]TheGOLDguidelinessuggestdividingpeopleintofourcategoriesbasedonsymptomsassessmentandairflowlimitation.[14]Weightlossand
muscleweakness,aswellasthepresenceofotherdiseases,shouldalsobetakenintoaccount.[14]
Othertests
AchestXrayandcompletebloodcountmaybeusefultoexcludeotherconditionsatthetimeofdiagnosis.[61]CharacteristicsignsonXrayareoverexpanded
lungs,aflatteneddiaphragm,increasedretrosternalairspace,andbullaewhileitcanhelpexcludeotherlungdiseases,suchaspneumonia,pulmonaryedemaora
pneumothorax.[62]Ahighresolutioncomputedtomographyscanofthechestmayshowthedistributionofemphysemathroughoutthelungsandcanalsobeuseful
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toexcludeotherlungdiseases.[15]Unlesssurgeryisplanned,however,thisrarelyaffectsmanagement.[15]Ananalysisofarterialbloodisusedtodeterminethe
needforoxygenthisisrecommendedinthosewithanFEV1lessthan35%predicted,thosewithaperipheraloxygensaturationoflessthan92%andthosewith
symptomsofcongestiveheartfailure.[14]Inareasoftheworldwherealpha1antitrypsindeficiencyiscommon,peoplewithCOPD(particularlythosebelowthe
ageof45andwithemphysemaaffectingthelowerpartsofthelungs)shouldbeconsideredfortesting.[14]
ChestXray
demonstratingsevere
COPD.Notethesmall
heartsizein
comparisontothe
lungs.
Alateralchestxrayof
apersonwith
emphysema.Notethe
barrelchestandflat
diaphragm.
Lungbullaasseenon
CXRinapersonwith
severeCOPD
Aseverecaseof
bullousemphysema
AxialCTimageofthe
lungofapersonwith
endstagebullous
emphysema.
Verysevere
emphysemawithlung
cancerontheleft(CT
scan)
Differentialdiagnosis
COPDmayneedtobedifferentiatedfromothercausesofshortnessofbreathsuchascongestiveheartfailure,pulmonaryembolism,pneumoniaorpneumothorax.
ManypeoplewithCOPDmistakenlythinktheyhaveasthma.[22]ThedistinctionbetweenasthmaandCOPDismadeonthebasisofthesymptoms,smoking
history,andwhetherairflowlimitationisreversiblewithbronchodilatorsatspirometry.[63]Tuberculosismayalsopresentwithachroniccoughandshouldbe
consideredinlocationswhereitiscommon.[14]Lesscommonconditionsthatmaypresentsimilarlyincludebronchopulmonarydysplasiaandobliterative
bronchiolitis.[61]ChronicbronchitismayoccurwithnormalairflowandinthissituationitisnotclassifiedasCOPD.[15]
Prevention
MostcasesofCOPDarepotentiallypreventablethroughdecreasingexposuretosmokeandimprovingairquality.[8]Annualinfluenzavaccinationsinthosewith
COPDreduceexacerbations,hospitalizationsanddeath.[64][65]Pneumococcalvaccinationmayalsobebeneficial.[64]
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Smokingcessation
KeepingpeoplefromstartingsmokingisakeyaspectofpreventingCOPD.[66]Thepoliciesofgovernments,publichealthagencies,andantismoking
organizationscanreducesmokingratesbydiscouragingpeoplefromstartingandencouragingpeopletostopsmoking.[67]Smokingbansinpublicareasandplaces
ofworkareimportantmeasurestodecreaseexposuretosecondhandsmokeandwhilemanyplaceshaveinstitutedbansmorearerecommended.[8]
Inthosewhosmoke,stoppingsmokingistheonlymeasureshowntoslowdowntheworseningofCOPD.[68]Evenatalatestageofthedisease,itcanreducethe
rateofworseninglungfunctionanddelaytheonsetofdisabilityanddeath.[69]Smokingcessationstartswiththedecisiontostopsmoking,leadingtoanattemptat
quitting.Oftenseveralattemptsarerequiredbeforelongtermabstinenceisachieved.[67]Attemptsover5yearsleadtosuccessinnearly40%ofpeople.[70]
Somesmokerscanachievelongtermsmokingcessationthroughwillpoweralone.Smoking,however,ishighlyaddictive,[71]andmanysmokersneedfurther
support.Thechanceofquittingisimprovedwithsocialsupport,engagementinasmokingcessationprogramandtheuseofmedicationssuchasnicotine
replacementtherapy,bupropionorvarenicline.[67][70]
Occupationalhealth
Anumberofmeasureshavebeentakentoreducethelikelihoodthatworkersinatriskindustriessuchascoalmining,constructionandstonemasonrywill
developCOPD.[8]Examplesofthesemeasuresinclude:thecreationofpublicpolicy,[8]educationofworkersandmanagementabouttherisks,promotingsmoking
cessation,checkingworkersforearlysignsofCOPD,useofrespirators,anddustcontrol.[72][73]Effectivedustcontrolcanbeachievedbyimprovingventilation,
usingwaterspraysandbyusingminingtechniquesthatminimizedustgeneration.[74]IfaworkerdevelopsCOPD,furtherlungdamagecanbereducedbyavoiding
ongoingdustexposure,forexamplebychangingtheworkrole.[75]
Airpollution
Bothindoorandoutdoorairqualitycanbeimproved,whichmaypreventCOPDorslowtheworseningofexistingdisease.[8]Thismaybeachievedbypublic
policyefforts,culturalchanges,andpersonalinvolvement.[76]
Anumberofdevelopedcountrieshavesuccessfullyimprovedoutdoorairqualitythroughregulations.Thishasresultedinimprovementsinthelungfunctionof
theirpopulations.[8]ThosewithCOPDmayexperiencefewersymptomsiftheystayindoorsondayswhenoutdoorairqualityispoor.[6]
Onekeyeffortistoreduceexposuretosmokefromcookingandheatingfuelsthroughimprovedventilationofhomesandbetterstovesandchimneys.[76]Proper
stovesmayimproveindoorairqualityby85%.Usingalternativeenergysourcessuchassolarcookingandelectricalheatingisalsoeffective.Usingfuelssuchas
keroseneorcoalmightbelessbadthantraditionalbiomasssuchaswoodordung.[8]
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Management
ThereisnoknowncureforCOPD,butthesymptomsaretreatableanditsprogressioncanbedelayed.[66]Themajorgoalsofmanagementaretoreducerisk
factors,managestableCOPD,preventandtreatacuteexacerbations,andmanageassociatedillnesses.[6]Theonlymeasuresthathavebeenshowntoreduce
mortalityaresmokingcessationandsupplementaloxygen.[77]Stoppingsmokingdecreasestheriskofdeathby18%.[5]Otherrecommendationsincludeinfluenza
vaccinationonceayear,pneumococcalvaccinationonceevery5years,andreductioninexposuretoenvironmentalairpollution.[5]Inthosewithadvanceddisease,
palliativecaremayreducesymptoms,withmorphineimprovingthefeelingsofshortnessofbreath.[78]Noninvasiveventilationmaybeusedtosupport
breathing.[78]
Exercise
Pulmonaryrehabilitationisaprogramofexercise,diseasemanagementandcounseling,coordinatedtobenefittheindividual.[79]Inthosewhohavehadarecent
exacerbation,pulmonaryrehabilitationappearstoimprovetheoverallqualityoflifeandtheabilitytoexercise,andreducemortality.[80]Ithasalsobeenshownto
improvethesenseofcontrolapersonhasovertheirdisease,aswellastheiremotions.[81]Breathingexercisesinandofthemselvesappeartohavealimited
role.[21]Pursedlipbreathingexercisesmaybeuseful.[20][21]
Beingeitherunderweightoroverweightcanaffectthesymptoms,degreeofdisabilityandprognosisofCOPD.PeoplewithCOPDwhoareunderweightcan
improvetheirbreathingmusclestrengthbyincreasingtheircalorieintake.[6]Whencombinedwithregularexerciseorapulmonaryrehabilitationprogram,thiscan
leadtoimprovementsinCOPDsymptoms.Supplementalnutritionmaybeusefulinthosewhoaremalnourished.[82]
Bronchodilators
Inhaledbronchodilatorsaretheprimarymedicationsused[5]andresultinasmalloverallbenefit.[83]Therearetwomajortypes,2agonistsandanticholinergics
bothexistinlongactingandshortactingforms.Theyreduceshortnessofbreath,wheezeandexerciselimitation,resultinginanimprovedqualityoflife.[84]Itis
uncleariftheychangetheprogressionoftheunderlyingdisease.[5]
Inthosewithmilddisease,shortactingagentsarerecommendedonanasneededbasis.[5]Inthosewithmoreseveredisease,longactingagentsare
recommended.[5]Longactingagentspartlyworkbyimprovinghyperinflation.[56]Iflongactingbronchodilatorsareinsufficient,theninhaledcorticosteroidsare
typicallyadded.[5]Withrespecttolongactingagents,itisuncleariftiotropium(alongactinganticholinergic)orlongactingbetaagonists(LABAs)arebetter,and
itmaybeworthtryingeachandcontinuingtheonethatworkedbest.[85]Bothtypesofagentappeartoreducetheriskofacuteexacerbationsby1525%.[5]While
bothmaybeusedatthesametime,anybenefitisofquestionablesignificance.[86]
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Thereareseveralshortacting2agonistsavailableincludingsalbutamol(Ventolin)andterbutaline.[87]Theyprovidesomereliefofsymptomsforfourtosix
hours.[87]Longacting2agonistssuchassalmeterolandformoterolareoftenusedasmaintenancetherapy.Somefeeltheevidenceofbenefitsislimited[88]while
othersviewtheevidenceofbenefitasestablished.[89][90]LongtermuseappearssafeinCOPD[91]withadverseeffectsincludeshakinessandheartpalpitations.[5]
Whenusedwithinhaledsteroidstheyincreasetheriskofpneumonia.[5]WhilesteroidsandLABAsmayworkbettertogether,[88]itisunclearifthisslightbenefit
outweighstheincreasedrisks.[92]
TherearetwomainanticholinergicsusedinCOPD,ipratropiumandtiotropium.Ipratropiumisashortactingagentwhiletiotropiumislongacting.Tiotropiumis
associatedwithadecreaseinexacerbationsandimprovedqualityoflife,[93]andtiotropiumprovidesthosebenefitsbetterthanipratropium.[94]Itdoesnotappearto
affectmortalityortheoverallhospitalizationrate.[95]Anticholinergicscancausedrymouthandurinarytractsymptoms.[5]Theyarealsoassociatedwithincreased
riskofheartdiseaseandstroke.[96][97]Aclidinium,anotherlongactingagentwhichcametomarketin2012,hasbeenusedasanalternativetotiotropium.[98][99]
Corticosteroids
Corticosteroidsareusuallyusedininhaledformbutmayalsobeusedastabletstotreatandpreventacuteexacerbations.Whileinhaledcorticosteroids(ICS)have
notshownbenefitforpeoplewithmildCOPD,theydecreaseacuteexacerbationsinthosewitheithermoderateorseveredisease.[100]Bythemselvestheyhaveno
effectonoveralloneyearmortality.[77][101]Itisuncleariftheyaffecttheprogressionofthedisease.[5]WhenusedincombinationwithaLABAtheymaydecrease
mortalitycomparedtoeitherICSorLABAalone.[102][103]Inhaledsteroidsareassociatedwithincreasedratesofpneumonia.[104]Longtermtreatmentwithsteroid
tabletsisassociatedwithsignificantsideeffects.[87]
Othermedication
Longtermantibiotics,specificallythosefromthemacrolideclasssuchaserythromycin,reducethefrequencyofexacerbationsinthosewhohavetwoormorea
year.[105][106]Thispracticemaybecosteffectiveinsomeareasoftheworld.[107]Concernsincludethatofantibioticresistanceandhearingproblemswith
azithromycin.[106]Methylxanthinessuchastheophyllinegenerallycausemoreharmthanbenefitandthusareusuallynotrecommended,[108]butmaybeusedasa
secondlineagentinthosenotcontrolledbyothermeasures.[6]Mucolyticsmayhelptoreduceexacerbationsinsomepeoplewithchronicbronchitis.[109]Cough
medicinesarenotrecommended.[87]
Oxygen
Supplementaloxygenisrecommendedinthosewithlowoxygenlevelsatrest(apartialpressureofoxygenoflessthan5055mmHgoroxygensaturationsofless
than88%).[87][110]Inthisgroupofpeopleitdecreasestheriskofheartfailureanddeathifused15hoursperday[87][110]andmayimprovepeople'sabilityto
exercise.[111]Inthosewithnormalormildlylowoxygenlevels,oxygensupplementationmayimproveshortnessofbreath.[112]Thereisariskoffiresandlittle
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benefitwhenthoseonoxygencontinuetosmoke.[113]Inthissituationsomerecommendagainstitsuse.[114]Duringacuteexacerbations,manyrequireoxygen
therapytheuseofhighconcentrationsofoxygenwithouttakingintoaccountaperson'soxygensaturationsmayleadtoincreasedlevelsofcarbondioxideand
worsenedoutcomes.[115][116]Inthoseathighriskofhighcarbondioxidelevels,oxygensaturationsof8892%arerecommended,whileforthosewithoutthisrisk
recommendedlevelsare9498%.[116]
Surgery
Forthosewithveryseveredisease,surgeryissometimeshelpfulandmayincludelungtransplantationorlungvolumereductionsurgery.[5]Lungvolumereduction
surgeryinvolvesremovingthepartsofthelungmostdamagedbyemphysemaallowingtheremaining,relativelygoodlungtoexpandandworkbetter.[87]Volume
reductionsurgeryseemstobeparticularlyeffectiveifemphysemapredominantlyinvolvestheupperlobe,buttheprocedureincreasestherisksofearlydeathand
adverseevents.[117]LungtransplantationissometimesperformedforverysevereCOPD,particularlyinyoungerindividuals.[87]
Exacerbations
Acuteexacerbationsaretypicallytreatedbyincreasingtheuseofshortactingbronchodilators.[5]Thiscommonlyincludesacombinationofashortactinginhaled
betaagonistandanticholinergic.[44]Thesemedicationscanbegiveneitherviaametereddoseinhalerwithaspacerorviaanebulizerwithbothappearingtobe
equallyeffective.[118][44]Nebulizationmaybeeasierforthosewhoaremoreunwell.[44]
Oralcorticosteroidsimprovethechanceofrecoveryanddecreasetheoveralldurationofsymptoms.[5][44]Theyworkequallywellasintravenoussteroidsbut
appeartohavefewersideeffects.[119]Fivedaysofsteroidsworkaswellastenorfourteen.[120]Inthosewithasevereexacerbation,antibioticsimprove
outcomes.[121]Anumberofdifferentantibioticsmaybeusedincludingamoxicillin,doxycyclineandazithromycinitisunclearifoneisbetterthantheothers.[64]
TheFDArecommendsagainsttheuseoffluoroquinoloneswhenotheroptionsareavailableduetohigherrisksofserioussideeffects.[122]Thereisnoclear
evidenceforthosewithlessseverecases.[121]
Forthosewithtype2respiratoryfailure(acutelyraisedCO2levels)noninvasivepositivepressureventilationdecreasestheprobabilityofdeathortheneedof
intensivecareadmission.[5]Additionally,theophyllinemayhavearoleinthosewhodonotrespondtoothermeasures.[5]Fewerthan20%ofexacerbationsrequire
hospitaladmission.[44]Inthosewithoutacidosisfromrespiratoryfailure,homecare("hospitalathome")maybeabletohelpavoidsomeadmissions.[44]
Prognosis
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COPDusuallygetsgraduallyworseovertimeandcanultimatelyresultindeath.Itisestimatedthat3%ofall
disabilityisrelatedtoCOPD.[124]TheproportionofdisabilityfromCOPDgloballyhasdecreasedfrom1990to
2010duetoimprovedindoorairqualityprimarilyinAsia.[124]Theoverallnumberofyearslivedwithdisability
fromCOPD,however,hasincreased.[10]
TherateatwhichCOPDworsensvarieswiththepresenceoffactorsthatpredictapooroutcome,including
severeairflowobstruction,littleabilitytoexercise,shortnessofbreath,significantlyunderweightoroverweight,
congestiveheartfailure,continuedsmoking,andfrequentexacerbations.[6]LongtermoutcomesinCOPDcan
beestimatedusingtheBODEindexwhichgivesascoreofzerototendependingonFEV1,bodymassindex,the
distancewalkedinsixminutes,andthemodifiedMRCdyspneascale.[125]Significantweightlossisabad
sign.[15]Resultsofspirometryarealsoagoodpredictorofthefutureprogressofthediseasebutnotasgoodas
theBODEindex.[15][16]
Chronicobstructivepulmonarydiseasedeathsper
millionpersonsin2012
963
117152
291375
6480
153189
3761089
8195
190235
96116
236290
Epidemiology
Globally,asof2010,COPDaffectedapproximately329millionpeople(4.8%ofthepopulation).[10]Thedisease
affectsmenandwomenalmostequally,astherehasbeenincreasedtobaccouseamongwomeninthedeveloped
world.[126]Theincreaseinthedevelopingworldbetween1970andthe2000sisbelievedtoberelatedto
increasingratesofsmokinginthisregion,anincreasingpopulationandanagingpopulationduetofewerdeaths
fromothercausessuchasinfectiousdiseases.[5]Somedevelopedcountrieshaveseenincreasedrates,somehave
remainedstableandsomehaveseenadecreaseinCOPDprevalence.[5]Theglobalnumbersareexpectedto
continueincreasingasriskfactorsremaincommonandthepopulationcontinuestogetolder.[66]
Between1990and2010thenumberofdeathsfromCOPDdecreasedslightlyfrom3.1millionto2.9million[127]
andbecamethefourthleadingcauseofdeath.[5]In2012itbecamethethirdleadingcauseasthenumberof
deathsroseagainto3.1million.[128]Insomecountries,mortalityhasdecreasedinmenbutincreasedin
women.[129]Thisismostlikelyduetoratesofsmokinginwomenandmenbecomingmoresimilar.[15]COPDis
morecommoninolderpeople[1]itaffects34200outof1000peopleolderthan65years,dependingonthe
populationunderreview.[1][62]
InEngland,anestimated0.84millionpeople(of50million)haveadiagnosisofCOPDthistranslatesinto
approximatelyonepersonin59receivingadiagnosisofCOPDatsomepointintheirlives.Inthemost
socioeconomicallydeprivedpartsofthecountry,onein32peoplewerediagnosedwithCOPD,comparedwith
Disabilityadjustedlifeyearslosttochronic
obstructivepulmonarydiseaseper
100,000inhabitantsin2004. [123]
nodata
660770
110
770880
110220
880990
220330
9901100
330440
11001350
440550
1350
550660
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onein98inthemostaffluentareas.[130]IntheUnitedStatesapproximately6.3%oftheadultpopulation,totalingapproximately15millionpeople,havebeen
diagnosedwithCOPD.[131]25millionpeoplemayhaveCOPDifcurrentlyundiagnosedcasesareincluded.[132]In2011,therewereapproximately730,000
hospitalizationsintheUnitedStatesforCOPD.[133]IntheUnitedState,COPD,isestimatedtobethethirdleadingcauseofdeathin2011.[134]
History
Theword"emphysema"isderivedfromtheGreekemphysanmeaning"inflate"itselfcomposedofen,meaning
"in",andphysan,meaning"breath,blast ".[135]Thetermchronicbronchitiscameintousein1808[136]whiletheterm
COPDisbelievedtohavefirstbeenusedin1965.[137]Previouslyithasbeenknownbyanumberofdifferentnames,including
chronicobstructivebronchopulmonarydisease,chronicobstructiverespiratorydisease,chronicairflowobstruction,chronic
airflowlimitation,chronicobstructivelungdisease,nonspecificchronicpulmonarydisease,anddiffuseobstructivepulmonary
syndrome.Thetermschronicbronchitisandemphysemawereformallydefinedin1959attheCIBAguestsymposiumandin
1962attheAmericanThoracicSocietyCommitteemeetingonDiagnosticStandards.[137]
Earlydescriptionsofprobableemphysemainclude:in1679byT.Bonetofaconditionof"voluminouslungs"andin1769by
GiovanniMorgagnioflungswhichwere"turgidparticularlyfromair".[137][138]In1721thefirstdrawingsofemphysemawere
madebyRuysh.[138]ThesewerefollowedwithpicturesbyMatthewBailliein1789anddescriptionsofthedestructivenature
ofthecondition.In1814CharlesBadhamused"catarrh"todescribethecoughandexcessmucusinchronicbronchitis.Ren
Laennec,thephysicianwhoinventedthestethoscope,usedtheterm"emphysema"inhisbookATreatiseontheDiseasesof
theChestandofMediateAuscultation(1837)todescribelungsthatdidnotcollapsewhenheopenedthechestduringan
autopsy.Henotedthattheydidnotcollapseasusualbecausetheywerefullofairandtheairwayswerefilledwithmucus.In
1842,JohnHutchinsoninventedthespirometer,whichallowedthemeasurementofvitalcapacityofthelungs.However,his
spirometercouldonlymeasurevolume,notairflow.TiffeneauandPinelliin1947describedtheprinciplesofmeasuring
airflow.[137]
In1953,Dr.GeorgeL.Waldbott,anAmericanallergist,firstdescribedanewdiseasehenamed"smoker'srespiratory
syndrome"inthe1953JournaloftheAmericanMedicalAssociation.Thiswasthefirstassociationbetweentobaccosmoking
andchronicrespiratorydisease.[139]
GiovanniBattistaMorgagni,who
madeoneoftheearliestrecorded
descriptionsofemphysemain
1769
Earlytreatmentsincludedgarlic,cinnamonandipecac,amongothers.[136]Moderntreatmentsweredevelopedduringthesecondhalfofthe20thcentury.Evidence
supportingtheuseofsteroidsinCOPDwerepublishedinthelate1950s.Bronchodilatorscameintouseinthe1960sfollowingapromisingtrialofisoprenaline.
Furtherbronchodilators,suchassalbutamol,weredevelopedinthe1970s,andtheuseofLABAsbeganinthemid1990s.[140]
Societyandculture
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COPDhasbeenreferredtoas"smoker'slung".[141]Peoplewithemphysemahavebeenknownas"pinkpuffers"or"typeA"duetotheirfrequentpinkcomplexion,
fastrespiratoryrateandpursedlips,[142][143]andpeoplewithchronicbronchitishavebeenreferredtoas"bluebloaters"or"typeB"duetotheoftenbluishcolorof
theskinandlipsfromlowoxygenlevelsandtheirankleswelling.[143][144]ThisterminologyisnolongeracceptedasusefulasmostpeoplewithCOPDhavea
combinationofbothemphysemaandchronicbronchitis.[15][143]
Manyhealthsystemshavedifficultyensuringappropriateidentification,diagnosisandcareofpeoplewithCOPDBritain'sDepartmentofHealthhasidentified
thisasamajorissuefortheNationalHealthServiceandhasintroducedaspecificstrategytotackletheseproblems.[145]
Economics
Globally,asof2010,COPDisestimatedtoresultineconomiccostsof$2.1trillion,halfofwhichoccurringinthedevelopingworld.[13]Ofthistotalanestimated
$1.9trillionaredirectcostssuchasmedicalcare,while$0.2trillionareindirectcostssuchasmissedwork.[146]Thisisexpectedtomorethandoublebytheyear
2030.[13]InEurope,COPDrepresents3%ofhealthcarespending.[1]IntheUnitedStates,costsofthediseaseareestimatedat$50billion,mostofwhichisdueto
exacerbation.[1]COPDwasamongthemostexpensiveconditionsseeninU.S.hospitalsin2011,withatotalcostofabout$5.7billion.[133]
Research
Infliximab,animmunesuppressingantibody,hasbeentestedinCOPDbuttherewasnoevidenceofbenefitwiththepossibilityofharm.[147]Roflumilastshows
promiseindecreasingtherateofexacerbationsbutdoesnotappeartochangequalityoflife.[5]Anumberofnew,longactingagentsareunderdevelopment.[5]
Treatmentwithstemcellsisunderstudy.[148]Whilethereistentativedatathatitissafeandwithpromisinganimaldatathereislittlehumandataasof
2014.[149][150][151]Someofthehumandatathatisavailablehasfoundpoorresults.[152]
Aprocedureknownastargetlungdenervation,whichinvolvesdecreasestheparasympatheticnervoussystemsupplyofthelungs,isbeingstudiedbutdoesnotyet
havesufficientdatatodetermineitsuse.[153]
Otheranimals
Chronicobstructivepulmonarydiseasemayoccurinanumberofotheranimalsandmaybecausedbyexposuretotobaccosmoke.[154][155]Mostcasesofthe
disease,however,arerelativelymild.[156]Inhorsesitisknownasrecurrentairwayobstruction,canbequitesevere,andmostoftenislinkedtoanallergicreaction
toafunguscontainedincontaminatedhayorstraw.[157]COPDisalsocommonlyfoundinolddogs.[158]
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ReviewofCytology.257:21347.doi:10.1016/S00747696(07)570063.
ISBN9780123737014.PMID17280899.
158.MillerMS,TilleyLP,SmithFW(January1989)."Cardiopulmonarydiseaseinthe
geriatricdogandcat".Vet.Clin.NorthAm.SmallAnim.Pract.19(1):87102.
PMID2646821.
Furtherreading
"GlobalStrategyfortheDiagnosis,Management,andPreventionofChronicObstructivePulmonaryDisease,Updated2013"(PDF).GlobalInitiativefor
ChronicObstructiveLungDisease.RetrievedNovember29,2013.
NationalInstituteforHealthandClinicalExcellence.Clinicalguideline101:ChronicObstructivePulmonaryDisease(http://guidance.nice.org.uk/CG101).
London,June2010.
Qaseem,AmirWilt,TJWeinberger,SEHanania,NACriner,GVanDerMolen,TMarciniuk,DDDenberg,TSchnemann,HWedzicha,W
MacDonald,RShekelle,PAmericanCollegeOfPhysiciansAmericanCollegeofChestPhysiciansAmericanThoracicSocietyEuropeanRespiratory
Society(2011)."DiagnosisandManagementofStableChronicObstructivePulmonaryDisease:AClinicalPracticeGuidelineUpdatefromtheAmerican
CollegeofPhysicians,AmericanCollegeofChestPhysicians,AmericanThoracicSociety,andEuropeanRespiratorySociety".AnnalsofInternalMedicine.
155(3):17991.doi:10.7326/00034819155320110802000008.PMID21810710.
Externallinks
Chronicobstructivepulmonarydisease(https://www.dmoz.org/Health/Conditions_and_Diseases/Respiratory_Disord
ers/Chronic_Obstructive_Pulmonary_Disease/)atDMOZ
Retrievedfrom"https://en.wikipedia.org/w/index.php?title=Chronic_obstructive_pulmonary_disease&oldid=747657610"
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obstructivepulmonary
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