COPD

Definition
• Chronic obstructive pulmonary disease (COPD) is defined as a
preventable and treatable disease characterised by persistent airflow
limitation that is usually progressive and associated with an enhanced
chronic inflammatory response in the airways and the lung to noxious
particles or gases
• Related diagnoses
- Chronic bronchitis: productive cough at least three months per year
for two consecutive years (clinical diagnosis)
- Emphysema: abnormal permanent enlargement of the airspaces
distal to the terminal bronchioles, accompanied by destruction of
their walls and without obvious fibrosis (pathologic diagnosis)

Most patients usually have both, with one more prominent

Epidemiology
• The prevalence of COPD is directly proportional to the prevalence of
risk factors

• More than 80 million worldwide

• It is predicted that, by 2030, COPD will represent the seventh leading

cause of disability and fourth most common cause of death
worldwide
Risk factors
Pathophysiology
• In chronic bronchitis phenotype:
Increase mucus-producing goblet cells causing chronic bronchitis, this
mucus will cause airflow limitation.
• In emphysema phenotype:
Damage of the wall distal to terminal bronchioles causing enlargement
- Centri-acinar emphysema.
concentrated around the respiratory bronchioles, while
the more distal alveolar ducts and alveoli tend to be well preserved.
This form of emphysema is extremely common.
- Pan-acinar emphysema.
This is less common, associated with α1-antitrypsin deficiency.
Distension and destruction affect the whole acinus
Clinical features
• Symptoms
- productive cough with white or clear sputum
- Wheeze
- Shortness of breath with exertion then -with progression of disease,
at rest
• Signs
- In mild COPD:
no signs or just quiet wheeze throughout the chest.
- In severe disease:
tachypnoea , prolonged expiration, accessory muscles use, intercostal
indrawing on inspiration and pursing of the lips on expiration.
The cricosternal distance is reduced. Chest expansion is poor, loss of
the normal cardiac and liver dullness.

- Patients in the later stages may develop respiratory failure, pulmonary

hypertension and cor pulmonale
Diagnosis
• Clinical suspicion is based on a history of breathlessness and sputum
production in a chronic smoker

• In the absence of smoking history asthma should be considered,

unless a family history suggesting α1-antitrypsin deficiency

• Post bronchodilator spirometry is needed to confirm the diagnosis

Assessment of symptoms
Assessment of symptoms
Refined ABCD assessment tool
Differential diagnosis
• Asthma
• Congestive heart failure
• Bronchiectasis
Laboratory investigations
• Pulmonary function tests
- Post bronchodilator (FEV1/FVC) ratio < 70%
- No or partial reversibility (<15%)
- If significant emphysema exists, low carbon monoxide diffusion
capacity (DLCO)
• Chest imaging
- Chest radiograph is often normal, classically with advanced disease
may show hyperinflation and maybe bullae
- Chest CT
May show evidence of emphysema
• Blood tests
- Complete blood count
Hemoglobin level could be elevated (secondary polycythemia)
- Arterial blood gases
To evaluate for respiratory failure
- α1-Antitrypsin levels and genotype
are worth measuring in premature disease or life-long non-smokers
• ECG
Often normal.
P-pulmonale and RBBB : secondary pulmonary artery hypertension
with RV hypertrophy
Management
• Smoking cessation: The most useful measure in treatment.
(decreases mortality and improves symptoms)
• Pharmacotherapy: illustrated later
(improves symptoms and decreases exacerbations)
• Home oxygen therapy: illustrated later
(decreases mortality and improves symptoms)
• Pulmonary rehabilitation
(Improves symptoms)
Management
• Vaccines: single polyvalent pneumococcal polysaccharide vaccine and
yearly influenza vaccinations.
• α1-Antitrypsin replacement: in selected α1-Antitrypsin deficiency
patients

• Treat heart failure: if coexist

• Venesection: if secondary polycythaemia with PVC>55%
Management
• Lung volume reduction Surgery: controversial benefit
Bullectomy
(could? improve symptoms and mortality in selected patients)
• Heart lung transplant and single lung transplant
• Endobronchial valve
These occlude airways of hyperinflated emphysematous lungs and
effectively achieve lung volume reduction
Long term oxygen therapy
• More than 15 (19) hours daily
• Indications
- resting PaO2 = 55 mmHg or SaO2 88% or less
while being at rest in a stable clinical condition
- resting PaO2 = 59 mm Hg or SaO2 89% or less
if there is evidence of cor pulmonale, right heart failure or
polycythemia (hematocrit greater than 55%) while being in a stable
clinical condition
Pharmacotherapy
Pharmacotherapy
• Bronchodilators

- Beta 2 agonists (short and long acting)

- Muscarinic antagonists (short and long acting)
- Theophyllines: less effective, narrow therapeutic index
• Phosphodiesterase type 4 inhibitors

- Roflumilast: used in more severe cases with chronic bronchitis

predominant type
• Corticosteroids
- Inhaled corticosteroids: indicated with frequent exacerbations

- Oral corticosteroids: used in exacerbations

• Antibiotics

- Used in exacerbations
- Long term treatment with macrolides (azithromycin) recently has
been shown to decrease exacerbations and improves quality of life.
• Mucolytic agents

- reduce sputum viscosity and can reduce the number of acute

exacerbations. as carbocysteine
COPD exacerbation
• COPD exacerbation: acute worsening of dyspnea and other symptoms
(amount of sputum, purulence of sputum, wheeze)
• Usually triggered by bacterial or viral infections (pneumonia or
bronchitis) and change in air quality.
Severity of COPD exacerbation
Respiratory Rate Use of Mental Status Improvement of Hypercarbia
(Breaths Per Accessory Changes Hypoxemia Present
Minute) Respiratory With Venturi
Muscles Mask
No ARF 20-30 no no yes no

ARF (nonlife- >30 yes yes yes Yes

threatening) 50-60mmHg
Or increase from
baseline
ARF (life- >30 yes yes No PaCO2 >60
threatening) Requiring high mmHg or pH
FiO2>40% ≤7.25
Management
• Supplemental O2, venturi mask
• Short acting bronchodilators
• Systemic steroids
• Antibiotics
• Consider non-invasive ventilation(Bi-PAP)
• Consider invasive ventilation