Chronic Obstructive

Pulmonary Disease: COPD

dr. Tjatur Winarsanto SpPD

 Chronic Obstructive
Pulmonary Disease: COPD

Disease of airflow
obstruction that is not
totally reversible
Chronic
Bronchitis
Emphysema
COPD: Etiology
Cigarette smoking #1
Recurrent respiratory infection
Alpha 1-antitrypsin deficiency
Aging
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:
1. Simple chronic bronchitis
2. Chronic mucopurulent bronchitis
3. Chronic bronchitis with obstruction
4. Chronic bronchitis with obstruction and
airway hyperreactivity.
Chronic Bronchitis
Recurrent or chronic productive
cough for a minimum of 3 months
for 2 consecutive years.
Risk factors
Cigarette smoke
Air pollution
Chronic Bronchitis
Pathophysiology
Chronic
inflammation
Hypertrophy &
hyperplasia of
bronchial glands
that secrete mucus
Increase number of
goblet cells
Cilia are destroyed
Chronic Bronchitis
Pathophysiology
Narrowing of
airway
Starting w/ bronchi
smaller airways
airflow resistance
work of breathing
Hypoventilation &
CO2 retention
hypoxemia &
hypercapnea
Chronic Bronchitis
Pathophysiology
Bronchospasm often occurs
End result
Hypoxemia
Hypercapnea
Polycythemia (increase RBCs)
Cyanosis
Cor pulmonale (enlargement of right side of
heart)
Chronic Bronchitis:
Clinical Manifestations
In early stages
Clients may not recognize early symptoms
Symptoms progress slowly
May not be diagnosed until severe episode
with a cold or flu
Productive cough
Especially in the morning
Typically referred to as cigarette cough
Bronchospasm
Frequent respiratory infections
Chronic Bronchitis:
Clinical Manifestations
Advanced stages
Dyspnea on exertion Dyspnea at rest
Hypoxemia & hypercapnea

Polycythemia

Cyanosis

Bluish-red skin color

Pulmonary hypertension Cor

pulmonale
Chronic Bronchitis:
Diagnostic Tests
PFTs
FVC: Forced vital capacity
FEV1: Forcible exhale in 1 second
FEV1/FVC = <70%
ABGs
PaCO2
PaO2
RBC
Hct
Emphysema
Abnormal
distension of air
spaces
Actual cause is
unknown
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:
1. Centriacinar ( centrilobular) emphysema
2. Panacinar emphysema
3. Paraseptal emphysema
4. Senile emphysema
Emphysema:
Pathophysiology
Structural changes
Hyperinflation of
alveoli
Destruction of alveolar
& alveolar-capillary
walls
Small airways narrow
Lung elasticity
decreases
Emphysema:
Pathophysiology
Mechanisms of
structural change
Obstruction of small
bronchioles
Proteolytic enzymes
destroy alveolar tissue
Elastin & collagen are
destroyed
Support structure is
destroyed
paper bag lungs
Emphysema:
Pathophysiology
The end result:
Alveoli lose elastic
recoil, then distend,
& eventually blow
out.
Small airways
collapse or narrow
Air trapping
Hyperinflation
Decreased surface
area for ventilation
Emphysema:
Clinical Manifestations
Early stages
Dyspnea
Non productive cough
Diaphragm flattens
A-P diameter increases
Barrel chest
Hypoxemia may occur
Increased respiratory rate
Respiratory alkalosis
Prolonged expiratory phase
Emphysema:
Clinical Manifestations
Later stages
Hypercapnea
Purse-lip breathing

Use of accessory muscles to breathe

Underweight

No appetite & increase breathing

workload
Lung sounds diminished
Emphysema: Clinical
Manifestations
Emphysema: Clinical
Manifestations
Pulmonary function
residual volume, lung capacity, DECREASED
FEV1, vital capacity maybe normal
Arterial blood gases
Normal in moderate disease
May develop respiratory alkalosis
Later: hypercapnia and respiratory acidosis
Chest x-ray
Flattened diaphragm
hyperinflation
Assess for COPD:
A Common Story
Cough
intermittent or daily
present throughout day- seldom only nocturnal
Sputum
Any pattern of chronic sputum production
Dyspnea
Progressive and Persistent
"increased effort to breathe" "heaviness" "air hunger"
or "gasping"
Worse on exercise
Worse during respiratory infections
Exposure to risk factors
Tobacco smoke
Occupational dusts and chemicals
Smoke from home cooking and heating fuels
 Assess and Monitor Disease
Classification of COPD
Stage 0 At Risk
Stage I Mild COPD
Stage II Moderate COPD
Stage III Severe COPD
Stage IV Very Severe
COPD
Stage 0 At Risk
Normal spirometry
+/- Chronic symptoms (cough,
sputum, production)
Stage I Mild COPD
FEV1/FVC <70%
FEV1 >80% predicted
With or without chronic
symptoms (cough, sputum
production)
Stage II Moderate COPD
FEV1/FVC <70%
50% <FEV1 <80% predicted
With or without chronic
symptoms (cough, sputum
production)
Stage III Severe COPD

FEV1/FVC <70%
30% <FEV1 <50% predicted
With or without chronic
symptoms (cough, sputum
production)
Stage IV Very Severe
COPD
FEV1/FVC <70%
FEV1 <30% predicted or FEV1
<50% predicted plus chronic
respiratory failure
Goals of Treatment:
Emphysema & Chronic
Bronchitis
Improved ventilation
Remove secretions
Prevent complications
Slow progression of signs &
symptoms
Promote patient comfort and
participation in treatment
Collaborative Care:
Emphysema & Chronic
Bronchitis
Treat respiratory infection
Monitor spirometry and PEFR
Nutritional support
Fluid intake 3 lit/day
O2 as indicated
Collaborative Care:
Medications
Anti-inflammatory
Corticosteroids
Bronchodilators
Beta-adrenergic agonist: Proventil
Methylxanthines: Theophylline
Anticholinergics: Atrovent
Mucolytics:
Expectorants:
Antihistamines:
Collaborative Care:
Emphysema & Chronic
Bronchitis
Client teaching
Support to stop smoking
Conservation of energy
Breathing exercises
Pursed lip breathing
Diaphragm breathing
Chest physiotherapy
Percussion, vibration
Postural drainage
Self-manage medications
Inhaler & oxygen equipment
Therapy by Stage- Pretty
Simple
Bronchodilators
Beta2-agonists
Short-acting
Fenoterol
Salbutamol (albuterol)

Terbutaline

Long-acting
Formoterol
Salmeterol
 Bronchodilators
Anticholinergics

Mode of Action
Cholinergic tone is only reversible component
of COPD
Normal airway have small degree of vagal
cholinergic tone
Short-acting
Ipratropium bromide
Oxitropium bromide
Long-acting
Tiotropium
Combos and
Methylxanthines

Combination beta2-agonists plus

anticholinergic in one inhaler
Fenoterol/Ipratropium
Salbutamol/Ipratropium

Methylxanthines
Aminophylline (slow release preparations)
Theophylline (slow release preparations)
RARELY OF SIGNIFICNAT BENEFIT
LEVEL 8-12 mcg/ml