COPD

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Introduction

06/28/2023
COPD by Meaza R( MD Internist)
 Defined as disease state characterized by persistent respiratory symptoms and
airflow obstruction(GOLD)
 The classic definition of COPD requires the presence of
chronic airflow obstruction by spirometry
 250 million people live with COPD world wide and
 is the 4th leading cause of death in US
Which one is to be considered symptom Vs air flow limitation? 3

06/28/2023
COPD by Meaza R( MD Internist)
 COPD
 Is based only on airflow obstruction determined by spirometric thresholds of
normality.
 Respiratory symptoms and other features of COPD can occur in subjects who do not
meet a definition of COPD
 Chronic bronchitis with out air flow limitation is not COPD
What are the mechanism of obstruction? 4

06/28/2023
COPD by Meaza R( MD Internist)
Small airway disease
Air way inflammation

Is there any significant airway hyperresponsive ness and smooth musles contraction?
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06/28/2023
COPD by Meaza R( MD Internist)
 Emphysema: an abnormal and permanent distension of air spaces distal to the
terminal bronchiole with destruction of the alveoli
 Classification
 Centrilobular
 Limited to the reparatory bronchiole and alveoli related to them, spare the periphery
 Upper lobe and superior segments of lower lobe
 Frequently associated with smoking , coal miners in some case
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06/28/2023
COPD by Meaza R( MD Internist)
 Panacinar
 Both peripheral and central acini are involved
 Predominantly the lower half of the the lung is affected
 Associate to α1 AT deficiency
 Paraseptal (distal acinar)
 may occur alone or in association with the above two.
 When it occurs alone, the usual association is a spontaneous pneumothorax in a young
adult.
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06/28/2023
COPD by Meaza R( MD Internist)
 chronic Bronchitis:
 Excess tracheobronchial mucus secretion thus cause productive chronic cough (3
month of a yr for more than two consecutive years), Goblet cells
 There is hypertrophied and hyperplastic mucus gland
 Is inflammation of the airways with reduced caliber

 Small airway disease : involve the bronchioles

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Risk factors

06/28/2023
COPD by Meaza R( MD Internist)
 Environmental
 Smoking: dose response relationship
 Occupational exposure(mining, textile, dust exposure)
 Air pollution
 Respiratory infection(exacerbation)
 Genetics
 Alpha 1 antitrypsin deficiency
 Abnormal lung development
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Pathogenesis

06/28/2023
COPD by Meaza R( MD Internist)
 The physiologic marker is Airflow obstruction which results from airway disease
and /or emphysema
 Lead to inflammatory cell recruitment within the
terminal air spaces of the lung 12

06/28/2023
COPD by Meaza R( MD Internist)
These inflammatory cells release elastolytic proteinases
that damage the extracellular matrix of the lung.

Structural cell death results from oxidant

stress and loss of matrix-cell attachment

Ineffective repair of elastin and other extracellular

matrix components result in air space
enlargement that defines pulmonary
emphysema.
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COPD by Meaza R( MD Internist)

06/28/2023
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pathophysiology

06/28/2023
COPD by Meaza R( MD Internist)
 Airflow obstruction determined by spirometry (FEV1/FVC)
 Hyperinflation : air trapping with increased residual volume

Clinical presentation
Chronic bronchitis
 Ongoing productive cough
 Copious purulent sputum
 Breathlessness( late )
 Wheeze
 Chest tightness
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06/28/2023
COPD by Meaza R( MD Internist)
Emphysema
 Minimal cough with exacerbation
 Breathlessness, insidious in
onset( initially exertional then at rest)
 Generalized weakness, lethargy
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Approach

06/28/2023
COPD by Meaza R( MD Internist)
 History( symptoms, smoking, occupation, family Hx, Hx medication)
 Physical examination
 Signs of smoking ( odor , stained finger),
 Barrel chest
 Accessory muscle use
 Tripod position
 Cyanosis, clubbing
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06/28/2023
COPD by Meaza R( MD Internist)
 Posture
 Pink puffers (thin, noncyanotic at rest and prominent use of accessory muscles):
Emphysema
 In chronic bronchitis: cyanotic and heavy(blue bloaters)
 Sign of right HF?
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06/28/2023
COPD by Meaza R( MD Internist)
 Poor diaphragmatic excursion
 Hyper resonant
 Decreased breath sound to silent chest
 Wheeze, prolonged expiratory phase
 Crepitation
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06/28/2023
COPD by Meaza R( MD Internist)
 investigation
 CBC--- anemia/ polycythemia, exacerbation
 ABG and oximetry
• Demonstrate resting or exertional hypoxemia.
• Alveolar ventilation and acid-base status by measuring arterial P CO2 and pH.
• The change in pH with PCO2 is 0.08 units/10 mmHg acutely and 0.03 units/10
mmHg in the chronic state.
• Arterial pH -ventilatory failure( PCO2 >45 mmHg) - acute or chronic
• Indications for ABG --- when to do ABG?
• Low FEV1( < 50%)
• SaO2 < 92%
• Depressed LOC
• Acute exacerbation
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06/28/2023
COPD by Meaza R( MD Internist)
 Spirometry
 FEV1/ FVC ratio < 0.7 ---- airflow limitation
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Is imaging important to Dx COPD?

06/28/2023
COPD by Meaza R( MD Internist)
 Not required to diagnose COPD
 CXR
 Used to exclude other diagnosis like kiynphosis
 Sensitivity for moderate cases(50%)
 Inc. radiolucency, flat diaphragm, long and narrow heart shadow
 Inc. retrosternal airspace on lateral x- ray
 Bullae
 Prominent hilar vascular shadows – in advanced disease with pulmonary HTN and cor
pulmonale
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COPD by Meaza R( MD Internist)

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….
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When to do chest CT?

06/28/2023
COPD by Meaza R( MD Internist)
 Indicated if
 Lung cancer is considered in the presence of emphysema
 To asses the presence of bronchiectasis
 Preoperative assesment for LVRS
 Centriacinar – upper lobe and holes in center of SPL
 Panacinar – lung bases and entire SPL
 Paraseptal – periphery
 Lung transplantation
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COPD by Meaza R( MD Internist)

06/28/2023
What is the role of chest CT?


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COPD by Meaza R( MD Internist)
How to assess level of air flow limitation ? 26

06/28/2023
COPD by Meaza R( MD Internist)
 Spirometry should be done after adequate does of SABA
 After 15 minute
How to assess symptom? 27

06/28/2023
COPD by Meaza R( MD Internist)
 COPD is beyond dyspnea so what to do?
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COPD by Meaza R( MD Internist)

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Combined assesment
How do you level the patient? 29

06/28/2023
COPD by Meaza R( MD Internist)
 Based on GOLD stage and grouping
 Less symptom, low exacerbation?
 More symptom, less exacerbation?
 Less symptom, frequent exacerbation?
 More symptom, frequent exacerbation?
 ABCD
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COPD by Meaza R( MD Internist)

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Management

06/28/2023
COPD by Meaza R( MD Internist)
 Acute exacerbation Vs stable COPD
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06/28/2023
COPD by Meaza R( MD Internist)
 Stable phase
 Goal: provide symptom relieve and reduce future risk
 survival is improved by:
 Quit smoking,
 oxygenation,
 lung volume reduction(emphysematous)
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pharmacotherapy

06/28/2023
COPD by Meaza R( MD Internist)
 Medical therapy
 symptomatic and decrease exacerbation( bronchodilators, steroid)
 Smoking cessation
 Oxygen
 Decrease mortality
 Indicated with person with resting SPo2<= 88%, history of pulmonary hypertension or
corplumonale or erythrocytosis
 `α 1 AT Augmentation Therapy
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Non pharmacotherapy

06/28/2023
COPD by Meaza R( MD Internist)
 Vaccination (influenza, pneumococcal, Bordetella pertussis)
 Lung rehabilitation ( pt education, exercise, psychosocial and nutritional)
 Improve QOL, dyspnea , exercise tolerance
 Reduce rate of hospitalization
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06/28/2023
COPD by Meaza R( MD Internist)
 Surgical volume reduction
 In emphysematous lung
 Improve lung function, exercise capacity
 Candidates: upper lobe predominant emphysema and pts with low post rehabilitation
exercise capacity

 Lung transplant
 Pts with very sever airflow obstruction
 COPD is 2nd leading cause for lung transplant
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06/28/2023
COPD by Meaza R( MD Internist)
 Acute exacerbation
 Bronchodilators
 Systemic glucocorticoid
 Antibiotics
 Oxygen supplement keep saturation above 90%
 Ventilatory support: invasive vs non invasive
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06/28/2023
COPD by Meaza R( MD Internist)
 COPD hospitalization
 20% rehospitalized in next 30 days
 45% in the next yr
 20% hospitalized pts die in the following yr after discharge
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06/28/2023
COPD by Meaza R( MD Internist)
 It has been shown that a multifactorial index (BODE), incorporating airflow
obstruction, exercise performance, dyspnea, and body mass index, is a better
predictor of mortality. Recently, GOLD added additional elements to their COPD
classification system incorporating respiratory symptoms and exacerbation history
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06/28/2023
COPD by Meaza R( MD Internist)
 Reference
 Harrison 21st ed
 UpToDate
 ATS
 GOLD 2020