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This lecture was conducted during the Nephrology Unit Grand Ground by Medical Student rotated under Nephrology

Division under the supervision and administration of Prof. Jamal Al Wakeel, Head of Nephrology Unit, Department of Medicine and Dr. Abdulkareem Al Suwaida, Chairman of the Department of Medicine. Nephrology Division is not responsible for the content of the presentation for it is intended for learning and /or education purpose only.

COPD
Chronic Obstructive Lung Disease

Prepared by: SAAD AL-AMRI Medical Student May 2008

What is COPD?


Defenition: It is a disease state characterized by presence of air flow obstruction due to chronic bronchitis or emphysema. The air flow limitation is generally progressive.

COPD

Chronic bronchitis

Emphysema

Clinically diagnosed

Pathologically diagnosed

Chronic bronchitis


 

Chronic productive cough on most days of 3 consecutive months in 2 consecutive years. Providing other causes have been excluded. >85% of COPD.

Emphysema

Abnormal and permanent dilatation of air spaces associated with destruction of their walls.

Etiology


Smoking

the primary risk factor Long-term smoking is responsible for 80-90 % of cases.  Prolonged exposures to harmful particles and gases from:

passive smoke, Industrial smoke, Chemical gases, vapors, mists & fumes Dusts from grains, minerals & other materials

Alpha 1-antitrypsin deficiency >>> emphysema

Pathophysiology
Exposure to inhaled noxious particles & gases inflammation imbalance of proteinases and anti-proteinases

Dilatation & destruction + mucus secretion

Clinical features
Hx:  Smoker  Productive cough
Constant Chest tightness in the morning Sputum>>>>>> mucoid If purulent>>>> infection

SOB>>>> on exertion

Aggravated by infection, heavy smoking.

On Examination:


Inspection:


Pt looks dyspnic  Use of accessory muscles  Burrel shaped chest Decrease chest expansion

 

Palpation


Percussion
hyper-resonant  Loss of normal area for cardiac & liver dullness


Auscultation:

Decreased breath sounds Normal vesicular breathing but prolonged expiration Coarse crepitatons>> on both phases

Investigations


Baseline ABG:
important for assessing patients with severe COPD. Annual monitoring test Detect acute & chronic hypercapnia Respiratory acidosis

Investigations


Chest X-Ray:

Not sensitive for Dx To exclude other diseases Hyper-inflation signs

Investigations


Pulmonary function testing (spirometry):

Main method for diagnosing COPD. low FEV1/FVC (< 70%) Used for classification of COPD severity.

PFT

   

Obstructive pattern FEV1>>>>>>>reduced (<80%) FEV1/FVC>>>reduced (<70%) PEF>>>>>>>>reduced TLC>>>>>>>>increased

Classification of severity of COPD




Mild
 

FEV1 60-79% Smoker , cough FEV1 40-59% SOB, wheeze, cough +/- sputum FEV1 < 40% SOB, wheeze, cough ,RD, swollen legs

Moderate
 

Severe
 

Other Investigations
   

Sputum C/S >> in acute ECG Echo >> assess pulmonary artery pressure Alpha 1-anti-trypsin

Treatment of COPD
    

Cessation of Smoking (most important) Oxygen Therapy Ongoing assessment & monitoring Education Rx of Acute exacerbations.

Management of COPD Improve quality of life Bronchodilators + steroids

Increase survival

stop smoking Supplemental O2

Oxygen Therapy (LTOT)

Home oxygen in low dose Given at least 15 hrs @ flow rate 1-3L/min If PaO2 <60% If SaO2 < 88%

Inhaled bronchodilators

Beta-agonists


Short acting>>> 2-4 puffs bid-qid & PRN e.g: salbutamol  Long acting >>> twise daily e.g: salmetrol, formoterol Side efferct: Tachycardia, tremors, hypokalemia


Anti-cholinergic
Ipratropium bromide (Atrovent) 2-4 puffs PRN

Steroids

Inhaled:
 

e.g : fluticasone Withdrawal may cause exacerbation Only for severe cases.

Systemic :


Vaccinations

 

Influenza Pneumococcal

No role for antibiotics


except in acute exacerbations

Acute exacerbation of COPD


  

Increased SOB Wheezing Causes :


Infections pollutions

Infections

Moraxella Streptococcus catarrhalis pneumoniae 19.2% 19. 17. 17.2% 30. 30.3% 33.3% 33. Haemophilus influenzae Other pathogens include: H parainfluenzae, Staphylococcus aureus2

Rx of acute exacerbation of COPD


 

Inhaled bronchodilators>>> short acting Antibiotics

Mild

Amoxicillin Cephalosporins

moderate to severe (G-ve rods)


Azithromycin 3rd generation Cephalosporins

  

Oxygen BiPAP Mechanical ventilation

Indicaton for ICU admession


  

Severe dyspnea not medical Rx Mental status changes Persistent hypoxemia, hypercapnia or Resp. acidosis despite medical Rx