chronic obstructive pulmonary disease

COPD – Harrison Club

Internal Medicine PGY-1Ranjita Pallavi

Definition

Chronic Obstructive Pulmonary Disease (COPD) is a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases.

Asthma and COPD

Risk factors

Smoking

Airway Responsiveness and COPD

Respiratory infections

Occupational exposure

Ambient Air Pollution

Passive smoke exposure

Genetic Considerations

Alpha 1 Antitrypsin Deficiency Allelles: M,S,Z and Null

Most common deficiency PiZ

1-2% of COPD patients with severe

alpha 1 AT deficiency

Early onset COPD

Variability among PiZ individuals:

explained by Smoking/Asthma/COPD

Risk in PiMZ individuals

In patients of Caucasian descent who develop COPD at a young age (< 45 years) or who have a strong family history of the disease, it may be valuable to identify coexisting alpha-1antitrypsin deficiency. This could lead to family screening or appropriate

Assessment and Monitoring

Natural History

Pathophysiology

Airflow Obstruction

Hyperinflation

Gas exchange

Pathology

Large Airways

Small Airways

Lung Parenchyma

Large AirwaysSmall AirwaysLung Parenchyma

Pathogenesis

Elastase:Antielastase Hypothesis


Clinical Presentation

History

Physical Examination

Lab Findings


The diagnosis and staging of COPD require what two spirometric measures?

Severity Classification Question

FEV1/FVC

FEV1

Severity Classification

FEV1/FVC < 0.7.


The diagnosis of COPD is confirmed when a post-bronchodilator:

GOLD Criteria for COPD


Spirometric classification has proved useful in predicting health status, utilization of healthcare resources, research, development of exacerbations and mortality.


In advanced COPD, measurement of arterial blood gases while the patient is breathing air is important. This test should be performed in stable patients with FEV1 < 50% predicted or with clinical signs suggestive of respiratory failure or right heart failure.

Assessment and Monitoring

Radiographic Studies

Chest X ray

CT Chest


Clinical Presentation

History

Physical Examination

Lab Findings


The Public Health Service recommends a five-step program (the five A’s) for smoking cessation intervention. After ASK, ADVISE, ASSESS, and ASSIST, what is the last step in the GOLD guidelines?

Assessment and Monitoring Question

ASK Systematically identify all tobacco users at

every visit

ADVISE Strongly urge all tobacco users to quit

ASSESS Determine willingness to make a quit

attempt.

ASSIST Aid the patient in quitting

ARRANGE Schedule follow-up contact

Assessment and MonitoringSmoking Cessation Strategy

True or False: Influenza vaccine and pneumococcal polysaccharide vaccine are recommended for all COPD patients.

Managing Stable Disease

False: In COPD patients, influenza vaccines canreduce serious illness. Pneumococcal polysaccharide vaccine is recommended for COPD patients 65 yearsand older and for COPD patients younger than age 65 with an FEV1 < 40% predicted


Nutritional support had no significant effect on anthropometric measures, lung function or exercise capacity in patients with stable COPD. Although some quality of life indices gave significant findings, these results were from a single small unblinded study and restricted to certain domains of health status measurements. More work in this particular area is needed to establish whether supplementation can lead to subjective benefits in quality of life.

Cochrane Database, 2007

Managing Stable DiseaseNutrition

Managing Stable DiseasePharmacotherapy

Anticholinergic Agents

Beta-2 Agonists

Inhalational Corticosteroids

Oral Corticosteroids

Theophylline

Oxygen

N-acetyl cysteine

Alpha-1 AT augmentation therapy

Managing COPD Exacerbations

Patient Assessment

Identify Precipitating Causes

Bronchodilators

Corticosteroids

Antibiotics

Oxygen

Mechanical Ventilator Support

Managing Stable DiseaseNon Pharmacologic Measures

General Medical Care

Pulmonary Rehabilitation

Lung Volume Reduction Surgery

Lung Transplantation

Rehabilitation relieves dyspnea and fatigue, improves emotional function and enhances patients’ sense of control over their condition. These improvements are moderately large and clinically significant. Rehabilitation forms an important component of the management of COPD.

Cochrane Database, 2007

Managing Stable DiseasePulmonary Rehabilitation

The long-term administration of oxygen (> 15 hours per day) to patients with chronic respiratory failure has been shown to increase survival. It can also have a beneficial effect on hemodynamics, hematologic characteristics, exercise capacity, lung mechanics and mental state.

Managing Stable Disease Oxygen Therapy

Long-term home oxygen therapy improved survival in a selected group of COPD patients with severe hypoxaemia (arterial PaO2 less than 55 mm Hg (8.0 kPa)). Home oxygen therapy did not appear to improve survival in patients with mild to moderate hypoxaemia or in those with only arterial desaturation at night.

Managing Stable DiseaseOxygen Therapy

PaO2 < 55 mm Hg, or SaO2 < 88 %, at rest,

breathing room air.

PaO2 < 55 mm Hg, or SaO2 < 88 %, during sleep for

a patient who demonstrates an PaO2 > 56 mm Hg, or

SaO2 > 89 percent, while awake.

PaO2 < 55 mm Hg or SaO2 < 88%, during exercise

for a patient who demonstrates an PaO2 > 56 mm Hg,

or SaO2 > 89 percent during the day, while at rest.


PaO2 is 56-59 mm Hg or whose SaO2 = 89%, if there

is evidence of:

Dependent edema suggesting congestive heart failure;

Pulmonary hypertension or cor pulmonale, determined

by measurement of pulmonary artery pressure, gated

blood pool scan, echocardiogram, or “P” pulmonale on

EKG (P wave greater than 3 mm in standard leads II, III,

or AVF); or

Erythrocythemia with a hematocrit greater than 56

percent.


Wise R, Tashkin D. AJM 2007;120:S4


Patients with FEV1/DLco < 20% of predicted AND homogeneous (diffuse) distribution of emphysema are at high risk for death after surgery and are unlikely to benefit from lung volume reduction surgery (LVRS).

NETT. NEJM 2001;345:1075-83.

Managing Stable Disease Surgery

Guidelines for Referral BODE index exceeding 5 Guidelines for Transplantation Patients with a BODE index of 7 to 10 or at least 1 of

the following: History of hospitalization for exacerbation associated

with acute hypercapnia (PCO2 exceeding 50 mm Hg) Pulmonary hypertension or cor pulmonale, or both

despite oxygen therapy. FEV1 of less than 20% and either DLCO of less than

20% or homogenous distribution of emphysema.

ISHLT Guidelines. JHeartLungTrans.2006;25:745


What is BODE an acronym for?

Managing Stable Disease Surgery Question

Celli B, et al. NEJM. 2004;350:1005


Thank You

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chronic obstructive pulmonary disease

Health & Medicine

copd patients younger

stable copd

diagnosis of copd

advanced copd

staging of copd

management of copd

stable patients

individual patients