CHRONIC OBSTRUCTIVE CHRONIC OBSTRUCTIVE PULMONARY DISEASEPULMONARY DISEASE

By Dr AguileraBy Dr Aguilera

DefinitionDefinition

In 2001, the Global Initiative for Chronic In 2001, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) report Obstructive Lung Disease (GOLD) report was developed to define COPD by an expert was developed to define COPD by an expert panel which includes the National Heart, panel which includes the National Heart, Lung and Blood Institute and the World Lung and Blood Institute and the World Health Organization.Health Organization.

COPD is “A disease state characterized by COPD is “A disease state characterized by airflow limitation that is not fully reversible; airflow limitation that is not fully reversible; it is usually both progressive and associated it is usually both progressive and associated with an abnormal inflammatory response of with an abnormal inflammatory response of the lungs to noxious particles or gases.”the lungs to noxious particles or gases.”

Definition Cont’dDefinition Cont’d

Previous Guidelines and Definitions Previous Guidelines and Definitions included Chronic bronchitis and included Chronic bronchitis and emphysema, but these are not emphysema, but these are not included in the current definition.included in the current definition.

The GOLD report’s definition of COPD The GOLD report’s definition of COPD regards chronic bronchitis, regards chronic bronchitis, emphysema and asthma as different emphysema and asthma as different aspects of the disease that are not aspects of the disease that are not mutually exclusive.mutually exclusive.

Definition Cont’dDefinition Cont’d Chronic BronchitisChronic Bronchitis

Defined by the presence of chronic productive cough Defined by the presence of chronic productive cough for three months in each of two successive years in a for three months in each of two successive years in a patient in whom other causes of cough are excludedpatient in whom other causes of cough are excluded

EmphysemaEmphysema Is a pathological term describing the abnormal Is a pathological term describing the abnormal

permanent enlargement of airspaces distal to the permanent enlargement of airspaces distal to the terminal bronchioles, accompanied by destruction of terminal bronchioles, accompanied by destruction of their walls without obvious fibrosis.their walls without obvious fibrosis.

AsthmaAsthma Chronic inflammatory disease of the airways with Chronic inflammatory disease of the airways with

bronchial hyper-responsiveness, reversible airway bronchial hyper-responsiveness, reversible airway obstruction, and respiratory symptoms. (See previous obstruction, and respiratory symptoms. (See previous lecture)lecture)

PathophysiologyPathophysiology Bronchial inflammationBronchial inflammation

Caused by inflammatory cells (macrophages, Caused by inflammatory cells (macrophages, neutrophils and CD8 cytotoxic T cells) in a neutrophils and CD8 cytotoxic T cells) in a response to noxious stimuliresponse to noxious stimuli

release of enzymes (proteases)release of enzymes (proteases) these cause destruction of connective tissue in the these cause destruction of connective tissue in the

airways and alveolar walls.airways and alveolar walls. Also stimulate mucus production by goblet cellsAlso stimulate mucus production by goblet cells

Different than what we see in Asthma (CD4 Different than what we see in Asthma (CD4 and eosinophils)and eosinophils)

Ciliary damage occurs directly by noxious Ciliary damage occurs directly by noxious stimuli (tobacco, occupational dusts and stimuli (tobacco, occupational dusts and chemicals, and air pollution)chemicals, and air pollution)

Pathophysiology Cont’dPathophysiology Cont’d

Variability of Response to Noxious Variability of Response to Noxious StimuliStimuli GeneticsGenetics

imbalance of antiproteasesimbalance of antiproteases May explain why only approximately 15% of May explain why only approximately 15% of

smokers develop COPDsmokers develop COPD Alpha-1-antitrypsin deficiencyAlpha-1-antitrypsin deficiency

As a result, air trapping, collapse of As a result, air trapping, collapse of alveoli and inability to clear debris alveoli and inability to clear debris from the airways occur, which manifest from the airways occur, which manifest clinically as the COPD syndrome.clinically as the COPD syndrome.

Disease InterrelationshipsDisease InterrelationshipsChronic bronchitis

Emphysema

Asthma

Airflow Obstruction

COPD

1 2

3 45

6 7

8

9

10

EpidemiologyEpidemiology Approx 16 million people in U.S. have COPDApprox 16 million people in U.S. have COPD 55thth leading cause of death leading cause of death

44thth in people > 45 yrs in people > 45 yrs Most deaths occur in people > 65 yearsMost deaths occur in people > 65 years

In 2000: ED visits = 1.5 millionIn 2000: ED visits = 1.5 million Hospitalizations = 726,000Hospitalizations = 726,000 Deaths = 119,000Deaths = 119,000 Health care costs approx 15 billion/yearHealth care costs approx 15 billion/year Tobacco smoking accounts for 80-90% of casesTobacco smoking accounts for 80-90% of cases

Only 15% of smokers develop COPDOnly 15% of smokers develop COPD Women are affected more than men with same tobacco exposureWomen are affected more than men with same tobacco exposure

Alpha-1-antitrypsin accounts for <.1% of casesAlpha-1-antitrypsin accounts for <.1% of cases Homozygous (.02%) < Heterozygous (2-3%) - whitesHomozygous (.02%) < Heterozygous (2-3%) - whites When to test for serum levels? In pts with COPD at young age, When to test for serum levels? In pts with COPD at young age,

particularly in those with (+) FHx and no exposure to tobaccoparticularly in those with (+) FHx and no exposure to tobacco Replace with alpha-1-proteinase inhibitor (Prolastin)Replace with alpha-1-proteinase inhibitor (Prolastin)

DiagnosisDiagnosis

HistoryHistory Patients with COPD usually have been smoking Patients with COPD usually have been smoking

at least 20 pack years before symptoms at least 20 pack years before symptoms develop.develop.

Cough usually is the first symptom. This is Cough usually is the first symptom. This is followed by sputum production and then followed by sputum production and then shortness of breath which worsen over time shortness of breath which worsen over time and may get worse with exacerbations.and may get worse with exacerbations.

Wheezing may be presentWheezing may be present Exposure to risk factors: tobacco, occupational Exposure to risk factors: tobacco, occupational

dusts and chemicals, air pollutiondusts and chemicals, air pollution

Diagnosis Cont’dDiagnosis Cont’d

Physical ExaminationPhysical Examination Usually normal early in the course of the diseaseUsually normal early in the course of the disease Findings are variable as the disease progressesFindings are variable as the disease progresses

Chest SignsChest Signs Prolonged expiration with/out wheeze; decreased breath Prolonged expiration with/out wheeze; decreased breath

sounds; Crackles especially with exacerbations; sounds; Crackles especially with exacerbations; Increased anteroposterior diameter due to hyperinflationIncreased anteroposterior diameter due to hyperinflation

Distant heart soundsDistant heart sounds Extrathoracic SignsExtrathoracic Signs

Leaning forward to relieve dyspnea; weight loss, Leaning forward to relieve dyspnea; weight loss, cyanosiscyanosis

Manifestations of Cor PulmonaleManifestations of Cor Pulmonale Poor PxPoor Px

Diagnosis cont’dDiagnosis cont’d Pulmonary Function Test (PFT)/SpirometryPulmonary Function Test (PFT)/Spirometry

Gold standard for diagnosis COPDGold standard for diagnosis COPD FEV1/FVC ratio of < 70% defines the presence of FEV1/FVC ratio of < 70% defines the presence of

obstructive disease.obstructive disease. Cannot determine difference between COPD, chronic Cannot determine difference between COPD, chronic

bronchitis or emphysemabronchitis or emphysema FEV1 is used to determine severity of diseaseFEV1 is used to determine severity of disease Peak Expiratory Flow Rate (PEFR) is used to monitor Peak Expiratory Flow Rate (PEFR) is used to monitor

response to therapyresponse to therapy Lung function should be measured with bronchodilator Lung function should be measured with bronchodilator

evaluation. The absence of a significant response (>15% evaluation. The absence of a significant response (>15% increase in FEV1) on one test should not be the reason increase in FEV1) on one test should not be the reason to hold bronchodilator therapy.to hold bronchodilator therapy.

If improvement >20% and FEV1 becomes normal = AsthmaIf improvement >20% and FEV1 becomes normal = Asthma If FEV1 increases but is still below normal = Mixed If FEV1 increases but is still below normal = Mixed

Asthma/COPDAsthma/COPD

Diagnosis Cont’dDiagnosis Cont’d Chest X-Ray (CXR)Chest X-Ray (CXR)

Radiological changes don’t usually occur until COPD is Radiological changes don’t usually occur until COPD is advanced (overdistention, bullae formationadvanced (overdistention, bullae formation

Done to identify co-existing conditionsDone to identify co-existing conditions Arterial Blood Gas (ABG)Arterial Blood Gas (ABG)

Used in most cases to determine if a patient requires Used in most cases to determine if a patient requires oxygen maintenance based on level of hypoxiaoxygen maintenance based on level of hypoxia

Usually done when FEV1 < 40%, and in those with signs Usually done when FEV1 < 40%, and in those with signs of respiratory failure (PO2<60 or PCO2>45) or right of respiratory failure (PO2<60 or PCO2>45) or right heart failureheart failure

Can also give information regarding CO2 levelsCan also give information regarding CO2 levels Complete Blood Count (CBC)Complete Blood Count (CBC)

Can identify erythrocytosis/polycythemia as a result of Can identify erythrocytosis/polycythemia as a result of chronic hypoxemia and should be done in patients being chronic hypoxemia and should be done in patients being considered for O2 supplementation considered for O2 supplementation

Classification of COPDClassification of COPD(Remember FEV1/FVC is used in the Dx COPD!)(Remember FEV1/FVC is used in the Dx COPD!)

% Predicted % Predicted FEV1FEV1

1995 ATS % 1995 ATS % Predicted FEV1Predicted FEV1

2001 GOLD 2001 GOLD Report % Report % Predicted FEV1Predicted FEV1

SymptomsSymptoms

Stage 0: At risk, Stage 0: At risk, but PFT’s are but PFT’s are normalnormal

FEV1/FVC > 70%FEV1/FVC > 70%

Cough and Cough and sputum sputum production may production may be presentbe present

80-100%80-100% Stage I: MildStage I: Mild

> 80% predicted> 80% predictedCough and Cough and sputum sputum production may production may be presentbe present

50-80%50-80% Stage I: MildStage I: Mild

50-80% predicted50-80% predictedStage IIA: Stage IIA: ModerateModerate

50-80% predicted50-80% predicted

Cough and Cough and sputum and sputum and dyspnea may be dyspnea may be presentpresent

0-50%0-50% Stage II: ModerateStage II: Moderate

35-50% predicted35-50% predictedStage IIB: Stage IIB: ModerateModerate

30-50% predicted30-50% predicted

Cough, sputum Cough, sputum and dyspnea with and dyspnea with more more exacerbationsexacerbations

Stage III: SevereStage III: Severe

<35% predicted<35% predictedStage III: SevereStage III: Severe

< 30% predicted < 30% predicted or resp failure or or resp failure or RHFRHF

Cough, sputum Cough, sputum and dyspnea with and dyspnea with frequent frequent exacerbationsexacerbations

Overall Treatment of COPDOverall Treatment of COPD 11stst Step is to establish a diagnosis Step is to establish a diagnosis

Spirometry in patients with Sx or RFSpirometry in patients with Sx or RF CXR to exclude other conditionsCXR to exclude other conditions

22ndnd Step is to Classify the stage of disease Step is to Classify the stage of disease Used to guide therapyUsed to guide therapy

For example, Stage II requires smoking cessation, an For example, Stage II requires smoking cessation, an ABG, pharmacotx and consultation with a ABG, pharmacotx and consultation with a pulmonologistpulmonologist

33rdrd Step is to educate your patients Step is to educate your patients This is the key component This is the key component Main goals of treatment are to improve quality Main goals of treatment are to improve quality

of life and decrease mortalityof life and decrease mortality Only 2 interventions decrease mortality: smoking Only 2 interventions decrease mortality: smoking

cessation and long term O2 supplementationcessation and long term O2 supplementation

Overall Treatment Cont’dOverall Treatment Cont’d

44thth Step is to begin Pharmacotherapy Step is to begin Pharmacotherapy Inhaled BronchodilatorsInhaled Bronchodilators

Improve symptoms and decrease airflow limitationImprove symptoms and decrease airflow limitation Albuterol 2 puffs Q6hrs/PRNAlbuterol 2 puffs Q6hrs/PRN IpratropiumIpratropium

Usually first line therapyUsually first line therapy Start with 2 puffs QID and may increase to 6 puffs TIDStart with 2 puffs QID and may increase to 6 puffs TID

Common problemsCommon problems Inadequate education regarding meds and techniqueInadequate education regarding meds and technique Suboptimal dosingSuboptimal dosing Inadequate monitoring of response to treatmentInadequate monitoring of response to treatment

The use of long acting beta agonists (Salmeterol and The use of long acting beta agonists (Salmeterol and Formoterol) in COPD is still in evolution.Formoterol) in COPD is still in evolution.

Overall Treatment Cont’dOverall Treatment Cont’d

Inhaled SteroidsInhaled Steroids Do not affect the decline in FEV1, thus the severityDo not affect the decline in FEV1, thus the severity In mod-severe disease these meds showed a In mod-severe disease these meds showed a

significant decrease in the frequency of symptoms significant decrease in the frequency of symptoms and exacerbationsand exacerbations

TheophyllineTheophylline GOLD report recommends against its use due to GOLD report recommends against its use due to

availability of other drugs, high Sfx profile and drug availability of other drugs, high Sfx profile and drug interactions.interactions.

Does work for some patientsDoes work for some patients Keep levels between 8-12 mcg/mlKeep levels between 8-12 mcg/ml Monitor regularlyMonitor regularly Be aware of drug interactionsBe aware of drug interactions

Overall Treatment Cont’dOverall Treatment Cont’d

Oral SteroidsOral Steroids Long term use is not recommendedLong term use is not recommended

A beneficial response to a short course of an oral A beneficial response to a short course of an oral steroid does not predict benefit from the chronic steroid does not predict benefit from the chronic use of oral steroids.use of oral steroids.

Long term disease effects are unknown.Long term disease effects are unknown. Studies failed to show a difference in the # of Studies failed to show a difference in the # of

exacerbations, symptoms or spirometry results exacerbations, symptoms or spirometry results when continuation vs withdrawal of prednisone when continuation vs withdrawal of prednisone was comparedwas compared

If considering long term oral steroids for a If considering long term oral steroids for a patient with severe disease, then use patient with severe disease, then use smallest dose possible. Usually done in smallest dose possible. Usually done in conjunction with pulmonologist.conjunction with pulmonologist.

Overall Treatment Cont’dOverall Treatment Cont’d

55thth step is to prevent and treat complications step is to prevent and treat complications

Chronic HypoxiaChronic Hypoxia Consequences include dyspnea, impaired cognition, Consequences include dyspnea, impaired cognition,

ischemic CM, ploycythemia/ erythrocytosis with ischemic CM, ploycythemia/ erythrocytosis with hyperviscosity syndromes, and pulmonary HTNhyperviscosity syndromes, and pulmonary HTN

Supplemental O2 can improve symptoms and prevent Supplemental O2 can improve symptoms and prevent some of these complications. In fact, life expectancy some of these complications. In fact, life expectancy increases.increases.

ABG evaluation at appropriate timesABG evaluation at appropriate times MediCare guidelinesMediCare guidelines

PaO2 < 55mmHg; POx < 88% for any patientPaO2 < 55mmHg; POx < 88% for any patient PaO2 55-59mmHg; POx = 89% for those with chronic PaO2 55-59mmHg; POx = 89% for those with chronic

hypoxic complications as listed abovehypoxic complications as listed above

Overall Treatment Cont’dOverall Treatment Cont’d

ImmunizationsImmunizations Annual influenza shotsAnnual influenza shots Polyvalent pneumococcal vaccine at time of Polyvalent pneumococcal vaccine at time of

diagnosis and again in 5 years or at age 65, diagnosis and again in 5 years or at age 65, whichever comes later.whichever comes later.

Consultation with a specialist Consultation with a specialist PulmonologistPulmonologist

Stage IIB and IIIStage IIB and III SurgeonSurgeon

When considering lung volume reduction surgery When considering lung volume reduction surgery or transplantationor transplantation

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