copd slides
TRANSCRIPT
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CHRONICCHRONIC
OBSTRUCTIVEOBSTRUCTIVE
PULMONARYPULMONARY
DISEASEDISEASE
Melito A. Vergara II, MDMelito A. Vergara II, MD
First Year ResidentFirst Year Resident
Department of Family & Community MedicineDepartment of Family & Community Medicine
Manila Doctors HospitalManila Doctors Hospital
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Definition of COPD
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
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I: Mild COPD FEV1/FVC < 0.7 FEV1 80% predicted
At this stage,
the patient may not beaware that their
lung function is abnormal
II: Moderate
COPD
FEV1/FVC < 0.7
50% FEV1 < 80%predicted
Symptoms usuallyprogress at this stage,with shortness
of breath typically
developing on exertion.
III: SevereCOPD
FEV1/FVC < 0.7 30% FEV1 < 50%
predicted
Shortness of breathtypically worsens at thisstage and often limitspatients daily
activities. Exacerbationsare especially seen
beginning at this stage.
IV: Very Severe
COPD
FEV1/FVC < 0.7
FEV1 < 30% predicted or
FEV1 < 50% predicted plus
chronic respiratory failure
At this stage, quality oflife is very appreciablyimpaired
and exacerbations may be
life-threatening
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Of the six leadingcauses of death in theUnited States, onlyCOPD has been
increasing steadily since1970
Of the sixleading causesof death in theUnited States,only COPD hasbeen increasing
steadily since1970
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0
10
20
30
40
50
60
70
1980 1985 1990 1995 2000
M en
Women
Number
Deathsx
1000
COPD Mortality by Gender,U.S., 1980-2000
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Risk Factors for COPD
NutritionNutrition
InfectionsInfections
Socio-Socio-
economiceconomic
statusstatus
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LUNG INFLAMMATIONLUNG INFLAMMATION
OxidativeOxidative
stressstress ProteinasesProteinases
RepairRepair
mechanismsmechanisms
Anti-proteinasesAnti-proteinasesAnti-oxidantsAnti-oxidants
Host factors
Amplifying mechanisms
Cigarette smokeCigarette smokeBiomass particlesBiomass particles
ParticulatesParticulates
Pathogenesis ofCOPD
COPDCOPD
PATHOLOGYPATHOLOGY
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Alveolar wall destruction
Loss of elasticity
Destruction of pulmonary
capillary bed
Changes in the Lung Parenchyma in COPD Patients
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YYYYYY
Mast cellMast cell
CD4+ cellCD4+ cell
(Th2)(Th2)EosinophilEosinophil
AllergensAllergens
Ep cellsEp cells
BronchoconstrictiBronchoconstricti
onon
Alv macrophageAlv macrophage Ep cellsEp cells
CD8+ cellCD8+ cell
(Tc1)(Tc1)NeutrophilNeutrophil
Cigarette smokeCigarette smoke
Small airway narrowingSmall airway narrowingAlveolar destructionAlveolar destruction
COPDCOPDASTHMAASTHMA
Airflow LimitationAirflow LimitationReversible Irreversible
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COPD and AsthmaCOPD and AsthmaCOPD ASTHMA
Onset in mid-life
Symptoms slowlyprogressive
Long smoking history
Dyspnea during exercise
Largely irreversibleairflow limitation
Onset early in life (oftenchildhood)
Symptoms vary from dayto daySymptoms at night/earlymorning
Allergy, rhinitis, and/oreczema also present
Family history of asthma
Largely reversible airflowlimitation
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Four Components of COPDFour Components of COPD
ManagementManagement
Assess and monitor disease
Reduce risk factors
Manage stable COPD Education
Pharmacologic
Non-pharmacologic
Manage exacerbations
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Management of Stable COPD
Assess and Monitor COPD: Key Points
A clinical diagnosis of COPD should be considered inany patient who has dyspnea, chronic cough orsputum production, and/or a history of exposure torisk factors for the disease.
The diagnosis should be confirmed by spirometry. Apost-bronchodilator FEV1/FVC < 0.70 confirms thepresence of airflow limitation that is not fullyreversible.
Comorbidities are common in COPD and should beactively identified.
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Diagnosis of COPD
SYMPTOMS
coughcough
sputumsputum
shortness of breathshortness of breath
EXPOSURE TO RISKFACTORS
tobaccotobaccooccupationoccupation
indoor/outdoor pollutionindoor/outdoor pollution
SPIROMETRYSPIROMETRY
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Management of Stable COPD
Reduce Risk Factors: Key Points
Reduction of total personal exposure totobacco smoke, occupational dusts andchemicals, and indoor and outdoor airpollutants are important goals to prevent the
onset and progression of COPD.
Smoking cessation is the single most effective and cost effective intervention in most
people to reduce the risk of developing COPDand stop its progression.
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Brief Strategies to Help the
Patient Willing to Quit Smoking 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.
M t f St bl COPD
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Management of Stable COPD
Manage Stable COPD: Key Points
The overall approach to managing stable COPDshould be individualized to address symptoms andimprove quality of life.
For patients with COPD, health education plays an
important role in smoking cessation and can also playa role in improving skills, ability to cope with illnessand health status.
None of the existing medications for COPD have been
shown to modify the long-term decline in lungfunction that is the hallmark of this disease.Therefore, pharmacotherapy for COPD is used todecrease symptoms and/or complications.
Th t E h St f COPD
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IV: Very Severe III: Severe II: Moderate I: Mild
Therapy at Each Stage of COPD
FEV1/FVC < 70%
FEV1 > 80%predicted
FEV1/FVC < 70%
50% < FEV1 < 80%predicted
FEV1/FVC < 70%
30% < FEV1 < 50%
predicted
FEV1/FVC < 70%
FEV1 < 30%
predictedorFEV
1< 50%
predicted pluschronic respiratoryfailure
Addregular treatment with one or more long-acting
bronchodilators (when needed); AddrehabilitationAddinhaled glucocorticosteroids ifrepeated exacerbations
Active reduction of risk factor(s); influenza vaccination
Addshort-acting bronchodilator (when needed)
Addlong termoxygenif chronicrespiratory failure.
Considersurgicaltreatments
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Management of Stable COPD
Other Pharmacologic Treatments Antibiotics: Only used to treat infectious
exacerbations of COPD
Antioxidant agents: No effect of n-
acetylcysteine on frequency ofexacerbations, except in patients nottreated with inhaled glucocorticosteroids
Mucolytic agents, Antitussives,Vasodilators: Not recommended in stableCOPD
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Management of Stable COPD
Non-Pharmacologic Treatments Rehabilitation: All COPD patients benefit from
exercise training programs, improving withrespect to both exercise tolerance andsymptoms of dyspnea and fatigue.
Oxygen Therapy: The long-termadministration of oxygen (> 15 hours per day)to patients with chronic respiratory failure has
been shown to increase survival.
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Management COPD Exacerbations
An exacerbation of COPD is defined as:
An event in the natural course of the
disease characterized by a change in thepatients baseline dyspnea, cough, and/orsputum that is beyond normal day-to-dayvariations, is acute in onset, and maywarrant a change in regular medication ina patient with underlying COPD.
b
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The most common causes of an exacerbation are
infection of the tracheobronchial tree and air pollution,but the cause of about one-third of severeexacerbations cannot be identified.
Patients experiencing COPD exacerbations withclinical signs of airway infection (e.g., increasedsputum purulence) may benefit from antibiotictreatment.
Inhaled bronchodilators (particularly inhaled 2-agonists with or without anticholinergics) and oralglucocortico-steroids are effective treatments forexacerbations of COPD.
Manage COPD Exacerbations
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KEY POINTSKEY POINTS
Better dissemination of COPD guidelines and theirBetter dissemination of COPD guidelines and their
effective implementation in a variety of health careeffective implementation in a variety of health care
settings is urgently required.settings is urgently required.
In many countries, primary care practitioners treatIn many countries, primary care practitioners treat
the vast majority of patients with COPD and may bethe vast majority of patients with COPD and may be
actively involved in public health campaigns and inactively involved in public health campaigns and in
bringing messages about reducing exposure to riskbringing messages about reducing exposure to risk
factors to both patients and the public.factors to both patients and the public.
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KEY POINTSKEY POINTS
Spirometric confirmation is a keySpirometric confirmation is a keycomponent of the diagnosis of COPDcomponent of the diagnosis of COPDand primary care practitioners shouldand primary care practitioners should
have access to high quality spirometry.have access to high quality spirometry.
COPD is increasing in prevalence in manycountries of the world.
COPD is treatable and preventable
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lobal Initiative for Chronic
bstructive
ung
isease
lobalInitiative for Chronic
bstructive
ung
isease
G
O
LD
G
O
LD
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THANK YOU!THANK YOU!