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  1. 1. C.O.P.D.
  2. 2. CHRONIC OBSTRUCTIVE PULMONARY DISEASE <ul><li>Definition </li></ul><ul><li>Chronic Obstructive Pulmonary Disease (COPD) is a chronic slowly progressive disorder characterized by airflow obstruction (reduced FEV1 and FEV1/VC ratio) that does not change markedly over several months. Most of the lung function impairment is fixed, although some reversibility can be produced by bronchodilator (or other) therapy. </li></ul>
  3. 3. EMPHYSEMA <ul><li>Centriacinar - Centrilobular </li></ul><ul><li>Panacinar - Panlobular </li></ul><ul><li>Periacinar - Paraseptal or distal Acinar </li></ul>
  4. 4. CHRONIC BRONCHITIS <ul><li>Simple mucoid bronchitis </li></ul><ul><li>Mucopurulent bronchitis </li></ul><ul><li>Chronic obstructive bronchitis. </li></ul>
  5. 5. PATHOLOGY <ul><li>Changes in Mucus gland thickness </li></ul><ul><li>Air Flow limitation due to:- </li></ul><ul><li>(i) Mechanical obstruction. </li></ul><ul><li>(ii) Loss of pulmonary elastic recoil. </li></ul><ul><li>(iii) Reduction of the alveolar attachment around the walls of the small air ways </li></ul><ul><li>Circulatory changes are confined to advanced disease. </li></ul>
  6. 6. CLINICAL FEATURES <ul><li>Symptoms include cough, sputum, dyspnoea, and wheeze. </li></ul><ul><li>Signs: Pink puffers & blue bloaters (2 ends of a spectrum). </li></ul><ul><li>Patients who have chronic cough and sputum production with a history of exposure to risk factors should be tested for airflow limitation, even if they do not have dyspnea. </li></ul>
  7. 7. SYMPTOMS TYPICAL OF COPD <ul><li>History of heavy smoking for many years. </li></ul><ul><li>Cough and sputum production for many years. </li></ul><ul><li>Cough often present only on waking at first; later cough occurs throughout the day. </li></ul><ul><li>Sputum usually mucoid – becomes purulent with exacerbation of disease, but not excessive. </li></ul><ul><li>Cough and sputum often worse in winter due to infection. </li></ul><ul><li>Insidious onset of breathlessness on exertion with wheezing or tightness of chest. </li></ul>
  8. 8. SYMPTOMS TYPICAL OF COPD (CONTD.) <ul><li>Some develop increasingly severe exacerbations of disease leading to chronic respiratory failure and heart failure – the “blue bloater’ type of COPD. </li></ul><ul><li>Others have little or no sputum or hypoxia at rest, but breathlessness and wheezing is severe and emphysema is prominent – the pink puffer’ type of COPD. These patients are commonly underweight. </li></ul><ul><li>Most patients with COPD present with a mixed pattern rather than the ‘blue bloater’ or ‘pink puffer’ extremes. </li></ul>
  9. 9. SYMPTOMS NOT TYPICAL OF COPD <ul><li>Haemoptysis – can occur due to COPD alone, but its appearance is such a patient suggests the possibility of malignancy, which must be carefully sought. </li></ul><ul><li>Seasonal exacerbations in spring or summer are more likely in asthma. </li></ul><ul><li>Excellent response to bronchodilators or steroids with definite symptom-free intervals is suggestive of asthma, not COPD. </li></ul>
  10. 10. SYMPTOMS NOT TYPICAL OF COPD (CONTD). <ul><li>Continuous expectoration of purulent sputum is more typical of bronchiectasis than COPD. </li></ul><ul><li>Breathlessness without productive cough or wheezing is more typical of cardiac disease or of other lung diseases such as interstitial pulmonary fibrosis.. </li></ul>
  11. 11. PHYSICAL EXAMINATION <ul><li>Large, barrel-shaped chest. </li></ul><ul><li>Prominent accessory respiratory muscles in neck. </li></ul><ul><li>Low, flat diaphragm causing costal margin retractions on inspiration. </li></ul><ul><li>Diminished breath sounds, distant heart sounds. </li></ul><ul><li>Prolonged expiration with generalized wheezing predominantly on expiration. </li></ul>
  12. 12. PHYSICAL EXAMINATION (CONTD). <ul><li>Depressed liver, which is not enlarged. </li></ul><ul><li>The ‘blue bloater’ type of COPD patient may also have: </li></ul><ul><ul><li>Cyanosis at rest or mild exertion. </li></ul></ul><ul><ul><li>Oedema of ankles </li></ul></ul><ul><ul><li>Crackles at lung bases. </li></ul></ul><ul><ul><li>Loud second heart sound in pulmonary area (difficult to hear in COPD). </li></ul></ul><ul><li>The ‘pink puffer’ type of COPD patient may also have:-. </li></ul><ul><li>expiratory pursed-lip breathing, thin body build and tendency to lean forward over a support to assist breathing. </li></ul>
  13. 13. RADIOLOGY <ul><li>Plain chest radiography </li></ul><ul><li>1. Signs due to hyperinflation. </li></ul><ul><li>2. Signs due to vascular changes. </li></ul><ul><li>3. Signs due to bullae. </li></ul><ul><li>1. Low flattened diaphragms. </li></ul><ul><li>2. Increase in the retrosternal space. </li></ul><ul><li>3. An obtuse costophrenic angle. </li></ul><ul><li>4. A reduction in size and numbers of </li></ul><ul><li>pulmonary vessels. Particularly in the </li></ul><ul><li>periphery of the lung. </li></ul><ul><li>5. Vessel distortion producing increased </li></ul><ul><li>branching, angles or bowing of vessels. </li></ul>
  14. 14. C.T. SCAN CHEST <ul><li>Areas of low attenuation without obvious margins or walls. </li></ul><ul><li>Attenuation and pruning of the vascular tree. </li></ul><ul><li>Abnormal vascular configuration. </li></ul><ul><li>C.T. Scan is the most sensitive and specific imaging technique for assessing Emphysema. </li></ul>
  15. 15. DIAGNOSIS <ul><li>Diagnosis of COPD is based on a history of exposure to risk factors and the presence of airflow limitation that is not fully reversible, with or without the presence of symptoms. </li></ul>
  16. 16. DIAGNOSIS (Contd.) <ul><li>For the diagnosis and assessment of COPD, spirometry is the gold standard as it is the most reproducible, standardized, and objective way of measuring airflow limitation. FEV 1 / FVC < 70% and a postbronchodilator FEV 1 < 80% predicted confirms the presence of airflow limitation that is not fully reversible. </li></ul>
  17. 17. Additional Investigation <ul><li>Bronchodilator reversibility testing </li></ul><ul><li>Glucocorticosteroid reversibility testing </li></ul><ul><li>Chest X-Ray </li></ul><ul><li>Arterial blood gas measurement </li></ul><ul><li>Alpha - 1 antitrypsin deficiency screening </li></ul>
  18. 18. Differential Diagnosis <ul><li>Asthma </li></ul><ul><li>Congestive Heart Failure </li></ul><ul><li>Bronchiectasis </li></ul><ul><li>Tuberculosis </li></ul><ul><li>Obliterative Bronchiolitis </li></ul>
  19. 19. Causes of Chronic cough with a normal Chest X-ray <ul><li>Intrathoracic </li></ul><ul><li>Chronic obstructive pulmonary disease </li></ul><ul><li>Bronchial asthma </li></ul><ul><li>Central bronchial carcinoma </li></ul><ul><li>Endobronchial tuberculosis </li></ul><ul><li>Bronchiectasis </li></ul><ul><li>Left heart failure </li></ul><ul><li>Interstitial lung disease </li></ul><ul><li>Cystic fibrosis </li></ul>
  20. 20. Causes of Chronic cough with a normal Chest X-ray <ul><li>Extrathoracic </li></ul><ul><li>Postnasal drip </li></ul><ul><li>Gastroesophageal reflux </li></ul><ul><li>Drug therapy (e.g. ACE inhibitors) </li></ul>
  21. 21. Management of COPD <ul><li>Assess and Monitor Disease </li></ul><ul><li>Reduce Risk Factors </li></ul><ul><li>Manage Stable COPD </li></ul><ul><li>Manage Exacerbations </li></ul>
  22. 22. Therapy at Each Stage of COPD <ul><li>Stage Characteristics Recommended Treatment </li></ul><ul><li>All * Avoidance of risk factor (s) </li></ul><ul><li>* Influenza vaccination </li></ul><ul><li>0: At risk * Chronic Symptoms </li></ul><ul><li> (cough, Sputum) </li></ul><ul><li>* Exposure to risk factors </li></ul><ul><li>* Normal spirometry </li></ul><ul><li>Mild COPD * FEV 1 /FVC < 70% * Short-acting bronchodilator </li></ul><ul><li>* FEV 1  80% predicted when needed </li></ul><ul><li>* With or without symptoms </li></ul>
  23. 23. Therapy at Each Stage of COPD <ul><li>Stage Characteristics Recommended Treatment </li></ul><ul><li>Moderate COPD FEV 1 40 - 59% * Regular treatment * Inhaled Gluccocorti - </li></ul><ul><li> with one or more costeorodis if </li></ul><ul><li> bronchodilators Significant </li></ul><ul><li>* Rehabilitation Symptoms and lung </li></ul><ul><li> function response </li></ul>
  24. 24. Therapy at Each Stage of COPD <ul><li>Stage Characteristics Recommended Treatment </li></ul><ul><li>Severe COPD FEV 1 < 40% * Regular treatment with one or more </li></ul><ul><li> bronchodilators </li></ul><ul><li>* Inhaled glucorticosteroids if significant </li></ul><ul><li> symptoms and lung function response or </li></ul><ul><li> if repeated exacerbations. </li></ul><ul><li>* Treatment of complications </li></ul><ul><li>* Rehabilitation </li></ul><ul><li>* Long-term oxygen therapy if respiratory </li></ul><ul><li> failure. </li></ul><ul><li>* Consider surgical treatments. </li></ul>
  25. 25. Manage Exacerbations <ul><li>Common Causes of Acute Exacerbations of COPD </li></ul><ul><li>Primary </li></ul><ul><li>Tracheobronchial infection </li></ul><ul><li>Air pollution </li></ul><ul><li>Secondary </li></ul><ul><li>Pneumonia </li></ul><ul><li>Pulmonary embolism </li></ul><ul><li>Pneumothorax </li></ul><ul><li>Rib fractures/chest trauma </li></ul><ul><li>Inappropriate use of sedatives, narcotics, beta-blocking agents </li></ul><ul><li>Right and/or left heart failure or arrhythmias </li></ul>
  26. 26. Management of Acute COPD <ul><li>Controlled oxygen therapy </li></ul><ul><li>Start at 24-28%; vary according to ABG </li></ul><ul><li>Aim for a PaO2 >8.0 kPa with a rise in PaCo2 <1.5kPa </li></ul><ul><li>↓ </li></ul><ul><li>Nebulized bronchodilators: </li></ul><ul><li>Salbutamol 5mg/4h and Ipratropium 500 µg/6h </li></ul><ul><li>↓ </li></ul><ul><li>Steroids </li></ul><ul><li>I/V hydrocortisone 200 mg and Oral Prednisolon 30-40 mg </li></ul><ul><li>↓ </li></ul>
  27. 27. Management of Acute COPD (Contd.) <ul><li>↓ </li></ul><ul><li>Antibiotics: </li></ul><ul><li>Use of evidence of infection: e.g. amoxicillin 500 mg/6h P.O. </li></ul><ul><li>↓ </li></ul><ul><li>Physiotherapy to aid sputum expectoration </li></ul><ul><li>↓ </li></ul><ul><li>If no response: Repeat nebulizers and consider I/V aminophyllin ↓ </li></ul>
  28. 28. Management of Acute COPD (Contd.) <ul><li>↓ </li></ul><ul><li>If no response: </li></ul><ul><li>1. Consider nasal intermittent positive pressure ventilation if respiratory rate >30 or pH <7.35. I is delivered by nasal mask and a flow generator ↓ </li></ul><ul><li>2. Consider intubation2 & ventilation if pH<7.26 and PaCO2 is rising </li></ul><ul><li>↓ </li></ul><ul><li>3. Consider respiratory stimulant drug e.g. doxapram 1-2 mg/min IV. SE: agitation, confusion, tachycardia, nausea Only for patients who are not suitable for mechanical ventilation A short – term measure only </li></ul>
  29. 29. Management of complications <ul><li>Acute exacerbations. </li></ul><ul><li>Chronic respiratory failure </li></ul><ul><li>Acute respiratory failure </li></ul><ul><li>COR pulmonale </li></ul>
  30. 30. PULMONARY REHABILITATION <ul><li>Education about the disease process. </li></ul><ul><li>Breathing retraining. </li></ul><ul><li>Exercise training. </li></ul><ul><li>Proper use of mediations and oxygen. </li></ul><ul><li>Nutritional support. </li></ul><ul><li>Psychological support. </li></ul>
  31. 31. Future trends <ul><li>New technologies i.e. (NIPPV) </li></ul><ul><li>Early detection </li></ul><ul><li>New therapies </li></ul><ul><ul><li>ą 1 – antitrypsin replacement therapy </li></ul></ul><ul><ul><li>New anticholonergics. i.e. Tiotropium bromide </li></ul></ul><ul><ul><li>Enzyme/mediator inhibitors i.e. Specific neutrophil elastase inhibitors </li></ul></ul><ul><ul><li>Anti-inflammatory treatment i.e. phosphodiesterase (PDE) type 4 inhibitors </li></ul></ul>