COPD PDF

Chronic Obstructive Pulmonary Disease ZIYAD Al NUFAIEI, PhD, RRT-NPS,CPFT 1  Chronic Obstructive Pulmonary Disease vIs a preventable and treatable disease state characterized by airflow limitation that is not fully reversible vThe airflow limitation is usually pro...

Chronic Obstructive Pulmonary Disease ZIYAD Al NUFAIEI, PhD, RRT-NPS,CPFT 1  Chronic Obstructive Pulmonary Disease vIs a preventable and treatable disease state characterized by airflow limitation that is not fully reversible vThe airflow limitation is usually progressive and is associated with an abnormal inflammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking. 2  Chronic Obstructive Pulmonary Disease Composed of 2 major disease entities: 1.Emphysema 2.Chronic bronchitis 3  ATS Definitions vChronic bronchitis is based on the major "clinical manifestations" associated with the disease. vEmphysema is based on the pathology, or the "anatomic alterations of the lung," associated with the disorder. 4  Chronic Bronchitis vChronic bronchitis is a pulmonary disease that causes a chronically productive cough due to bronchial inflammation. vThis disease is termed chronic when it lasts for at least 3 consecutive months of the year for 2 successive years. 5  Pathology vThe bronchial mucous glands enlarge (hypertrophy) and the goblet cells increase in number, resulting in an increase in mucous production. vExcessive mucus production and reduced ciliary function leads to mucus plugging of the smaller airways. vMucus plugging promotes infection and cause V/Q mismatching which leads to significant changes in gas exchange as well as hypoxemia. 6  Etiology The factors contributing to the onset of chronic bronchitis include: üCigarette smoking üAtmospheric pollutants üInfection üGastroesophageal reflux disease 7  Clinical Manifestation vExcessive Bronchial Secretions vBronchospasm 8 9  Emphysema Is defined pathologically as the presence of permanent enlargement of the airspaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis. 10 11  Anatomic Alterations of the Lungs Associated with Emphysema vPermanent enlargement and destruction of the air spaces distal to the terminal bronchioles vDestruction of the alveolar-capillary membrane vWeakening of the distal airways, primarily the respiratory bronchioles vAir trapping and hyperinflation 12 Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 13  Anatomic Alterations of the Lungs Associated with Emphysema vDue to the tissue destruction and loss of elastic recoil that occurs in emphysema, limitations in exhaled flow and abnormalities in gas exchange exist. vThe main cause of an impairment in expiratory flow is the loss of elastic recoil by the lung tissue vThese elements lead to air trapping during forced exhalation and an increase in FRC, RV and TLC. vThese abnormalities cause V/Q mismatching with large areas of dead space ventilation and contribute to increased work of breathing. 14  Emphysema Risk Factors According to GOLD vGenetic predisposition üAlpha 1-antitrypsin deficiency vAge and gender—COPD increases with age. vExposure to particles üTobacco smoke üOccupational dusts and chemicals üIndoor air pollution üOutdoor air pollution 15  Emphysema Risk Factors According to GOLD (Cont.) vSocioeconomic status vAsthma/bronchial hyperreactivity vChronic bronchitis vRespiratory infections vTuberculosis 16 17  Chronic Obstructive Pulmonary Disease (COPD) vEven though chronic bronchitis and emphysema can each develop alone, they often occur together as one disease complex. vWhen this happens, the disease entity is called chronic obstructive pulmonary disease (COPD). 18  Physical examination Chronic Bronchitis and Vital Signs Emphysema ˜ Stable patients: normal vital signs ˜ Exacerbations: Usually acute increase in Heart rate and respiratory rate heart rate and respiratory rate (Tachypnea) Ø Classic sign of hypoxemia  Physical examination Inspection üIncreased A-P diameter (Barrel Chest) üPursed Lip Breathing üDigital Clubbing üCyanosis üPeripheral Edema üUse of accessory muscles in üDistended Neck Veins. inspiration & expiration.  Physical examination Palpation üDiminished Tactile and Vocal Fremitus Percussion üHyperresonant percussion note Auscultation üDiminished Breath Sounds üCrackles/Rhonchi/Wheezing  Laboratory Finding vHEMATOLOGY üIncreased hematocrit and hemoglobin (H&H) vSPUTUM EXAMINATION üStreptococus pneumonia üHaemophilus influenzae  ABG Finding vMild to Moderate ØpH: Increased ØPaCO2: Decreased (20 to hyperventilation) ØHCO3: Slightly Decreased ØPaO2: Decreased vSevere ØpH: Normal ØPaCO2: Increased ØHCO3: Significantly Increased ØPaO2: Decreased 24  Diffusion Capacity (DLCO) Emphysema Chronic Bronchitis Decreased ˜ A decreased DLCO is a classic diagnostic sign of emphysema 25  RADIOLOGIC FINDINGS vTranslucent (Dark) Lung Fields vDepressed, Flattened Diaphragm vLong, narrow heart vEnlarged heart (when pulmonary hypertension is present)  Radiology Findings (Cont.) Test Emphysema Common Chest Radiograph ˜ Translucent ˜ Depressed or flattened diaphragms ˜ Long and narrow heart ˜ Increased retrosternal air space Occasionally ˜ Cor pulmonale ˜ Emphysematous bullae Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 27 Chest x-ray of a patient with emphysema. The heart often appears long and narrow as a result of being drawn downward by the descending diaphragm. 29  Management of COPD vEstablishing diagnosis with airflow obstruction ØSeparating COPD from asthma ØFeatures favoring COPD are üChronic productive cough, ⇓diffusing capacity üDiminished vascularity on chest radiograph ØAsthma is favored if diminished FEV1 is normalized after the use of an inhaled bronchodilator ØOnce COPD is established, check for AAT deficiency 30  Optimizing Lung Function: Stable COPD vPRN bronchodilator for all COPD patients üSympathomimetic &/or anticholinergic üReversibility if postbronchodilator FEV1 ⇑12% üNo survival benefit, but often improves symptoms vSystemic corticosteroid üIf patient responds (⇑FEV1), use inhaled steroids üLung decline continues, but decreases exacerbations üMay lead to higher rate of pneumonia in COPD users vMethylxanthines decrease feelings of dyspnea üTry to avoid toxicity serum levels of 8–10 µg/mL 31  Management of Acute COPD Exacerbations According to GOLD, an exacerbation of COPD is defined as an acute event characterized by a worsening of the patient’s respiratory symptoms that is beyond normal day-to-day variations and leads to a change in medication. 32  Optimizing Lung Function: Acute Exacerbations vInhaled bronchodilators, especially b2-agonists vOral antibiotics if purulent sputum is present (7–10 days) vA short course of systemic corticosteroids vSupplemental oxygen to keep SaO2 >90% vWith hypercapnia (pH