COPD 2025 (1) PDF

Chronic Obstructive Pulmonary Disease Pr o f. H agga gy Ma n s o ur DEFINITION OF COPD COPD: Is a heterogeneous lung condition characterized by chronic respiratory symptoms (dyspnea, cough, sputum production) due to abnormalities of the airways (bronchitis, bronchiolitis) and/o...

Chronic Obstructive Pulmonary Disease Pr o f. H agga gy Ma n s o ur DEFINITION OF COPD COPD: Is a heterogeneous lung condition characterized by chronic respiratory symptoms (dyspnea, cough, sputum production) due to abnormalities of the airways (bronchitis, bronchiolitis) and/or alveoli (emphysema) that cause persistent, often progressive, airflow obstruction. Pathophysiology of COPD: 5  Patients with COPD present primarily with symptoms of chronic bronchitis (chronic productive cough) and emphysema (severe breathlessness on exertion). Cigarette smoke activates neutrophils in the lungs which invade the bronchial mucosa and secrete proteases, including elastase and collagenase, which damage the alveoli, resulting in the formation of bullae. This progresses to the development of widespread emphysema. Much of the alveolar surface of the lung is destroyed and not available for gas exchange; this can be measured as a reduction in TLCO and KCO. 11/11/2024 6  The ventilation/perfusion mismatch results in an increase in the alveol-ararterial gradient (A‐a gradient) and hypoxaemia. Hypoxic pulmonary vasoconstriction results in raised pulmonary artery pressure and, over time, leads to pulmonary hypertension and right heart failure (cor pulmonale). 11/11/2024 7  There is an increase in the number of goblet cells and hypertrophy of the goblet cells, resulting in the production of viscous mucus which is hard to clear. This mucus acts as a culture medium for infective organisms. Damage to cilia affects the host defence mechanisms, which also predisposes to recurrent respiratory tract infections. 11/11/2024 8  DIAGNOSIS OF COPD: 11/11/2024 9 A diagnosis of COPD should be suspected in any individual over the age of 40 years who presents with symptoms of breathlessness and has a history of cigarette smoking. Clinical presentation of COPD: Symptoms Breathlessness on exertion (dyspnoea) Wheeze Frequent lower respiratory tract infections Chronic productive cough 10 The Medical Research Council (MRC) Dyspnoea Scale is commonly used. Grade 1 breathless only on strenuous exertion Grade 2 breathless when walking up a slight hill Grade 3 breathless when walking on flat ground Grade 4 breathless on walking 100 metres Grade 5 breathless on dressing or undressing There are several validated questionnaires which can be used to assess overall function, quality of life (QOL), and impact of the disease. 11/11/2024 11  Clinical Examination 11/11/2024 12 Signs Tachypnoea (respiratory rate > 25 breaths/ min) Tachycardia (> 100 beats/ min) Barrel chest Increased anteroposterior diameter of thoracic cage Pursed‐lip breathing Prolonged expiratory phase of respiration, wheeze. Cor pulmonale: raised JVP, peripheral oedema Cachexia 13  In mild COPD clinical examination may be normal. But as the condition gets worse, signs will become apparent, especially during an exacerbation. Patients who develop type 2 respiratory failure may show signs of CO2 retention Severe hypercapnia symptoms include: Confusion Depression or paranoia Anxiety Nausea and vomiting Seizure Fainting Loss of consciousness or coma Panic attack Arrhythmia Patients with severe COPD may have the signs of cor pulmonale, which is right heart failure secondary to chronic lung disease. This will result in pulmonary hypertension. 14  Spirometry: 11/11/2024 15 Spirometry showing an FEV1/FVC ratio of less than 70% predicted post administration of a short‐acting bronchodilator confirms the diagnosis of COPD. GOLD define severity of COPD as Mild, Moderate, Severe, and Very Severe, based on the spirometry values when the FEV1/FVC is less than 70% predicted. Mild FEV1 ≥ 80% Moderate FEV1 50 –79% Severe FEV1 30 –49% Very severe FEV1 ≤ 30 11/11/2024 16 Full lung function tests: Full lung function tests will show that the total lung capacity (TLC) and the residual volume (RV) are increased due to air trapping and static hyperinflation. The destruction of alveoli will result in a reduction in transfer factor for CO (TLCO) and transfer coefficient (KCO). 11/11/2024 17 Pulse oximetry: May be normal in mild COPD, but may gradually drop to below 90%, initially on exertion, and then at rest. 11/11/2024 18 A CXR: A CXR is recommended in all patients presenting with symptoms suggestive of COPD to exclude other conditions which can present with similar symptoms, including community acquired pneumonia, pneumothorax, lung cancer, pulmonary embolus, and heart failure. If the patient has emphysema, the CXR will show hyperinflation: With flat diaphragms, Increased retrosternal airspace, and an Elongated cardiac shadow. 19 20  Management of COPD 11/11/2024 21 The aim of management of COPD is To prevent progression of the disease, Relieve symptoms, Improve the quality of life, Reduce morbidity, and Prevent hospital admissions. 11/11/2024 22 It includes: Lifestyle changes, most importantly smoking cessation, Pharmacological treatment, Pulmonary rehabilitation, Nutrition, and Psychological support. Patients with severe COPD may require long term oxygen therapy (LTOT). Some patients, especially those who are under the age of 60 years with no significant co‐morbidities, should be referred for consideration of lung transplantation. Patients with chronic type 2 respiratory failure can be managed with domiciliary non‐invasive ventilation (NIV) and LTOT. 11/11/2024 23  Pharmacological treatment 11/11/2024 24 Inhaled Therapy: Improves symptoms, improves QOL, and reduces the number of exacerbations and hospital admissions. Inhaled therapy includes SABA, such as salbutamol and terbutaline, LABA, such as salmeterol and formoterol, short‐acting anticholinergic drugs, such as ipratropium bromide, long‐acting anticholinergic drugs, such as tiotropium and aclidinium and inhaled corticosteroids (ICS). SABA and LABA improve symptoms and reduce the risk of exacerbations, especially when they are combined. Combining bronchodilators with different modes of pharmacological action gives sustained bronchodilation with fewer side effects. 25  LABA are more effective at symptom control and in reducing exacerbations than the short acting drugs. ICS are also recommended for patients with moderate or severe COPD (FEV1 < 60% predicted) who have experienced at least two exacerbations in the previous year, although the dose‐response relationships is unknown in COPD. ICS, when combined with a LABA, has been shown to improve symptoms, quality of life (QOL), and reduce frequency of exacerbations and hospital admissions. They do, however, increase the risk of non‐fatal pneumonia. A combination of ICS, LABA, and LAMA (often called triple therapy) is recommended for those with severe COPD. 26 Roflumilast: Roflumilast , a phosphodiesterase‐4 inhibitor, has been shown to reduce exacerbations in those with moderate and severe COPD. Theophylline: Theophylline, a phosphodiesterase‐5 inhibitor, can also be considered in those with moderate and severe COPD who are still symptomatic despite optimal inhaled therapy. Slow‐release preparations are used in COPD, but theophylline has a narrow therapeutic range with a high risk of toxicity which is doserelated. A mucolytic drug, such as carbocisteine, can improve the symptom of chronic, productive cough in some, but not all, patients. 11/11/2024 27  NON - Pharmacological management: 11/11/2024 28 Smoking cessation: Is the only intervention that reduces the progression of the disease and the risk of death. The earlier the diagnosis of COPD is made, and the earlier the patient stops smoking, the better the outcome. 11/11/2024 29 Pulmonary rehabilitation Has been shown to be an effective intervention when a patient is discharged from hospital after an acute exacerbation. Pulmonary rehabilitation improves: Breathlessness, Exercise tolerance, Muscle strength, and QOL 30 Pulmonary rehabilitation includes: Exercises to strengthen the deconditioned muscles of the arms, legs, and muscles of respiration. An eightweek programme, comprising of aerobic exercises three times a week, is carried out by trained nurse specialists and physiotherapists. The exercise programme should be continued for maximum and ongoing benefit. 11/11/2024 31 Relaxation techniques: Including yoga and cognitive behavioural therapy (CBT), can help the patient gain more control of their breathing and reduce the symptom of dyspnoea. Chest physiotherapy and postural drainage: Including the use of a flutter valve, can help expectorate the thick secretions that are part of the symptomatology of COPD. Patients with severe COPD are often in a catabolic state and appear cachectic due to the increased work of breathing. The BODE index, which is a measure of body mass index (BMI), airflow obstruction, dyspnoea, and exercise capacity, can be of prognostic value and used in determining patients suitable for lung transplantation. Nutritional support improves muscle strength and health status. 11/11/2024 32 Psychological Support: Chronic illnesses predispose to anxiety and depression. The Hospital Anxiety and Depression (HAD) questionnaire can be used to assess this. Patients should be referred for psychological support. Patients with respiratory conditions often run support groups, such as the ‘Breathe Easy Club’, which many find beneficial. 11/11/2024 33  Vaccinations: It is recommended that all patients over the age of 65 with COPD and those with FEV1 < 40% are offered the influenza and pneumonia vaccinations which will reduce the risk of serious respiratory illnesses and death. 11/11/2024 34 11/11/2024 35 LTOT: LTOT should be commenced in patients who develop pulmonary hypertension and hypoxia. Type 1 respiratory failure, with a PaO2 < 55 mm Hg at rest or a PaO2 of < 59 mm Hg with evidence of peripheral oedema, polycythaemia, or pulmonary hypertension, are indications for starting LTOT. Two measurements of the ABG should be done three weeks apart when the patient has recovered from an exacerbation and is stable. 11/11/2024 36  Patients on LTOT should be encouraged to use it for at least 15 hours in a 24‐hour period (including while they are asleep) as this improves survival. LTOT is not a treatment for breathlessness and should be used with caution in those who continue to smoke. NIV together with LTOT can be considered in patients with chronic type 2 respiratory failure secondary to COPD. 11/11/2024 37  Surgical Treatments: 11/11/2024 38 There are several surgical treatments for severe emphysema: Bullectomy: Is the removal of redundant lung tissue which allows adjacent lung parenchyma to expand more effectively by reducing static hyperinflation. Lung volume reduction surgery (LVRS): Is recommended for those with emphysema affecting the upper lobes and low exercise capacity but with no significant co‐morbidities.LVRS can be done as a video‐assisted thoracoscopic surgery (VATS) procedure. LVRS decreases hyperinflation, improves elastic recoil and airflow limitation. 11/11/2024 39 Bronchoscopic lung volume reduction: Which involves the placement of a valve into the bronchus, is a non‐surgical alternative for patients with : Heterogeneous emphysema on CT, FEV1 between 15% and 45%, and  hyperinflation (TLC > 100% predicted and RV > 150% predicted). Patients who are appropriately selected show improvement in symptoms and exercise tolerance but appear to have an increased frequency of exacerbations and haemoptysis. 40  Patients who have heterogeneous emphysema, with FEV1 of less than 20%, and a BODE index of 5–10, should be referred for consideration of a single lung transplant if they are less than 65 years or for a double lung transplant if they are less than 60 years. They must have stopped smoking for at least six months, be able to participate in a pulmonary rehabilitation programme, have no significant co‐morbidities, and be motivated. Patients with COPD often have co‐morbidities which should be diagnosed and treated. Lung cancer is the commonest cause of death in patients with mild COPD. 41  Thank you!! Any Questions?? 11/11/2024 42