Chronic Obstructive Pulmonary Disease: COPD

dr. Tjatur Winarsanto SpPD

Chronic Obstructive Pulmonary Disease: COPD

Disease of airflow obstruction that is not totally reversibleChronic BronchitisEmphysema

COPD: Etiology

Cigarette smoking #1 Recurrent respiratory infection Alpha 1-antitrypsin deficiency Aging

Def: Chronic Bronchitis Excessive tracheobronchial mucus production

sufficient to cause cough with expectoration for most days of at least 3 months of the year for 2 consecutive years.

Classification:

1. Simple chronic bronchitis

2. Chronic mucopurulent bronchitis

3. Chronic bronchitis with obstruction

4. Chronic bronchitis with obstruction and airway hyperreactivity.

Chronic Bronchitis

Recurrent or chronic productive cough for a minimum of 3 months for 2 consecutive years.

Risk factors Cigarette smoke Air pollution

Chronic Bronchitis Pathophysiology Chronic inflammation Hypertrophy &

hyperplasia of bronchial glands that secrete mucus

Increase number of goblet cells

Cilia are destroyed

Chronic Bronchitis Pathophysiology Narrowing of airway

Starting w/ bronchi smaller airways

airflow resistance work of breathing Hypoventilation & CO2

retention hypoxemia & hypercapnea

Chronic Bronchitis Pathophysiology

Bronchospasm often occurs End result

Hypoxemia Hypercapnea Polycythemia (increase RBCs)

Cyanosis Cor pulmonale (enlargement of right side of heart)

Chronic Bronchitis: Clinical Manifestations In early stages

Clients may not recognize early symptoms Symptoms progress slowly May not be diagnosed until severe episode with a

cold or flu Productive cough

• Especially in the morning• Typically referred to as “cigarette cough”

Bronchospasm Frequent respiratory infections

Chronic Bronchitis: Clinical Manifestations

Advanced stages Dyspnea on exertion Dyspnea at rest Hypoxemia & hypercapnea Polycythemia Cyanosis Bluish-red skin color Pulmonary hypertension Cor pulmonale

Chronic Bronchitis: Diagnostic Tests PFTs

FVC: Forced vital capacity FEV1: Forcible exhale in 1 second FEV1/FVC = <70%

ABGs PaCO2 PaO2

RBC Hct

Emphysema Abnormal distension

of air spaces Actual cause is

unknown

Def: Emphysema Permanent abnormal distention of air spaces distal to

the terminal bronchiole with destruction of alveolar septa (containing alveolar capillaries) and attachments to the bronchial walls.

Classification:

1. Centriacinar ( centrilobular) emphysema

2. Panacinar emphysema

3. Paraseptal emphysema

4. Senile emphysema

Emphysema: Pathophysiology Structural changes

Hyperinflation of alveoli Destruction of alveolar &

alveolar-capillary walls Small airways narrow Lung elasticity decreases

Emphysema: Pathophysiology Mechanisms of

structural change Obstruction of small

bronchioles Proteolytic enzymes destroy

alveolar tissue Elastin & collagen are

destroyed Support structure is destroyed “paper bag” lungs

Emphysema: Pathophysiology The end result: Alveoli lose elastic recoil,

then distend, & eventually blow out.

Small airways collapse or narrow

Air trapping Hyperinflation Decreased surface area

for ventilation

Emphysema: Clinical Manifestations Early stages

Dyspnea Non productive cough Diaphragm flattens A-P diameter increases

• “Barrel chest” Hypoxemia may occur

• Increased respiratory rate• Respiratory alkalosis

Prolonged expiratory phase

Later stages Hypercapnea Purse-lip breathing Use of accessory muscles to breathe Underweight

• No appetite & increase breathing workload Lung sounds diminished

Emphysema: Clinical Manifestations

Emphysema: Clinical Manifestations

Emphysema: Clinical Manifestations

Pulmonary function residual volume, lung capacity, DECREASED FEV1,

vital capacity maybe normal

Arterial blood gases Normal in moderate disease May develop respiratory alkalosis Later: hypercapnia and respiratory acidosis

Chest x-ray Flattened diaphragm hyperinflation

Assess for COPD:A Common Story Cough

intermittent or daily present throughout day- seldom only nocturnal

Sputum Any pattern of chronic sputum production

Dyspnea Progressive and Persistent "increased effort to breathe" "heaviness" "air hunger" or

"gasping" Worse on exercise Worse during respiratory infections

Exposure to risk factors Tobacco smoke Occupational dusts and chemicals Smoke from home cooking and heating fuels

Assess and Monitor Disease Classification of COPD

Stage 0 At RiskStage I Mild COPDStage II Moderate COPDStage III Severe COPDStage IV Very Severe COPD

Stage 0 At Risk

Normal spirometry +/- Chronic symptoms (cough, sputum,

production)

Stage I Mild COPD

FEV1/FVC <70% FEV1 >80% predicted With or without chronic symptoms (cough,

sputum production)

Stage II Moderate COPD

FEV1/FVC <70% 50% <FEV1 <80% predicted With or without chronic symptoms (cough,

sputum production)

Stage III Severe COPD

FEV1/FVC <70% 30% <FEV1 <50% predicted With or without chronic symptoms (cough,

sputum production)

Stage IV Very Severe COPD

FEV1/FVC <70% FEV1 <30% predicted or FEV1 <50%

predicted plus chronic respiratory failure

Goals of Treatment: Emphysema & Chronic Bronchitis

Improved ventilation Remove secretions Prevent complications Slow progression of signs & symptoms Promote patient comfort and participation

in treatment

Collaborative Care: Emphysema & Chronic Bronchitis

Treat respiratory infection Monitor spirometry and PEFR Nutritional support Fluid intake 3 lit/day O2 as indicated

Collaborative Care: Medications

Anti-inflammatory Corticosteroids

Bronchodilators Beta-adrenergic agonist: Proventil Methylxanthines: Theophylline Anticholinergics: Atrovent

Mucolytics: Expectorants: Antihistamines:

Collaborative Care: Emphysema & Chronic Bronchitis

Client teaching Support to stop smoking Conservation of energy Breathing exercises

• Pursed lip breathing• Diaphragm breathing

Chest physiotherapy• Percussion, vibration• Postural drainage

Self-manage medications• Inhaler & oxygen equipment

Therapy by Stage- Pretty Simple

Bronchodilators Beta2-agonists

Short-acting Fenoterol Salbutamol (albuterol) Terbutaline

Long-acting Formoterol Salmeterol

BronchodilatorsAnticholinergics

Mode of Action Cholinergic tone is only reversible component of COPD Normal airway have small degree of vagal cholinergic

tone

Short-acting Ipratropium bromide Oxitropium bromide

Long-acting Tiotropium

Bronchodilators- Combos and Methylxanthines

Combination beta2-agonists plus anticholinergic in one inhaler Fenoterol/Ipratropium Salbutamol/Ipratropium

Methylxanthines Aminophylline (slow release preparations) Theophylline (slow release preparations) RARELY OF SIGNIFICNAT BENEFIT LEVEL 8-12 mcg/ml