CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

Definition:

                   COPD is a chronic pulmonary disease characterized by persistent respiratory symptoms and airflow limitations which is caused by small airway obstruction and parenchymal distruction.

Anatomy:                   

Epidimiology:

            Male:Female ratio -  3:2
 3^rd most common cause of death worldwide              

Etiology:

1.     Environmental factors

 Tabacco smoke -95%of case

 Indoor airpollution

 Occupational exposure. Eg: coal dust,silica

 Lung malformations. Eg : childhood infections,maternal smoking

Recurrent infection of lung

 Low socioeconomic status

 Cannabis smokking {inhalation of smoke by heating the flowers,leaves or extract of cannabis}

2.     Host factors

 Genetic factors – alpha 1-antitrypsi deficiency

 Airwayhyperreactivity

Types:

1.     Chronic bronchitis

2.     Emphysema

 

1.CHRONIC BRONCHITIS: (blue bloaters)

                  Productive cough for at least 3months each year for 2 consecutive years

2.EMPHYSEMA: (pink buffers)

                   Persistent dilation of pulmonary air space distal to the terminal bronchioles caused by distruction of the alveolar walls and the pulmonary capillaries required for gas exchange   

  

Types of empysema:

1.Centriacinar emphysema:

Focal enlargement and destruction of respiratory bronchioles

 Alveoli unaffected

 Seen in smokers,affect upper lobe

2.Paracinar (Panlobular) emphysema:                   

 Destruction and enlargement of all portion of the Acinus

 Associated with alpha-1 antitrypsin deficiencty

 Affect lower lobe

3.Paraseptal (distal acinar) emphysema:

 Enlargement and destruction of alveoli

 Bronchioles are unaffected

4.Irregular (para-cicatrical) emphysema :

                                   Associated with scaring

5.Mixed emphysema:

                             Consist of above two or more types

 

              Difference between chronic bronchitis and emphysema                       

FEAUTURE CHRONIC BRONCHITIS EMPHYSEA LOCATION Bronchous Acinus AGE OF DIAGNOSIS Adults Adults ETIOLOGY Smoking,air polution Smoking,air polution PATHOGENESIS Impared ciliary movement alpha 1-antitrypsi deficiency MAJOR GROSS FEAUTURE Thickened bronchial wall Broken alveolar septa MAIN HISTOLOGY Hyperplasia of mucous glands Broken alveolar septa MAJOR CLINICAL FEAUTURE Persistent cough with expectoration Exertional dyspnea

 

Pathophysiology:

1.Chronic bronchitis :

                                      

                                     

    2.Empysema :

                             

                         

 Clinical feautures :

Common

Chronic cough with expectoration (sputum)

Dyspnea and tachypnea

 Pursed lip breathing (to increase +pressure in lungs and prevent airway collapse)

 End expiratory wheezing ,crackles

 Tachycardia

 Cyanosis    (bluish  colouration on skin and mucous membrane)                                                        

 Weight loss and cachexia (weight loss and muscle wasting syndrome)

In advanced COPD

 Congested neck veins (due to increased jugular venous pressure)

 Barrel chest

Asynchronous movement of chest and abdominal during respiration

 Use of accessory respiratory muscles due to diaphragmatic dysfunction

Hyperresonant lung

 Decreased breath sounds on auscultation (silent lung)

 Prolonged expiratory phase

 Finger clubbing   

   

 Diagnosis:

1.Assessment : age,history,clinical signs

2.Spirometery :

                                    Spirometry is performed pre and post bronchodilator admisteration to determine whether airflow limitation is present,partial or fully reversible     
                            COPD is confirmed when FEV/FVC ≤ 70%

Ø                                Pulseoxinometer –to detect O₂ saturation

Dyspnea scale              

RATIO	CONDITION
≥80%	Mild
50-79%	Moderate
30-49%	Severe
≤30%	Very severe

3.Blood gas analysis BGA:

                             To find  hypoxemia-absence of O₂, in blood

    Hypercapnia-increased CO₂ in blood

    Polycythemia-RBC elevated in blood

4.Chest X-ray:

          Shows signs of Barrel chest [hyperinflated chest]

 Decreased lung markings

 Increase anterior ,posterior diameter

 Diaphragm pushed down and flattened

 Horizontal ribs and widened intercostal space

4.CT scan :

 To evaluate complications

 To rule out differential diagnosis

To plan surgery

5.Lab test :

 Haemoglobin levels

 Alpha-1 antitrypsin level

6.Gram strain :

                   In case of pulmonary bacterial infection

7.Bronchoscopy : procedure to look inside the lungs

8.ECG:  shows signs of heart failure

Management :

1.Cessation of smoking

2.Bronchodilators : dilate bronchial walls

 Shortacting –for mild case Eg: Salmetrol,ipratropium

 Long acting –for moderate to severe case 

                             Eg: tiotropium  bromide,formoterol

 

3.inhaled corticosteroids : lowers inflammation

 Budesonide

 Beclomethasone

 Fluticasone

4.Vaccination :

                                    Pneumococcal,influenza vaccination

5.Oxygen theraphy :

 For patient with severe dyspnea

 It increase the chance of survival in COPD

6.Pulmonary rehabilation :

Physiotheraphy

 Pursed lip breathing,

 Postural drinage

 Physical activity to maintain endurance,dyspnea

7.Vitamine D3 and calcium in case of deficiency :

it reduce acute exerbration (worsening of symptoms)

8.Surgery :

                        Lung resection – Section of lung or entire lung is removed

                                       For emphysema patients to improve symptoms

 Lung transplant

                                       For patients with non reparable lung damage

Complications:  

1.Acute exerbation of Chronic obstructive pulmonary disease (AECOPD)

                             Acute worsening of respiratory symptoms 

                                    Eg: icreased dyspnea,sputum consistency changes

2.Chronic respiratory failure

3.Corpulmonale (Right heart failure) :

4.Pulmonary cachexia (weight loss syndrome)

5.Secondary spontaneous pneumothorax –due to rupture of bullae (fluid filled sac)

Differential diagnosis :

 Tuberculosis

 Bronchiectasis

Asthma

 Congestive heart failure

 Lung cancer

 Additional images :

Pink Puffers vs Blue Bloater