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    Chronic Obstructive Pulmonary Disease: Olivia Faye J Listanco IM Resident January 21, 2016

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    Chronic obstructive pulmonary disease (COPD) is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response. It is caused by noxious particles or gas, mainly from cigarette smoking. It currently affects over 10 million Americans but is projected to become the third leading cause of death by 2020. The main components of COPD are emphysema and chronic bronchitis. Diagnosis requires assessment of symptoms, spirometry showing post-bronchodilator FEV1/FVC <70%, and risk factors. Management involves smoking cessation, bronchodilators, glucocorticoids, oxygen therapy, vaccination, and mechanical ventilation for acute exacerbations.

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    Chronic Obstructive Pulmonary Disease: Olivia Faye J Listanco IM Resident January 21, 2016

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    FayeListanco
    375 views52 pages
    Chronic obstructive pulmonary disease (COPD) is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response. It is caused by noxious particles or gas, mainly from cigarette smoking. It currently affects over 10 million Americans but is projected to become the third leading cause of death by 2020. The main components of COPD are emphysema and chronic bronchitis. Diagnosis requires assessment of symptoms, spirometry showing post-bronchodilator FEV1/FVC <70%, and risk factors. Management involves smoking cessation, bronchodilators, glucocorticoids, oxygen therapy, vaccination, and mechanical ventilation for acute exacerbations.

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    Chronic obstructive pulmonary disease (COPD) is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response. It is caused by noxious particles or gas, mainly from cigarette smoking. It currently affects over 10 million Americans but is projected to become the third leading cause of death by 2020. The main components of COPD are emphysema and chronic bronchitis. Diagnosis requires assessment of symptoms, spirometry showing post-bronchodilator FEV1/FVC <70%, and risk factors. Management involves smoking cessation, bronchodilators, glucocorticoids, oxygen therapy, vaccination, and mechanical ventilation for acute exacerbations.

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    © All Rights Reserved
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    Download as pptx, pdf, or txt
    375 views52 pages

    Chronic Obstructive Pulmonary Disease: Olivia Faye J Listanco IM Resident January 21, 2016

    Uploaded by

    FayeListanco
    Chronic obstructive pulmonary disease (COPD) is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response. It is caused by noxious particles or gas, mainly from cigarette smoking. It currently affects over 10 million Americans but is projected to become the third leading cause of death by 2020. The main components of COPD are emphysema and chronic bronchitis. Diagnosis requires assessment of symptoms, spirometry showing post-bronchodilator FEV1/FVC <70%, and risk factors. Management involves smoking cessation, bronchodilators, glucocorticoids, oxygen therapy, vaccination, and mechanical ventilation for acute exacerbations.

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    CHRONIC OBSTRUCTIVE

    PULMONARY DISEASE

    Olivia Faye J Listanco


    IM Resident
    January 21, 2016

    airflow limitation that is not fully


    reversible
    affects >10 million persons in
    the United States
    will rise from the 6th to 3rd most
    common cause of death by 2020

    Harrisons Principle of Internal Medicine, 19th Ed, Ch


    314 1700pp

    Definition
    EMPHYSEMA
    an anatomically defined condition
    characterized by destruction and enlargement

    CHRONIC BRONCHITIS
    condition characterized by destruction and
    enlargement the lung alveoli

    SMALL AIRWAY DISEASE


    chronic cough and phlegm

    COPD is present only if


    chronic airflow obstruction
    Principle of Internal Medicine, 19 Ed, Ch
    occursHarrisons
    314 1700pp
    th

    Definition
    Persistent airflow limitations that
    is usually progressive and
    associated with an enhanced
    chronic inflammatory response in
    the airway and the lung to
    noxious particles or gas.

    Global Initiative for Chronic Obstructive Lung

    RISK FACTORS

    Tobacco smoke
    Indoor air pollution
    Occupational dust and chemicals
    Outdoor air pollution

    Global Initiative for Chronic Obstructive Lung

    Smoki
    ng

    Harrisons Principle of Internal Medicine, 19th Ed, Ch

    Emphysema
    1.
    2.
    3.
    4.

    Chronic exposure to cigarette smoke


    Release of elastiolytic antiproteases
    Structural cell death
    Ineffective repair of elastin

    Elastin Hypothesis
    Balance between elastin and anti
    elastin proteases determines the
    susceptibility of lung to damage
    Anti elastin
    elastin

    Level of damage
    Large airways
    - Result in mucus gland enlargement
    and goblet cell hyperplasia
    - Cough and mucus secretions
    ( CHRONIC BRONCHITIS)
    Small airways
    - Goblet cell metaplasia, shift to
    mucus secreting from Clara cells

    Airflow limitation
    Major physiologic change in COPD
    Due to small airway obstruction in
    emphysema

    Pathophysiology

    Harrisons Principle of Internal Medicine, 19th Ed, Ch

    Assessment
    1.
    2.
    3.
    4.
    5.

    Assess symptoms
    Assess Degree of air flow limitations
    Assess Risk for exacerbation
    Assess comorbidities
    Combined assessment of COPD

    Assess symptoms
    Most common symptoms
    Cough
    Sputum production
    Exertion dyspnea

    Establish chronicity of the symptoms


    Determine the development of the
    gradual process of airflow obstruction

    Harrisons Principle of Internal Medicine, 19th Ed, Ch

    Indicators for the diagnosis


    >40 years old
    Dyspnea
    Chronic
    cough
    Chronic
    sputum
    production
    Risk factors
    Global Initiative for Chronic Obstructive Lung

    Assessment
    1.
    2.
    3.
    4.
    5.

    Assess symptoms
    Assess Degree of air flow limitations
    Assess Risk for exacerbation
    Assess comorbidities
    Combined assessment of COPD

    Measure of breathlessness
    COPD Assessment Test (CAT)
    8 item, score 0-40

    COPD Control Questionnaire (CCQ)


    10 item

    Assessment
    1.
    2.
    3.
    4.
    5.

    Assess symptoms
    Assess Degree of air flow limitations
    Assess Risk for exacerbation
    Assess comorbidities
    Combined assessment of COPD

    Spirometry
    Spirometry is required

    Post-bronchodilator
    FEV1/FVC <70%
    Index of airflow limitations
    FVC volume of air forcibly exhaled from
    the point of maximal inspiration
    FEV1 volume of air exhaled after 1st
    second, how quick the lung is emptied

    Post-bronchodilator
    FEV1/FVC <70%
    Normal: 0.70-0.80 in adults
    COPD: <0.70
    FEV declines over time, used to
    measure the progression of COPD,
    reliable interval spans 12 months

    GOLD criteria

    Assessment
    1.
    2.
    3.
    4.
    5.

    Assess symptoms
    Assess Degree of air flow limitations
    Assess Risk for exacerbation
    Assess comorbidities
    Combined assessment of COPD

    Risk for exacerbation


    Acute event characterized by
    worsening of the patients symptom
    that is beyond the normal day-to-day
    activity and leads to changes in
    medications
    Hx of prev treated events
    ( hospitalizations)

    Assessment
    1.
    2.
    3.
    4.
    5.

    Assess symptoms
    Assess Degree of air flow limitations
    Assess Risk for exacerbation
    Assess comorbidities
    Combined assessment of COPD

    Combined assessment of COPD

    Management
    Smoking Cessation
    Oxygen Therapy
    Lung Volume Reduction Surgery

    Global Initiative for Chronic Obstructive Lung

    Symptomatic phase
    Anticholinergic
    Agents
    Beta Agonists
    Inhaled / Oral
    Glucocorticoids
    Theophylline
    Oxygen

    Harrisons Principle of Internal Medicine, 19th

    Symptomatic phase
    Anticholinergic
    Agents

    Ipratropium bromide
    Tiotropium

    Beta Agonists
    Inhaled / Oral
    Glucocorticoids
    Theophylline
    Oxygen

    Harrisons Principle of Internal Medicine, 19th

    Symptomatic phase
    Anticholinergic Agents

    Beta Agonists

    Salmeterol
    Formoterol

    Inhaled / Oral
    Glucocorticoids
    Theophylline
    Oxygen
    Harrisons Principle of Internal Medicine, 19th

    Symptomatic phase
    Anticholinergic Agents
    Beta Agonists

    Inhaled / Oral
    Glucocorticoids
    Theophylline
    Oxygen

    exacerbation
    frequency by ~25%
    unfavorable
    benefit/risk ratio

    candidiasis
    Osteoporosis
    weight gain
    cataracts,

    glucose intolerance
    risk of infection

    Harrisons Principle of Internal Medicine, 19th

    Symptomatic phase
    Anticholinergic Agents
    Beta Agonists
    Inhaled / Oral
    Glucocorticoids

    Theophylline

    expiratory flow rates


    vital capacity
    arterial oxygen and
    carbon dioxide
    levels

    Oxygen
    Harrisons Principle of Internal Medicine, 19th

    Symptomatic phase
    Anticholinergic Agents
    Beta Agonists
    Inhaled / Oral
    Glucocorticoids
    Theophylline

    mortality rates
    proportional to
    the number of
    hours/day oxygen

    Oxygen
    Harrisons Principle of Internal Medicine, 19th

    Symptomatic phase
    Phosphodiest
    erase-4
    inhibitor
    Methyxanthines
    Vaccines

    In GOLD 3 and 4
    with hx of
    exacerbations
    ROFLUMILAST
    reduces
    exacerbations

    Harrisons Principle of Internal Medicine, 19th

    Symptomatic phase
    Phosphodiesterase4 inhibitor

    Vaccines

    Pnuemococcal
    vaccines
    recommended
    yearly in px >65
    yo

    Harrisons Principle of Internal Medicine, 19th

    Acute Exacerbations
    BRONCHODILATORS
    ANTIBIOTICS
    OXYGEN
    GLUCOCORTICOIDS
    MECHANICAL VENTILATORY SUPPORT
    Harrisons Principle of Internal Medicine, 19th

    Stable patients
    Management should be individualized

    Goals should be reached with minimal


    side effects of treatment

    Non pharmacologic

    Management of
    exacerbations
    Acute event characterized by
    worsening of the patients symptom
    that is beyond the normal day-to-day
    activity and leads to changes in
    medications
    Most common cause respiratory
    infection

    Assessment of exacerbations
    WBC: Polycythemia or bleeding
    Purulent sputum
    Electrolyte imbalance, poor
    nutrition, poorly controlled DM

    ABG: PaO2 < 8.0kPA


    with or witout O2
    PaCO@ > 6.5KPa at
    room air

    Spirometry
    is not
    recommend
    ed during
    exacerbatio
    n

    Acute Exacerbations
    BRONCHODILATORS
    Nebulized therapy
    ANTIBIOTICS
    Metered dose
    inhalers

    OXYGEN
    GLUCOCORTICOIDS
    MECHANICAL
    VENTILATORY
    SUPPORT

    Harrisons Principle of Internal Medicine, 19th

    Acute Exacerbations
    BRONCHODILATORS

    ANTIBIOTICS
    OXYGEN
    GLUCOCORTICOIDS
    MECHANICAL
    VENTILATORY SUPPORT

    If with: inc dyspnea, inc


    vol of sputum, inc
    purulent sputum
    MCGS: Streptococcus
    pneumoniae,
    Haemophilus influenzae,
    Moraxella catarrhalis,
    Mycoplasma
    pneumoniae, Chlamydia
    pneumoniae

    Harrisons Principle of Internal Medicine, 19th

    Global Initiative for Chronic Obstructive Lung

    ACUTE EXACERBATIONS
    CHRONIC OBSTRUCTIVE PULMONARY DISEASE

    BRONCHODILATORS
    ANTIBIOTICS

    Harrison: 90%
    GOLD: 88-92%

    OXYGEN
    GLUCOCORTICOIDS
    MECHANICAL
    VENTILATORY
    SUPPORT

    Harrisons Principle of Internal Medicine, 18th

    ACUTE EXACERBATIONS
    CHRONIC OBSTRUCTIVE PULMONARY DISEASE

    BRONCHODILATORS
    ANTIBIOTICS
    OXYGEN
    GLUCOCORTICOIDS
    MECHANICAL
    VENTILATORY
    SUPPORT

    Length of stay
    hasten recovery
    chance of
    exacerbation or
    relapse up to 6
    months
    HYPERGLYCEMIA

    Harrisons Principle of Internal Medicine, 18th

    ACUTE EXACERBATIONS
    CHRONIC OBSTRUCTIVE PULMONARY DISEASE

    BRONCHODILATORS
    ANTIBIOTICS
    OXYGEN
    GLUCOCORTICOIDS
    VENTILATORY
    SUPPORT

    Noninvasive
    Positive-Pressure
    Ventilation (NIPPV)
    mortality rate
    need for intubation
    complications of
    therapy
    hospital length of
    stay

    Harrisons Principle of Internal Medicine, 18th

    ACUTE EXACERBATIONS
    CHRONIC OBSTRUCTIVE PULMONARY DISEASE

    BRONCHODILATORS
    ANTIBIOTICS
    OXYGEN
    GLUCOCORTICOIDS
    VENTILATORY
    SUPPORT

    Global Initiative for Chronic Obstructive Lung

    Global Initiative for Chronic Obstructive Lung

    Global Initiative for Chronic Obstructive Lung

    Reference
    Harrisons Principle of Internal
    Medicine, 19th Ed, Ch 314
    Global Initiative for Chronic
    Obstructive Lung Disease, 2015
    CAT: http://www.thoracicmedicine.org/article.asp?
    issn=18171737;year=2014;volume=9;issue=1;spage=3;epa
    ge=7;aulast=Al

    CCQ:http://www.goldcopd.org/uploads/users
    /files/GOLD_Report_2015.pdf

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