Chronic Obstructive
Pulmonary Disease(COPD)
Melaku Yitbarek(M.D)
Internal Medicine Unit
March,2018
Lecture Outline
• Defintion
• Epidemiology
• Risk factors
• Pathophysiology
• Clinical Presentation
• Diagnosis
• Treatment
Definition
Chronic obstructive pulmonary disease
(COPD) is defined as a disease state
characterized by airflow limitation that is not
fully reversible
COPD includes emphysema, an anatomically
defined condition characterized by destruction
and enlargement of the lung alveoli;
chronic bronchitis,a clinically defined
conditionWith chronic cough and phlegm; and
small airways disease,a condition in which
small bronchioles are narrowed
Definition…
Epidemiology
• COPD is the third leading cause of death and affects >10
million persons in the United States
• COPD is also a disease of increasing public health
importance around the world.
• Estimates suggest that COPD will rise from the sixth to the
third most common cause of death worldwide by 2020.
• In Ethiopia, no adequate epidemiologic data.
• COPD accounted for 3.6% of chest clinic visit at TASH
( 2014)
Risk factors
• Cigarette smoking-pack year(dose X years) ↓FEV1 faster
• Airway responsive as in asthma(genetic predisposition)
• Respiratory infections-childhood(initiate/exacerbate)
• Occupational exposure-dust,gold,↓FEV1
• Air pollution town>rural,↑Women( indoor pollution)
• +/_ genetic /environmental+passive
• Genetic –α1 antitrypsin deficiency(emphysema)
Pathophysiology
Inflammatory Process in COPD
Macrophages in
activates respiratory
tract
release
Neutrophils
release Parenchym
Proteases stimulate al
Destructio
n
NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease. April 2001 (Updated
2003).
Barnes PJ. Chronic obstructive pulmonary disease. N Engl J Med. 2000;343:269-280.
Causes of Airflow Limitation
Irreversible
Fibrosis and narrowing of the airways
Loss of elastic recoil due to alveolar
destruction
Destruction of alveolar support that maintains
patency of small airways
Reversible
Accumulation of inflammatory cells, mucus,
and plasma exudate in bronchi
Smooth muscle contraction in peripheral
and central airways
Dynamic hyperinflation during exercise
Pathophysiology in Chronic bronchitis
Normal versus Diseased
Bronchi
Pathophysiology in Emphysema
Pathophysiology in Emphysema
Emphysema
Not only smoking but smoke
Air pollution resulting from the
burning of wood and other
biomass fuels is estimated to kill
two million women and children
each year.
Natural History
The effects of cigarette smoking on pulmonary function
appear to depend on the intensity of smoking exposure,
the timing of smoking exposure during growth, and the
baseline lung function of the individual
The rate of decline in pulmonary function can be modified
by changing environmental exposures (i.e., quitting
smoking), with smoking cessation at an earlier age
providing a more beneficial effect than smoking cessation
after marked reductions in pulmonary function have
already developed.
Genetic factors likely contribute to the level of pulmonary
function achieved during growth and to the rate of decline
in response to smoking and potentially to other
environmental factors as well
Clinical Presentation
History:
The three most common symptoms in COPD are
cough, sputum production,and exertional dyspnea
Many patients have such symptoms for months or
years before seeking medical attention.
Activities involving significant arm work, particularly
at or above shoulder level, are particularly difficult for
patients with COPD
In the most advanced stages, patients are breathless
doing simple activities of daily living
Patients may also develop resting hypoxemia and
require institution of supplemental oxygen
Clinical Presentation
Physical findings:
In the early stages of COPD, patients usually have
an entirely normal physical examination
In patients with more severe disease, the physical
examination is notable for a prolonged expiratory
phase and may include expiratory wheezing.
In addition, signs of hyperinflation include a barrel
chest and enlarged lung volumes with poor
diaphragmatic excursion as assessed by percussion
Patients with severe airflow obstruction may also
exhibit sitting in “Tripod postion”
Clinical Presenatation
Physical findings:
• Patients may develop cyanosis, visible in the
lips and nail beds
• Advanced disease may be accompanied by
cachexia, with significant weight loss,
bitemporal wasting
• Clubbing of the digits is not a sign of COPD,
and its presence should alert the clinician to
initiate an investigation for causes of
clubbing.
Laboratory findings
The hallmark of COPD is airflow obstruction
Pulmonary function testing shows airflow
obstruction with a reduction in FEV1 and
FEV/FVC
With worsening disease severity, lung
volumes may increase, resulting in an
increase in total lung capacity,functional
residual capacity, and residual volume
Spirometry
Spirometry
5 Normal
4
Volume, liters
3
FEV1 = 1.8L
2 FVC = 3.2L
FEV1/FVC = 0.56
1 Obstruc
tive
1 2 3 4 5 6
Time, seconds
Treatment
Stable phase COPD:
Only three interventions :smoking cessation,
oxygen therapy in chronically hypoxemic
patients, and lung volume reduction surgery
in selected patients with emphysema—have
been demonstrated to influence the natural
history of patients with COPD
All other current therapies are directed at
improving symptoms and decreasing the
frequency and severity of exacerbations
Tx…
Pharmacotherapy:
• Smoking cessation
• Bronchodilators
• Anticholinergics
• Beta agonists
• Inhaled corticosteroids
• Oral corticosteroids
• Theophyline
• O2: has mortality benefit
Tx
COPD Exacerbations:
Exacerbations are a prominent feature of the
natural history of COPD.
Exacerbations are episodes of increased dyspnea
and cough and change in the amount and character
of sputum
The approach to the patient experiencing an
exacerbation
includes an assessment of the severity of the
patient’s illness, both acute and chronic
components; an attempt to identify the precipitant
of the exacerbation; and the institution of therapy.
Tx…
Acute COPD Exacerbations:
• Bronchodilators: Inhaled Beta agonists with
anticholinergic agents
• Antibiotics: azithromycine
• Glucocorticoids:
• Oxygen
• Mechanical Ventilatory support: In pts with
respiratory failure, decrease mortality rate
Referrences
Harrison’s Principles of Internal
Medicine,19th Edition
Standard Treatment Guideline for general
Hospital 2014
Uptodate 21.6
Thank You…
