Chronic Obstructive Pulmonary Disease

COPDDefinitionsEpidemiologyRisk factorsPathologyDiagnosisTreatment

DefinitionA disease state characterized by airflow limitation that is not fully reversible and usually it is progressive and associated with abnormal inflammatory response of the lungs to noxious particles or gases. It is a preventable and treatable disease with some significant extrapulmonary effects.

COPD Airflow obstruction is caused by a mixture of small airway disease (obstructive bronchiolitis) and parenchymal destruction (emphysema)

Chronic BronchitisThe presence of cough and sputum production for at least 3 months in each of 2 consecutive years

EmphysemaPermanent airspace enlargement beyond the terminal bronchioles due to alveolar destruction.

COPD in USA12.1 million adults has COPD in 2001Estimated number now is 16 millions14 million undiagnosed124,816 deaths in 20024th leading cause of death in USA

Percent Change in Age-Adjusted Death Rates, U.S., 1965-199800.51.01.52.02.53.0Proportion of 1965 Rate

1965 - 19981965 - 19981965 - 19981965 - 19981965 - 199859%64%35%+163%7%CoronaryHeartDiseaseStrokeOther CVDCOPDAll OtherCausesSource: NHLBI/NIH/DHHS

Of the six leading causes of death in the United States, only COPD has been increasing steadily since 1970Source: Jemal A. et al. JAMA 2005

COPD Mortality by Gender,U.S., 1980-2000Number Deaths x 1000Source: US Centers for Disease Control and Prevention, 2002

Risk Factors for COPDNutritionInfectionsSocio-economic statusAging Populations

COPD Prevalence Study in Latin AmericaThe prevalence of post-bronchodilator FEV1/FVC < 0.70 increases steeply with age in 5 Latin American Cities

Source: Menezes AM et al. Lancet 2005

Prevalence of Smoking in JordanAdults above age 25 yearMales 48%Females 10.5%School children 13-15 yearMales26%Females11.5%

Pathology

Mucus gland hyperplasiaGoblet cellhyperplasiaMucus hypersecretionNeutrophils in sputumSquamous metaplasia of epithelium MacrophagesNo basement membrane thickeningLittle increase in airway smooth muscle CD8+ lymphocytesChanges in Large Airways of COPD Patients Source: Peter J. Barnes, MD

Disrupted alveolar attachmentsInflammatory exudate in lumenPeribronchial fibrosisLymphoid follicleThickened wall with inflammatory cells- macrophages, CD8+ cells, fibroblastsChanges in Small Airways in COPD Patients Source: Peter J. Barnes, MD

Alveolar wall destructionLoss of elasticityDestruction of pulmonarycapillary bed Inflammatory cells macrophages, CD8+ lymphocytesChanges in the Lung Parenchyma in COPD Patients Source: Peter J. Barnes, MD

Mast cellCD4+ cell(Th2)EosinophilAllergensEp cellsASTHMABronchoconstrictionAHRReversibleIrreversibleAirflow LimitationSource: Peter J. Barnes, MD

DiagnosisClinical featuresPulmonary function tests

Radiology

SYMPTOMScoughsputumshortness of breathEXPOSURE TO RISKFACTORS tobaccooccupationindoor/outdoor pollutionSPIROMETRYDiagnosis of COPD

Differential Diagnosis: COPD and AsthmaCOPDAsthma Onset in mid-life Symptoms slowly progressive Long smoking history Dyspnea during exercise Largely irreversible airflow limitation

Onset early in life (often childhood)Symptoms vary from day to day and usually worse at nightOther atopic diseases or family of atopy. Largely reversible airflow limitation

Pulmonary Function TestsFEV1/FVC< 70FEV1variableAirway resistanceincreasedTotal lung capacityincreasedResidual volumeincreasedDiffusion capacitychronic bronchitisnormalemphysemadecreased

Spirometry: Normal and Patients with COPD

Classification of COPD Severity by SpirometryStage I: Mild FEV1/FVC < 0.70 FEV1 > 80% predictedStage II: Moderate FEV1/FVC < 0.70 50% < FEV1 < 80% predicted

Stage III: Severe FEV1/FVC < 0.70 30% < FEV1 < 50% predicted

Stage IV: V. Severe FEV1/FVC < 0.70 FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure

Relieve symptoms Prevent disease progression Improve exercise tolerance Improve health status Prevent and treat complications Prevent and treat exacerbations Reduce mortalityGoals of COPD Management

TreatmentPrevent disease progressionsmoking cessationvaccinesImprove pulmonary functionMedical treatmentRehabilitationSurgical treatmentTreat complications

Prevention of Disease ProgressionSmoking cessationVaccinesinfluenza (A)pneumococcal (B)

Brief Strategies to Help the Patient Willing to Quit Smoking AskSystematically identify all tobacco users at every visit. AdviceStrongly urge all tobacco users to quit. Assess Determine willingness to make a quit attempt. Assist Aid the patient in quitting.Nicotine, antidepressants, varenicline ArrangeSchedule follow-up contact.

IV: Very Severe III: Severe II: Moderate I: MildAdd regular treatment with one or more long-acting bronchodilators (when needed); Add rehabilitationAdd inhaled glucocorticosteroids if repeated exacerbations Add long term oxygen if chronic respiratory failure. Consider surgical treatments

Therapy at Each Stage of COPD

FEV1/FVC < 70%

FEV1 > 80% predicted

FEV1/FVC < 70%

50% < FEV1 < 80% predicted

FEV1/FVC < 70%

30% < FEV1 < 50% predicted

FEV1/FVC < 70%

FEV1 < 30% predictedor FEV1 < 50% predicted plus chronic respiratory failure

Surgical TreatmentLung volume reduction surgeryBullectomyLung transplantation

Acute ExacerbationsOxygen therapyBronchodilatorsAntibioticsCorticosteroidsAssisted ventilation

Respiratory FailurePaO2 < 7.3 kPa (55mmHg)PaO2 7.3-8 kPa (55-60mmHg)+CorpulmonaleErythrocytosis PCV > 55%

COPD and Co-MorbiditiesCOPD patients are at increased risk for: Myocardial infarction, anginaOsteoporosisRespiratory infectionDepressionDiabetesLung cancer