Pathophysiology of Pathophysiology of Chronic Airflow LimitationChronic Airflow Limitation

Chronic Obstructive Lung Chronic Obstructive Lung DiseaseDisease

Emphysema Emphysema Abnormal permanent enlargement of the Abnormal permanent enlargement of the

airspaces distal to the terminal airspaces distal to the terminal bronchioles, accompanied by destruction bronchioles, accompanied by destruction of their walls and without obvious fibrosisof their walls and without obvious fibrosis

Risk FactorsRisk Factors:: Cigarette SmokingCigarette Smoking

Irritation - > 4,000 chemicals inhaledIrritation - > 4,000 chemicals inhaled Hyperplasia – reduces airway diameterHyperplasia – reduces airway diameter Abnormal dilatation of distal airspacesAbnormal dilatation of distal airspaces

Destruction of alveolar wallsDestruction of alveolar walls

Chronic Obstructive Lung Chronic Obstructive Lung DiseaseDisease

Emphysema Emphysema Risk Factors (cont’dRisk Factors (cont’d):):

Recurring respiratory tract infectionsRecurring respiratory tract infections H. flu, Strep pneumoniae, Moraxella catarrhalisH. flu, Strep pneumoniae, Moraxella catarrhalis

HeredityHeredity – alpha 1 – – alpha 1 –Antitrypsin (ATT) deficiencyAntitrypsin (ATT) deficiency Accounts for <1% of COPD in USAccounts for <1% of COPD in US AAT is a serum protein produced by the liver and normally AAT is a serum protein produced by the liver and normally

found in the lungsfound in the lungs IV or nebulized AAT (Prolastin) slows COPD progressionIV or nebulized AAT (Prolastin) slows COPD progression

Aging Aging – Changes in lung structure – Changes in lung structure Gradual loss of elastic recoil – thin alveolar wall – thoracic Gradual loss of elastic recoil – thin alveolar wall – thoracic

cage changes from osteoporosis & calcificationcage changes from osteoporosis & calcification

COPDCOPDPulmonary Blebs & BullaePulmonary Blebs & Bullae

Pathophysiology of Chronic Pathophysiology of Chronic Bronchitis and EmphysemaBronchitis and Emphysema

Interferences with Interferences with VentilationVentilation

Collaborative Care GoalsCollaborative Care Goals Improve ventilationImprove ventilation Promote removal of secretionsPromote removal of secretions Prevent complications & Prevent complications &

progression of symptomsprogression of symptoms Promote patient comfort & Promote patient comfort &

participation in careparticipation in care Improve quality of life as much Improve quality of life as much

as possibleas possible

Interferences with Interferences with VentilationVentilation

Collaborative TreatmentCollaborative Treatment Patients are treated primarily as Patients are treated primarily as

outpatientsoutpatients HospitalizationsHospitalizations

Acute exacerbationsAcute exacerbations ComplicationsComplications

Respiratory failure, pneumonia, Respiratory failure, pneumonia, congestive heart failurecongestive heart failure

Interferences with Interferences with VentilationVentilation

Collaborative ManagementCollaborative Management Smoking cessationSmoking cessation Treatment of respiratory infectionsTreatment of respiratory infections Bronchodilator therapyBronchodilator therapy

Beta2-adrenergic agonistsBeta2-adrenergic agonists Anticholinergic agentsAnticholinergic agents Long-acting theophyllineLong-acting theophylline

CorticosteroidsCorticosteroids PEFR monitoring (peak expiratory flow rate)PEFR monitoring (peak expiratory flow rate) Chest physiotherapy / Breathing exercises & Chest physiotherapy / Breathing exercises &

retrainingretraining Hydration 3L/day (unless contraindicated)Hydration 3L/day (unless contraindicated) Rest - Progressive plan of exerciseRest - Progressive plan of exercise Patient & family educationPatient & family education Influenza / Pneumovax immunizationInfluenza / Pneumovax immunization Low flow oxygen rate (if indicated)Low flow oxygen rate (if indicated) Pulmonary rehabilitation programPulmonary rehabilitation program