1.6E COPD.pdf

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MEDICINE II 1.6E CHRONIC OBSTRUCTIVE PULMONARY DISEASE

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COPD Chronic obstructive pulmonary disease(COPD) is a preventable and treatable disease with some significant extra pulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases. • Emphysema • Chronic Bronchitis • Small Airways Disease PERCENT CHANGE IN AGE-AGJUSTED DEATH RATES, US., 1965 - 1998

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RISK FACTORS FOR COPD Environmental factors Congenital factors Cigarette smoke Alpha-1-anti trypsin Occupational deficiency exposure (cadium & silica) Likely (burden of proof Environmental Low birth weight good) pollution Airway hyper Passive smoking responsiveness Possible Adenovirus infection Genetic disposition Degree of certainty Certain

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LEADING CAUSE OF DEATH

− Non-pharmacologic Manage exacerbations

Normal nonsmokers lose FEV1 at a rate of about 25 - 35 mL/yr Among susceptible smokers the rate of FEV1 decline is about 90 mL per year The heavier the smoking, the steeper the decline in FEV1 The increased rate of decline moves toward normal soon after smoking cessation

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OTHER RISK FACTORS Airway responsiveness Respiratory infections ? Occupational exposures ? Ambient air pollution Passive, or Second-Hand Smoking

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GENETIC CONSIDERATIONS Alpha1-antitrypsin deficiency Encoded by protease Inhibitor (PI) locus S allele – slightly reduced levels Z allele – markedly reduced levels Caucasian populations Piz individuals – severe deficiency AIRFLOW LIMITATION

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CURRENT FACTS ABOUT COPD More prevalent than asthma, this debilitating disease affects about 30 million persons in US In Philippines, it is estimated that 6.3% of adult population have COPD Mirroring cigarette usage trends, COPD related mortality leveled off in men during past 2 decades but increased markedly in women Because advanced COPD leads to extensive use of health care resources, national financial burden is substantial ( in US exceeds $ 30 billion annually)

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4 COMPONENTS OF COPD MANAGEMENT Reduce risk factors Assess and monitor disease Manage stable COPD − Education − Pharmacologic

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Increased airways resistance Reduced recoil Reduced tethering Expiratory flow limitation HYPERINFLATION Caused by reduced expiratory flow rate, destruction of alveoli, and short exhalation time. Hyperinflation of the lungs in COPD occurs because of progressive destruction of the alveoli, reduced expiratory flow rate, and the relatively short time of exhalation that COPD patients experience because of obstruction to airflow. Cholinergic tone contributes to reduced expiratory flow rate and inadequate exhalation time.

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Medicine II •

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1.6E CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Other complications are the fact that chest wall recoil remains inward, which results in a threshold load at the start of inspiration; and the flattened, shortened diaphragm muscle, which leads to inefficiency in force generation. Patients work harder to breathe. The posteroanterior (PA) and lateral chest radiographs shown here illustrate advanced findings of COPD and hyperinflation. Chest radiograph changes occur late. The expanded chest, retrosternal air space, low and flat diaphragm, and decrease in peripheral vascularity highlight the major radiographic findings. Hyperinflation is readily apparent.

1.5C END STAGE RENAL DISEASE

PaO2 remains normal until FEV1 is 50% of predicted Elevated PaCO2 not expected until FEV1 is =2

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CLASSIFICATION BY SEVERITY STAGE CHARACTERISTICS I: Mild FEV1/FVC < 70%; FEV1 ³ 80% predicted With or without chronic symptoms (cough, sputum) II: Moderate FEV1/FVC < 70%; 50% £ FEV1 < 80% predicted With or without chronic symptoms III: Severe FEV1/FVC < 70%; 30% £ FEV1 < 50% predicted With or without chronic symptoms IV: Very Severe FEV1/FVC < 70%; FEV1 < 30% predicted or FEV1< 50% predicted plus chronic respiratory failure

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• LABORATORY FINDINGS • • • • • •

ABGs Oximetry Hypoxemia PaCO2> 45mmHg Elevated Hematocrit Right ventricular hypertrophy

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CHEST RADIOGRAPHY

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Patient A

ASSESSMENT OF COPD Symptoms (CAT or mMRC) Degree of airflow limitation Risk of exacerbation Co-morbidities COMBINED COPD ASSESSMENT Characteristic Spirometry Exacerbations Low risk GOLD 1-2 65 y.o. admitted to the ICU COPD AND THE PROBLEM OF RECOGNITION

CLINICAL FEATURES OF ASTHMA & COPD Features Asthma COPD Age group All ages Usually > 40 years Sex M=F M>F Hx of smoking Occasional Frequent Hx of allergy Often (+) Occasionally (+) Major SSX: Cough, Episodic, seasonal Usually daily, dyspnea progressive Inh B2 response Marked Fast but minimal Status when not in (Almost) normal Chronic symptoms & exacerb activity

1.5C END STAGE RENAL DISEASE

Study on Physicians’ Awareness of COPD in Philippines (1997) • Out of 237 physicians surveyed on a hypothetical case of COPD, only 137 (58%) gave a correct diagnosis of COPD • Only 43/137 (31%) would use a spirometer to establish diagnosis of COPD ASTHMA OR COPD?

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KEY MESSAGES TO PHYSICIANS & PUBLIC Think COPD Do spirometry Reduce risk factors Manage actively “COPD is preventable and treatable”

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COPD problem will worsen in the coming years in developing countries like the Philippines (WHO) • COPD is a preventable and “treatable” disease • Physicians can make a difference in preventing the worsening of COPD problem (with early detection and effective treatment) __________________________________________________________ END OF TRANX

DIFFERENCES & SIMILARITIES BETWEEN ASTHMA & COPD

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