Chronic obstructive pulmonary disease
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Chronic Obstructive Pulmonary Disease (COPD) is characterized by airflow limitation that is not fully reversible. It includes emphysema, chronic bronchitis, and small airways disease. COPD risk factors include cigarette smoking, air pollution, and genetic conditions. Symptoms include cough, sputum production, and shortness of breath. Diagnosis involves pulmonary function tests showing airflow obstruction. Treatment focuses on smoking cessation, bronchodilators, and pulmonary rehabilitation.
Chronic obstructive pulmonary disease
- 1. Chronic Obstructive Pulmonary Disease Dr. Ravi Jain M.D.(Hom) Assistant Professor Department of Practice of Medicine Jayoti Vidyapeeth Women’s University Jaipur
- 2. Chronic Obstructive Pulmonary Disease A disease state characterized by airflow limitation that is not fully reversible. It includes : Emphysema : an anatomically defined condition characterized by destruction and enlargement of the lung alveoli. Chronic bronchitis : a clinically defined condition with chronic cough and phlegm. Small airways disease : a condition in which small bronchioles are narrowed. COPD is present only if chronic airflow obstruction occurs.
- 3. COPD is the third leading cause of death and affects >10 million persons in the United States. Estimates suggest that COPD will rise from the sixth to the third most common cause of death worldwide by 2020.
- 4. Asthma V/s COPD Dutch hypothesis. This suggests that asthma, chronic bronchitis, and emphysema are variations of the same basic disease, which is modulated by environmental and genetic factors to produce these pathologically distinct entities. British hypothesis contends that asthma and COPD are fundamentally different diseases: Asthma is viewed as largely an allergic phenomenon, whereas COPD results from smoking-related inflammation and damage.
- 5. Risk Factors Cigarette smoking : accelerated decline in FEV1 in a dose-response relationship to the intensity of cigarette smoking. Airway Responsiveness and COPD : many patients with COPD also share this feature of airway hyperresponsiveness. Increased airway responsiveness is a significant predictor of subsequent decline in pulmonary function. Respiratory Infections : respiratory infections are important causes of exacerbations of COPD.
- 6. Occupational exposures :exposure to dust and fumes at work. Several specific occupational exposures, including coal mining, gold mining, and cotton textile dust, have been suggested as risk factors for chronic airflow obstruction. Ambient air pollution : ambient air pollution is a much less important risk factor for COPD than cigarette smoking. Passive smoking exposure : Exposure of children to maternal smoking results in significantly reduced lung growth. Genetic considerations :Severe α1 antitrypsin deficiency is a proven genetic risk factor for COPD.
- 7. Clinical Presentation History of Cough Sputum production Exertional dyspnea : increased effort to breathe, heaviness, air hunger, or gasping. As COPD advances, there is worsening dyspnea on exertion with increasing intrusion on the ability to perform vocational or avocational activities. In the most advanced stages, patients are breathless doing simple activities of daily living.
- 8. Physical Findings : Early stages, patients usually have an entirely normal physical examination. Current smokers may have signs of active smoking, including an odor of smoke or nicotine staining of fingernails. In more severe disease, the physical examination is notable for a prolonged expiratory phase and may include expiratory wheezing.
- 9. The signs of hyperinflation include a barrel chest and enlarged lung volumes with poor diaphragmatic excursion as assessed by percussion. In severe airflow obstruction exhibit use of accessory muscles of respiration Sitting in the characteristic “tripod” position to facilitate the actions of the sternocleidomastoid, scalene, and intercostal muscles. Patients may develop cyanosis, visible in the lips and nail beds.
- 11. Predominant emphysema, termed “pink puffers” are thin and noncyanotic at rest and have prominent use of accessory muscles. Patients with chronic bronchitis are more likely to be heavy and cyanotic “blue bloaters” Advanced disease is accompanied by cachexia, with significant weight loss, bitemporal wasting, and diffuse loss of subcutaneous adipose tissue.
- 12. EMPHYSEMA
- 13. It is defined as a pathological increase increase in the size of airspaces distal to the terminal bronchioles, with destruction of alveolar walls. Etiology : Alpha 1 antitrypsin deficiency. Cigarette smoking Repeated respiratory infections Occupational causes : requiring forceful expiration
- 14. Pathology Seen during autopsy : Findings includes : Lungs in inflated position Elastic tissue is damaged Diaphragm is depressed Alveoli are overdistended Septa rupture and neighbouring coalesce to form cyst.
- 15. Pulmonary vasular bed is diminished leading to pumonary hypertension. Reduction of alveolar surface area leads to impairment of gas exchange. Right ventricular hypertrophy and cor pulmonale develops.
- 16. Clinical Features Dyspnoea : With grades : 0 No breathlessness except with strenuous exercise 1 Breathlessness when hurrying on the level or walking up a slight hill 2 Walks slower than contemporaries on level ground because of breathlessness or has to stop for breath when walking at own pace. 3 Stops for breath after walking about 100 m or after a few minutes on level ground 4 Too breathless to leave the house, or breathless when dressing or undressing.
- 17. Physical examination Barrel shaped chest : rounded, bulging chest that resembles the shape of a barrel. Hyper resonance on percussion. Obliteration of cardiac and liver dullness Diminished breath sounds Prolonged expiration Right ventricular hypertrophy
- 19. Emphysema is classified into distinct pathologic types, the most important being centriacinar and panacinar. Centriacinar emphysema : the type most frequently associated with cigarette smoking. Characterized by enlarged air spaces found (initially) in association with respiratory bronchioles. most prominent in the upper lobes and superior segments of lower lobes and is often quite focal.
- 21. Panacinar emphysema It refers to abnormally large air spaces evenly distributed within and across acinar units. Usually observed in patients with α1AT deficiency. It has a predilection for the lower lobes.
- 22. Special forms of Emphysema Compensatory emphysema : Normal lung tissue undergoes hypertrophy to compensate for extensive damage. Atrophic emphysema : The condition results from senile atrophy of inter alveolar septa. The lung volume is not increased. Bullous emphysema : Air spaces exceeding 1 cm in diameter develop either genetically or acquired. With time the bullae enlarge to become giant bullous emphysema.
- 24. Disease characterized by : Hyper-secretion of mucous sufficient to cause cough and sputum for most of the days for at least three months in a year for two or more consecutive years in absence of any other respiratory or cardiovascular disease. Larger air passage are effected. Later small airways are affected producing obstructive features. Infection causes aggravation of symptoms and sputum becomes purulent. As airway obstruction sets in emphysema develops together known as Chronic bronchitis emphysema syndrome. (CEBS)
- 25. Pathology Bronchial mucosa shows hypertrophy and increase of mucous glands and goblet cells with overproduction of mucous. Distal airways shows narrowing of lumen. Mucosa becomes ulcerated and when ulcers heal, fibrosis occurs resulting in distortion of lumen with stenosis and dilatation. Distortion of airways leads to permanent obstruction. Secondary infection occurs in the later stage. Ciliary movement is impaired.
- 26. Clinical features Depends on severity and duration. Cough recurring year after year specially in winter months later becomes constant. Expectoration is mucoid and sputum is tenaceous, specially on waking In morning. Tightness in chest
- 27. Diagnosis History of chronic cough. Mucopurulent sputum X ray normal in initial stage Lung function test shows reduction in vital capacity, increase in closing volume and features of airway obstruction. Pulmonary function testing shows airflow obstruction with a reduction in FEV1 and FEV1/FVC Spirometry values are markedly reduced.
- 28. Global Initiative for Lung Disease GOLD GOLD Criteria for Severity of Airflow Obstruction in COPD GOLD Stage Severity Spirometry I Mild FEV1/FVC <0.7 and FEV1 ≥80% predicted II Moderate FEV1/FVC <0.7 and FEV1 ≥50% but <80% predicted III Severe FEV1/FVC <0.7 and FEV1 ≥30% but <50% predicted IV Very severe FEV1/FVC <0.7 and FEV1 <30% predicted
- 29. Complications Frequent respiratory infections Respiratory failure Right sided heart failure.
- 30. Management General management Smoking cessation Improvement of general health Regular exercise Deep breathing exercises Adequate sleep Treatment of obesity.
- 31. Specific treatment STABLE PHASE COPD Only three interventions: Smoking cessation, Oxygen therapy in chronically hypoxemic patients Lung volume reduction surgery in selected patients with emphysema.
- 32. Use of inhaled glucocorticoids may alter mortality rate (but not lung function). Current therapies are directed at improving symptoms and decreasing the frequency and severity of exacerbations. This should be followed by an assessment of response to therapy, and a decision should be made whether or not to continue treatment.
- 33. Pharmacotherapy Smoking cessation Bronchodilators Anticholinergic agents : Ipratropium bromide improves symptoms and produces acute improvement in FEV1. Beta agonists : provide symptomatic benefit. Inhaled glucocorticoids :apparent benefit from the regular use of inhaled glucocorticoids on the rate of decline of lung function. Oral Glucocorticoids : not recommended, significant side effects, including osteoporosis, weight gain, cataracts, glucose intolerance, and increased risk of infection.
- 34. Non Pharmacologic Therapies General Medical Care : Patients with COPD should receive the influenza vaccine annually. Polyvalent pneumococcal vaccine. Pulmonary Rehabilitation : treatment program that incorporates education and cardiovascular conditioning. Lung Volume Reduction Surgery (LVRS) : offers both a mortality benefit and a symptomatic benefit in certain patients with emphysema Lung Transplantation
- 35. Patient Assessment : The history should include quantification of the degree of dyspnea by asking about breathlessness during activities of daily living and typical activities for the patient. The patient should be asked about fever; change in character of sputum; any ill contacts; and associated symptoms such as nausea, vomiting, diarrhea, myalgias, and chills. Inquiring about the frequency and severity of prior exacerbations can provide important information.
- 36. Acute Exacerbations Bronchodilators : typically with an inhaled β agonist, often with the addition of an anticholinergic agent. Antibiotics : for potential respiratory pathogens. Glucocorticoids : to reduce the length of stay, hasten recovery, and reduce the chance of subsequent exacerbation or relapse. Oxygen : O2 is b supplied to keep arterial saturations ≥90%. Mechanical Ventilatory Support :The initiation of noninvasive positivepressure ventilation (NIPPV)
- 37. Homoeopathic Management Antimonium ars : an excellent remedy for COPD with emphysema. There is excessive dyspnea and cough with much mucus secretion , worse on eating or lying down. Antimonium tart : indicated in emphysema of the aged, coughing and gasping consequently . There is great rattling of mucus in the lungs and rapid , short, difficult breathing. Aspidosperma - is one of the best remedies for COPD and it is considered a tonic for lungs. It removes temporary obstruction to the oxidation of blood by stimulating respiratory centres. Another guiding symptom is want of breath during exertion .
- 38. Bryonia alba : excellent remedy prescribed when there is frequent desire to take long breath, must expand lungs.There is dry, barking cough , worse at night. Respiration is quick , difficult with pain in the chest.< motion, > absolute rest. Coca : prescribed for COPD where there is want of breath or shortness of breath. It is especially useful for aged sports men and alcoholics. There is hoarseness or loss of voice and dyspnea. Curare - where there is threatened cessation of respiration on falling asleep . Short breath, short dry cough, very distressing dyspnea.
- 39. Lobelia : indicated in COPD where there is coughing with vomiting, asthma preceded by prickling all over, hyperventilation, panting, threatened with suffocation, fear of death, chest feels constricted, worse from any movement. Naphthaline : indicated where there is dyspnea and sighing respiration. It is useful for emphysema of the aged with asthma. There is long and continued paroxysms of coughing and tenacious expectoration.
- 40. SENEGA : an effective remedy with increased respiration. There is excessive dyspnea and sharp contractive pains in the muscles of chest. Persistent cough. STRYCHNINUM : Respiration increased. Excessive dyspnea. Sharp contractive pains in the muscles of chest. Persistent cough.