COPD
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Obstructive Lung Disease
• Chronic Obstructive Pulmonar y Disease (COPD)
• Asthma
• Bronchiectasis
CC (4.0): CFCF
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COPD
• Presentation: Dyspnea initially on exertion
• Progresses to dyspnea at rest
• Cough
• Sputum production
• May stay sedentary to avoid exertional dyspnea
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COPD
• Presentation: Predominantly Emphysema or Chronic Bronchitis
Emphysema (“Pink Puffers”)
• Thin (due to high energy use w/
respiration)
• Lean forward when sitting
• Barrel chest w/ high AP diameter
Chronic Bronchitis (“Blue Bloaters)
• Definition: Productive cough for ≥3
months over 2 consecutive years
• Overweight and cyanotic (due to high CO2
and low O2)
• Tachypnea w/ pursed lips
• May have cor pulmonale
• Distressed appearance and uses accessory
• Normal RR or slightly tachypneic
resp. muscles
• No distress or use of accessory resp.
muscles
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COPD
• Path:
• Emphysema: Destruction of alveolar walls
• High ratio of proteases and elastases to antiproteases (e.g. a1-antitrypsin)
• Chronic bronchitis: ↑ mucus production
• Airway inflammation, smooth muscle hyperplasia => Obstruction
Emphysema
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Modified.
Chronic Bronchitis
© Adobe Stock / tolgasez33.
Modified.
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COPD
• Path: Centrilobular vs. Panlobular Emphysema
Centrilobular
Panlobular
• Most common in smokers
• Seen in a1-antitrypsin deficiency
• Limited to proximally located
• Involves both proximal and distal
respiratory bronchioles
acini
• Does not affect distal acini
• Hence the term “Panlobular”
• Targets the upper lung zones
• Targets the lung bases
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COPD
• Risk Factors: Smoking tobacco (#1)
• A1-antitrypsin deficiency
• Second-hand smoke
• Asthma
CC (0): fotografierende
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COPD
• Dx: Spirometr y (Best test) => ↓ FEV1 and ↓ FEV1/FVC ratio
• Increased residual volume, functional reserve capacity, and TLC
CC (4.0): CFCF
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COPD
• Dx: Spirometr y (Best test) => ↓ FEV1 and ↓ FEV1/FVC ratio
• Increased residual volume, functional reserve capacity, and TLC
GOLD staging system:
• FEV1 > 80% = Mild
• FEV1 50-80% = Moderate
• FEV1 30-50% = Severe
• FEV1 < 30% = Very severe
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COPD
• Dx (cont.): CXR => Hyperinflation
• Flattened diaphragm
• Diminished vascular markings
• Enlarged retrosternal space
CC (3.0): James Heilman, MD
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COPD
• Dx (cont.): Auscultation => End-expirator y wheezes
• May have inspiratory crackles
• Hyper-resonance to percussion
• ABG => Respiratory acidosis w/ metabolic compensation
• A1-antitrypsin => Order if personal/family history of emphysema ≤45 years old
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Clubbing
• Presentation: Enlargement and broadening of the fingertips
• Angle between nail fold and nail plate (Lovibond) > 180˚
• In isolation or in association with hypertrophic osteoarthropathy, which
presents w/ joint effusions and painful, enlarged joints
Clubbing
• Path:
• Malignancy
• Obstructive: COPD, CF, Bronchiectasis
• Interstitial lung disease
• Congenital heart disease
CC (2.0): Desherinka
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COPD
• Mgmt: Stop smoking (↓ mortality)
• If COPD and chronic hypoxemia => Supplemental O2 therapy (↓ mortality)
• Medications:
• Inhaled short-acting B2-agonists (e.g. albuterol)
• Inhaled anticholinergics (e.g. ipratropium)
• Long-acting B2 agonists (e.g. salmeterol)
• Long-acting muscarinic agonists (e.g. Tiotropium)
• Inhaled corticosteroids (e.g. budesonide, fluticasone)
• Oral theophylline (narrow therapeutic index)
• Antibiotics (for COPD exacerbations)
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COPD Chronic Management
Mild to Moderate COPD
• Short-acting (B-agonist or
Severe COPD
• Short-acting (B-agonist or
Anticholinergic)
Anticholinergic)
• LAMA or LABA
• LAMA or LABA
• Inhaled corticosteroids
• Inhaled corticosteroids
• Theophylline (+/-)
• Theophylline (+/-)
• If hypoxemic => O2 therapy
• Pulmonary rehab
• Triple inhaler: B-agonist +
Anticholinergic + Inhaled
corticosteroids
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Long-Term Home O2 Therapy
• Indications:
• Resting PO2 ≤55 mmHg
• Pulse Ox saturation (SaO2) ≤88%
• SaO2 ≤89% if one of the following:
• Right heart failure
• Polycythemia (Hct > 55%)
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Theophylline
• Narrow therapeutic index
• Metabolized by liver (altered by antibiotics, antiepileptics, liver
disease)
• Toxicity:
• CNS toxicity => Seizures, headaches
• GI toxicity => N/V/D
• Cardiac toxicity => Arrhythmia (e.g. Multifocal atrial tachycardia)
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COPD
• Mgmt (cont.): Influenza vaccine annually
• Pneumococcal vaccine every 5 years
• 1. If COPD and > 65 years old
• 2. If < 65 but has severe COPD
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COPD Exacerbations
• Presentation: Cardinal symptoms
• Can progress to acute respiratory failure
Cardinal symptoms
• 1. ↑ dyspnea
• Path: Pulmonary infections (#1)
• Strep pneumoniae
• 2. ↑ cough
• 3. Change in sputum color
or volume
• H flu
• Mycoplasma
• M catarrhalis
• Viral
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COPD Exacerbations
• Dx/Work-up: CXR
• Mgmt:
Medications
Other Interventions
• Inhaled B2 agonists/anticholinergics
• Supplemental O2 (target 88-92%)
• Systemic corticosteroids (i.e. IV
• Noninvasive positive pressure
methylprednisolone)
• Antibiotics (e.g. Azithromycin,
ventilation (NPPV) = BIPAP or CPAP
• If rising PCO2 and RR => Intubation
Levofloxacin, Doxycycline)
• If influenza + => Oseltamivir
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COPD Exacerbations
• Mgmt: Antibiotics (e.g. Azithromycin, Levofloxacin, Doxycycline)
• Give antibiotics if at least one of the following:
• Has at least 2 out of the 3 cardinal symptoms
• Requires mechanical ventilation
Cardinal symptoms
• 1. ↑ dyspnea
• 2. ↑ cough
• 3. Change in sputum color
or volume
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COPD Exacerbations
• Mgmt (cont.): Need to cover Pseudomonas if complicated COPD
• Give antipseudomonal coverage (Fluoroquinolone, Cefepime, Pip-Tazo) if:
• > 65 years old
• FEV 1 < 50%
• > 2 exacerbations in the last year
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COPD Exacerbations
• Mgmt: Noninvasive positive pressure ventilation (NPPV)
• BIPAP or CPAP
• Has been shown to ↓ mortality, ↓ need for intubation
• Indications:
• COPD exacerbation
• Cardiogenic pulmonary edema
• Acute respiratory failure
• Help to extubate a patient early
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COPD Exacerbations
• Mgmt: Intubation and Mechanical Ventilation (Invasive)
• Indications:
• Hypercapnia w/ AMS (e.g. ↓ responsiveness, inability to clear secretions)
• Unstable vitals
• Severe acidemia (pH <7.1)
• Failure of a 2 hour trial of NPPV
Hypercapnia alone is NOT an indication for intubation!
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COPD Exacerbations
CPAP
Intubation
CC (4.0): MyUpChar
© Adobe Stock / Crystal light. Modified.
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COPD
• Complications:
• Exacerbations
• Polycythemia (↑ EPO production)
• Pulmonary hypertension
Spontaneous Pneumothorax
• Cor pulmonale
• Pneumothorax (rupture of pleural blebs)
• Multifocal atrial tachycardia (MAT)
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A1-Antitrypsin Deficiency
• Presentation: Nonsmoker ≤45 years old develops COPD
• Basilar-predominant (lower lobe destruction due to pan-acinar emphysema)
• Liver disease: Cirrhosis, Hepatocellular carcinoma
• Family history
CC (0): National Cancer Institute
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A1-Antitrypsin Deficiency
• Path: Autosomal codominant
• M is normal allele, Z is abnormal allele deficient in antitrypsin
• MM = normal
• MZ = normal or slightly elevated risk of COPD
• ZZ = high risk for COPD, cirrhosis, HCC
• Deficiency of antiprotease
• Leads to excess elastase => Destruction of alveolar walls
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A1-Antitrypsin Deficiency
• Dx: Serum A1-Antitr ypsin, PCR
• Mgmt: Manage COPD, eliminate exposures
• IV A1-Antitrypsin
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Obstructive Lung Disease
• Chronic Obstructive Pulmonar y Disease (COPD)
• Asthma
• Bronchiectasis
CC (4.0): CFCF
29
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