COPD
Disease of Airway Obstruction-Chronic Obstructive Pulmonary Disease
Definition
A syndrome of irreversible, persistent, progressive airflow obstruction.
Gradual decrease in lung functions and episodes of acute exacerbations.
Classified by GOLD definition
Subtypes
1. Chronic bronchitis Blue bloater
Chronic productive cough for three months in each of two consecutive
years in a patient in whom other causes of chronic cough have been
excluded. More common in smokers, those exposed to indoor cooking
with biofuels and in the elderly.
a. Mucous gland hypertrophy, increased number of goblet cells and
hyper-secretion of mucus in the bronchial tress = Chronic cough
and sputum
2. Emphysema Pink puffers
Abnormal or permanent enlargement of the airspaces that are distal to
the terminal bronchioles. This is accompanied by destruction of the
airspace walls, without obvious fibrosis. More common in smokers,
those exposed to indoor cooking with biofuels and in the elderly.
a. Pathological increase beyond normal in the size of the air spaces
distal to the terminal bronchioles
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Specific Symptoms and Signs
Chronic Bronchitis Emphysema
Symptoms
Chronic productive cough Dyspnea (+/- exertion)
Purulent sputum Minimal cough
Hemoptysis Tachypnea
Mild dyspnea initially Decreased exercise tolerance
Signs
Cyanosis (20 hypoxemia and Pink skin
Hypercapnea)
Peripheral oedema from RVF (cor Pursed-lip breathing
pulmonale)
Crackles, wheezes Accessory muscle use
Prolonged expiration if obstructive Cachectic appearance due to anorexia
and increased work of breathing
Frequently obsess Hyperinflation/ barrel chest/ hyper-
resonant to percussion
Decreased breath sounds
Decreased diaphragmatic excursion
Clinical Features
PINK PUFFER SIGNS DUE TO HYPERINFLATION
Barrel shaped chest and increased AP diameter
Pursed lip breathing (emphysema) increases end expiratory pressure
and keeps airway open
Accessory muscle of respiration and drawing in of the lower intercostal
muscle with inspiration
Drowsiness/coma CO2 retention
Warm peripheries, bounding pulse, flapping tremor CO2 retention
1. Palpation
a. Reduced expansion + hyper-inflated
b. Hoovers sign
c. Tracheal tug
2. Percussion
a. Hyperresonant with decreased liver dullness
3. Breath sounds
a. Decrease
b. Forced expiratory time >9s
c. Early inspiratory crackles
4. Other
a. Wheeze ABSENT
b. Signs of RHF may occur late is disease
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BLUE BLOATER SIGNS DUE TO BROCHIAL HYPERSECRETION AND AIRWAY
OBSTUCTION
Loose cough and sputum (mucoid or mucopurulent), in the morning
Cyanosis and associated oedema from RVF
1. Palpation
a. Hyperinflated with reduced chest expansion
2. Percussion
a. Increased resonance
3. Breath sounds
a. Wheezes and early inspiratory crackles
b. Forced expiratory time >9s
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4. Other
a. Signs of RVF (cor pulmonale)
Precipitant of COPD Exacerbation (NB!)
Sustained worsening of the patient's symptoms from his or her usual stable state,
which is beyond normal day-to-day variations and is acute in onset. Commonly
reported symptoms are worsening dyspnea, cough, increased sputum production
and change in sputum color
1. Progression of COPD
2. Lung pathology
a. Alveoli Pulmonary oedema
b. Parenchyma Infections e.g. Pneumonia
c. Airways Smoking, dust, pollutants (environmental), viral
URTI
d. Vessels PE
e. Plural space Pneumothorax, pleural effusion
3. Acute heart failure
4. Non-adherence
Can lead to Respiratory failure, Cor pulmonale, and death
Investigations/Diagnosis/ Criteria
Clinical suspicion:
Usually made on the basis of three findings:
1. Significant history of heavy smoking
a. More then 40 packet years LR* 8.3
2. Reduced breath sounds (+/- signs of hyperinflation)
3. Previous diagnosis of emphysema or COPD
Gold standard = Pulmonary function tests (PFTs)
FEV1/FVC ratio less than 0.70 POST BRONCHODILATOR indicates obstruction
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Criteria: GOLD (grade severity)
GOLD 1: Mild FEV 1 >80% of predicted value
GOLD 2: Moderate FEV 1 50-80%
GOLD 3: Severe FEV 1 30-50%
GOLD 4: Very Severe FEV <30% OR <50% + RHF
Investigations
1. Oxygen sat <93%
2. ABG hypoxemia and hypercapnea
3. CXR rule out other diseases
a. Chronic findings include: flattened diaphragm, increase
radiolucency of the lung, bullae
b. Acute exacerbation rule out: pneumonia, acute heart failure,
pneumothorax
4. FBC
5. HIV
6. Sputum for MCS if fever and sputum
7. Sputum for AFB if productive cough, > 2week with fever, night sweats
and weight loss
Lung Functions:
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Treatment
Acute Exacerbation
Increase in symptoms including one of the cardinal symptoms cough, sputum
production, and dyspnea
1. Admit
a. High risk comorbidity (that caused it) pneumonia, cardiac
arrhythmia, heart failure, DM, renal failure, liver failure
b. Inadequate improvement of symptoms in causality
c. Marked increase in dyspnea
d. Worsening hypoxemia or hypercapnea
2. Admit to ICU
a. RR >25
b. HR > 105
c. Silent chest
d. Cyanosis
e. Bradycardia
f. Hypotension
g. Feeble respiratory effort or confusion
3. Immediate Treatment
a. Oxygen
b. Reliever (improve lung function)
i. Salbutamol (SABA) 2 puffs every hour
ii. Ipratropium (anticholinergic) 2 puffs 4 hourly
c. Steroids
d. Antibiotics (if infection suspected)
e. Treatment failed and still has symptoms intubate
Stable Chronic Disease (Outpatient)
1. Mild
a. Salbutamol 2 puffs as needed
b. Education on correct use of the inhaler
2. Moderate
a. Add a long acting bronchodilator (Salmeterol)
3. Severe
a. Add inhaled glucocorticoid (ICS) if need better control
4. Very Severe
a. Long term oxygen therapy
b. Frequent symptoms add theophylline
c. Symptoms despite max therapy add oral steroids
The only things that reduces mortality is long term O2 therapy and smoking
cessation
