CHRONIC OBSTRUCTIVE

PULMONARY DISEASE

Olivia Faye J Listanco

IM Resident
January 21, 2016

 airflow limitation that is not fully

reversible
affects >10 million persons in
the United States
will rise from the 6th to 3rd most
common cause of death by 2020

Harrisons Principle of Internal Medicine, 19th Ed, Ch

314 1700pp

Definition
EMPHYSEMA
an anatomically defined condition
characterized by destruction and enlargement

CHRONIC BRONCHITIS
condition characterized by destruction and
enlargement the lung alveoli

SMALL AIRWAY DISEASE

chronic cough and phlegm

COPD is present only if

chronic airflow obstruction
Principle of Internal Medicine, 19 Ed, Ch
occursHarrisons
314 1700pp
th

Definition
Persistent airflow limitations that
is usually progressive and
associated with an enhanced
chronic inflammatory response in
the airway and the lung to
noxious particles or gas.

Global Initiative for Chronic Obstructive Lung

RISK FACTORS

Tobacco smoke
Indoor air pollution
Occupational dust and chemicals
Outdoor air pollution

Global Initiative for Chronic Obstructive Lung

Smoki
ng

Harrisons Principle of Internal Medicine, 19th Ed, Ch

Emphysema
1.
2.
3.
4.

Chronic exposure to cigarette smoke

Release of elastiolytic antiproteases
Structural cell death
Ineffective repair of elastin

Elastin Hypothesis
Balance between elastin and anti
elastin proteases determines the
susceptibility of lung to damage
Anti elastin
elastin

Level of damage
Large airways
- Result in mucus gland enlargement
and goblet cell hyperplasia
- Cough and mucus secretions
( CHRONIC BRONCHITIS)
Small airways
- Goblet cell metaplasia, shift to
mucus secreting from Clara cells

Airflow limitation
Major physiologic change in COPD
Due to small airway obstruction in
emphysema

Pathophysiology

Harrisons Principle of Internal Medicine, 19th Ed, Ch

Assessment
1.
2.
3.
4.
5.

Assess symptoms
Assess Degree of air flow limitations
Assess Risk for exacerbation
Assess comorbidities
Combined assessment of COPD

Assess symptoms
Most common symptoms
Cough
Sputum production
Exertion dyspnea

Establish chronicity of the symptoms

Determine the development of the
gradual process of airflow obstruction

Harrisons Principle of Internal Medicine, 19th Ed, Ch

Indicators for the diagnosis

>40 years old
Dyspnea
Chronic
cough
Chronic
sputum
production
Risk factors
Global Initiative for Chronic Obstructive Lung

Assessment
1.
2.
3.
4.
5.

Assess symptoms
Assess Degree of air flow limitations
Assess Risk for exacerbation
Assess comorbidities
Combined assessment of COPD

Measure of breathlessness
COPD Assessment Test (CAT)
8 item, score 0-40

COPD Control Questionnaire (CCQ)

10 item

Assessment
1.
2.
3.
4.
5.

Assess symptoms
Assess Degree of air flow limitations
Assess Risk for exacerbation
Assess comorbidities
Combined assessment of COPD

Spirometry
Spirometry is required

Post-bronchodilator
FEV1/FVC <70%
Index of airflow limitations
FVC volume of air forcibly exhaled from
the point of maximal inspiration
FEV1 volume of air exhaled after 1st
second, how quick the lung is emptied

Post-bronchodilator
FEV1/FVC <70%
Normal: 0.70-0.80 in adults
COPD: <0.70
FEV declines over time, used to
measure the progression of COPD,
reliable interval spans 12 months

GOLD criteria

Assessment
1.
2.
3.
4.
5.

Assess symptoms
Assess Degree of air flow limitations
Assess Risk for exacerbation
Assess comorbidities
Combined assessment of COPD

Risk for exacerbation

Acute event characterized by
worsening of the patients symptom
that is beyond the normal day-to-day
activity and leads to changes in
medications
Hx of prev treated events
( hospitalizations)

Assessment
1.
2.
3.
4.
5.

Assess symptoms
Assess Degree of air flow limitations
Assess Risk for exacerbation
Assess comorbidities
Combined assessment of COPD

Combined assessment of COPD

Management
Smoking Cessation
Oxygen Therapy
Lung Volume Reduction Surgery

Global Initiative for Chronic Obstructive Lung

Symptomatic phase
Anticholinergic
Agents
Beta Agonists
Inhaled / Oral
Glucocorticoids
Theophylline
Oxygen

Harrisons Principle of Internal Medicine, 19th

Symptomatic phase
Anticholinergic
Agents

Ipratropium bromide
Tiotropium

Beta Agonists
Inhaled / Oral
Glucocorticoids
Theophylline
Oxygen

Harrisons Principle of Internal Medicine, 19th

Symptomatic phase
Anticholinergic Agents

Beta Agonists

Salmeterol
Formoterol

Inhaled / Oral
Glucocorticoids
Theophylline
Oxygen
Harrisons Principle of Internal Medicine, 19th

Symptomatic phase
Anticholinergic Agents
Beta Agonists

Inhaled / Oral
Glucocorticoids
Theophylline
Oxygen

exacerbation
frequency by ~25%
unfavorable
benefit/risk ratio

candidiasis
Osteoporosis
weight gain
cataracts,

glucose intolerance
risk of infection

Harrisons Principle of Internal Medicine, 19th

Symptomatic phase
Anticholinergic Agents
Beta Agonists
Inhaled / Oral
Glucocorticoids

Theophylline

expiratory flow rates

vital capacity
arterial oxygen and
carbon dioxide
levels

Oxygen
Harrisons Principle of Internal Medicine, 19th

Symptomatic phase
Anticholinergic Agents
Beta Agonists
Inhaled / Oral
Glucocorticoids
Theophylline

mortality rates
proportional to
the number of
hours/day oxygen

Oxygen
Harrisons Principle of Internal Medicine, 19th

Symptomatic phase
Phosphodiest
erase-4
inhibitor
Methyxanthines
Vaccines

In GOLD 3 and 4
with hx of
exacerbations
ROFLUMILAST
reduces
exacerbations

Harrisons Principle of Internal Medicine, 19th

Symptomatic phase
Phosphodiesterase4 inhibitor

Vaccines

Pnuemococcal
vaccines
recommended
yearly in px >65
yo

Harrisons Principle of Internal Medicine, 19th

Acute Exacerbations
BRONCHODILATORS
ANTIBIOTICS
OXYGEN
GLUCOCORTICOIDS
MECHANICAL VENTILATORY SUPPORT
Harrisons Principle of Internal Medicine, 19th

Stable patients
Management should be individualized

Goals should be reached with minimal

side effects of treatment

Non pharmacologic

Management of
exacerbations
Acute event characterized by
worsening of the patients symptom
that is beyond the normal day-to-day
activity and leads to changes in
medications
Most common cause respiratory
infection

Assessment of exacerbations
WBC: Polycythemia or bleeding
Purulent sputum
Electrolyte imbalance, poor
nutrition, poorly controlled DM

ABG: PaO2 < 8.0kPA

with or witout O2
PaCO@ > 6.5KPa at
room air

Spirometry
is not
recommend
ed during
exacerbatio
n

Acute Exacerbations
BRONCHODILATORS
Nebulized therapy
ANTIBIOTICS
Metered dose
inhalers

OXYGEN
GLUCOCORTICOIDS
MECHANICAL
VENTILATORY
SUPPORT

Harrisons Principle of Internal Medicine, 19th

Acute Exacerbations
BRONCHODILATORS

ANTIBIOTICS
OXYGEN
GLUCOCORTICOIDS
MECHANICAL
VENTILATORY SUPPORT

If with: inc dyspnea, inc

vol of sputum, inc
purulent sputum
MCGS: Streptococcus
pneumoniae,
Haemophilus influenzae,
Moraxella catarrhalis,
Mycoplasma
pneumoniae, Chlamydia
pneumoniae

Harrisons Principle of Internal Medicine, 19th

Global Initiative for Chronic Obstructive Lung

ACUTE EXACERBATIONS
CHRONIC OBSTRUCTIVE PULMONARY DISEASE

BRONCHODILATORS
ANTIBIOTICS

Harrison: 90%
GOLD: 88-92%

OXYGEN
GLUCOCORTICOIDS
MECHANICAL
VENTILATORY
SUPPORT

Harrisons Principle of Internal Medicine, 18th

ACUTE EXACERBATIONS
CHRONIC OBSTRUCTIVE PULMONARY DISEASE

BRONCHODILATORS
ANTIBIOTICS
OXYGEN
GLUCOCORTICOIDS
MECHANICAL
VENTILATORY
SUPPORT

Length of stay
hasten recovery
chance of
exacerbation or
relapse up to 6
months
HYPERGLYCEMIA

Harrisons Principle of Internal Medicine, 18th

ACUTE EXACERBATIONS
CHRONIC OBSTRUCTIVE PULMONARY DISEASE

BRONCHODILATORS
ANTIBIOTICS
OXYGEN
GLUCOCORTICOIDS
VENTILATORY
SUPPORT

Noninvasive
Positive-Pressure
Ventilation (NIPPV)
mortality rate
need for intubation
complications of
therapy
hospital length of
stay

Harrisons Principle of Internal Medicine, 18th

ACUTE EXACERBATIONS
CHRONIC OBSTRUCTIVE PULMONARY DISEASE

BRONCHODILATORS
ANTIBIOTICS
OXYGEN
GLUCOCORTICOIDS
VENTILATORY
SUPPORT

Global Initiative for Chronic Obstructive Lung

Global Initiative for Chronic Obstructive Lung

Global Initiative for Chronic Obstructive Lung

Reference
Harrisons Principle of Internal
Medicine, 19th Ed, Ch 314
Global Initiative for Chronic
Obstructive Lung Disease, 2015
CAT: http://www.thoracicmedicine.org/article.asp?
issn=18171737;year=2014;volume=9;issue=1;spage=3;epa
ge=7;aulast=Al

CCQ:http://www.goldcopd.org/uploads/users
/files/GOLD_Report_2015.pdf