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PATHO(i E N ESIS
Cigarette smoke
FoundtfOJ
MMP
Serine
proteinases
Neutrophil
MMP ....
Cysteine ....
proteinases
Macrophage
ltynhibbbit
ECM dadatlon;
Emphysema
FIGURE 314-1
......
Repair
Pathogenesis of emphysema.
PATHOLOGY
Cigarette smoke exposure may affect the large airways small airways
(2 mm diameter) and alveoli. Changes in large airways cause cough
and sputum while changes in small airways and alveoli are responsible
for physiologic alterations. Emphysema and small airway pathology
are both present in most persons with COPD; however they do not
appear to be mechanistically related to each other and their relative
contributions to obstruction vary from one person to another
LARGE AI RWAY
1 701
SMALL AI RWAYS
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leading to airflow limitation. Neutrophil influx has been associated with purulent sputum of upper respiratory tract infections.
Independent of its proteolytic activity neutrophil elastase is among the
most potent secretagogues identified.
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6AS EXCHAN6E
1 S D. Mean
nununu
q44l nununu
44l
1 702
20
10
0
40
60 80 100 120
% FEV1
+ 1 S.D.
Median
14
0 160
percent prd icted FEV 1 a re shown for each smoking g roup. Although
a dose-rspons lationship between smoking i ntensity and FEV 1 was
found ma rked va ria bil ity i n p u l lO na ry fu nction was observed among
s u bjects with s i m i l a r smoking histories. (From B Brrows et I: Am Rev
Respir Dis 1 1 5:95 1 977; with permission.)
NATURAL HISTORY
1 703
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1 704
PHYSICAL F I N D I NGS
Early decline
H
nF
100
0
ol
m
o
c
w
LL
75
50
25
......
Respiratory symptoms
10
20
30
40
50
60
70
Rapid decline
80
Age year
FIGURE 314'3
vol u m e in
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The three most common snptoms in COPD are cough sputum pro
duction and exertional dyspnea Many patients have such symptoms
for months or years before seeking medicaI attention. Although the
development of airflow obstruction is a gradual process many patients
date the onset of their disease to an acute illness or exacerbation. A
careful history however usually reveals the presence of symptoms
prior to the acute exacerbation The development of exertional dys
pnea often described as increased effort to breathe heaviness air
hunger or gasping can be insidious. It is best eliited by a careful his
tory focused on typial physical activities and how the patient's ability
to perform them has changed Actirities involving significant arm
work particularly at or above shoulder level are particularly difficult
for patients with COPD. Conversely activities that allow the patient
to brae the arms and use accessory muscles of respiration are better
tolerated Examples of such activities include pushing a shopping cart
or walking on a treadmill. As COPD advances the principal feature is
worsening dyspnea on exertion with increasing intrusion on the ability
to perform vocationaI or avocational activities. In the most advanced
stages patients are breathless doing simple activities of daily living
Accompanying worsening airflow obstruction is an increased fre
quency of exacerbations (described below) Patients may also develop
resting hypoxemia and require institution of supplementaI oxygen.
GOLD Stage
111
G0lDE(RII T ERm5EvER F
Severity
Spi rometry
Mild
Moderate
Severe
Very severe
C H R O N I C O BST R U CT I V E P U l M O N A RY
D I S EA S E
STABLE PHASE COPD
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Oral Glucocorticoids
Theophylline
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Antibiotics
Pulmonary Rehabilitation
111
ACUTE EXACERBATIONS
Bronchodilators Typical ly patients a re treated with an inhaled
agonist often with the add ition of a n a nticholi nergic agent. These
may be admin istered sepa rately or together and the freq uency
of admin istration depends on the severity of the exacerbation.
Antibiotics
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