CHRONIC

OBSTRUCTIVE
AIRWAY DISEASE
ASSOC PROFESSOR DR. VINOTHINI
 COAD Definition
Characterized by chronic airflow limitation that is
not fully reversible.

The airflow limitation is usually both progressive

and associated with an abnormal inflammatory
response of the lungs to noxious particles or
gases.

Reference : GOLD=Global Initiative for Chronic

Obstructive Lung Disease
What is airflow limitation? Post
bronchodilator FEV1/FVC ratio less than 0.70
 OLD Subtypes

Chronic bronchitis:
chronic productive cough for 3 months in 2
consecutive years.

Emphysema:
Abnormal and permanent enlargement of the
airspaces distal to the terminal bronchioles,
accompanied by destruction of airspace walls
without obvious fibrosis.
 Pathophysiology
Important pathological changes in airways are :
Inflammation
Hypertrophy of mucous secreting glands
Increase in number of goblet cells
Decreased mucociliary clearance

Therefore the mechanical obstruction in the airflow and loss of

elastic recoil of lungs result in airflow limitation.

The persistent hypoxia and pulmonary vascular changes cause:

- pulmonary hypertension
- right ventricular hypertrophy (cor pulmonale) and
- right heart failure.
 Aetiological factors
Cigarette smoking
- most important factor
- positive correlation between intensity of smoking and
development of COAD

Air pollution
Occupational exposure to dusts
Genetic (hereditary) risk
- Severe alpha -1 antitrypsin deficiency
 Symptoms
Cough
Sputum production mucoid, scanty and thick,
blood streaks occ.
Exertional dyspnea
Exacerbated by chest infection

Other symptoms
- weight loss
- tiredness
- ankle swelling right heart failure
Grading symptoms
 Clinical signs
General
Cyanosis
Signs of right heart failure raised JVP,
hepatomegaly, ascites
Signs of CO2 retention flapping tremor,
bounding pulse.
Pursed lips breathing
Wasting and weight loss.
 Clinical signs
Respiratory

Use of accessory muscles of respiration

Indrawing of intercostal muscles
The presence of barrel chest increased AP
diameter
Loss of cardiac and liver dullness
Auscultate the chest
- Diminished breath sound
- Prolonged expiratory phase
- Wheeze
- Crepitations at bases of lungs
 INVESTIGATIONS
Pulmonary function test (spirometry)
- airway obstruction without significant reversal
- Significant reversal is defined as 15% or more
increase in FEV1 after 2 puffs of beta adrenergic
agonist.
- Abnormal FEV1 < 80% predicted.
- Post bronchodilator FEV1/FVC ratio less than
0.70
Spirometry
 INVESTIGATIONS
Sample of sputum to diagnose infection
Chest x-ray
- Demonstrate bullae, translucent lung fields,
flattened diaphragm, prominent pulmonary
arterial shadows.

High-resolution CT (HRCT scan)

Arterial blood gases test
Pulse oximeter
Serum alpha 1 antitrypsin level
 Diagnosis of COPD
EXPOSURE TO RISK
SYMPTOMS FACTORS
cough tobacco
sputum occupation
dyspnea indoor/outdoor pollution

SPIROMETRY
 Complications
Pneumothorax
- Due to rupture of bullae

Respiratory failure
Cor pulmonale
 Treatment
Described as of:

a. Chronic stable phase

b. Acute exacerbation
 Treatment - Chronic stable phase
Objectives :
Prevent disease progression
Relieve symptoms
Improve exercise tolerance
Improve health status
Prevent exacerbations
Prevent and treat complications
Reduce mortality
Minimize side effects from treatment
 Treatment - Chronic stable phase
Stepwise increase in treatment, depending on the
severity of the disease

Patient education improves skills, ability to cope with

illness and health status.

None of the existing medications has been shown to

modify the long-term decline in lung function.

Medications are used to :

- decrease symptoms
- reduce the frequency and severity of exacerbations
- improve health status and
- improve exercise tolerance
 Treatment - Chronic stable phase
Bronchodilator medications

central to the symptomatic management of COPD.

are given on as-needed basis or on a regular basis to
prevent or reduce symptoms.

Anticholinergics: block muscarinic receptors

Short acting: Ipratropium bromide (Atrovent)
Long acting: Tiotropium bromide (Spiriva)
- Inhaler form.
 Treatment - Chronic stable phase
Bronchodilator medications

Beta2-agonists:
- increase cyclic adenosine monophosphate levels and
promote airway smooth-muscle relaxation

Short acting: salbutamol (ventolin)

Long acting: salmeterol (serevent) and
formoterol fumarate (Foradil)
 Treatment - Chronic stable phase
Inhaled Steroids (ICS)
- Reduce frequency of exacerbations
- Appropriate for symptomatic COPD patients
with an FEV1 < 50% and repeated
exacerbations
 Treatment - Chronic stable phase
Other pharmacologic treatments :

Vaccines: Influenza vaccine reduces serious

illness and death in COPD patients by 50%.

Antibiotics for infectious exacerbations

(amoxicillin-clavulanate, macrolide,
fluoroquinolones)

Alpha-1 Antitrypsin Augmentation Therapy:

young patients with severe deficiency and
established emphysema.
 Treatment - Chronic stable phase
Pulmonary rehabilitation
- Improve both exercise tolerance and symptoms of dyspnea and fatigue.

Oxygen administration
-The long-term administration of oxygen (> 15 hours per day) to patients with chronic
respiratory failure (Stage IV) has been shown to increase survival.

Smoking cessation
- Improves rate of decline in pulmonary function
- Nicotine replacement therapy

Surgical Treatments
Bullectomy: effective in reducing dyspnea and improving lung function
Lung Volume Reduction Surgery
Lung Transplantation
 Acute exacerbation
Symptoms
Increased breathlessness, wheezing, chest tightness
Increased cough and sputum
An increase in sputum volume and purulence points
to a bacterial cause
Fever
Confusion

Assessment of severity of exacerbation

Peak flow <100 L/min or FEV1 <1.0 L indicates severe
exacerbation
ABG
CXR
Sputum culture
 Acute exacerbation
Treatment :
Hospitalization
Oxygen therapy
Antibiotics
Bronchodilators
Short course oral corticosteroids
Diuretics if heart failure
Ventilatory support.
 Implications on dental practice
Ipratropium causes dry mouth.

There is association between oral infections and

exacerbation of COAD.
- Maintenance of good oral hygiene is important.

If breathing adequate, treat in semi supine position.

- if they are breathless on lying flat, treat them in
upright position.
 Implications on dental practice
No narcotics or barbiturates should be used because
of respiratory depressant properties.

Avoid giving macrolide antibiotics (erythromycin,

azithromycin) and ciprofloxacin to patients on
theophylline because of possible toxicity.

Avoid outpatient general anesthesia.