defined as a disease state characterized by persistent respiratory symptoms and airflow limitation that is not fully reversible. • Emphysema- an • CHRIONIC anatomically defined BRONCHITIS- a condition clinically defined characterized by condition with chronic destruction of the lung cough and phlegm alveoli with air space enlargement
SMALL AIRWAY DISEASE- a
condition in which small bronchioles are narrowed and reduced in number. • copd is third leading cause of death and affects >10 million people in US. • Airflow limitation is a major physiolgic change in copd, it can result from small airway disease and/or emphysema. • Small airways may become narrowed by cells(hyperplasia and accumulation),mucus and fibrosis, and extensive small airway destruction is a Hallmark of copd. • (1) Chronic exposure to cigarette smoke in genetically susceptible individuals triggers inflammatory and immune cell recruitment within large and small airways and in the terminal air spaces of the lung. (2) Inflammatory cells release proteinases that damage the extracellular matrix supporting airways, vasculature, and gas exchange surfaces of the lung. (3) Structural cell death occurs through oxidant-induced damage, cellular senescence, and proteolytic loss of cellular-matrix attachments leading to extensive loss of smaller airways, vascular pruning, and alveolar destruction. (4) Disordered repair of elastin and other extracellular matrix components contributes to air space enlargement and emphysema. • Cigarette smoke • Airway inflammation, exposure affect the destruction and the large and small development of airways and alveoli. emphysema are present in most with COPD. Gold 1,2- little or no Emphysema Gold 3,4- Extensive Emphysema At Greatest Risk Of Progression In COPD= THOSE WITH AGGRESSIVE AIRWAY DISEASE AND EMPHYSEMA • LARGE AIRWAYS • SMALL AIRWAYS • cigarette smoking • Major site of often results in mucus increased resistance gland enlargement in airway <or= 2mm and goblet cell hyperplasia, leading to COUGH and MUCUS production that define as CHRONIC BRONCHITIS • Emphysema is characterized by destruction of gas-exchanging air spaces(respiratory bronchioles, alveolar ducts,alveoli) • Types of emphysema • Centrilobular-mostly with cigarette smoking,most prominent in upper lobes and superior segment of lower lobes. • Panlobular- commonly in patient with Alpha1AT deficiency, mostly in lower lobes. • Paraseptal- In 10-15% cases and is distributed along the pleural margins with relative sparing of lung central region • Most typical finding- persistent reduction in forced expiratory flow rates.
Airflow obstruction determined by spirometry
key parameters include the volume of air exhaled within the first second of Forcd expiratory maneuver (FEV1) and total volume of air exhaled during the entire spirometric maneuver(FVC) • Hyperinflation • in copd there is often air-trapping(increase residual volume and increased ratio of residual volume to TLC) • Hyperinflation can push the diaphragm into a flattened position • cigarette smoking • respiratory infections • occupational exposure • ambient air pollution • passive or second hand, smoking exposure • alpha 1 antitrypsin deficiency CLINICAL PRESENTATION • HISTORY • PHYSICAL FINDING • Three most common • Early stages can have symptoms- entirely normal PE cough,sputum • in patient with more sever disease the pe of lung is production, exertional notable for a prolonged dyspnea expiratory phase and may include expiratory wheezing • hyperinflation-barrel chest and enlarged lung volumes, triopd position to facilitate action of scm,scalene, intercostal muscles • some patient with advanced disease have paradoxical inward movement of the rib cage with inspiration= HOOVER'S SIGN • Two main goals • 1) provide symptomatic relief (reduce respiratory symptom, improve exercise tolerance, improve health status) • 2) reduce future risk (prevent disease progression,prevent and treat exacerbation, reduce mortality • mMRC Dyspnea Scale CAT-COPD ASSESSMENT TEST • 1—hurrying on level ground or walking up a slight hill • 2— walk slower than peers or stop walking at their own pace 3— walking about 100 yards or after a few minutes on level ground 4—too breathless to leave the house or when dressing • Smoking Cessation- • Bronchodilator- nicotine replacement primary treatment for therapy available as all patient with copd gum, patch,nasal and used for spray, buporpion and symptomatic benefits varenicline and to reduce exacerbation. • Anticholinergic • Beta Agonist- short Muscarine acting ease symptoms with acute improvement Antagonists- short in lunf function. LABA- acting ipratropium symptomatic benefits and bromide. LAMA- reduce exacerbation aclidinium,glycopyrrol (arformoterol,formoterol,i ate,tiotropium. ndacaterol,salmeterol) Improve symptoms and • Side effect- Tremors and Tachycardia reduce exacerbations. NONPHARMACOLOGIC THERAPIES • Pulmonarynary • Lung Transplant- Rahabilitation COPD is 2nd leading • Lung volume reduction surgery- patient with indication for lung upper lobe predominant transplant. Candidate emphysema and low post should have very rehabilitation exercise severe airflow capacity are likely to limitation,severe benefit from LVRS disability despite • patient with FEV1<20% maximal medical and diffusely distributed emphysema on ct scan therapy and no have increased mortality comorbid condition after the procedure and thus are not candidate for LVRS • Episode of acute • Patient with worsening of severe(FEV1 <50%) respiratory symptom, very severe increased (FEV1<30%) have dyspnea,cough,whee and average 1-3 zing, change in episode per year amount or character of sputum. • Strongest predictor of exacerbation is history of previous exacerbation • Bronchodilator • Mechanical ventilatory support- initiation of • Antibiotics- bacteria NIPPV in patient with frequently implicated respiratory failure which in COPD is defined as PaCO2 exacerbation include >45mmHg . S.pneumoniae, Contraindication include H.influenza, cardiovascular instability, impaired mental status, Morexella catarrhalis inability to • Oxygen- maintain cooperate,copious >or=90% secretions or inability to clear secretion, significant burns • Following a hospitalization for COPD- 20% re-hospitalized in 30days, • 45% in next year