COPD

Two classic types

o Chronic bronchitis chronic cough w/sputum for at least 3 months
for 2 straight years
Clinical dx
Too much mucus narrowing airways
Inflammation + scarring of airways, mucus glands and smooth
muscle hypertrophy
o Emphysema destruction of alveolar walls permanent
enlargement of air spaces
Pathologic dx
Too much protease activity, deficient 1-antitrypsin
Unopposed oxidative stress onto lungs
o The two usually occur together
Risks
o Tobacco, second-hand smoke (centrilobular proximal)
o 1-antitrypsin deficiency (panlobular both distal and proximal
airways)
o Asthma
Symptoms
o Cough, sputum, SOB that progressively gets worse, limited activity,
Pink puffer (emphysema) Blue bloaters (bronchitis)
Barrel chest
Tend to be thin due to increased
energy usage when breathing
Tend to be overweight and
cyanotic (secondary to
hypercapnia and hypoxemia)
Lean forward Cor pulmonale in severe disease
Tachypnea, prolonged expiration
through pursed lips (prevents
airway collapse)
RR normal or slightly increased
Appear distressed, accessory
muscles
NAD, no accessory muscles
Diagnosis
o PFTs
FEV1
70% of predicted value mild
50% - severe
FEV1 /FVC ratio less than 0.70
Increased TLC, residual volume, FRC
o CXR low sensitivity
Hyperinflation, flattened diaphragm
o 1-antitrypsin
Useful if positive family history of premature emphysema
o ABG increased pCO2 and decreased pO2
Treatment
o Smoking cessation most important
o 2-agonist bronchodilator symptomatic relief, long-acting or short-
acting formulations
o Inhaled anticholinergic (e.g. ipratropium bromide) slower but lasts
longer than 2-agonist
o Inhaled corticosteroids anti-inflammatory; for repeated
exacerbations and significant symptoms
Must use with long-acting bronchodilators
o Theophylline controversial
o Oxygen therapy
Some need continuous, others at certain times like during sleep
or exertion
Reduces mortality and quality of life
o Rehab
o Vaccines against influenza (everyone), streptococcus pneumonia
(>65yo or anyone with severe disease q5-6 years)
o Antibiotics acute exacerbations
With corticosteroids
o Guidelines
Mild to moderate
Begin with 2-agonist and/or anticholinergic
bronchodilators
Add glucocorticoids if needed, use lowest dose
Theophylline may be added if above dont work
Severe
Meds as above
Oxygen
Pulmonary rehab
Triple inhaler (long-acting 2-agonist + long-acting
anticholinergic + glucocorticoids)
Acute exacerbations
2-agonist bronchodilator alone or with anticholinergic
as first-line
IV steroids
Antibiotics azithromycin or levofloxacin
Oxygen
Non-invasive positive-pressure ventilation
Intubate + mechanical ventilation if required
Complications
o Acute exacerbations causes include infection, noncompliance with
meds, cardiac disease
o Polycythemia (Hct >55% in men, >47% in women)
o Pulmonary HTN and cor pulmonale