COPD (D.E.P.C.I.

T)
Chronic Obstructive Pulmonary Disease
Definition - Disease state characterized by presence of airflow obstruction
due to Chronic Bronchitis + Emphysema

Etiology MEDS GiRL

M- Male > female

E- Environmental pollution
D- Dusty occupation(gold,coal miners, farmers, grain, cement,cotton)
S- Smoking

G- Genetic Deficiency – alpha 1- antitrypsin

R- Recurrent bronchopulm. Infection
L- Low socioeconomic status
Pathophysiology Chronic Bronchitis Emphysema
and classification Def- Cough and expectoration Def- Abnormal permanent
of most days for 3 successive enlargement of gas-exhanging
months in at least 2 successive of the lungs (acini) + destruction
years and cannot diagnosed as of alveolar walls +/- fibrosis
other pulmonary or cardiac
causes
Classification-
1. Simple CB- Chr
productive cough +
normal airflow
2. Chronic Obstructive
bronchitis – Chr
productive cough +
progressive decline
airflow
Pathological feature:
A. Chronic Bronchitis
1. Mucous Gland Hypertrophy – neutrophils, T lymphocytes)
2. Cartilage atrophy-> scarring and remodelling that thickens the
wall of bronchi
3. Muscle hypertrophy
Pathophysiology:-
Inflammation -> changes of cilia -> cilia lose fx -> cilia is replaced with goblet cells ->
goblet cells produce a lot of mucus -> that mucus provide a good medium for bacterial
growth (pseudominas or staph) -> mucus infected and discoloured by the overgrowth
of bacteria -> swelling,mucus hypersecretion -> swelling of bronchi + bronchioles ->
problem airflow to and from the lungs -> meanwhile, muscle of airways is stimulated
by this irritants -> bronchospasm -> further narrowing of resp. airway -> long standing
inflammation -> fixed, non-reversible narrowing of airway
-> COPD

Done by: Miya Wong

 B. Emphysema Pathological Feature:

Types of emphysema
Centrilobular Part – proximal central part
Lungs – upper lobe
Associates w smoking, COPD, CB
Panacinar Part – complete resp- lobules
Lungs- lower lobes anterior margin
Associates with A1AT deficiency
Paraseptal Part- Distal
Lungs – Upper half
Associates – pneumothorax, smoking,
Findings – enlarged airspaces <0.5 cm > 2cm
Bullae formation

Done by: Miya Wong

 Pathophysiology:

Clinical Picture HACOWA

History of heavy smoking

Age > mid – old
Cough > 1st upon walking up -> throughout the day
- Productive cough – mucoid -> purulent sputum + exarcebation of
dse but not excessive
Onset – insidious – dyspnea on exertion and slowly progressive
Wheezes- persistent
Associated symptoms – wt loss, insomnia -> severe COPD

Done by: Miya Wong

 Objective: Investigation and principles of treatment of COPD
Severe Dyspnea, Orthopnea,
1. Physical Examination: Tachypnea, + scanty sputum
a. Pink Puffer (Type 1)
Expiratory pursed lips
Elevated shoulder

Congested neck vein on Inspiratory tracheal tug

expiration;
Prominent accessory ms in
Pulsus Paradoxus
neck (scalene)

Abdominal Protuberance

Indrawing suprasternal + Usually thin build

supraclavicular fossae
General Muscle wasting in
advanced cases

Professorial attitude

b. Blue Bloater (Type 2)

Cyanosis

Mild dyspnea

Usually Obese
Large Sputum

Edema @ ankles

Done by: Miya Wong

 2. Local Examination
a. Inspection and Palpation
i. Large barrel shaped chest + widening of Xiphersternal angle due to increase
Of A-P diameter

ii. Diminished chest expansion

iii. Hoover’s sign

Due to horizontal position

of diaphragm it acts to pull
inwards the lower ribs
during inspiration causing
retraction of costal margin
during inspiration

iv. In mild cases : no abnormality

v. s/s of resp. failure like cor-pulmonale + RSHF may present
vi. Blue Bloater Vs Pink Puffer (like the first page)
b. Percussion
i. Hyperresonance with encroachment on hepatic + cardiac dullness
(hyperinflation)
ii. Depressed liver due to flat diaphragm not enlarged
c. Auscultation
i. Diminished vesicular breath sound
ii. Distant heart sound -> damping of heart sound due to shifted position of
ventricles. Right ventricle is more anterior > Left ventricle (vertical narrow
heart seen in x-ray of COPD patient esp. the ones that has emphysema)
iii. Expiratory wheezes (constrict bronchioles)
iv. Crackles at lung base + crepitations (fluid in alveoli) during inspiration

Done by: Miya Wong

Investigation:
1. Imaging study
a. CXR
i. Hyperinflation of the lungs
ii. Flat diaphragm
iii. Hyperlucent lung fields (many air)
iv. Increased AP diameter
v. Increased retrosternal air
vi. Vertical narrow heart
vii. Peripheral vascular attenuation -> less vascular marking due to chronic
hypoxemia
b. CT
i. To diagnose early cases

2. PFT
a. Spirometer
i. Decreased FEV1 < 80%
ii. Decreased FEV1/FVC : <70%
stage FEV1 (%) FEV1/FVC (%)
0 At risk >80 N
1 Mild >80 <70
2 Moderate 50 -80 <70
3 Severe 30-50 <70
4 Very severe <30 <70
b. Bronchodilator test: Bronchial asthma improves FEV1 >15% , COPD <15%
improvement
3. ABG
a. Type A (Type 1) -> only 1 thing -> Hypoxemia no hypercapnia
b. Type B (Type 2) -> got 2 things -> Hypoxemia + Hypercapnia
c. 2ry polycythemia -> chronic hypoxia
d. May be deficiency of A1AT: N( 2 – 4 gm/L)
4. ECG
a. P-pulmonale (Peaked P wave in inferior leads) -> RVE
b. RVE in cor-pulmonale
c. Low voltage QRS complex especially in precordial leads
5. Echocardiography
a. Assess cardiac function
i. Contractility
ii. Pulmonary artery pressure (N: >30mmhg)

Done by: Miya Wong

Normal X-ray

Done by: Miya Wong

Done by: Miya Wong
Done by: Miya Wong
Management of COPD:
Pharmacological treatment:

Non pharmacological management:

1. Good nutrition
2. Rehab (Chest physiotherapy) -> to increase ms strength

Done by: Miya Wong