Chronic Obstructive Pulmonary

Disease
Kai Stürmann, MD
Associate Professor, Clinical
Emergency Medicine
AECOM
Where’s the church, who took the steeple?
Religion is in the hands of some crazy-ass people
Television preachers with bad hair and dimples
The God’s honest truth is it’s not that simple
It’s the Buddhist in you, it’s the pagan in me…
It’s the Muslim in him, she’s Catholic ain’t she?
It’s the born-again look, it’s the Wasp and the Jew
Tell me what’s goin on, I ain’t gotta clue…

- Jimmy Buffett
COPD - Guidelines

American Thoracic Society

European Respiratory Society
British Thoracic Society
GOLD
– WHO
– NIH
COPD - Guidelines

American College of Physicians / ACCP

Agency for Healthcare Research and

Quality
– www.ahcpr.gov/clinic/epcsums/copdsum.htm
Definitions

Emphysema - abnormal permanent enlargement of

the airspace distal to the terminal bronchioles,
accompanied by destruction of their walls and without
obvious fibrosis.
Chronic Bronchitis - presence of chronic
productive cough for 3 months in each of 2 successive
years…
COPD - disease state characterized by airflow
limitation that is not fully reversible.
COPD -
Will you know it when you see it?

A 52-year-old smoker with recurrent

respiratory infections and wheeze…
COPD -
Will you know it when you see it?

the 52-year-old smoker with, and without,

a history of chronic bronchitis.
COPD -
Will you know it when you see it?

the 52-year-old male

the 52-year-old female

COPD - Epidemiology

9.34 / 1000 (males)

7.33 / 1000 (females)
~14,000,000 Americans
700,000 hospital D/Cs per year
female > male since 1992
COPD - Etiology

 Tobacco smoke, tobacco smoke, tobacco sm

 Tobacco smoke, tobacco smoke, tobacco sm
 Tobacco smoke, tobacco smoke, tobacco sm
 Tobacco smoke, tobacco smoke, tobacco sm
 Tobacco smoke, tobacco smoke, tobacco sm
 Tobacco smoke, tobacco smoke, tobacco sm
 Tobacco smoke, tobacco smoke, tobacco sm
Etiology

15% of smokers develop COPD

10% of COPD patients did not smoke
alpha-1 antitrypsin deficiency
occupational dusts and chemicals
passive smoking (SAPALDIA study)
COPD - Pathophysiology

Chronic airflow obstruction of small

airways
enzymatic destruction of lung parenchyma
loss of lung elasticity
macrophages, neutrophils
CD8+ T-lymphocytes (COPD)
CD4+ T-lymphocytes (asthma)
 Pathophysiology

Tobacco smoke ⇒
loss of surfactant
⇑ goblet cells
cellular activation
macrophages / neutrophils
neutrophil elastase
cathepsins
matrix metalloproteinases
Differential Diagnosis

Asthma
CHF / ACS
pulmonary embolism
pneumonia
pneumothorax
Asthma and COPD

If there is clinical evidence of wheezing -

treat as if a reversible condition.
Congestive Heart Failure

Orthopnea / dyspnea on exertion

HJR
Chest x-ray
PEFR
β -natruretic peptide
COPD v. PE

Consider risk factors

pleuritic chest pain
arterial blood gas
COPD - Differential Diagnosis

Acute Coronary Syndrome

Pneumothorax
Pneumonia
Lobar Atelectasis
COPD Evaluation - History

Acuity of onset
chest pain
change in sputum production
fever
hemoptysis
orthopnea
COPD history - baseline status

Last ED visit
last hospital admission
prior intubations
home oxygen
How bad is this attack??
PMH
COPD Medication History

Inhalers
steroids
oxygen
theophylline
non-compliance
drug-drug interactions
COPD - ED examination

General / airway
breathing
– general
– trachea
– neck veins
– chest wall movement / auscultation
circulation
COPD - patient monitoring

EKG
O2 saturation
capnometry
IV access
COPD - diagnostic studies

Arterial blood gases

CBC / SMA6
aminophylline level
brain natruretic peptide
COPD - diagnostic studies

spirometry
sputum analysis
CXR
EKG
COPD treatment - O2

If oxygen saturation < 90-92%

– maintain PaO2 > 60 mmHg
– maintain SaO2 > 90%
nasal cannula v. venturi mask
↓ FiO2 as condition improves
β agonists / anticholinergics

both effective
combination therapy more effective
MDI v. nebulizer
compressed air v. oxygen
COPD - corticosteroids

oral
intravenous
inhaled
 Methylxanthines

No significant ↑ in FeV1

No significant ↓ in hospital admissions
↑ adverse effects
check theophylline level if indicated
COPD - Antibiotics

increased dyspnea
increased sputum production
increased sputum volume

- Anthonisen NR, et al. Ann Intern Med 1987

Non-invasive assisted ventilation

↑ tidal volume
Prevents collapse of distal airways
↓ work of respiration
Improves ABG’s, pH
↓ need for intubation
↓ length of stay
COPD v. asthma
 NIV - Indications

inability to maintain O2 saturation >90%

moderate acidosis (pH 7.30 – 7.35)
RR > 25 / minute
patient must be
– alert
– breathing
– able to cooperate
 NIV - Contraindications

apnea
pneumothorax
inability to protect airway
altered mental status
C-V instability
increased secretions
NIV – CPAP and BiPAP

Pressure controlled devices

Continuous positive airway pressure
– 5 cm H2O
Bi-level positive airway pressure
– 8-10 cm H2O / 2-4 cm H2O
Non-invasive ventilation…

Advantages
– No need for ICU
– Reduced mortality
– Lower incidence of pneumonia
– Cost effective
Non-invasive ventilation…

Disadvantages
– Discomfort / claustrophobia
– Poor fit – leaks / facial trauma
– Gastric distension

***Remember to ensure close observation

for your patient***
COPD–Endotracheal intubation

RR > 35 / min

PaO2 < 40mmHg
pH < 7.25 / PaCO2 > 60 mmHg
Altered mental status
C-V instability
NIV failure
Cardiac arrest (!)
 ETT / RSI considerations

Re-evaluate paralysis
Etomidate
Ketamine
Succinylcholine v. rocuronium
ETT size
 Ventilator considerations

short inspiratory time

prolonged expiratory time
decreased minute ventilation
PEEP
keep pCO2 elevated
pneumothorax v. dynamic hyperinflation
 Interventions / New horizons

Interventions
– Smoking cessation
– Influenza vaccine
On the horizon…
– Lung volume reduction surgery
– tiotropium
 Smoking Cessation

death / illness reduction even if late

before success → 5–7 attempts on average
5-10% success rate without assistance
average weight gain of 4-6 kilos
anxiety, insomnia, depressed mood
 Smoking Cessation

brief advice v. no advice

Nicotine replacement therapy v. placebo
Bupropion v. placebo
physical exercise
Professional advice
Acupuncture v. sham treatment
anxiolytics
 Smoking Cessation

brief advice 12% v. no advice 10%

nicotine replacmt 17% v. placebo 10%
Bupropion v. placebo
physical exercise
Professional advice 10% v. 10%
Acupuncture v. sham treatment
anxiolytics