Chronic Obstructive

Pulmonary Disease
Dr .Mohammad Kharraz MD
Internist
Arab-Jordanian-Palestinian Board

Definition of COPD
Chronic Obstructive
Pulmonary Disease is a
preventable and treatable
disease with some significant
extrapulmonary effects.
The pulmonary component is
characterized by airflow
limitation that is not fully
reversible.

Healthy
Alveolus

COPD

Chronic Obstructive Pulmonary

Disease (COPD)
The airflow limitation in
COPD is usually progressive
and associated with an
abnormal inflammatory
response of the lungs to
noxious particles and gases
Severe COPD leads to
respiratory failure,
hospitalization and
eventually death from
suffocation

COPD Mortality Worldwide

1990
Ischaemic heart disease
Cerebrovascular disease
Lower resp infection
Diarrhoeal disease
Perinatal disorders

COPD

2020
3rd

6th

Tuberculosis
Measles
Road Traffic Accidents
Lung Cancer

Stomach Cancer
HIV
Suicide
Source: Murray & Lopez. Lancet 1997

COPD Mortality increased 22% over

.the last decade
COPD is the third most common
cause of death for both men and
.women worldwide

 About 13.9% of the U.S. adult population (25+

years) have been diagnosed with COPD*
An estimated 15-19% of COPD cases are workrelated**

24 million other adults have evidence of

troubled breathing, indicating COPD is under
diagnosed by up to 60%***
*Braman, S. Update on the ATS Guidelines for COPD. Medscape Pulmonary Medicine. 2005;9(1):1.
**CDC programs in Brief Workplace Health and Safety-Work-related Lung Diseases.
www.cdc.gov/programs/workpl18.htm
***COPD Fact Sheet. Oct 2003. www/lungusa.org

Obstructive Lung Disease

EMPHYSEMA
CHRONIC BRONCHITIS
ASTHMA
BRONCHECTASIS
CYSTIC FIBROSIS
BULLOUS LUNG DISEASE

Causes
Most cases of COPD occur as a result of long-term exposure to lung
irritants that damage the lungs and the airways
The most common irritant that causes COPD is cigarette smoke
In rare cases, a genetic condition called alpha-1 antitrypsin
deficiency may play a role in causing COPD

Risk Factors for COPD

Nutrition
Infections
Socio-economic
status

Aging Populations

Other risk factors

About 20% or more of all COPD in USA

.occur in never-smokers

Childhood recurrent viral infections and childhood

Asthma contribute to increase risk of developing
.COPD in the future
Tuberculosis can result in airflow obstruction
.secondary to destruction of lung tissue

Hereditary factors
Data show that relatives of patients with COPD have a
higher prevalence of the disease ,that cannot be
.attributed to environmental factors
Best documented genetic influence is hereditary
: deficiency of alfa-1-antitrypsin
.COPD at age <45.non-smoker.basilar lung disease.concurrent liver disease-

Pathology
Central airways shows mucous gland hypertrophy and goblet
cell metaplasia.

 Peripheral airway shows smooth muscle hypertrophy,

peribronchial fibrosis, luminal occlusion by mucus and
enlarged lymphoid follicles.
Alveoli enlarged by loss of the alveolar walls with evidence of
persistent inflammation with neutrophils in the airway lumen
and macrophage in the airway wall.

Normal versus Diseased Bronchi

Comorbid conditions commonly

observed in PTs with COPD
CVD, AF,CHF,MI
High cholesterol
GERD
Depression
Osteoporosis
DM
Glaucoma
Erectile dysfunction

High blood pressure

Arthritis
Cataracts
Sleep apnea
Stroke
Cancer

Diagnosis of COPD
Guidelines from both American College of Physicians
and GOLD define airflow obstruction as
.postbrochodilator FEV1/FEV ratio less than 70%
.Spirometry is essential for diagnosis of COPD
Testing should not be performed in asymptomatic
.peoples as screening intervention

Classification of COPD
Severity by Spirometry
Stage I: Mild
GOLD 1

FEV1/FVC < 0.70

FEV1 > 80% predicted

Stage II: Moderate

GOLD 2
predicted
Stage III: Severe
GOLD 3
predicted
Stage IV: Very Severe

FEV1/FVC < 0.70

50% < FEV1 < 80%
FEV1/FVC < 0.70
30% < FEV1 < 50%
FEV1/FVC < 0.70

Physiology
Reduced forced expiratory flow ( FEV1)
FEV1/Forced vital capacity ( FVC) ratio less than 0.7
Lung compliance is increased in emphysema.
Loss of elastic recoil in emphysema which result in alteration
in lung compliance.

 Changes in end expiratory lung volume and increase

residual volume result in a lower, flatter diaphragm and more
horizontal rib cage which will impair the inspiratory muscles
ability to develop pressure and increase the overall work of
breathing.
Flattening of the diaphragm redirects the axis of shortening
of skeletal muscle and produce paradoxical in drawing of the
lower rib cage

Gas exchange
Arterial Hypoxemia which become clinically significant when
the PO2 fall below 60 mmHg
Arterial Hypercapnia due to increase dead space and reduce
alveolar ventilation

Pulmonary circulation
Hypoxic vasoconstriction with increase in the pulmonary
artery pressure
Treatment with oxygen prevents disease progression and
reduce pulmonary artery pressure

Diagnosis of COPD
EXPOSURE TO RISK
FACTORS
tobacco
occupation
indoor/outdoor pollution

SYMPTOMS
cough
sputum
shortness of breath

SPIROMETRY

Volume Measuring Spirometer

Flow Measuring Spirometer

Desktop Electronic Spirometers

Small Hand-held Spirometers

Spirometry
Predicted Normal
Values

Predicted Normal Values

: Affected by
Age
Height
Sex
Ethnic Origin

Criteria for Normal

Post-bronchodilator Spirometry

FEV1: % predicted > 80%

FVC: % predicted > 80%
FEV1/FVC: > 0.7 - 0.8, depending
on age

Spirometric Diagnosis of COPD

COPD is confirmed by post
bronchodilator FEV1/FVC < 0.7
Post-bronchodilator FEV1/FVC
measured 15 minutes after 400g
salbutamol or equivalent

Bronchodilator Reversibility Testing

Provides the best achievable FEV1
(and FVC)
Helps to differentiate COPD from
asthma
Must be interpreted with clinical
history - neither asthma nor COPD are
diagnosed on spirometry alone

When to refer to Pulmonologist

Disease onset before 40 years age
Rapidly progressive course of disease
Severe COPD despite optimal treatment
Need for oxygen therapy
Diagnostic uncertainty
Confirmed or suspected alpha 1 antitrypsin
deficiency
.

Management

Reduce symptoms
Prevent exacerbations
Enhance quality of life
Reduce disease morbidity and mortality

Medications
:Bronchodilators
Inhaled short acting anticholinergic
Inhaled short acting B2 agonists
Inhaled long acting anticholinergics

Methylxanthine
Oral phosphodiesterase -4 inhibitor
Roflumilast

Anti -inflamatory agents

Inhaled and oral steroids

Recently FDA approved an inhaled long acting B2- agonist

Indacaterol (arcapta) for once daily maintenance treatment
.of airflow obstruction in pt with COPD

Roflumilast

is indicated to reduce the risk and frequency of

exacerbations or to improve
.symptoms with severe COPD
Its not indicated for the relief of acute bronchospasm or rescue
.therapy

.Not indicated in the treatment of emphysema

Antibiotics
;

Indicated to treat exacerbations

Increased dyspnea
Sputum volume
Sputum purulence
Severe exacerbation of COPD requiring
mechanical ventilation
Respiratory fluoroquinolones or
Third generation cephalosporin plus macrolide

Influenza and pneumococcal vaccine are

.recommended for pts with COPD
Smoking cessation
;Pulmonary rehabilitation
Can be considered in all pts with
.FEV1<50%
Involves education,nutritional counseling,
.excersize training

Oxygen therapy
Indicated for pts who have resting hypoxia ,
defined as arterial Po2 of 55 mmHg or
.lower arterial oxygen saturation of 88%
Duration of oxygen therapy not less than
.15 hours daily
Oxygen therapy improves survival,
hemodynamics, excersize capacity and
mental status

Noninvasive positive pressure ventilation

in pts with COPD exacerbation

Improve respiratory acidosis

Increase pH
Decrease the need for endotracheal
intubation
Reduce arterial Pco2 ,respiratory rate,
.length of hospital stay and mortality

Lung volume reduction surgery

Resecting up to 30% of diseased or non
functioning parynchyma to reduce hyperinflation
and allow the remaining lung to function more
.efficiently
LVRS indicated in pts with advanced COPD
.FEV1<45% and >20% and Dlco> 20%

Lung trasplantation
.For patients with very advanced COPD
The leading cause of long term morbidity at 5
years posttransplant is chronic allograft rejection
.( bronchiolitis obliterance )