Documente Academic
Documente Profesional
Documente Cultură
CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
-- Indirect
Indirect costs
costs include
include loss
loss of
of productivity
productivity in
in the
the workplace
workplace
owing
owing to
to symptoms
symptoms33
WORLDWIDE PREVALENCE OF COPD
Sub-Saharan Africa
India
0 2 4 6 8 10 12
Adapted from the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary
Disease, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2005.
COPD MISDIAGNOSIS IS COMMON IN WOMEN
49%
Hypothetical Female
Patient With COPD
Diagnosed Symptoms
as COPD by
49% of physicians
Inhaled substances
+
Genetic
susceptibility
Breathlessness
Breathlessness Weight
Weight changes
changes
Bronchitis:
Bronchitis: coughing, sputum
coughing, sputum production
production Co-morbidities
Co-morbidities
Emphysema:
Emphysema: hyperinflation,
hyperinflation, wheezing
wheezing (e.g.
(e.g. diabetes,
diabetes, cardiovascular
cardiovascular disease)
disease)
NYC/DAXAS/10/012
WHAT IS THE ROLE OF INFLAMMATION IN
COPD?
COPD IS A DISEASE CHARACTERISED
BY INFLAMMATION
Cigarette smoke
Epithelial
cells
Macrophage/Dendriti
c cell Neutrophil
Monocyte
Fibrosis
cell
Neutrophils
Inflammation
Inflammation CD8+ T-lymphocytes
Macrophages
Chronic
Chronic inflammation
inflammation
Structural
Structural changes
changes
Bronchoconstricti
Bronchoconstricti
Systemic
Systemic on,
on, Acute
Acute
inflammation
inflammation oedema,
oedema, mucus,
mucus, exacerbation
exacerbation
emphysema
emphysema
Airflow
Airflow
limitation
limitation
Adapted from Barnes PJ, in Stockley, et al (editors), Chronic Obstructive Pulmonary Disease. Oxford, England: Blackwell Publishing; 2007:860.
NYC/DAXAS/10/012
COPD INFLAMMATION IS DIFFERENT FROM ASTHMA
INFLAMMATION
COPD Asthma
Noxious
Noxious agent
agent Onset Sensitising
Sensitising agent
agent
From the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Global Initiative for
Chronic Obstructive Lung Disease (GOLD) 2009. Available from: http://www.goldcopd.org.
NYC/DAXAS/10/012
AIRWAY INFLAMMATION OCCURS FROM COPD ONSET
AND INCREASES WITH DISEASE SEVERITY
Airways with measurable cells (%)
NYC/DAXAS/10/012
COPD IS DIAGNOSED BASED ON SYMPTOMS,
RISK FACTORS AND SPIROMETRY
RISK FACTORS
SYMPTOMS Tobacco
Cough Occupational
Sputum production + hazards
Shortness of breath Indoor/outdoor
pollution
Spirometry
From the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Global Initiative for
Chronic Obstructive Lung Disease (GOLD) 2009. Available from: http://www.goldcopd.org.
NYC/DAXAS/10/012
CLASSIFICATION OF
COUGH
Cough is classified into acute
and chronic
and
Clinically subdivided into
productive and dry cough.
Productive cough
is present at an expectoration
rate of
30 ml/24 hours,
CLASSIFICATION OF
COUGH
Acute cough is defined as one
lasting less than three weeks
Differential Diagnosis
SYMPTOMS
MILD MODERATE SEVERE AND LIFE-
THREATENING
Physical
Exhaustion No No Yes, may have
paradoxical chest wall
movement
Pulse rate < 100 / min 100 120 / min > 120 / min
Central cyanosis absent May be present Likely to be present
Wheeze intensity variable Moderate Often quiet
Peak expiratory . 75% 50 75% < 50 %
flow
(% predicted)
Relieve symptoms
Improve current
Improve exercise tolerance
Improve health status
control
Reduce future
Prevent and treat exacerbations
Prevent disease progression
risks
Prevent and treat complications
Reduce mortality
Adapted from the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Global Initiative
for Chronic Obstructive Lung Disease (GOLD) 2009. Available from: http://www.goldcopd.org.
NYC/DAXAS/10/012
CONTINUED SMOKING LEADS TO RAPID DECLINE
OF FEV11
100
75 and smoke
susceptibl
e to its
effects
Disabili
ty
25)
50
Stopped
at 45
Disabili
ty
25
Death Stopped at
65
0
25 50 75
Age (years)
Adapted from Fletcher C and Peto R , 1977.
NYC/DAXAS/10/012
WHAT ARE EXACERBATIONS ?
NYC/DAXAS/10/012
WHAT ARE EXACERBATIONS?
Lower
Lower quality
quality of
of life
life Increased
Increased mortality
mortality rat
rat
Increased
Increased Increased
Increased risk
risk of
of
inflammation
inflammation recurrent
recurrent exacerbations
exacerbations
Faster
Faster disease
disease Increased
Increased likelihood
likelihood
progression
progression of
of hospitalisation
hospitalisation
Adapted from Wedzicha JA et al, 2007; Donaldson GC et al, 2006.
NYC/DAXAS/10/012
COUGH AND SPUTUM PRODUCTION INDICATE AN
INCREASED RISK OF EXACERBATIONS
Number of
exacerbations
Chronic
Chronic 3
inflammation
inflammation
Frequent
Frequent exacerbations
exacerbations
0
Patients WITH Patients WITHOUT
chronic cough and chronic cough and
sputum sputum
TRIGGE
RS
Viruses
Pollutants
Bacteria
Inflamed
EFFECTS COPD
airways
Greater airway
inflammation
Bronchoconstri
Systemic ction
oedema,
inflammation mucus
Expiratory flow
limitation
Cardiovascula
Cardiovascula Exacerbation Dynamic
rr
symptoms hyperinflation
comorbidity
comorbidity
Reprinted from The Lancet, 370, Wedzicha JA, Seemungal TA, COPD exacerbations: defining their cause and
28
prevention, 786-796, Copyright 2007, with permission from Elsevier.
FACTORS PRECIPITATING ACUTE
FAILURE
Sputum retention
Bronchospasm
Infection
Pneumothorax
Large bullae
Uncontrolled O22 - administration
Pulmonary embolism
Left-ventricular failure
End-stage disease
PATHO- PHYSIOLOGY.
Mucosal edema
Hypertrophy of mucosa
Increased secretions
Increased bronchospasm
incr. Airway tortuosity
More airway turbulance
Loss of lung recoil
PATHO-PHYSIOLOGY.contd
PATHO-PHYSIOLOGY.contd
AIR-FLOW OBSTRUCTION
PROLONGED EXPIRATION
PULMONARY HYPERINFLATION
DUE TO AIR-TRAPPING
DYSPNOEA
PATH-PHYSIO..CONTD
ALVEOLAR DISTORTION
AND DESTRUCTION
LOSS OF
HYPOXIA CAUSING
CAPILLARY BED
PULMONARY
VASOCONSTRICTION
PULMONARY HYPERTENSION
Stage IV:
Stage III: Very Severe
Stage II: Severe FEV1/FVC<0.70
Stage I: Moderate
Mild FEV1 <30%
FEV1/FVC<0.70 FEV1/FVC<0.70 predicted or
FEV1/FVC<0.70 30% FEV1 <50% FEV1 <50%
50% FEV1 <80%
FEV1 80% predicted predicted plus
predicted
chronic respiratory
predicted
failure
Active reduction of risk factor(s); influenza vaccination
Add short-acting bronchodilator (when needed)
# BRONCHODILATORS
ROUTINELY GIVEN
HELP RESIDUAL BRONCHODILATION
AND MUCO-CILIARY CLEARANCE
[ I.V.AMINOPHYLLINE / B22-AGONIST /
IPRATROPIUM ]
CONSERVATIVE
CONSERVATIVE MANAGEMENT
MANAGEMENT .contd
.contd
# ANTIBIOTICS
# STEROIDS AVOID IN ARF DUE TO
INFECTION
# OTHER
* STEAM / PHYSIOTHERAPY / ENCOURAGE
COUGH
* GENERAL HYDRATION
* DIURETICS / LOW DIGOXIN IF LVF
* HEPARIN S /C FOR D V T / PULM
EMBOLISM
* NUTRITION
* RESPIRATORY STIMULANTS
MANAGEMENT - NON CONSERVATIVE.
1.
1. INVASIVE
INVASIVE TECHNIQUES
TECHNIQUES FOR
FOR SPUTUM
SPUTUM
CLEARANCE
CLEARANCE
OROPHARYNGEAL
OROPHARYNGEAL // NASOPHARYNGEAL
NASOPHARYNGEAL
SUCTION
SUCTION
NASO-PHARYNGEAL
NASO-PHARYNGEAL AIR-WAY
AIR-WAY
THERAPEUTIC
THERAPEUTIC AND
AND DIAGNOSTIC
DIAGNOSTIC F
FOOB
B
MINI
MINI TRACHEOSTOMY/
TRACHEOSTOMY/ CRICOTHYROTOMY
CRICOTHYROTOMY FOR
FOR
SUCTION
SUCTION
ENDOTRACHEAL
ENDOTRACHEAL INTUBATION
INTUBATION
*
* FOR
FOR BETTER
BETTER ACCESS
ACCESS
*
* FOR
FOR VENTILATORY
VENTILATORY SUPPORT
SUPPORT
TRACHEOSTOMY
TRACHEOSTOMY
*
* IF
IF VERY
VERY THICK
THICK SECRETIONS
SECRETIONS
*
* INTUBATION
INTUBATION >> SEVEN
SEVEN DAYS
DAYS
Emphysema
The fourth leading cause of death in the US
34 million people in the US suffer from
emphysema
Current treatment is limited in efficacy
Bronchoscopic Lung Volume
Reduction for Emphysema
Continued Impaired
smoking mucous clearance
Exacerbation
Submucousal gland
Alveolar hypertrophy
destruction
Exacerbation
Hypoxaemia
DEATH
From the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease,
Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2008. Available from: http://www.goldcopd.org.
THANK-YOU