Chronic obstructive pulmonary disease

Spirometric Criteria for COPD• Forced expiratory volume in one second FEV1 < 80% predicted... Toxic Inhaled Agent tobacco smoke, air pollution, occupational Occupation Respiratory infec

Chronic Obstructive Pulmonary Disease

Josh Solomon, MD

• A clinical syndrome characterized by:

– Partially reversible airflow limitation

– Slow clinical progression

– Minimal airway hyperresponsiveness vs

Airflow obstruction

Spirometric Criteria for COPD

• Forced expiratory volume in one

second (FEV1) < 80% predicted

0 20

Fletcher C, Peto R Br Med J 1977; 1.

Natural History: FEV1 Decline

Never-smoker Smoker

COPD - Pathology

• Irreversible changes:

– Airway fibrosis and narrowing

– Loss of airways elastic recoil

– Alveoli destruction

• Reversible changes:

– Smooth muscle contraction/hypertrophy – Airway accumulation of cells, mucus

Toxic Inhaled Agent

(tobacco smoke, air pollution, occupational)

Occupation Respiratory infection Airway responsiveness

Socioeconomics

COPD

Susceptibility

Genetics

Patient X

• 65 years old

• Smoke 1 pack/day for 30 years

• Complains of morning cough with a lot of sputum and

worsening shortness of breath over last 5 years

Chest X-ray

Chest CT

Exacerbation

• Requires change in medication

• Increase in frequency as disease gets more severe

• infection account for 80% of

exacerbations

•Strep Pneumonia, Hemophilus influenza,

Moraxella catarrhalis most common

• Other causes include pulmonary

embolism, heart failure, pneumothorax

Sethi et al CHEST 2001; 115.

• History/physical exam

• Chest Xray - 20% abnormal

• Arterial Blood Gas

– Degree of hypoxemia (O2) and hypercarbia

(CO2)

•Nebulized or MDI have same delivery

•inhaled better than intravenous (FEV1)

Mcrory et at CHEST 2001; 119.

• anticholinergics (ipratropium)

•use with beta agonists in inhaled form

• Methylxanthines (aminophylline)

•No good data that they work in COPD

•Minimal if any improvement in FEV1

•Only use if no access to B- agonists or

anticholinergics

Barr et al Cochrane Review 2001

• Antibiotics

•All ICU and ventilated patients

Saint et al JAMA 1995, 273.

COPD and respiratory failure

• Non-invasive ventilation

•studied in COPD – prevents intubation and

improves outcome in respiratory failure

Brochard et al NEJM 1995, 333.

• Contraindications : altered mental status, increased secretions, CV instability

COPD and respiratory failure

• Ventilation Goals

•rest muscles of breathing

•allow time for exhalation

•prevent hyperinflation

COPD and respiratory failure

• Signs - hypotension, high airway

pressures, hypoxemia, pneumothorax

• Measure - breath hold at end expiration (iPEEP, autoPEEP)

Hyperinflation Treatment

• Increase expiratory time

– Decrease respiratory rate

– Decrease tidal volume

– Increased flow rate/change I:E ratio

– Tolerate higher CO2 levels

• Decrease airflow obstruction

– Aggressive use of bronchodilators

– Sedation/paralysis if necessary

COPD and respiratory failure

• Ventilation

•Extubate as soon as patient tolerates a 30

minute wean

•Target patients baseline CO2

•Can extubate early to noninvasive

Ferrer et al AJRCCM 2006; 173.

• Smoking cessation #1

• inhaled albuterol/salbuterol + ipratropium

• slow prednisone taper(2 weeks

•patients admitted for COPD get antibiotics,

steroids, inhaled albuterol/ipratropium and O2

•if intubated, careful to avoid hyperinflation by altering RR, I:E time

•at discharge, all go home with prednisone taper, inhaled albuterol/ipratropium and follow-up