Chronic Obstructive

Pulmonary DiseaseAustin Paul K

What is COPD?• A chronic inflammatory lung disease

resulting in persistent and usually progressive obstruction of airflow from the lungs

• Patients with COPD have

★ breathing difficulty,

★ cough,

★ sputum production.

What causes COPD?• Smoking - primary or second

hand smoke

• Air pollutants -

★chemicals, dust, fumes from industry

★poorly vented cooking fires

• Genes - Alpha 1 anti-trypsin deficiency (AATD)

Some facts about COPD

• Worldwide more than 3 million people died of COPD in 2012 - cause of 6% of all deaths.

• It is the 3rd commonest cause of death worldwide.

• It affects about 5% of the world’s population.

COPD in INDIA

• One of the most affected countries in the world.

• It is the 2nd commonest cause of death in India

COPD IN INDIA

Pathophysiology• COPD is an obstructive lung disease

• Due to inflammation, there is breakdown of lung tissue (emphysema) and small airways disease (bronchiolitis) - this combination, results in poor outflow of air from the lung.

• Air trapping and hyperinflation of lungs - respiratory effort increases.

Symptoms of patients with COPD• Cough - a chronic cough is often the first symptom. Cough

and sputum on most days for at least 3 months, in each of 2 consecutive years is defined as “chronic bronchitis” which is a related diagnoses. However, it may be unproductive.

• Breathlessness -

★ progressive,

★ persistent

★ characteristically worse on exercise

• Sputum production - any pattern may indicate COPD

• Extra pulmonary effects include weight loss and skeletal muscle dysfunction.

Physical findings in COPD

• Physical findings are often non-specific and correlate poorly with lung function

• A barrel chest

• Auscultation usually reveals a quiet chest with poor air entry.

• Crackles if present indicate infection or bronchiectasis

• Clubbing is not a feature of COPD and if present, evaluation for other diseases is needed.

Investigations for COPD

• CAT - COPD Assessment Test - a set of 8 questions to ask patients.

• Blood counts

• Spirometry - the gold standard. Post-bronchodilator FEV1/FVC should be <70%

• CXR - over-expanded lungs and flattened diaphragm

• HRCT of chest to evaluate for presence of bullae

• Evaluation for Alpha 1 anti-trypsin deficiency

GOLD - Global Initiative for Chronic Obstructive Lung

Disease.

• GOLD was launched in 1997 in collaboration with the National Heart, Lung, and Blood Institute, National Institutes of Health, USA and WHO.

• GOLD’s program is determined and its guidelines for COPD care are shaped by committees made up of leading experts from around the world.

“GOLD” grading for severity of

COPDSEVERITY FEV1 % predicted

Mild (GOLD 1) >80

Moderate (GOLD2) 50-79

Severe (GOLD 3) 30-49

Very severe (GOLD 4)

<30

Differential Diagnosis of COPD• Congestive heart failure

• Pneumothorax

• Pulmonary embolism

• Pneumonia

• ASTHMA

Diseases often seen with COPD• Cardiovascular diseases.

• Cerebrovascular diseases.

• Respiratory infections.

• Diabetes

• Lung cancer

• Bronchiectasis

• Respiratory infections

• Anxiety and depression

Treatment of COPD• Stop smoking• Avoiding air pollutants, especially avoiding the use of

biomass fuels at home and preventive measures at affected industries.

• Pneumococcal and Influenza vaccine to prevent exacerbations.

• No known cure

• Symptomatic relief with inhaled bronchodilators, anticholinergics, oral theophylline and sometimes steroids.

• Pulmonary rehabilitation exercises.

• Oxygen therapy to be given with careful monitoring.

Future outcomes

• The incidence of COPD is gradually going up, especially in developing countries with increasing industrialization.

• Prevention is the cornerstone of the strategy for reducing the burden of COPD. In developing countries, resources are often the restricting factors.

• Patients with Alpha 1 anti-trypsin deficiency are now being offered intravenous replacement therapy in some centers.

• Various newer drugs like PDE 4 inhibitors (roflumilast) are being tried out.

Bibliography• Davidson’s Principles and and Practice

of Medicine 22nd ed.

• Special issue on COPD. Journal of the Association of Physicians of India. Feb. 2012. Vol. 60

• www.goldcopd.org

• www.uptodate.com

• www.medscape.com