COPD

Chronic Obstructive Pulmonary Disease

Prepared by:
KOPP, MELANIE P.
SALCEDO, MARK ANTHONY

Submitted to:
MS KAREN ANN MABAO

01 September 2010
 W HAT IS COPD?

Chronic Obstructive Pulmonary Decease (COPD) is not a single disease, but a group of
conditions (including chronic bronchitis, emphysema, and asthma) that damage the lungs,
blocking the passage of air in and out, and making it difficult to breathe. Please see Table 1 for
the Definition Matrix, and Figure 1.1 for its Relationship to COPD.
Table 1.1
Definition Matrix
Disease Clinical Definition
Chronic bronchitis involves inflammation and swelling of the lining of the
airways that leads to narrowing and obstruction of the airways. The
inflammation also stimulates production of mucous (sputum), which can cause
further obstruction of the airways. Obstruction of the airways, especially with
Chronic Bronchitis
mucus, increases the likelihood of bacterial lung infections. The American
Thoracic Society (ATS) defines chronic bronchitis as the persistence of cough
and excessive mucus secretion on most days over a 3-month period for at least
2 successive years.
The ATS defines emphysema as airspace enlargement distal to the terminal
bronchiole and destruction of the alveolar wall; later refinements of the
Emphysema
definition include the requirements that the airspace enlargement is
permanent and that fibrosis is not a feature.
Asthma is characterized by airway inflammation that is manifested by airway
hyper-responsiveness to a variety of stimuli and by airway obstruction that is
Asthma
reversible spontaneously or in response to treatment; reversibility may be
incomplete in some patients.

Figure 1.1
Venn diagram illustrating the overlap between the diagnosis of chronic bronchitis,
emphysema, and asthma, and their contribution to COPD

Air needs to move in and out of your lungs to meet your body’s needs. COPD decreases
the lungs’ ability to take in oxygen and remove carbon dioxide when we breathe. As the
disease gets worse, small airways within the walls of the lungs become less elastic. Finally, the
airways collapse, and become clogged with mucus. Although air continues to reach the lungs
when you breathe in, it becomes trapped, making it difficult and uncomfortable to breathe out.

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 Risk factors include exposure to a wide variety of inhaled particles and gases, but in the
Western world, inhaled cigarette smoke is the most important known causative factor. COPD
is more than a pulmonary disorder with a known effect on cardiovascular function and on the
risks of lung cancer, the metabolic syndrome, osteoporosis, and depression. (Information for
health care professionals and patients with COPD is available on the Web site of the National
Heart, Lung, and Blood Institute, at www.nhlbi.nih.gov/health/public/lung/copd).
There are four stages of COPD, and it is summarized in Table 1.2 below .

Stage Characteristics
0: normal spirometry
At Risk chronic symptoms (cough, sputum
  production)
FEV1/FVC < 70%
I:
FEV1 ≥ 80% predicted
Mild
with or without chronic symptoms
COPD
II: (cough, sputum
FEV1/FVC < 70%production)
Modera 50% ≤ FEV1 < 80% predicted
te with or without chronic symptoms
COPD (cough, sputum
FEV1/FVC < 70%production)
III:
30% ≤ FEV1 < 50% predicted
Severe
IV: with or without chronic symptoms
COPD FEV1/FVC < 70%production)
Very (cough, sputum
FEV1 ≤ 30% predicted or FEV1 < 50%
Severe
predicted plus chronic respiratory
failure
COPD
COPD Key Points
Patients with COPD die mainly from extra-pulmonary diseases, and COPD-related
mortality is probably underestimated because identifying the precise cause of death is difficult
in elderly patients with this disease, in whom cardiac arrhythmias, ischemia and chronic
pulmonary heart disease (cor pulmonale) or pulmonary embolism, or both could be suspected.
A recent global survey has cited Metro Manila as one of the most polluted cities in the
world, as bad as Mexico City, New Delhi, Shanghai, and other polluted cities in Eastern Europe.
Add to this the fact that half of the entire Filipino male population are smokers and you get a
society that is on the brink of a COPD epidemic.
COPD is chronic obstructive pulmonary disease, also known as the "smoker's disease."
It is the fourth major cause of death throughout the world. In the Philippines, it is the seventh
leading killer, while it is third in the U.S.
Medical researchers are projecting that if the trend continues, COPD will become one
of the top diseases causing illness and death in the Philippines by the year 2020. Yet, a lot of
people know little about this dreaded disease because its recognition as a public health
problem has been evolving slowly despite the rising mortality rate.

Some Worldwide Alarming Statistics

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  The World Health Organization (WHO) estimates that COPD as a single cause of death
shares 4th and 5th places with HIV/AIDS (after coronary heart disease, cerebro-vascular
disease and acute respiratory infection).
 The WHO estimates that in 2000, 2.74 million people died of COPD worldwide.
 In 1990, a study by the World Bank and WHO ranked COPD 12th as a burden of disease;
by 2020, it is estimated that COPD will be ranked 5th.
 According to the WHO, passive smoking carries serious risks, especially for children and
those chronically exposed. The WHO estimates that passive smoking is associated with
a 10 to 43 percent increase in risk of COPD in adults.
 Although cigarette smoking is the primary cause of COPD, the WHO estimates that
there are 400,000 deaths per year from exposure to biomass fuels.
 In Algeria, the prevalence of tuberculosis and acute respiratory infection has decreased
since 1965, but an increase in chronic respiratory diseases (asthma and COPD) has been
observed in the last decade.
 COPD is estimated to be 6.2 percent in 11 Asian countries surveyed by the Asian Pacific
Society of Respiratory Diseases.
 The use of biomass fuels, especially in the rural areas, contributes towards a higher
prevalence of COPD in some of these countries and suggests that COPD may be
significantly greater in this region of the world than previously estimated.
 In China, where it is estimated that over 50 percent of the men smoke, chronic
respiratory diseases are the 4th leading cause of death in large urban areas, but the first
leading cause of death in rural areas.
 In China, smoking rates among women remain low (estimated at 6 percent), although
the prevalence of COPD in men and women is about the same. This points to the
importance of risk factors other than smoking as a cause for COPD in Chinese women.
 In Malaysia, respiratory illness is the primary cause of visits to health clinics and
outpatient hospital clinics. It is estimated that 50 percent of the male population
smokes, with higher rates in the rural areas than the urban areas.

P AT HOL OGY

The pathological hallmarks of COPD are destruction of the lung parenchyma, which
characterizes emphysema, inflammation of the peripheral airways, which characterizes
bronchitis, and inflammation of the central airways, which characterizes chronic bronchitis.
The functional consequence of these abnormalities is expiratory airflow limitation. Technically,
this flow is the result of a driving pressure (elastic recoil of the lung) and of an opposing
resistance (airway obstruction). It is best to refer to the changes in flow seen in smokers as
airflow limitation, rather than airflow obstruction, since both loss of elastic recoil and increase
in airway resistance play an important role in the observed decrease in flow. Emphysema will
contribute to the airflow limitation by reducing the elastic recoil of the lung through
parenchymal destruction, as well as by reducing the elastic load applied to the airways through
destruction of alveolar attachments. On the other hand, bronchitis will contribute to the
airflow limitation by narrowing and obliterating the lumen and by actively constricting the
airways. The role of symptoms of chronic bronchitis in the development of chronic airflow

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limitation is still controversial. In fact, chronic sputum production has traditionally been
considered to be irrelevant to the development of chronic airflow limitation (Turato, Zuin, and
Saetta, 2001).
In sum, in the peripheral airways of patients with COPD, there is airflow limitation due
to loss of alveolar attachments, as well as inflammation, fibrosis, and mucus secretion, which
result in the obstruction of airway. The contributions to airflow limitation from this process
vary from individual to individual.

S I GNS AND S YMPT OMS

Smokers often overlook COPD symptoms thinking ‘smoker’s cough’ and general
breathlessness are just par for the course – the ‘natural’ side-effects of smoking, or ‘normal’
signs of getting older. In many cases, however, they could be the earliest signs of COPD.
Common symptoms of COPD include:
 ‘wet’ cough, usually accompanied by a lot of phlegm
 tightness in the chest
 shortness of breath (particularly in cold weather and in the mornings)
 wheezing with mild exertions, like climbing stairs
 frequent clearing of the throat
 chest infections with phlegm becoming yellow or green.

A cough can occur quite a long time before breathlessness occurs. The breathlessness
of COPD can cause panic. Some people describe it as like ‘drowning on land’.

D I A G N O SI S AND D I AGNO ST I C T OOL S

If one has any of the symptoms listed earlier, let him seek advice from a health
professional as soon as possible. The condition may not be caused by COPD, so it will need to
be properly assessed by a GP, practice nurse, or occupational health nurse (if the victim works
and has an occupational health service). If COPD is suspected, they will need to check the lung
function using a spirometer, which tests how much ‘puff’ you have in your lungs.
Practice nurses and occupational health nurses usually carry out the spirometry test,
and all the patient has to do is blow into a machine, which measures the breathing over a
specified time.
Spirometry (meaning the measuring of breath), is the most common of the Pulmonary
Function Tests (PFTs), measuring lung function, specifically the measurement of the amount
(volume) and/or speed (flow) of air that can be inhaled and exhaled. Spirometry is an important
tool used for generating pneumotachographs (lung photos), which are helpful in assessing
conditions such as asthma, pulmonary fibrosis, cystic fibrosis, and COPD.
Aside from spirometry is a chest x-ray. A chest X-ray can show emphysema — one of
the main causes of COPD. An X-ray can also rule out other lung problems or heart failure.
Another is the arterial blood gas analysis. This blood test measures how well your lungs
are bringing oxygen into your blood and removing carbon dioxide.

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 Next is a sputum examination. Analysis of the cells in your sputum can help identify the
cause of your lung problems and help rule out some lung cancers.
Then the computerized tomography (CT) scan. A CT scan is an X-ray technique that
produces more-detailed images of your internal organs than those produced by conventional
X-rays. A CT scan of your lungs can help detect emphysema and help determine if you might
benefit from surgery for COPD.
Victims are advised not to be shy; smokers sometimes feel guilty or embarrassed about
seeking help for a condition they think they might have ‘brought upon themselves’ by
smoking, but doctors would much rather they get help early and there is a lot surgery that can
do to help the patient manage the condition.

COPD T RE AT ME NT S

There is no cure for COPD, and one cannot undo the damage to the lungs. But, COPD
treatments can control symptoms, reduce the risk of complications and exacerbations, and
improve one’s ability to lead an active life.

Smoking cessation
The most essential step in any treatment plan for smokers with COPD is to stop all
smoking. It is the only way to keep COPD from getting worse, which can eventually result in
losing the patient’s ability to breathe. But, quitting smoking is never easy. The victim, then, is
advised to talk to the doctor about nicotine replacement products and medications that might
help, as well as how he might handle relapses. It is not known what role exposure to
secondhand smoke plays in COPD, but one should avoid it whenever possible.

Medications
Doctors use several basic groups of medications to treat the symptoms and
complications of COPD. The patient may take some medications on a regular basis and others
as needed:
 Bronchodilators. These medications, which usually come in an inhaler, relax the
muscles around the airways. This can help relieve coughing and shortness of breath and
make breathing easier. Depending on the severity of your disease, you may need a
short-acting bronchodilator before activities, a long-acting bronchodilator that you use
every day, or both.
 Inhaled steroids. Inhaled corticosteroid medications can reduce airway inflammation
and help you breathe better. But prolonged use of these medications can weaken your
bones and increase your risk of high blood pressure, cataracts and diabetes. They're
usually reserved for people with moderate or severe COPD.
 Antibiotics. Respiratory infections, such as acute bronchitis, pneumonia and influenza,
can aggravate COPD symptoms. Antibiotics can help fight bacterial infections, but are
only recommended when necessary.

Surgery

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 Surgery is an option for some people with some forms of severe emphysema who aren't
helped sufficiently by medications alone:
 Lung volume reduction surgery. In this surgery, your surgeon removes small wedges of
damaged lung tissue. This creates extra space in your chest cavity so that the remaining
lung tissue and the diaphragm work more efficiently. The surgery has a number of risks,
and long-term results may be no better than for nonsurgical approaches.
 Lung transplant. Single-lung transplantation may be an option for certain people with
severe emphysema who meet specific criteria. Transplantation can improve your ability
to breathe and be active, but it doesn't appear to prolong life and you may have to wait
for a long time to receive a donated organ. So the decision to undergo lung
transplantation is complicated.

Other therapies
Doctors often use these additional therapies for people with moderate or severe COPD:
 Oxygen therapy. If there isn't enough oxygen in your blood, you may need
supplemental oxygen. There are several devices to deliver oxygen to your lungs,
including lightweight, portable units that you can take with you to run errands and get
around town. Some people with COPD use oxygen only during activities or while
sleeping. Others use oxygen all the time. Oxygen therapy can improve heart function,
exercise capacity, depression, mental clarity and quality of life. In some people, it may
also extend life. Talk to your doctor about your needs and options.
 Pulmonary rehabilitation program. Comprehensive pulmonary rehabilitation may be
able to decrease the length of any hospitalizations you require, increase your ability to
participate in everyday activities and improve your quality of life. These programs
typically combine education, exercise training, nutrition advice and counseling. If you
are referred to a program, you'll probably work with a range of health care
professionals, including physical therapists, respiratory therapists, exercise specialists
and dietitians. These specialists can tailor your rehabilitation program to meet your
needs.

Managing exacerbations
Even with ongoing treatment, one may experience times when symptoms suddenly get
worse. This is called an acute exacerbation, and it may cause lung failure if the patient do not
receive prompt treatment. Exacerbations may be caused by a respiratory infection or a change
in temperature or air pollution. Whatever the cause, it's important to seek prompt medical help
if one notice more coughing, a change in the mucus or if he has a harder time breathing.
When exacerbations occur, you may need additional medications, supplemental
oxygen or treatment in the hospital. Once symptoms improve, you'll want to take measures to
prevent future exacerbations. This may include quitting smoking, avoiding indoor and outdoor
pollutants as much as possible, exercise and treatment for GERD.
References:
http://www.nhlbi.nih.gov http://www.nhlbi.nih.gov/health/public/lung/other/copd_fact.pdf
http://www.copdinamerica.org/background.html http://gsk.ibreathe.com/ibreathe_pages/3_0_copd/3_1_2_statistics.htm
http://www.hosppract.com/issues/1998/04/dmmferg.htm http://www.lungusa.org/data/lae_02/lae_index02.html