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CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
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.
Hypothetical Male Patient With
COPD Symptoms
Diagnosed as COPD by
65% of physicians
65%
49%
Hypothetical Female Patient
With COPD Symptoms
Diagnosed as COPD by
49% of physicians
Inhaled substances +
Genetic susceptibility
Epithelial
cells
Macrophage/Dendritic cell
Neutrophil
Monocyte
Fibrosis
Reproduced from The Lancet, Vol 364, Barnes PJ & Hansel TT, "Prospects for new drugs for chronic obstructive pulmonary disease", pp985-96.
Copyright 2004, with permission from Elsevier.
CHRONIC INFLAMMATION PLAYS A CENTRAL ROLE
IN COPD
Smoke Pollutants Key inflammatory cells
Neutrophils
CD8+ T-lymphocytes
Macrophages
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
Onset
Inflammatory cells
Airflow limitation
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
100
Airways with measurable cells (%)
GOLD Stage I
60
40
20
NYC/DAXAS/10/012
COPD IS DIAGNOSED BASED ON SYMPTOMS,
RISK FACTORS AND 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
Pulse rate < 100 / min 100 120 / min > 120 / min
Relieve symptoms
Improve exercise tolerance
Improve health status
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 FEV1
100
to its effects
Disability
50
Stopped at 45
Disability
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?
Number of exacerbations
p<0.0001
1
0
Patients WITH Patients WITHOUT
chronic cough and chronic cough and
sputum sputum
Viruses
Pollutants
Bacteria
Inflamed
COPD airways
EFFECTS
Greater airway
inflammation
Bronchoconstriction
Systemic oedema, mucus
inflammation
Expiratory flow
limitation
Sputum retention
Bronchospasm
Infection
Pneumothorax
Large bullae
Uncontrolled O2 - 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
AIR-FLOW OBSTRUCTION
PROLONGED EXPIRATION
PULMONARY HYPERINFLATION
DUE TO AIR-TRAPPING
DYSPNOEA
PATH-PHYSIO..CONTD
ALVEOLAR DISTORTION
AND DESTRUCTION
PULMONARY HYPERTENSION
COR-PULMONALE
PHARMACOLOGICAL TREATMENTS SHOULD BE ADDED
STEPWISE AS COPD PROGRESSES
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% predicted plus
FEV1 80% predicted 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
CONTD
CONSERVATIVE MANAGEMENT .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. INVASIVE TECHNIQUES FOR SPUTUM CLEARANCE
OROPHARYNGEAL / NASOPHARYNGEAL SUCTION
NASO-PHARYNGEAL AIR-WAY
THERAPEUTIC AND DIAGNOSTIC F O B
MINI TRACHEOSTOMY/ CRICOTHYROTOMY FOR SUCTION
ENDOTRACHEAL INTUBATION
* FOR BETTER ACCESS
* FOR VENTILATORY SUPPORT
TRACHEOSTOMY
* IF VERY THICK SECRETIONS
* INTUBATION > SEVEN 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