Chronic Obstructive Pulmonary Disease

1
COPD
Chronic Obstructive Pulmonary Disease
David J Pierson MD Pulmonary Critical Care
Medicine Harborview Medical Center
2
Your Next Clinic Patient

• 62 yo woman, seen for f/u of type-II diabetes
• URI symptoms last 3 days
• Cough whitish sputum 1-block dyspnea no
  fever, chills, chest pain, hemoptysis
• You take a more detailed history
• Longstanding productive cough
• Progressive DOE last several years
• 3 chest colds in last year
• 40 pack-year smoking history

3
Your Next Clinic Patient

• Normal vital signs SpO2 94
• Mild nasal erythema mucosal swelling
• Chest clear to auscultation
• You do a more thorough chest exam
• Increased forced expiratory time
• Hyper-resonance to percussion
• Generally diminished breath sounds
• Scattered early-inspiratory basilar crackles

4
Your Next Clinic Patient

• In addition to a viral URI, what else does this
  patient have that would be important to document
  and treat?
• Does she have COPD?
• What should be done to find out?
• History and physical exam?
• Response to treatment?
• Chest X-ray?
• If she has COPD, how will this change your
  management?

5
Outline of Presentation

• Definition of COPD and its components
• Epidemiology and importance
• Pathophysiology
• Clinical presentations
• Diagnosis assessment of severity
• Approach to management

6
COPD Definitions

• A chronic condition characterized by respiratory
  symptoms (cough exertional dyspnea) and airflow
  obstruction (reduced FEV1/FVC) that is
  incompletely reversible.
• A clinical syndrome (not a disease)
• 3 separate contributing disease processes
• Chronic bronchitis
• Emphysema
• Asthma

7
Emphysema
Chronic Bronchitis
Asthma
8
Chronic Bronchitis

• Defined and diagnosed by history
• Productive cough
• Present on most days
• At least 3 months/year
• At least 2 years in a row
• Most heavy smokers have it
• Only about 15 have COPD

9
Pathology of Chronic Bronchitis
Chronic Bronchitis
Normal
80x
Submucosal Glands
Submucosal Glands
150x
Thurlbeck WM, Wright JL Thurlbecks Chronic
Airflow Obstruction, 2nd ed. Hamilton, B C
Decker, 199919
10
Emphysema
Chronic Bronchitis
Asthma
11
Emphysema

• Defined and diagnosed anatomically (by histology
  or CT scan)
• Destructive process
• Dissolution of alveolar walls and loss of
  associated pulmonary capillaries
• Most consistent clinical finding ? DLCO
• Loss of elastic recoil ? lung compliance
• Correlation with airflow obstruction poor

12
Pathology of Emphysema
Normal
Emphysema
From Heard BE. Pathology of Chronic Bronchitis
and Emphysema. London, Churchill, 1969
13
Pathology of Emphysema
Normal
Emphysema
From Heard BE. Pathology of Chronic Bronchitis
and Emphysema. London, Churchill, 1969
14
Pathology of Emphysema
Pacinar (Panlobular) Emphysema Seen in Alpha-1
Antitrypsin Deficiency Everywhere in lung but
especially in lower zones
Centriacinar (Centrilobular) Emphysema Most
common form seen in smokers Everywhere in lung
but especially in upper zones
Robins Pathology (on line version), Fig 15-5
15
The Chest X-Ray in Severe Emphysema
Increased Retrosternal Air Space
Large, Hyperlucent Lungs
Absence of Vascular Markings in Periphery
Flattened Diaphragms
Wright FW. Radiology of the Chest. London,
Taylor Francis, 2002
16
Chest CT in Severe Emphysema
Normal
Centrilobular
Panlobular
Emphysema Images from UpToDate High-Resolution
CT of the Lungs, 2008
17
Emphysema
Chronic Bronchitis
Asthma
18
Asthma, as a Component of COPD

• Defined physiologically
• Component of obstruction that varies
  spontaneously or in response to therapy
• Present in many patients with smoking-associated
  COPD
• Patients with longstanding asthma and persistent
  obstruction on maximal therapy may be considered
  to have COPD

19
Emphysema
Chronic Bronchitis
e
f
d
COPD
h
g
i
Airflow Obstruction
Asthma
20
Emphysema
Chronic Bronchitis
e
f
d
COPD
h
g
i
Asthma with Incompletely Reversible
Airflow Obstruction (COPD)
Airflow Obstruction
Asthma with Completely Reversible
Airflow Obstruction (Not COPD)
Asthma
21
Emphysema
Chronic Bronchitis
b
a
c
e
e
d
f
f
d
COPD
h
h
g
g
i
i
j
Airflow Obstruction
k
l
Asthma
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Epidemiology of COPD

• 10.1 million people in US
• 120,000 deaths in 2000
• 750,000 hospitalizations
• 1.5 million ER visits
• 8 million office/clinic visits

Physician-diagnosed
Mannino DM, Respir Care 200348(12)1185-91
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Epidemiology of COPDEstimates from NHANES

• 24 million people in US have COPD
• 15 of people aged 55-64
• 25 of people aged 75 and older

Lung function study of representative sample of
adult Americans
http//archive.nlm.gov/proj/dxpnet/nhanes/docs/nha
nesDocs.php
24
Change in Age-Adjusted US Death Rates, 1965-1998
Percentage of 1965 Rate
Coronary Heart Disease
Stroke
Other CVD
All Other Causes
COPD
250
200
150
100
50
-64
-35
163
-7
-59
www.goldcopd.com
25
Deaths from COPD in the US
As many (or more) women as men now die of COPD in
the US
Mannino DM, Respir Care 200348(12)1185-91
26
Prevalence of COPD in 17 Countries
Worldwide, 10.1 of adults over 40 have at least
GOLD Stage II COPD
Buist AS et al International variation in the
prevalence of COPD (The BOLD Study) a
population-based prevalence study. Lancet 2007
Sept 1370741-50.
27
Cost of Managing COPD in Different Countries
Mannino DM, Buist AS. Global burden of COPD
risk factors, prevalence, and future trends.
Lancet 2007 Sept 1370765-73.
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Outline of Presentation

• Definition of COPD and its components
• Epidemiology and importance
• Pathophysiology
• Clinical presentations
• Diagnosis assessment of severity
• Approach to management

29
Relationship of Airway Caliber to Airflow During
Forced Exhalation
30
Mechanisms of Airflow Obstruction in COPD
Secretions in Airway Lumen
Thickening of Airway Walls
Loss of Tethering by Parenchyma
West JB Pulmonary Pathophysiology.
Philadelphia, Wolters Kluwer, 7th ed, 200852
31
Forced Spirogram in COPD vs Normal and
Restrictive Disease
COPD
32
Forced Spirogram in COPD vs Normal and
Restrictive Disease
COPD Increased Expiratory Time
33
Pulmonary Hyperinflation in COPD
COPD Stable State
Normal
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Chest X-Ray at TLC and RV Normal
35
Chest X-Ray at TLC and RV COPD
36
Pulmonary Hyperinflation in COPD
Exacerbation
Exercise
COPD Stable State
Normal
COPD
Hyperpnea (Any Cause)
37
How Hyperinflation Develops in Patients with
Airflow Obstruction
No Obstruction Complete Exhalation Prior to
Next Breath
Obstruction Exhalation Just Complete Prior to
Next Breath
More Severe Obstruction or Increased Rate
Incomplete Exhalation Prior to Next Breath with
Progressive Air Trapping
38
Gas Exchange Abnormalities in Patients with COPD

• Alveolar Hypoventilation
• Acute respiratory acidosis
• Chronic respiratory acidosis
• Acute-on-chronic acidosis
• Hypoxemia
• Low VA/Q
• Hypoxemia
• High VA/Q and dead space

.
.
.
.
.
39
Ventilation-Perfusion Matching in COPD One Reason
Why Some Patients Are More Hypoxemic Than Others
Parallel Reduction in Ventilation and Perfusion
Continued Perfusion to Poorly-Ventilated Areas
40
Factors Affecting Symptoms and Clinical Severity
in COPD

• Severity of obstruction (FEV1)
• Degree of hyperinflation

.
41
Relationship between Physiological and Clinical
Impairment as COPD Progresses
42
Factors Affecting Symptoms and Clinical Severity
in COPD

• Severity of obstruction (FEV1)
• Degree of hyperinflation
• Asthmatic component (degree of reversibility)
• Presence of chronic hypoxemia
• Status of underlying ventilatory drives
• Stronger drives more dyspnea, more exercise
  limitation, less hypoxemia
• Weaker drives less dyspnea, more hypoxemia, cor
  pulmonale

.
43
Clinical Presentations of COPD
The Pink Puffer (Type A)

• Emphysematous phenotype
• Long history of exertional dyspnea
• Little sputum
• Infrequent exacerbations
• Hyperinflation
• Use of accessory muscles
• Pursed-lips breathing
• Normal oxygenation
• Thin weight loss a problem

Netter FH. The Ciba Collection of Medical
Illustrations, vol 7, 1979148
44
Clinical Presentations of COPD
The Blue Bloater (Type B)

• Bronchitic phenotype
• Long history of cough and sputum production
• Frequent exacerbations
• Less dyspnea
• Chronic hypoxemia
• Pulmonary hypertension
• Cor pulmonale
• Right-sided heart failure
• Normal habitus or obese

Netter FH. The Ciba Collection of Medical
Illustrations, vol 7, 1979149
45
Clinical Presentations of COPD

• The Pink Puffer and the Blue Bloater are
  largely hypothetical extremes.
• These extremes are helpful in understanding the
  pathophysiology and diversity of presentations
  among patients with COPD.
• The clinical features of most patients lie
  between these extremes.

46
Outline of Presentation

• Definition of COPD and its components
• Epidemiology and importance
• Pathophysiology
• Clinical presentations
• Diagnosis assessment of severity
• Approach to management

47
Current Guidelines www.goldcopd.com

• Full workshop report
• Executive summary
• Pocket guide for clinicians
• Slide set
• Patient teaching materials

48
COPD Making the Diagnosis

• Chronic respiratory symptoms
• Appropriate clinical setting and risk factors
• Exclusion of other causes for symptoms
• Spirometry demonstrating airflow obstruction that
  persists after inhaled bronchodilator
• FEV1/FVC lt 0.70 (www.goldcopd.com)
• It is not possible to diagnose COPD accurately
  without spirometry

49
GOLD Staging System for COPD
www.goldcopd.com
50
Recommended Stepwise Management for Patients with
COPD www.goldcopd.com
51
Progression of COPD in Relation to Continued
Smoking
3.0
Non-Smoker, or Not Susceptible to COPD
FEV1 (liters)
COPD, Stopped Smoking at Age 40
2.0
Benefit of Smoking Cessation Occurs at Any Stage
of Disease
1.0
COPD, Continued Smoking
60
40
45
50
55
65
70
Age (years)
52
Effects of Available Interventions in COPD

• Affect natural history of obstruction and
  increase survival smoking cessation
• Increase survival and reduce morbidity in
  appropriately selected patients long-term
  oxygen therapy
• Increase physical functioning and quality of
  life pulmonary rehabilitation
• Decrease exacerbation frequency and improve
  quality of life long-acting bronchodilators
  inhaled steroids (in selected patients effects
  modest at best)
• Improve pulmonary function bronchodilators
  (variable typically much less effect than in
  asthma)

53
Recommended Stepwise Management for Patients with
COPD www.goldcopd.com
54
Back to Your Clinic Patient

• In addition to a viral URI, what else does this
  patient have that would be important to document
  and treat?
• Does she have COPD?
• What should be done to find out?
• History and physical exam?
• Response to treatment?
• Chest X-ray?
• If she has COPD, how will this change your
  management?