Written by Dr.Md.Redwanul Huq (Masum)

Sunday, 15 January 2012 16:00

Definition:

Chronic Obstructive Pulmonary Diseases (COPD) is a disease state characterized by progressive airflow obstruction either due to chronic bronchitis or emphysema.

Chronic bronchitis:

Definition:

It can be defined as cough with sputum production for more than 3 consecutive months of the year for more than two successive years provided other causes of expectoration (e.g. Pulmonary tuberculosis, Bronchogenic carcinoma) has been excluded.

Etiology:

1. Air pollution

• Outdoor
• Indoor (due to solid fuel used for cooking and heating)

2. Cigarette smoking

• Active
• Passive

3. Hyper responsiveness of the airway.

Symptoms:

1. Repeated cough with production of sputum which is mucoid or mucopurulent
2. Recurrent infection of respiratory tract
3. Exertional dyspnea
4. Chest tightness
5. Wheeze
6. Haemoptysis.

Sings:

1.General examination findings:

* Signs of respiratory distress like-

• Increased respiratory rate
• Pursing lip
• Cyanosis
• Tracheal tug
• Suprasternal and intercostal recession
• Prominent accessory muscles of respiration

2. Respiratory system examination findings:

a) Inspection-

• Tracheal tug
• Suprasternal and intercostal recession
• Prominent accessory muscles of respiration
• Restricted movement of the chest (symmetrical)

b) Palpation-

Chest expansion- decreased.

c) Percussion-

May be normal or may have-

• Hyper resonant lung fields
• Lower down of upper border of liver dullness.

d) Auscultation-

• Breath sound- Vesicular with prolonged expiration
• Rhonchi- present bilaterally
• Crepitations- may be present over lower lobes which disappear after coughing.

3. Late signs (i.e. signs of chronic Type- 2 respiratory failure) which are present in advanced cases:

1. Bounding pulse
2. Flapping tremor
3. Papiloedema.

4. Evidence of Rt ventricular hypertrophy may be present-

1. Lt parasternal heave
2. Palpable P2
3. Epigastric pulsation.

5. Evidence of Rt heart failure or Cor- Pulmonale may be present-

1. Engorged neck vein
2. Enlarged tender liver
3. Dependent edema.

Emphysema:

Definition:

It can be defined as abnormal and permanent dilatation of air spaces distal to the terminal bronchioles associated with destruction of the alveolus and without obvious fibrosis.

Etiology:

1. Cigarette smoking

• Active
• Passive

2. Alpha1-anti trypsine deficiency:

• Family history of emphysema- positive
• May be associated with liver disease.

Symptoms of emphysema:

1. Exertional breathlessness which is long standing and slowly progressive
2. Cough with sputum production
3. May have wheeze or chest tightness.

Sings of emphysema:

1.General examination findings:

1. Signs of respiratory distress like-

• Increased respiratory rate
• Pursing lip
• Cyanosis
• Tracheal tug
• Suprasternal and intercostal recession
• Prominent accessory muscles of respiration

2. TRIPOD sitting posture

3. May have clubbing.

2. Respiratory system examination findings:

a) Inspection-

• Tracheal tug present
• Suprasternal and intercostal recession
• Prominent accessory muscles of respiration
• Barrel shaped chest

b) Palpation-

• Chest expansion- decreased
• Apex beat- may be impalpable
• Vocal fremitus- decreased on both sides.

c) Percussion-

• Hyper resonant on both lung fields
• Lower down of upper border of liver dullness
• Reduction or obliteration of cardiac dullness.

d) Auscultation-

• Breath sound – Vesicular with prolonged expiration
• Vocal resonance – decreased on both sides.

3. Late signs (i. e. signs of chronic Type- 2 respiratory failure) which are present in advanced cases:

1. Bounding pulse
2. Flapping tremor
3. Papiloedema.

4. Evidence of Rt ventricular hypertrophy may be present-

i. Lt parasternal heave

ii. Palpable P2

iii. Epigastric pulsation.

5. Evidence of Rt heart failure or Cor- Pulmonale may be present-

i. Engorged neck vein

ii. Enlarged tender liver

iii. Dependent edema.

Differences between Chronic bronchitis and Emphysema:

Traits	Chronic Bronchitis	Emphysema
Appearance	Blue bloater, blue due to cyanosis and bloated due to Oedema	Pink puffer, pink due to polycythaemia and puffy due to dyspnea.
Age	Usually in middle age	Elderly pt in most cases of emphysema
Body built	Usually obese person	Usually lean and thin person
Muscle wasting	Not significant	Gross wasting
Predominant symptom	Productive cough	Breathlessness
Signs	Rhonchi- present bilaterally Crepitations- may be present over lower lobes which disappear after coughing	Barrel chest Apex beat- may be impalpable Hyper resonant on both lung fields Lower down of upper border of liver dullness Reduction or obliteration of cardiac dullness
X-ray findings	Nothing significant	Hyperinflated Lung fields with low flat diaphragm and long tubular heart Pulmonary vascular markings at perihilar regions are prominent Peripheral lung markings are scanty Presence of bullae
Complications	Cor pulmonale and respiratory failure develop early in chronic bronchitis	These are late features

 Investigations for COPD:

1. CBC with ESR:

• May be normal
• During acute exacerbation neutrophilic leukocytosis may be present
• Secondary polycythaemia
• Decreased ESR

2. Sputum for Gram stain -if infection is present

3. X-ray chest P/A view:

•  Early stage – may be normal
• Hyperinflated Lung fields with low flat diaphragm and long tubular heart
• Pulmonary vascular markings at perihilar regions are prominent
• Peripheral lung markings are scanty
• Presence of bullae

4. Pulmonary functions tests:

Parameters	Normal	COPD	Restrictive
a)FEV1	> 80%	< 70%	> 80%
b)FEV1/ VC	> 75%	< 70%	> 80%
c)VC	Normal	Normal or reduced	Markedly reduced.

5. ECG :

a) Low voltage ECG- may be in emphysema

b) If Right heart failure-

• Evidence of Right atrial hypertrophy – P Pulmonale
• Right ventricular hypertrophy

6. Echo: Right ventricular hypertrophy may be present

7. ABG (Arterial blood gas analysis):To detect – respiratory failure and its prognosis

8. CT Scan of the chest.

Management of COPD:

Management of stable COPD:

I) Advice to stop smoking

II) Drug treatment:-

a) Short-acting beta2 -agonist bronchodilator (e.g. salbutamol, terbutaline) inhaler- 200 mcg (2 puffs) at a time when required, up to 4-6 times per day. OR, Anti cholinergic drugs, e.g. Ipratropium bromide inhaler.

b) Combination of both of the above mentioned drugs

c) (b) + LABA(Long-acting beta2 -agonists, e.g. Salmeterol,Bambuterol or Formoterol) bronchodilator inhaler

d) (c) + ICS (Inhaled corticosteroids, e.g. Beclomethasone or Budesonide).

III) Supplementary therapy: low conc. (2 – 3 L / min) intermittent O2 inhalation for > 19 hrs / day including sleeping time with ventimax.

IV) Surgical treatment:

a) Bullectomy – if the bulla covers >30% of hemi thorax.

b) LVRS (Lung volume Reduction Surgery).

c) Lung transplantation.

Management of acute exacerbation of COPD:

Immediate treatment of COPD:

1.Position: Propped up position of the patient

2.Oxygen: low conc. (2 – 3 L / min) intermittent O2 inhalation for > 19 hrs / day including sleeping time with ventimax

3.Nebulization: Respiratory solution ofshort-acting ?₂-agonist bronchodilator (e.g. salbutamol, terbutaline etc) with(if needed) or withoutIpratropium bromide are given stat by nebulizer

4.Antibiotic(s): Antibiotics should be given if there is respiratory infection

5.Parenteral or Oral Steroids: Inj. Hydrocortisone 200 mg IV or Oral Prednisolone 30-60 mg stat.

Subsequent treatment of COPD:

If patient improves:

1.  Low concentrations of oxygen should be continued until cyanosis persists or blood gas analysis shows normal levels
2. Nebulization should be reduced- 4 hourly, 6 hourly, 8 hourly, 12 hourly and then inhalers should be started
3. Inj. Hydrocortisone 200 mg IV should be reduced- 6 hourly, 8 hourly, 12 hourly and then oral prednisolone should be started at a dose of 30–45 mg od in the morning for 5 – 10 days, then the lowest dose required to control symptoms (usually 7.5-10 mg od in the morning) should be continued if necessary.

If patient does not improve:

1. Low concentrations of oxygen should be continued
2. Nebulization should be repeated after 30 minutes and continued hourly until patient improves
3. Assisted Ventilation may be needed.
4. Management of complications – if present.

Complications of COPD: (3P,R,C)

1. P = Pneumothorax

2. P = Pulmonary bullae

3. P = Polycythaemia (secondary)

4. R = Respiratory failure (chronic type – II)

5. C = Cor Pulmonale.