2. Chronic Obstructive Pulmonary Disease (COPD) Abtahi H, MD Packnejad, MD

3. Obstructive Lung Diseases  Pulmonary disorders characterized by airflow limitation Common entities Chronic Obstructive Pulmonary Disease (COPD) Asthma Bronchiectasis ( In some cases) Cystic Fibrosis Less Common entities Bronchiolitis Obliterans Bronchopulmonary dysplasia (newborn) Localized intrathoracic tracheal/bronchial obstruction – Neoplasms, Extrinsic compression, Granulomatous disease, Malacic lesions, Trauma,…

4. COPD Definition  COPD is a chronic lung disease characterized by expiratory airflow limitation that is not fully reversible  The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to smoking or other noxious materials

5. FEV 1 change in susceptible smokers & nonsmokers

6. Chronic Bronchitis (Gross Pathology)

7. Chronic Bronchitis (Pathology)

8. Small airway changes in COPD Source: Murray 2010

9. Disrupted alveolar attachments Inflammatory exudate in lumen Peribronchial fibrosis Lymphoid follicle Thickened wall with inflammatory cells - macrophages, CD8 + cells, fibroblasts Small airway changes in COPD(Advanced) Source: COLD 2007

10. Alveolar wall destruction Loss of elasticity Destruction of pulmonary capillary bed ↑ Inflammatory cells macrophages, CD8 + lymphocytes Source: GOLD 2007 Emphysematous changes in COPD

11. Normal small airway with alveolar Emphysematous airway attachments. with loss of alveolar walls, enlargement of alveolar spaces, and decreased alveolar wall attachment Small airway collapse in emphysema

12. 12 Risk Factors for COPDNutrition Infections Socio-economic status Aging Populations Genetic susceptibility

13. Distribution of FEV 1 values ( % predicted) Vs. Pack- year smoking

14. FEV 1 change in susceptible smokers & nonsmokers

15. LUNG INFLAMMATION COPD PATHOLOGY Oxidativestress Proteinases Repairmechanisms Anti-proteinases Anti-oxidants Host factors Amplifying mechanisms Cigarette smoke Biomass particles Particulates Source: GOLD 2007 Pathogenesis of COPD

16. Patient 1  64 year old man with a 80+ pack-year smoking history, presents with dyspnea while climbing stairs and an occasional, non-productive cough  What would you look for/expect on exam?

17. Patient 1 : Pink Puffer  Diminished breath sounds on auscultation  Forced expiratory time >6 seconds  Increased thoracic circumference and decreased change with respiration  Increased resonance to percussion Tripod positioning

18. Patient 2  55 year man with 40 p-yr history presents with chronic cough for 3 months, productive of clear to light yellow phlegm  What would you look for/expect on exam?

19. Patient 2: Blue blutter  Rhonchus breath sounds  1+ ankle edema Not all patients are blue or pink

20. Spirometry Normal and COPD Patient

21. Classification of COPD Severity by post bronchodilator spirometry (Gold stages ) Stage I: Mild FEV1/FVC < 0.70 FEV1 > 80% predicted Stage II: Moderate FEV1/FVC < 0.70 50% < FEV1 < 80% predicted Stage III: Severe FEV1/FVC < 0.70 30% < FEV1 < 50% predicted Stage IV: Very Severe FEV1/FVC < 0.70 FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure * Adapted from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2007

22. CXR (Hyperinflaion)

23. HRCT (Emphysema)

24. Pneumothorax

25. Giant Bullae

26. Systemic features of COPD  Cachexia  Skeletal muscle wasting and disuse atrophy  Increased risk of cardiovascular disease  increased concentrations of CRP  Normochromic normocytic anaemia  Secondary polycythaemia  Osteoporosis  Depression and anxiety

27.  Advanced disease may be accompanied by systemic wasting, with significant weight loss, bitemporal wasting, and diffuse loss of subcutaneous adipose tissue. This syndrome has been associated with both inadequate oral intake and elevated levels of inflammatory cytokines (TNF-).  Such wasting is an independent poor prognostic factor in COPD

29. Chronic hypoxia Pulmonary vasoconstriction MuscularizationIntimalhyperplasiaFibrosisObliteration Pulmonary hypertension Cor pulmonale Death Edema Pulmonary Hypertension in COPD Source: GOLD 2007 Emphysematous changes

30. Differential Diagnosis COPD and Asthma COPD ASTHMA Onset in mid-life Symptoms slowly progressive Long smoking history Dyspnea during exercise Largely irreversible airflow limitation Onset early in life (often childhood) Symptoms vary from day to day Symptoms at night/early morning Allergy, rhinitis, and/or eczema also present Family history of asthma Largely reversible airflow limitation