1. This lecture was conducted during the Nephrology Unit Grand Ground by Medical Student rotated under Nephrology Division under the supervision and administration of Prof. Jamal Al Wakeel, Head of Nephrology Unit, Department of Medicine and Dr. Abdulkareem Al Suwaida, Chairman of the Department of Medicine. Nephrology Division is not responsible for the content of the presentation for it is intended for learning and /or education purpose only.

2. COPD COPD Chronic Obstructive Lung Disease الداء الرئوي الساد المزمن Prepared by: SAAD AL-AMRI Medical Student May 2008

3. What is COPD? Defenition:  It is a disease state characterized by presence of air flow obstruction due to chronic bronchitis or emphysema.  The air flow limitation is generally progressive.

4. Clinically diagnosed Pathologically diagnosed

5. Chronic productive cough on most days of 3 consecutive months in 2 consecutive years. Providing other causes have been excluded. >85% of COPD. Chronic bronchitis

6. Emphysema Abnormal and permanent dilatation of air spaces associated with destruction of their walls.

8. Etiology Smoking the primary risk factor Long-term smoking is responsible for 80-90 % of cases. Prolonged exposures to harmful particles and gases from: – passive smoke, – Industrial smoke, – Chemical gases, vapors, mists & fumes – Dusts from grains, minerals & other materials Alpha 1-antitrypsin deficiency >>> emphysema

9. Pathophysiology Exposure to inhaled noxious particles & gases inflammation imbalance of proteinases and anti-proteinases Dilatation & destruction + mucus secretion

10. Clinical features Hx: Smoker Productive cough Constant Chest tightness in the morning Sputum>>>>>> mucoid If purulent>>>> infection SOB>>>> on exertion – Aggravated by infection, heavy smoking.

11.  On Examination:  Inspection:  Pt looks dyspnic  Use of accessory muscles  Burrel shaped chest  Palpation  Decrease chest expansion  Percussion  hyper-resonant  Loss of normal area for cardiac & liver dullness

12.  Auscultation: – Decreased breath sounds – Normal vesicular breathing but prolonged expiration – Coarse crepitatons>> on both phases

13. Investigations Baseline ABG:  important for assessing patients with severe COPD.  Annual monitoring test  Detect acute & chronic hypercapnia  Respiratory acidosis

14. Chest X-Ray: – Not sensitive for Dx – To exclude other diseases – Hyper-inflation signs Investigations

15. Pulmonary function testing (spirometry): – Main method for diagnosing COPD. low FEV1/FVC (< 70%) – Used for classification of COPD severity. Investigations

16. PFT  Obstructive pattern FEV1>>>>>>>reduced (<80%) FEV1/FVC>>>reduced (<70%) PEF>>>>>>>>reduced TLC>>>>>>>>increased

17. Classification of severity of COPD Mild FEV1 60-79% Smoker, cough Moderate FEV1 40-59% SOB, wheeze, cough +/- sputum Severe FEV1 < 40% SOB, wheeze, cough,RD, swollen legs

18. Other Investigations Sputum C/S >> in acute ECG Echo >> assess pulmonary artery pressure Alpha 1-anti-trypsin

19. Treatment of COPD Cessation of Smoking (most important) Oxygen Therapy Ongoing assessment & monitoring Education Rx of Acute exacerbations.

20. Management of COPD Increase survival stop smoking Supplemental O2 Improve quality of life Bronchodilators + steroids

21. Oxygen Therapy (LTOT) Home oxygen in low dose Given at least 15 hrs @ flow rate 1-3L/min If PaO2 <60% If SaO2 < 88%

22. Inhaled bronchodilators – Beta-agonists Short acting>>> 2-4 puffs bid-qid & PRN e.g: salbutamol Long acting >>> twise daily e.g: salmetrol, formoterol Side efferct: Tachycardia, tremors, hypokalemia – Anti-cholinergic Ipratropium bromide (Atrovent) 2-4 puffs PRN

23. Steroids – Inhaled: e.g : fluticasone Withdrawal may cause exacerbation – Systemic : Only for severe cases.

24. Vaccinations Influenza Pneumococcal

25. No role for antibiotics except in acute exacerbations

26. Acute exacerbation of COPD Increased SOB Wheezing Causes : – Infections – pollutions

27. Infections Moraxella catarrhalis Haemophilus influenzae Streptococcus pneumoniae 30.3% 33.3% 17.2% 19.2% Other pathogens include: H parainfluenzae, Staphylococcus aureus 2

28. Rx of acute exacerbation of COPD Inhaled bronchodilators>>> short acting Antibiotics – Mild – Amoxicillin – Cephalosporins – moderate to severe (G-ve rods) – Azithromycin – 3 rd generation Cephalosporins

29. Oxygen BiPAP Mechanical ventilation

30. Indicaton for ICU admession Severe dyspnea not medical Rx Mental status changes Persistent hypoxemia, hypercapnia or Resp. acidosis despite medical Rx