copd notes
DESCRIPTION
COPD notes prepared by notable Dr Ng KS. very useful review for medical students!TRANSCRIPT
BlueBloatersAnd PinkPuffers
Dr Ng Kian SengIMU Kluang2014
Blue BloatersChronic Bronchitis
Pink PuffersEmphysema
Pink Puffers & Blue Bloaters
Low paO2>Cyanosis=BlueRetention Of Fluid=Bloater
PaO2 MaintainedAt Normal Levels=PinkHyperventilate=Puffer
Chronic obstructive pulmonary disease (COPD)
“Chronic obstructive pulmonary disease (COPD) is characterized by *airflow limitation that is usually progressive and associated with an *enhanced chronic
inflammatory response in the airways and the lung to noxious particles or gases. “
Chronic bronchitis is defined as a chronic productive cough for three months in each of two successive years in a patient in whom other causes of chronic cough (eg, bronchiectasis) have been excluded . It may precede or follow development of airflow limitation.
Emphysema is defined by abnormal and permanent enlargement of the airspaces distal to the terminal bronchioles that is accompanied by destruction of the airspace walls, without obvious fibrosis
“Asthma is a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role. The chronic inflammation is associated with airway responsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning. These episodes are usually associated with widespread, but variable, airflow obstruction within the lung that is often reversible either spontaneously or with treatment.
Venn Diagram In COPD
1,2,11 Persons with chronic bronchitis or emphysema without airflow obstruction are not classified as having COPD.
9 Patients with asthma whose airflow obstruction is completely reversible are not considered to have COPD
10 Patients with airway obstruction due to diseases with known etiology or specific pathology, such as cystic fibrosis or obliterative bronchiolitis (10), are not included in the definition of COPD.
Gray: The subsets defined as COPD are shaded gray.
These Conditions Are Not COPD…
Venn Diagram In COPD
6, 7, 8. In many cases it is virtually impossible to differentiate patients
with asthma whose airflow obstruction does not remit
completely from persons with chronic bronchitis and emphysema
who have partially reversible airflow obstruction with airway hyperreactivity.
Thus, patients with unremitting asthma are classified as
having COPD
These Conditions Are COPD…
Venn Diagram In COPD
5 Chronic bronchitis and emphysema with airflow obstruction usually occur together (5).
6 Individuals with asthma exposed to chronic irritation, as from cigarette smoke, may develop chronic productive cough, a feature of chronic bronchitis (6). Such patients are often referred to as having asthmatic bronchitis or the asthmatic form of COPD.
8 Some patients may have asthma associated with these two disorders (8).
These Conditions Are COPD…
3, 4. Chronic Bronchitis & Emphysema with Airflow Obstruction, COPD
COPD Risk Scale
Clinical characteristics associated with adverse events in patients with exacerbation of chronic obstructive pulmonary disease: a prospective cohort study, Ian G. Stiell MD MSc, February 18 2014
Schematic representation of the chief prognostic dimensions in COPD. Airflow limitation is one of the mechanisms with the greatest influence on survival. This central mechanism is surrounded by various disease components that have prognostic implications, many of which are interrelated. Inflammation, both local and systemic, may be the pathogenic substrate that links these different dimensions. PHT indicates pulmonary hypertension
Smoking less than 10 to 15 pack years of cigarettes is unlikely to result in COPD. On the other hand, the single best variable for predicting which adults will have airflow obstruction on spirometry is a history of more than 40 pack years of smoking .
Ardi Rizal, a 2 yo Indonesian boy who developed a 2-pack-a-day cigarette habit.
Calculate the number of pack years smoked (packs of cigarettes per day multiplied by the number of years), as the majority (80 %) of patients with COPD have a history of cigarette smoking .
Cigarettes & COPD
Cigarette smokingMost important risk factor. It causes 90% of cases of COPD. Elicits an inflammatory response and causes cilia dysfunction and oxidative injury.Advanced ageThe effect of age may be related to a longer period of cigarette smoking as well as the normal age-related loss of FEV1.Genetic factorsAirway responsiveness to inhaled insults depends on genetic factors. Alpha-1 antitrypsin deficiency is a genetic disorder, mostly encountered in Northern Europeans, which causes panacinar emphysema in lower lobes in young people.
Risk Factors In COPD
Background of Triad +Episodes of increased cough, Purulent Sputum, Dyspnoea (Wheeze) + Fever
Relatively Asymptomatic
Classic Triad of Cough, Dyspnoea& Copious Sputum ProductionCOPD Sucks The Breath Out ofTheir mornings
Modes of Presentation
This Is The Day I Long For
Spirometry is the first test for diagnosis of COPD and for monitoring disease progress. Patients with COPD have a distinctive pattern seen on spirometry, with a reduced FEV1 and FEV1/FVC ratio. The presence of airflow limitation
is defined by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria as a post-bronchodilator FEV1/FVC <0.70.
Spirometry
Stage I (mild): FEV1 80% or greater of predictedStage II (moderate): FEV1 50-79% of predictedStage III (severe): FEV1 30-49% of predictedStage IV (very severe): FEV1 less than 30% of predicted or FEV1 less than 50% and chronic respiratory failure
1 Dark lung fields.2 Low set diaphragm in 11th or 12th posterior rib.3 Heart is vertical & narrow. This is the result of downward push of diaphragm by lungs.4 Flattened diaphragms in lateral chest.5 Infra cardiac air: Left diaphragm is seen in its entirety.6 Retrosternal air is increased.7 Increased AP diameter.
7 radiological features of COPD
*Lungs are large and hyper inflated.*Signs of hyperinflation are:Low set diaphragmFlat diaphragm best determined by lateral chestHyper lucent lung fieldsIncreased AP diameterIncreased retrosternal airVertical heart*Signs of hyperinflation can be seen in emphysema, chronic bronchitis and asthma.
We can call it emphysema only when hyperinflation is associated with blebs and paucity of vascular markings in the outer third of the film.
Lateral chest is best to evaluate flattening of diaphragm, AP diameter and retrosternal air.
This lateral chest shows:Increased AP diameterLow set flat diaphragmsHyper lucent lung fieldsIncreased retrosternal air encroaching on heart densityMultiple blebs: Avascular zones surrounded by thin wall
Schamroth’s Sign In COLD
Isoelectric P wave in lead I combined with a very small QRS complex of < 1.5 mm total deflection and a T wave of less than 0.5 mm in lead I.
