9/21- COPD Flashcards
Spectrum of Obstructive Lung Diseases (picture)
What is COPD (definition)
- Onset
Preventable and treatable disorder of the airways characterized by airflow limitation that is not fully reversible
- Onset in midlife
- Airflow limitation usually progressive and associated with abnormal inflammatory response to particles or gases primarily caused by cigarette smoking
Epidemiology of COPD
- Affected
- Diagnosed
- Deaths
- Disability
- 24 million affected in US
- Only 50% diagnosed (12 million)
- Estimated 130,000 deaths, being the #3 COD in the US (2012)
- #2 cause of disability (prob most common by 2020)
Affected populations in COPD
- Age
- Gender
Age: 70% are under 65 yo
- COPD > diabetes and asthma in pts 45-64
Gender: women > men (5x)
- Deaths in women > men as well
What is chronic bronchitis?
A clinical disorder
- Chronic cough on most days for at least 3 mo/year
- At least two consecutive years
- Cough and sputum production not due to any other specific causes
What is emphysema?
A disease in which airspaces distal to the terminal bronchioles are enlarged with destruction of alveolar walls.
(defined in anatomic-pathologic terms)
What are risk factors for COPD?
- Host factors
- Exposures
- Other
Host factors:
- Genetics (not all smokers get COPD)
- Gender
- Airway hyperreactivity
Exposures:
- Smoking
- Environmental pollution
- Perinatal events and childhood infection
- Recurrent infections
- Occupational and environmental exposure (e.g. coal dust, silica)
- Socio-economic status and (poor) diet
Others:
- Preexisting bronchial hyperreactivity (Dutch hypothesis)
What is the relationship between smoking and COPD?
- Smoking is the predominant risk factor for development of COPD (>90% of pts with COPD)
- Dose-response relationship of FEV1 to the intensity of cigarette smoking
What is the most important genetic risk factor for COPD?
- Mechanism (chrom)
- Alleles
- Inheritance
- Normal function
Alpha-1 anti-trypsin deficiency
- Deficiency of the protein from deficiency alleles of the AAT gene on chrom 14
Alleles:
- Normal = M, causes production of normal AAT
- S allele: slightly reduced levels
- Z allele: markedly reduced levels
- Null alleles may rarely be present
Inheritance:
- Autosomal recessive
- 1/3000 inherit, but only minority recognized - Not all pts with PiZZ develop COPD
- AAT def accounts for under 1% of COPD in US
Function:
- AAT-protein has potent protease inhibitor activity; protects normal lung tissue from proteolytic attack during inflammation
- Normal levels are 120-200 mg/dL
When should you screen for AAT deficiency?
- COPD in a never-smoker
- Premature onset of COPD (moderate to severe impairment, by/before age 50)
- A predominance of basilar (lower lobe) emphysema
- Family Hx of AAT def or COPD onset before age 50
- Cirrhosis without apparent risk factors
- Bronchiectasis, esp. w/o risk factors for the disease
What is the pathophysiology of COPD?
- What are the 2 main components of COPD?
- Environment/occupational exposures and childhood respiratory infections (and other risk factors) act on genetic susceptibility
- CD8 lymphocyte and neutrophil activation (MCP-1) and release of proteases
- Protease activation and tissue destruction (protease inhibitors knocked out)
- Airway inflammation and remodeling
Overall result = airflow limitation
2 main components of COPD:
- Airway wall thickening and inflammation (presentation = chronic bronchitis)
- Destruction of lung tissue (presentation = emphysema)
How many COPD patients have never smoked?
~10%
What cell types play a big role in COPD? Asthma?
COPD
- Macrophages
- Neutrophils
- CD8 lymphocytes
(elevated inflammatory mediators: IL-8, TNF-a, LTB-4, oxidants and imbalance in protease/anti-proteases)
Asthma
- CD4 lymphocytes
- Eosinophils
How does cigarette smoking predispose people to COPD?
- Smooth muscle hypertrophy
- Replacement of Clara cells with mucus-secreting cells; less surfactant and more mucus
- Small airway, goblet cell metaplasia
- Neutrophil activation; elastases destroy walls of terminal bronchioles and alveolar ducts
All result in airway narrowing -> dyspnea
What are the structural changes in COPD (histological/micro-anatomical)?
- Goblet cell hyperplasia/metaplasia
- Mucus gland hypertrophy
- Increased smooth muscle mass
- Airway fibrosis
- Alveolar destruction
Mucociliary dysfunction:
- Mucus hypersecretion
- Reduced mucociliary transport
- Mucosal damage
Airflow limitation in COPD is caused by what?
- Loss of alveolar attachments
- Loss of elastic recoil
- Increased smooth muscle contraction
What are the end results of the pathologic changes seen in COPD?
- Airflow obstruction
- Hyperinflation
- Impaired gas exchange
What factor of COPD correlates more directly with patient-reported outcomes?
Hyperinflation (increased airway resistance)
What are the clinical features expected in a COPD patient’s history?
- Smoking history
- Cough with sputum production
- Exertional dyspnea: usually gradual and progressive, constant
- RV failure (cor pulmonale) symptoms like pedal edema
What is expected upon inspection of COPD patient? Palpation? Percussion?
Inspection
- Thin, asthenic (more in emphysema)
- Tachypnea
- Use of accessory muscles
- Tripod position
- Barrel chest
- Cyanosis rare
- Nicotine stained fingernails
- Hoover’s sign-inward movement of rib cage with inspiration
- Elevated JVD (if RHF)
Palpation:
- Barrel chest
Percussion:
- Enlarged lung volumes