COPD: Basics + Epidemiology + Clinical manifestations Flashcards
What is COPD?
- Heterogeneous disease characterized by chronic, persistent respiratory symptoms resulting from airflow obstruction and alveolar gas exchange abnormalities, with little or no reversibility
- COPD includes emphysema (an anatomically defined condition), chronic bronchitis (clinically defined condition), and small airway disease
What are exogenous risk factors for COPD?
*Tobacco use:
- Smoking is the major and most common risk factor for COPD (80% of cases are due to smoking but only one in five smokers is affected, so it is likely that a genetic predisposition also plays a role in the development of the disease), but those who have quit ≥ 10 years ago are not at increased risk
- Passive smoking
*Exposure to air pollution or fine dusts:
- Nonorganic dust: such as industrial bronchitis in coal miners
- Organic dust: ↑ incidence of COPD in areas where biomass fuel (e.g., wood, animal dung) is regularly burned indoors
What are endogenous risk factors for COPD?
*Lung growth and development abnormalities:
- Recurrent pulmonary infections and tuberculosis
- Premature birth (The lower the birth weight, the higher the risk of poor lung growth and developing COPD)
*α1-antitrypsin deficiency
*Airway hyperresponsiveness
*Antibody deficiency syndrome (e.g., IgA deficiency)
*Primary ciliary dyskinesia (e.g., Kartagener syndrome)
What is chronic bronchitis?
Productive cough for at least 3 months per year for 2 consecutive years that cannot be explained by an alternative diagnosis
Presence of chronic bronchitis, emphysema, and small airway disease in COPD patients
- Emphysema, chronic bronchitis, and small airway disease are present in varying degrees in different COPD patients
- Chronic bronchitis is common in patients with COPD, especially in young, male patients who are exposed to tobacco smoke or pollution
- Chronic bronchitis and emphysema often occur simultaneously in patients with COPD
What is emphysema?
Permanent dilatation of pulmonary air spaces distal to the terminal bronchioles that is caused by the destruction of the alveolar walls and pulmonary capillaries required for gas exchange
COPD epidemiology
- COPD will typically present in adulthood, primarily present in smokers and those greater than age 40, often during winter months
- Prevalence increases with age, with a prevalence of 10–20% of the over-40s;
- 3:2 male/female ratio (Formerly, COPD was significantly more prevalent in men, but the incidence has gradually been reaching parity between genders)
Symptoms and physical findings of COPD
- The three cardinal symptoms of COPD are dyspnea, chronic cough, and sputum production (morning is usually when symptoms are worse)
- The most common early symptom is exertional dyspnea
- Less common symptoms include wheezing and chest tightness
- Other findings can include pursed lip breathing, prolonged expiratory phase, crackles, muffled breath sounds, and/or coarse rhonchi on auscultation, cyanosis due to hypoxemia, and tachycardia
What are features of advanced COPD
- Congested neck veins
- Barrel chest (Increased anterior-posterior chest wall diameter): This deformity is most commonly seen in individuals with emphysema.
- Asynchronous movement of the chest and abdomen during respiration
- Use of accessory respiratory muscles due to diaphragmatic dysfunction
- Hyperresonant lungs, reduced diaphragmatic excursion, and relative cardiac dullness on percussion
- Decreased breath sounds on auscultation: “silent lung”
- Peripheral edema (most often ankle edema)
- Right ventricular hypertrophy with signs of right heart failure and cor pulmonale
- Hepatomegaly
- Often weight loss and cachexia
- Secondary polycythemia
- Confusion: due to hypoxemia and hypercapnia
- Nail clubbing in the case of certain comorbidities (e.g., bronchiectasis, pulmonary fibrosis, lung cancer) [15]
Nail clubbing in COPD
Nail clubbing is not a finding specific to COPD; its presence usually suggests comorbidities such as bronchiectasis, pulmonary fibrosis, or lung cancer.
What can COPD patients be categorized into based on their clinical appearance?
Often categorized as either “Pink Puffer” or “Blue Bloater”
Describe a pink puffer COPD patient
- Main pathomechanism: emphysema
- Clinical features: Noncyanotic, cachectic, pursed lip breathing, mild cough
- PaO2: Slighlty reduced
- PaCO2: Normal (or low possibly in late hypercapnia)
Describe a blue bloater COPD patient
- Main pathomechanism: chronic bronchitis
- Clinical features: Productive cough, overweight, peripheral edema
- PaO2: Markedly reduced
- PaCO2: Increased (early hypercapnia)
Features of COPD due to α1-antitrypsin deficiency
- Age of onset is generally younger (< 60 years)
- Often have hepatic signs and symptoms (jaundice) related to hepatitis or cirrhosis
What can emphysema be divided into?
Emphysema can be divided into the following subtypes:
* Centrilobular/centriacinar emphysema
* Panlobular/panacinar emphysema
* Other subtypes: Cicatricial emphysema, giant bullous emphysema, and age related emphysema (
What are the possible grades a COPD patient may receive based on GOLD grades?
In all of them, FVC<0.7
What are the possible groups a COPD patient may be put in based on GOLD group classification?
Extra notes:
- The number and severity of past exacerbations are good predictors for future exacerbations
- Symptom severity is evaluated using the modified British Medical Research Council (mMRC) questionnaire and the COPD Assessment Test (CAT)
What is the mMRC dyspnea scale and how is it scored
- The modified British Medical Research Council (mMRC) questionnaire is an assessment tool used to evaluate the extent of a patient’s functional disability caused by dyspnea (e.g., secondary to chronic obstructive pulmonary disease)
- Its scale ranges from 0 (dyspnea only with strenuous exercise) to 4 (too dyspneic to leave the house or breathless when dressing)
What is the CAT and how is it scored?
- The COPD Assessment Test (CAT) provides a score on eight functional parameters to measure the impact of the disease on a patient’s daily life
- Patients rate the following symptoms on a scale from 0 (best) to 5 (worst): cough, phlegm production, chest tightness, breathlessness walking uphill, limitation of daily activities at home, limitation of activities outside the home, quality of sleep, and level of energy
How can differentiate between asthma and COPD?
- Untreated COPD and asthma are frequently distinguishable on the basis of history (and examination) in people presenting for the first time
- Whenever possible, use features from the history and examination (such as those in the table in this flashcard) to differentiate COPD from asthma
- When diagnostic uncertainty remains, or both COPD and asthma are present, use the following findings to help identify asthma:
- a large (over 400 ml) response to bronchodilators
- a large (over 400 ml) response to 30 mg oral prednisolone daily for 2 weeks
- serial peak flow measurements showing 20% or greater diurnal or day-to-day variability
- Clinically significant COPD is not present if the FEV1 and FEV1/FVC ratio return to normal with drug therapy
- Reconsider the diagnosis of COPD for people who report a marked
improvement in symptoms in response to inhaled therapy
Additional investigations in COPD patients
Perform additional investigations when needed as detailed in this table (NICE guidelines)
