-Definition:
It is a preventable and treatable disease with some significant extra-pulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by airflow limitation that is not fully reversible. The limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases.
Chronic Bronchitis (Blue Bloater) | Emphysema (Pink Puffer) | |
Definition | -Presence of cough &sputum production for at least 3 Ms in each of 2 consecutive yrs. -Not included in COPD definitions | - Permanent enlargement of airspaces distal to terminal bronchioles accompanied with destruction of their walls +/- fibrosis. (except in compensatory, focal emphysema) - A pathological term that is often (but incorrectly) used clinically and describes only one of several structural abn. present in patients 'e COPD. |
Classification | -Simple (mucoid): irritation 'e no infection. -Muco-purulent chronic -Chronic obstructive (irrev.) | -Ciba-Symposium class.: .Unselective àcompensatory à Pan-acinar .Selective dist.à Focal (dust) à Centri-acinar .Irregular emphysema -Leopold, Gough class.: .Pan-acinar àAAT (LL>UL) .Centri-acinar àSmoker, CWP (UL>LL). .Distal acinar à apical bullae with pneumothorax. |
C/P .Dyspnea .Cough .Sputum .Built .Cyanosis .Breath sound .Wheezes .Cor-pulmon. | -History of freq. resp. infect. -Variable, mild -Considerable -Copious, purulent -Usually obese -Marked - -Common -Common + P++ | -Usually –ve past history. -Severe, progressive -Negligible -Scanty, mucoid -Usually thin -Absent or mild -Distant -Rare -Rare |
Investigations .CXR .PFT | -Common polycythemia -Inc. BV markings (basal >) -Obstructive pattern, Low VC, N or Low RV, N DLCo, Low PO2, High PCO2 -FEV1 >25% à CO2 retention + corpulmonale | -Absent polycythemia -Hyperinflation +/- Bullae -m.b Mild obstruction, N VC, High RV, Low DLCo, N or mild dec. PO2, high TLC -FEV1 <50% à exertional dyspnea <25% à dyspnea at rest + CO2 retention + corpul. |
Death | Usually cardio-respiratory failure | -Frequently not related to chest condition. -Die of RF before corpulmonale development. |
-Overlap between COPD, BA:
COPD | BA | Mixed | |
Cells | -Neutrophils ++ (inc. in smokers even with no COPD) -MQs +++++ -CD8 cells -Eosinophils (occur in exacerbations) | -Eosinophils ++ -MQs + -CD4 cells -Mast cells | -Neutrophils + -MQs -CD4 -CD8 |
Mediators | NO + IL8 (activates neutrophils) , IL1,6 TNF (weight loss & Cachexia à persist inflammation) | Cotaxin IL4,5,13 NO ++++ | IL8,5,13 NO ++ |
Oxid.stress | +++ | + | +++ |
Site | -Peripheral airway -Lung parenchyma -Pulmonary Vs | -Proximal airways | -Proximal airways -Peripheral airways |
Consequences | -Sq. metaplasia -Mucus " -Small AW fibros. -Parench. Destruct. -Pul. vascular remodeling. | -Fragile epithelium -Mucus metaplasia -Broncho-spasm -Thick BM | --------- |
Responsive ttt | -Small b/d response. -Poor response to steroids. | -Large b/d response. -Good response to steroids (rev.>20%) | -Smaller b/d response. -Dec. steroid response (partial rev. 10-20%) |
-Classification: (post-BD FEV1)
· According to GOLD 2007:
Mild | Moderate | Severe | V. Severe | |
FEV1/FVC | < 70% | < 70% | < 70% | < 70% |
FEV1 +/- ch. Sympt. | > 80% of predicted | 50-80% | 30-50% | < 30% or > 50% with RF |
-Pathology:
Central Airway | Peripheral AW | Lung Parenchyma | Vascular changes | |
Site | -Trachea -Bronchi -Bronchioles (> 2-4mm) | -Small bronchi -Bronchioles (<2mm) | -Respiratory bronchioles. | -Pulmonary vessels. |
Mechanisms | -Infl. Cells infilt. Surface epithelium. -Hypert. MS. -Hypertrophy mucus glands -Inc. goblet cell no. (thick glandular layer in comp. to bronchial wall à Reid index) | Chronic inflammation (repeat. Infl, then repair) -Remodeling of AW wall (metaplasia). -Inc. collagen content, scar tissue. -Lost cartilage | - Bronchiolar dilatation, destruction. Gas exchange abn. (diffusion defect) à dec. O2 only so inc. ventil. à dysp., no cyanosis. Dec. elastic recoil à dec. traction forces à inc. R in AW | -Thick. Of vessel wall (early) (intima, MS, wall infilt. with infl. cells) -Increased smooth MS ('e low o2) + proteoglycans + collagen à scaring (later) |
-Path- physiology | -Mucus Hypersecret. -Ciliary dysfunction | -AW fixed obstruction or limitation à Increase Alveolar pr. à P++ | -P++ à corpulmonale -AW fixed obstruction | -P++ à corpulmonale -Systemic effects of COPD |
Symptoms (+ general weakness, fatigue, weight loss, anorexia, rel. social isolat., mood swing) | .Ch. cough (morning then over day) à chest pain .Sputum .Inc. 'e exac. | .Dyspnea (acute attacks then in winter then all year) .Wheezes .+/- Cyanosis .S of high CO2 | .Hyperinflated chest (inc. static FRC) .Dyspnea inc. (trial to maintain O2, CO2) .S of corpulm. .LV++(25-60%) .S of low O2 | .S of corpul. .PE .Pul. thromb. .Dec. work of diaphragm (dec. muscle weight) |
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