《copd英文課》

1、Chronic Obstructive Pulmonary Disease (COPD)Guohua ZhenTongji HospitalPercent Change in Age-Adjusted Death Rates, U.S., 1965-19980Proportion of 1965 Rate 0.00.51.01.52.02.53.01965 - 19981965 - 19981965 - 19981965 - 19981965 - 199859%64%35%+163%7%CoronaryHeartDiseaseStrokeOther CVDCOPDAll OtherCauses

2、Why COPD is Important ?COPD is the only chronic disease that is showing progressive upward trend in both mortality and morbidityIt is expected to be the third leading cause of death by 2020Approximately 3% Chinese above 15 are currently suffering from COPDDefinitionCOPD is a preventable and treatabl

3、e disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and is associated with an abnormal inflammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking.Relationship of COPD and Chronic

4、bronchitis, Asthma or EmphysemaChronic BronchitisChronic BronchitisDefinition: Chronic and unspecific inflammation of bronchi and the surrounding tissue.Feature: chronic mucus hypersecretion and cough.Morbidity: 3.2% in population over 15 y，up to 15% in elderly over 50 y.Etiology and mechanism Envir

5、onment FactorsCigarette smokingOccupational dusts and chemicalsInfectionsHost FactorsGenes Lung growth and defense mechanismChronic BronchitisClinical manifestation Character: chronic onset, recurrent attack and long course of diseaseMain symptoms: cough: chronic, long term, repeatedly expectoration

6、: mucoid sputum, purulent sputum when infection wheezing: seen in some patientsClinical manifestation Sign: 1. no obvious sign in early stage2. sometimes moist rales and rhonchi Examination Chest x-ray imagingExamination Pulmonary function test: maybe normal in early stage. Gradually obstructive air

7、way function appeared.Blood routine: elevated neutrophil or eosinophil Sputum examination: bacterial culture guide antibiotic treatmentDiagnosis Chronic cough and sputum production for 3 consecutive months in at least 2 successive years（3m/y2y）, excluding other chronic lung diseases (TB, Bronchiecta

8、sis )Definite chest imaging or lung functionTyping Typing :1、simple：cough, sputum2、wheezing：with wheezing (actually Chronic bronchitis plus asthma)Emphysema整理整理pptDefinitionEmphysema is characterized by enlargement and destruction of respiratory bronchioles and /or alveoli in the lungs.Etiology Envi

9、ronment FactorsCigarette smokingOccupational dusts and chemicalsInfectionsHost FactorsGenes: Alpha1-antitrypsin deficiencyContributing factorAirway obstruction due to chronic inflammationDamaged bronchial cartilage and lead to the loss of supporting functionIncreased activity of proteinase due to ch

10、ronic airway inflammation or smokingAlpha1-antitrypsin deficiencyOthers: Poor nutrition of alveoli or respiratory bronchiole due to decreased blood supply because of oppression of high airway pressureCigarette smokeAlveolar macrophageNeutrophil PROTEASES Alveolar wall destruction(Emphysema)Mucus hyp

11、ersecretion(Chronic bronchitis)PROTEASEINHIBITORSNeutrophil chemotactic factors CELLULAR MECHANISMS OF COPD Neutrophil elastaseCathepsinsMatrix metalloproteinasesCytokines (IL-8)Mediators (LTB4)?CD8+lymphocyte-MCP-1 1-Antitrypsin TIMPs SLPI Elafin Neutrophil elastase Cathepsins MMP-1, MMP-9, MMP12 G

12、ranzymes, perforins Others.PROTEASE-ANTIPROTEASE IMBALANCE IN COPDPathology feature Alveolar walls become thinnerAlveolar sacs enlargementRupture of alveoli and formation of blebPathological CategoryIn panlobular emphysema, the enlargement and destruction of air space involve the acinus more or less

13、 uniformly.In centrilobular emphysema, respiratory bronchioles are selectively and dominantly involved.COPD- chronic bronchitis- emphysemaCOPD PathophysiologyHypoventialtion- PaO2 , PaCO2 Airflow obstruction / airway narrowing mucus plugging airway inflammation, edema, fibrosis airway collapse due t

14、o alveolar wall destruction Hyperinflation: air trappingGas exchange defects- PaO2 Destruction of alveolar wall/alveolar-capillary membrane V/Q mismatch (shunt)Clinical manifestationSymptom1. cough, sputum and/or wheezing2. gradually progressive dyspnea, shortness of breath, chest tightnessClinical

15、manifestationSign:1. not obvious in early stage2. typical sign: barrel chest, decreased chest movement, diminished tactile fremitus, hyperresonance, decreased vesicular breath sound and prolong expiration or wheezeExaminationPulmonary function test Diagnosis Assessing severity Assessing prognosis Mo

16、nitoring progressionExamination: pulmonary function test Dynamic lung function airflow obstructionFEV1, FEV1/FVC Static lung function hyperinflation TLC, FRC air trapping RVExamination: pulmonary function testChest X-ray：ECG：Blood gas：to detect respiratory failure.Blood routine and sputum examinatio

17、n： ExaminationChest X-rayIntercostal space wideningDiaphragm are low and flatVascular marking deficiencyShadow of the heart narrowinglow, flat diaphragms, hyperlucency, vascular marking deficiencyDiagnosis 1、Smoking history2、Symptom: cough, sputum production, gradually progressive dyspnea3、Sign：emph

18、ysema4、PFT: airway flow limitationCOPD classification based on pulmonary function testSeverityPostbronchodilator FEV1/FVCPostbronchodilator FEV1% predicted0: At risk0.780I: Mild COPD80II: Moderate COPD0.750-80III: Severe COPD0.730-50IV: Very severe COPD0.730Clinical Features of COPD Patients of diff

19、erent severityMild COPD: no abnormal signs, smokers cough, little or no breathlessnessModerate COPD: breathlessness with/without wheezing, cough with/without sputumSevere COPD: breathlessness on any exertion/at rest, wheeze and cough prominent, lung inflation usual, cyanosis, peripheral edema, and p

20、olycythemia in advanced diseaseStage of diseaseAcute ExacerbationsStableAcute exacerbation of COPDAE-COPD“Exacerbation” of COPD Respiratory dyspnea / chest tightness cough / sputum, purulent Systematic decreased activity, fatigue, headache, poor appetite, somnolenceDifferential diagnosis Bronchial a

21、sthma: reversibility of the airflowBronchiectasis: especially mild patients, chronic cough and mucus sputumPulmonary TB：positive anti-fast smearBronchogenic carcinoma：Emphysema due to other cause: for compensationComplications of COPDChronic respiratory failure Spontanous pneumothorax Cor pulmonale

22、hypoxia, pedal edema, passive hepatic congestion. Management of COPDPrevent decline in FEV1 Reduce mortalityImprove quality of life symptoms exercise tolerance exacerbationsMinimal side-effectsNon-pharmacologic TherapiesCOPDSmoking cessation Physician intervention critical Multidisciplinary approach

23、 Withdrawalanxiety, irritability, difficult concentrating, sleep disruption, fatigue, drowsiness, depression Nicotine replacement withdrawal symptoms nicotine gum (2 mg = cigarette) transdermal nicotine patches x 8 wks 20-40% / 6 mos vs 5-20% / 6 mos with placeboEffects of Smoking and Smoking Cessat

24、ion on FEV10255075100255075Age (years)FEV1(%)Nonsmoker or Non-susceptibleStopped at 45Stopped at 65Susceptible Smoker COPD: Pharmacology Bronchodilators Corticosteroids Long term oxygen therapy Management of COPD exacerbationsCOPD: Pharmacology2-agonist bronchodilators Rapid-acting 2-agonists (SABA)

25、 salbutamol, terbutaline symptomatic relief pre-exertional 2 puffs 4-6 x /d prn minimal risk Long acting 2-agonists (LABA) salmeterol, formoterol regular therapy 1-2 puffs bid benefit: activity / exertion, QOLCOPD: PharmacologyAnticholinergic bronchodilators Benefits vs Risks Regular therapy Symptom

26、atic benefit ? exacerbations Minimal s/edry mouth, urinary retention Agents Ipratropium /Atrovent4-6 puffs qid Tiotropium /Spiriva1 puff qdCOPD: PharmacologyTheophylline Multiple effects bronchodilation, respiratory stimulant, improved cardiovascular function, improved diaphragm function Limited rol

27、e because of narrow therapeutic window s/e GI, CNS, cardiac qd - bid dosing with long-acting preparationsCOPD: PharmacologyInhaled Steroids Symptomatic COPD patients with “asthmatic” tendency (20%) FEV1 18 hrs /d Improved survival, right heart failure Improved exercise tolerance, QOL Indications PaO

28、2 55 mmHg (SaO2 88%)COPD: ExacerbationsOxygenation: low concentration oxygen therapy Risks of excessive O2 (PaO2 100 mmHg) hypercapnia ( PaCO2 ) acidemia ( pH 0.8 L) Lung volume reduction surgery (LVRS)prognosisRelate to the value of FEV1 FEV11.2L survive for 10y， FEV11.0 L survive for 5y ，F(xiàn)EV11, in

29、 V51)P-pulmonale pattern(an increase in P wave amplitude in II, III, AVF)ExaminationEchocardiography 1、inner diameter of RV outflow (30mm)，2、RV internal dimension(20mm)，3、RV anterior wall thickening4、enlargement of right atriumDifferential diagnosisCoronary artery disease：can exist together.Rheumatic heart disease: systolic murmur.Primary cardiomyopathy：accompanied with distension of whole heart.ComplicationPulmonary encephalopathy：Acid-base imbalance and elec