Overview
Chronic obstructive pulmonary disease is a severely functionally limiting condition primarily affecting previous tobacco smokers. Management is targeted to the severity of the disease, and underpinned by smoking cessation.
Pathogenesis
Risk Factors for COPD
- Smoking
- Occupational exposure - coal, toluene (plastics)
- Environmental air pollution
- Alpha-1 antitrypsin deficiency
Manifestations
Complications of COPD
Disease-Related
- Pneumonia
- Cor pulmonale
- Pulmonary hypertension
- Pneumothorax
- Respiratory failure
- Polycythaemia
Treatment-Related
- Cushing's syndrome (steroids)
- Oral candidiasis (steroids)
- Tremor (beta agonists)
Diagnosis
Signs of Chronic Obstruction Pulmonary Disease
General Signs
- Respiratory distress - tachypnoea, pursed lip breathing, accessory muscle use, intercostal / subcostal recession
- Barrel chest (emphysema)
- Tar-stained fingers (smoking)
- Asterixis (CO2 retention)
- Reduced chest expansion
- Reduced breath sounds
- Wheeze
Signs of Complications
- Infective exacerbation - fevers, green sputum
- Cor pulmonale - raised JVP, ascites, pleural effusions, peripheral oedema
- Pulmonary hypertension - prominent a wave, parasternal heave, loud / palpable P2
- Polycythaemia - polycythaemic facies
- Steroid complications - Cushing's syndrome, oral candidiasis
Signs of Management
- Oxygen
- Inhalers
- Lung transplant scar
Chest X-Ray Signs of Emphysema
- Hyperinflation - hyperlucency of lung fields, diaphragmatic flattening, mediastinal narrowing
- Bullae
- Lung scarring
Examples
- Hyperinflation in a patient with emphysema
![Hyperinflation in a patient with emphysema]()
- Hyperinflation with multiple right apical bullae
![Hyperinflation with multiple right apical bullae]()
Management
Management Strategies
Lifestyle Measures
- Smoking cessation
- Pulmonary rehab
- Nutritional support
- Develop social support
Pharmacologic
- Long-acting beta agonists (LABAs) - salmeterol, formoterol, indacaterol
- Long-acting anti-muscarinic agents (LAMAs) - tiotropium, aclidinium, umeclidinium, glycopyrronium
- LAMA / LABA combinations - tiotropium / olodaterol, aclidinium / formoterol, glycopyrronium / indacaterol, umeclidinium / vilanterol
- Inhaled corticosteroid (ICS) / LABA combinations - budesonide / formoterol, fluticasone / salmeterol, fluticasone / formoterol, fluticasone / vilanterol
- LAMA / LABA / ICS combination - fluticasone / umeclidinium / vilanterol
Supportive Measures
- Home oxygen
- Vaccinations - influenza, pneumococcal
Surgical Options
- Lung volume reduction surgery
- Lung transplantation
Pearls
- Smoking cessation has the greatest ability to influence the course of COPD
- Tailor pharmacologic options to the severity of disease
- Ensure that the patient has an exacerbation management plan in place
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