2. Chronic Obstructive Pulmonary Disease ystic Fibrosis ronchitis – Chronic sthma ronchiectasis mphysema

3. Chronic Obstructive Pulmonary Disease Smoking #1 cause of COPD Increased mucous production Inhibition of mucociliary clearance Toxicity of inhaled gases and particulates Bronchospasm Decrease in macrophage activity Disruption of the alveolar wall and capillary endothelium

4. Epidemiology Some 16 Million Americans are affected COPD is the 3rd leading cause of death in the U.S. COPD causes millions of hospital admissions per year Total health expenditure of $32.1 Billion in 2000 Most common form of COPD is Chronic Bronchitis

5. Risk Factors for COPD 1.Cigarette smoking/passive smoking 2.Pollution 3.Occupational exposure to dust and fumes 4.Recurrent lung infections 5.Hereditary factors 6.Allergies 7.Socioeconomic factors 8.Alcohol ingestion 9.Age

6. General Manifestations of COPD 1.Small airways ( < 2mm) are most susceptible to airway obstruction in COPD 2.Diagnosed by Pulmonary Function Testing, clinical signs and symptoms 3.Early to middle manifestations of COPD include: I.Changes in pulmonary function testing II.Shortness of breath with exertion III.Changes in CXR IV.Increases in sputum production V.Cough VI.Recurrent pulmonary infections VII.Wheezing 4.Late manifestations of COPD include: I.Accessory muscle usage II.Edema from Cor Pulmonale III.Mental status changes from chronic hypoxia/hypercapnea IV.Clubbing of fingers V.Barrel Chest or Increased A-P Diameter

7. What is Emphysema? Loss of elastic recoil This loss of recoil leads to an increased compliance and inability to expel gas out of the alveoli Leading to trapped air in the lung Alveoli cluster together forming “bullae”

8. What is Emphysema Cont… Damage occurs to the tiny airways in the lungs called bronchioles. Bronchioles are joined to alveoli, tiny grape-like clusters of sacs in the lungs where oxygen from the air is exchanged for carbon dioxide from the body. The elastic properties of the lung reside in the tissue around the alveoli Because the lungs lose elasticity they become less able to retract This prevents the alveoli from deflating completely, and the person has difficulty exhaling.

9. Emphysema Cont… Hence, the next breath is started with more air in the lungs. The trapped "old" air takes up space, so the alveoli are unable to fill with enough fresh air to supply the body with needed oxygen.

10. Pulmonary Emphysema Centrilobular emphysema Abnormal weakening and enlargement of the respiratory bronchioles in the proximal portion of the acinus Primary changes occur in upper lobes High correlation with smoking

11. Pulmonary Emphysema Bullous emphysema Changes seen at both respiratory bronchiole and alveolar levels Prominent bullae formation (air spaces greater than 1 cm in diameter)

12. Emphysema Typically, symptoms of emphysema appear only after 30 to 50 percent of lung tissue is lost. Emphysema rates are highest for men age 65 and older. More people in the Midwest have emphysema than in any other region in the country. Emphysema is an irreversible disease that can be slowed but not reversed or stopped.

13. Accessory muscle use

14. Causes Generally, lungs become damaged because of reactions to irritants entering the airways and alveoli. Researchers continue to investigate the factors that may make some people more susceptible to emphysema than others. But there are some clear causes for emphysema: Cigarette smoking Alpha-1 antitrypsin deficiency

15. Causes Cigarette smoking is the major cause of emphysema. When exposed to cigarette smoke, the air sacs of the lungs produce defensive cells, called macrophages, which "eat" the inhaled particles. But macrophages are stimulated to release materials which can destroy the proteins that let the lungs expand and contract, called elastin and collagen. Cigarette smoke also damages the cilia, tiny hair-like projections in the bronchi that "sweep" foreign bodies and bacteria out of the lungs

16. Other Cause Alpha-1 Antitrypsin Deficiency People who a deficiency of a protein called alpha-1 antitrypsin (AAT) are at a higher risk of developing severe emphysema. Alpha-1 antitrypsin deficiency (AAT deficiency) is an inherited condition and occurs in varying degrees

18. AAT AAT is thought to protect against some of the damage caused by macrophages. In AAT deficiency-related emphysema, the walls of the bronchial tubes and the alveoli are both damaged, often leading to severe disease. About 2 out of every 1,000 people have an alpha-1 antitrypsin deficiency. People who smoke and have AAT deficiency are almost certain to develop emphysema.

19. Symptoms The first sign of emphysema is shortness of breath during exertion. Eventually, this shortness of breath occurs while at rest As the disease progresses, the following symptoms which are related to one of the other major lung diseases also caused by smoking - bronchitis - may occur: Difficulty breathing (dyspnea) Coughing (with or without sputum) Wheezing (this can also be caused by emphysema itself) Excess mucus production A bluish tint to the skin (cyanosis) Hypoxemia Tachycardia Polytcythemia (increased hemoglobin levels)

20. More Symptoms Clubbed fingers (chronic hypoxia) Right Heart Failure Stained yellow fingers, teeth

21. Diagnosis History And Physical Examination Smoking history (calculate pack years, # packs smoked times # years smoked) Working environment- Breathing in any harmful chemicals? A physical examination will include an examination of your chest and breathing patterns; prolonged expiratory times Nasal flaring, accessory muscle usage (due to loss of diaphragm recoil from air trapping)

22. Diagnosis Continued X-Ray and/or CT of the Chest Chest x-rays are a very useful tool to evaluate anatomy of the lung. In emphysema, there is evidence of increased air in the chest and destruction of some of the lung tissue. Bronchitis can be suspected on a chest x-ray by presence of thickening of the tissue around the large airways (bronchi). Chest x-rays are also useful as screening for lung cancer and heart disease. Computerized axial tomography or CAT scans indicate lung anatomy in greater detail. In some cases, this information is needed to fully evaluate lung disease.

23. Cat scan of chest Air Trapping, flattened diaphragm

24. Pulmonary Function Testing Spirometry measures breathing capacity. A common measure of breathing capacity is the forced expiratory volume in one second (FEV1), or the amount of air that can be forced out of the lungs in one second. This is a common way to determine the amount of airway obstruction.

25. Pulmonary Function Testing Spirometry and body plethysmography be repeated after administration of an inhaled bronchodilator This test will help your physician determine if there is an asthmatic component present Lung Volumes measures the amount of air in the lungs. This increases markedly in emphysema.

26. Arterial Blood Gas Patient’s with emphysema have chronic CO2 retention due to the inability to expel gas. Their blood reflects higher levels of CO2 than normal people; CO2 is acidic in nature Over time their body compensates for this higher CO2 by creating more buffer in the blood in the form of Bicarb from the Kidney

27. Treatment There is no cure for emphysema. The goal of treatment is to slow the development of disabling symptoms. The most important step to take is to stop smoking. Treatments for emphysema caused by smoking include medication, breathing retraining, and surgery. People with inherited emphysema due to alpha-1 antitrypsin deficiency can receive alpha 1-proteinase inhibitor (A1PI), which slows lung tissue destruction.

28. Breathing Techniques Diaphragmatic Breathing The diaphragm is a major muscle used in breathing and is located beneath the lowest two ribs. At rest, the diaphragm muscle is bell shaped. During inspiration, it lowers and flattens out. Optimizing the use of the diaphragm is beneficial because it pulls air into the lower lobes of the lungs where more gas exchange takes place. Not only is the diaphragm the most efficient of all respiratory muscles, but using it tends to be very relaxing and calming. Along with our diaphragm, we use intercostal and abdominal muscles in the work of breathing. The intercostals (muscles between the ribs) pull to lift the rib cage up and out. This causes the lungs to open in all directions and air can be pulled down the airways. To exhale, the muscles that have been pulling relax and air is forced out.

29. Medications Used Medications To Treat Emphysema Emphysema cannot be cured and, except for oxygen, does not reverse with any medication. However, emphysema is frequently associated with bronchitis and asthma and the symptoms associated with these processes often can be alleviated with medication (hence, you can see the value of pulmonary function and other tests designed to discover if there is asthmatic component present: Bronchodilator medication Corticosteroids Supplemental oxygen

30. Bronchodilator Medication Bronchodilator medication may be prescribed for airway tightness. Bronchodilators react similar to norepinephrine through the sympathetic nervous system The most commonly prescribed bronchodilators are beta2 agonists, the anti-cholinergic drug ipatropium bromide, and theophylline Anti-cholinergics block musacaric receptors which normally respond to acetylcholine and cause bronchoconstriction

31. Corticosteroids The potent anti-inflammatory medications known as corticosteroids - commonly called steroids - may be used to help lessen the inflammation that often accompanies emphysema. These may be taken by mouth or inhaled.

32. Therapy at Each Stage of COPD

33. Oxygen Due to the chronic state of increased CO2 in the blood (hypercapnia), the patient has adapted a breathing regulation in the brain that responds to changes in O2 and not CO2 like most people If you give a patient with COPD more than 30% oxygen they will slow their breathing Give low flow oxygen at 2 LPM by NC Or high flow with venturi mask at 22-30%

34. Lung Reduction A surgical procedure called lung reduction may improve symptoms for people with certain types of emphysema. During the procedure, part of the lung is cut out, giving healthy lung tissue more room to expand. Lung reduction may eliminate the need for supplemental oxygen and make it much easier for the person to breathe. Early studies show that it reduces the volume of the over-inflated lungs. This improves the ability of the lung and chest wall to spring back during exhalation. This more-elastic lung appears to be the biggest reason that emphysema sufferers experience relief.

35. Conclusion Emphysema is a chronic disease that takes years to progress; usually as a result of heavy cigarette smoking but also can be caused by inherited Alpha-1 antitrypsin deficiency It destroys the stability of the alveoli and bronchioles leaving them over compliant This leads to air trapping and an accumulation of CO2 and decrease in O2 The air trapping leads to dyspnea Diagnose with symptoms, ABG, CXR, PFT and history Treatment consists of stop smoking, medications and lung reduction surgery or transplant