1. Chronic Obstructive Pulmonary Disease
Allison Miller

2. (Winland-Brown & Porter, 2011)
COPD
COPD refers to a group of lung diseases that block airflow during exhalation and result in dyspnea.
COPD is a progressive disease that results from a chronic inflammatory response.
It is characterized by airflow limitation that is not fully reversible.
There is no cure for COPD
80 to 90 % of all cases of COPD are due to cigarette smoking.
(Winland-Brown & Porter, 2011)

3. Chronic Bronchitis and Emphysema
Chronic bronchitis and emphysema are the two diseases present with COPD.
Chronic bronchitis is defined by a recurrent cough and increased mucus production that is present for at least two years and occurs on most days for at least three months.
Emphysema is a disease process that affects the alveoli. Emphysema is characterized by the destruction of the alveolar walls due to an imbalance of proteinase and anti-proteinase enzymatic activity.
(Winland-Brown & Porter, 2011)

4. Chronic Bronchitis and Emphysema
Chronic bronchitis is the most common disease process that occurs in COPD, but most people with COPD have both chronic bronchitis and emphysema.
(Winland-Brown & Porter, 2011)

5. Pathophysiology of Chronic Bronchitis
Chronic irritation of the airway epithelium can result in:
Increased inflammation and mucus production
increased number and size of mucus glands and goblet cells
Secretion of thick mucus
Decrease in ciliary function
Thick mucus in the bronchi can facilitate bacterial growth and infection.
Chronic Inflammation can lead to bronchospasm and permanent narrowing of the airways.
(Williams & Bourdet, 2008)

6. Pathophysiology of Emphysema
Alveoli walls are weakened and broken down by increased protease activity that is a result of chronic inflammation.
The increased protease activity causes the breakdown of elastin within the alveolar walls.
Results in the destruction of the alveolar walls, loss of elastic recoil within the alveoli, and a decrease in the alveolar surface area.
Results in retained carbon dioxide, increased residual lung volume, reduced expiratory flow, and hypoxemia.
(Brashers, 2010)

7. Alpha 1 antitrypsin deficiency
Rare genetic disease in which individuals have low or absent levels of alpha one antitrypsin.
Alpha 1 antitrypsin is a major anti-proteinase enzyme that is normally produced in the liver.
Without this protective anti-proteinase enzyme, the alveolar walls can be broken down by protease activity (Brashers, 2010).
Only accounts for 1-2% of all cases of COPD.
(Devereux, 2006)

8. Risk Factors for COPD
COPD is typically caused by long-term exposure to airborne irritants such as;
Tobacco smoke
Dust
Chemical Fumes
Air pollution
Alpha-1-antitrypsin deficiency
The most significant risk factor for COPD is long term cigarette smoking.
People over 40 are at greater risk because COPD generally develops slowly
(Mayo Clinic, 2011)

9. Incidence of COPD
COPD is the fourth leading cause of death in the world and is projected to be the third leading cause of death by 2020 (GOLD: The Global Initiative for Chronic Obstructive Lung Disease, 2011).
More than 120,000 Americans die due to COPD each year. This equals one death every four minutes within the United States (Centers for Disease Control and Prevention, 2012).
More than 12 million people are currently diagnosed with COPD and an additional 12 million likely have the disease but have not been diagnosed (U.S Department of Health and Human Services).
The total deaths from COPD are projected to increase by more than 30% in the next ten years if there are no interventions placed to cut this risk (World Health Organization, 2011).
Around 10-20% of cigarette smokers will develop clinically significant COPD (Devereux, 2006).

10. Symptoms of COPD Shortness of breath Wheezing Chest tightness
Chronic cough
Fatigue
Frequent respiratory infections
(Mayo Clinic, 2011)
For most people COPD is not diagnosed until at least 50% of their lung function is lost (Freeman & Price, 2006).

11. Diagnosis of COPD
Spirometry is the gold standard for the diagnosis and assessment of COPD (GOLD, 2011).
The spirometer is a machine that measures the total amount of air exhaled or Forced Vital Capacity (FVC) and the amount of air that is exhaled in the first second, which is the forced expiratory volume in one second (FEV1).
Spirometry can be used to detect COPD before symptoms occur and can be used to monitor the progression of the disease (Mayo Clinic, 2011).
The hallmark of COPD is an FEV1/ FVC ratio of less than seventy percent, which indicates airway obstruction, and a post bronchodilator FEV1 of less than 80% of the predicted value, which confirms the presence of airflow limitation that is not fully reversible (Williams & Bourdet, 2008).

12. Chronic Bronchitis Clinical Findings
Physical exam: cyanosis, wheezing, weight gain, diminished breath sounds, and distant heart sounds.
Arterial blood gases may show elevated carbon dioxide and decreased oxygen levels.
X-ray: May show increased bronchovascular markings and cardiomegaly.
(Winland-Brown & Porter, 2011)

13. Clinical Findings of Emphysema
Physical exam: Barrel chest, use of accessory muscles for breathing, pursed lip breathing, may have slight cyanosis, breath sounds may be diminished. As the disease progresses they may have significant weight loss, increasing dyspnea, and increased episodes of acute exacerbations.
Chest x-ray and CT scan may show hyperinflation of the lungs, hypovascularity, and large air spaces within the lung parenchyma.
Arterial Blood Gas may show decreased oxygen levels.
(Winland-Brown & Porter, 2011)

14. Treatment of COPD
Treatment and medications are given for COPD in order to:
Dilate the airways
Decrease bronchoconstriction
Improve oxygenation
Decrease levels of carbon dioxide within the body
Prevent exacerbations
Prevent or Fight Infections
Improve quality of life

15. Treatment of COPD Medications and treatments for COPD include:
Inhaled beta-2 agonists: long and short acting
Inhaled Anticholinergic bronchodilators
Corticosteroids
Xanthines
Antibiotics
Diuretics
Mucolytics
Home oxygen
Surgery
Pulmonary Rehabilitation

16. GOLD guidelines for treatment
Stage 1 or mild COPD: short acting bronchodilator as needed.
Stage 2- moderate COPD: short acting bronchodilator as needed, regular treatments with one or more long acting bronchodilators, and pulmonary rehabilitation.
Stage 3- severe COPD: short acting bronchodilator as needed, regular treatments with one or more long-acting bronchodilators, inhaled glucocorticosteriods if having repeated exacerbations, and pulmonary rehab.
Stage 4- very severe COPD: short acting bronchodilator as needed, regular treatments with one or more long acting bronchodilators, inhaled glucocorticosteriods if having repeated exacerbations, treatment of complications, rehabilitation, long term oxygen therapy for respiratory failure, and surgical consideration
(GOLD: The Global Initiative for Chronic Obstructive Lung Disease, 2011).

17. First line Medications for COPD
Short acting beta agonist: Albuterol
Anticholinergics: Atrovent (ipratropium) and Spiriva (tiotropium).
Long Acting Beta agonists: Servent (salmeterol), Foradil (formoterol), Brovana (aformoterol, and Perforomist (formoterol)
(Cropp, 2012).

18. Complications of COPD
Dyspnea, fatigue, malnutrition, insomnia, infections, pneumothorax, arrhythmias, weight loss, cor pulmonale, osteoporosis, edema, pulmonary hypertension, heart attack, anemia, depression, and anxiety.
(GOLD: The Global Initiative for Chronic Obstructive Lung Disease, 2011).

19. Counseling and Education
The most important intervention for decreasing the progression of COPD is smoking cessation.
If there are no contraindications, people with COPD should receive the flu and pneumonia vaccines.
Avoid second hand smoke
Avoid travel at high altitudes.
Create an advanced health directive
Discuss end of life care for those with advanced COPD.
(Cropp, 2012)

20. Consultation and Referral
Health care professionals that are involved with treating people with COPD include:
Pulmonologists
Respiratory therapists
Dieticians
Cardiologist
Mental health workers
Surgeons
General practitioners
Social workers
Physical and occupational therapists

21. COPD Summary
COPD is a disease that results in airway obstruction and a decreased ability to exhale air and carbon dioxide out of the lungs.
Chronic bronchitis and emphysema are two forms of COPD and usually occur together.
There is no cure for COPD
COPD is the fourth leading cause of death in the U.S.
Primary symptoms of COPD are dyspnea and chronic cough
Treatments are aimed at increasing bronchodilation, decreasing bronchial constriction, and maintaining appropriate oxygen and carbon dioxide levels within the body.

22. References
Brashers, V. L. (2010). Alterations of pulmonary function. In L. K. McCance, S. E. Huether, V. L. Brashers, & N. S. Rote (Eds.), Pathophysiology: the biologic basis for disease in adults and children (6 ed., pp ). Maryland Heights, MS: Mosby. Centers for Disease Control and Prevention (2012, March). Chronic obstructive pulmonary disease. Retrieved September 26, 2012, from Cropp, A. J. (2012). Chronic obstructive pulmonary disease and emphysema. In F. J. Domino, R. A. Baldor, J. Golding, J. A. Grimes, & J. S. Taylor (Eds.), The 5-minute clinical consult 2013 (21ed., pp ). Philadelphia, PA: Liippincott, Williams, & Wilkins. Devereux, G. (2006). Abc of chronic obstructive pulmonary disease: Definition, epidemiology, and risk factors. British Medical Journal, 332 (7550),

23. References
GOLD: The Global Initiative for Chronic Obstructive Lung Disease (2011, December). Global strategy for diagnosis, management, and prevention of COPD. Retrieved September 26, 2012, from strategy-for –diagnosis. Mayo Clinic (2011, March). COPD. Retrieved September 26,2012, from Williams, D. M., & Bourdet, S. V. (2008). Chronic obstructive pulmonary disease. In J. T. Dipiro, R. L. Talbert, G. C. Yee, G. R. Matzke, B. G. Wells, & L. M. Posey (Eds.), Pharmacotherapy: a pathophysiologic approach (7 ed.), pp ). New York, NY: McGraw Hill. Winland-Brown, J. E., & Porter, B. O. (2011). Respiratory problems. In L. M. Dunphy, J. E. Winland, B. O. Porter, & D. J. Thomas (Eds.), Primary care: the art and science of advanced practice nursing (3 ed., pp ). Philadelphia, PA: F. A. Davis Co. World Health Organization (2011, November). Chronic obstructive pulmonary disease. Retrieved September 26, 2012 from