COPD AS Systemic disease BY Dr/Sami EL-Dahdouh (MD) Lecturer of Pulmonary & Critical care Faculty of Medicine, Menofia University

PATHOGENSIS  Release of mediators & cytokines e.g. IL6, TNF alpha.  hypoxemia and its effect on tissues.  oxidative stress.  increase acute phase proteins.

Manifestations  Wt loss and muscle wasting.  Endocrinal manifestations.  Effect on other systems as heart, GIT, Neuro- psychiatry, sleep disorders, kidney.

Wt loss & Muscle Weakness  Is due to 1-imbalance between increase catabolism (TNF alpha, IL1&6) and decrease anabolic hormones( GH, Insulin & Testerone). 2-Decrease caloric intake due to dyspnea, anorexia and GIT disturbances.  Wt loss & muscle weakness lead to impaired excises intolerance & poor outcome of the patients.  This is demonstrated by BODE index.

The BODE Index  Predicts survival based on  Body mass index (< 21 is associated with greater mortality)  FEV1 (airflow obstruction)  Degree of dyspnea (MRC grade)  Capacity for exercise (6-minute walk distance) Can Fam Physician 2008;54:706-11

The BODE Index Score Points Used To Calculate Can Fam Physician 2008;54:706-11

Medical Research Council dyspnoea scale Grade Degree of breathlessness related to activities  0 Not troubled by breathlessness except on strenuous exercise  1 Short of breath when hurrying or walking up a slight hill  2 Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace  3 Stops for breath after walking about 100m or after a few minutes on level ground  4 Too breathless to leave the house, or breathless when dressing or undressing

 If score more than 7 associated with 30% mortality in 2 years.  If score 5-6 associated with 15% mortality in 2 years.  If less than 5 associated with less than 10% mortality in 2 years.

Endocrinal manifestations 1- Hypogonadism & impotence due to hypoxemia, steroid used, increase s. leptin & decrease s. testerone. 2- Salt &water retention is due to  increase renin –angiotensin system.  vasopressin.  increase ADH.  Hypercapnia ++CAE salt and water retention.

3- Osteoporosis is due to:  mal nutrition,  Steroid use,  Hypoxemia increase renal exertion of ca +2 and  Acidosis decrease absorption of ca +2.

Other system affections CVS: cor pulomnale, lt sided dystolic dysfunction, IHD. GIT: -Reflux oesphgitis due to hypoxemia. Hypercapnia, hyperinflation, also coughing lead to increase in intra abdominal pressure. - Peptic ulcer effect of hypoxia and hypercapnia and effect of drugs.

Sleep disturbances is due to  H ypoxemia,  Nocturnal bronchospasm,  Drugs as theophylline,  Anxiety, depression &  Sleep apnea syndromes may be associated with COPD (overlap syndrome), or complication of sever air flow obstruction.

 Neuro- psychiatric disorders in the form of depression psychosis anxiety panic disorders.

Treatment  Nutritional problems - high fat diet ( increase caloric intake) - decrease CHO intake. - give anabolic hormone. - give appetizer e.g. megastrol.

 O2 therapy.  Antioxidants.  Anti mediators asTNF alpha antagonist.  Rehabilitation. All COPD patients benefit from exercise training programs, improving with respect to both exercise tolerance and symptoms of dyspnea and fatigue.