1. CHRONIC OBSTRUCTIVE LUNG DISEASE Dr. Rehab F.M. Gwada

2. Objectives of the Lecture  The student at the end of this lecture will be able  To outline how does the normal lung work?  To define chronic obstructive lung disease (COPD) according to scientific rational  To describe its causes &pathogenesis.  To explain sign & symptoms associated with COLD  to diagnose COLD according to scientific base.  To out line the goals of treatment.  To describe the strategies of management in patient with COLD according to scientific protocol.

3. How does the normal lung work?  The lung is the organ for gas exchange; it transfers oxygen from the air into the blood and carbon dioxide (a waste product of the body) from the blood into the air.  the lung has two components; Airways: are branching, tubular passages like the branches of a tree that allow air to move in and out of the lungs The wider segments of the airways are the trachea and the two bronchi The smaller segments are called bronchioles alveoli: At the ends of the bronchioles, thin-walled sacs. Small blood vessels (capillaries) run in the walls of the alveoli, and it is across the thin walls of the alveoli where gas exchange between air and blood takes place.

5. How does the normal lung work?  Breathing is under automatic control by the brain  Breathing involves inspiration followed by exhalation.  During inspiration, muscles of the diaphragm and the rib cage contract and expand the size of the chest (as well as the airways and alveoli) causing negative pressure within the airways and alveoli air is sucked through the airways and into the alveoli and the chest wall is enlarged.  During exhalation, the same muscles relax and the chest wall springs back to its resting positions, creating positive pressure within the airways and alveoli air is expelled from the lungs.

6. How does the normal lung work?  The walls of the bronchioles are weak and have a tendency to collapse, especially while exhaling.  Normally, the bronchioles are kept open by the elasticity of the lung.  Elasticity of the lung is supplied by elastic fibers which surround the airways and line the walls of the alveoli.  When lung tissue is destroyed, as it is in patients with COPD who have emphysema, there is loss of elasticity and the bronchioles can collapse and obstruct the flow of air.  Normal lung tissues look a lot like a normal sponge. Emphysema often looks like an old sponge with large irregular holes and loss of the spring and elasticity.

7. What is COPD?  Chronic obstructive pulmonary disease (COPD) is comprised primarily of - chronic bronchitis and emphysema.chronic bronchitis emphysema  Asthma is no longer regarded as a true COPD.  In each condition there is chronic obstruction of the flow of air through the airways and out of the lungs, and the obstruction generally is permanent ( not fully reversible) and may be progressive over time.

8. Asthma and COPD  While asthma features obstruction to the flow of air out of the lungs, usually, the obstruction is reversible.  Between "attacks" of asthma the flow of air through the airways typically is normal.

9. COPD Cont.  Often patients with COPD are labeled by the symptoms they are having at the time of an exacerbation of their disease.  For instance, if they present with mostly shortness of breath, they may be referred to as emphysema patients. While if they have mostly cough and mucus production, they are referred to as having chronic bronchitis.shortness of breath  In reality, it is better to refer to these patients as having COPD since they can present with a variety of lung symptoms.  There is frequent overlap among COPD patients. Thus, patients with emphysema may have some of the characteristics of chronic bronchitis and vice a versa.

10. What is chronic bronchitis?  It is an inflammation and swelling of the lining of the airways that leads to narrowing and obstruction of the airways.  The inflammation also stimulates production of mucous (sputum), which can cause further obstruction of the airways.  Obstruction of the airways, especially with mucus, increases the likelihood of bacterial lung infections. Chronic bronchitis usually is defined clinically as a daily cough with production of sputum for three months, two years in a row.daily cough

12. What is emphysema?  There is permanent enlargement of the alveoli due to the destruction of the walls between alveoli.  The destruction of the alveolar walls leads to  A) decrease the number of capillaries available for gas exchange. This adds to the decrease in the ability to exchange gases.  B)reduce the elasticity of the lung overall. Hyperexpansion from Emphysema

14. Emphysema cont.  Loss of elasticity leads to the collapse of the bronchioles obstructing airflow out of the alveoli. Air becomes "trapped" in the alveoli and reduces the ability of the lung to shrink during exhalation. This trapped air takes up space and results in: a reduced amount of air that can be taken in during the next breath. less air gets to the alveoli for the exchange of gasses. compress adjacent less damaged lung tissue, preventing it from functioning to its fullest capacity.

15. Emphysema cont.  Normally, energy is only required for inhalation to inflate the lungs. While, exhalation, a passive process that does not require energy.  In emphysema, inefficient breathing occurs because extra effort and energy has to be expended to empty the lungs of air due to the collapse of the airways.  In addition, because of the reduced capacity to exchange gases with each breath, it is necessary to breathe more frequently.

16. What causes COPD? Cigarette smoking and second-hand smoke  Smoking is responsible for 90% of COPD in the United States. Smokers with COPD have higher death rates than nonsmokers with COPD. Smoking  Effects of passive smoking or "second-hand smoke" on the lungs are not well-known; however, evidence suggests that respiratory infections, asthma, and symptoms are more common in children who live in households where adults smoke.  Cigarette smoking damages the lungs in many ways:  the irritating effect of cigarette smoke attracts inflammatory cells to the lungs that promote inflammation.  Cigarette smoke also stimulates these inflammatory cells to release elastase, an enzyme that breaks down the elastic fibers in lung tissue.

17. What causes COPD Air pollution  air pollution may be a contributing factor for COPD, as it is thought to slow the normal growth of the lungs air pollution Occupational pollutants  Some occupational pollutants such as cadmium and silica do increase the risk of COPD.

18. What causes COPD Alpha-1 antitrypsin deficiency(AAT)  The AAT deficiency is a rare genetic (inherited) disorder  Allows the destruction of tissue in the lungs. This causes emphysema by age 40 or 50.

20. What are the symptoms of COPD?  chronic cough and sputum production are the major symptoms of Chronic bronchitis  The sputum is usually clear and thick.  shortness of breath(Dyspnea),is the major symptom of emphysema.  Frequent respiratory infections can cause:  fever, dyspnea, coughing, production of purulent (cloudy and discolored) sputum,wheezingfeverpurulent  Chest tightness

21. Advanced COPD symptoms  Cyanosis (bluish discoloration of the lips and nail beds) due to a lack of oxygen in blood.  Morning headaches due to an inability to remove carbon dioxide from the blood.  Weight loss  Cor pulmonale results and leads to swelling of the feet and ankles (a strain on the heart due to the extra work required by the heart to pump blood through the affected lungs).  Cough up blood (hemoptysis). Usually hemoptysis is due to damage to the inner lining of the airways and the airways' blood vessels ;

22. Signs of COPD  tachypnea, a rapid breathing rate tachypnea  wheezing sounds in the lungs heard through a stethoscope stethoscope  breathing out taking a longer time than breathing in  enlargement of the chest, particularly the front-to-back distance)  active use of muscles in the neck to help with breathing  breathing through pursed lips  increased anteroposterior to lateral ratio of the chest (barrel chest).barrel chest

24. How is COPD diagnosed?  Medical history  physical examination  chest X-ray, chest X-ray  computerized tomography (CT scan) of the chest,  tests of lung function (pulmonary function tests- Spirometry)  Arterial Blood Gas,the measurement of carbon dioxide and oxygen levels in the blood. Arterial Blood Gasoxygen levels in the blood  Six minute walking test (6MWT) toDeterminie the physical capability

25. The goals of COPD treatment  to prevent further deterioration in lung function.  to improve symptoms.  to improve performance of daily activities and quality of life. quality of life

26. The treatment strategies  Smoking cessation.  taking medications to dilate airways (bronchodilators) and decrease airway inflammation.  vaccination against flu influenza and pneumonia.flu influenzapneumonia  regular oxygen supplementation.  Replacement of the missing or inactive AAT by injection  pulmonary rehabilitation.  Surgery

27. Medication  Bronchodilators  Beta-2 agonists  Methylxanthines like a beta agonist, relaxes the muscles surrounding the airways  Corticosteroids anti-inflammatory medications  dilate airways Anti-cholinergic Agents

28. What is the role of oxygen as therapy in COPD?  Sufficient oxygen is a requirement for the proper function of tissues in the body.  can relax the blood vessels and decrease blood pressure in the lungs. This decreases the work that the right side of the heart must perform and can improve heart failure.

29. Pulmonary rehabilitation  A cornerstone in the management of moderate to severe COPD.  Pulmonary rehabilitation: is a program of exercise, disease management and counseling coordinated to benefit the individual.  It is defined by the American Thoracic Society and the European Respiratory Society as an evidence-based, multidisciplinary, and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities.  Pulmonary rehabilitation appears to improve over all quality of life, the ability to exercise, and mortality.

30. Cont.  occupational and physical therapy are used to teach optimal and efficient body mechanics.  Surgery  Eg. Lung volume reduction surgery, lung transplantation

31. Prognosis  COPD usually gradually gets worse over time and can lead to death.  The factors that predict a poorer prognosis are:  Severe airflow obstruction.  Poor exercise capacity  Shortness of breath  Significantly underweight or overweight  Complications like respiratory failure or cor pulmonale  Continued smoking  Frequent acute exacerbations

32. Q?  During inspiration: A- muscles of the diaphragm and the rib cage relax and expand the size of the chest. B-there is negative pressure within the airways. C-There is positive pressure within the airways and alveoli. D- All of above.

33. Q?  During expiration: A- muscles of the diaphragm and the rib cage contract and expand the size of the chest. B-there is negative pressure within the airways. C-There is positive pressure within the airways and alveoli. D- All of above.

34. Q?  In emphysema, inefficient breathing occurs because: A- the collapse of the airways B- extra effort and energy required for expiration. C- reduced capacity to exchange gases. D- all of above.

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