《copd英文课》

1、Chronic Obstructive Pulmonary Disease (COPD) Guohua Zhen Tongji Hospital Percent Change in Age-Adjusted Death Rates, U.S., 1965-1998 0 0.5 1.0 1.5 2.0 2.5 3.0 Proportion of 1965 Rate 0.0 0.5 1.0 1.5 2.0 2.5 3.0 1965 - 19981965 - 19981965 - 19981965 - 19981965 - 1998 59%64%35%+163%7% Coronary Heart D

2、isease StrokeOther CVDCOPDAll Other Causes Why COPD is Important ? COPD is the only chronic disease that is showing progressive upward trend in both mortality and morbidity It is expected to be the third leading cause of death by 2020 Approximately 3% Chinese above 15 are currently suffering from CO

3、PD Definition COPD is a preventable and treatable disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and is associated with an abnormal inflammatory response of the lungs to noxious particles or gases, primarily caused by cig

4、arette smoking. Relationship of COPD and Chronic bronchitis, Asthma or Emphysema Chronic Bronchitis Chronic Bronchitis Definition: Chronic and unspecific inflammation of bronchi and the surrounding tissue. Feature: chronic mucus hypersecretion and cough. Morbidity: 3.2% in population over 15 y，up to

5、 15% in elderly over 50 y. Etiology and mechanism Environment Factors Cigarette smoking Occupational dusts and chemicals Infections Host Factors Genes Lung growth and defense mechanism Chronic Bronchitis Clinical manifestation Character: chronic onset, recurrent attack and long course of disease Mai

6、n symptoms: cough: chronic, long term, repeatedly expectoration: mucoid sputum, purulent sputum when infection wheezing: seen in some patients Clinical manifestation Sign: 1. no obvious sign in early stage 2. sometimes moist rales and rhonchi Examination Chest x-ray imaging Examination Pulmonary fun

7、ction test: maybe normal in early stage. Gradually obstructive airway function appeared. Blood routine: elevated neutrophil or eosinophil Sputum examination: bacterial culture guide antibiotic treatment Diagnosis Chronic cough and sputum production for 3 consecutive months in at least 2 successive y

8、ears（3m/y2y）, excluding other chronic lung diseases (TB, Bronchiectasis ) Definite chest imaging or lung function Typing Typing : 1、simple：cough, sputum 2、wheezing：with wheezing (actually Chronic bronchitis plus asthma) Emphysema 整理整理ppt Definition Emphysema is characterized by enlargement and destr

9、uction of respiratory bronchioles and /or alveoli in the lungs. Etiology Environment Factors Cigarette smoking Occupational dusts and chemicals Infections Host Factors Genes: Alpha1-antitrypsin deficiency Contributing factor Airway obstruction due to chronic inflammation Damaged bronchial cartilage

10、and lead to the loss of supporting function Increased activity of proteinase due to chronic airway inflammation or smoking Alpha1-antitrypsin deficiency Others: Poor nutrition of alveoli or respiratory bronchiole due to decreased blood supply because of oppression of high airway pressure Cigarette s

11、moke Alveolar macrophage Neutrophil PROTEASES Alveolar wall destruction (Emphysema) Mucus hypersecretion (Chronic bronchitis) PROTEASE INHIBITORS Neutrophil chemotactic factors CELLULAR MECHANISMS OF COPD Neutrophil elastase Cathepsins Matrix metalloproteinases Cytokines (IL-8) Mediators (LTB4) ? CD

12、8+ lymphocyte - MCP-1 1-Antitrypsin TIMPs SLPI Elafin Neutrophil elastase Cathepsins MMP-1, MMP-9, MMP12 Granzymes, perforins Others. PROTEASE-ANTIPROTEASE IMBALANCE IN COPD Pathology feature Alveolar walls become thinner Alveolar sacs enlargement Rupture of alveoli and formation of bleb Pathologica

13、l Category In panlobular emphysema, the enlargement and destruction of air space involve the acinus more or less uniformly. In centrilobular emphysema, respiratory bronchioles are selectively and dominantly involved. COPD - chronic bronchitis - emphysema COPD Pathophysiology Hypoventialtion- PaO2 ,

14、PaCO2 Airflow obstruction / airway narrowing mucus plugging airway inflammation, edema, fibrosis airway collapse due to alveolar wall destruction Hyperinflation: air trapping Gas exchange defects- PaO2 Destruction of alveolar wall/alveolar-capillary membrane V/Q mismatch (shunt) Clinical manifestati

15、on Symptom 1. cough, sputum and/or wheezing 2. gradually progressive dyspnea, shortness of breath, chest tightness Clinical manifestation Sign: 1. not obvious in early stage 2. typical sign: barrel chest, decreased chest movement, diminished tactile fremitus, hyperresonance, decreased vesicular brea

16、th sound and prolong expiration or wheeze Examination Pulmonary function test Diagnosis Assessing severity Assessing prognosis Monitoring progression Examination: pulmonary function test Dynamic lung function airflow obstructionFEV1, FEV1/FVC Static lung function hyperinflation TLC, FRC air trapping

17、 RV Examination: pulmonary function test Chest X-ray： ECG： Blood gas：to detect respiratory failure. Blood routine and sputum examination： Examination Chest X-ray Intercostal space widening Diaphragm are low and flat Vascular marking deficiency Shadow of the heart narrowing low, flat diaphragms, hype

18、rlucency, vascular marking deficiency Diagnosis 1、Smoking history 2、Symptom: cough, sputum production, gradually progressive dyspnea 3、Sign：emphysema 4、PFT: airway flow limitation COPD classification based on pulmonary function test Severity Postbronchodilator FEV1/FVC Postbronchodilator FEV1% predi

19、cted 0: At risk0.780 I: Mild COPD80 II: Moderate COPD 0.750-80 III: Severe COPD 0.730-50 IV: Very severe COPD 0.730 Clinical Features of COPD Patients of different severity Mild COPD: no abnormal signs, smokers cough, little or no breathlessness Moderate COPD: breathlessness with/without wheezing, c

20、ough with/without sputum Severe COPD: breathlessness on any exertion/at rest, wheeze and cough prominent, lung inflation usual, cyanosis, peripheral edema, and polycythemia in advanced disease Stage of disease Acute Exacerbations Stable Acute exacerbation of COPD AE-COPD “Exacerbation” of COPD Respi

21、ratory dyspnea / chest tightness cough / sputum, purulent Systematic decreased activity, fatigue, headache, poor appetite, somnolence Differential diagnosis Bronchial asthma: reversibility of the airflow Bronchiectasis: especially mild patients, chronic cough and mucus sputum Pulmonary TB：positive a

22、nti-fast smear Bronchogenic carcinoma： Emphysema due to other cause: for compensation Complications of COPD Chronic respiratory failure Spontanous pneumothorax Cor pulmonale hypoxia, pedal edema, passive hepatic congestion. Management of COPD Prevent decline in FEV1 Reduce mortality Improve quality

23、of life symptoms exercise tolerance exacerbations Minimal side-effects Non-pharmacologic Therapies COPD Smoking cessation Physician intervention critical Multidisciplinary approach Withdrawalanxiety, irritability, difficult concentrating, sleep disruption, fatigue, drowsiness, depression Nicotine re

24、placement withdrawal symptoms nicotine gum (2 mg = cigarette) transdermal nicotine patches x 8 wks 20-40% / 6 mos vs 5-20% / 6 mos with placebo Effects of Smoking and Smoking Cessation on FEV1 0 25 50 75 100 255075 Age (years) FEV1 (%) Nonsmoker or Non-susceptible Stopped at 45 Stopped at 65 Suscept

25、ible Smoker COPD: Pharmacology Bronchodilators Corticosteroids Long term oxygen therapy Management of COPD exacerbations COPD: Pharmacology 2-agonist bronchodilators Rapid-acting 2-agonists (SABA) salbutamol, terbutaline symptomatic relief pre-exertional 2 puffs 4-6 x /d prn minimal risk Long acting

26、 2-agonists (LABA) salmeterol, formoterol regular therapy 1-2 puffs bid benefit: activity / exertion, QOL COPD: Pharmacology Anticholinergic bronchodilators Benefits vs Risks Regular therapy Symptomatic benefit ? exacerbations Minimal s/edry mouth, urinary retention Agents Ipratropium /Atrovent4-6 p

27、uffs qid Tiotropium /Spiriva1 puff qd COPD: Pharmacology Theophylline Multiple effects bronchodilation, respiratory stimulant, improved cardiovascular function, improved diaphragm function Limited role because of narrow therapeutic window s/e GI, CNS, cardiac qd - bid dosing with long-acting prepara

28、tions COPD: Pharmacology Inhaled Steroids Symptomatic COPD patients with “asthmatic” tendency (20%) FEV1 18 hrs /d Improved survival, right heart failure Improved exercise tolerance, QOL Indications PaO2 55 mmHg (SaO2 88%) COPD: Exacerbations Oxygenation: low concentration oxygen therapy Risks of ex

29、cessive O2 (PaO2 100 mmHg) hypercapnia ( PaCO2 ) acidemia ( pH 0.8 L) Lung volume reduction surgery (LVRS) prognosis Relate to the value of FEV1 FEV11.2L survive for 10y， FEV11.0 L survive for 5y ，FEV11, in V51) Rv1+Sv5 1.05mV P-pulmonale pattern (an increase in P wave amplitude in II, III, AVF) Exa

30、mination Echocardiography 1、inner diameter of RV outflow (30mm)， 2、RV internal dimension(20mm)， 3、RV anterior wall thickening 4、enlargement of right atrium Differential diagnosis Coronary artery disease：can exist together. Rheumatic heart disease: systolic murmur. Primary cardiomyopathy： accompanied with distension of whole heart. Complication Pulmonary encephalopathy： Acid-base imbala