Lec: 3 Dr.

Mohammed Alhamdany

Objective:

1- To know the definitions of chronic obstructive pulmonary disease.

2- To identify the extrapulmonary effect and risk factors of chronic obstructive
pulmonary disease.
3- To understand the pathophysiology of COPD.
4- To know the clinical features of COPD.
5- To determine the step wise manner of investigations of COPD
6- To identify the severity of COPD.

Chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is defined as persistent respiratory
symptoms and airflow limitation that is due to airway and/or alveolar
abnormalities, usually caused by significant exposure to noxious particles or gases.

The spectrum of COPD includes chronic bronchitis and emphysema.

Chronic bronchitis is defined as cough and sputum for at least 3 consecutive

months in each of 2 consecutive years.

Emphysema is abnormal permanent enlargement of the airspaces distal to the

terminal bronchioles, accompanied by destruction of their walls.

Extrapulmonary effects include:

1- Muscular weakness.
2- Increased circulating inflammatory markers.
3- Impaired salt and water excretion leading to peripheral oedema.
4- Altered fat metabolism contributing to weight loss.
5- ↑ Prevalence of osteoporosis.

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Risk factors

A- Environmental factors

1- Tobacco smoke: accounts for 95% of cases in the UK

2- Indoor air pollution: cooking with biomass fuels in confined areas in low-
income countries

3- Occupational exposures, such as coal dust, silica and cadmium

4- Cannabis smoking

5- Low birth weight: may reduce maximally attained lung function in young adult
life

6- Lung growth: childhood infections or maternal smoking may affect growth of

lung during childhood, resulting in a lower maximally attained lung function in
adult life

7- Infections: recurrent infection may accelerate decline in FEV1; persistence of

adenovirus in lung tissue may alter local inflammatory response, predisposing to
lung damage; HIV infection is associated with emphysema

8- Low socioeconomic status

B- Host factors:

1- alpha-1-antitrypsin deficiency.

2- Airway hyper-reactivity

Cigarette smoking represents the most significant risk factor for COPD and the risk
of developing the condition relates to both the amount and duration of smoking. It
is unusual to develop COPD with less than 10 pack years (1 pack year=20
cigarettes daily per year) and not all smokers develop the condition, suggesting that
individual susceptibility factors are important.

Pathophysiology

The presence of airflow limitation combined with premature airway closure leads
to gas trapping and hyperinflation, adversely affecting pulmonary and chest wall
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compliance. Pulmonary hyperinflation also results, which flattens the
diaphragmatic muscles and leads to an increasingly horizontal alignment of the
intercostal muscles, placing the respiratory muscles at a mechanical disadvantage.
The work of breathing is therefore markedly increased.

Emphysema may be classified by the pattern of the enlarged airspaces:

centriacinar, panacinar and paraseptal.

Some individuals develop bullae; permanent air-filled spaces within the lung that
are more than 1 cm in diameter. This results in impaired gas exchange and
respiratory failure.

Clinical features:

Symptoms:

1- Cough and associated sputum production are usually the first symptoms, and
are often referred to as a ‘smoker’s cough’. Haemoptysis may complicate
exacerbations of COPD but should not be attributed to COPD without
thorough investigation.
2- Breathlessness usually prompts presentation to a health professional.

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 3- In advanced disease: oedema (which may be seen for the first time during an
exacerbation) and morning headaches (which may suggest hypercapnia).
4- Fatigue, anorexia and weight loss may point to the development of lung
cancer or tuberculosis, but are common in patients with severe COPD. Body
mass index (BMI) is of prognostic significance.
5- Depression and anxiety are also common.

Signs:

1- Breath sounds are typically quiet; crackles may accompany infection but, if
persistent, raise the possibility of bronchiectasis.
2- Finger clubbing is not a feature of COPD and should trigger further
investigation for lung cancer or fibrosis.
3- pitting oedema may be due:
A- Right heart failure may develop in patients with advanced COPD, This is
known as ‘cor pulmonale
B- If there is coexisting sleep apnoea or thromboembolic disease.
C- From salt and water retention caused by renal hypoxia and hypercapnia.

Two classical phenotypes have been described: ‘pink puffers’ and ‘blue
bloaters’. The former are typically thin and breathless, and maintain a normal
PaCO2 until the late stage of disease. The latter develop (or tolerate)
hypercapnia earlier and may develop oedema and secondary polycythaemia. In
practice, these phenotypes often overlap.

Differential diagnoses include

1- Asthma
2- Tuberculosis
3- Bronchiectasis
4- Congestive cardiac failure.

Investigations

1- Although there are no reliable radiographic signs that correlate with the
severity of airflow limitation, a chest X-ray is essential to identify alternative
diagnoses such as cardiac failure, lung cancer and the presence of bullae.

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2- A blood count is useful to exclude anaemia or document polycythaemia, and
all patients should be tested for alpha-1-antitrypsin deficiency.
3- The diagnosis requires objective demonstration of airflow obstruction by
spirometry and is established when the post-bronchodilator FEV1 / FVC is
<70%. The severity of COPD may be defined in relation to the post-
bronchodilator FEV1 as following:

4- Measurement of lung volumes provides an assessment of hyperinflation.

This is generally performed by helium dilution technique; however, in
patients with severe COPD, and in particular large bullae, body
plethysmography is preferred because the use of helium may under-estimate
lung volumes.
5- The presence of emphysema is suggested by a low gas transfer.
6- Exercise tests provide an objective assessment of exercise tolerance, and
may also be valuable when assessing prognosis.
7- Pulse oximetry may prompt referral for a domiciliary oxygen assessment if
less than 93%.
8- High-resolution computed tomography (HRCT) is likely to play an
increasing role in the assessment of COPD, as it allows the detection of

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 emphysema and is more sensitive than the chest X-ray at detecting bullae. It
is also used to guide lung volume reduction surgery.

References:
Ian D. Penman, Stuart H., et al., editors. Davidson's Principles and Practice of
Medicine. 24th ed., Elsevier Health Sciences, 2022.
Further information

goldcopd.org Global Initiative for Chronic Obstructive Lung Disease: comprehensive overview of COPD.

brit-thoracic.org.uk :British Thoracic Society: access to guidelines on a range of respiratory conditions.

ersnet.org :European Respiratory Society: provides information on education and research, and patient
information.

thoracic.org :American Thoracic Society: provides information on education and research, and patient
information.

With best regard