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Leading Causes of Deaths
U.S. 1998
Cause of Death Number
1.5
1.0
0.5
–59% –64% –35% +163% –7%
0
1965 - 1998 1965 - 1998 1965 - 1998 1965 - 1998 1965 - 1998
Facts About COPD
■ Between 1985 and 1995, the number of
physician visits for COPD in the United
States increased from 9.3 million to
16 million.
■ The number of hospitalizations for COPD
in 1995 was estimated to be 500,000.
Medical expenditures amounted to an
estimated $14.7 billion.
Facts About COPD
Cigarette smoking is the primary cause of
COPD.
In the US 47.2 million people (28% of
men and 23% of women) smoke.
The WHO estimates 1.1 billion smokers
worldwide, increasing to 1.6 billion by
2025. In low- and middle-income
countries, rates are increasing at an
alarming rate.
Age-Adjusted Death Rates
for COPD, U.S., 1960-1995
Deaths per 100,000
60
50
40
30
20
10
0
1960 1965 1970 1975 1980 1985 1990 1995 2000
It is unusual for a person to have clinically
apparent COPD without a history of smoking
for at least 20 pack years, and most patients
have at least 40 pack years of exposure.
A pack year is the equivalent of smoking 20
cigarettes per day for a year
COPD 是可以治疗
和预防的疾病
Definition of COPD ( 1 )
COPD 是一种具有气流受限特征的可以预防和治疗的
疾病,气流受限不完全可逆、呈进行性发展,与肺部
对香烟烟雾等有害气体或有害颗粒的异常炎症反应有
关
COPD不仅影响肺,也可以引起显著的全身反应。
FEV1/FVC%
支气管扩张药用后
Airflow FEV1/FVC <70% 证实存在
limitation 气道受限不完全可逆
pathologic processes
Patients with COPD have varying
degrees of three pathologic processes,
each associated with smoking: chronic
bronchitis, small airways obstruction, and
emphysema.
Pathobiology
Chronic Bronchitis
Peripheral Airway Disease
Emphysema
Reduction in Maximum Expiratory Flow
Chronic bronchitis is a clinical diagnosis,
defined as the presence of chronic cough and
sputum production for at least 3 months of the
year for at least 2 consecutive years in the
absence of any other disease.
The anatomic basis of chronic bronchitis is
hypertrophy and hyperplasia of the mucus-
secreting glands normally found in the
epithelium of larger airways.
These cells increase in size and number; as a
consequence, they are found in smaller
diameter airways
than in nonsmokers
chronic bronchitis may
contribute to the progression
of airways obstruction.
Peripheral Airway Disease
the most striking increase in the resistance to
airflow occurs in peripheral airways or
bronchioles.
The degree of abnormality in these airways is
correlated with lung function.
The mechanisms involved in these changes are
unknown.
Emphysema
the enlargement of air spaces distal to the
conducting airways
There are two important types of emphysema,
centrilobular and panacinar. Centrilobular
emphysema primarily involves the respiratory
bronchioles , Panacinar emphysema involves
the entire distal lung unit
病理学( Pathology)
小叶中央型肺气肿
centrilobular
正常肺组织 全小叶型肺气肿
α1-antitrypsin (AAT) deficiency
severe panacinar emphysema associated with
α1-antitrypsin (AAT) deficiency.
AAT is an acute phase serum protein that is
secreted by the liver and that binds to and
neutralizes neutrophil elastase; it is the most
abundant antiprotease in the lung periphery.
but it is not clear
Reduction in Maximum Expiratory
Flow
Reduced expiratory flow is the hallmark of
COPD
the lung's elastic recoil is reduced by
emphysema, and airways resistance is
increased. Maximum expiratory flow is
reduced, and even less effort than normal
causes limitation of flow.
Tests of maximum expiratory flow, such as the
flow-volume curve and the FEV1, are of
clinical value because they reflect major
pathologic processes in COPD and are
relatively insensitive to a patient's effort and
cooperation beyond a threshold minimum
effort.
Clinical Manifestations
Lung Function
Dyspnea
Lung Function
The decrease in maximum expiratory flow that
characterizes COPD is most easily identified
in terms of a reduction in FEV1 that is larger
than the reduction in vital capacity, measured
in the same forced expiratory maneuver and
termed the forced vital capacity (FVC)
lower ratios indicate airways obstruction
<70%
Both the FEV1 and the FVC may increase
after treatment with an inhaled bronchodilator,
but the FEV1 does not attain normal values in
COPD, whereas it can return to normal in
patients with asthma
Hyperinflation of the lungs, which is often
manifested as an increase in total lung
capacity, is characteristic of COPD and
reflects loss of lung recoil and limitation of
expiratory flow.
Residual volume often is increased even in
mild cases of COPD.
Functional residual capacityis routinely
increased in moderate and severe COPD.
Arterial hypoxemia with or without carbon
dioxide retention is common in severe COPD.
Hypoxemia generally precedes carbon dioxide
retention, rarely occurs in patients with an
FEV1 in excess of 40% of the predicted
normal value, and is common when the FEV1
is less than 30% of the predicted value. Gas
exchange abnormalities in COPD are due to
abnormally large differences in ventilation-
perfusion ratios among units in the lung.
Dyspnea
Dyspnea is the major cause of disability in
COPD.
SPIROMETRY
History
COPD is insidious .
Dyspnea typically does not occur until the
FEV1 is about 50% of normal, when the
disease has usually been present for decades.
Patients with COPD often have a history of
chronic bronchitis that has antedated the onset
of dyspnea
first experienced during episodes of acute
bronchitis.
Eventually, dyspnea becomes consistent
being present at rest
Wheezing is also common in COPD, usually
with exertion, but may occur at rest in severe
disease
Patients with COPD have periodic exacerbations,
marked by increased dyspnea, wheezing, cough, and
sputum production..
Exacerbations usually occur in the winter, often with
upper respiratory infections, and are more common in
patients with symptomatic chronic bronchitis and in
those with severe obstruction.
Exacerbations of COPD are the most common cause
of hospitalization and result in substantial morbidity.
Some patients with COPD lose weight and
muscle mass especially in the presence of
severe emphysema. Weight loss is an ominous
prognostic sign in COPD
Physical Examination
the physical examination is usually normal. In
severe disease, signs are often apparent
The breathing rate is increased, often to more
than 20 breaths per minute at rest in patients
with hypoxemia or carbon dioxide retention.
Physical signs
the appearance of a barrel chest with increased
anteroposterior diameter,
relatively low-lying diaphragms, and faint
heart sounds. Patients with severe disease use
the strap muscles of the
neck during inspiration..
Breath sounds are often diminished, and both
crackles and wheezes may be heard.
Hypoxemic patients may be cyanotic
In advanced disease, secondary pulmonary
hypertension ,leads to right-sided heart failure
Spirometry
Spirometry, the measurement of the FEV1 and
FVC, is the “gold standard” for diagnosis of
COPD and is easy to perform in the office
setting Airways obstruction (FEV1/FVC <
0.70) in a person with at least 20 pack years of
tobacco exposure is a presumptive diagnosis of
COPD.
Spirometry: Normal and COPD
0
FEV1 FVC FEV1/ FVC
Normal 4.150 5.200 80 %
1 COPD 2.350 3.900 60 %
2
FEV1
Liter
3
COPD
4 FVC
FEV1
5 Normal
FVC
1 2 3 4 5 6 Seconds
Classification by Severity
Stage Characteristics
0: At risk Normal spirometry
Chronic symptoms (cough, sputum)
I: Mild FEV1/FVC < 70%; FEV1 ≥ 80% predicted
With or without symptoms (cough, sputum)
II: Moderate FEV1/FVC < 70%; 30% ≤ FEV1 < 80% predicted
(IIA: 50% ≤ FEV1 < 80% predicted;
IIB: 30% ≤ FEV1 < 50% predicted)
With or without chronic symptoms (cough, sputum,
dyspnea)
III: Severe FEV1/FVC < 70%; FEV1 < 30% predicted or FEV1
< 50%predicted plus respiratory failure or clinical
signs of right heart failure
Radiologic Studies
Routine chest radiographs are insensitive for
detecting COPD
In advanced cases, patients develop hyperinflation
with flattened diaphragms, increased retrosternal air
space, and an apparently small, vertical heart ( Fig.
88-4 ). Increased or decreased lung markings and
thin-walled bullae may be seen. Signs of pulmonary
hypertension, including fullness of the main
pulmonary arteries, are occasionally observed.
Computed tomographic (CT)
Computed tomographic (CT) scans are of
considerable value in assessing the presence,
distribution, and extent of emphysema. There
are no standard grading systems.
Emphysematous spaces are seen as “holes” in
the lung
Serial Evaluation
Patients thought to have COPD should undergo full
pulmonary function testing at least once Testing
should also include repeated spirometry at yearly
intervals and when the patient is acutely ill. If the
FEV1 is less than 40% of the predicted normal value,
arterial blood gas analysis is advisable Annual chest
radiographs should be performed only if the patient is
a candidate for cancer surgery. Finally, the degree of
dyspnea should be documented carefully, as should
dietary intake, weight loss, and occurrence of
exacerbations.
Differential Diagnosis
The most difficult disease to differentiate from
COPD is asthma
Asthma typically begins early in life with
episodes of dyspnea and wheezing of rapid
onset and that reverse rapidly and completely.
However, patients with asthma can develop
chronic airways obstruction that reverses little
with therapy,
In these instances, the difference between
asthma and COPD can become a matter of
semantics.
Fortunately, the therapies for asthma and
COPD are similar enough so that diagnostic
uncertainties between these two entities should
have little impact on management of the
patient.
Management of COPD
Management of COPD (1)
The goals of COPD management include:
• Relieve symptoms
• Prevent disease progression
• Improve exercise tolerance
• Improve health status
• Prevent and treat complications
• Prevent and treat exacerbations
• Reduce mortality
• Prevent or minimize side effects from treatment.
Cessation of cigarette smoking should be included
as a goal throughout the management program.
Management of COPD (2)
These goals can be achieved
through implementation of a COPD
management program with four
components:
1. Assess and Monitor
Disease
2. Reduce Risk Factors
3. Manage Stable COPD
4. Manage Exacerbations
GOLD Workshop Report
Four Components of COPD
Management
• Assess and monitor
disease
• Manage exacerbations
Reduce Risk Factors
Key Points
• Reduction of total personal exposure to
tobacco smoke, occupational dusts and
chemicals, and indoor and outdoor air
pollutants are important goals to prevent the
onset and progression of COPD.
- smoking cessation
- reduction of indoor pollution
- reduction of occupational exposure
Influenza vaccination
Management of COPD
Stage 0: At Risk
Characteristics Recommended
Treatment
• Chronic symptoms
- cough
- sputum
• No spirometric
abnormalities
Management of COPD
Stage I: Mild COPD
Characteristics Recommended
Treatment
• FEV1/FVC < 70 % • Short-acting
• FEV1 > 80 % bronchodilator as
predicted needed
• With or without
symptoms
Management of COPD
Stage IIA: Moderate COPD
Characteristics Recommended
Treatment
•FEV1/FVC < 70% •Regular treatment
with one or more
•50% < FEV1< 80%
bronchodilators
predicted
•Rehabilitation
•With or without
•Inhaled glucocortico-
symptoms
steroids if significant
symptoms and lung
function response
Management of COPD
Stage IIB: Moderate COPD
Characteristics Recommended
Treatment
•FEV1/FVC < 70% Regular treatment
with one or more
•30% < FEV1 < 50%
bronchodilators
predicted
•Rehabilitation
•With or without symptoms
•Inhaled
glucocortico-steroids
if significant
symptoms and lung
function response or
if repeated
Management of COPD
Stage III: Severe COPD
Characteristics Recommended
Treatment •Regular treatment with one or
•FEV1/FVC < 70%
more bronchodilators
•FEV1 < 30% predicted •Inhaled glucocorticosteroids if
or presence of significant symptoms and lung
function response or if repeated
respiratory failure or exacerbations
right heart failure •Treatment of complications
•Rehabilitation
•Long-term oxygen therapy if
respiratory failure
•Consider surgical options
Manage ExacerbationsKey Points
Exacerbations of respiratory symptoms
requiring medical intervention are important
clinical events in COPD.