COPD英文课

Chronic Obstructive Pulmonary Disease (COPD),Guohua ZhenTongji 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,1965 - 1998,1965 - 1998,1965 - 1998,1965 - 1998,1965 - 1998,59%,64%,35%,+163%,7%,CoronaryHeartDisease,Stroke,Other CVD,COPD,All OtherCauses,Why COPD is Important ?,COPD is the only chronic disease that is showing progressive upward trend in both mortality and morbidityIt is expected to be the third leading cause of death by 2020Approximately 3% Chinese above 15 are currently suffering from COPD,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 cigarette 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 15% in elderly over 50 y.,Etiology and mechanism,Environment FactorsCigarette smokingOccupational dusts and chemicalsInfectionsHost FactorsGenes Lung growth and defense mechanism,Chronic Bronchitis,Clinical manifestation,Character: chronic onset, recurrent attack and long course of diseaseMain 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 stage2. sometimes moist rales and rhonchi,Examination,Chest x-ray imaging,Examination,Pulmonary function 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 years（3m/y2y）, excluding other chronic lung diseases (TB, Bronchiectasis )Definite chest imaging or lung function,Typing,Typing :1、simple：cough, sputum2、wheezing：with wheezing (actually Chronic bronchitis plus asthma),Emphysema,Definition,Emphysema is characterized by enlargement and destruction of respiratory bronchioles and /or alveoli in the lungs.,Etiology,Environment FactorsCigarette smokingOccupational dusts and chemicalsInfectionsHost FactorsGenes: Alpha1-antitrypsin deficiency,Contributing factor,Airway obstruction due to chronic inflammationDamaged bronchial cartilage and lead to the loss of supporting functionIncreased activity of proteinase due to chronic airway inflammation or smokingAlpha1-antitrypsin deficiencyOthers: Poor nutrition of alveoli or respiratory bronchiole due to decreased blood supply because of oppression of high airway pressure,Cigarette smoke,Alveolar macrophage,Neutrophil,PROTEASES,Alveolar wall destruction,(Emphysema),Mucus hypersecretion,(Chronic bronchitis),PROTEASEINHIBITORS,Neutrophil chemotactic factors,CELLULAR MECHANISMS OF COPD,Neutrophil elastase,Cathepsins,Matrix metalloproteinases,Cytokines (IL-8),Mediators (LTB4),?,CD8+,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 thinnerAlveolar sacs enlargementRupture of alveoli and formation of bleb,Pathological 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 , PaCO2 Airflow obstruction / airway narrowingmucus pluggingairway inflammation, edema, fibrosisairway collapse due to alveolar wall destructionHyperinflation: air trappingGas exchange defects- PaO2 Destruction of alveolar wall/alveolar-capillary membraneV/Q mismatch (shunt),Clinical manifestation,Symptom1. cough, sputum and/or wheezing2. gradually progressive dyspnea, shortness of breath, chest tightness,Clinical manifestation,Sign:1. not obvious in early stage2. typical sign: barrel chest, decreased chest movement, diminished tactile fremitus, hyperresonance, decreased vesicular breath sound and prolong expiration or wheeze,Examination,Pulmonary function testDiagnosisAssessing severityAssessing prognosisMonitoring progression,Examination: pulmonary function test,Dynamic lung functionairflow obstructionFEV1, FEV1/FVCStatic lung functionhyperinflation TLC, FRCair trapping RV,FEV1/FVC, FEV1 % predicted to estimate obstruction and severity。Bronchodilator Reversibility Testing: to detect the reversibility, after bronchodilator, FEV1/FVC 40%,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 wideningDiaphragm are low and flatVascular marking deficiencyShadow of the heart narrowing,low, flat diaphragms, hyperlucency, vascular marking deficiency,Diagnosis,1、Smoking history2、Symptom: cough, sputum production, gradually progressive dyspnea3、Sign：emphysema4、PFT: airway flow limitation,COPD classification based on pulmonary function test,Clinical Features of COPD Patients of different severity,Mild COPD: no abnormal signs, smokers cough, little or no breathlessnessModerate COPD: breathlessness with/without wheezing, cough with/without sputumSevere 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 ExacerbationsStable,Acute exacerbation of COPDAE-COPD,“Exacerbation” of COPDRespiratory dyspnea / chest tightness cough / sputum, purulentSystematicdecreased activity, fatigue, headache, poor appetite, somnolence,Differential diagnosis,Bronchial asthma: reversibility of the airflowBronchiectasis: especially mild patients, chronic cough and mucus sputumPulmonary TB：positive anti-fast smearBronchogenic 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 mortalityImprove quality of life symptoms exercise tolerance exacerbationsMinimal side-effects,Goals,Non-pharmacologic Therapies,Adjustment Therapy & Education,Avoidance of Tobacco & Pollution,Vaccination,Nutrition,Lung Volume Reduction or Transplant,Exercise & Rehabilitation,COPD,Smoking cessationPhysician intervention criticalMultidisciplinary approachWithdrawalanxiety, irritability, difficult concentrating, sleep disruption, fatigue, drowsiness, depressionNicotine replacement withdrawal symptomsnicotine gum (2 mg = cigarette)transdermal nicotine patches x 8 wks20-40% / 6 mos vs 5-20% / 6 mos with placebo,Effects of Smoking and Smoking Cessation on FEV1,0,25,50,75,100,25,50,75,Age (years),FEV1(%),COPD: Pharmacology,BronchodilatorsCorticosteroidsLong term oxygen therapyManagement of COPD exacerbations,COPD: Pharmacology,2-agonist bronchodilatorsRapid-acting 2-agonists (SABA)salbutamol, terbutalinesymptomatic reliefpre-exertional2 puffs 4-6 x /d prnminimal riskLong acting 2-agonists (LABA)salmeterol, formoterolregular therapy1-2 puffs bidbenefit: activity / exertion, QOL,COPD: Pharmacology,Anticholinergic bronchodilatorsBenefits vs RisksRegular therapySymptomatic benefit? exacerbationsMinimal s/edry mouth, urinary retentionAgentsIpratropium /Atrovent4-6 puffs qidTiotropium /Spiriva1 puff qd,COPD: Pharmacology,TheophyllineMultiple effectsbronchodilation, respiratory stimulant, improved cardiovascular function, improved diaphragm functionLimited role because of narrow therapeutic windows/e GI, CNS, cardiacqd - bid dosing with long-acting preparations,COPD: Pharmacology,Inhaled SteroidsSymptomatic COPD patients with “asthmatic” tendency (20%)FEV1 18 hrs /dImproved survival, right heart failureImproved exercise tolerance, QOLIndicationsPaO2 55 mmHg (SaO2 88%),COPD: Exacerbations,Oxygenation: low concentration oxygen therapyRisks of excessive O2 (PaO2 100 mmHg)hypercapnia ( PaCO2 )acidemia ( pH 0.8 L)Lung volume reduction surgery (LVRS),prognosis,Relate to the value of FEV1FEV11.2L survive for 10y， FEV11.0 L survive for 5y ，FEV11, in V51)Rv1+Sv5 1.05mVP-pulmonale pattern(an increase in P wave amplitude in II, III, AVF),Examination,Echocardiography 1、inner diameter of RV outflow (30mm)，2、RV internal dimension(20mm)，3、RV anterior wall thickening4、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 imbalan