Disease state characterized by chronic airflow limitations which is not fully reversible

includes emphysema

Includes chronic bronchitis

Includes small airways disease (narrowing of small brinchioles)

cig smoke activates epithelial cells and alveolar macrophages

cytokines are released by the above

neutraphils and macrophages are recruited and accumulate in alveoli and respiratory bronchioles

loss sof cillia, = dec clearing

inflammation: can lead to inhibition of antiproteinases and lower colonization with P.aeruginosa is common

WBC recruited and can cause damage

neutrophil proteinases and macrophage proteinases.

macrophase induced injury seems to be most important relative to cig smoke induced copd.

-collagen metabolism is complex and inc collagen deposition around small airways is often found

 cell death: both cells and matrix disappear leading to airspace enlargement. it may be the loss of matrix leads to apoptosis of the alveolar cellls

ineffective repair: limited ability to repair alveolar damage, as well as the extracellular matrix

squamous metaplasia in bronchi (dec ciliary clearance of mucous)

hypertrophy of bronchial smooth muscle

Bronchial hyperreactivity (air flow obstruction)

clara cells (surfactant) replaced by goblet cells -mucus cells

airway narrowing secondary to fibrosis, edema, cellular inflammation, mucus

loss of patency seconday to loss of parenchyma

above changes may lead to hypperreactivity

destruction of respiratory bronchioles, alveolar ducts, and alveoli (gas exchange)

macrophages accumulate

loss of support for the small and large airways

loss of elastic recoil

impaired movement of air

obstructive pattern on spirometry

decreased elastic recoil

++dec support for the airways, which then dec in cross-sectional area resulting in inc resistance

air trapping: incomplete expiration

=inc residual vol

hyperinflation (inc work of breathing)

flattening of the diaphragm -adversely affects bellows function-requiring greater effort to effect inspiration

auto PEEP (positive end-expiratory pressure) can increase the work of breathing 

V/Q mismatch accounts for the PA02 reduction

can lead to pulm hypertension when the Pa02 is <55 mmhg (hypoxic vasocinstriction)

May lead to cor pulmonale and rv failure

-Airflow limitation (loss of recoil)

-airflow obstruction

-inc work of breathing

-hypoxia from v/q mismatch

-hypoxemia->inc pulm vascular tone->pulm htn->cor pulmonale 

1. Older onset >40yo

2.atopy uncommon

3. not fully responsive to bronchodilators

4. BMI low

5. dec breath sounds

6. morning cough -productive

7. dec diffusing capacity

8. dyspnea persistent

9. fam hx variable

10. noct sym uncommon

11. progressive

12. purulent sputum uncommon

13. poor response to corticosteroids

14. 90-95% smoking

dyspnea

cough (chronic-progressive)

sputum production  (3+mo/2yr), clear, or purulent=inflammation, large amounts=bronchiectasis

wheezing and chest tightness

-hyperinflation of chest-accessory muscles, pursed lips, reduced expansion

-prolonged expiration

-distant breath sounds

-hyperresonant chest

-signs of cor pulmonale

-signs of hyposxemia: cyanosis, clubbing

-cachexia

-Spirometry=obstructive

not for large populations

symptomatic patients with risk factors should be screened

1. control symptoms

2. improve exercise tolerance

3. dec frquency and severity of exacerbations

FEV1/FVC = <70%

FEV1> 80% predicted

++with or without symptoms

=tx with short-acting bronchodilator when needed

FEV1/FVC <70%

50%<FEV1<80% predicted

with or without symptoms

Tx with = one or more long-acting bronchodilators and rehabilatation

FEV1/FVC <70%

30%<FEV1<50% predicted

with or without symptoms

Tx= one or more bronchodilators, inhaled corticosteroids for patients with repeated exacerbations or persistent symps + rehab

FEV1/FVC <70%

FEV1<30% or FEV1 <50% predicted plus:

chronic respiratory failure

paO2<60mmhg

TX=one or more bronchodilators, inhaled corticosteroid, rehab, 02 therapy

TX=

1. FVC dec

2. FEV1 dec

3. FEF25-75 dec

4.MVV dec

5.FRC inc

6.RV inc

7. TLC inc

1. FVC dec

2. FEV1 dec

3. FEF25-75 dec

4.MVV dec

5.FRC dec

6.RV dec

7. TLC dec

does not inc survival rates for moderate hypoxemia or nocturnal desaturation

-beneficial for short-term during activity/exercise

dyspnea at rest

new use of accessory muscles

change in mental status

inc vent rate >25 breaths/min

hypoxemia (cyanosis)

1. equipotent bronchodilators

2. longer acting bronchodilator

1. albuterol

2. ipraatropium

++combo has greater effect

follow up

1 mild

2. moderate

3. severe

1. annually

2. every 3-6 mo

3. every 2-4 mo