Chronic Obstructive Pulmonary Disease (COPD)!

 CHRONIC ABSTRUCTIVE PULMONARY DISEASE (COPD)

Definition:

• COPD is defined as "a disease state characterized by airflow limitation that is not fully reversible and this airflow limitation is progressive associated with abnormal inflammatory response to the noxious or gaseous particles.
• According to Davidson, COPD is defined as " COPD is preventable and treatable disease characterized by airflow limitation that is usually progressive and is associated with enhanced chronic inflammatory response in the airways and lungs to the noxious particles.
• According to National Institute for Health and Clinical Excellence (NICE), COPD is defined as "Airflow obstruction with reduced FEV1/FEVc is less than 0.7, if FEV1 is greater than or equal to80%; so, diagnosis of COPD should be made on the presence of symptoms".

Signs and Symptoms:

• Shortness of breathing
• Cough
• Pink puffers and Blue Blotters or Smokers Cough (classical signs of COPD).

*Pink puffer is the major sign of emphysema.

*Blue blotters are a major sign of chronic bronchitis.

COPD includes Chronic Bronchitis and Emphysema

Difference Between Chronic Bronchitis and Emphysema

• On chronic bronchitis, there is frequent cough and sputum. 
• In emphysema, the major symptom is shortness of breath.

Emphysema is sometimes called pink puffer due to difficulty for catching air and their faces become pink for gasping air. Chronic bronchitis is often described by blue blotters which present with cough in their skin and fingertips become blue.

1.CHRONIC BRONCHITIS

Chronic bronchitis is defined as "Chronic or recurrent cough with sputum production on most of the days for at least 3 months of the year during at least 2 consecutive years."

2.EMPHYSEMA

In emphysema elastases enzyme destroy elastin. This will lead to dilatation and destruction of respiratory bronchioles, alveoli and air sacs.

Types of Emphysema:

• On the basis of Air Entrapment: 

1. Centrilobular Emphysema: Dilation of respiratory bronchioles, alveolar air sacs. Occurs due to a1-antitrypsin deficiency.
2. Panacinar Emphysema: Destruction of whole acinus. It involves acinus starting from bronchioles to alveoli.

Risk Factors of COPD:

• Smoking: 1 pack per year= No. of cigarettes smoked per day/20 *No. of years of smoking.
• Age
• Gender (more common in males due to higher smoking caese)
• Occupation (industrial workers are more prone)
• Genetic factors (a1-antitrypsin deficiency)
• Air pollution
• Socio-economic status
• Airway hyper-response (allergy)
• Proteinases/Anti-proteinases (Either increased production of proteinases or decreased production of anti-proteinases will lead to COPD.
• Oxidative stress (Imbalance between oxidants and antioxidants. Increased acetylation of histone causes increased release of inflammatory response. The imbalance results in COPD. Acetylation process also decreases the activity of a1-antitrypsin).
• Hypoxia (low level oxygen in tissue)
• Hypoxemia (low level partial o2 saturation)
• Hypercapnia (Increase level of CO2 in blood)
• Pulmonary Involvement

Management of COPD

Management of either Stable COPD or Acute Exacerbation COPD as described by NICE Guidelines stepwise approach.

Stable COPD

1. Nicotine Replacement Therapy is highly recommended.
2. Weak bronchodilators: Theophylline (we can use sustained release theophylline tablets). Theophylline decreases the activity of histone acetylase. Theophylline increases the activity of histone deacetylase. Reduction in the oxidative stress process. So, this drug can be used in COPD patients.
3. Inhaled corticosteroids 
4. Oral corticosteroids: Use possible minimum dose. 
5. Mucolytic agents: can be used in chronic COPD. Used in patients of stable COPD having increased cough with sputum.
6. Antibiotics: Erythromycin, Doxycycline is used in patients of chronic COPD.

Acute Exacerbations

1. Bronchodilators:  Metered Dose Inhalers and B2 agonists can be given with or without anticholinergic drugs depending upon situation.
2. Antibiotics: Penicillin, Macrolides, Oxytetracyclines
3. Corticosteroids
4. IV Aminophylline
5. Oxygen therapy (Long term oxygen therapy LTOT)
6. Nicotine Replacement Therapy (NRT): Varenicline and Bupropion are the two recommended drugs used as replacement of nicotine therapy.

• Transdermal Patches: Not applied on broken skin. These patches effects remain for 24hours (long time) and are used as once daily dose. However, patients may cause local skin irritation, Insomnia. 
• Gums: 2-4mg. Headaches, burning sensation, sore throat is reported with gums.
• Sub-lingual tablets: Effect occurs within 2-3 seconds.
• Lozenges: 1/2/4mg. Lozenges should be placed between gums and cheeks. Cough problems are reported with these.
• Inhalers/Nasal sprays: 10mg or as required of inhalers. Nasal sprays are recommended usually as 1 spray to each nostril.

Non-Pharmacological Therapy

1. Advice patients to stop smoking.
2. Nutritional assessment should be taken.
3. Preventing excessive exercise (to reduce breathlessness).
4. Strength training for upper and lower limbs.
5. Breathing training.
6. Counselling about their medicine and nutrition.
7. Self-management plan.
8. Psychological support.