Chronic obstructive pulmonary disease is a progressive disease characterized by an inflammatory component, a violation of bronchial patency at the level of the distal bronchi and structural changes in lung tissue and blood vessels. The main clinical signs are cough with the release of mucopurulent sputum, shortness of breath, discoloration of the skin (cyanosis or pinkish color). Diagnostics is based on data from spirometry, bronchoscopy, and blood gas examination. Treatment includes inhalation therapy, bronchodilators
ICD 10
J44 Other chronic obstructive pulmonary disease
Meaning
Today, chronic obstructive disease (COPD) is distinguished as an independent lung disease and is distinguished from a number of chronic processes of the respiratory system occurring with obstructive syndrome (obstructive bronchitis, secondary emphysema, bronchial asthma, etc.). According to epidemiological data, COPD more often affects men after 40 years, occupies a leading position among the causes of disability and 4th place among the causes of mortality of the active and able-bodied part of the population.
Causes of chronic obstructive pulmonary disease
Among the causes causing the development of chronic obstructive pulmonary disease, 90-95% is attributed to tobacco smoking. Among other factors (about 5%) there are occupational hazards (inhalation of harmful gases and particles), respiratory infections of childhood, concomitant bronchopulmonary pathology, the state of the environment. In less than 1% of patients, COPD is based on a genetic predisposition, expressed in a deficiency of alpha1–antitrypsin, which is formed in liver tissues and protects the lungs from damage by the enzyme elastase.
COPD is an occupational disease of miners, railway workers, builders in contact with cement, workers in the pulp and paper and metallurgical industries, agricultural workers engaged in the processing of cotton and grain. Among the occupational hazards among the causes of COPD development are the leaders:
- contacts with cadmium and silicon
- by metal processing
- the harmful role of products formed during the combustion of fuel.
Pathogenesis
Environmental factors and genetic predisposition cause chronic inflammatory damage to the inner lining of the bronchi, leading to a violation of local bronchial immunity. At the same time, the production of bronchial mucus increases, its viscosity increases, thereby creating favorable conditions for the reproduction of bacteria, impaired bronchial patency, changes in lung tissue and alveoli. The progression of COPD leads to the loss of a reversible component (edema of the bronchial mucosa, smooth muscle spasm, mucus secretion) and an increase in irreversible changes leading to the development of peribronchial fibrosis and emphysema. Bacterial complications may be associated with progressive respiratory failure in COPD, leading to relapses of lung infections.
The course of COPD is aggravated by a gas exchange disorder, manifested by a decrease in O2 and CO2 retention in arterial blood, an increase in pressure in the pulmonary artery and leading to the formation of a pulmonary heart. Chronic pulmonary heart causes circulatory failure and death in 30% of patients with COPD.
Classification
International experts distinguish 4 stages in the development of chronic obstructive pulmonary disease. The criterion underlying the classification of COPD is a decrease in the ratio of FEV (forced expiratory volume) to FVC (forced vital capacity of the lungs) < 70%, recorded after taking bronchodilators.
- Stage 0 (pre-illness). It is characterized by an increased risk of COPD, but it is not always transformed into it. It is manifested by a constant cough and sputum secretion with unchanged lung function.
- Stage I (mild COPD). Minor obstructive disorders are detected (the volume of forced exhalation in 1 sec. – FEV1 > 80% of the norm), chronic cough and sputum production.
- Stage II (moderate course of COPD). Obstructive disorders are progressing (50% < FEV1 < 80% of the norm). There is shortness of breath and clinical symptoms that increase with exertion.
- Stage III (severe COPD). The restriction of air flow increases during exhalation (30% < FEV, < 50% of the norm), shortness of breath increases, exacerbations become more frequent.
- Stage IV (extremely severe course of COPD). It is manifested by a severe form of life-threatening bronchial obstruction (FEV, < 30% of the norm), respiratory failure, and the development of a pulmonary heart.
Chronic obstructive pulmonary disease symptoms
In the early stages, chronic obstructive pulmonary disease proceeds covertly and is not always detected in time. A characteristic clinic unfolds, starting with the moderate stage of COPD.
The course of COPD is characterized by cough with sputum and shortness of breath. In the early stages, an episodic cough with the release of mucosal sputum (up to 60 ml per day) and shortness of breath during intense exertion worries; as the severity of the disease progresses, the cough becomes constant, shortness of breath is felt at rest. With the addition of infection, the course of COPD worsens, the nature of sputum becomes purulent, its amount increases. The course of COPD can develop in two types of clinical forms:
Bronchitic type. In patients with bronchitic type of COPD, the predominant manifestations are purulent inflammatory processes in the bronchi, accompanied by intoxication, cough, copious sputum separation. Bronchial obstruction is pronounced significantly, pulmonary emphysema is weak. This group of patients is conventionally referred to as “blue puffers” due to diffuse blue cyanosis of the skin. The development of complications and the terminal stage occur at a young age.
Emphysematous type. With the development of COPD of the emphysematous type, expiratory dyspnea (with difficulty exhaling) comes to the fore in the symptoms. Emphysema of the lungs prevails over bronchial obstruction. According to the characteristic appearance of patients (pink-gray skin color, barrel chest, cachexia), they are called “pink puffers”. It has a more benign course, patients, as a rule, live to old age.
Complications
The progressive course of chronic obstructive pulmonary disease can be complicated by pneumonia, acute or chronic respiratory failure, spontaneous pneumothorax, pneumosclerosis, secondary polycythemia (erythrocytosis), congestive heart failure, etc. In severe and extremely severe COPD, patients develop pulmonary hypertension and a pulmonary heart. The progressive course of COPD leads to changes in the daily activity of patients and a decrease in their quality of life.
Diagnostics
The slow and progressive course of chronic obstructive pulmonary disease raises the question of timely diagnosis of the disease, which contributes to improving the quality and increasing life expectancy. When collecting anamnestic data, it is necessary to pay attention to the presence of bad habits (smoking) and production factors.
- FER research. The most important method of functional diagnostics is spirometry, which reveals the first signs of COPD. It is mandatory to measure the speed and volume indicators: the vital capacity of the lungs (VCL), the forced vital capacity of the lungs (FVCL), the volume of forced exhalation in 1 second. (OFV1) and others. in a post-bronchodilation test. Summation and correlation of these indicators allows to diagnose COPD.
- Sputum analysis. Cytological examination of sputum in patients with COPD allows us to assess the nature and severity of bronchial inflammation, to exclude oncological alertness. Outside of exacerbation, the nature of sputum is mucous with a predominance of macrophages. In the phase of exacerbation of COPD, sputum becomes viscous, purulent.
- Blood test. A clinical blood test in COPD reveals polycetemia (an increase in the number of red blood cells, hematocrit, hemoglobin, blood viscosity) as a consequence of the development of hypoxemia in bronchitis type of disease. In patients with severe respiratory insufficiency, the gas composition of the blood is examined.
- Chest x-ray. Lung x-ray excludes other diseases with similar clinical manifestations. In patients with COPD, the X-ray shows the compaction and deformation of the bronchial walls, emphysematous changes in the lung tissue.
The changes detected by ECG are characterized by hypertrophy of the right parts of the heart, indicating the development of pulmonary hypertension. Diagnostic bronchoscopy in COPD is indicated for differential diagnosis, examination of the bronchial mucosa and assessment of its condition, sampling for analysis of bronchial secretions.
Chronic obstructive pulmonary disease treatment
The goals of therapy for chronic obstructive pulmonary disease are to slow the progression of bronchial obstruction and respiratory failure, reduce the frequency and severity of exacerbations, improve the quality and increase the life expectancy of patients. A necessary element of complex therapy is the elimination of the cause of the disease (primarily smoking).
COPD treatment is carried out by a pulmonologist and consists of the following components:
- teaching the patient to use inhalers, spacers, nebulizers, criteria for assessing his condition and skills of self-care;
- prescribing bronchodilators (drugs that expand the lumen of the bronchi);
- prescribing mucolytics (drugs that dilute sputum and facilitate its discharge);
- administration of inhaled glucocorticosteroids;
- antibiotic therapy during exacerbations;
- oxygenation of the body and pulmonary rehabilitation.
In the case of complex, methodical and adequately selected COPD treatment, it is possible to reduce the rate of respiratory failure, reduce the number of exacerbations and prolong life.
Prognosis and prevention
Regarding a full recovery, the prognosis is unfavorable. The steady progression of COPD leads to disability. Prognostic criteria for COPD include: the possibility of excluding the provoking factor, compliance with the patient’s recommendations and therapeutic measures, the social and economic status of the patient. An unfavorable course of COPD is observed in severe concomitant diseases, heart and respiratory failure, elderly patients, bronchitis type of the disease. A quarter of patients with severe exacerbations die within a year. COPD prevention measures are the exclusion of harmful factors (refusal to smoke tobacco, compliance with occupational safety requirements in the presence of occupational hazards), prevention of exacerbations and other bronchopulmonary infections.
Literature
- Diagnostic differences in asthma and chronic obstructive pulmonary disease. Nishiyama O, Tohda Y. Rinsho Byori. 2014 May;62(5):457-63. link
- Chronic obstructive pulmonary disease in a new concept. Murărescu ED, Mitrofan EC, Mihailovici MS. Rom J Morphol Embryol. 2007;48(3):207-14. link
- The Interplay Between Immune Response and Bacterial Infection in COPD: Focus Upon Non-typeable Haemophilus influenzae. Su YC, Jalalvand F, Thegerström J, Riesbeck K. Front Immunol. 2018 Nov 5;9:2530. link
- Pathophysiology of chronic obstructive pulmonary disease. Maestrelli P. Ann Ist Super Sanita. 2003;39(4):495-506. link