Chronic Lung Disease / COPD

Clinical Description

A ccommon disease that is preventable, treatable, and progressive and that is characterized by:

• Persistent respiratory symptoms
• Frequent exacerbations - infective and non-infective
• Airflow limitation that is not fully reversible
• Associated with abnormal inflammatory response of the airways / alveoli to noxious particles or gases
• Pulmonary and systemic effects

Risk factors

• Indoor cooking of solid fuels (biomass fuel exposure to firewood, charcoal, dung, crop residues, stove) – main risk factor in malawi
• Cigarette smoking (tobacco / cannabis, active or passive): Main risk factor globally
• Urban air pollution destructive lung disease (e.g., Tb, bronchiectasis)
• Low socioeconomic status
• aging population (longevity ↑ exposure time to risk factors)
• Poorly controlled asthma
• Impaired foetal and childhood lung growth (prematurity, childhood infections, hiv infection, maternal smoking)
• Genetic (e.g., Α1-antitrypsin deficiency).

Signs and Symptoms

• Chronic dyspnea/shortness of breath (common symptom)
• Sputum production
• Pursed lip breathing
• Prolonged expiration
• Cyanosis
• Paradoxical retraction of lower intercostal spaces during inspiration
• Decreased crico-sternal distance
• Barrel chest (hyper-inflated chest)
• Mild wheezing, even when they are not under acute distress
• Hyperresonance percussion note
• Coarse basal crackles
• Apex beat difficult to localize
• Loss of cardiac dullness
• Distant heart sounds
• Liver displaced inferiorly
• Raised Jugular Vein Pressure, hepatomegaly and pedal oedema if right heart failure (in severe COPD)

Complications of COPD

• Acute exacerbations
• Spontaneous pneumothorax
• Cor pulmonale and right heart failure
• Arrhythmias
• Polycythaemia
• Skeletal muscle wasting/cachexia
• Worsening of comorbidities (heart failure, obstructive sleep apnoea)
• Osteoporosis (recurrent use of oral steroids)
• Diabetes mellitus (recurrent use of oral steroids)
• Metabolic syndrome (multiple use of oral steroids and inactivity)
• Normocytic anaemia
• Depression / anxiety
• Lung cancer (if smoker)
• Death

Investigations

• Oxygen saturation: hypoxia (if severe COPD)
• CXR can reveal hyper-inflated lungs
• flattened diaphragms
• small heart shadow
• teardrop shaped heart shadow
• increased retrosternal air space
• Spirometry is needed to confirm the diagnosis of COPD
• Post-bronchodilator FEV1 / FVC < 70%

Treatment

Treatment objectives

• Advise patients to stop smoking if they are smokers.
• Avoid indoor cooking in poorly ventilated kitchen / homes if possible

Non-pharmacological

• Advise to stop smoking and exposure to biomass fuel

Pharmacological

• Step 1: Inhaled salbutamol 2puffs prn or ipratropium bromide inhaler
• Step 2: if not improving on step 1 treatment: add aminophylline 100mg 8 hourly

PO or long-acting beta –agonists inhaler (salmeterol or formoterol) or long-acting muscarinic antagonists (tiotropium inhaler) if available. Refer to specialist clinic

• Step 3: add inhaled corticosteroid (e.g., beclomethasone, fluticasone) if frequent exacerbator- ≥ 2 exacerbations in past 12 months or FEV1 <50% predicted

Note:

• If COPD patient requires surgery, please stabilize the COPD first before surgery and refer to specialist if need be.
• Refer to specialist if COPD patient has chronic hypoxia for further evaluation