Chronic Obstructive Pulmonary Disease

Physical Examination

General examination

• Cyanosis: bluish discoloration of skin, lips, and nails

• Barrel chest: increased anteroposterior diameter

• Pursed-lip breathing: voluntary or involuntary

• Accessory muscle use: neck and chest muscles

• Tripod position: leaning forward with hands on knees

Chest inspection

• Tachypnea: rapid respiratory rate

• Reduced chest expansion: asymmetry or bilateral reduction

Palpation

• Tactile fremitus: decreased or normal

• Chest wall tenderness: absent

Percussion

• Hyperresonance: increased resonance due to trapped air

Auscultation

• Diminished breath sounds: decreased intensity

• Prolonged expiratory phase: increased expiratory time

• Wheezing: high-pitched, continuous sounds during expiration

• Coarse crackles: discontinuous, low-pitched sounds, usually at lung bases

Investigations

• Laboratory

  • Complete blood count (CBC): Polycythemia: compensatory response to hypoxia

  • Arterial blood gas (ABG) analysis: Chronic respiratory acidosis, hypoxemia

  • Alpha-1 antitrypsin (AAT) level: AAT deficiency: rare genetic cause of COPD

  • Sputum culture: Identify bacterial pathogens during exacerbations

• Imaging

  • Chest X-ray (CXR): Hyperinflated lungs, flattened diaphragms, bullae

  • High-resolution computed tomography (HRCT): Assess bronchiectasis, emphysema, complications

• Pulmonary function tests (PFTs)

  • Spirometry: Reduced FEV1/FVC ratio (<0.7), FEV1 reversibility <12% or 200ml post-bronchodilator

  • Lung volumes: Increased total lung capacity (TLC), residual volume (RV)

  • Diffusing capacity of the lung for carbon monoxide (DLCO): Reduced DLCO in emphysema

• Invasive tests

  • Bronchoscopy: Evaluate complications (e.g., hemoptysis, malignancy)

  • Right heart catheterization: Assess pulmonary hypertension, cor pulmonale

• Other tests

  • Pulse oximetry: Monitor oxygen saturation at rest, during sleep, and exercise

  • 6-minute walk test (6MWT): Evaluate functional capacity, desaturation during exertion

  • Echocardiography: Assess right ventricular function, pulmonary hypertension

  • Electrocardiogram (ECG): Signs of right ventricular hypertrophy, strain, or cor-pulmonale

Management

General management:

• Smoking cessation: most important intervention to slow disease progression

• Pulmonary rehabilitation: exercise, education, and support to improve quality of life

• Oxygen therapy: long-term for chronic hypoxemia

• Vaccination: annual influenza, pneumococcal to reduce risk of infection

• Nutritional support: for weight loss and malnutrition

• Psychological support: to address anxiety and depression

• Palliative care: for symptom control and end-of-life care

Medical management:

• Short-acting bronchodilators: beta-2 agonists (e.g., salbutamol) or anticholinergics (e.g., ipratropium) for symptom relief

• Long-acting bronchodilators: beta-2 agonists (e.g., salmeterol) or anticholinergics (e.g., tiotropium) for maintenance therapy

• Inhaled corticosteroids (ICS): e.g., fluticasone, for frequent exacerbations or asthma-COPD overlap

• Phosphodiesterase-4 inhibitors: e.g., roflumilast, to reduce exacerbations in severe COPD with chronic bronchitis

• Mucolytics: e.g., N-acetylcysteine, to reduce mucus viscosity and improve expectoration

• Antibiotics: for acute bacterial exacerbations (e.g., amoxicillin, doxycycline)

• Systemic corticosteroids: for moderate to severe exacerbations (e.g., prednisolone)

Surgical management:

• Lung volume reduction surgery (LVRS): removal of emphysematous lung tissue to improve lung function in selected patients

• Bullectomy: removal of large bullae to reduce dyspnea and improve lung function

• Lung transplantation: for end-stage COPD with poor prognosis despite optimal medical management

Other management:

• Non-invasive ventilation (NIV): bilevel positive airway pressure (BiPAP) for hypercapnic respiratory failure during exacerbations

• Endobronchial valve placement: to reduce lung hyperinflation in selected patients

Airflow obstruction using GOLD staging (Global Initiative for Chronic

Obstructive Lung Disease (GOLD) staging

Long-term oxygen therapy (LTOT)

LTOT is indicated in patients with COPD to improve survival, reduce complications, and enhance quality of life. The primary goal is to correct chronic hypoxemia.

Indications for LTOT in COPD:

Confirmed by arterial blood gas (ABG) analysis on two separate occasions ≥3 weeks apart

Moderate resting hypoxemia with associated complications:

• Non-smoker

• PaO2 ≤ 55 mmHg (7.3 kPa)

or

PaO2 56-59 mmHg (7.4-7.8 kPa) plus one or more of the following:

a) Pulmonary hypertension

b) Right-sided heart failure (cor pulmonale)

c) Polycythemia (hematocrit > 55%)

The oxygen should be delivered at a flow rate of 2-4 L/min via nasal prongs

The patient should receive LTOT for at least 15 hours a day.

Management of Acute Exacerbation of COPD

An acute exacerbation of COPD is a worsening of respiratory symptoms that requires additional medical treatment. The main causes are infections (bacterial or viral) and environmental factors (e.g., air pollution). Management involves:

1. Oxygen therapy:

   • Target SpO2: 88-92%

   • Administer oxygen with caution to avoid hypercapnia and respiratory acidosis

2. Bronchodilators:

   • Short-acting beta-agonists: e.g., salbutamol via nebulizer or inhaler with spacer

   • Short-acting anticholinergics: e.g., ipratropium via nebulizer or inhaler with spacer

3. Corticosteroids:

   • Systemic: e.g., oral prednisolone (30-40 mg/day) for 5-7 days

4. Antibiotics:

   • Indicated if bacterial infection is suspected or confirmed (e.g., purulent sputum)

   • Examples: amoxicillin, doxycycline, or co-amoxiclav

5. Non-invasive ventilation (NIV):

   • Indicated for acute hypercapnic respiratory failure (pH < 7.35, PaCO2 > 6.5 kPa) despite optimal medical therapy

1. Fluid management:

   • Cautious fluid administration to avoid fluid overload

2. Monitoring and supportive care:

   • Vital signs, oxygen saturation, mental status, urine output

   • Regular arterial blood gas (ABG) analysis

   • Chest X-ray to rule out pneumonia, pneumothorax, or other complications

   • DVT prophylaxis, if indicated

3. Consider hospital admission:

   • Severe or worsening symptoms, inadequate response to initial treatment, or presence of complications

4. Follow-up and reassessment:

   • Review inhaler technique, medication adherence, and self-management plan

   • Reassess the need for long-term oxygen therapy, pulmonary rehabilitation, or other interventions