notes by dr. Claudio Italiano
Chronic Obstructive Pulmonary Disease (COPD) is a common, preventable and
treatable disease characterized by persistent respiratory symptoms and airflow
limitation, which is due to airway and / or alveolar abnormalities usually
caused by significant exposure to harmful particles or gases, usually cigarette
smoke and environmental and domestic pollutants.
For example, even those who live by heating themselves at the home or with the
braziers, in the mountain villages where the old people are warmed
by the fireplace that is often smoky.
The main problems are the frequent exacerbations, for which a patient needs more
and more frequent admissions over time.
Chronic obstructive pulmonary disease (COPD) is also a gradual disease in the
sense that it manifests itself slowly and subtly and leads over the years to the
obstruction of the airways, ie those channels (bronchi and bronchioles) that
allow breathing, connecting the parenchyma of the lung to the first airways:
therefore it is not a reversible process, that is, once damage is created, it is
complicated or impossible to return the patient to the integrum!
Thus the clinical diagnosis of COPD should be considered in all patients with
dyspnea, persistent chronic cough or expectoration and / or a history of
exposure to risk factors for the disease. . Spirometry is required in this
clinical context for diagnosis; the presence of a post-bronchodilator VEMS / CFV
ratio <0.70 (measurements obtained with spirometry) confirms the presence of a
persistent airflow limitation and therefore of COPD in patients with adequate
symptoms and significant exposure to harmful stimuli.
Spirometry should measure the volume of expired air forcibly from a maximal
inspiration (forced vital capacity, CVF) and the volume of exhaled air during
the first second of this maneuver (maximum expiratory volume in the first second,
VEMS), so it should The ratio of these two measures (VEMS / CVF) should be
calculated.
The main symptoms of bronchitis are the hunger of air or breathlessness (see
link), called technically "dyspnea", from the Greek bad breath, which worsens,
and is accentuated with efforts (making differential diagnosis with heart
failure, coughing production and chronic expectoration The symptoms are in
practice the same as in asthma, from which it differs precisely because of the
irreversibility of airflow limitation.
COPD
It appears in adulthood; Daily and slowly progressive symptoms;
Associated with a long history of smoking; Dyspnea during exercise; Largely
irreversible expiratory air flow reduction
Asthma
It often appears in the child; Symptomatology variable according to the days,
with accesses; Often associated with allergy, rhinitis and / or eczema and
family history of asthma; More often nocturnal symptoms: greatly reversible
expiratory air flow reduction
Chronic Obstructive Pulmonary Disease (COPD) is one of the main causes of
chronic morbidity and mortality in the world and in the USA it is the fourth
leading cause of death, with a trend that is constantly increasing.
The most important risk factor of COPD is cigarette smoking, because it contains
more than 10,000 irritants and only one that gives nicotine dependence and
voluptuousness to smoking. The presence of the cigarette paper is responsible
for the presence of aromatic substances and tar that sulphides the lung and not
only, but also the smoke of pipes, cigars and other types of tobacco spread in
many countries are risk factors able to determine the onset of COPD. In addition,
cigarette smoking is responsible for AOCP, and is associated with a worsening of
the clinical picture of varicose veins, especially due to carbon monoxide,
contained in the smoke, which damages the endothelium of the vessels and the
veins themselves.
What does a healthy environment have to do with green plants that humidify the
air and lower the dust content, and then, what are the powders?
Other risk factors for COPD include:
- Dust breathed in the workplace and chemicals (vapors, irritants and fumes, see
pollution) when exposure to these substances is sufficiently intense or
prolonged
- Pollution of indoor environments determined by kitchens and heating in poorly
ventilated areas.
- External pollution the aspiration of the so-called PM10, which are inhaled
into the smaller bronchioles, whose role in determining COPD is not yet well
determined.
- Passive cigarette smoking.
The diagnosis of COPD should be considered in all subjects presenting the
characteristic symptoms of the disease and a history of exposure to risk factors,
in particular cigarette smoking
- Chronic cough:
Present daily or intermittently.
Often present all day, rarely only at night
- Chronic sputum:
- Any type of chronic sputum can indicate COPD.
- Acute bronchitis:
- Repeated episodes
- Dyspnea which is:
- Progressive (worse over time).
- Persistent (present every day).
- Worse with exercise.
- Worsens during respiratory infections.
Exposure to other risk factors
- Tobacco smoke (including some local preparation methods)
- Occupational powders and chemicals.
- Smoke coming from the combustion of kitchens and heating.
The diagnosis should be confirmed by a spirometry.
It consists of a very simple examination where the patient is connected to a
machine by means of a mouthpiece and must breathe and, above all, exhale, ie
throw out the air, in the shortest possible time.
From this individual capacity, we will evaluate some parameters, including the
vital capacity, ie how much air there is inside the lungs and the peak velocity
at the first second, ie how much air the subject is able to "throw out" to the
first second, expression of lung health.
Where it is not possible to perform a spirometry, one should arrive at the
diagnosis of COPD with all the available tools, even a good and old chest plate
can give information about (RX Thorax) symptoms and signs (dyspnea and increase
in exhalation time forced) can contribute to the diagnosis of COPD.
Low peak expiratory flow values are present in COPD, but have low specificity,
as they may also be present in other lung diseases and may be present in the
case of poorly performed tests. To improve the accuracy of the diagnosis of COPD,
it is necessary to make every effort to perform a standardized spirometry.
In spirometry it is necessary to measure:
- Forced Vital Capacity (CVF) e
- Forced Expiratory Volume in a Second (FEV1),
and calculate the FEV1 / CVF ratio. % of predicted (Tiffenau Index) - expressed
considering normal values by gender, age and height.
Patients with COPD typically have a reduction in both FEV1 and FEV1 / CVF. The
magnitude of spirometric alteration generally correlates with the severity of
COPD. However, both symptoms and spirometry alterations should be considered
before starting a personalized treatment for each patient with COPD.
The following representation shows the severity classification of airflow
limitation in COPD. Specific spirometric intervals are used to simplify.
Spirometry should be performed after administration of an appropriate dose of at
least a short-acting inhaled bronchodilator to minimize variability. Table 2.4.
Severity classification of airflow limitation in COPD (based on
post-bronchodilator VEMS)
In patients with VEMS / CVF <0.70:
GOLD 1: Mild VEMS ≥80% of predicted
GOLD 2: Moderate 50% ≤VEMS <80% of predicted
GOLD 3: Severe 30% ≤VEMS <50% of predicted
GOLD 4: Very serious VEMS <30% of predicted
It should be noted that there is only a weak correlation between VEMS, symptoms
and a reduction in the quality of life of the patient linked to health. For this
reason it is also necessary to evaluate the symptoms. A simple measure of
dyspnoea like that with the modified questionnaire of the British Medical
Research Council (mMRC)
mMRC Rank 0. I have dyspnoea only for intense efforts.
mMRC Rank 1. I am short of breath if I walk fast (or run) flat or slightly
uphill.
mMRC Grade 2. On flat paths I walk more slowly than my peers, or I need to stop
and breathe when I walk at a normal pace.
mMRC Rank 3. I need to stop to breathe after walking flat for about 100 meters
or for a few minutes.
mMRC Grade 4. I have no breath left to leave the house or to dress / undress.
An exacerbation of COPD is defined as an acute event characterized by worsening
of the patient's respiratory symptoms requiring additional therapy. These events
are classified as:
- mild (treated only with short-acting bronchodilators),
- moderate (treated with short-acting bronchodilators plus antibiotics and / or
oral corticosteroids) or
- severe (the patient requires hospitalization or an urgent visit)
Patients with COPD almost always present concomitant chronic diseases and COPD
itself is an important component of multimorbidity development especially in the
elderly in response to common risk factors (eg aging, smoking, alcohol, diet and
physical inactivity).
COPD itself has significant (systemic) extrapulmonary effects including weight
loss, nutritional changes and skeletal muscle dysfunction. The latter is
characterized by both sarcopenia (loss of muscle cells) and abnormal function of
the remaining cells, presents multifactorial causes (eg physical inactivity,
poor diet, inflammation, hypoxia) and contributes to reduced exercise tolerance
and poor health status in patients.
It is important to stress that skeletal muscle dysfunction is a treatable cause
of reduced exercise tolerance
Understanding the impact of COPD on an individual patient means evaluating the
symptoms together with the spirometric classification and / or the risk of
exacerbation.
The "ABCD" evaluation tool of the GOLD 2011 update was a step forward compared
to the simple spirometric classification system, but this is also overcome.
In the newly reviewed assessment tool, patients must undergo spirometry to
determine the severity of bronchial obstruction (spirometric degree), so they
must undergo evaluation of the degree of dyspnoea using mMRC or symptoms via CAT.
Their history of moderate and severe exacerbations (including previous
admissions) must be recorded.
This table has today been superseded by the GOLD guidelines, which correlates
the staging even with the patient's clinic, as well as simply spirometric
assessments. In fact there is a concrete problem to be faced for the patient
with COPD which is represented by the frequent bronchial exacerbations and
relapses in the pathology.
The assessment of COPD proposed by GOLD is based on the patient's symptoms level,
the future risk of exacerbations, the severity of spirometric dysfunction and
the detection of comorbidities.
The "ABCD" assessment tool in the GOLD 2011 update was an advancement compared
to the simple spirometric classification system of previous versions as it
included a multifunctional assessment and the impact generated by the symptoms,
as well as emphasizing the importance of prevention. of exacerbations in the
management of COPD. There are, however, some important limitations in this
scheme.
The "ABCD" assessment tool was not better than the spirometric degrees in
predicting mortality or other important clinical health indicators. To address
these and other topics (while maintaining consistency and simplicity for the
practical clinician), an improvement was then proposed in the GOLD 2017 Report
of the "ABCD" assessment tool that separated the spirometric severity grades
from the "ABCD" categories. ".
Therefore, the "ABCD" categories and their associated therapeutic implications
and / or rehabilitation recommendations derive exclusively from the patient's
symptoms and the history of exacerbations.
Separating the airway obstruction from the clinical parameters makes it clearer
what needs to be evaluated and classified by gravity.
This revised assessment tool recognizes the limitations of VEMS in influencing
some therapeutic decisions on the patient's personalized treatment, and
emphasizes the importance of symptoms and the risk of exacerbations of patients
with COPD.
Spirometry continues to play a key role in diagnosis, prognosis and treatment
with non-pharmacological therapies but is associated with other criteria for
framing patients.
To deepen the theme of chronic bronchitis: