What degree of COPD is a disability? COPD - details about the disease and its treatment COPD 3 4 stages
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Chronic obstructive pulmonary disease (COPD) - 4 stages
Chronic obstructive pulmonary disease is a pathology in which irreversible changes in the lung tissue occur. As a result of the inflammatory reaction to the influence of external factors, the bronchi are affected and emphysema develops.
The air flow rate decreases, resulting in respiratory failure. The disease inevitably progresses, gradually causing destruction of the lungs. In the absence of timely measures, the patient faces disability.
A fatal outcome cannot be ruled out - according to the latest data, the disease ranks fifth in mortality. A classification specially developed for COPD is of great importance for the correct selection of treatment therapy.
Causes of the disease
The development of pulmonary obstruction occurs under the influence of various factors.
Among them, it is worth highlighting the conditions that predispose to the occurrence of the disease:
- Age. The highest incidence rate is observed among men over 40 years of age.
- Genetic predisposition. People with congenital deficiencies of certain enzymes are especially susceptible to COPD.
- The impact of various negative factors on the respiratory system during intrauterine development.
- Bronchial hyperactivity occurs not only with prolonged bronchitis, but also with COPD.
- Infectious lesions. Frequent colds both in childhood and in older age. COPD has common diagnostic criteria with diseases such as chronic bronchitis and bronchial asthma.
- Smoking. This is the main cause of morbidity. According to statistics, in 90% of all cases those suffering from COPD are experienced smokers.
- Harmful working conditions when the air is filled with dust, smoke, and various chemicals that cause neutrophilic inflammation. Risk groups include construction workers, miners, workers in cotton mills, grain drying shops, and metallurgists.
- Air pollution from combustion products when burning wood, coal).
Long-term influence of even one of the listed factors can lead to obstructive disease. Under their influence, neutrophils manage to accumulate in the distal parts of the lungs.
Pathogenesis
Harmful substances, such as tobacco smoke, negatively affect the walls of the bronchi, which leads to damage to their distal sections. As a result, the discharge of mucus is disrupted and small bronchi are blocked. With the addition of infection, inflammation moves to the muscle layer, provoking the proliferation of connective tissue. Broncho-obstructive syndrome occurs. The parenchyma of the lung tissue is destroyed, and emphysema develops, in which the release of air is difficult.
This becomes one of the causes of the most basic symptom of the disease – shortness of breath. Subsequently, respiratory failure progresses and leads to chronic hypoxia, when the entire body begins to suffer from lack of oxygen. Subsequently, with the development of inflammatory processes, heart failure occurs.
Classification
The effectiveness of treatment largely depends on how accurately the stage of the disease is determined. COPD criteria were proposed by the GOLD Expert Committee in 1997.
The indicators of FEV1 were taken as a basis - the volume of forced expiration in the first second. According to the severity, it is customary to define four stages of COPD - mild, moderate, severe, and extremely severe.
Mild degree
Pulmonary obstruction is mild and rarely accompanied by clinical symptoms. Therefore, diagnosing mild COPD is not easy. In rare cases, a wet cough occurs; in most cases, this symptom is absent. With emphysematous obstruction, only mild shortness of breath is observed. The air passage in the bronchi is practically not impaired, although the gas exchange function is already decreasing. The patient does not experience a deterioration in the quality of life at this stage of the pathology, so, as a rule, he does not consult a doctor.
Average degree
In the second degree of severity, a cough begins to appear, accompanied by the release of viscous sputum. A particularly large amount of it gathers in the morning. Endurance is noticeably reduced. Shortness of breath occurs during physical activity.
COPD stage 2 is characterized by periodic exacerbations when the cough is paroxysmal in nature. At this moment, sputum with pus is released. During an exacerbation, moderate emphysematous COPD is characterized by the appearance of shortness of breath even in a relaxed state. With the bronchitis type of illness, you can sometimes hear wheezing in the chest.
Severe degree
COPD stage 3 occurs with more noticeable symptoms. Exacerbations occur at least twice a month, which sharply worsens the patient’s condition. Obstruction of the lung tissue increases, and bronchial obstruction forms. Even with little physical activity, shortness of breath, weakness, and darkness appear in the eyes. Breathing is noisy and heavy.
When the third stage of the disease begins, external symptoms also appear - the chest expands, acquiring a barrel-shaped shape, blood vessels become visible on the neck, and body weight decreases. With the bronchitis type of pulmonary obstruction, the skin becomes bluish. Considering that physical endurance is reduced, the slightest effort can lead to the patient becoming disabled. Patients with third degree bronchial obstruction, as a rule, do not live long.
Extremely severe
At this stage, respiratory failure develops. In a relaxed state, the patient suffers from shortness of breath, coughing, and wheezing in the chest. Any physical effort causes discomfort. A pose in which you can lean on something helps to make exhalation easier.
The condition is complicated by the formation of cor pulmonale. This is one of the most severe complications of COPD, which results in heart failure. The patient is unable to breathe on his own and becomes disabled. He requires constant hospital treatment and has to constantly use a portable oxygen tank. The life expectancy of a person with stage 4 COPD is no more than two years.
For this COPD classification, severity levels are determined based on spirometry test readings. Find the ratio of the forced expiratory volume in the 1st second (FEV1) to the forced vital capacity of the lungs. If it is no more than 70%, this is an indicator of developing COPD. An indicator of less than 50% indicates local changes in the lungs.
Classification of COPD in modern conditions
In 2011, a decision was made that the previous GOLD classification was insufficiently informative.
Additionally, a comprehensive assessment of the patient’s condition was introduced, which takes into account the following factors:
- Symptoms.
- Possible exacerbations.
- Additional clinical manifestations.
The degree of shortness of breath can be assessed using a modified questionnaire called the MRC Scale for diagnosis.
A positive answer to one of the questions determines one of 4 stages of obstruction:
- The absence of the disease is indicated by the appearance of shortness of breath only with excessive physical exertion.
- Mild degree - shortness of breath occurs from fast walking or with a slight rise up.
- A moderate walking pace that causes shortness of breath indicates a moderate degree.
- The need to rest while walking at a leisurely pace on a level surface every 100 meters is a suspicion of moderate COPD.
- Extremely severe degree - when the slightest movements cause shortness of breath, which is why the patient cannot leave the house.
To determine the severity of respiratory failure, an indicator of oxygen tension (PaO2) and an indicator of hemoglobin saturation (SaO2) are taken. If the value of the first is more than 80 mmHg, and the second is at least 90%, this indicates that the disease is absent. The first stage of the disease is indicated by a decrease in these indicators to 79 and 90, respectively.
At the second stage, memory impairment and cyanosis are observed. Oxygen tension decreases to 59 mmHg. Art., hemoglobin saturation – up to 89%.
The third stage is characterized by the signs indicated above. PaO2 is less than 40 mm Hg. Art., SaO2 is reduced to 75%.
All over the world, doctors use the CAT test (COPD Assessment Test) to assess COPD. It consists of several questions, the answers to which help determine the severity of the disease. Each answer is scored on a five-point system. You can talk about the presence of a disease or an increased risk of acquiring it if the total score is 10 or more.
To give an objective assessment of the patient’s condition, to assess all possible threats and complications, it is necessary to use a complex of all classifications and tests. The quality of treatment and how long a COPD patient will live will depend on correct diagnosis.
Phases of the disease
Generalized obstruction is characterized by a stable course followed by exacerbation. It manifests itself in the form of pronounced, developing signs. Shortness of breath, coughing intensifies, and general health deteriorates sharply. The previous treatment regimen does not help, we have to change it and increase the dosage of medications.
Even a minor viral or bacterial infection can cause an exacerbation. A harmless acute respiratory infection can reduce lung function, which will require a long time to return to its previous state.
In addition to patient complaints and clinical manifestations, blood tests, spirometry, microscopy, and laboratory examination of sputum are used to diagnose exacerbations.
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Chronic obstructive pulmonary disease.
Clinical forms of COPD
Doctors distinguish two forms of the disease:- Emphysematous. The main symptom is expiratory shortness of breath, when the patient complains of difficulty exhaling. In rare cases, a cough occurs, usually without sputum production. External symptoms also appear - the skin turns pink, the chest becomes barrel-shaped. For this reason, patients with emphysematous COPD are called “pink puffers.” They usually can live much longer.
- Bronchitic. This type is less common. Of particular concern to patients is a cough with a large amount of sputum, and intoxication. Heart failure quickly develops, as a result of which the skin acquires a bluish tint. Conventionally, such patients are called “blue swelling”.
The division into emphysematous and bronchitis types of COPD is quite arbitrary. Usually there is a mixed type.
Basic principles of treatment
Considering that the first stage of COPD is practically asymptomatic, many patients come to the doctor late. Often the disease is detected at a stage when disability has already occurred. Therapeutic therapy is aimed at alleviating the patient's condition. Improved quality of life. There is no talk of a complete recovery. Treatment has two directions - medicinal and non-pharmacological. The first involves taking various medications. The goal of non-pharmacological treatment is to eliminate factors influencing the development of the pathological process. This includes quitting smoking, using personal protective equipment in hazardous working conditions, and physical exercise.
It is important to correctly assess how serious the patient’s condition is, and if there is a threat to life, ensure timely hospitalization.
Drug treatment for COPD is based on the use of inhaled drugs that can widen the airways.
The standard regimen includes the following medications based on:
- Spiritiotropium bromide. These are first-line drugs used only for adults.
- Salmeterol.
- Formoterol.
They are produced both in the form of ready-made inhalers and in the form of solutions and powders. Prescribed for moderate and severe COPD,
When basic therapy does not give a positive result, glucocorticosteroids can be used - Pulmicort, Beclazon-ECO, Flixotide. Hormonal agents in combination with bronchodilators are effective - Symbicort, Seretide.
Disabling shortness of breath, chronic cerebral hypoxia are indications for long-term use of humidified oxygen inhalation.
Patients diagnosed with severe COPD require ongoing care. They are unable to perform even the simplest self-care activities. It is very difficult for such patients to take a few steps. Oxygen therapy, carried out at least 15 hours a day, helps to alleviate the situation and prolong life. The effectiveness of treatment is also influenced by the patient’s social status. The treatment regimen, dosage and course duration are determined by the attending physician.
Prevention
Preventing any disease is always easier than treating it. Pulmonary obstruction is no exception. Prevention of COPD can be primary and secondary.
The first includes:
- Complete smoking cessation. If necessary, nicotine replacement therapy is carried out.
- Stopping contact with occupational pollutants both in the workplace and at home. If you live in a contaminated area, it is recommended to change your place of residence.
- Treat colds, ARVI, pneumonia, bronchitis in a timely manner. Get a flu shot annually.
- Maintain hygiene.
- Engage in hardening of the body.
- Do breathing exercises.
If it was not possible to avoid the development of pathology, secondary prevention will help reduce the likelihood of exacerbation of COPD. It includes vitamin therapy, breathing exercises, and the use of inhalers.
Periodic treatment in specialized sanatorium-type institutions helps maintain the normal state of lung tissue. It is important to organize working conditions depending on the severity of the disease.
Chronic obstructive pulmonary disease (COPD) is a pathology of lung tissue that arises and progresses from the harmful influence of external factors. This restricts the air flow. After the cessation of the harmful effects and appropriate treatment, the lung tissue is not restored or is only partially restored. COPD is classified according to various indicators.
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Classification of COPD by severity (GOLD)
The classification of COPD is very important in the treatment of the disease. The patient’s subsequent therapy depends on how accurately the stage is determined. In 2006, the Global Initiative on COPD (GOLD) identified four stages of the disease:
- Mild stage - rarely has clinical symptoms. The obstruction is mild, cough may be absent, and is difficult to diagnose.
- Moderate stage - tissue obstruction increases. Shortness of breath appears, more often during physical activity.
- Severe stage - the disease often worsens, shortness of breath increases, clinical manifestations progress.
- An extremely severe stage - deterioration of the patient's condition, often life-threatening. Bronchial obstruction is pronounced and leads to disability. Pulmonary heart syndrome develops.
Classification of COPD severity (according to post-bronchodilator FEV1 GOLD2007)
This classification is based on spirometry test performance. Forced expiratory volume in the first second (FEV1) and forced vital capacity (FVC) are determined. And then they find the ratio of the first indicator to the second. Only post-bronchodilator values are taken into account. Regardless of the stage of the disease, an FEV1/FVC value below 70% may be the first sign of developing bronchial obstruction.
FEV1 indicators correspond to the stages of the disease:
- Forced exhalation is 80%.
- FEV1 decreases below 80%, but not less than 50%.
- The figure drops to 30%.
- FEV1 less than 30%. Or cor pulmonale is present.
A classification of bronchial obstruction was carried out. A disease is considered chronic if exacerbations occur more than three times a year, regardless of treatment.
Change in COPD GOLD2011 classification
In 2011, the Global Initiative decided that the previous classification of COPD was not sufficiently informative. The correspondence between spirometric indicators and stages of the disease remains the same. But the overall assessment of the patient’s condition becomes complex.
The following factors are additionally taken into account:
- Symptoms;
- the likelihood of exacerbations;
- the presence of additional clinical manifestations (comorbid conditions).
MRC scale
The MRC is a modified questionnaire that is used in the diagnosis of COPD and assesses the severity of shortness of breath. Created by the British Medical Research Council. It gives the best results together with other methods of classification and diagnosis, and allows one to make a prediction regarding the risk of death. The severity is determined by a positive answer to one of the questions:
- Absence of illness - shortness of breath can occur only in case of heavy physical exertion.
- Mild degree - shortness of breath is caused by walking at a fast pace or minor climbs.
- Moderate - walking at a moderate pace causes shortness of breath; rest is required when walking slowly on level ground.
- Severe degree - rest due to shortness of breath occurs every 100 m when walking slowly without climbing up, that is, in 10 minutes of travel the patient stops 2 - 3 times.
- Extremely severe - the patient cannot leave the house, even minor movements lead to shortness of breath.
How to assess the severity of respiratory failure?
The degree of external respiration insufficiency is assessed by indicators of oxygen tension (PaO2) and hemoglobin saturation (SaO2).
In the absence of disease, PaO2 is more than 80 mm Hg. Art., and SaO2 more than 90%.
- In the initial stage of the disease, the indicators drop to 60-79 and 90-94, respectively. There are no clinical manifestations in both cases.
- The second stage of respiratory failure is accompanied by cyanosis and memory impairment. Oxygen tension indicators are reduced to 40-59, and hemoglobin saturation to 75-89.
- In the third stage, in addition to the above symptoms, loss of consciousness may also be observed. PaO2 is less than 40 mm Hg. Art., SaO2 less than 75%.
CAT test (COPD Assessment Test) for assessing COPD
The CAT test has been translated into many languages and is used throughout the world. These are 8 questions asked to the patient, which reliably allow you to assess the severity of his illness. Each question is scored from 0 to 5 points. If the total score is greater than or equal to 10, this indicates a high risk of obstruction or the presence of a disease.
COPD is classified by severity. The classification is based on two criteria: clinical, taking into account the main clinical symptoms - cough, sputum and shortness of breath; functional - taking into account the degree of irreversibility of airway obstruction. All FEV 1 values given in the classification are post-bronchodilator, i.e. measured after the use of bronchodilators (beta-2 agonists or anticholinergics).
Classification of COPD by severity (gold, 2003)
Stage 0 – increased risk of developing COPD. Characterized by the presence of occupational risk factors and/or nicotine addiction, manifested by chronic cough and sputum production in response to exposure to risk factors against the background of normal lung function. This stage is interpreted as a pre-disease, which does not always result in the development of classic COPD.
Stage 1 - mild COPD, in which everyday physical activity does not cause respiratory discomfort, but obstructive pulmonary ventilation disorders are detected (FEV 1 / FVC less than 70%), patients are bothered by chronic cough and sputum production.
Stage 2 – moderate course of COPD, in which patients seek medical help due to shortness of breath and exacerbation of the disease, which is caused by an increase in broncho-obstructive disorders (FEV 1 less than 80%, but more than 50%, FEV 1, FEV 1 / FVC less than 70% of proper values), increased shortness of breath is noted.
Stage 3 – severe COPD, characterized by a further increase in airflow limitation (FEV 1 less than 50%, but more than 30% of the expected values, FEV 1 /FVC less than 70%), increasing shortness of breath, the frequency of exacerbations of the disease, which affects the quality of life of patients .
Stage 4 is an extremely severe course of COPD, in which the quality of life noticeably deteriorates, and exacerbations can be life-threatening. The disease becomes disabling and is characterized by extremely severe bronchial obstruction: FEV 1/FVC less than 70%, FEV 1 less than 30% of predicted, or FEV 1 less than 50% of predicted with the presence of pronounced signs of respiratory failure.
At formulation of the diagnosis of COPD the severity of the disease is indicated: mild (stage I), moderate (stage II), severe (stage III) or very severe (stage IV); phase of the process: remission or exacerbation; DN; presence of complications; concomitant diseases that influence the severity of COPD.
Clinic of chronic obstructive pulmonary disease
Complaints.
Cough is the earliest symptom of the disease. It is chronic in nature, observed every day or from time to time in the damp, cold season after ARVI.
Separation of a small (no more than 100 ml per day) amount of mucous, mucopurulent or purulent sputum of varying viscosity. Sputum comes out mainly in the morning. Sputum production is chronic.
Shortness of breath during physical exertion, and in advanced cases, at rest, more pronounced in the morning, decreasing after coughing up sputum and depending on weather conditions and respiratory infection. Dyspnea is progressive, intensifies over time, initially expiratory, and then mixed.
Increased sweating, especially at night.
General weakness, decreased performance (during exacerbations of the disease).
Anamnestic data. When collecting anamnesis from a patient, it is necessary to clarify the following points.
Were there any nasal breathing problems or diseases of the nasopharynx (rhinitis, tonsillitis, sinusitis, pharyngitis, etc.).
Tobacco smoking (experience, number of cigarettes smoked per day).
Occupational hazards (working in conditions of smoke and air pollution, contact with aerosols from electric and gas welding, flour dust), contact with smoke when using biological fuel for heating and cooked food.
Hereditary predisposition.
Frequent hypothermia.
Objective data detected in a patient with COPD.
At examination, palpation of the chest, percussion of the lungs in the first and second stages of the disease, no changes are detected, but in the third and fourth stages, signs of pulmonary emphysema are detected (see the corresponding section).
At auscultation lungs, you can detect hard breathing, prolongation of exhalation (with the development of pulmonary emphysema, breathing becomes weakened), dry scattered wheezing of various timbres, mainly in the exhalation phase. Low-pitched wheezing is better heard when inhaling, and high-pitched wheezing is better heard when exhaling. In the presence of liquid sputum in the bronchi, silent moist rales may be heard, the timbre of which depends on the caliber of the bronchi.
Signs of bronchial obstruction syndrome are revealed:
the variable nature of shortness of breath and its dependence on weather conditions (air temperature, humidity), time of day (worsening at night), exacerbations of pulmonary infection;
difficulty in exhalation and its lengthening compared to the inhalation phase;
hacking cough, increasing shortness of breath;
the patient feels wheezing in the chest during shortness of breath;
dry, high-pitched wheezing during quiet breathing or forced exhalation (detected by auscultation of the lungs).
Laboratory and instrumental diagnosis of chronic obstructive pulmonary disease. Principles of treatment and prevention
Data from laboratory research methods.
Complete blood count: an increase in the number of red blood cells, an increase in hematocrit above 55%, an increase in hemoglobin levels, a decrease in ESR (signs of chronic respiratory failure), neutrophilic leukocytosis with a shift in the nuclear formula of neutrophils to the left and an increase in ESR (signs of exacerbation of the disease).
Biochemical blood test: with exacerbation of COPD - an increase in the level of indicators of the acute phase of inflammation.
General analysis of sputum: mucous, mucopurulent or purulent; viscous; microscopy reveals a significant number of leukocytes, mainly neutrophils, bronchial epithelial cells.
X-ray examination of the lungs.
Deformation and strengthening of the pulmonary pattern.
Expansion and compaction of the roots of the lungs.
Signs of pulmonary emphysema.
Bronchoscopy: the mucous membrane of the bronchial tree is diffusely hyperemic, edematous, deposits of mucus and pus on the walls, deformation, uneven diameter and unevenness of the internal contour of the bronchi, subsequently - signs of atrophy of the bronchial mucosa.
Spirography and pneumotachography: a decrease in forced expiratory volume in the first second (FEV I), a decrease in the Tiffno index, and with emphysema - a decrease in vital capacity (VC).
Principles of treatment and prevention.
For chronic obstructive pulmonary disease, medications are used that improve bronchial patency: M-anticholinergics (Atrovent), ß-adrenergic agonists (salbutamol, Berotek), myotropic antispasmodics (aminophylline). In case of exacerbation of the disease, antibacterial drugs are prescribed, as well as expectorants and mucolytic drugs. For purulent inflammatory processes, therapeutic bronchoscopy with endobronchial administration of drugs is used.
Prevention of chronic obstructive pulmonary disease involves quitting smoking, systematically combating air pollution, sanitizing foci of chronic infection, and rationally employing patients.
The concept of bronchial obstruction syndrome and its clinical manifestations
Bronchial obstruction syndrome (bronchial obstruction syndrome) is a pathological condition characterized by difficulty in the passage of air through the bronchi due to a narrowing of their lumen with an increase in resistance to air flow during ventilation of the lungs.
The following mechanisms underlie bronchial obstruction syndrome.
Spasm of bronchial smooth muscles.
Inflammatory swelling of the bronchial mucosa.
Hyper- and discriminatory bronchial glands with the production of excess mucus.
Fibrous changes in the bronchi.
Hypotonic dyskinesia of the trachea and large bronchi.
Collapse of small bronchi during exhalation in the case of the development of pulmonary emphysema, and as a factor in its development.
Currently, the group of diseases characterized by broncho-obstructive syndrome includes chronic obstructive pulmonary disease, bronchial asthma, and cystic fibrosis.
Clinical manifestations of bronchial obstruction syndrome.
Complaints:
shortness of breath of an expiratory nature, aggravated by physical activity and under the influence of various irritating factors (sudden changes in air temperature, smoke, strong odors);
hacking, unproductive cough with viscous sputum; the discharge of sputum brings relief to the patient (shortness of breath decreases) - with the exception of cases of severe emphysema.
Inspection, palpation of the chest wall and percussion of the lungs: signs of pulmonary emphysema are characteristic (see the corresponding section).
Auscultation of the lungs: hard breathing with prolonged exhalation, dry, different timbre depending on the level of obstruction, wheezing, better heard on exhalation, weakening of bronchophony.
X-ray examination: signs of pulmonary emphysema.
Spirometry, pneumotachography: decrease in FEV 1; a decrease in peak fluometry indicators, a decrease in the Tiffno index (in a healthy person it is at least 70%), a decrease in vital capacity (a sign of pulmonary emphysema).
If you've been diagnosed with chronic obstructive pulmonary disease (COPD), the first thing you probably want to know is what happens next.
As a progressive disease, COPD is characterized by disease stages that tell us what to expect at that point in time. To do this, doctors will refer to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification system, which divides the progression of the disease into four different stages.
Triage is determined using a simple in-office spirometry test, which can assess your lung capacity as well as the force of your inhalation and exhalation. Determining the GOLD classification helps your doctor formulate a treatment plan appropriate for your stage of disease.
Stage 1: mild COPD
With COPD stage 1, a person will have some airflow limitation, but most likely they will not be aware of it. In many cases there will be no symptoms of the disease or the symptoms will be so minor that they can be attributed to other causes. If present, symptoms may include a persistent cough with visible sputum production (a mixture of saliva and mucus). Due to low-grade symptoms, people at this stage rarely seek treatment.
Stage 2: moderate COPD
In stage 2 COPD, airflow limitation begins to worsen and COPD symptoms become more obvious. These may include a persistent cough, increased mucus production, and shortness of breath with mild exertion.
This is usually the stage when most people seek treatment.
Stage 3: severe COPD
In grade 3 COPD, airway restriction and/or obstruction is evident. People will experience a worsening of acute symptoms (known as an exacerbation of COPD) and increased frequency and severity of cough.
Not only will the person have less tolerance for physical activity, but there will be more fatigue and chest discomfort.
Stage 4: very severe COPD
With COPD grade 4, a person's quality of life will be severely affected, with symptoms ranging from severe to life-threatening. The risk of respiratory failure is high in class 4 disease and can lead to heart complications (including a potentially fatal disorder called cor pulmonale).
How is GOLD spirometry performed?
Spirometry is the main tool for assessing the degree of COPD. It specifically looks at four key indicators of lung function, namely:
- How much air can a person forcefully exhale after taking a deep breath (forced vital capacity)
- How much air can a person forcefully exhale in one second (forced expiratory volume in 1 second)
- The percentage of air remaining in the lungs after a complete exhalation (known as the ratio of the first to the second point)
- Total volume of air in the lungs (total lung capacity)
Together, these four measures not only show how much damage has been done to your lungs, but also ways you can improve your long-term outcomes if you have COPD.
Changing Your Disease Outcomes
The GOLD classification system is intended only to formulate the best course of action for your stage of disease.
While this may be a prediction of the results, it does not mean that the results are set in stone.
There are things you can definitely do to slow down or even reverse some of the progressive symptoms of COPD. The main one is to quit smoking. Without quitting, there is little you can do to mitigate the ongoing damage caused by smoking day after day.
In contrast, smoking cessation improves both survival time and quality of life for people living with COPD. Eating right and exercising daily are also key.
Don't let the stage of your disease stop you from achieving a healthier lifestyle.
You and you have the power to change a lot if you are living with COPD.
Chronic obstructive pulmonary disease ( COPD) is a slowly progressive chronic disease with damage to the distal respiratory tract, caused by an inflammatory reaction, and the lung parenchyma, manifested by the development of emphysema, and accompanied by reversible or irreversible bronchial obstruction.
According to WHO, the prevalence of COPD among men is 9.34:1000, among women - 7.33:1000. People over 40 years predominate. In Russia, according to official statistics from the Ministry of Health of the Russian Federation, there are about 1 million patients with COPD. However, according to epidemiological studies, their number may exceed 11 million people. There is a pronounced tendency towards an increase in this disease mainly in women (in men - by 25% and in women - by 69% for the period from 1990 to 1999). At the same time, mortality from COPD is increasing. Among the leading causes of death in the world, this disease is in 6th place, and this figure doubles every 5 years.
Etiology and pathogenesis
COPD is a consequence of chronic obstructive bronchitis, emphysema and bronchial asthma, the etiology and pathogenesis of which were described earlier. These diseases are combined into one group - COPD - from the moment when obstruction develops and FEV 1 becomes less than 40%. The main etiological factors of COPD are smoking, air pollution, occupational hazards, infections, family and hereditary factors.
The pathophysiological essence of COPD is an increase in airway resistance in bronchitis and bronchial asthma due to primary damage to the bronchi and in emphysema - due to a decrease in the tensile force of the bronchi and a decrease in the rate of forced expiration. In COPD, the normal ratio of lung volumes is disrupted: the residual volume, FOB and total lung capacity increase. Increased airway resistance, decreased elastic traction of the lungs, or a combination of both lead to an increase in the time of complete exhalation, which does not have time to complete as the disease progresses. This leads to an increase in FOB and positive pressure in the alveoli before inhalation, which is accompanied by an increase in the work of the respiratory system.
With COPD, gas exchange worsens and BAC indicators change. Alveolar ventilation, an indicator of which is PaCO 2, can be increased, normal or decreased depending on the ratio of tidal volumes and the volume of dead space. When ventilation of normally perfused areas of the lungs is impaired, intracellular blood discharge develops from right to left, and P (A-a) O 2 increases.
COPD is characterized by both a decrease in the perfusion of certain parts of the lungs and pulmonary hypertension at rest of varying severity, and its disproportionate increase in cardiac output during exercise. Pulmonary hypertension is caused by a decrease in the total cross-sectional area of the pulmonary vascular bed and hypoxic pulmonary vasoconstriction, which is more important than the cross-section of the vascular bed. Acidosis, which develops during acute and chronic respiratory failure, increases pulmonary vasoconstriction and causes erythrocytosis, which worsens the rheological properties of the blood. Persistent pulmonary hypertension leads to overload of the right ventricle, its hypertrophy and right ventricular failure.
Classification
According to the international recommendations GOLD 2003 (Global Initiative for Chronic Obstructive Lung Disease), the diagnostic criterion for all stages of COPD is a decrease in the ratio of FEV 1 to forced vital capacity, i.e. Tiffno index
According to the severity of the disease, four stages are distinguished. The classification does not include stage zero, which is characterized by clinical symptoms (cough with sputum and the presence of risk factors), but lung function is not changed. This stage is considered as a pre-disease, which does not always develop into chronic obstructive pulmonary disease.
Classification by severity |
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Stage | Clinical picture | Functional indicators |
I | Mild COPD is characterized by periodic cough with sputum. There is no or slight shortness of breath. | FEV 1 /FVC FEV 1 ≥ 80% of the required values. |
II | Moderate COPD. Patients experience shortness of breath during exercise. The cough becomes constant with sputum production. Obstructive disorders are increasing. Sometimes exacerbations of the disease develop. | FEV 1 /FVC 50% ≤ FEV 1 |
III | Severe COPD. Shortness of breath increases and appears with little physical exertion, cough with sputum and wheezing in the chest are always present. There is a further increase in airflow restriction. Exacerbations occur frequently and worsen the patient's quality of life. | FEV 1 /FVC 30% ≤ FEV 1 |
IV | Extremely severe COPD. The disease leads to disability; exacerbations can be life-threatening for patients; as a rule, cor pulmonale develops. Bronchial obstruction becomes extremely severe. | FEV 1 /FVC FEV 1 Characteristic respiratory failure: PaO 2 |
Symptoms
The main complaints in chronic obstructive pulmonary disease are cough with sputum and shortness of breath. The cough is initially periodic, observed in the morning and afternoon. As the disease progresses, the cough becomes constant and may develop at night. The sputum is usually mucous, and no more than 40 ml is released in the morning. An increase in the amount of sputum and its purulent nature are signs of exacerbation of the disease. Hemoptysis is usually absent. Dyspnea is expiratory in nature, usually appears on average 10 years later than cough and has varying degrees of severity. Initially, shortness of breath occurs during normal physical activity. As the disease progresses, shortness of breath develops with less exertion, becomes constant and intensifies with a respiratory infection.
When questioning, it is necessary to study the smoking history and calculate the smoker's index (SI) (pack/years) using the formula:
IR (pack/years) = Number of cigarettes smoked (days) ∗ Smoking experience (years) / 20
IR = 10 pack/year is a significant risk factor for COPD. It is necessary to find out the presence of other risk factors (dust, chemical pollutants, alkali and acid vapors), previous infectious diseases (especially ARVI) and genetic predisposition (α1-antitrypsin deficiency). Physical examination reveals an emphysematous (“barrel-shaped”) shape of the chest, and the participation of auxiliary muscles in the act of breathing. The percussion tone is boxy, the borders of the lungs are lowered, the mobility of the lower edge of the lungs is limited. On auscultation - weakened vesicular breathing, less often harsh, dry buzzing and whistling wheezing, increasing with forced breathing.
There are two clinical types of chronic obstructive pulmonary disease in patients with moderate and severe disease - emphysematous and bronchitis.
- Emphysematous type. Patients with this type are called “pink puffers”, since there is no cyanosis against the background of severe shortness of breath. The physique of this type of chronic obstructive pulmonary disease is asthenic, emaciation and a mild cough with scanty mucous sputum often develop. Physical and functional examination reveals signs of pulmonary emphysema.
- Bronchitic type. In patients with this type, symptoms of chronic bronchitis predominate. These patients are called “blue edema” because they are characterized by cyanosis and edema caused by right ventricular failure. The leading symptom is a cough with sputum for many years.
The main differences between the types of chronic obstructive pulmonary disease are presented in the table. Emphysematous and bronchitis types of COPD are extreme manifestations of the disease. Most patients have symptoms characteristic of both, with some predominance of one of them.
Diagnostics
Laboratory research. In a general blood test, changes are usually not detected. In some patients, polycythemia is possible. With exacerbation of the disease, neutrophilic leukocytosis, band shift and increased ESR are observed. The emphysematous type is characterized by a decrease in the blood serum content of α1-antitrypsin. In the sputum, a cellular composition is detected that characterizes chronic inflammation. Bacteriological research allows you to identify the pathogen and determine its sensitivity to antibiotics. A double bacterioscopic examination is required to exclude pulmonary tuberculosis. A blood gas composition study is carried out to detect hypoxia and hypercapnia.
Instrumental research. A study of pulmonary function (PRF) is mandatory to establish a diagnosis for all patients, even if they do not have shortness of breath. Early diagnostic signs of COPD are FEV 1/FVC less than 70% and daily fluctuations in PEF less than 20% with peak flow monitoring.
Bronchodilator test is carried out:
- with short-acting β2-agonists (inhaled salbutamol 400 mcg or fenoterol 400 mcg), assessed after 30 minutes;
- with M-anticholinergics (inhalation of ipratropium bromide 80 mcg or a combination of fenoterol 50 mcg and ipratropium bromide 20 mcg (4 doses)), assessment is carried out after 30 - 45 minutes.
The increase in FEV 1 is calculated using the formula:
((FEV 1 dilate (ml) − FEV ref (ml)) / FEV 1 ref) ∗ 100%
An increase in FEV 1 >15% (or 200 ml) of the predicted value is a positive test, indicating the reversibility of bronchial obstruction. In the absence of an increase in FEV 1, but a decrease in shortness of breath, the prescription of bronchodilators is indicated.
Primary X-ray examination allows us to identify changes in the lungs and hilar areas corresponding to emphysema and chronic bronchitis, and other lung diseases with clinical symptoms similar to COPD (lung cancer, tuberculosis). During exacerbation of COPD, pneumonia, spontaneous pneumothorax, pleural effusion and others are excluded.
An ECG is used to exclude possible heart pathology leading to stagnation in the pulmonary circulation with a clinical picture of left ventricular failure, and to identify right ventricular hypertrophy - a sign of cor pulmonale. EchoCG is used to determine the morphometric parameters of the left and right ventricles and calculate the pressure in the pulmonary artery.
Bronchoscopic examination is carried out for the differential diagnosis of COPD with diseases of the bronchi and lungs that have similar symptoms. Bronchoscopy is performed during frequently recurring exacerbations of COPD to obtain secretions and bacteriological examination and lavage of the bronchial tree. Bronchographic examination is indicated for suspected bronchiectasis, obliteration of small bronchi and bronchioles, cicatricial bronchial stenosis.
Differential diagnosis. Differential diagnosis is made with lung cancer, which may include coughing with blood, chest pain, weight loss and lack of appetite, hoarseness, and pleural effusion. The diagnosis of lung cancer is confirmed by cytological examination of sputum, bronchoscopy, computed tomography and transthoracic puncture biopsy. In some cases, differential diagnosis is carried out with chronic heart failure, bronchiectasis, pneumonia, tuberculosis, bronchiolitis obliterans.
Treatment
General recommendations. The goal of treatment is to slow the progression of the disease. One of the main measures for the treatment of COPD is smoking cessation, which gives a more pronounced and persistent slowdown in the decline in FEV 1 Smokers should be helped to give up this bad habit: a date for quitting smoking should be set, the patient should be supported and helped to implement this decision. To combat nicotine addiction, some patients may be advised to use a nicotine patch or chewing gum with nicotine, which significantly increases the number of people who quit smoking. But only 25-30% of patients refrain from smoking for 6-12 months.
If there are harmful factors in the external environment that cause COPD, a change of profession or place of residence can be recommended. But these recommendations can cause great difficulties for the patient and his family. They recommend combating dust and gas pollution in the workplace and at home, and avoiding the use of aerosols and household insecticides.
Vaccination against influenza and pneumococcal infection is mandatory. Exercise therapy is useful for increasing tolerance to physical activity and training the respiratory muscles.
Drug treatment. Treatment of patients with chronic obstructive pulmonary disease with a stable course is carried out with bronchodilator drugs. Typically, short-acting inhaled brochodilators are used: β2-agonists (salbutamol and fenoterol) or M-anticholinergics (ipratropium bromide, tiotropium bromide), after 4-6 hours. Long-term monotherapy with short-acting β2-agonists is not recommended. For some patients, if inhaled oronchodilators are insufficient, long-acting theophyllines are recommended.
Treatment of exacerbations on an outpatient basis. Exacerbation of COPD is manifested by increased cough with purulent sputum, increased temperature, increased shortness of breath, and weakness. For mild exacerbation of COPD, increase the dose and/or frequency of bronchodilators. Patients who have not used these drugs are prescribed combinations of bronchodilators (M-anticholinergics with short-acting β2-agonists), and if their effectiveness is insufficient, theophylline is prescribed.
With an increase in purulent sputum and increased shortness of breath, antibacterial therapy is carried out. Amoxicillin, new generation macrolides (azithromycin, clarithromycin), second generation cephalosporins (cefuroxime) or respiratory fluoroquinolones (levofloxacin, moxifloxacin) are prescribed for 10 to 12 days.
With the development of bronchial obstruction for the first time, anamnestic indications of the effectiveness of treatment with glucocorticoids for previous exacerbations and a decrease in FEV 1
Treatment of exacerbation in a hospital setting. Indications for hospitalization are the following criteria:
- deterioration of the patients' condition during treatment (pronounced increase in shortness of breath, deterioration in general condition, sharp decrease in activity);
- lack of positive dynamics from long-term outpatient treatment, including glucocorticoids, in patients with severe COPD;
- the appearance of symptoms characterizing increased respiratory and right ventricular failure (cyanosis, swelling of the jugular veins, peripheral edema, liver enlargement), and the occurrence of rhythm disturbances;
- elderly age;
- severe concomitant diseases;
- unsatisfactory social status.
Therapy should begin with oxygen treatment using nasal catheters or face masks 4 - 6 l/min with a fractional oxygen concentration in the inhaled mixture of 30 - 60% and humidification. Blood gas composition should be monitored every 30 minutes. PaO 2 should be maintained at 55 - 60 mm Hg. Art.
Bronchodilator therapy. Inhaled combinations of β2-adrenergic agonists and M-anticholinergics are prescribed. Solutions of ipratropium bromide 2 ml should be used: 40 drops (0.5 mg) through a nebulizer with oxygen in combination with solutions of salbutamol 2.5 - 5.0 mg gilifenoterol 0.5 - 1 mg (0.5 - 1 ml 10 - 20 drops) every 4-6 hours. If inhaled drugs are insufficiently effective, aminophylline 240 mg/hour up to 960 mg/day is administered intravenously at a rate of 0.5 mg/kg/hour under ECG monitoring and the concentration of theophylline in the blood, which should be 10-15 mcg/ ml.
If bronchodilators are not effective enough, or if the patient is already taking systemic glucocorticoids, it is necessary to increase the oral dose. Oral prednisolone is prescribed at 0.5 mg/kg/day (~ 40 mg/day). It is possible to replace prednisolone with another glucocorticoid in an equivalent dose. If there are contraindications to taking the drug orally, prednisolone is prescribed intravenously at a dose of 3 mg/kg/day. The course of treatment is 10-14 days. The daily dose is reduced by 5 mg/day after 3-4 days until complete cessation of use.
If signs of a bacterial infection appear (increased volume of purulent sputum and increased shortness of breath), antibacterial therapy is carried out. The causative agents of bacterial infection are most often Haemophilus influenzae, Streptococcus pncumoniae, Moraxella catarrhalis, Enterococcus spp, Mycoplasma pneumoniae. The drugs of choice are amoxicillin / clavulant orally 625 mg 3 times a day for 7 - 14 days, clarithromycin orally 500 mg 2 times a day or azithromycin 500 mg once a day or 500 mg on the first day, then 250 mg /day for 5 days. It is possible to prescribe pneumotropic fluoroquinolones (levofloxacin orally 250-500 mg 1-2 times a day or ciprofloxacin orally 500 mg 2-3 times a day).
In case of complicated exacerbation of COPD in elderly patients and FEV 1
Sputum discharge. For COPD, treatment is aimed at improving sputum production. For debilitating nonproductive cough, postural drainage is effective. To thin sputum, expectorants and mucolytics are used orally and in aerosols. But the same effect can be obtained by simply drinking plenty of water.
Surgery. There are surgical treatments for COPD. A bullectomy is performed to relieve symptoms in patients with large bullae. But its effectiveness has been established only in those who quit smoking in the near future. Thoroscopic laser bullectomy and reduction pneumoplasty (removal of an overinflated part of the lung) have been developed. But these operations are currently only used in clinical trials. There is an opinion that if there is no effect from all the measures taken, you should contact a specialized center to resolve the issue of lung transplantation.
Forecast
Chronic obstructive pulmonary disease has a progressive course. The prognosis depends on the age of the patient, elimination of provoking factors, complications (acute or chronic respiratory failure, pulmonary hypertension, chronic pulmonary heart disease), a decrease in FEV 1 and the effectiveness of the treatment. In severe and extremely severe cases of the disease, the prognosis is unfavorable.
Prevention
The greatest importance for prevention is the elimination of risk factors that contribute to the progression of the disease. The main components of prevention are smoking cessation and prevention of infectious respiratory diseases. Patients must strictly follow the recommendations of doctors; they must be informed about the disease itself, treatment methods, trained in the correct use of inhalers, self-monitoring skills using a peak fluorometer and decision-making during an exacerbation.