Chronic Obstructive Pulmonary Disease

Chronic Obstructive Pulmonary Disease is a topic covered in the Harrison's Manual of Medicine.

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Chronic obstructive pulmonary disease (COPD) is a disease state characterized by chronic airflow obstruction; thus, pulmonary function testing is central to its diagnosis. The presence of airflow obstruction is determined by a reduced ratio of the forced expiratory volume in 1 s (FEV1) to the forced vital capacity (FVC). Among individuals with a reduced FEV1/FVC ratio, the severity of airflow obstruction is determined by the level of reduction in FEV1 (Table 131-1): ≥80% is stage I, 50–80% is stage II, 30–50% is stage III, and <30% is stage IV. Cigarette smoking is the major environmental risk factor for COPD. The risk of COPD increases with cigarette smoking intensity, which is typically quantified as pack-years. (One pack of cigarettes smoked per day for 1 year equals 1 pack-year.) Individuals with airway hyperresponsiveness and certain occupational exposures (e.g., coal mining, gold mining, and cotton textiles) are likely also at increased risk for COPD. In countries in which biomass combustion with poor ventilation is used for cooking, an increased risk of COPD among women has been reported. COPD is a progressive disorder; however, the rate of loss of lung function often slows markedly if smoking cessation occurs. In normal individuals, FEV1 reaches a lifetime peak at around age 25 years, enters a plateau phase, and subsequently declines gradually and progressively. Subjects can develop COPD by having reduced maximally attained lung function, shortened plateau phase, or accelerated decline in lung function.

GOLD StageSeveritySpirometry
IMildFEV1/FVC <0.7 and FEV1 ≥80% predicted
IIModerateFEV1/FVC <0.7 and FEV1 ≥50% but <80% predicted
IIISevereFEV1/FVC <0.7 and FEV1 ≥30% but <50% predicted
IVVery severeFEV1/FVC <0.7 and FEV1 <30% predicted
Abbreviation: GOLD, Global Initiative for Lung Disease.
Source: From the Global Strategy for Diagnosis, Management and Prevention of COPD 2014. Available from; with permission.

Symptoms often occur only when COPD is advanced; thus, early detection requires spirometric testing. The PaO2 typically remains near normal until the FEV1 falls to <50% of the predicted value. Hypercarbia and pulmonary hypertension are most common after FEV1 has fallen to <25% of predicted. COPD pts with similar FEV1 values can vary markedly in their respiratory symptoms and functional impairment. COPD often includes periods of increased respiratory symptoms, such as dyspnea, cough, and phlegm production, which are known as exacerbations. Exacerbations are often triggered by bacterial and/or viral respiratory infections. These exacerbations become more common as COPD severity increases, but some individuals are much more susceptible to developing exacerbations than others with similar degrees of airflow obstruction.

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