copd icd 9 - Chronic obstructive pulmonary disease international classification of diseases -9

Chronic obstructive pulmonary disease or COPD

COPD is a chronic, slowly progressive lung disorder, which cause airway obstruction and consists of emphysema and chronic bronchitis.

Emphysema is pathologically defined as permanent destructive enlargement of the air spaces distal to terminal bronchioles

Chronic bronchitis is clinically defined as chronic cough with production of sputum on most days for at least 3 months per year for 2 consecutive years.

COPD is associated with damage to the bronchial and alveolar as a result from environmental insult/agent that is cigarette smoking. If the patient is young and non smoker, consider alpha anti trypsin deficiency ( rare cases > than 1 % ) .

COPD is associated with smoking, especially for people with 20 pack year of smoking . ( 10% - 20% will develop COPD. Other risk factors include patient who suffers from recurrent bronchopulmonary infections as well as occupational exposure to dust especially for workers who work at the cotton and mining industries. Patient with COPD may also suffer from asthma. Asthma is co present and overlap with chronic obstructive pulmonary disease.

In term of epidemiology, it is common with prevalence up to 8% . Middle age and elderly are most commonly affected with COPD. COPD is most commonly present in male than female however this is going to change as a result of increase in female smoker. COPD is also responsible for large number of admission to the hospital with 30000 deaths per year.

The patient will complains of breathlessness and wheezing with reduced exercise tolerance and also present with chronic cough and sputum production.

In term of examining the patient we need to perform inspection, percussion, auscultation and look for the signs of carbon dioxide retention. On inspection, the patient may have an overinflated barrel shaped chest, reduction in cricosternal distance, look blue `( cyanosis) , use the accessory muscle and present with signs of respiratory distress. While on percussion, there will be a loss in the cardiac dullness and liver dullness with hyper resonant of the chest. On auscultation , the patient has prolonged expiration, quiet breath sounds and present with wheeze and other signs such as crepitation and rhonchi are rarely present. The signs of carbon dioxide retention includes( asterixis) flapping tremor of the hand, warm peripheries and bounding pulses. In later stage, patient may present with right ventricular heave, ankle oedema and raised JVP ( jugular venous pressure ) which are the signs of right ventricular failure.

Pathology of the emphysema includes permanent destructive enlargement of the alveoli/air space at the distal terminal of the bronchiole. In smoker it is mostly centriacinar while in alpha antitrypsin deficiency patient it is mostly panacinar. This condition will leads to the loss of elastic traction that keep the small airways open during expiration. This will later leads to large emphysematous space or known as bullae when the diameter is more than 1 cm.

Chronic bronchitis is associated with inflammation of the bronchi and bronchioles ( bronchiolitis) that present with squamous metaplasia, mucous gland hypertrophy, mucous hypersecretion and mucosal oedema. This will finally leads to the narrowing of the airway.

The investigations include blood test, arterial blood gases, pulmonary function test , chest x ray, ECG and echocardiogram, sputum and blood cultures. The blood test includes full blood count that shows an increase in the haemoglobin and packed cell volume or PCV which indicates secondary polycythemia and increase in white cell count that indicates acute exacerbation of infection. Arterial blood gases or ABG may shows hypoxia with reduction of partial pressure of oxygen ( PaO2) and normal or increase in partial pressure of carbon dioxide ( PaCo2).

The pulmonary function test may indicates an obstructive pattern of lung disease which is proved with reduction in PEFR or peak expiratory flow rates, increase in lung volume or carbon monoxide gas transfer co efficient which may decrease if there are significant destruction of the alveoli. There also be a reduction in FEV1:FVC with 60-80% in mild cases, 40-60% in moderate cases and less than 40% in severe cases.

The chest x ray may shows an elongated cardiac silhouette, appear normal or hyperinflated with more than 6 ribs visible and reduced peripheral marking as well as flat hemi diaphragm. ECG treatment is useful to detect any cor pulmonale which is the complication of COPD, and sputum and culture is useful to detect any acute exacerbation of infection.

The management aspects involve advice, medical treatment and treatment of complication.The advice include advice to stop smoking while the medical treatment include bronchodilator such as salbutamol or beta agonist and anti cholinergic such as ipratropium that are useful for symptomatic relief in the form of inhalers or nebulizers.

The management also include steroid therapy. Trial of beclomethasone for 6- 8 weeks are given to the patient and it is continue if there is an improvement in the FEV1 for more than 15%. In non responsive patient, long term corticosteroid treatment is given however the effect of the treatment is controversial. Oral corticosteroid is reserved for cases of acute exacerbation.

For those who already stop smoking, oxygen therapy is given. Mortality has been improved with long term home oxygen therapy. The indication for oxygen therapy includes:

Partial pressure of oxygen, PaO2 more than 7.3kPa on air during the period of clinical instability or partial pressure of oxygen , PaO2 is between 7.3-8kPa and sign of pulmonary hypertension, secondary polycythemia, peripheral oedema and nocturnal hypoxaemia. For those who require more than 8 hour per day oxygen , oxygen concentrators are more economical.

Treatment for complication such as acute infective exacerbation includes the supply of 24% of oxygen via non variable flow Venturi mask . Measured by arterial blood gases, if there is no improvement raised the oxygen level slowly to avoid the danger of respiratory distress as a loss of hypoxic drive.Starts empirical antibiotic treatment such as amoxicillin and erythromycin.Oral or inhaled corticosteroid are proven beneficial as well as chest physiotherapy. Consider ventilation in severe cases.Vaccination against pneumococus and influenza is required for prevention of acute exacerbation of infection.

The complication of COPD include acute respiratory failure, right heart failure, pulmonary hypertension, streptococcus pneumoniae and haemophilus influenza infection, secondary polycythemia and pneumothorax such as bursting of emphysematous bullae.

In term of prognosis, there is high level of morbidity with more than 90% 3 year survival rates for patient who is < 60 years and FEV1 > 50 % predicted and 75 % 3 year survival rates for patient who is > 60 years and FEV1 is 40% -49% predicted.

The chest x ray shows elongated silhouette, signs of hyperinflation with more than 6 ribs visible, flat hemidiaphragms and reduced peripheral marking
The chest x ray shows elongated silhouette, signs of hyperinflation with more than 6 ribs visible, flat hemidiaphragms and reduced peripheral marking

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