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Chronic obstructive pulmonary disease (COPD) is the only major cause of death that is increasing.1 Recent efforts to improve much needed public awareness and research in COPD worldwide have resulted in the recent release of at least five sets of guidelines directed at the evaluation and treatment of COPD.2–7 According to the U.S. National Heart, Lung, and Blood Institute and the World Health Organization’s Global Initiative for Chronic Obstructive Lung Disease (GOLD), COPD is characterized by airflow limitation that is not fully reversible. The airflow obstruction is generally progressive and associated with an abnormal inflammatory response to noxious particles or gases.6 Approximately 85% of patients with COPD suffer from chronic bronchitis, and 15% suffer primarily from emphysema.7 Chronic bronchitis is the presence of chronic productive cough for 3 months in each of 2 successive years, where other causes of chronic cough have been excluded.3 Emphysema results from destruction of bronchioles and alveoli. Chronic bronchitis is defined in clinical terms, and emphysema is defined in terms of anatomic pathology that limits the clinical utility of the definitions.3 In contrast, the GOLD definition encompasses chronic bronchitis, emphysema, bronchiectasis, and, to a lesser extent, asthma and is more flexible by acknowledging that most patients have a combination of the different diseases.5

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This chapter discusses the pathophysiology, clinical features, and treatment of chronic compensated COPD and acute exacerbations of COPD.

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COPD is the sixth leading cause of death in the world, the fourth most common cause of death in the U.S. (120,000 deaths in 2002), and the third most common cause of hospitalization.

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Conflicting definitions of COPD combined with delayed diagnosis in many patients make prevalence estimates difficult. Although close to 24 million Americans had evidence of impaired lung function, only 14 million people are diagnosed with COPD, indicating that the condition remains underdiagnosed.8,9

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COPD accounted for 1.5 million ED visits and 726,000 hospitalizations in 2000.10 Total costs for COPD in the U.S. are projected to be $49.9 billion in 2010.11 The prevalence of COPD in women has doubled in the past few decades, and women now account for >50% of COPD-related deaths, while the prevalence has remained stable in men.12,13 The prevalence of COPD is highest in those countries that have the greatest cigarette use.

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The mortality of patients while hospitalized for a COPD exacerbation is approximately 5% to 14%.14 Mortality of COPD patients admitted to an intensive care unit for an exacerbation is 24%. For patients 65 years or older and discharged from the intensive care unit after treatment of a COPD exacerbation, the 1-year mortality is 59%, nearly double the expected 30%.

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Pathophysiology

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Although tobacco smoke is the major risk factor for developing COPD, only 15% of smokers will develop COPD. Occupational dust, chemical exposure, and air pollution are other risk factors for COPD. ...

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