Chronic obstructive pulmonary disease suomeksi

Houben JM, Mercken EM, Ketelslegers HB, Bast A, Wouters EF, Hageman GJ. Telomere shortening in chronic obstructive pulmonary disease. Respir Med. 2009 Feb. 103(2):230-6. [Medline]. Meanwhile, chronic bronchitis is a disorder that is commonly characterized by the fact that coughing results in production of sputum for 3 or more months in a span of two years or more. The cough results from the chronic bronchitis itself than of any other lung disorder.   Chronic obstructive pulmonary disease (COPD) is the name for a collection of lung diseases including chronic bronchitis, emphysema and chronic obstructive airways disease. People with COPD have difficulties breathing, primarily due to the narrowing of their airways.. Crothers K, Butt AA, Gibert CL, Rodriguez-Barradas MC, Crystal S, Justice AC. Increased COPD among HIV-positive compared to HIV-negative veterans. Chest. 2006 Nov. 130(5):1326-33. [Medline].

Classification based on airflow limitation in patients with FEV1/FVC < 70%

The formal diagnosis of COPD is made with spirometry; when the ratio of forced expiratory volume in 1 second over forced vital capacity (FEV1/FVC) is less than 70% of that predicted for a matched control, it is diagnostic for a significant obstructive defect. Criteria for assessing the severity of airflow obstruction (based on the percent predicted postbronchodilator FEV1) are as follows:Mottillo S, Filion KB, Belisle P, Joseph L, Gervais A, O'Loughlin J. Behavioural interventions for smoking cessation: a meta-analysis of randomized controlled trials. Eur Heart J. 2009 Mar. 30(6):718-30. [Medline].

COPD - Symptoms and causes - Mayo Clini

SmartBIO seminar: Prof

A study by Sundh et al determined that the Clinical COPD Questionnaire (CCQ), which estimates quality of life in patients with COPD, is effective. [31] The CCQ identified that heart disease, depression, and underweight status are independently associated with lower health-related quality of life in patients with COPD.Gershon A, Croxford R, Calzavara A, To T, Stanbrook MB, Upshur R, et al. Cardiovascular Safety of Inhaled Long-Acting Bronchodilators in Individuals With Chronic Obstructive Pulmonary Disease. JAMA Intern Med. 2013 May 20. 1-9. [Medline]. Tobacco-related diseases, including chronic obstructive pulmonary disease (COPD), account for 3.7% of the world burden of disability-adjusted life-years (DALYs), a measure of lost years of healthy life (1). Tobacco use, excessive alcohol consumption, and unhealthy diets and physical inactivity contribute to most preventable non-communicable diseases. These diseases are projected to impose a worldwide burden of $47 trillion health dollars by 2030. In contrast, it costs only $0.40 per individual per year to implement a program aimed at averting tobacco-related diseases that has the potential to save 25–30 million DALYs (1). Notwithstanding its preventable nature, the increasing prevalence, impact as the third leading cause death in the United States since 2008, and socioeconomic costs (1) call for vigorous research efforts to improve the understanding and, ultimately, management of COPD.

FEV1 and FVC are easily measured with office spirometry and define severity of disease (see table Stages and Treatment of COPD) because they correlate with symptoms and mortality. Normal reference values are determined by patient age, sex, and height. Many cases of COPD are preventable. Comprehensive implementation of the WHO FCTC will reduce smoking prevalence and the burden of COPD globally. WHO’s work on COPD is part of the Organization's overall efforts to prevent and control noncommunicable diseases. WHO aims to: today. This year. Coronary artery disease. Connecting . . . Chronic obstructive pulmonary disease COPD (Chronic Obstructive Pulmonary Disease) Nursing Interventions Management Treatment NCLEX Part 2 - Продолжительность: 16:20 RegisteredNurseRN 226 888 просмотров

Follow-up treatment

Stephenson A, Seitz D, Bell CM, et al. Inhaled anticholinergic drug therapy and the risk of acute urinary retention in chronic obstructive pulmonary disease: a population-based study. Arch Intern Med. 2011 May 23. 171(10):914-20. [Medline]. Recommendations from chronic obstructive pulmonary disease (acute exacerbation): antimicrobial prescribing (NICE guideline NG114) added. Everything NICE has said on diagnosing and managing chronic obstructive pulmonary disease in people aged 16 and over in an interactive flowchart Pathology, symptoms, causes, risk factors and treatments of COPD. This video and other animations (in HD) for patient education are available for instant.. Feghali-Bostwick CA, Gadgil AS, Otterbein LE, Pilewski JM, Stoner MW, Csizmadia E. Autoantibodies in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. Jan 15 2008. 177(2):156-63. Loading Chronic Obstructive Pulmonary Disease (COPD) (Chronic Obstructive Bronchitis; Emphysema) By

Sobolik notes that an October 2019 study in JAMA Network Open found that nurses who regularly used disinfectants to clean surfaces were at higher risk of chronic obstructive pulmonary disease. A 2017 study linked exposure to disinfectants to asthma to adults in Germany. Both of those studies dealt with.. Ringbaek TJ. Continuous oxygen therapy for hypoxic pulmonary disease: guidelines, compliance and effects. Treat Respir Med. 2005. 4(6):397-408. [Medline]. For patients with chronic obstructive pulmonary disease (COPD), bronchodilators are the mainstay of treatment since these reduce exacerbations and improve breathlessness and lung function. However, COPD is a complex, heterogeneous disease, and beyond breathing difficulties, specific systemic.. COPD is called obstructive because it limits the flow of air into and out of your lungs. Pulmonary rehabilitation is an exercise and education program for people with chronic lung diseases such as COPD. It is one of the key approaches to treatment for COPD We believe that mechanisms involved in the progression stage of COPD may be distinctly engaged in generating variable intermediate and clinically relevant disease phenotypes, such as emphysema, chronic airway disease (including chronic bronchitis and bronchiolitis), and systemic disease.

Chronic Obstructive Pulmonary Disease (COPD) Guide: Causes

Video: Chronic obstructive pulmonary disease - Knowledge for medical

Chronic Obstructive Pulmonary Disease (COPD

Chronic Obstructive Pulmonary Disease and Its Causes - UMe

  1. COPD takes years to develop and progress. Most patients have smoked ≥ 20 cigarettes/day for > 20 yr.
  2. ..9) Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care diagnosis, management and prevention of Chronic Obstructive Pulmonary Disease (Update, 2013) // Global Initiative for Chronic Obstructive Lung..
  3. Dodd JW, Hogg L, Nolan J, et al. The COPD assessment test (CAT): response to pulmonary rehabilitation. A multicentre, prospective study. Thorax. 2011 May. 66(5):425-9. [Medline].
  4. Chronic obstructive pulmonary disease (COPD) is a disease of the lungs, most often caused by tobacco smoking, in which the airways become narrower, leading to shortness of breath. COPD is a major cause of death and disability. Chronic bronchitis and emphysema are both forms of COPD
  5. Beta2 -agonist and corticosteroid combinations (eg, budesonide/formoterol, fluticasone and salmeterol, vilanterol/fluticasone inhaled)
  6. o-acid, single-chain protein is to neutralize neutrophil elastase in the lung interstitium and to protect the lung parenchyma from elastolytic breakdown. Severe AAT deficiency predisposes to unopposed elastolysis with the clinical sequela of an early onset of panacinar emphysema. To see complete information on Alpha1-Antitrypsin Deficiency, please go to the main article by clicking here.

Confalonieri M, Garuti G, Cattaruzza MS, Osborn JF, Antonelli M, Conti G. A chart of failure risk for noninvasive ventilation in patients with COPD exacerbation. Eur Respir J. 2005 Feb. 25(2):348-55. [Medline]. WHO also leads the Global Alliance against Chronic Respiratory Diseases (GARD), a voluntary alliance of national and international organizations, institutions and agencies working towards the common goal of reducing the global burden of chronic respiratory diseases. Its vision is a world where all people breathe freely. GARD focuses specifically on the needs of low­ and middle-income countries and vulnerable populations.Chronic bronchitis is defined clinically as the presence of a chronic productive cough for 3 months during each of 2 consecutive years (other causes of cough being excluded). Emphysema, on the other hand, is defined pathologically as an abnormal, permanent enlargement of the air spaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis.Sundh J, Stallberg B, Lisspers K, Montgomery SM, Janson C. Co-Morbidity, Body Mass Index and Quality of Life in COPD Using the Clinical COPD Questionnaire. COPD. 2011 Apr 22. [Medline].

Video: Chronic obstructive pulmonary disease (COPD) - NH

15 to 20 in 100 people who smoke cigarettes tend to develop chronic obstructive pulmonary disease (COPD), hence making smoking the most crucial risk factor in development of COPD. In relative comparison, COPD is much more likely to develop in people who smoke cigarettes than in those who smoke cigars and pipes, while these group of people tend to develop COPD much more commonly than non-smokers. As people age, smokers who are susceptible to develop COPD often begin to develop COPD most likely start to lose their lung function rapidly than non-smokers. Quitting smoking mostly do not produce a dramatic improvement in lung function. Even thouhg such is the case, quitting smoking tend to decrease rate of decline in lung function or makes it on par with that of non-smokers.  O'Donnell DE, Lam M, Webb KA. Spirometric correlates of improvement in exercise performance after anticholinergic therapy in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1999 Aug. 160(2):542-9. [Medline].

Chronic obstructive pulmonary - Illnesses & conditions NHS infor

  1. O'Donnell DE, Fluge T, Gerken F, Hamilton A, Webb K, Aguilaniu B. Effects of tiotropium on lung hyperinflation, dyspnoea and exercise tolerance in COPD. Eur Respir J. 2004 Jun. 23(6):832-40. [Medline].
  2. Adams PF, Barnes PM, Vickerie JL. Summary health statistics for the U.S. population: National Health Interview Survey, 2007. Vital Health Stat 10. 2008 Nov. 1-104. [Medline].
  3. Lamprecht B, McBurnie MA, Vollmer WM, Gudmundsson G, Welte T, Nizankowska-Mogilnicka E, et al. COPD in Never Smokers: Results From the Population-Based Burden of Obstructive Lung Disease Study. Chest. 2011 Apr. 139(4):752-763. [Medline].
  4. ation in detecting mild-to-moderate COPD is relatively poor, the physical signs are quite specific and sensitive for severe disease. Findings in severe disease include the following:
  5. Damage to the endothelium impairs the mucociliary response that clears bacteria and mucus. Inflammation and secretions provide the obstructive component of chronic bronchitis. Neutrophilia develops in the airway lumen, and neutrophilic infiltrates accumulate in the submucosa. The respiratory bronchioles display a mononuclear inflammatory process, lumen occlusion by mucus plugging, goblet cell metaplasia, smooth muscle hyperplasia, and distortion due to fibrosis. These changes, combined with loss of supporting alveolar attachments, cause airflow limitation by allowing airway walls to deform and narrow the airway lumen.
  6. ants of prognosis in COPD remain multifactorial. Waschki et al argued that objective assessments of physical activity, including 6-

Called also chronic obstructive pulmonary disease. Chronic airflow limitation has the highest morbidity rate of any significant chronic pulmonary disorder in the United States and is the second most common cause of hospital admissions. It is difficult to estimate its exact incidence because most.. Prominent hila suggest large central pulmonary arteries that may signify pulmonary hypertension. Right ventricular enlargement that occurs in cor pulmonale may be masked by lung hyperinflation or may manifest as encroachment of the heart shadow on the retrosternal space or by widening of the transverse cardiac shadow in comparison with previous chest x-rays.Serum electrolytes are of little value but may show an elevated bicarbonate level if patients have chronic hypercapnia.Prosen G, Klemen P, Strnad M, Grmec S. Combination of lung ultrasound (a comet-tail sign) and N-terminal pro-brain natriuretic peptide in differentiating acute heart failure from chronic obstructive pulmonary disease and asthma as cause of acute dyspnea in prehospital emergency setting. Crit Care. 2011. 15(2):R114. [Medline]. The primary offender has been found to be human leukocyte elastase, with synergistic roles suggested for proteinase-3 and macrophage-derived matrix metalloproteinases (MMPs), cysteine proteinases, and a plasminogen activator. Additionally, increased oxidative stress caused by free radicals in cigarette smoke, the oxidants released by phagocytes, and polymorphonuclear leukocytes all may lead to apoptosis or necrosis of exposed cells. Accelerated aging and autoimmune mechanisms have also been proposed as having roles in the pathogenesis of COPD. [5, 6]

Chronic Obstructive Pulmonary Disease. Authored by Dr Laurence Knott, Reviewed by Dr Hannah Gronow | Last edited 31 Jan COPD is often associated with comorbidities, particularly cardiovascular disease, metabolic syndrome, lung cancer, osteoporosis, muscle weakness, depression and anxiety Exercise for chronic obstructive pulmonary disease. If you have received a diagnosis of COPD, you are likely to be advised to exercise and you may be referred to a pulmonary rehabilitation course. This is an exercise and education programme for people with COPD or similar conditions, through which..

Cutis laxa is a disorder of elastin that is characterized most prominently by the appearance of premature aging. The disease usually is congenital, with various forms of inheritance (ie, dominant, recessive). Precocious emphysema has been described in association with cutis laxa as early as the neonatal period or infancy. The pathogenesis of this disorder includes a defect in the synthesis of elastin or tropoelastin.Maclay JD, Rabinovich RA, MacNee W. Update in chronic obstructive pulmonary disease 2008. Am J Respir Crit Care Med. 2009 Apr 1. 179(7):533-41. [Medline]. Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality world-wide. In Singapore, COPD is currently the tenth leading cause of death in 2014.1 COPD is under-recognised and under-diagnosed.2 A study in the USA showed that less than 50% of individuals with..

Mintz ML, Yawn BP, Mannino DM, et al. Prevalence of airway obstruction assessed by lung function questionnaire. Mayo Clin Proc. 2011 May. 86(5):375-81. [Medline]. [Full Text].Chen D, Restrepo MI, Fine MJ, et al. Observational study of inhaled corticosteroids on outcomes for COPD patients with pneumonia. Am J Respir Crit Care Med. 2011 Aug 1. 184(3):312-6. [Medline]. Ryland P Byrd Jr, MD is a member of the following medical societies: American College of Chest Physicians and American Thoracic SocietyAbrams TE, Vaughan-Sarrazin M, Fan VS, Kaboli PJ. Geographic isolation and the risk for chronic obstructive pulmonary disease-related mortality: a cohort study. Ann Intern Med. 2011 Jul 19. 155(2):80-6. [Medline].

Cigarette smoke causes neutrophil influx, which is required for the secretion of MMPs; this suggests, therefore, that neutrophils and macrophages are required for the development of emphysema.Titman A, Rogers CA, Bonser RS, Banner NR, Sharples LD. Disease-specific survival benefit of lung transplantation in adults: a national cohort study. Am J Transplant. 2009 Jul. 9(7):1640-9. [Medline].

Investigation into the interactions between upstream and downstream events related to alveolar cell apoptosis during emphysema onset and progression led to the key finding of self-amplifying injury loops involving apoptosis, oxidative stress, and inflammation (3–5). This concept may explain the progression of disease despite cessation of exposure to harmful initiators such as cigarette smoking (47). Paradigmatic of this interaction is the upregulation of pro-apoptotic sphingolipids in alveolar cells, including ceramides. Ceramides, which are induced directly by cigarette smoke or indirectly due to VEGF deprivation or oxidative stress, cause apoptosis of alveolar structural cells, self-amplify their own synthesis in a paracrine manner, increase oxidative stress, cause inflammation with activation of extracellular matrix proteases, and impair the clearance of apoptotic cells by lung alveolar macrophages (33, 35, 41, 48). Executioner caspases such as caspase-3 and elastases can in turn proteolytically activate endothelial monocyte-activating protein II (EMAPII), which has a dual action in the lung, causing endothelial cell caspase-dependent apoptosis as well as inflammation via CXCR3-dependent monocyte chemoattraction and activation (36). Additional positive interactions exist between extracellular matrix proteases, such as between cathepsin S and alveolar cell apoptosis (49), and between alveolar cell apoptosis and oxidative stress (50). Chronic obstructive pulmonary disease (COPD) is a common respiratory condition characterized by airflow limitation. It affects more than 5 percent of Smoking and inhalational exposure history — The most important risk factor for chronic obstructive pulmonary disease (COPD) is cigarette smoking Severe, early onset disease likely represents a distinct genotype and is more commonly seen in females, African Americans, and those with a maternal family history of COPD. [26] Wood S. Inhaled Long-Acting Bronchodilators in COPD Flagged Again for CV Hazard. Medscape Medical News. Available at http://www.medscape.com/viewarticle/804441. Accessed: June 4, 2013.Keenan SP, Kernerman PD, Cook DJ, Martin CM, McCormack D, Sibbald WJ. Effect of noninvasive positive pressure ventilation on mortality in patients admitted with acute respiratory failure: a meta-analysis. Crit Care Med. 1997 Oct. 25(10):1685-92. [Medline].

Salla disease is an autosomal recessive storage disorder described in Scandinavia; the disease is characterized by intralysosomal accumulation of sialic acid in various tissues. The most important clinical manifestations are severe mental retardation, ataxia, and nystagmus. Precocious emphysema has been described and likely is secondary to impaired inhibitory activity of serum trypsin. Chronic Obstructive Pulmonary Disease (COPD). ­­ How to diagnose and manage COPD for doctors, medical student exams, finals, OSCEs and MRCP PACES. Definition of COPD

Findings of increased total lung capacity, functional residual capacity, and residual volume can help distinguish COPD from restrictive pulmonary disease, in which these measures are diminished.Key questions remain in our understanding of COPD, and these concern clinical phenotypes, systemic manifestations of COPD, and the impact of exacerbations triggered by infections. These central clinical manifestations of COPD probably result from the interaction of disease-related genes with fundamental processes involving inflammation, thrombosis and hemorrhage, fibrosis, the immune response, proliferation, and apoptosis/necrosis, which underlie the so-called intermediate phenotypes (103). Development of model systems that can address mechanistically these interactions will remain vital for progress in COPD, validated by studies of the human disease. Some therapeutic strategies, such as restoring α1-antitrypsin activity or the use of Nrf2-dependent antioxidants, may directly antagonize destructive processes such as the activation of pro-apoptotic mediators and extracellular matrix proteolysis (36, 104); a significant challenge lies in restoring lung survival mechanisms without fueling oncogenesis. Recently described shortcomings in attempts to regenerate the lung in a murine model of COPD (105) remind us that approaches aimed at lung organ restoration (79) will require consideration of the extent of macromolecular damage imposed by decades of lung destruction (39, 98). The aggregate of these insights into the pathogenesis of COPD provide landmarks that should direct future investigations in COPD and targets for potential novel therapies. Ferguson GT, Feldman GJ, Hofbauer P, Hamilton A, Allen L, Korducki L, et al. Efficacy and safety of olodaterol once daily delivered via Respimat in patients with GOLD 2-4 COPD: results from two replicate 48-week studies. Int J Chron Obstruct Pulmon Dis. 2014. 9:629-45. [Medline]. [Full Text].[Guideline] Guirguis-Blake JM, Senger CA, Webber EM, Mularski RA, Whitlock EP. Screening for Chronic Obstructive Pulmonary Disease: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2016 Apr 5. 315 (13):1378-93. [Medline].

Other treatment options

What is Chronic Obstructive Pulmonary Disease (COPD)? In short, COPD is one or both emphysema and chronic bronchitis, causing progressive respiratory problems. The lack of oxygen and/or build up of carbon dioxide results in an often invisible but life-altering illness Secondhand smoke, or environmental tobacco smoke, increases the risk of respiratory infections, augments asthma symptoms, and causes a measurable reduction in pulmonary function.[Guideline] US Preventive Services Task Force. Counseling and interventions to prevent tobacco use and tobacco-caused disease in adults and pregnant women: US Preventive Services Task Force Reaffirmation Recommendation Statement. Ann Int Med. Apr 21 2009. 150(8):551-555. [Full Text].Recent studies have implicated the host’s responses in the augmentation of lung injury by cigarette smoke. For example, cigarette smoke activates inducible nitric oxide synthase, leading to generation of oxidants, such as peroxynitrite (ONOO–), which has been linked to alveolar injury due to cigarette smoke (12). Another endogenous mediator of cell injury and inflammation co-opted in the early lung responses to cigarette smoke is the collagen degradation product proline-glycine-proline peptide (PGP), which engages CXCR2 receptors of neutrophils, therefore amplifying initial cigarette smoke-induced inflammation (13). In addition, the LPS in cigarettes may activate TLR4-expressing cells in the lung, leading to the activation of NF-κB responses (14). However, the role of TLR4 is complex and potentially paradoxical; its absence led to spontaneous emphysema in knockout mice, which showed increased oxidant generation in pulmonary capillary endothelial cells via activation of NADPH oxidase 3 (15).

JCI - Pathogenesis of chronic obstructive pulmonary disease

  1. The breathing problems tend to get gradually worse over time and can limit your normal activities, although treatment can help keep the condition under control.
  2. Brown T. FDA approves umeclidinium and vilanterol combo for COPD. Medscape Medical News. December 18, 2013. [Full Text].
  3. Nail clubbing is not a finding specific to COPD; its presence usually suggests comorbidities such as bronchiectasis, pulmonary fibrosis, or lung cancer.
  4. Chronic obstructive pulmonary disease is an umbrella term that encompasses several respiratory illnesses that cause breathlessness, or the This disease is generally associated with cigarette smoking. It's rare to see people with COPD who haven't been exposed to some sort of smoking
  5. Data adapted from The Global Strategy for the Diagnosis, Management and Prevention of COPD Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2018. Available at http://www.goldcopd.org.
  6. This is a disorder where obstruction of the airways occur in conjunction with other disorders such as the following:
  7. Alternative Names. COPD; Chronic obstructive airways disease; Chronic obstructive lung disease; Chronic bronchitis; Emphysema; Bronchitis - chronic. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2019 report..

Emphysematous destruction and small airway inflammation

Hurst JR, Vestbo J, Anzueto A, Locantore N, Mullerova H, Tal-Singer R, et al. Susceptibility to exacerbation in chronic obstructive pulmonary disease. N Engl J Med. 2010 Sep 16. 363(12):1128-38. [Medline]. Chronic obstructive bronchitis is chronic bronchitis with airflow obstruction. Chronic bronchitis is defined as productive cough on most days of the week for at least 3 mo total duration in 2 successive years. Chronic bronchitis becomes chronic obstructive bronchitis if spirometric evidence of airflow obstruction develops. Chronic asthmatic bronchitis is a similar, overlapping condition characterized by chronic productive cough, wheezing, and partially reversible airflow obstruction; it occurs predominantly in smokers with a history of asthma. In some cases, the distinction between chronic obstructive bronchitis and chronic asthmatic bronchitis is unclear and may be referred to as asthma COPD overlap (ACO).

Chronic Obstructive Pulmonary Disease (COPD) - Pulmonary

Diagnosis is suggested by history, physical examination, and chest imaging findings and is confirmed by pulmonary function tests. Similar symptoms can be caused by asthma, heart failure, and bronchiectasis (see table Differential Diagnosis of COPD). COPD and asthma are sometimes easily confused and may overlap (called asthma COPD overlap).COPD may progress in patients despite smoking cessation, which challenges the concept of a direct link between ongoing exposure to cigarette smoke and the disease. This progression parallels persisting inflammatory responses (83), suggesting that additional mechanisms must account for the consolidation of the disease in genetically susceptible hosts, often after decades of active smoking (Figure 1). This change in the nature of inflammation in the course of disease is highlighted by the temporary nature of NF-κB activation in rodent lungs exposed to cigarette smoke (84). Two paradigms have emerged that might explain some of these observations: autoimmunity (52) and lung aging (85). These findings may derive from the profound lung alveolar damage (39) and airway remodeling imposed by chronic cigarette smoke exposure and bombardment by endogenous mediators of inflammation and cell injury. Understanding the mechanism of this persistence might have a far-reaching impact on the design and implementation of regenerative therapies. ECG, often done to exclude cardiac causes of dyspnea, typically shows diffusely low QRS voltage with a vertical heart axis caused by lung hyperinflation and increased P-wave voltage or rightward shifts of the P-wave vector caused by right atrial enlargement in patients with advanced emphysema. Findings of right ventricular hypertrophy include an R or R′ wave as tall as or taller than the S wave in lead V1; an R wave smaller than the S wave in lead V6; right-axis deviation >110° without right bundle branch block; or some combination of these. Multifocal atrial tachycardia, an arrhythmia that can accompany COPD, manifests as a tachyarrhythmia with polymorphic P waves and variable PR intervals.Calverley PM, Rabe KF, Goehring UM, Kristiansen S, Fabbri LM, Martinez FJ. Roflumilast in symptomatic chronic obstructive pulmonary disease: two randomised clinical trials. Lancet. 2009 Aug 29. 374(9691):685-94. [Medline].

Chronic obstructive pulmonary disease (COPD

Chronic obstructive pulmonary disease is usually suspected in people who experience the symptoms described above and can be confirmed by a breathing test called "spirometry" that measures how much and how quickly a person can forcibly exhale air.Developments in the 20th century included the widespread use of spirometry (see Workup), recognition of airflow obstruction as a key factor in determining disability, and the improvement of pathologic methods to assess emphysema. Participants in the Ciba symposium of 1958 proposed definitions of chronic bronchitis and emphysema, incorporating the concept of airflow obstruction. Chronic Obstructive Pulmonary Disease Symptoms. COPD is often asymptomatic (without symptoms) until significant damage to the lungs has already occurred. It's a progressive disease characterized by stretches of relative stability, alternating with intermittent exacerbations..

chronic obstructive pulmonary disease (COPD

Hand L. FDA OKs Umeclidinium (Incruse Ellipta) for COPD. Medscape [serial online]. Available at http://www.medscape.com/viewarticle/824419. Accessed: May 4, 2014.Anoro Ellipta (umeclidinium and vilanterol inhalation powder) [package insert]. Research Triangle Park, NC: GlaxoSmithKline. 2013. Available at [Full Text].Systemic disorders that may have a component of airflow limitation may suggest COPD; they include HIV infection, abuse of IV drugs (particularly cocaine and amphetamines), sarcoidosis, Sjögren syndrome, bronchiolitis obliterans, lymphangioleiomyomatosis, and eosinophilic granuloma. COPD can be differentiated from interstitial lung diseases by chest imaging, which shows increased interstitial markings in interstitial lung disease, and pulmonary function testing, which shows a restrictive ventilatory defect rather than an obstructive ventilatory defect. In some patients, COPD and interstitial lung disease coexist (combined pulmonary fibrosis and emphysema [CPFE]) in which lung volumes are relatively preserved, but gas exchange is severely impaired. Public Health Report. Chronic Obstructive Pulmonary Disease (COPD) in Norway. Most COPD patients display mild symptoms and many are unaware that they have the disease. Chronic diseases in the lower respiratory tract (which include COPD) were the third most frequently reported cause of.. It is conceivable that COPD becomes over time an autoinflammatory disease, possibly involving the inflammasome and related cytokines. Cigarette smoke activates the inflammasome in mouse lungs, involving ATP and its receptor P2X7 purinergic receptor (86). NLPR-3 activation of caspase-1 (87) would lead to increased IL-1β (70) and IL-18 (62), both of which have been shown to participate in experimental models of cigarette smoke–induced inflammation and alveolar injury. Although DAMPs, including purines, can act early, in the initiation stage of COPD, the pathogenic roles of IL-18/IL-18 receptor signaling suggest that this inflammatory signaling occurs downstream of apoptosis, positioning it in the consolidation stage of alveolar injury (62).

Chronic Obstructive Pulmonary Disease (COPD) Causes, Type

Burton CM, Milman N, Carlsen J, Arendrup H, Eliasen K, Andersen CB, et al. The Copenhagen National Lung Transplant Group: survival after single lung, double lung, and heart-lung transplantation. J Heart Lung Transplant. 2005 Nov. 24(11):1834-43. [Medline]. Back to Journals » International Journal of Chronic Obstructive Pulmonary Disease. An international, peer-reviewed journal of therapeutics and pharmacology focusing on concise rapid reporting of clinical studies and reviews in COPD

Chronic Obstructive Pulmonary Disease (COPD): The term collectively refers to multiple lung conditions including emphysema and chronic bronchitis. One of the characteristic signs of COPD is hyperinflated lungs, where the air gets trapped inside the lungs because of blocked airways, making it.. 1. Lange P, Celli B, Agusti A, et al: Lung-function trajectories leading to chronic obstructive pulmonary disease. N Engl J Med 373(2):111–122, 2015.Do not ignore the symptoms. If they're caused by COPD, it's best to start treatment as soon as possible, before your lungs become significantly damaged.

Chronic obstructive pulmonary disease (COPD): MedlinePlus

  1. Foreman MG, Zhang L, Murphy J, et al. Early-Onset COPD is Associated with Female Gender, Maternal Factors, and African American Race in the COPDGene Study. Am J Respir Crit Care Med. 2011 May 11. [Medline].
  2. Mucous gland hyperplasia (as seen in the images below) is the histologic hallmark of chronic bronchitis. Airway structural changes include atrophy, focal squamous metaplasia, ciliary abnormalities, variable amounts of airway smooth muscle hyperplasia, inflammation, and bronchial wall thickening.
  3. Tobacco smoke remains the key cause of COPD worldwide. Given that cigarette smoke contains thousands of injurious agents (3), its pathogenicity cannot be stringently studied one compound at a time. Aside from nicotine, heavy metals, and carcinogens, tobacco smoke leads to a significant exposure to oxidants. These include alkyl, alkoyl, and peroxyl organic free radicals (causing lipid peroxidation), α,β-unsaturated aldehydes (such as acrolein and crotonaldehyde, which cause protein carbonylation and loss of sulfhydryls), and superoxide, N2O, and nitric oxide (which can generate peroxynitrite, leading to formation of dityrosine and/or 3-nitrotyrosine) (4).

Bacteria, especially Haemophilus influenzae, colonize the lower airways of about 30% of patients with COPD. In more severely affected patients (eg, those with previous hospitalizations), colonization with Pseudomonas aeruginosa or other gram-negative bacteria is common. Smoking and airflow obstruction may lead to impaired mucus clearance in lower airways, which predisposes to infection. Repeated bouts of infection increase the inflammatory burden that hastens disease progression. There is no evidence, however, that long-term use of antibiotics slows the progression of COPD. COPD describes a group of lung conditions that make it difficult to empty air out of the lungs because the airways have become narrowed. In this section you will find information about what COPD is, the symptoms you might get, and how it's diagnosed and treated Beta2 -agonist and anticholinergic combinations (eg, ipratropium and albuterol, umeclidinium bromide/vilanterol inhaled)Lung volumes, particularly dynamic hyperinflation, have also been shown to play a crucial role in the development of dyspnea perceived during exercise. In fact, the improvement in exercise capacity brought about by several treatment modalities, including bronchodilators, oxygen therapy, lung volume reduction surgery (LVRS), and maneuvers learned in pulmonary rehabilitation, is more likely due to delaying dynamic hyperinflation rather than improving the degree of airflow obstruction. [10, 11, 12, 13, 14, 15, 16, 17] Additionally, hyperinflation (defined as the ratio of inspiratory capacity to total lung capacity [IC/TLC]) has been shown to predict survival better than forced expiratory volume in 1 second (FEV1). [7] Walters JA, Walters EH, Wood-Baker R. Oral corticosteroids for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2005 Jul 20. CD005374. [Medline].

The inflammation in COPD increases as disease severity increases, and, in severe (advanced) disease, inflammation does not resolve completely despite smoking cessation. This chronic inflammation does not seem to respond to corticosteroids. Chronic obstructive pulmonary disease (COPD), which is often concurrent with chronic bronchitis or emphysema, is a chronic lung disease that causes the airways in the lung to inflame and thicken, resulting in shortness of breath. According to the American Lung Association, COPD has no cure.. Waschki B, Kirsten A, Holz O, et al. Physical activity is the strongest predictor of all-cause mortality in patients with COPD: a prospective cohort study. Chest. 2011 Aug. 140(2):331-42. [Medline]. Martinez FJ, de Oca MM, Whyte RI, Stetz J, Gay SE, Celli BR. Lung-volume reduction improves dyspnea, dynamic hyperinflation, and respiratory muscle function. Am J Respir Crit Care Med. 1997 Jun. 155(6):1984-90. [Medline].

Chronic obstructive pulmonary disease (COPD) represents a spectrum of obstructive airway diseases. It includes two key components which are chronic bronchitis-small airways disease and emphysema. Epidemiology The most common cause has historic.. Vincken W, van Noord JA, Greefhorst AP, Bantje TA, Kesten S, Korducki L, et al. Improved health outcomes in patients with COPD during 1 yr's treatment with tiotropium. Eur Respir J. 2002 Feb. 19(2):209-16. [Medline]. Sandland CJ, Morgan MD, Singh SJ. Patterns of domestic activity and ambulatory oxygen usage in COPD. Chest. 2008 Oct. 134(4):753-60. [Medline]. Right-sided heart catheterization can confirm pulmonary artery hypertension and gauge the response to vasodilators

Find articles by Tuder, R. in: JCI | PubMed | Google Scholar Chronic obstructive pulmonary disease (COPD), also known as chronic obstructive lung disease (COLD), chronic obstructive airway disease (COAD), chronic airflow limitation (CAL) and chronic obstructive respiratory disease (CORD), is the co-occurrence of chronic bronchitis and emphysema.. Cigarette smoking in susceptible people is the major cause of chronic obstructive pulmonary disease (COPD) in the developed world.ICS = inhaled corticosteroid; LABA = long-acting beta-agonist; LAC = long-acting anticholinergic; mMRC = Modified British Medical Research Council; PDE4I = phosphodiesterase-4 inhibitor; SABA = short-acting beta-agonist; SAC = short-acting anticholinergic.Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Dynamic hyperinflation

Bronchiectasis. Bronchiolitis Obliterans. Chronic Obstructive Pulmonary Disease (COPD). Cystic Fibrosis. ►Interstitial Lung Diseases. According to the 2019 Global Initiative for Chronic Obstructive Lung Disease (GOLD) guideline, chronic obstructive pulmonary disease (COPD) is.. Chronic obstructive pulmonary disease: causes, risk factors, symptoms, diagnosis, treatment, outlook. COPD is not contagious - you cannot catch it from someone else. What causes chronic obstructive pulmonary disease? Smoking is the most common cause of COPD The primary cause of COPD is exposure to tobacco smoke. Overall, tobacco smoking accounts for as much as 90% of COPD risk.This work was supported by NIH grants ES016285 (to R.M. Tuder), HL077328 and HL090950 (to I. Petrache), and P50 HL084945 (Project 1, to R.M. Tuder and I. Petrache), a FAMRI research award (to R.M. Tuder), and a Veterans Health Administration merit award (to I. Petrache).The authors acknowledge the input of Alvar Agusti and Bartolome R. Celli regarding the current clinical challenges in COPD and Eric Schmidt and Laura Davis for proofreading this Review.

Chronic obstructive pulmonary disease overvie

Symptoms usually progress quickly in patients who continue to smoke and in those who have a higher lifetime tobacco exposure. Morning headache develops in more advanced disease and signals nocturnal hypercapnia or hypoxemia.Emphysema is destruction of lung parenchyma leading to loss of elastic recoil and loss of alveolar septa and radial airway traction, which increases the tendency for airway collapse. Lung hyperinflation, airflow limitation, and air trapping follow. Airspaces enlarge and may eventually develop blebs or bullae. Obliteration of small airways is thought to be the earliest lesion that precedes the development of emphysema.Categorize patients based on symptoms and exacerbation risk into one of 4 groups and use that category to guide drug treatment.Relieve symptoms rapidly with primarily short-acting beta-adrenergic drugs and decrease exacerbations with inhaled corticosteroids, long-acting beta-adrenergic drugs, long-acting anticholinergic drugs, or a combination.Serum potassium – Diuretics, beta-adrenergic agonists, and theophylline act to lower potassium levels

Short PM, Lipworth SI, Elder DH, Schembri S, Lipworth BJ. Effect of beta blockers in treatment of chronic obstructive pulmonary disease: a retrospective cohort study. BMJ. 2011 May 10. 342:d2549. [Medline]. [Full Text].Nader Kamangar, MD, FACP, FCCP, FCCM Professor of Clinical Medicine, University of California, Los Angeles, David Geffen School of Medicine; Chief, Division of Pulmonary and Critical Care Medicine, Vice-Chair, Department of Medicine, Olive View-UCLA Medical Center Nader Kamangar, MD, FACP, FCCP, FCCM is a member of the following medical societies: Academy of Persian Physicians, American Academy of Sleep Medicine, American Association for Bronchology and Interventional Pulmonology, American College of Chest Physicians, American College of Critical Care Medicine, American College of Physicians, American Lung Association, American Medical Association, American Thoracic Society, Association of Pulmonary and Critical Care Medicine Program Directors, Association of Specialty Professors, California Sleep Society, California Thoracic Society, Clerkship Directors in Internal Medicine, Society of Critical Care Medicine, Trudeau Society of Los Angeles, World Association for Bronchology and Interventional PulmonologyDisclosure: Nothing to disclose. COPD stands for Chronic Obstructive Pulmonary Disease. It is a long-term lung disease that makes it difficult for air to move into and out of the lungs. Asthma and COPD Awareness Molina Breathe with Ease sm and Chronic Obstructive Pulmonary Disease Molina Healthcare of Michigan Fall 2012.. What Is It? Chronic obstructive pulmonary disease (COPD) refers to a group of disorders that damage the lungs. These disorders make breathing increasingly difficult over time. The most common forms of COPD are chronic bronchitis and emphysema

There are two types of respiratory diseases and disorders: infectious and chronic. Pulmonary infections are most commonly bacterial or viral. In the viral type, a pathogen replicates inside a cell and causes a disease, such as the flu. Chronic diseases, such as asthma, are persistent and long-lasting The cardinal pathophysiologic feature of COPD is airflow limitation caused by airway narrowing and/or obstruction, loss of elastic recoil, or both.Weight loss may occur, perhaps in response to decreased caloric intake and increased levels of circulating tumor necrosis factor (TNF)-alpha.

Environmental factors

Hemoglobin and hematocrit are of little diagnostic value in the evaluation of COPD but may show erythrocythemia (Hct > 48%) if the patient has chronic hypoxemia. Patients with anemia (for reasons other than COPD) have disproportionately severe dyspnea. The differential WBC count may be helpful. A growing body of evidence suggests that eosinophilia predicts response to corticosteroids.John J Oppenheimer, MD Clinical Professor, Department of Medicine, Rutgers New Jersey Medical School; Director of Clinical Research, Pulmonary and Allergy Associates, PA John J Oppenheimer, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Allergy, Asthma and Immunology, New Jersey Allergy, Asthma and Immunology societyDisclosure: Received research grant from: quintiles, PRA, ICON, Novartis: Adjudication<br/>Received consulting fee from AZ for consulting; Received consulting fee from Glaxo, Myelin, Meda for consulting; Received grant/research funds from Glaxo for independent contractor; Received consulting fee from Merck for consulting; Received honoraria from Annals of Allergy Asthma Immunology for none; Partner received honoraria from ABAI for none. for: Atlantic Health System. Chronic Obstructive Pulmonary Disease and Related Disorders. Decreased DLco is nonspecific and is reduced in other disorders that affect the pulmonary vascular bed, such as interstitial lung disease, but can help distinguish emphysema from asthma, in which DLco is normal or elevated

Chronic obstructive pulmonary disease (COPD) is one of the commonest lung disorders that is associated with smoking. It is typically characterized by chronic airflow obstruction and difficulty in breathing Conditions We Treat. Chronic Obstructive Pulmonary Disease (COPD). COPD was once deemed to be a disease with a hopeless prognosis, but is now known to be very treatable. Early diagnosis and treatment can enable people with COPD to take charge of their breathing and regain control of their..

The stage of progression of alveolar injury has attracted most of the research efforts in the COPD field (Figure 1). For more than 30 years, initiation and progression have been linked to extracellular matrix proteolysis, notably degradation of elastin by elastases, largely of inflammatory cell source. Key to this paradigm were the landmark discoveries of emphysema in α1-antitrypsin–deficient patients (21) and the induction of emphysema by intratracheal instillation of pancreatic elastase (22), as well as the finding that MMP-12–deficient mice are resistant to cigarette smoke–induced mouse emphysema (23). While extracellular matrix proteolysis is a central event in emphysema, it is apparent that it cannot explain the complexity of alveolar destruction in COPD. Mirza S, Clay RD, Koslow MA, Scanlon PD. COPD Guidelines: A Review of the 2018 GOLD Report. Mayo Clin Proc. 2018 Oct. 93 (10):1488-1502. [Medline]. Singh S, Loke YK, Enright PL, Furberg CD. Mortality associated with tiotropium mist inhaler in patients with chronic obstructive pulmonary disease: systematic review and meta-analysis of randomised controlled trials. BMJ. 2011 Jun 14. 342:d3215. [Medline]. [Full Text].Breathing may be assisted by pursed lips and use of accessory respiratory muscles; patients may adopt the tripod sitting positionChest x-ray may have characteristic findings. In patients with emphysema, changes can include lung hyperinflation manifested as a flat diaphragm (ie, increase in the angle formed by the sternum and anterior diaphragm on a lateral film from the normal value of 45° to > 90°), rapid tapering of hilar vessels, and bullae (ie, radiolucencies > 1 cm surrounded by arcuate, hairline shadows). Other typical findings include enlargement of the retrosternal airspace and a narrow cardiac shadow. Emphysematous changes occurring predominantly in the lung bases suggest alpha-1 antitrypsin deficiency. The lungs may look normal or have increased lucency secondary to loss of parenchyma. Among patients with chronic obstructive bronchitis, chest x-rays may be normal or may show a bibasilar increase in bronchovascular markings as a result of bronchial wall thickening.

Diagnosis of Chronic Obstructive Pulmonary Disease

Fishman A, Martinez F, Naunheim K, Piantadosi S, Wise R, Ries A, et al. A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema. N Engl J Med. 2003 May 22. 348(21):2059-73. [Medline]. Disease Types and Palliative Care. They treat people suffering from the symptoms and stress of serious illnesses such as cancer, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), kidney disease, Alzheimer's, Parkinson's, Amyotrophic Lateral Sclerosis (ALS) and..

The current epidemic of chronic obstructive pulmonary disease (COPD) has produced a worldwide health care burden, approaching that imposed by transmittable infectious diseases. COPD is a multidimensional disease, with varied intermediate and clinical phenotypes. This Review discusses the pathogenesis of COPD, with particular focus on emphysema, based on the concept that pulmonary injury involves stages of initiation (by exposure to cigarette smoke, pollutants, and infectious agents), progression, and consolidation. Tissue damage entails complex interactions among oxidative stress, inflammation, extracellular matrix proteolysis, and apoptotic and autophagic cell death. Lung damage by cigarette smoke ultimately leads to self-propagating processes, resulting in macromolecular and structural alterations — features similar to those seen in aging.Breathlessness: The most significant symptom, but usually does not occur until the sixth decade of life

Essential Oils for COPD (Chronic Obstructive Pulmonary Disease

Bronchial hyperresponsiveness in cardiac failure. N Engl J Med. 1989 Dec 21. 321 (25):1756-8. [Medline]. Modified Medical Research Council (MMRC) dyspnea scale: MMRC 0 = dyspneic on strenuous exercise (0 points); MMRC 1 = dyspneic on walking a slight hill (0 points); MMRC 2 = dyspneic on walking level ground, must stop occasionally due to breathlessness (1 point); MMRC 3 = dyspneic after walking 100 yards or a few minutes (2 points); MMRC 4 = cannot leave house; dyspneic doing activities of daily living (3 points)Celli BR, Cote CG, Marin JM, Casanova C, Montes de Oca M, Mendez RA, et al. The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. N Engl J Med. 2004 Mar 4. 350(10):1005-12. [Medline].

Spitzer C, Koch B, Grabe HJ, et al. Association of airflow limitation with trauma exposure and post-traumatic stress disorder. Eur Respir J. 2011 May. 37(5):1068-75. [Medline]. Acute exacerbation of COPD is a life-threatening emergency, so patients with COPD should be assessed as soon as possible and admitted to the intensive care unit.If you already smoke, stopping can help prevent further damage to your lungs before it starts to cause troublesome symptoms.Airflow limitation in emphysema is due to loss of elastic recoil and decrease in airway tethering, whereas chronic bronchitis leads to narrowing of airway caliber and increase in airway resistance. Although some patients predominantly display signs of one of these diseases or the other, most fall somewhere in between the spectrum of these two conditions.Oral and inhaled medications are used for patients with stable COPD to reduce dyspnea, improve exercise tolerance, and prevent complications. Most of the medications used in COPD treatment are directed at the potentially reversible mechanisms of airflow limitation. (See Medication.)

Chronic Obstructive Pulmonary Disease (COPD): Overview and Mor

Chronic obstructive pulmonary disease (COPD) is a progressive condition characterized by irreversible airflow limitation. In general, this condition results from an abnormal inflammatory response after exposure of the lung to noxious particles and/or gases. Since the early nineteenth century.. COPD is a common condition that mainly affects middle-aged or older adults who smoke. Many people do not realise they have it.Without treatment, the symptoms usually get progressively worse. There may also be periods when they get suddenly worse, known as a flare-up or exacerbation.

COPD National Heart, Lung, and Blood Institute (NHLBI

1Program in Translational Lung Research, Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado, School of Medicine, Denver, Colorado, USA. 2Division of Pulmonary and Critical Care Medicine, Department of Medicine, and 3Richard L. Roudebush Veteran Affairs Medical Center, Indiana University, Indianapolis, Indiana. Chronic obstructive pulmonary disease is the collective term for a number of lung diseases that prevent proper breathing. Better living with chronic obstructive pulmonary disease: a patient guide, 3rd edition, 2016, The State of Queensland (Queensland Health) and Lung Foundation Australia

Chronic Obstructive Pulmonary Disease

Rice KL, Dewan N, Bloomfield HE, Grill J, Schult TM, Nelson DB, et al. Disease management program for chronic obstructive pulmonary disease: a randomized controlled trial. Am J Respir Crit Care Med. 2010 Oct 1. 182(7):890-6. [Medline]. The tiny airways of the lungs are kept open by their alveolar wall. As a consequence of developing emphyesema, the alveolar wall tends to get obliterated causing the tiny airways to completely collapse. This will cause permanent obstruction of the airways. On the other hand, chronic bronchitis tend to cause enlargement of the tiny glands lining the bronchi, often resulting in increased mucus secretion. These often has two distinct effects: Chronic obstructive pulmonary disease (COPD) is characterised by an inappropriate/excessive inflammatory response of the lungs to respiratory pollutants, mainly tobacco smoking. Recently, besides the typical pulmonary pathology of COPD (i.e. chronic bronchitis and emphysema).. Increased airway resistance increases the work of breathing. Lung hyperinflation, although it decreases airway resistance, also increases the work of breathing. Increased work of breathing may lead to alveolar hypoventilation with hypoxia and hypercapnia, although hypoxia and hypercarbia can also be caused by ventilation/perfusion (V/Q) mismatch. COPD is (currently) an incurable disease, but with the right diagnosis and treatment, there are many things you can do to breathe better and enjoy life and Chronic -. This means that the disease lasts a long time and is always present. While the symptoms may take years to develop and the severity may..

Patients with chronic obstructive pulmonary disease (COPD) should be aggressively treated in order to achieve their best possible baseline level of function. While any patient with lung disease should be treated regardless of plans for surgery the focus is prevention of health and illness from pulmonary.. Hypocomplementemic vasculitis urticaria syndrome (HVUS) may be associated with obstructive lung disease. Other manifestations include angioedema, nondeforming arthritis, sinusitis, conjunctivitis, and pericarditis. You can prevent or ease your COPD symptoms, like shortness of breath, cough, mucus build-up and tiredness by taking your prescribed medication. Chronic Obstructive Pulmonary Disease (COPD). Get Help Measure AAT in all patients younger than 40 years, in those with a family history of emphysema at an early age, or with emphysematous changes in a nonsmoker (also see Alpha1-Antitrypsin Deficiency). chronic obstructive pulmonary disease (plural chronic obstructive pulmonary diseases). (pathology) Any of a group of diseases characterized by the pathological limitation of airflow in the airway that is not fully reversible

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