o COPD is the 4th leading cause of death worldwide and is

projected to be the 3rd leading case in 2020

o The overall incidence rate of COPD was 8.9/1000 person-
years
o Higher in males and in smokers
o The proportion of female COPD participants without a
history of smoking was 27.2% while proportion was 7.3% in
males
o Burden of Obstructive Lung Disease (BOLD) –has used
standardized methodology comprising questionnaires and
pre and post bronchodilator spirometer to assess the
prevalence and risk factors of COPD in people aged 40
around the world.
chronic obstructive pulmonary disease

A common, preventable and

treatable disease that is
characterized by persistent
respiratory symptoms and airflow
limitation that is due to airway
PATHOPHYSIOLOGY
• Pathological changes characteristic of COPD are found in
the proximal airways, peripheral airways, lung parenchyma,
and pulmonary vasculature. These changes include chronic
inflammation, and structural changes resulting from
repeated injury and repair.
• Inhaled cigarette smoke and other noxious particles cause
lung inflammation, a normal response which appears to be
amplified in patients who develop COPD.
 PATHOPHYSIOLOGY
 Airflow Limitation and Air
Trapping
 Gas Exchange Abnormalities
 Mucus Hypersecretion
 Pulmonary Hypertension
 Risk of developing COPD is related to following
factors:
• Lung growth and
• Tobacco smoke development
• Indoor air pollution • Socioeconomic status
• Asthma and airway
• Occupational exposures
• Outdoor air pollution hyper-reactivity
• Genetic factor • Chronic bronchitis
• Age and sex • Infection
Differential diagnosis
A major differential diagnosis is
asthma. In some patients with chronic
asthma, a clear distinction from COPD is
not possible using current imaging and
physiological testing techniques. In these
patients, current management is similar to
that of asthma. Other potential diagnoses
are usually easier to distinguish from
COPD.
DIAGNOSIS SUGGESTIVE FEATURES

• Onset in mid-life
• Symptoms slowly progressive
• History to tobacco smoking or
COPD exposure to other types of smokes

• Onset early in life (often childhood)

• Symptoms vary widely from day to day
ASTHMA • Symptoms worst at night or early morning
• Allergy, rhinitis, and/or eczema is also
present
• Family history of asthma
• Obesity coexistence
 • Chest X-ray shows dilated heart, pulmonary
edema
CONGESTIVE HEART FAILURE • Pulmonary function tests indicate volume
restriction not airflow

• Large volumes of purulent sputum

• Commonly associated with bacterial
infection
BRONCHIECTASIS • Chest X-ray/CT shows bronchial
dilation, bronchial wall thickening

• Onset all ages

• Chest X-ray shows lung infiltrate
TUBERCULOSIS • Microbiological confirmation
• High local prevalence of TB
 • Onset at younger age, nonsmokers
• May have history of rheumatoid arthritis
or acute fume exposure
OBLITERATIVE BRONCHIOLITIS • Seen after lung or bone marrow
transplantation
• CT on expiration shows hypodense areas

• Predominantly seen in patients of Asian

descent
DIFFUSE PANBRONCHIOLITIS • Most patients are male and nonsmokers
• Almost all have chronic sinusitis
• Chest X-ray and HRCT show diffuse small
centrilobular nodular opacities and
hyperinflation
 EXPOSURE TO RISK
SYMPTOMS FACTORS
Cough Tobacco smoking
Sputum Occupation
Shortness of Breath Indoor/Outdoor pollution

SPIROMETRY
Diagnosis and Assessment
 Assess and Monitor COPD
A clinical diagnosis of COPD should be considered in
any patient who has dyspnea, chronic cough or sputum
production and a history to risk factors of disease.
The diagnosis should be confirmed by SPIROMETRY,
the presence of a post- bronchodilator FEV1/FVC < 0.70
confirms the presence of persistent airflow limitation
and thus of COPD.
SPIROMETRY
• is a measure of air flow and
lung volumes during a
forced expiratory maneuver
from full inspiration
• a method of assessing lung
function by measuring the
total volume of air the
patient can expel from the
lungs after a maximal
inhalation.
The measurements to be really concern with are:
 FVC – full amount of air that can be exhaled with
effort in a complete breath
 FEV1- the volume of air that can be forced out in
one second after taking a deep breath
 FEV1/FVC ratio- measurement of the amount of
air you can forcibly exhale from your lungs
 Pulmonary Function Testing
When performing PFT’s three values
are reported:
 Actual
• Predicted- what the patient should
have performed based on:
• 1. Age 2. Height
• 3. Sex 4. Weight 5. Ethnicity
 %Predicted- a comparison of the
actual value to the predicted value
Spirogram Patterns
 Obstructive Pattern
FEV1: <80% predicted
FVC: can be normal or
reduced, usually to a
lesser degree than FEV1
FEV1/FVC: <70% predicted
 Assessment of COPD
• Assess degree of airflow limitation, its impact on the
patient’s health status and the risk of future events (such as
exacerbations, hospital admission or death)
• To achieve these goals, COPD assessment must consider the
following aspects:
The presence and severity of the spirometric abnormality
Current nature and magnitude of the patient’s symptoms
Exacerbation history and future risk
Presence of comordities
GOLD Staging System for COPD
COMBINED ASSESSMENT
Modified MRC Dyspnea Scale
Combined assessment
• Example:
• Consider two patients- both patients with FEV1
<30% of predicted, CAT scores of 18 and with no
exacerbations in the past year and the other with three
moderate exacerbation in the past year. Both would
have been labelled GOLD D in the prior classification
scheme. However with a new proposed scheme, the
subject with 3 moderated exacerbations in the past
year would be labelled GOLD grade 4, group D; and the
other subject with no exacerbation would be labelled
GOLD grade 4, group B.
Example:
A 73-year-old male has a symptom
CAT score of 16 and FEV1 of 55% of
predicted, and a history of three
exacerbations within the last 12 months.
 EVIDENCE
SUPPORTINGPREVENTION
AND MAINTENANCE
THERAPY
 SMOKING CESSATION
• Smoking cessation has the greatest capacity to influence the natural
history of COPD.
• A five-step program for intervention provides a helpful strategic
framework to
• guide health care providers interested in helping their patients stop
smoking.
- Ask
- Advise
- Assess
- Assist
- Arrange
 VACCINATIONS
PNEUMOCOCCAL VACCINE
• Such as PCV13 and PPSV23 are recommended for all patients ≥ 65 years
of age

• PPSV23 is recommended for younger COPD patients

Influenza Vaccine
• Can reduce serious illness
• Death in COPD patients
PHARMACOLOGIC THERAPY FOR
STABLE COPD
• Pharmacologic Therapy for COPD

• is used to reduce symptoms, reduce the

frequency & severity of exacerbations, and
• improve exercise tolerance and health
status.
 Bronchodilators
• increase FEV1 and/or change
other spirometric variables.
• most often given on a regular
basis to prevent or reduce
symptoms.
 Beta 2- agonists
• relax airway smooth muscle by stimulating beta2-adrenergic
receptors
• which increases cyclic AMP and produces functional antagonism
bronchoconstriction.
 SABA (short acting beta agonists)
 LABA (Long acting beta agonists)
LABA:
- Formeterol and salmeterol
- Indacaterol
- Oladaterol and vilanterol
 Adverse effects :
 Produce resting sinus tachycardia
 Cardiac rhythm disturbances
 Exaggerated somatic tremor
 Antimuscarinic drugs
• block the bronchoconstrictor effects of acetylcholine on M3
muscarinic receptors.
• SAMA (Short acting Antimuscarinics):
• - Ipratropium LAMA (Long acting
• - Oxitropium Antimuscarinics) :
- Tiotropium
- Aclidinium
- Glycopyrronium bromide
- Umeclidinium
 Adverse effects :
• Inhaled anticholinergic drugs are poorly
absorbed which limits the troublesome
systemic effects observed with atropine.
• Dryness of mouth
 Methylxanthines
• Theophylline- most commonly used
methylxanthine

• * Addition of theophylline to salmeterol

produces a greater improvement in FEV1
and breathlessness than salmeterol alone.
 Adverse effects :

Toxicity is dose-related, which is

a particular problem with xanthine
derivatives.
Combination bronchodilator therapy
• increase the degree of bronchodilation with a lower
risk of side-effects compared to increasing the dose of a
single bronchodilator
• treatment with formoterol and tiotropium in separate
inhalers has a bigger impact on FEV1than either
component alone
• There are numerous combinations of a LABA and LAMA
in a single inhaler available
• A lower dose, twice daily regimen for a combination
LABA/LAMA
 Inhaled Corticosteroids (ICS)
– ICS in combination with long-acting
bronchodilator therapy

• ADVERSE EFFECTS :
Higher prevalence of oral candidiasis, hoarse voice,
skin bruising and pneumonia.
Withdrawal of ICS
 Triple inhaled therapy

This may improve lung function and

patient reported outcomes.
 Oral glucocorticoids

Play a role in the acute management of

exacerbations, they have no role in the
chronic daily treatment in COPD
 Phosphodiesterase-4 (PDE4) inhibitors
Roflumilast reduces moderate and severe
exacerbations treated with systemic corticosteroids in
patients with chronic bronchitis, severe to very severe
COPD, and a history of exacerbations.
• Adverse effect:
The most frequent are nausea, reduced appetite,
weight loss, abdominal pain, diarrhea, sleep disturbance,
and headache.
 Antibiotics
• AZITHROMYCIN/ERYTHROMYCIN
• -reduced the risk of exacerbations compared
to usual care
• - increased incidence of bacterial resistance
and impaired hearing tests
Mucolytic and antioxidant agents

• MUCOLYTIC (MUCOKINETICS,
MUCOREGULATORS)
• ANTIOXIDANT AGENTS (NAC,
CARBOCYSTEINE)
• - reduce exacerbations and modestly
improve health status.
 Issues related to inhaled delivery

The main errors in delivery device use relate to problems with

• - inhalation rate
• - inhalation duration
• - coordination
• - dose preparation
• - exhalation maneuver prior to inhalation and breath-
holding following dose inhalation
 MANAGEMENT OF COPD

• MANAGEMENT OF STABLE
COPD
 PULMONARY REHABILITATION
Components:
Exercise Training
Nutrition Counseling
Education
 OXYGEN THERAPY
One of the nonpharmacologic
treatment for patients with Stage IV:
Very Severe COPD.
Goal: to increase baseline of PaO2 to
80 mmHg and SaO2 of 90%
• LONG-TERM CONTINUOUS
THERAPY
>15 hours per day to:
o patients with chronic respiratory failure
o patients with PaO2 of 55 mmHg and
SaO2 of 88%
 VENTILATORY SUPPORT
 Non-invasive ventilation treat acute
exacerbation of COPD.
 Combining Non-invasive Intermittent
Positive Pressure and Long-term O2
therapy lessen CO2 retention and decrease
shortness of breath.
 SURGICAL TREATMENT
o Bullectomy – removal of large bulla that
does not contribute in gas exchange
o Lung Volume Reduction Surgery (LVRS) –
removal of emphysematous lung tissue
o Lung Transplantation – partially or totally
replacement of the lung.
MANAGEMENT OF
EXACERBATIONS
 GOAL

- TO REDUCE THE SEVERITY OF THE

DISEASE

- TO PREVENT THE REOCCURENCE

OF THE FUTURE EXACERBATION/S
 Exacerbation
- Acute worsening of respiratory symptoms
that result in additional therapy

MOST COMMON CAUSE:

Respiratory Tract Infection

 VENTILATORY SUPPORT
- Noninvasive Mechanical
Ventilation
- Invasive Mechanical Ventilation