COPD Updated 2018

WEEK
10
Chronic Obstructive
Pulmonary Disease (COPD)
Slide 1 of 51 MPHM13 Respiratory Therapeutics - COPD

WEEK
10
Learning Outcomes
• Understand the principles and wider implications underpinning evidence
based therapeutics in the key clinical specialities
• Objectively analyse the rationale underlying the treatment of disease,

including pharmacological therapy and non-pharmacological therapy,
with consideration of the evidence base, underpinning scientific
principles, cost and political agenda around healthcare
• Assess and critically appraise patients’ medication regimens, including

related calculations, identify areas in which improvements to care may
be made and propose suitable solutions
• Assess and evaluate the signs and symptoms of illness employing

appropriate examination skills, determine if a treatment intervention is
warranted or referral to an alternative health professional

WEEK
10
Aims
• Recap what COPD is
• Look at diagnostic criteria for COPD
• Outline the management COPD
• Describe the current evidence base
• Pharmacists role in the management of COPD

WEEK
10
Recap…COPD
• Under diagnosed, life threatening lung

disease
– Chronic
– Characterised by airflow obstruction
– Associated with an abnormal inflammatory
response
– Not fully reversible
– Progressive i.e. worsens over time

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10
Definition
• Characterised by airflow obstruction. The airflow

obstruction is usually progressive, not fully reversible,
and does not change markedly over several months.
Obstruction is due to a combination of airway and
parenchymal damage. The damage is the result of
chronic inflammation that differs from that seen in
asthma, and is usually the result of smoking.

WEEK
10
Prevalence - COPD
• Common:
– 900,000 sufferers in the UK
• Estimated 2 million are not diagnosed
• In primary care, consultation rates for COPD are at least

twice as high as for angina
• One in eight hospital admissions may be due to COPD
• The prevalence increases with age, and the mean age of

diagnosis in the UK is 67 years
• COPD is more common in men and low socioeconomic

groups.
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10
Signs and symptoms
• Exertional breathlessness
• Chronic cough
• Regular sputum production
• Frequent winter ‘bronchitis’
• Wheeze
• Chest tightness
• Fatigue

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10
Complications
• Cor pulmonale/heart failure
• Respiratory failure
• Sleep apnoea syndrome –prolonged
pauses in breath whilst asleep
– Reduced binding of oxygen to RBCs
– Leads to pulmonary hypertension, cardiac
arrhythmias & cardiac failure
• Repeated respiratory infections particularly
in the winter
• Osteoporosis
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10
Diagnosis
• Consider a diagnosis of COPD in patients who are:
– Over 35 and
– Smokers or ex-smokers
– Have any of the symptoms
• Exertional breathlessness
• Chronic cough
• Regular sputum production
• Frequent winter bronchitis
• Wheeze
• Without clinical symptoms of asthma:

– Chronic unproductive cough
– Significant variability in breathlessness
– Night time symptoms
– Significant diurnal or day to day variability in symptoms

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10
Diagnosis
• Patients in whom a diagnosis of COPD is considered should also be
asked about the presence of the following factors:
– weight loss
– effort intolerance
– waking at night
– ankle swelling
– fatigue
– occupational hazards
– chest pain
– haemoptysis.
• NB These last two symptoms are uncommon in COPD and raise the
possibility of alternative diagnoses.

WEEK
10 Diagnosis
• Diagnosis is determined by spirometry
• Reversibility testing?
• This gives the following values:

– FEV1 (forced expiratory volume in 1 second)
– FVC (forced vital capacity)
– The FEV1/FVC ratio gives a good estimate of
severity of airways obstruction
– Normal FEV1/FVC ratio is 80%
WEEK
10
NICE 2016 Quality statement
• People aged over 35 years who present with a risk factor
and one or more symptoms of chronic obstructive
pulmonary disease (COPD) have post-bronchodilator
spirometry.
• Rationale
– A diagnosis of COPD is confirmed by post-
bronchodilator spirometry. To ensure early diagnosis,
spirometry should be done in primary care when a
person presents with a risk factor for COPD (which is
usually smoking) and one or more symptoms of
COPD.

WEEK
10 Spirometry
• Restrictive effect (e.g.
lung fibrosis)
– FVC is reduced and the
FEV1/FVC ratio is >80%
– The lung volume is
reduced and the FEV1 and
FVC are reduced
proportionately
• Obstructive effect (e.g.

asthma or COPD)
– FEV1 is reduced more than
the FVC and the FEV1/FVC
ratio is <80%
– FEV1 is less than 80% of
predicted
– FVC can be near predicted

WEEK
10
Additional investigations
• At the time of their initial diagnostic

evaluation in addition to spirometry all
patients should have:
– a chest radiograph to exclude other
pathologies
– a full blood count to identify anaemia or
polycythaemia
– BMI calculated.

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Severity
• From NICE guidelines

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10
Dyspnoea scale
1 Not troubled by breathlessness except on strenuous
exercise
2 Short of breath when hurrying or walking up a slight hill
3 Walks slower than contemporaries on level ground

because of breathlessness, or has to stop for breath
when walking at own pace
4 Stops for breath after walking about 100m or after a

few minutes on level ground
5 Too breathless to leave the house, or breathless when

dressing or undressing

WEEK
10 GOLD = Global Initiative for Chronic

Obstructive Lung Disease

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10
Severity
• From GOLD

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10
Management - COPD
• No cure
• Pharmacological and non-pharmacological methods
• Adopt a holistic approach
• Aims:
– Prevent symptoms and their recurrence
– Slow the progression of the disease
– Preserve optimal lung function (short and long term)
– Enhance quality of life

WEEK
10 Management - COPD
• All people should have a self-
management plan including information
on lifestyle issues.
• Advise all people to:
– stop smoking
– comply with medication
– take regular exercise/pulmonary rehabilitation
– attend for a regular influenza vaccination, and
a (once-only) pneumococcal vaccination.

WEEK
10 Evidence – smoking and COPD

• A National Institute for Health and Clinical Excellence
(NICE) review included one systematic review (five
studies, n = 6491) and three additional studies
comparing the effects of smoking cessation in people
with chronic obstructive pulmonary disease (COPD), with
not quitting.
• looked at effects on forced expiratory volume in 1

second (FEV1) and symptoms
• concluded that in people who stopped smoking there

was a significant reduction in FEV1 decline and a
significantly lower prevalence of symptoms such as
chronic cough, sputum production, wheezing, and
shortness of breath compared with people who
continued to smoke
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10
Smoking cessation

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10
Smoking cessation
• Unless contraindicated, offer:
– NRT
– Varenicline
– Bupropion
• 'Varenicline for smoking cessation' (NICE technology

appraisal guidance 123).
– Varenicline is recommended within its licensed indications
as an option for smokers who have expressed a desire to
quit smoking
– Varenicline should normally be prescribed only as part of a
programme of behavioural support.

WEEK
10
Pharmacological Management
• Bronchodilators
– Beta2 receptor agonists, antimuscarinic
agents, theophylline
• Corticosteroids
• Oxygen therapy

WEEK
10

WEEK
10 Management - COPD
• In people with stable COPD who are symptomatic with
breathlessness and/or reduced exercise tolerance use the following:
– Start with a short-acting bronchodilator (beta2-agonist or

antimuscarinic [anticholinergic]) as required.
– In patients with stable COPD who remain breathless or have
exacerbations despite use of short acting bronchodilators as
required offer the following as maintenance therapy:
• If forced expiratory volume in 1 second > 50% predicted: either LABA or

LAMA
• If FEV1 <50% predicted either LABA with an inhaled corticosteroids in a
combination inhaler or LAMA
– Offer LAMA in addition to LABA and ICS to people with COPD

who remain breathless or have exacerbations despite taking
LABA and ICS irrespective of the their FEV1

WEEK
10
Management - COPD
• Review people 1-2 months after starting a

treatment and if there is no symptomatic
improvement discontinue it.
• Consider a longer trial period in people

who have started an inhaled corticosteroid

WEEK
10
Evidence - COPD
• Studies have shown that compared with placebo, long-
acting ß2-adrenoceptor agonists and long-acting
antimuscarinic bronchodilators improve:
– Lung function
– Symptoms
– Quality of life
– Frequency of exacerbations
Studies have shown that the only significant benefit

associated with corticosteroid use is a reduction of
around 25% in exacerbation rate in people with more
severe COPD

WEEK
10
Quality statement: NICE 2016
• People with chronic obstructive pulmonary disease (COPD) who are
prescribed an inhaler have their inhaler technique assessed when
starting treatment and then regularly during treatment.
• Rationale
• Bronchodilator therapy is usually delivered using a hand-held inhaler
device. People with COPD need to use their inhaler correctly to
receive the optimal treatment dose. Assessing inhaler technique
should happen at the first prescription once a person has been
taught the correct technique, and then be reassessed regularly (for
example, at their annual review, if their treatment changes or after
an acute exacerbation) throughout the duration of a person’s
treatment in primary, community and secondary care services.

WEEK
10 Oral therapy
• Steroids
– Maintenance use of oral corticosteroid
therapy in COPD is not usually recommended
– Some people with advanced COPD may
require them, use lowest dose for shortest
duration
– Note adrenal suppression – can occur with
high dose inhaled therapy
• Mucolytics
– Consider in people with a chronic productive
cough and continue use if symptoms improve.
WEEK
10
Oral therapy
• Theophylline
– Offer only after trials of short- and long-acting
bronchodilators or to people who cannot use inhaled
therapy
– Theophylline can be used in combination with beta2
agonists and muscarinic antagonists
– Take care when prescribing to older people because
of pharmacokinetics, comorbidities and interactions
with other medications
– Reduce theophylline dose if macrolide or
fluroquinolone antibiotics (or other drugs known to
interact) are prescribed to treat an exacerbation.

WEEK
10
Oral therapy
• Roflumilast, as an add-on to bronchodilator therapy, is
recommended as an option for treating severe chronic obstructive
pulmonary disease in adults with chronic bronchitis, only if:
– the disease is severe, defined as a forced expiratory volume in 1 second (FEV1)
after a bronchodilator of less than 50% of predicted normal, and
– the person has had 2 or more exacerbations in the previous 12 months despite
triple inhaled therapy with a long-acting muscarinic antagonist, a long-acting
beta-2 agonist and an inhaled corticosteroid.
• Treatment with roflumilast should be started by a specialist in
respiratory medicine.

WEEK
10 Oxygen saturation of arterial

blood
• Used to monitor patients
progress and during
exacerbations
• SpO2
• Normal 97-99%
• Refer to specialist
services if Sp02 <92% on
one or more occasion

WEEK
10
Arterial blood gases
• Blood taken from the artery – give measures of pH, Pa02
and PaC02
• Normal pH is in the range 7.35-7.45
• Normal Pa02 range is 10.5-13.5kPa
• Normal PaC02 range is 4.5-6.5kPa. PaC02 is directly

related to alveolar ventilation.
• A PaC02 <4.5kPa indicates hyperventilation

• A PaC02 >6.5kPa indicates hypoventilation

WEEK
10 Control of respiration
• The purpose of respiration is to provide the tissues with oxygen and
to remove the carbon dioxide derived from oxidative metabolism
• This is achieved by close regulation of the PCO2 and PO2 in the

arterial
• The peripheral arterial chemoreceptors (the carotid bodies) respond

to changes in CO2 and O2 and the pH of arterial blood. Afferents
from the carotid body increase their rate of discharge significantly as
PO2 falls
• The central chemoreceptors respond to changes in the pH of the

CSF resulting from alterations in PCO2
• Increased PCO2 results in an increase in the PCO2 of the CSF and
the hydration reaction for carbon dioxide is driven to the right:
CO2 + H2O ↔ H+ + HCO3-
• As a result, the pH falls in proportion to the rise in PCO2 and
stimulates the chemoreceptors
WEEK
10
COPD and oxygen
• Some patients with COPD have reduced alveolar
ventilation with a low Pa02 and a high PaC02.
They may be cyanosed but not breathless. Their
respiratory centres are relatively insensitive to C02
and they rely on hypoxic drive to maintain
respiration – caution with oxygen

WEEK
10
Emergency oxygen use
• For most patients with known chronic obstructive

pulmonary disease (COPD) or other known risk
factors for hypercapnic respiratory failure (eg,
morbid obesity, chest wall deformities or
neuromuscular disorders), a target saturation
range of 88–92% is suggested pending the
availability of blood gas results.

WEEK
10
• People receiving emergency oxygen for an acute exacerbation of chronic
obstructive pulmonary disease (COPD) have their oxygen saturation levels
maintained between 88% and 92%.
• Rationale
• During an exacerbation, people with COPD may experience a worsening of
gas exchange in the lungs, which can lead to low blood oxygen levels.
Emergency oxygen is often given during the treatment of an exacerbation,
either in the community, during transfer to hospital in an ambulance or while
being assessed at hospital.
• In some people, uncontrolled oxygen therapy may reduce the depth and
frequency of breathing, leading to a rise in blood carbon dioxide levels and
a fall in the blood pH (acidosis). Controlled oxygen therapy must therefore
be administered by a delivery device and at a flow rate that helps the
oxygen saturation to be maintained between 88% and 92%.

WEEK
10
Oxygen use

WEEK
10
Long term oxygen therapy LTOT
• People with stable chronic obstructive pulmonary
disease (COPD) and a persistent resting stable oxygen
saturation level of 92% or less have their arterial blood
gases measured to assess whether they need long-term
oxygen therapy (LTOT).
• Rationale
• LTOT is used to treat people with stable COPD who
have developed daytime hypoxaemia. People with
COPD and a persistent resting stable oxygen saturation
of 92% or less should be assessed for their suitability for
LTOT, which can improve survival, pulmonary
haemodynamics, polycythaemia and neuropsychological
health.
WEEK
10 Oxygen therapy
• People receiving LTOT should breathe

supplemental oxygen for at least 15 hours per
day. If they smoke warn them about the risk of
fire and explosion

WEEK
10
Nebulisers
• Deliver high doses of bronchodilators
• For patients with:

– Distressing or disabling breathlessness
– On maximal inhaler therapy
• Mainly used in hospital setting

• Use at home:
– Controversial
– Fully assessed

WEEK
10
Nebulisers

WEEK
10 Exacerbations
• Definition:
– A sustained worsening of the patient’s symptoms from
his or her usual stable state that is beyond normal
day-to-day variation, and is acute in on set
• Symptoms:
– Worsening breathlessness/dyspnoea
– Cough
– Increased sputum production/sputum volume
– Change in sputum colour

WEEK
10
Treatment at home vs hospital

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10

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10
Self management of exacerbations
• Give people at risk of exacerbations a course of

antibiotic and corticosteroid tablets to keep at home.
• Encourage people at risk of having an exacerbation to

respond quickly to the symptoms of an exacerbation by:
– starting oral corticosteroid therapy (unless
contraindicated) if increased breathlessness
interferes with activities of daily living
– starting antibiotic therapy if their sputum is purulent
– adjusting bronchodilator therapy to control symptoms.

WEEK
10
Pulmonary Rehabilitation
• Pulmonary rehabilitation is defined as a multidisciplinary
programme of care for patients with chronic respiratory
impairment that is individually tailored and designed to
optimise each patient's physical and social performance
and autonomy.
• Includes:
– Multidisciplinary interventions
– Physical training
– Disease education
– Nutritional, psychological and behavioural intervention

WEEK
10
• People with stable chronic obstructive

pulmonary disease (COPD) and exercise
limitation due to breathlessness are referred to a
pulmonary rehabilitation programme.
• Rationale
• Pulmonary rehabilitation programmes improve a
person’s exercise capacity, quality of life,
symptoms and levels of anxiety and depression.

WEEK
10
Cor pulmonale
• Cor pulmonale
– The clinical syndrome of cor pulmonale includes
patients who have right heart failure secondary to
lung disease and those whose primary pathology is
retention of salt and water, leading to the
development of peripheral oedema
• Diagnosis
– Peripheral oedema
– Raised venous pressure
– A systolic parasternal heave
– A loud pulmonary second heart sound

WEEK
10 Cor pulmonale
• Patients presenting with cor pulmonale should be
assessed for the need for long-term oxygen therapy
• Oedema associated with cor pulmonale can usually be

controlled symptomatically with diuretic therapy

WEEK
10
References
• NICE Clinical Guideline 101

– Chronic Obstructive Pulmonary Disease, June
2010
• World Health Organisation: www.who.int
• British Lung Foundation: www.lung.uk.org

COPD Updated 2018

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WEEK

Slide 1 of 51 MPHM13 Respiratory Therapeutics - COPD

• Objectively analyse the rationale underlying the treatment of disease,

• Assess and critically appraise patients’ medication regimens, including

• Assess and evaluate the signs and symptoms of illness employing

Slide 2 of 51 MPHM13 Respiratory Therapeutics - COPD

• Look at diagnostic criteria for COPD

• Outline the management COPD

• Describe the current evidence base

• Pharmacists role in the management of COPD

Slide 3 of 51 MPHM13 Respiratory Therapeutics - COPD

• Under diagnosed, life threatening lung

Slide 4 of 51 MPHM13 Respiratory Therapeutics - COPD

• Characterised by airflow obstruction. The airflow

Slide 5 of 51 MPHM13 Respiratory Therapeutics - COPD

• In primary care, consultation rates for COPD are at least

• One in eight hospital admissions may be due to COPD

• The prevalence increases with age, and the mean age of

• COPD is more common in men and low socioeconomic

Slide 7 of 51 MPHM13 Respiratory Therapeutics - COPD

• Without clinical symptoms of asthma:

Slide 9 of 51 MPHM13 Respiratory Therapeutics - COPD

Slide 10 of 51 MPHM13 Respiratory Therapeutics - COPD

• This gives the following values:

Slide 12 of 51 MPHM13 Respiratory Therapeutics - COPD

• Obstructive effect (e.g.

Slide 13 of 51 MPHM13 Respiratory Therapeutics - COPD

• At the time of their initial diagnostic

Slide 14 of 51 MPHM13 Respiratory Therapeutics - COPD

Slide 15 of 51 MPHM13 Respiratory Therapeutics - COPD

2 Short of breath when hurrying or walking up a slight hill

3 Walks slower than contemporaries on level ground

4 Stops for breath after walking about 100m or after a

5 Too breathless to leave the house, or breathless when

Slide 16 of 51 MPHM13 Respiratory Therapeutics - COPD

10 GOLD = Global Initiative for Chronic

Slide 17 of 51 MPHM13 Respiratory Therapeutics - COPD

Slide 18 of 51 MPHM13 Respiratory Therapeutics - COPD

Slide 19 of 51 MPHM13 Respiratory Therapeutics - COPD

Slide 20 of 51 MPHM13 Respiratory Therapeutics - COPD

10 Evidence – smoking and COPD

• looked at effects on forced expiratory volume in 1

• concluded that in people who stopped smoking there

Slide 22 of 51 MPHM13 Respiratory Therapeutics - COPD

• 'Varenicline for smoking cessation' (NICE technology

Slide 23 of 51 MPHM13 Respiratory Therapeutics - COPD

Slide 24 of 51 MPHM13 Respiratory Therapeutics - COPD

Slide 25 of 51 MPHM13 Respiratory Therapeutics - COPD

– Start with a short-acting bronchodilator (beta2-agonist or

• If forced expiratory volume in 1 second > 50% predicted: either LABA or

– Offer LAMA in addition to LABA and ICS to people with COPD

Slide 26 of 51 MPHM13 Respiratory Therapeutics - COPD

• Review people 1-2 months after starting a

• Consider a longer trial period in people

Slide 27 of 51 MPHM13 Respiratory Therapeutics - COPD

Studies have shown that the only significant benefit

Slide 28 of 51 MPHM13 Respiratory Therapeutics - COPD

Slide 29 of 51 MPHM13 Respiratory Therapeutics - COPD

Slide 31 of 51 MPHM13 Respiratory Therapeutics - COPD

Slide 32 of 51 MPHM13 Respiratory Therapeutics - COPD

10 Oxygen saturation of arterial

Slide 33 of 51 MPHM13 Respiratory Therapeutics - COPD

• Normal pH is in the range 7.35-7.45