Case Presentation on

COPD
By,
Thomas Eipe
Pharm D Intern
 Introduction
• Chronic obstructive pulmonary disease (COPD) is a chronic
inflammatory lung disease that causes obstructed airflow from the
lungs
• It is a progressive lung disease that includes Emphysema and
Chronic bronchitis.
• Emphysema damages the elasticity of the airways that lead to the air
sacs
• Chronic bronchitis, the air passages in the lungs become inflamed.
In response to the inflammation, the lungs produce excess mucus,
causing painful coughing and sputum.
 Stages of COPD(GOLD)

FEV1% (Forced expiratory

GRADE/ STAGES NAME
volume)

1 MILD ≥ 80

2 MODERATE 50-79

3 SEVERE 30-49

VERY SEVERE OR END-

4 <30
STAGE COPD
Differences between COPD and asthma
 Epidemiology

• The Global Burden of Disease Study reports a

prevalence of 251 million cases of COPD globally in
2016.
• India contributes a significant and growing percentage
of COPD mortality estimated to be amongst the
highest in the world; i.e. more than 64.7 estimated age
standardized death rate per 100,000.
• Prevalence of COPD was 22.1% among the study
population. Males (39.2%) had higher prevalence
than females (12.2%). ( Tamil Nadu) - 2017
Pathophysiology
 Causes
Smoking
Smoking is the main cause of COPD and is thought to be responsible
for around 9 in every 10 cases.
Fumes and dust at work
Exposure to certain types of dust and chemicals at work may damage the
lungs and increase your risk of COPD.
Air pollution
Exposure to air pollution over a long period can affect how well the lungs
work and some research has suggested it could increase your risk of COPD.
Genetics
Around 1 in 100 people with COPD has a genetic tendency to develop COPD
called alpha-1-antitrypsin deficiency. Alpha-1-antitrypsin is a substance that
protects the lungs. Without it, the lungs are more vulnerable to damage. People
who have an alpha-1-antitrypsin deficiency usually develop COPD at a
younger age, often under 35 – particularly if they smoke.
 Causes

• Tobacco smoking is the most important and dominant

risk factor for COPD
• Tobacco exposure is quantified in pack-years:
Total pack years =
no. of cigarettes smoked per day × no. of years of smoking
20
• 1-20 pack years – 10% risk of developing mild
COPD & 4% risk of severe COPD
• 61 pack years – 24% of mild & 7% of severe COPD
 Signs and Symptoms

• Chronic cough
• Dyspnea (during physical activity and rest)
• Frequent respiratory infections
• Production of purulent sputum
• Bluish discoloration of lips and nail beds
• Morning headaches
• Wheezing
• Weight loss
• Pulmonary hypertension
• Peripheral oedema
• Hemoptysis
 Diagnosis

• Tests may include:

– Lung (pulmonary) function tests.
– Chest X-ray.
– CT scan.
– Arterial blood gas analysis.
– Laboratory tests.
 Management

• Currently there is no cure for COPD, but treatment can help

to slow down the progression of the condition and control the
symptoms.
• Smoking cessation/ Reduce contact with smoke.
• Oxygen therapy
Vaccination
• Influenza vaccine: It can reduce serious illness (LRI and
hospitalization due to it), death in COPD patients.
• Pneumococcal vaccine: PCV13 & PPSV23 is recommended
for all patients ≥65 yrs. PPSV23 is also recommended for
younger COPD patients with significant co-morbid condition.
 Management

Pharmacological:
• Bronchodilators inhaled bronchodilators are preferred to
oral formulations in view of better efficacy and lesser
side effects.
• Inhaled bronchodilators include short acting beta agonists
(salbutamol, terbutaline), long acting beta agonists
(salmeterol, formoterol), short acting anticholinergics
(Ipratropium), long acting anti-cholinergic (tiotropium).
• Glucocorticoids - Inhaled corticosteroids should be given
in severe COPD or in those with repeated exacerbation.
• Systemic corticosteroids should be given only in patients
with acute exacerbation of COPD.
 Management

• Antibiotics only when there is evidence of

infection in the form of purulent sputum or fever.
• Antioxidant agents: No effect of n-acetylcysteine
on frequency of exacerbations, except in patients
not treated with inhaled glucocorticosteroids.
• Mucolytic agents, Antitussives, Vasodilators: Not
recommended in stable COPD.
• Surgical Bullectomy.
• Lung transplantation.
Algorithm
REAL CASE
 SUBJECTIVE

Patient Name: Mrs. P

Sex: Female

Age: 60 year

Date of admission: 15/03/19

Ward: FMW

IP No: 447
17
 SUBJECTIVE

• Chief complaints: C/O breathlessness for past 1 week,

No H/O fever, C/O cough + without sputum

• Past medical history: Not K/C/O copd

• No other relevant history

18
 OBJECTIVE
On Examination
Patient conscious, oriented, afebrile, PE°

o BP : 120/80 mmHg
o CVS : S1 S2 +
o RS : B/L AE+
o CNS : NFND
o P/A : Soft
 Altered lab parameters

• No altered lab parameters

DIAGNOSIS: COPD

21
 Assessment
Date Day On Examination Drug(s) prescribed
15/3 1 GC fair Inj. Ceftriaxone 1g IV bd
Afebrile, conscious, Inj. Rantac 2cc IV bd
oriented Inj. Deriphylline 2cc IV bd
CVS, RS: NAD Neb. Salbutamol tds
P/A: soft Vitals monitoring

16/3 2 Conscious, oriented DIL

CVS- S1S2 Nasal O2 2L SOS
B/L – wheeze Soft solid diet
CNS – NFND Inj. Cefotaxim 1g IV bd
Inj. Rantac 50mg IV bd
P/A- soft Inj. Deriphylline 2cc IV tds
Inj. Dexamethasone 8mg IV bd
Tab. Paracetamol 500mg 1-1-1
Tab. Cetrizine 10mg 0-0-1
Tab. BCT 1-0-0
Neb with salbutamol 6th hrly
 Assessment
Date Day On Examination Patient Drug(s) prescribed
Complaints

17/3 3 BP: 130/90 mmHg C/O abd pain, Nasal O2 2L SOS

Pulse: 80 b/min epigastric Soft solid diet
Resp: 22/ min discomfort Inj. Cefotaxim 1g IV bd
GC fair Inj. Rantac 50mg IV bd
Afebrile, conscious, Inj. Deriphylline 2cc IV tds
oriented Dec. SOB Tab. Paracetamol 500mg 1-1-1
RS: B/L airentry + Tab. Cetrizine 10mg 0-0-1
B/L wheeze Tab. BCT 1-0-0

18/3 4 BP: 130/90 mmHg No specific Nasal O2 2L/min

Pulse: 76 b/min complaints Soft solid diet
Resp: 22/ min Inj. Cefotaxim 1g IV bd
RS: BAE+, wheeze + Inj. Rantac 50mg IV bd
Inj. Deriphylline 2cc IV tds
Inj. Dexamethasone 8mg IV bd
Tab. Paracetamol 500mg 1-1-1
Tab. Cetrizine 10mg 0-0-1
Tab. BCT 1-0-0
Neb with salbutamol 6th hrly
 Assessment
Date Day On Examination Patient Drug(s) prescribed
Complaints
19/03 5 BP: 130/80 mmHg No specific T. Deriphylline 100mg 1-0-1
Pulse: 72 b/min complaints T. Azithromycin 250mg 2-0-0
Resp: 22/ min BCT 1-0-0
GC fair,Afebrile, conscious, T. Salbutamol 4mg 1-0-1
oriented T. Paracetamol 500mg TID
CVS, RS: NAD T. Cetrizine 10mg 0-0-1
P/A: soft

Review in OPD after 15 days
Discharge medication
T. Deriphylline 100mg 1-0-1
T. Azithromycin 250mg 2-0-0
BCT 1-0-0
T. Salbutamol 4mg 1-0-1
T. Paracetamol 500mg TID
T. Cetrizine 10mg 0-0-1
 Interventions

• SPO2 was not checked for this patient, and

oxygen therapy was started.
• Cetrizine was contraindicated in COPD
patients.
• Paracetamol was given without any indicated.
• Pulmonary function tests can be done.
 My plan

• T. Azithromycin 250mg 2-0-0

• T. Ranitidine 150mg BD
• T. Salbutamol 1-0-1
• T. Deriphylline (23/77) mg 1-0-1
• Nasal O2 after SPO2 checking
 ADR,MONITORING PARAMETERS,
BRAND NAMES
DRUGS ADR MONITORING BRAND NAME
PRAMETERS
Deriphylline Insomnia, Palpitations, Pulmonary function test, Deriphyllin –OD
arrythmias,tachycardia Serum theophylline
Salbutamol Tremor, Nausea ,Fever, Broncho Renal function Asthalin,Albutamol
-spasm , Vomiting, Headache
,Dizziness ,Cough

Ranitidine Headache , [Abdominal Hemoglobin,Hematocrit, Zantac , Meditin ,

pain,Agitation,Alopecia,Confusion,C SGOT, SGPT, RFT
onstipation,Diarrhea,Dizziness,
Hypersensitivity reaction,
Nausea, Vomiting]

Azithromycin diarrhea or loose stools, Azithral – Alembic No routine tests

nausea,abdominal pain, Aziwok- Wockhardt recommended.
stomach upset,vomiting.
 Patient Counseling

Regarding Disease
• The patient was made well aware about her condition and was
counseled about the signs and symptoms of the disease.
• The patient was counseled about the causes of the disease and the
necessity to avoid triggering factors such as, dusts and chemicals,
indoor and outdoor pollution and smoke.
Regarding Lifestyle
• Patient was asked to wear a mask to prevent triggering factors like
smoke and to keep herself warm in this cold climate.
• Practicing breathing exercises aim to improve the symptoms of
COPD by improving the muscles a person uses to take breaths
and improve their ability to exercise.
 Patient Counseling

Regarding Drugs
• Patient was counseled to be adhered to the medication.
• Patient was counseled about the medications.
• Patient was advised not to miss out on any dose as this would
worsen the condition.
• The patient was asked not to discontinue the medication
without asking the prescriber.
 Take Away Points
USFDA has approved a fixed-dose combination of aclidinium
bromide 400ug and formoterol fumarate 12ug (Duaklir, Circassia
Pharmaceuticals) for the maintenace treatment of chronic
obstructive pulmonary disease (COPD). The combination is
administered twice daily via the breath-actuated inhaler Pressair
(AstraZeneca).

Aclidinium bromide is a long-acting muscarinic antagonist

(LAMA) that acts primarily on the M3 receptor to relieve
bronchospasm. Formoterol fumarate is a long-acting beta-agonist
(LABA) that stimulates B2-receptors, resulting in bronchodilation.
 References
1.GBD 2015 Chronic Respiratory Disease Collaborators. Global, regional, and national deaths,
prevalence, disability-adjusted life years, and years lived with disability for chronic obstructive
pulmonary disease and asthma, 1990–2015: a systematic analysis for the Global Burden of
Disease Study 2015. Lancet Respir Med. 2017; 5: 691-706
2.India State-Level Disease Burden Initiative Collaborators. Nations within a nation: variations in
epidemiological transition across the states of India, 1990–2016 in the Global Burden of Disease
Study. Lancet. 2017; 390: 2437-2460
3. https://www.nhs.uk/conditions/chronic-obstructive-pulmonary-disease-copd/living-with/
4.Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the diagnosis,
management, and prevention of COPD. Jan 2014 [cited 29 Jan 2014]. Available from:
http://www.goldcopd.org/guidelines-global-strategy-for-diagnosis-management.html
5.https://www.webmd.com/lung/copd/copd-diet-avoiding-weight-loss-staying-healthier#2
6.https://www.prnewswire.com/news-releases/theravance-biopharma-and-mylan-receive-fda-
approval-for-yupelri-revefenacin-in-adults-with-chronic-obstructive-pulmonary-disease-
300747672.html
7.Corticosteroids in the treatment of acute exacerbations of chronic obstructive pulmonary disease. J
Andrew Woods, James S Wheeler et al. Int J Chron Obstruct Pulmon Dis. 2014; 9: 421–430.
Published online 2014 May 3. doi:  [10.2147/COPD.S51012]. Available at
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4014384/
Thank You