COPD

(Chronic obstructive
pulmonary disease)
INTRODUCTION
• It affects more than 5 percent of the population and is associated
with high morbidity and mortality
• It is the third-ranked cause of death in the United States, killing more
than 120,000 individuals each year
Burden of COPD
• The burden of COPD is projected to increase in coming decades due
to continued exposure to COPD risk factors and the aging of the
world’s population.
• COPD is associated with significant economic burden.
Definition of COPD
• COPD, a common preventable and treatable disease, is characterized
by persistent airflow limitation that is usually progressive and
associated with an enhanced chronic inflammatory response in the
airways and the lung to noxious particles or gases.
COPD includes
1) Chronic Bronchitis
2) Emphysema
Chronic bronchitis
• Defined as a chronic productive cough for three months in each of
two successive years in a patient in whom other causes of chronic
cough have been excluded.
Emphysema
• Abnormal and permanent enlargement of the airspaces distal to the
terminal bronchioles that is accompanied by destruction of the
airspace walls, without obvious fibrosis.
PATHOLOGICAL CHANGES IN AIRWAY
• Chronic inflammation
• Increased numbers of goblet cells
• Mucus gland hyperplasia
• Fibrosis
• Narrowing and reduction in the number of small airways
• Airway collapse due to the loss of tethering caused by
• alveolar wall destruction in emphysema
Changes in Lung Parenchyma
• Emphysema affects the structures distal to the terminal bronchiole,
consisting of the respiratory bronchiole, alveolar ducts, alveolar sacs,
and alveoli, known collectively as the acinus.
•EMPHYSEMA - TYPES
NORMAL ACINUS
Centrilobular emphysema (Proximal
acinar)
• Abnormal dilation or destruction of the respiratory bronchiole, the
central portion of the acinus. It is commonly associated with cigarette
smoking.
Panacinar emphysema
• Refers to enlargement or destruction of all parts of the acinus.
• Seen in alpha-1 antitrypsin deficiency and in smokers
Paraseptal emphysema
• Distal acinar - the alveolar ducts are predominantly affected.
Emphysema
Changes in Pulmonary vasculature
• Intimal hyperplasia and smooth muscle hypertrophy or hyperplasia
thought to be due to chronic hypoxic vasoconstriction of the small
pulmonary arteries.
• Destruction of alveoli due to emphysema can lead to loss of the
associated areas of the pulmonary capillary bed and pruning of the
distal vasculature.
Risk Factors for COPD
Genetics
• Alpha 1-antitrypsin deficiency is a genetic condition that is responsible
for about 2% of cases of COPD.
• In this condition, the body does not make enough of a protein, alpha
1-antitrypsin.
• Alpha 1-antitrypsin protects the lungs from damage caused by
protease enzymes, such as elastase and trypsin, that can be released
as a result of an inflammatory response to tobacco smoke.
Symptoms of COPD
• The characteristic symptoms of COPD are chronic and progressive dyspnea,
cough, and sputum production that can be variable from day- to-day.
• DYSPNOEA – progressive, persistent and more with exercise.
• CHRONIC COUGH
• CHRONIC SPUTUM PRODUCTION
• Others – wheezing
• chest tightness
• respiratory infections
• weight loss
Modified MRC (mMRC)Questionnaire
Physical signs
• *Inspection:
• Barrel-shaped chest ,
• Accessory respiratory muscle participate , Prolonged expiration
during quiet breathing. Expiration through pursed lips
• Paradoxical retraction of the lower interspaces during inspiration (ie,
hoover's sign)
• Tripod Position
Tripod Position
Clinical Manifestation
*Palpation:
• Decreased fremitus vocalis
*Percussion :
• Hyperresonant
• Depressed diaphragm
• Dimination of the area of absolute cardiac dullness.
*Auscultation:
• Prolonged expiration
• Reduced breath sounds
• The presence of wheezing during quiet breathing
• Crackle can be heard if infection exist.
 Diagnosis of COPD

SYMPTOMS EXPOSURE TO RISK

shortness of FACTORS
tobacco
breath occupation
chronic cough indoor/outdoor pollution
sputum

è
SPIROMETRY: Required to establish diagnosis

© 2015 Global Initiative for Chronic Obstructive Lung Disease

Diagnosis
• The presence of a post-bronchodilator FEV1/FVC < 0.70 confirms the
presence of persistent airflow limitation and thus of COPD.
CHRONIC BRONCHITIS
• No apparent abnormality
• Or thickened and increased
lung markings are noted.
EMPHYSEMA – CHEST X Ray
• Marked over inflation is noted
with flattend and low diaphragm
• Intercostal space becomes widen
• A horizontal pattern of ribs
• A long thin heart shadow
• Decreased markings of lung peripheral
vessels
CT(Computed tomography)
• Greater sensitivity and specificity for emphysema
• For evaluation of bullous disease.
MANAGEMENT
Based on the principles of
• Prevention of further progress of disease
• Preservation and enhancement of pulmonary functional capacity
• Avoidance of exacerbations in order to improve the quality of life.
• Stable phase COPD
• COPD on Acute exacerbation
STABLE PHASE COPD
• Two main goals
1) symptomatic relief (reduce respiratory symptoms, improve exercise
tolerance, improve health status) and
2) reduce future risk (prevent disease progression, prevent and treat
exacerbations, and reduce mortality).
• Only three interventions—smoking cessation, oxygen therapy in
chronically hypoxemic patients, and lung volume reduction surgery
(LVRS) in selected patients with emphysema—have been
demonstrated to improve survival of patients with COPD.
• There is suggestive, but not definitive, evidence that the use of
inhaled corticosteroids (ICS) and muscarinic antagonists may reduce
the mortality rate.
PHARMACOTHERAPY
• Smoking cessation
• Bronchodilators
SMOKING CESSATION
• Bupropion
• Nicotine replacement therapy available as gum, transdermal
patch, inhaler, and nasal spray; and
• Varenicline, a nicotinic acid receptor agonist/antagonist
BRONCHODIALATORS
• Anticholinergics
• B2 Agonists
• Inhaled bronchodialators are mainstay of COPD management.

* However no evidence that regular bronchodilator use slows

deterioration of lung function.
* Anticholinergics have a greater bronchodilating effect than b2
agonists.
 SABA Inhaler /mdi For nebuliser DOA (hr)
Salbutamol 100,200 mcg 5 mg/ml 4-6

Levalbuterol
Albuterol
Pirbuterol
Terbutaline
LABA Inhaler (mcg) Oral DOA (hr)
Salmeterol 25-50 12
Formeterol
Bambuterol 10-20 mg od

Indacarterol
• Side effects: tremor and tachycardia
 SAA Inhaler For nebuliser DOA (HR)
mg/ml
Ipratropium 20,40 0.25-0.5 6-8
MDI
Oxitropium 100 1.5 7-9
MDI
LAA Inhaler Oral DOA (hr)
(mcg)
Tiotropium 18 DPI 24

• Side effects: urinary retention,dry mouth,tremor and

tachycardia
STEROIDS IN STABLE COPD
• Inhaled Glucocorticoids
• Oral Glucocorticoids

• In COPD, inhaled GCs are used as part of a combined regimen, but

should NOT be used as sole therapy for COPD (ie, without long-
acting BDs).
• Regular Rx improves symptoms, lung function and quality of life and
reduce frequency of exacerbations in COPD with FEV1 <60% but
however does not modify long term decline of FEV1 nor mortality .
INHALED GLUCOCORTICOIDS
• Their use has been associated with increased rates of
oropharyngeal candidiasis & an increased rate of loss of bone
density.
• A trial of inhaled GC should be considered in patients with
frequent exacerbations, defined as ≥2/yr, and in pts who
demonstrate a significant amount of acute reversibility in
response to inhaled bronchodialators.
ORAL GLUCOCORTICOIDS
• The chronic use of oral GCs for treatment of COPD is not
recommended because of an unfavorable benefit/risk ratio.
• The chronic use of oral GCs is associsted with significant side
effects like osteoporosis, weight gain, cataracts, glucose
intolerance and increased risk of infection.
THEOPHYLLIN(METHYL XANTHINES
• Theophylline produces modest improvements in expiratory flow
rates and vital capacity and a slight improvement in arterial O2 and
CO2 levels in patients with moderate to severe COPD.
• Nausea is a common SE; tachycardia and tremor have also been
reported.
• Methyl Xanthines are less effective and less well tolerated than long
acting inhaled bronchodilators and is not recommended if others
treatment options are available & affordable.
• Addition of low dose slow release theophylline may be given along
with long acting BronchoDialators.
PHOSPHO DIESTERASE 4 INHIBITORS
• Once a day dosage
• No direct bronchodilator activity but has shown to improve FEV1 in
patients treated with salmeterol or tiotropium.
• Roflumilast decrease moderate to severe exacerbations when treated
with Corticosteroids by 15-20 % in patients with chronic bronchitis,
severe and very severe COPD and a acute exacerbations.
• S/E: nausea, pain abodmen, diarrhea insomnia

• Note: Roflumilast & Theophylline should not be given together.

ANTIBIOTICS
Azithromycin - for both its anti- inflammatory and antimicrobial
properties,administered daily to subjects with a history of
exacerbation in the past 6 months demonstrated a reduced
exacerbation frequency (in RCTs)
VACCINATION
• All Patients with COPD should receive the influenza vaccine
annually.
• Polyvalent pneumococcal vaccine is also recommended, (in pt
≥65 yrs old or <65 + Fev1 <40 %)
• Specific treatment in the form of IV a1AT augmentation therapy
is available for individuals with severe a1AT deficiency.
• Eligibility for a1AT augmentation therapy requires a serum
a1AT level <11 uM (approximately 50 mg/dL).
OXYGEN(>15 HOURS/DAY)
• Supplemental O2 is the only pharmacologic therapy
demonstrated to unequivocally decrease mortality rates in
patients with COPD.
• 1. PaO2 ≤ 7.3 kPa (55 mmhg) or SaO2 <88%, with or without
hypercapnia confirmed twice over a 3 week period.
• 2. PaO2 :7.3 -8.0 kPa(55-60 mmhg) or SaO2 of 88%, if there
is evidence of pulmonary HTN, peripheral edema s/o CCF, or
polycythemia (HCT>55%).
NON PHARMACOLOGICAL THERAPIES
PULMONARY REHABILITATION
• Exercise
• Education
• Psychosocial and nutritional counseling.
LUNG VOLUME REDUCTION
SURGERY(LVRS)
• Surgery to reduce the volume of lung in patients with
emphysema was first introduced with minimal success in the
1950s and was reintroduced in the 1990s.
• Patients are excluded if they have significant pleural disease,
a pulmonary artery systolic pressure >45 mmHg, extreme
deconditioning, congestive heart failure, or other severe
comorbid conditions.
• Patients with an FEV1 <20% of predicted or diffusely distributed
emphysema on CT scan have an increased mortality rate
after the procedure and thus are not candidates for LVRS.
• Patients with upper lobe–predominant emphysema and a low
post rehabilitation exercise capacity are most likely to benefit
from LVRS.
LUNG TRANSPLANTATION
• COPD is currently the second leading indication for lung
transplantation.
• Current recommendations are that candidates for lung
transplantation should be <65 years; have severe disability
despite maximal medical therapy; and be free of comorbid
conditions such as liver, renal, or cardiac disease.
ACTE EXACERBATION OF COPD
• The goal of treatment in COPD AE is minimize the impact of
current exacerbation and to prevent the development of
subsequent exacerbations
SIGNS OF SEVERITY
• The Global Initiative for COPD(GOLD), a report produced by the
National Heart, Lung, and Blood Institute (NHLBI) and the WHO,
defines an exacerbation of COPD as an acute increase in
symptoms beyond normal day-to-day variation. This generally
includes an acute increase in one or more of the following cardinal
symptoms:
1. Cough increases in frequency and severity
2. Sputum production increases in volume and/or changes character
3. Dyspnea increases
COMMON BACTERIA
• Haemophilus influenzae
• Moraxella catarrhalis
• Streptococcus pneumoniae
• Pseudomonas aeruginosa
• Enterobacteriaceae
• Haemophilus parainfluenzae
• Staphylococcus aureus
•(Note: Despite the frequent implication of bacterial infection, chronic
suppressive or "rotating" antibiotics are not beneficial in patients with COPD
and is not recommended.)
•Most common cause is viral upper RTI
• Typically, patients are treated with an inhaled b-agonist, often
with the addition of an anticholinergic agent.
• Patients are often treated initially with nebulized therapy, as
such treatment is often easier to administer in older patients or
to those in respiratory distress.
•Antibiotics
Inexpensive commonoral antibiotics usually adequate
Broader spectrum if not responsive.
•Glucocorticoids
• Among patients admitted to the hospital, the use of glucocorticoids
has been demonstrated to reduce the length of stay, hasten recovery,
and reduce the chance of subsequent exacerbation or relapse for a
period of up to 6 months.
• The GOLD guidelines recommend 30–40 mg of oral prednisolone or
its equivalent for a period of 10–14 days.
OXYGEN
• Target Pao2: 60-70 mmhg
• Nasal cannulae can provide flow rates up to 6 L/min with an
associated FiO2 of approximately 40 % .
• Simple facemasks can provide an FiO2 up to 55% using flow rates
of 6 to 10 L per minute.
• Venturi masks can deliver an FiO2 of 24, 28, 31, 35, 40, or 60
percent.
• Non-rebreathing masks with a reservoir, one-way valves, and a tight
face seal can deliver an inspired oxygen concentration up to 90 %.
MECHANICAL VENTILATORY SUPPORT
CONTRADICTIONS OF NIPPV
• cardiovascular instability,
• impaired mental status or inability to cooperate,
• copious secretions or the inability to clear secretions,
• craniofacial abnormalities
• extreme obesity,
• significant burns.
INDICATIONS FOR INVASIVE
MECHANICAL VENTILATION
OTHER CAUSES OF CHRONIC COUGH
•THANK YOU