DANIEL AMAN, MD (ASS’T PROFESSOR OF EMERGENCY

COPD MEDICINE AND CRITICAL CARE,SPHMMC)

COPD 1 07/31/2022
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

• IS A COMMON, PREVENTABLE AND TREATABLE DISEASE

• CHARACTERIZED BY
• PERSISTENT RESPIRATORY SYMPTOMS AND
• AIRFLOW LIMITATION THAT IS DUE TO AIRWAY AND/OR
• ALVEOLAR ABNORMALITIES USUALLY CAUSED BY SIGNIFICANT EXPOSURE TO
NOXIOUS PARTICLES OR GASES

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PATHWAYS FOR DX OF COPD

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COPD

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COPD
• IS CURRENTLY THE FOURTH LEADING CAUSE OF DEATH IN THE WORLD BUT IS PROJECTED TO BE THE 3RD
LEADING CAUSE OF DEATH BY 2020.

• MORE THAN 3 MILLION PEOPLE DIED OF COPD IN 2012 ACCOUNTING FOR 6% OF ALL DEATHS GLOBALLY.
• COPD REPRESENTS AN IMPORTANT PUBLIC HEALTH CHALLENGE THAT IS BOTH PREVENTABLE AND
TREATABLE.

• COPD IS A MAJOR CAUSE OF CHRONIC MORBIDITY AND MORTALITY THROUGHOUT THE WORLD; MANY
PEOPLE SUFFER FROM THIS DISEASE FOR YEARS, AND DIE PREMATURELY FROM IT OR ITS
COMPLICATIONS.

• GLOBALLY,THE COPD BURDEN IS PROJECTED TO INCREASE INCOMING DECADES BECAUSE OF

CONTINUED EXPOSURE TO COPD RISK FACTORS AND AGING OF THE POPULATION.

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COPD

• THE MOST COMMON RESPIRATORY SYMPTOMS INCLUDE

• DYSPNEA,
• COUGH AND/OR SPUTUM PRODUCTION.
• THESE SYMPTOMS MAY BE UNDER-REPORTED BY PATIENTS.

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COPD
• COPD SHOULD BE CONSIDERED IN ANY PATIENT WHO HAS DYSPNEA, CHRONIC
COUGH OR SPUTUM PRODUCTION, A HISTORY OF RECURRENT LOWER
RESPIRATORY TRACT INFECTIONS AND/OR A HISTORY OF EXPOSURE TO RISK
FACTORS FOR THE DISEASE.

• SPIROMETRY IS REQUIRED TO MAKE THE DIAGNOSIS; THE PRESENCE OF A POST-

BRONCHODILATOR FEV1/FVC < 0.70 CONFIRMS THE PRESENCE OF PERSISTENT
AIRFLOW LIMITATION.

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COPD 8 07/31/2022
COPD
• THE GOALS OF COPD ASSESSMENT ARE
• TO DETERMINE THE LEVEL OF AIRFLOW LIMITATION,
• THE IMPACT OF DISEASE ON THE PATIENT’S HEALTH STATUS, AND
• THE RISK OF FUTURE EVENTS (SUCH AS EXACERBATIONS, HOSPITAL ADMISSIONS, OR
DEATH),
• IN ORDER TO GUIDE THERAPY.

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COPD
• CONCOMITANTCHRONIC DISEASES OCCUR FREQUENTLY IN COPD PATIENTS,
INCLUDING CARDIOVASCULAR DISEASE, SKELETAL MUSCLE DYSFUNCTION,
METABOLIC SYNDROME, OSTEOPOROSIS, DEPRESSION, ANXIETY, AND LUNG
CANCER.

• THESE COMORBIDITIES SHOULD BE ACTIVELY SOUGHT AND TREATED

APPROPRIATELY WHEN PRESENT AS THEY CAN INFLUENCE MORTALITY AND
HOSPITALIZATIONS INDEPENDENTLY.

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DDX

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COPD 12 07/31/2022
COPD EXACERBATIONS
• DEFINESAS "AN ACUTE EVENT CHARACTERIZED BY A WORSENING OF THE
PATIENT'S RESPIRATORY SYMPTOMS THAT IS BEYOND NORMAL DAY-TO-DAY
VARIATIONS AND LEADS TO A CHANGE IN MEDICATION".

• THIS GENERALLY INCLUDES AN ACUTE CHANGE IN ONE OR MORE OF THE

FOLLOWING CARDINAL SYMPTOMS:
• COUGH INCREASES IN FREQUENCY AND SEVERITY
• SPUTUM PRODUCTION INCREASES IN VOLUME AND/OR CHANGES CHARACTER
• DYSPNEA INCREASES

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COPD EXACERBATIONS
• THEY ARE CLASSIFIED AS:
• MILD (TREATED WITH SHORT ACTING BRONCHODILATORS ONLY, SABDS)
• MODERATE (TREATED WITH SABDS PLUS ANTIBIOTICS AND/OR ORAL
CORTICOSTEROIDS) OR
• SEVERE (PATIENT REQUIRES HOSPITALIZATION OR VISITS THE EMERGENCY ROOM).
• SEVERE EXACERBATIONS MAY ALSO BE ASSOCIATED WITH ACUTE RESPIRATORY
FAILURE.

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TREATMENT SETTING

• OPD……80%
• HOSPITALIZATION

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INDICATION FOR HOSPITALIZATION

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HOSPITALIZATION

• IN
HOSPITALIZED PTS THE SEVERITY OF EXACERBATION SHOULD BE ASSESSED
BASED ON THE PATIENTS CLINICAL SIGNS AND RECOMMENDED THE FOLLOWING
CLASSIFICATION.

• SEVERE COPD EXACERBATION

• NO RESPIRATORY FAILURE:
• ACUTE RESPIRATORY FAILURE – NON-LIFE-THREATENING:
• ACUTE RESPIRATORY FAILURE – LIFE-THREATENING:

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HOSPITALIZED COPD

• NO RESPIRATORY FAILURE:
• RESPIRATORY RATE: 20-30 BREATHS PER MINUTE;
• NO USE OF ACCESSORY RESPIRATORY MUSCLES;
• NO CHANGES IN MENTAL STATUS;
• HYPOXEMIA IMPROVED WITH SUPPLEMENTAL OXYGEN GIVEN VIA VENTURI MASK 28-
35% INSPIRED OXYGEN (FIO2);
• NO INCREASE IN PACO2.

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COPD

• ACUTE RESPIRATORY FAILURE – NON-LIFE-THREATENING:

• RESPIRATORY RATE: > 30 BREATHS PER MINUTE;
• USING ACCESSORY RESPIRATORY MUSCLES;
• NO CHANGE IN MENTAL STATUS;
• HYPOXEMIA IMPROVED WITH SUPPLEMENTAL OXYGEN VIA VENTURI MASK 25-30% FIO2;
• HYPERCARBIA I.E., PACO2 INCREASED COMPARED WITH BASELINE OR ELEVATED 50-60
MMHG.

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COPD
• ACUTE RESPIRATORY FAILURE – LIFE-THREATENING:
• RESPIRATORY RATE: > 30 BREATHS PER MINUTE;
• USING ACCESSORY RESPIRATORY MUSCLES;
• ACUTE CHANGES IN MENTAL STATUS;
• HYPOXEMIA NOT IMPROVED WITH SUPPLEMENTAL OXYGEN VIA VENTURI MASK OR REQUIRING
FIO2 > 40%;
• HYPERCARBIA I.E., PACO2 INCREASED COMPARED WITH BASELINE OR ELEVATED > 60 MMHG OR
• THE PRESENCE OF ACIDOSIS (PH ≤ 7.25).

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COPD 21 07/31/2022
MGT
• GOALS
• TO MINIMIZE THE NEGATIVE IMPACT OF THE CURRENT EXACERBATION AND
• TO PREVENT THE DEVELOPMENT OF SUBSEQUENT EVENTS.
• OUTPATIENT OR INPATIENT SETTING.

• MORE THAN 80% OF EXACERBATIONS ARE MANAGED ON AN OUTPATIENT BASIS WITH

PHARMACOLOGICAL THERAPIES INCLUDING BRONCHODILATORS,
CORTICOSTEROIDS, AND ANTIBIOTICS.

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MGT
• HOME MANAGEMENT OF COPD EXACERBATIONS
• BETA ADRENERGIC AGONISTS;  INHALED SHORT-ACTING BETA ADRENERGIC AGONISTS (EG, 
ALBUTEROL, LEVALBUTEROL)
• ANTICHOLINERGIC AGENTS;  
• IPRATROPIUM BROMIDE,A N INHALED SHORT-ACTING ANTICHOLINERGIC AGENT (ALSO KNOWN AS A
SHORT-ACTING MUSCARINIC AGENT)
• TWO INHALATIONS BY METERED DOSE INHALER (MDI) EVERY FOUR TO SIX HOURS

• ORAL GLUCOCORTICOID THERAPY

• PREDNISONE 40 MG PER DAY FOR FIVE DAYS

• ANTIBIOTICS
• ADJUNCTIVE CARE

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MGT….
• HOSPITAL MANAGEMENT OF COPD EXACERBATIONS
• OXYGEN THERAPY
• BETA ADRENERGIC AGONISTS
• ALBUTEROL, LEVALBUTEROL

• ANTICHOLINERGIC AGENTS
• SYSTEMIC GLUCOCORTICOIDS
• ANTIBIOTICS AND ANTIVIRAL AGENTS
• SUPPORTIVE CARE
• PALLIATIVE CARE
• TREATMENTS WITHOUT DOCUMENTED BENEFIT

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BRONCHODILATORS
• INHALED SHORT-ACTING BETA ADRENERGIC AGONISTS 
• ALBUTEROL;
• 2.5 MG (DILUTED TO A TOTAL OF 3 ML) BY NEBULIZER EVERY ONE TO FOUR HOURS AS NEEDED,
OR
• FOUR TO EIGHT PUFFS (90 MCG PER PUFF) BY MDI WITH A SPACER EVERY ONE TO FOUR HOURS

• LEVALBUTEROL
• SUBCUTANEOUS INJECTION OF SHORT-ACTING BETA ADRENERGIC AGONISTS (EG, 
TERBUTALINE, EPINEPHRINE) 

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ANTICHOLINERGIC AGENTS —

• INHALED SHORT-ACTING ANTICHOLINERGIC AGENTS (EG, IPRATROPIUM

 BROMIDE)
• 500 MCG BY NEBULIZER EVERY FOUR HOURS AS NEEDED.
• TWO TO FOUR PUFFS (18 MCG PER PUFF) CAN BE ADMINISTERED BY MDI WITH A
SPACER EVERY FOUR HOURS.

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GLUCOCORTICOIDS
• SYSTEMIC GLUCOCORTICOIDS IN COPD EXACERBATIONS
• SHORTEN RECOVERY TIME
• IMPROVE LUNG FUNCTION (FEV1)
• IMPROVE OXYGENATION,
• THE RISK OF EARLY RELAPSE,
• TREATMENT FAILURE, AND
• THE LENGTH OF HOSPITALIZATION.

COPD 27 07/31/2022
DRUG &DOSE
• A DOSE OF 40 MG PREDNISONE PER DAY FOR 5 DAYS
• PO VS IV
• NEBULIZED BUDESONIDE
• IV METHYLPREDNISOLONE
• INTENSIFIED COMBINATION THERAPY WITH ICS/LABA FOR 10 DAYS AT URTI
ONSET.

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ANTIBIOTICS.

• ANTIBIOTICS REDUCE THE RISK OF

• SHORT TERM MORTALITY BY 77%,
• TREATMENT FAILURE BY 53% AND
• SPUTUM PURULENCE BY 44%

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CAUSE OF EXACERBATIONS

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EXACERBATION VS INFECTION
• 70 TO 80 PERCENT OF EXACERBATIONS OF COPD ARE DUE TO RESPIRATORY
INFECTIONS.

• THE REMAINING 20 TO 30 PERCENT ARE DUE TO

• EOSINOPHILIC INFLAMMATION ,
• ENVIRONMENTAL POLLUTION, OR
• HAVE AN UNKNOWN ETIOLOGY .
• VIRAL (ONE-THIRD TO TWO-THIRDS OF EXACERBATIONS)AND BACTERIAL
INFECTIONS(ONE-THIRD TO ONE-HALF OF COPD EXACERBATIONS) CAUSE MOST
EXACERBATIONS, WHEREAS ATYPICAL BACTERIA ARE A RELATIVELY
UNCOMMON CAUSE.

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CONT…

• EVALUATION FOR INFECTION —

• CLINICAL CHARACTERISTICS
• SPUTUM STUDIES
• DETECTION OF RESPIRATORY VIRUSES
• PROCALCITONIN AND C-REACTIVE PROTEIN

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ABS
• THE CHOICE OF THE ANTIBIOTIC SHOULD BE BASED ON THE LOCAL BACTERIAL
RESISTANCE PATTERN.

• USUALLY INITIAL EMPIRICAL TREATMENT IS AN AMINOPENICILLIN WITH

CLAVULANIC ACID, MACROLIDE, OR TETRACYCLINE.

• THE ROUTE OF ADMINISTRATION (ORAL OR INTRAVENOUS) DEPENDS ON

• THE PATIENT’S ABILITY TO EAT AND
• THE PHARMACOKINETICS OF THE ANTIBIOTIC, ALTHOUGH IT IS PREFERABLE THAT
ANTIBIOTICS BE GIVEN ORALLY.

• IMPROVEMENTS IN DYSPNEA AND SPUTUM PURULENCE SUGGEST CLINICAL SUCCESS.

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OPD

* Pseudomonas risk factors:
•Advanced COPD
•Previous isolation
of Pseudomonas from sputum
•Concomitant bronchiectasis
•Frequent administration of antibiotics
•Frequent hospital admissions
BY KDA
•Systemic glucocorticoid use 34 07/31/2022
ADMITTED

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ANTIVIRAL THERAPY

• IS RECOMMENDED FOR PATIENTS WITH CLINICAL AND LABORATORY EVIDENCE

OF INFLUENZA INFECTION WHO REQUIRE HOSPITALIZATION FOR AN
EXACERBATION OF COPD.

• BECAUSE OF THE RISK OF ACUTE BRONCHOCONSTRICTION WITH INHALATION

OF ZANAMIVIR, OSELTAMIVIR IS PREFERRED UNLESS LOCAL RESISTANCE
PATTERNS SUGGEST A LIKELIHOOD OF OSELTAMIVIR-RESISTANT INFLUENZA.

COPD 36 07/31/2022
RESPIRATORY SUPPORT
• OXYGEN THERAPY TARGET
• SATURATION OF 88-92%
• ABG ---VENOUS VS ARTERIAL
• ROUTE
• VENTURI MASKS (HIGH-FLOW DEVICES)
• HIGH-FLOW OXYGEN THERAPY BY NASAL CANNULA (HFNC)
• VENTILATORY SUPPORT
• NON-INVASIVE (NASAL OR FACIAL MASK) OR
• INVASIVE (ORO-TRACHEAL TUBE OR TRACHEOSTOMY) VENTILATION.

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SUPPLEMENTAL
OXYGEN

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INDICATION FOR ICU ADMISSION

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NIV VS INVASIVE

• NIVIS PREFERRED OVER INVASIVE VENTILATION (INTUBATION AND POSITIVE

PRESSURE VENTILATION)

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INDICATIONS FOR NIV

• AT LEAST ONE OF THE FOLLOWING

• RESPIRATORY ACIDOSIS
• SEVERE DYSPNEA
• PERSISTENT HYPOXIA DESPITE SUPPLEMENTAL OXYGEN THERAPY

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NIV

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INDICATIONS INVASIVE MV

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MV

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COPD 45 07/31/2022
CHRONIC FOLLOW UP

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BY KDA 47 07/31/2022
GOAL OF TREATMENT OF STABLE COPD

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GOLD GRADING

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COPD 50 07/31/2022
INTERVENTIONAL BRONCHOSCOPY &SURGERY

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•THANKS
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