COPD

Dr. Imran Masood, PhD

drimranmasood@iub.edu.pk
Table of contents

• Definition
• Etiology
• Pathophysiology
• Clinical presentation
• Diagnosis
• Assessment of severity
• Treatment
• Patient care
Definition
Chronic obstructive pulmonary disease (COPD) is a disease
state characterized by airflow limitation that is not fully
reversible.
The airflow limitation is usually both progressive and associated
with an abnormal inflammatory response of the lungs to noxious
particles or gases.( GOLD, 2009)

COPD has been defined (National Institute for Health and

Clinical Excellence, 2010) as:
• Airflow obstruction with a reduced FEV1/FVC ratio of
less than 0.7.
Chronic Bronchitis
is defined as
a chronic or recurrent cough with sputum production on
most days for at least 3 months of the year during at least 2
consecutive years, in the absence of other diseases recognized
to cause sputum production.

Emphysema
is defined as
an abnormal enlargement of the air spaces distal to the terminal
bronchioles.
Etiology

• Tobacco smoking
• Noxious particles
• Natural ageing process
• Gender
• Proteinase and anti-proteinase imbalance
• Oxidative stress
Pathophysiology
Cor pulmonale
Clinical presentation

Respiratory
At risk Symptomatic Exacerbation
Failure

Regular sputum Exertional

Cough Wheeze
production dyspnoea
The bronchitic ‘blue bloater’
and
emphysemic ‘pink puffer’
represent two ends of the COPD spectrum.

Signs and symptoms of COPD lie somewhere between the two

extremes described

The clinical progress of COPD depends on whether bronchitis

or emphysema predominates
Diagnosis

Lung function tests are used to assist in diagnosis.

A spirometer is used to measure lung volumes and flow rates

Airflow obstruction is defined as:

• FEV1 less than 80% of that predicted for the patient and
• FEV1/FVC less than 0.7.

VC decreases in bronchitis and emphysema.

RV increases in both cases but tends to be higher in patients
with emphysema
Chest radiographs
A patient with emphysema will have a flattened
diaphragm with loss of peripheral vascular markings.

A patient with bronchitis will have increased Broncho vascular

markings and may also have cardiomegaly with prominent
pulmonary arteries.

α1-Antitrypsin

Pulse oximetry

Sputum culture
Assessment of severity of airflow obstruction (adapted from
National Institute for Health and Clinical Excellence, 2010;
GOLD, 2009)
Treatment
Stable COPD

Smoking cessation
Nicotine replacement therapy

Mucolytics
In chronic productive cough

Antibiotics
Co-amoxiclav, amoxicillin, erythromycin, doxycycline,
erythromycin or flucloxacillin

Immunisation
Pneumococcal vaccine (single dose)
Class Sub class Drugs Dose Major side effects
Short-acting short-acting b2- Salbutamol 200–400μg Tachycardia,
bronchodilators adrenoceptor QID palpitation tremors at
agonist Terbutaline 500 μcg prn high dose
short-acting Ipratropium 40 μg qid Dry mouth and other
muscarinic antagonist anticholinergic S.E
Long-acting Long acting beta Formoterol 12–24μg BD Same as SABA
bronchodilators agonist Salmeterol 50–100μgBD
Long acting Tiotropium 18 μg Same as SAMA
muscarinic antagonist OD
Oral Theophylline 175-500mg Tachycardia, seizures
bronchodilator BID insomnia, urination,
vomiting
Corticosteroid Inhaled corticosteroid Beclometasone 100–400 μcg Adrenal suppression
Budesonide twice a day Candidiasis
Fluticasone 50–200 μcg
Mometasone 200–400 μcg O.D
Oral corticosteroid Prednisone 10mg every Hypertension
Prednisolone morning Diabetes
Osteoporosis
Stepwise approach to the pharmacological management of chronic COPD
Acute exacerbations of COPD
Bronchodilators to treat increased breathlessness
A β2-agonist can be given with or without an anticholinergic
agent.

Antibiotics
First line agents
An aminopenicillin or a macrolide or oxytetracycline.

Corticosteroids
Prednisolone 30 mg every morning, given for 7–14 days.

Other treatment
Intravenous aminophylline
Oxygen therapy
Chest physiotherapy
Intravenous hydration
Treatment of hypoxaemia and cor pulmonale

Peripheral oedema is managed using thiazide or loop diuretics.

Oxygen is used to treat hypoxaemia, and this should also
promote a diuresis.

Domiciliary oxygen therapy

Oxygen can be prescribed as oxygen cylinders or by use of a
concentrator.

Intermittent (short burst) administration

Continuous LTOT for at least 15h/day

Treatment of Chronic Bronchitis
Stable chronic bronchitis
Class Drugs Major effects
Anti tussives codeine Short term symptomatic relief of
dextromethorphan cough
Short-acting b2- albuterol, Relaxes bronchial smooth muscles
adrenoceptor metaproterenol And control symptoms
Agonists Facilitate mucus elimination
Bronchodilators theophylline To control symptoms such as
brochospasm, dyspnea and cough
Facilitate mucus elimination
anti cholinergic ipratropium Control symptoms
Reduce mucus production
Long acting beta Formoterol LABA coupled with ICS may offer
agonist Salmeterol relief of chronic cough

Inhaled corticosteroids beclomethasone, Anti inflammatory activity

fluticasone Decrease airway hyper-
budesonide responsiveness
Relaxes bronchial smooth musles
Acute exacerbation
• SABA or SAMA in addition a short course of systemic
corticosteroid therapy (prednisone, prednisolone)
• Antibiotics

Mild to moderate ABECB

• No antibiotics recommended
• Smoking cessation
• Postural drainage exercises
• Oral or aerosolized bronchodilators
• Condition not improve in 3-5 days then antibiotic therapy
Antibiotics recommendation

Moderate ABECB and /or any one of Severe ABECB and /or anyone of
following : age ˂65 years, FEV1 following: age ≥65 years, FEV1
˃50% predicted, no cardiac disease ≤50% predicted, cardiac disease, or ≥
or˂3 exacerbations per year 3 exacerbations per year

Azithromycin Amoxicillin and clavulanate

Clarithromycin Levofloxacin
Doxycycline Gemifloxacin
Trimethoprim - Sulfamethoxazole Moxifloxacin
Cefuroxime
Cefdinir
Patient care

Non-pharmacological treatment

• advice and support to stop smoking

• nutritional assessment
• aerobic exercise training to increase capacity and endurance
for exercise
• relaxation techniques
• education about their medicines, nutrition, self-management of
their disease and lifestyle issues
• psychological support because COPD patients often have
decreased capacity to participate in social and recreational
activities and can become anxious, depressed or fatigued