CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Global burden of COPD

COPD

COPD is one of the leading causes of morbidity and mortality

worldwide.

Lancet Global Health, 2015; 3(12): e776-e784), Lancet Global Health Sept 12th, 2018; 6(12): e1363-e1373
Burden of COPD in India

http://www.healthdata.org/india. As accessed on 18th December 2020.

Some COPD facts from India

1 in 3 COPD 46 % COPD patients 85 % patients feared

patients had were exposed to worsening of
symptoms due to
never smoked biomass smoke
weather change

89 % patients
visited the doctor Every 1 in 2 COPD
for worsening of patients get
symptoms hospitalized at
least once a year
What is COPD?

“Chronic Obstructive Pulmonary Disease

(COPD) is a common, preventable and
treatable disease that is 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”
GOLD 2021
Disease trajectory of a COPD patient with exacerbations

GOLD 2021
Risk factors for COPD

Age above 40 years Occupational exposure Air pollution

Smoking Recurrent lung infections Exposure to

Long-standing asthma biomass smoke
Symptoms of COPD

Dyspnea: Chronic Cough Chronic sputum

Progressive over time Recurrent wheeze production

Worse with exercise Maybe intermittent or Any pattern of chronic

Persistent unproductive sputum production

Pathophysiology of COPD

01. 02.
Chronic Bronchitis Emphysema
Clinically it is a Destruction of the
condition wherein there alveolar walls and
is presence of cough loss of alveolar
and sputum production elasticity
for most days over 3
months for 2
consecutive years
Chronic Bronchitis

Irritation

Lung infections
Emphysema
Destruction of the alveolar walls
Decreases the lung elastic recoil
Enlargement of the alveoli
Reduces maximal expiratory airflow
Diagnosing COPD
Age above 40
years

GOLD 2021
Spirometry

Gold standard test for confirmed

diagnosis of asthma and COPD

It is required to make the diagnosis; the

presence of a post-bronchodilator
FEV1/FVC < 0.70 confirms the presence
of persistent airflow limitation and thus of
COPD.
>12 % or 200 mL reversibility
Spirometry Parameters
FEV1: Forced
Expiratory Volume in 1
second
The maximal volume of
gas which can be
expired from the lungs in
the first second of a
forced expiration from a
position of full inspiration
Decreases in COPD
FVC: Forced Vital Capacity
The maximal volume of gas
which can be expired from
the lungs during a forced
and complete expiration
from a position of full
inspiration
Decreases in COPD
Spirogram in COPD
Approach to diagnosis and management of COPD

Assessment
of severity

Assessment of
Assessment of
risk of
symptoms
exacerbations
The classification of COPD severity 80-50-30 rule
STAGE 1 MILD FEV1 more than or equal
to 80% predicted

STAGE 2 MODERATE FEV1/FVC FEV1: 50 to 80%

less than 0.70 predicted

STAGE 3 SEVERE FEV1: 30 to 50%

predicted

STAGE 4 VERY FEV1 less than 30%

SEVERE predicted
Assessment of Symptoms

mMRC score CAT score

Measurement of Comprehensive score
dyspnea
mMRC dyspnea scale
0 “I only get breathless with strenuous exercise”

1 “I get short of breath when hurrying on the level or walking up a slight hill”

“I walk slower than people of the same age on the level because of breathlessness or
2 have to stop for breath when walking at my own pace on the level”

3 “I stop for breath after walking about 100 yards or after a few minutes on the level”

4 "I am too breathless to leave the house” or “I am breathless when dressing ”

COPD Assessment Test (CAT)

• It is a short 8
question compiled
questionnaire which
covers broad range
of effects of COPD
of the patients’
health.
• It is a symptom
based assessment
scale
Total score can range from 0-40
Assessing Symptoms

(C) (D)
Less symptoms More symptoms

(A) (B)
Less symptoms More symptoms

mMRC 0-1 mMRC > 2

CAT less than 10 CAT more than 10
ABCD assessment as per GOLD 2021

> 2 not leading to

(C) (D) hospitalization or 1

(Exacerbation history)
Less symptoms More symptoms leading to
High risk High risk hospitalization in a year

Risk
(A) (B) 1 not leading to
hospitalization in a
Less symptoms More symptoms year
Low risk Low risk
mMRC 0-1 mMRC > 2
Symptoms
CAT less than 10 CAT more than 10
GOLD 2021
Objectives of COPD management
• Relieve symptoms
Reduction of
• Improve exercise tolerance symptoms
• Improve health status

• Prevent disease progression

• Prevent and treat exacerbations Reduction of
• Reduce mortality risks
GOLD 2021
Management of stable COPD
Self management
education and smoking
cessation

ITY
Bronchodilators

ER
EV
Inhaled
Corticosteroids

EA IN S
Pulmonary

SE
DIS SE
rehabilitation

OF REA
Oxygen

INC
Therapy

Surgery
Initial Pharmacological Management

GOLD 2021
Commonly Used Maintenance
Commonly used Maintenance medications Medications in COPD

Inhaled
Antimuscarinic
Beta2 agonist Corticosteroids Methylxathines Antioxidant
drugs- (ICS)-
• Short-acting β2- • Short -acting • Budesonide • Theophylline • N-
agonists (SABAs) anti-muscarinic • Doxophylline acetylcysteine
– Salbutamol / agents (SAMA)-
• Acebrophylline
Ipratropium
Levosalbutamol
• Long acting β2-
• Long -acting anti-
agonists (LABAs) muscarinic
– agents (LAMA)-
Salmeterol/Formot Tiotropium/
eroI/ Indacaterol glycopyrronium

GOLD Guideline 2020

2020 Global Initiative for Chronic
Obstructive Lung Disease
 What is the role of mucolytics in maintenance of
COPD?
GOLD 2021
guideline on use of mucolytic agents (Mucokinetics and
Mucoregulators):1
In COPD patients not receiving inhaled corticosteroids, regular treatment with mucolytics such
as erdosteine, carbocysteine and N-acetylsysteine may reduce exacerbations and modestly
improve health status.

NICE guideline 2020 on use of oral mucolytic agents in stable COPD:

• Consider mucolytic drug therapy for people with a chronic cough productive of sputum.
• Only continue mucolytic therapy if there is symptomatic improvement (for example, reduction in
frequency of cough and sputum production).
The role of antioxidants in COPD

GOLD 2021 report

 Pune Bus Driver Study
n = 71 male bus drivers,

eCO ppb in exhalation

Pune city
Group 1: Placebo

(p<0.0001)
Group 2: Mucinac 600 mg once daily
Group 3: Mucinac 600 mg twice daily
eCO: Exhaled carbon monoxide

Outcome: In 4 weeks, NAC BID

reduces the amount of exhaled CO

Eur Respir J. 30: Suppl. 51, 474s

PANTHEON POST HOC
Aim: To evaluate the effect of long-term treatment with high-dose NAC
(1200 mg daily) on the rate of exacerbations in COPD
Study design: One year, prospective, randomized, double blind,
placebo-controlled trial

N=1006 patients with moderate-to-severe COPD (%FEV1: 30-70%

predicted)

Outcome: 1 year BID NAC reduces overall exacerbation by 25%,

moderate exacerbation with LABDs by 66% and severe
exacerbation with LABDs by 88%
What is the role of Methylxanthines in COPD?

Act as bronchodilator, mucoregulator and anti-inflammatory

Methylxanthines are recommended as an

Add On maintenance medication

in GOLD Guideline, however not in exacerbation

management

GOLD 2020 report

 Obj • Objective- Open randomized comparative longitudinal study
ecti
ve
• N=40 patient
• Moderate degree COPD patients
Des • Duration- 6 weeks
ign • FEV1 < 80% but > 50%

• Group-1:receiving Acebrophylline 100mg twice daily

Ar • Group-2: receiving sustained release (SR) Theophylline 300mg once
ms daily orally, in addition to 18μgm Tiotropium inhalation

Tapadar et al. Journal of Clinical and Diagnostic Research.2014;Vol-8(9): MC11-MC14

Significant Improvement of shortness of
breath (SOB)
Improvement of FEV1
Shortness of Breath
after treatment
70% 65%
60%
50% 45%
40%
30%
20%
10%
0%
Group 1 Group 2

Significant improvement of FEV1 from Improvement of SOB by 65%

66.28% to 66.75% at 3rd visit

Tapadar et al. Journal of Clinical and Diagnostic Research.2014;Vol-8(9): MC11-MC14

Effective Symptom Safer than Theophylline
Improvement
55
%

Cardiovascular related complaints e.g. pain chest,

palpitation, tremor, tachycardia not found in patients
treated with Acebrophylline
Effective as add on treatment
Tapadar et al. Journal of Clinical and Diagnostic Research.2014;Vol-8(9): MC11-MC14
 Acebrophylline showed significant
improvement in PEFR (Peak
Expiratory Flow rate) and FEV1
(Forced Expiratory Volume).

IMPROVEMENT OF FEV1 BY
29%

Sarvanakumar et al.Int J Pharm Bio Sci 2014 April ; 5 (2) : (P) 214 - 222
Safety: Lesser Side Effects
Acebrophylline: Safe and well tolerated

• Side effects were

more among
Theophylline than
Acebrophylline.
• Theophylline was
associated with
cardiac and central
nervous system
stimulatory side
effects

Sarvanakumar et al.Int J Pharm Bio Sci 2014 April ; 5 (2) : (P) 214 - 222
Follow-up pharmacological treatment

GOLD 2021
2020 Global Initiative for Chronic Obstructive Lung Disease
© 2020 Global Initiative for Chronic Obstructive Lung Disease
2020 Global Initiative for Chronic Obstructive Lung Disease
2020 Global Initiative for Chronic Obstructive Lung Disease
2020 Global Initiative for Chronic Obstructive Lung Disease
GOLD 2021 report
2020 Global Initiative for Chronic Obstructive Lung Disease
2020 Global Initiative for Chronic Obstructive Lung Disease
2020 Global Initiative for Chronic Obstructive Lung Disease
THANK YOU!
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