Chronic Obstructive

Pulmonary Disease
(COPD)
Chronic Obstructive Pulmonary Disease
(COPD)

• 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 and influenced
by host factors including abnormal lung development
Causes

• Tobacco smoke
• Indoor or air pollution
• Occupational Exposures
• Outdoor air pollution
• Genetic factors
• Age and Sex
• Lung growth and development
• Socioeconomic status
• Asthma and airway hyperactivity
• Chronic Bronchitis
• Infections
Diagnosis

• 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 finding of a post bronchodilator FEV1/FVC < 0.70

confirms presence of airflow limitation
Assessment

• Goals of assessment:
• Determine the level of airflow limitation, impact on patient’s health status
and risk for future events (such as exacerbations, hospital admissions or
death) to guide therapy
• Presence and severity of the spirometric abnormality
• Current nature and magnitude of patient’s symptoms
• History of moderate and severe exacerbations
• Presence of co morbidities
Classification and severity of airflow
limitation

In patients with FEV1/FVC < 0.70

GOLD 1 Mild FEV1>/= 80% predicted
GOLD 2 Moderate 50% </= FEV1 <80% predicted
GOLD 3 Severe 30%</= FEV1 <50% predicted
GOLD 4 Very Severe FEV1<30% predicted
Assessment of Symptoms

• modified Medical Research Council scale questionnaire (mMRC)

• COPD Assessment Test (CAT)
Modified MRC Scale
COPD Assessment Test (CAT)
Spirometry

Image from rtmagazine.com/spirometry-testing-from-occupational-screening-to-disease-

management/
• 65 year old male
• Chief complaint of chronic cough and dyspnea. He is a 20 pack
years smoker
• Spirometry done and revealed
Classification and severity of airflow
limitation

In patients with FEV1/FVC < 0.70

GOLD 1 Mild FEV1>/= 80% predicted
GOLD 2 Moderate 50% </= FEV1 <80% predicted
GOLD 3 Severe 30%</= FEV1 <50% predicted
GOLD 4 Very Severe FEV1<30% predicted
Modified MRC Scale
The Refined ABCD Assessment Tool

COPD GOLD 2, GROUP B

FEV1 64 – GOLD
2 (moderate)

FEV1/FVC
0.66
Treatment

• Non pharmacologic
• Pharmacologic
Non pharmacologic Treatment

• Smoking cessation
• Vaccination
• Influenza
• SARS-Cov2 (COVID 19) vaccination
• 23 valent pneumococcal polysaccharide vaccine 23 (PPSV 23)
• 13 valent conjugated pneumococcal vaccine (PCV 13)
• Tdap vaccination
• Zoster vaccine
• Pulmonary rehabilitation
• Oxygen supplementation
• paO2 less than 55 or Oxygen saturation less than 88% or paO2 55-60 with RHF/erythrocytosis
• Non Invasive Ventilation
• Surgery
• Palliative care
Non pharmacologic Management of COPD

Patient Group Essential Recommended Depending on Local

Guidelines
A Smoking Cessation Physical Activity Flu Vaccination
Pneumococcal
Vaccination
Pertussis Vaccination
Covid-19 Vaccination
B,C and D Smoking Cessation Physical Activity Flu Vaccination
Pulmonary Pneumococcal
Rehabilitation Vaccination
Pertussis Vaccination
Covid-19 Vaccination
Pharmacological Therapy for Stable COPD

• Bronchodilators
• Long Acting Beta2 Agonist (LABA), Long Acting Muscarinic Antagonist
(LAMA), Short Acting Muscarinic Antagonist (SAMA), Short Acting Beta2
Agonist (SABA), Theophylline (a methylxanthine)
• Anti-inflammatory agents
• Inhaled corticosteroids (ICS)
• Roflumilast
• Azithromycin
• Antioxidant mucolytics
• Other pharmacological treatments
 Commonly Used Maintenance Medications in
COPD
LABA LAMA LABA/LAMA
Arformoterol Aclidinium bromide Formoterol/aclidinium
Formoterol Glycopyrronium bromide Formoterol/glycopyrronium
Indacaterol Tiotropium Indacaterol/glycopyrronium
Olodaterol Umeclidinium Vilanterol/umeclidinium
Salmeterol Glycopyrrolate Olodaterol/tiotropium
Revefenacin

LABA/ICS
Formoterol/beclomethasone
Formoterol/budesonide
Formoterol/mometasone
Salmeterol/Fluticasone propionate
Vilanterol/Fluticasone furoate
ICS/LAMA/LABA
Fluticasone/umeclidinium/vilanterol
Beclometasone/formoterol/glycopyrronium
Budesonide/formoterol/glycopyrrolate
Receptors:
Muscarinic Receptors
Beta 2 Receptors

Inhalers:
Muscarinic Antagonist
Beta 2 Agonist
Inhaled Corticosteroids
 Commonly Used Maintenance Medications in
COPD
LABA LAMA LABA/LAMA
Arformoterol Aclidinium bromide Formoterol/aclidinium
Formoterol Glycopyrronium bromide Formoterol/glycopyrronium
Indacaterol Tiotropium Indacaterol/glycopyrronium
Olodaterol Umeclidinium Vilanterol/umeclidinium
Salmeterol Glycopyrrolate Olodaterol/tiotropium
Revefenacin

LABA/ICS
Formoterol/beclomethasone
Formoterol/budesonide
Formoterol/mometasone
Salmeterol/Fluticasone propionate
Vilanterol/Fluticasone furoate
ICS/LAMA/LABA
Fluticasone/umeclidinium/vilanterol
Beclometasone/formoterol/glycopyrronium
Budesonide/formoterol/glycopyrrolate
• Going back to our case
• Diagnosis: COPD Gold 2, Group B
• Treatment:
• Non pharmacologic : smoking cessation, pulmonary rehabilitation, vaccines
• Pharmacologic: LABA or LAMA
Non pharmacologic Management of COPD

Patient Group Essential Recommended Depending on Local

Guidelines
A Smoking Cessation Physical Activity Flu Vaccination
Pneumococcal
Vaccination
Pertussis Vaccination
Covid-19 Vaccination
B,C and D Smoking Cessation Physical Activity Flu Vaccination
Pulmonary Pneumococcal
Rehabilitation Vaccination
Pertussis Vaccination
Covid-19 Vaccination
Follow-up Pharmacological Treatment
COPD Exacerbation

• Exacerbation of COPD
• Acute worsening of respiratory symptoms that results in additional therapy
• Complex events usually associated with increased airway inflammation,
increased mucus production and marked gas trapping.
• Classifications:
• Mild – treated with SABDs
• Moderate – treated with SABDs plus antibiotics and/or oral corticosteroids
• Severe – requires hospitalizations or visit to the emergency room; May also be
associated with acute respiratory failure
Treatment Options for COPD Exacerbation

• Short acting inhaled beta 2 agonists with or without short acting

anticholinergics
• Systemic corticosteroids
• Antibiotics
• Non invasive mechanical ventilation if with acute respiratory
failure who have no absolute contraindication
• Invasive Mechanical Ventilation
Reference

• Global Initiative for Chronic Obstructive Lung Disease.

2022 Edition