1. Chronic Obstructive Pulmonary Disease Austin Paul K

2. What is COPD? A chronic inflammatory lung disease resulting in persistent and usually progressive obstruction of airflow from the lungs Patients with COPD have ★ breathing difficulty, ★ cough, ★ sputum production.

3. What causes COPD? Smoking - primary or second hand smoke Air pollutants - ★ chemicals, dust, fumes from industry ★ poorly vented cooking fires Genes - Alpha 1 anti-trypsin deficiency (AATD)

4. Some facts about COPD Worldwide more than 3 million people died of COPD in 2012 - cause of 6% of all deaths. It is the 3rd commonest cause of death worldwide. It affects about 5% of the world’s population.

5. COPD in INDIA One of the most affected countries in the world. It is the 2nd commonest cause of death in India

6. COPD IN INDIA

7. Pathophysiology COPD is an obstructive lung disease Due to inflammation, there is breakdown of lung tissue (emphysema) and small airways disease (bronchiolitis) - this combination, results in poor outflow of air from the lung. Air trapping and hyperinflation of lungs - respiratory effort increases.

8. Symptoms of patients with COPD Cough - a chronic cough is often the first symptom. Cough and sputum on most days for at least 3 months, in each of 2 consecutive years is defined as “chronic bronchitis” which is a related diagnoses. However, it may be unproductive. Breathlessness - ★ progressive, ★ persistent ★ characteristically worse on exercise Sputum production - any pattern may indicate COPD Extra pulmonary effects include weight loss and skeletal muscle dysfunction.

9. Physical findings in COPD Physical findings are often non-specific and correlate poorly with lung function A barrel chest Auscultation usually reveals a quiet chest with poor air entry. Crackles if present indicate infection or bronchiectasis Clubbing is not a feature of COPD and if present, evaluation for other diseases is needed.

10. Investigations for COPD CAT - COPD Assessment Test - a set of 8 questions to ask patients. Blood counts Spirometry - the gold standard. Post-bronchodilator FEV1/FVC should be <70% CXR - over-expanded lungs and flattened diaphragm HRCT of chest to evaluate for presence of bullae Evaluation for Alpha 1 anti-trypsin deficiency

11. GOLD - Global Initiative for Chronic Obstructive Lung Disease. GOLD was launched in 1997 in collaboration with the National Heart, Lung, and Blood Institute, National Institutes of Health, USA and WHO. GOLD’s program is determined and its guidelines for COPD care are shaped by committees made up of leading experts from around the world.

12. “GOLD” grading for severity of COPD SEVERITYFEV 1 % predicted Mild (GOLD 1)>80 Moderate (GOLD2)50-79 Severe (GOLD 3)30-49 Very severe (GOLD 4) <30

13. Differential Diagnosis of COPD Congestive heart failure Pneumothorax Pulmonary embolism Pneumonia ASTHMA

14. Diseases often seen with COPD Cardiovascular diseases. Cerebrovascular diseases. Respiratory infections. Diabetes Lung cancer Bronchiectasis Respiratory infections Anxiety and depression

15. Treatment of COPD Stop smoking Avoiding air pollutants, especially avoiding the use of biomass fuels at home and preventive measures at affected industries. Pneumococcal and Influenza vaccine to prevent exacerbations. No known cure Symptomatic relief with inhaled bronchodilators, anticholinergics, oral theophylline and sometimes steroids. Pulmonary rehabilitation exercises. Oxygen therapy to be given with careful monitoring.

16. Future outcomes The incidence of COPD is gradually going up, especially in developing countries with increasing industrialization. Prevention is the cornerstone of the strategy for reducing the burden of COPD. In developing countries, resources are often the restricting factors. Patients with Alpha 1 anti-trypsin deficiency are now being offered intravenous replacement therapy in some centers. Various newer drugs like PDE 4 inhibitors (roflumilast) are being tried out.

17. Bibliography Davidson’s Principles and and Practice of Medicine 22nd ed. Special issue on COPD. Journal of the Association of Physicians of India. Feb. 2012. Vol. 60 www.goldcopd.org www.uptodate.com www.medscape.com