Definition of COPD COPD is a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases. 1

Inflammation in COPD 2

Pathogenesis of COPD 3

indoor/outdoor pollution Diagnosis of COPD EXPOSURE TO RISK FACTORS SYMPTOMS cough tobacco sputum occupation dyspnea indoor/outdoor pollution Diagnosis of COPD is based on a history of exposure to risk factors and the presence of airflow limitation that is not fully reversible, with or without the presence of symptoms. Patients who have chronic cough and sputum production with a history of exposure to risk factors should be tested for airflow limitation, even if they do not have dyspnea. For the diagnosis and assessment of COPD, spirometry is the gold standard. Health care workers involved in the diagnosis and management of COPD patients should have access to spirometry.  SPIROMETRY 4

Spirometry: Normal and Patients with COPD 5

Spirometry “How-To” Resources from GOLD Spirometry Guide Spirometry Quick Guide Spirometry Teaching Slide Set To help health care professionals understand how to perform & evaluate spirometry. All resources available at www.goldcopd.org.

Classification of COPD Severity by Spirometry Stage I: Mild FEV1/FVC < 0.70 FEV1 > 80% predicted Stage II: Moderate FEV1/FVC < 0.70 50% < FEV1 < 80% predicted Stage III: Severe FEV1/FVC < 0.70 30% < FEV1 < 50% predicted Stage IV: Very Severe FEV1/FVC < 0.70 FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure 7

Therapy at Each Stage of COPD I: Mild II: Moderate III: Severe IV: Very Severe FEV1/FVC < 70% FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure FEV1/FVC < 70% 30% < FEV1 < 50% predicted FEV1/FVC < 70% 50% < FEV1 < 80% predicted FEV1/FVC < 70% FEV1 > 80% predicted Active reduction of risk factor(s); influenza vaccination Add short-acting bronchodilator (when needed) Add regular treatment with one or more long-acting bronchodilators (when needed); Add rehabilitation This provides a summary of the recommended treatment at each stage of COPD. Add inhaled glucocorticosteroids if repeated exacerbations Add long term oxygen if chronic respiratory failure. Consider surgical treatments 8

Differential Diagnosis: COPD and Asthma Onset in mid-life Symptoms slowly progressive Long smoking history Dyspnea during exercise Largely irreversible airflow limitation Onset early in life (often childhood) Symptoms vary from day to day Symptoms at night/early morning Allergy, rhinitis, and/or eczema also present Family history of asthma Largely reversible airflow limitation 9

COPD and Co-morbid Conditions Common co-morbid conditions in COPD patients: Cardiovascular disease Lung cancer Osteoporosis Musculoskeletal disorders Depression/anxiety Obesity/type II diabetes Physicians should identify and treat co-morbid conditions that impact on the clinical course of COPD. Smoking prevention and cessation, weight control, exercise, and rehabilitation have the potential to beneficially affect COPD and co-morbid conditions.

Preventing COPD Exacerbations Prevent respiratory infections: pneumococcal vaccine, annual influenza vaccine. Avoid air pollution: remain indoors and close windows on bad air pollution days. Quit smoking and avoid exposure to secondhand smoke. Understand medication regimen and proper inhaler use. Patients with severe COPD and repeated exacerbations (3 or more in a year): use inhaled glucocorticosteroids. Recognize and respond to early signs of exacerbations to minimize impact when exacerbations do occur.

Risk Factors for COPD Genes Oxidative stress Exposure to particles Tobacco smoke Occupational dusts, organic and inorganic Indoor air pollution from heating and cooking with biomass in poorly ventilated dwellings Outdoor air pollution Lung growth and development Oxidative stress Gender Age Respiratory infections Socioeconomic status Nutrition Comorbidities 12

Brief Strategies to Help the Patient Willing to Quit Smoking ASK Systematically identify all tobacco users at every visit. ADVISE Strongly urge all tobacco users to quit. ASSESS Determine willingness to make a quit attempt. ASSIST Aid the patient in quitting. ARRANGE Schedule follow-up contact. Reduction of total personal exposure to tobacco smoke, occupational dusts and chemicals, and indoor and outdoor air pollutants are important goals to prevent the onset and progression of COPD. Smoking cessation is the single most effective - and cost effective - intervention to reduce the risk of developing COPD and stop its progression. Brief tobacco dependence treatment is effective, and every tobacco user should be offered at least this treatment at every visit to a health care provider. Three types of counseling are especially effective: practical counseling, social support as part of treatment, and social support arranged outside of treatment. 13

Lower Respiratory System Anatomy of the Lower Respiratory System Trachea Main bronchi Left Right Bronchioles Acinus Bronchus rigid because of C-shaped cartilage rings Alveolus Acinus Capillary Attenuated epithelium Alveolus Alveolar space Capillaries 14

Trachea and major bronchi Anatomy of the Airways Trachea and major bronchi Bronchioles Smooth muscle Connective tissue Cartilage Mucous membrane Airway mucous membrane Mucus Cilia Secretory cells Epithelium Ciliated cells Basal membrane Submucosa 15