1. COPD Chronic Obstructive Lung Disease
Dr. M. A. Sofi, MD; FRCP; FRCPEdin: FRCSEdin
AL Maarefa College of Science & Technology

2. WHAT IS COPD?
Chronic obstructive pulmonary disease (COPD) is estimated to affect 32 million persons in the USA and is the fourth leading cause of death.
COPD limits air flow and is not fully reversible.
Usually progressive and is associated with inflammation of the lungs as they respond to noxious particles or gases.
Potentially preventable with proper precautions and avoidance of precipitating factors.
Symptomatic treatment is available .

3. Definition of COPD
Chronic Obstructive Pulmonary Disease is a preventable and treatable disease with some significant extrapulmonary effects.
The pulmonary component is characterized by airflow limitation that is not fully reversible.
Healthy
Alveolus
COPD

4. Two Major Causes of COPD
Chronic Bronchitis is characterized by
Chronic inflammation and excess mucus production
Presence of chronic productive cough
Emphysema is characterized by
Damage to the small, sac-like units of the lung that deliver oxygen into the lung and remove the carbon dioxide
Chronic cough

5. What can cause COPD? Smoking is the primary risk factor
Long-term smoking is responsible for % of cases
Smoker, compared to non-smoker, is 10 times more likely to die of COPD
Prolonged exposures to harmful particles and gases from:
Second-hand smoke
Industrial smoke
Chemical gases, vapors, mists & fumes
Dusts from grains, minerals & other materials

6. Chronic Obstructive Pulmonary Disease (COPD)
The airflow limitation in COPD is usually progressive and associated with an abnormal inflammatory response of the lungs to noxious particles and gases
Severe COPD leads to respiratory failure, hospitalization and eventually death from suffocation

7. Risk Factors for COPD Aging Populations Nutrition Infections
Socio-economic status
Aging Populations

8. late in the course of their disease.
HISTORY
Most patients with (COPD) seek medical attention
late in the course of their disease.
Patients often ignore the symptoms because they
start gradually and progress over the course of
years.
Patients often modify their lifestyle to minimize
dyspnea and ignore cough and sputum production.
Patients typically present with a combination of
signs and symptoms of chronic bronchitis, emphysema,
and reactive airway disease.

9. G O L D lobal Initiative for Chronic bstructive ung isease
November 19, 2006
World COPD Day, Kyoto Japan

10. Why was GOLD Started?
The social and economic burden of COPD is increasing rapidly in countries at all levels of economic development
COPD is under-appreciated, under-diagnosed and under-treated
Important questions about COPD are still unanswered

11. GOLD Objectives
Increase awareness of COPD among health professionals, health authorities, and the general public
Improve diagnosis, management and prevention of COPD
Stimulate research in COPD

12. Global Strategy for Diagnosis, Management and Prevention of COPD
Revised 2006
Definition, Classification
Burden of COPD
Risk factors
Pathogenesis, pathology, pathophysiology
Management
Practical Considerations

13. COPD Mortality Worldwide
Ischaemic heart disease
Cerebrovascular disease
Lower resp infection
Diarrhoeal disease
Perinatal disorders
COPD
Tuberculosis
Measles
Road Traffic Accidents
Lung Cancer
3rd
6th
Stomach Cancer
HIV
Suicide

14. Physical Examination
The sensitivity of a physical examination in detecting mild to moderate COPD is relatively poor.
Physical signs are quite specific and sensitive for severe disease.
Patients with severe disease experience tachypnea and respiratory distress with simple activities.
The respiratory rate increases in proportion to disease severity.
Use of accessory respiratory muscles and paradoxical in drawing of lower intercostal spaces is evident (Hoover sign).
In advanced disease, cyanosis, elevated jugular venous pulse (JVP), and peripheral edema can be observed.

15. Physical Examination. Thoracic examination reveals the following:
Hyperinflation (barrel chest)
Wheezing – Frequently heard on forced and unforced expiration
Diffusely breath sounds
Hyper-resonance on percussion
Prolonged expiration
Use of accessory muscles of respiration is common
Coarse rhonchi and wheezing.
Signs of (cor- pulmonale).
Patients may be very thin with a barrel chest.
Typically have little or no cough or expectoration.
Pursed lips breathing and use of accessory respiratory muscles.
patients may adopt the tripod sitting position
Chest may be hyper-resonant, and wheezing may be heard.
Heart sounds are very distant.

16. Barrel shaped Chest
Emphysematous Chest

17. COPD EXACERBATIONS COPD exacerbations defined:
“An event in the natural course of the disease characterized by a change in the patient’s baseline dyspnea, cough, and/or sputum that is beyond normal day-to-day variations, is acute in onset, and may warrant a change in regular medication in a patient with underlying COPD.”
Antibiotics with specific advice
Care at home/follow up

18. indoor/outdoor pollution
Diagnosis of COPD
EXPOSURE TO RISK
FACTORS
SYMPTOMS
cough
tobacco
sputum
occupation
shortness of breath
indoor/outdoor pollution
A diagnosis of COPD should be considered in any patient who has cough, sputum production, or dyspnea and/or a history of exposure to risk factors. The diagnosis is confirmed by spirometry.
To help identify individuals earlier in the course of disease, spirometry should be performed for patients who have chronic cough and sputum production even if they do not have dyspnea.
Spirometry is the best way to diagnose COPD and to monitor its progression and health care workers to care for COPD patients should have assess to spirometry. è
SPIROMETRY

19. CT Scan: This gives a detailed picture of the lungs.
TESTS DONE AS NEEDED
Arterial blood gas test. This test measures how much oxygen, carbon dioxide, and acid is in blood. It helps to decide whether oxygen is needed for the treatment.
Oximetry: This test measures the oxygen saturation in the blood. It can be useful in finding out whether oxygen treatment is needed, but it provides less information than the arterial blood gas test.
CT Scan: This gives a detailed picture of the lungs.
Electrocardiogram (ECG) or echocardiogram. These tests may find certain heart
problems that can cause shortness of breath.
Transfer factor for carbon monoxide: This test looks at whether lungs have been damaged, and if so, how much damage there is and how bad COPD might be.
Alpha-1 antitrypsin: Is a protein that helps protect the lungs. People whose bodies don't make enough AAT are more likely to get emphysema.

20. Cor pulmonale also known as pulmonary heart disease, is enlargement and failure of the right ventricle of the heart as a response to (pulmonary hypertension).
SOB of breath which occurs at exertion but when severe can occur at rest
Wheezing
Chronic wet cough
Swelling of the abdomen with fluid (ascites)
Swelling of the ankles & feet (edema)
Enlargement or prominent neck and facial veins
Raised jugular venous pressure (JVP)
Enlargement of the liver
Bluish discoloration of the skin (cyanosis)

21. Congestive heart failure Bronchiectasis Bronchiolitis obliterans
Diagnostic Considerations: Differential Diagnosis
Congestive heart failure
Bronchiectasis
Bronchiolitis obliterans
Chronic asthma
Alpha1-Antitrypsin Deficiency
Bronchitis
Emphysema
Nicotine Addiction
Pulmonary Embolism

22. Approach Considerations: Work up
Serum Chemistry
Patients with COPD tend to retain sodium.
In addition, serum potassium should be monitored carefully, because diuretics, beta-adrenergic agonists, and theophylline act to lower potassium levels.
Beta-adrenergic agonists also increase renal excretion of serum calcium and magnesium, which may be important in the presence of hypokalemia.
Chronic respiratory acidosis leads to compensatory metabolic alkalosis.
In the absence of blood gas measurements, bicarbonate levels are useful for following disease progression

23. GOALS of COPD MANAGEMENT VARYING EMPHASIS WITH DIFFERING SEVERITY
• Prevent disease progression
Improve exercise tolerance
• Improve health status
• Prevent and treat complications
• Prevent and treat exacerbations
• Reduce mortality

24. Four Components of Care
Approach Considerations: Treatment
Four Components of Care
Assess and Monitor Disease
Reduce Risk Factors
Manage Stable COPD
Manage Exacerbations

25. Approach Considerations: Treatment
Diet
Bronchodilation
Beta2 agonists and anticholinergics
Phosphodiesterase inhibitors
Smoking Cessation
Management of Sputum Viscosity and Secretion Clearance
Oxygen Therapy and Hypoxemia
PPIs for Exacerbations and the Common Cold
Vaccination to Reduce Infections
Treatment for acute exacerbation of COPD
Long-term Monitoring
Lung Transplantation

26. Approach Considerations: Treatment
Oral and inhaled medications are used for patients with stable disease to reduce dyspnea and improve exercise tolerance.
Most of the medications used are directed at the
following 4 potentially reversible causes of airflow
limitation in a disease state that has largely fixed
obstruction.
Bronchial smooth muscle contraction
Bronchial mucosal congestion and edema
Airway inflammation
Increased airway secretions

27. Phosphodiesterase-4 inhibitors
Phosphodiesterase-4 inhibitors. A new type of medication approved for COPD
Theophylline. This very inexpensive medication helps improve breathing and prevents exacerbations.
Antibiotics. Respiratory infections, such as acute bronchitis, pneumonia and influenza, can aggravate COPD symptoms.
Oxygen therapy.  Oxygen therapy can improve quality of life and is the only COPD therapy proven to extend life.
Lung transplant. Transplantation can improve ability to breathe and to be active, but it's a major operation that has significant risks, such as organ rejection, and it obligates you to take lifelong immune-suppressing medication.
Bronchodilators. Usually come in an inhaler — relax the muscles around airways.
Inhaled steroids. Inhaled corticosteroid can reduce airway inflammation and help prevent exacerbations. Budesonide (Pulmicort) is an examples of inhaled steroids.
Combination inhalers. Sometimes combination of bronchodilators and inhaled steroids. Salmeterol and fluticasone (Advair) and formoterol and budesonide (Symbicort) are examples of combination inhalers.
Oral steroids. For people who have a moderate or severe acute exacerbation, oral steroids prevent further worsening of COPD.

28. Approach Considerations: Treatment
Approaches to management
include recommendations such
as those provided by GOLD:
Stage I (mild obstruction) Reduction of risk factors (influenza vaccine).
Short acting bronchodilator.
Stage II (moderate obstruction):
Reduction of risk factors (influenza vaccine).
short & long-acting bronchodilator as needed.
Cardiopulmonary rehab.
Stage III (severe obstruction):
Reduction of risk factors (influenza vaccine).
Bronchodilator(s).
Cardiopulmonary rehabilitation
Inhaled glucocorticoids if repeated exacerbations.
Stage IV (very severe obstruction or moderate obstruction)
Bronchodilators (Short & long- acting.
Cardiopulmonary rehabilitation.
Inhaled glucocorticoids.
Long-term oxygen therapy.
Consider surgical options such as LVRS and lung transplantation.

29. 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

30. 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)
This provides a summary of the recommended treatment at each stage of COPD.
Add regular treatment with one or more long-acting bronchodilators (when needed); Add rehabilitation
Add inhaled glucocorticosteroids if repeated exacerbations
Add long term oxygen if chronic respiratory failure. Consider surgical treatments

31. THANK YOU
FOR
YOUR
ATTENTION