1. Chronic Obstructive Pulmonary Disease

2. Why COPD is Important ?
COPD is the only chronic disease that is showing progressive upward trend in both mortality and morbidity
It is expected to be the third leading cause of death by 2020
Approximately 14 million Indians are currently suffering form COPD*
Currently there are 94 million smokers in India
10 lacs Indians die in a year due to smoking related diseases
*The Indian J Chest Dis & Allied Sciences 2001; 43:139-47

3. Disease Trajectory of a Patients with COPD
Symptoms
Exacerbations
Deterioration
End of Life

4. Respiratory Medicine 2002; 96: S1-S31
“Despite this burden, COPD is a “Cindrella” conditions that receives limited recognition from both patients and physicians”
Respiratory Medicine 2002; 96: S1-S31

5. Obstructive Airway Disease
Asthma
Explosion in research
Revolution in therapy
COPD
Little research (? neglect)
Few advances in therapy

6. New Definition
Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease state characterised by airflow limitation that is not fully reversible.
The airflow limitation is usually progressive and is associated with an abnormal inflammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking.
Although COPD affects the lungs, it also produces significant systemic consequences.
ATS/ERS 2004

7. Risk Factors Smoke from home cooking and heating fuel
Occupational dust and chemicals
Gender: More common in men. M:F ratio is 5%:2.7% (in India)
Increasing age
Others: Infection, nutrition and deficiency of a1 antitrypsin

8. Pathophysiology of COPD
Increased mucus production and reduced mucociliary clearance - cough and sputum production
Loss of elastic recoil - airway collapse
Increase smooth muscle tone
Pulmonary hyperinflation
Gas exchange abnormalities - hypoxemia and/or hypercapnia

9. Key Indicators for COPD Diagnosis
Chronic cough
Present intermittently or every day often present throughout the day; seldom only nocturnal
Chronic sputum production
Present for many years, worst in winters. Initially mucoid – becomes purulent with exacerbation
Dyspnoea that is
Progressive (worsens over time)
Persistent (present every day)
Worse on exercise
Worse during respiratory infections
Acute bronchitis
Repeated episodes
History of exposure to risk factors
Tobacco smoke (including beedi) occupational dusts and chemical smoke from home cooking and heating fuel

10. Physical signs Large barrel shaped chest (hyperinflation)
Prominent accessory respiratory muscles in neck and use of accessory muscle in respiration
Low, flat diaphragm
Diminished breath sound

11. Algorithm for Diagnosis at Primary Care
Pt reporting with respiratory symptoms
Assess by
- H/o exposure to risk factors
- Physical examination
Sputum for AFB
+ve
-ve
Treat as TB
Provisional Diagnosis of COPD
Poor response refer to secondary care
Treat as COPD
National Guidelines for Management of COPD at Primary Care Level

12. Spirometry Diagnosis Assessing severity Assessing prognosis
Monitoring progression

13. Spirometry FEV1 – Forced expired volume in the first second
FVC – Total volume of air that can be exhaled from maximal inhalation to maximal exhalation
FEV1/FVC% - The ratio of FEV1 to FVC, expressed as a percentage.

14. COPD classification based on spirometry GOLD 2003
Severity
Postbronchodilator FEV1/FVC
Postbronchodilator FEV1% predicted
At risk
>0.7
>80
Mild COPD
<0.7
Moderate COPD
50-80
Severe COPD
30-50
Very severe COPD
<30
SPIROMETRY is not to substitute for clinical judgment in the evaluation of the severity of disease in individual patients.

15. Pharmacotherapy for Stable COPD
Bronchodilators
Short-acting b2-agonist – Salbutamol
Long-acting b2-agonist - Salmeterol and Formoterol
Anticholinergics – Ipratropium, Tiiotropium
Methylxanthines - Theophylline
Steroids
Oral – Prednisolone
Inhaled - Fluticasone, Budesonide

16. Post-bronchodilator FEV1 (% predicted)
Management based on GOLD
Post-bronchodilator FEV1 (% predicted)

17. “Bronchodilator medications are central to the symptomatic management of COPD”
GOLD Report 2003

18. How Do Bronchodilators Work?
Reverse the increased bronchomotor tone
Relax the smooth muscle
Reduce the hyperinflation
Improve breathlessness

19. “All guidelines recommend inhaled bronchodilator as first line therapy
“All guidelines recommend inhaled bronchodilator as first line therapy. The ATS suggest initial therapy with an anticholinergic drug if regular therapy is needed”
Chest 2000; 117: 23S-28S

20. Mode of Action
Cholinergic tone is the only reversible component of COPD
Normal airway have small degree of vagal cholinergic tone (no perceptible effect due to patent airways)

21. Mode of Action (Contd.)
Airways are narrowed in COPD therefore vagal cholinergic tone has greater effect on airway resistance (Resistance a1/radius4)
Therefore, the need for anticholinergic drugs that will act as muscarinic receptor antagonist and block the acetylcholine induced bronchoconstriction

22. Mode of Action (Contd.)
Anticholinergics may also reduce mucus hypersecretion
Anticholinergic have no effect on pulmonary vessels, and therefore do not cause a fall in PaO2
Drugs of Today 2002; 38(9):

23. “Combining bronchodilators with different
“Patients with moderate to severe symptoms of COPD require combination of bronchodilators”
“Combining bronchodilators with different
mechanisms and durations of actions may
increase the degree of bronchodilation for
equivalent or lesser side effects’’
GOLD Report 2003

24. Algorithm for the management of COPD
Mild
Short acting bronchodilator – as required
Tiotropium
Long acting beta agonist
assess with symptoms and spirometry
Tiotropium+LABA
LABA + tiotropium
Add
-Inhaled steroids
-Theophylline
Severe