1. بسم الله الرحمن الرحيم

2. Ayman Farghaly MD FCCP Military Medical Academy
COPD Guideline
Ayman Farghaly MD FCCP
Military Medical Academy

3. © Global Initiative for Chronic Obstructive Lung Disease
G O L D
lobal Initiative for Chronic bstructive ung isease
© Global Initiative for Chronic Obstructive Lung Disease

4. GOLD Objectives
Increase awareness of COPD among health professionals, health authorities, and the general public
Improve diagnosis, management and prevention
Decrease morbidity and mortality
Stimulate research

5. Definition and Overview Diagnosis and Assessment Therapeutic Options
Global Strategy for Diagnosis, Management and Prevention of COPD, 2011: Chapters
REVISED 2011
Definition and Overview
Diagnosis and Assessment
Therapeutic Options
Manage Stable COPD
Manage Exacerbations
Manage Comorbidities

6. Definition and Overview Diagnosis and Assessment Therapeutic Options
Global Strategy for Diagnosis, Management and Prevention of COPD, 2011: Chapters
REVISED 2011
Definition and Overview
Diagnosis and Assessment
Therapeutic Options
Manage Stable COPD
Manage Exacerbations
Manage Comorbidities

7. Global Strategy for Diagnosis, Management and Prevention of COPD
Definition of COPD
COPD, a common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases.
Exacerbations and comorbidities contribute to the overall severity in individual patients.

8. Mechanisms Underlying Airflow Limitation in COPD
Global Strategy for Diagnosis, Management and Prevention of COPD
Mechanisms Underlying Airflow Limitation in COPD
Small Airways Disease
Airway inflammation
Airway fibrosis, luminal plugs
Increased airway resistance
Parenchymal Destruction
Loss of alveolar attachments
Decrease of elastic recoil
AIRFLOW LIMITATION

9. COPD is a leading cause of morbidity and mortality worldwide.
Global Strategy for Diagnosis, Management and Prevention of COPD Burden of COPD
COPD is a leading cause of morbidity and mortality worldwide.
The burden of COPD is projected to increase in coming decades due to continued exposure to COPD risk factors and the aging of the world’s population.
COPD is associated with significant economic burden.

10. Aging Populations Risk Factors for COPD Genes Infections
Global Strategy for Diagnosis, Management and Prevention of COPD
Risk Factors for COPD
Genes
Infections
Socio-economic status
Aging Populations

16. Definition and Overview Diagnosis and Assessment Therapeutic Options
Global Strategy for Diagnosis, Management and Prevention of COPD, 2011: Chapters
REVISED 2011
Definition and Overview
Diagnosis and Assessment
Therapeutic Options
Manage Stable COPD
Manage Exacerbations
Manage Comorbidities

17. Global Strategy for Diagnosis, Management and Prevention of COPD Diagnosis and Assessment: Key Points
A clinical diagnosis of COPD should be considered in any patient who has dyspnea, chronic cough or sputum production, and/or a history of exposure to risk factors for the disease.
Spirometry is required to make the diagnosis; the presence of a post-bronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow limitation and thus of COPD.

18. Global Strategy for Diagnosis, Management and Prevention of COPD Diagnosis and Assessment: Key Points
The goals of COPD assessment are to determine the severity of the disease, including the severity of airflow limitation, the impact on the patient’s health status, and the risk of future events.
Comorbidities occur frequently in COPD patients, and should be actively looked for and treated appropriately if present.

19. indoor/outdoor pollution
Global Strategy for Diagnosis, Management and Prevention of COPD
Diagnosis of COPD
EXPOSURE TO RISK
FACTORS
SYMPTOMS
shortness of breath
tobacco
chronic cough
occupation
sputum
indoor/outdoor pollution
SPIROMETRY: Required to establish diagnosis

20. Spirometry: Obstructive Disease
Normal 5 4 3
Volume, liters
FEV1 = 1.8L
FVC = 3.2L
FEV1/FVC = 0.56 2
Obstructive 1 1 2 3 4 5 6
Time, seconds

21. Chronic cough: May be intermittent and may be unproductive.
Global Strategy for Diagnosis, Management and Prevention of COPD Symptoms of COPD
The characteristic symptoms of COPD are chronic and progressive dyspnea, cough, and sputum production.
Dyspnea: Progressive, persistent and characteristically worse with exercise.
Chronic cough: May be intermittent and may be unproductive.
Chronic sputum production: COPD patients commonly cough up sputum.

22. Use the COPD Assessment Test(CAT) or mMRC Breathlessness scale
Global Strategy for Diagnosis, Management and Prevention of COPD Assessment of COPD
Assess symptoms
Assess degree of airflow limitation using spirometry
Assess risk of exacerbations
Assess comorbidities
Use the COPD Assessment Test(CAT) or
mMRC Breathlessness scale

23. Global Strategy for Diagnosis, Management and Prevention of COPD Assessment of Symptoms
COPD Assessment Test (CAT): An 8-item measure of health status impairment in COPD (
Breathlessness Measurement using the Modified British Medical Research Council (mMRC) Questionnaire: relates well to other measures of health status and predicts future mortality risk.

24. Global Strategy for Diagnosis, Management and Prevention of COPD Modified MRC (mMRC)Questionnaire

26. Assess degree of airflow limitation using spirometry
Global Strategy for Diagnosis, Management and Prevention of COPD Assessment of COPD
Assess symptoms
Assess degree of airflow limitation using spirometry
Assess risk of exacerbations
Assess comorbidities
Use spirometry for grading severity according to spirometry, using four grades split at 80%, 50% and 30% of predicted value

27. In patients with FEV1/FVC < 0.70:
Global Strategy for Diagnosis, Management and Prevention of COPD Classification of Severity of Airflow Limitation in COPD*
In patients with FEV1/FVC < 0.70:
GOLD 1: Mild FEV1 > 80% predicted
GOLD 2: Moderate % < FEV1 < 80% predicted
GOLD 3: Severe % < FEV1 < 50% predicted
GOLD 4: Very Severe FEV1 < 30% predicted
*Based on Post-Bronchodilator FEV1

28. Assess degree of airflow limitation using spirometry
Global Strategy for Diagnosis, Management and Prevention of COPD Assessment of COPD
Assess symptoms
Assess degree of airflow limitation using spirometry
Assess risk of exacerbations
Assess comorbidities
Use history of exacerbations and spirometry.
Two exacerbations or more within the last year
or an FEV1 < 50 % of predicted value are
indicators of high risk

29. (C) (D) (B) (A) Risk Risk Symptoms
Global Strategy for Diagnosis, Management and Prevention of COPD Combined Assessment of COPD 4
(C)
(D)
> 2 3
(Exacerbation history)
Risk
(GOLD Classification of Airflow Limitation)
Risk 2
(A)
(B) 1 1
mMRC 0-1
CAT < 10
mMRC > 2
CAT > 10
Symptoms
(mMRC or CAT score))

30. Use combined assessment
Global Strategy for Diagnosis, Management and Prevention of COPD Combined Assessment of COPD
Use combined assessment
Patient is now in one of
four categories:
A: Les symptoms, low risk
B: More symtoms, low risk
C: Less symptoms, high risk
D: More Symtoms, high risk 4
(C)
(D)
> 2 3
(GOLD Classification of Airflow Limitation)
Risk
(Exacerbation history)
Risk 2 1
(A)
(B) 1
mMRC 0-1
CAT < 10
mMRC > 2
CAT > 10
Symptoms
(mMRC or CAT score))

31. COPD patients are at increased risk for: Cardiovascular diseases
Global Strategy for Diagnosis, Management and Prevention of COPD Assess COPD Comorbidities
COPD patients are at increased risk for:
Cardiovascular diseases
Osteoporosis
Respiratory infections
Anxiety and Depression
Diabetes
Lung cancer
These comorbid conditions may influence mortality and hospitalizations and should be looked for routinely, and treated appropriately.

32. COPD and Asthma ASTHMA COPD Onset early in life (often childhood)
Global Strategy for Diagnosis, Management and Prevention of COPD Differential Diagnosis:
COPD and Asthma
COPD
Onset in mid-life
Symptoms slowly progressive
Long smoking history
ASTHMA
Onset early in life (often childhood)
Symptoms vary from day to day
Symptoms worse at night/early morning
Allergy, rhinitis, and/or eczema also present
Family history of asthma

33. Global Strategy for Diagnosis, Management and Prevention of COPD Additional Investigations
Chest X-ray: Seldom diagnostic but valuable to exclude alternative diagnoses and establish presence of significant comorbidities. 
Lung Volumes and Diffusing Capacity: Help to characterize severity, but not essential to patient management. 
Oximetry and Arterial Blood Gases: Pulse oximetry can be used to evaluate a patient’s oxygen saturation and need for supplemental oxygen therapy.
Alpha-1 Antitrypsin Deficiency Screening: Perform when COPD develops in patients of Caucasian descent under 45 years or with a strong family history of COPD.  

34. Global Strategy for Diagnosis, Management and Prevention of COPD Additional Investigations
Exercise Testing: Objectively measured exercise impairment, assessed by a reduction in self-paced walking distance (such as the 6 min walking test) or during incremental exercise testing in a laboratory, is a powerful indicator of health status impairment and predictor of prognosis.
Composite Scores: Several variables (FEV1, exercise tolerance assessed by walking distance or peak oxygen consumption, weight loss and reduction in the arterial oxygen tension) identify patients at increased risk for mortality.

35. Definition and Overview Diagnosis and Assessment Therapeutic Options
Global Strategy for Diagnosis, Management and Prevention of COPD, 2011: Chapters
REVISED 2011
Definition and Overview
Diagnosis and Assessment
Therapeutic Options
Manage Stable COPD
Manage Exacerbations
Manage Comorbidities

36. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Key Points
Smoking cessation has the greatest capacity to influence the natural history of COPD. Health care providers should encourage all patients who smoke to quit.
Pharmacotherapy and nicotine replacement reliably increase long-term smoking abstinence rates.
All COPD patients benefit from regular physical activity and should repeatedly be encouraged to remain active.

37. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Key Points
Appropriate pharmacologic therapy can reduce COPD symptoms, reduce the frequency and severity of exacerbations, and improve health status and exercise tolerance.
None of the existing medications for COPD has been shown conclusively to modify the long-term decline in lung function.
Influenza and pneumococcal vaccination should be offered depending on local guidelines.

38. 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

39. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Risk Reduction
Encourage comprehensive tobacco-control policies with clear, consistent, and repeated nonsmoking messages.
Emphasize primary prevention, best achieved by elimination or reduction of exposures in the workplace. Secondary prevention, achieved through surveillance and early detection, is also important.
Reduce or avoid indoor air pollution from biomass fuel, burned for cooking and heating in poorly ventilated dwellings.
Advise patients to monitor public announcements of air quality and, depending on the severity of their disease, avoid vigorous exercise outdoors or stay indoors during pollution episodes.

40. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: COPD Medications
Beta2-agonists
Short-acting beta2-agonists
Long-acting beta2-agonists
Anticholinergics
Short-acting anticholinergics
Long-acting anticholinergics
Combination short-acting beta2-agonists + anticholinergic in one inhaler
Methylxanthines
Inhaled corticosteroids
Combination long-acting beta2-agonists + corticosteroids in one inhaler
Systemic corticosteroids
Phosphodiesterase-4 inhibitors

41. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Bronchodilators
Bronchodilator medications are central to the symptomatic management of COPD.
Bronchodilators are prescribed on an as-needed or on a regular basis to prevent or reduce symptoms.
The principal bronchodilator treatments are beta2- agonists, anticholinergics, theophylline or combination therapy.
The choice of treatment depends on the availability of medications and each patient’s individual response in terms of symptom relief and side effects..

42. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Bronchodilators
Long-acting inhaled bronchodilators are convenient and more effective for symptom relief than short-acting bronchodilators.
Long-acting inhaled bronchodilators reduce exacerbations and related hospitalizations and improve symptoms and health status.
Combining bronchodilators of different pharmacological classes may improve efficacy and decrease the risk of side effects compared to increasing the dose of a single bronchodilator.

43. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Inhaled Corticosteroids
Regular treatment with inhaled corticosteroids (ICS) improves symptoms, lung function and quality of life and reduces frequency of exacerbations for COPD patients with an FEV1 < 60% predicted.
Inhaled corticosteroid therapy is associated with an increased risk of pneumonia.
Withdrawal from treatment with inhaled corticosteroids may lead to exacerbations in some patients.

44. Long-term Use of Inhaled Corticosteroids and the Risk of Pneumonia in Chronic Obstructive Pulmonary Disease
Sonal Singh, MD, MPH; Aman V. Amin, MD; Yoon K. Loke, MD , Arch Intern Med
Conclusion  Among patients with COPD, inhaled corticosteroid use for at least 24 weeks is associated with a significantly increased risk of serious pneumonia, without a significantly increased risk of death

45. Invasive Aspergillosis
Intermediate Risk
Prolonged corticosteroid therapy
COPD
Autologous HSCT
Cirrhosis with duration of stay >7 days
Solid-organ cancer
HIV infection
Lung transplantation
Systemic disease requiring prolonged immunosuppression
Meersseman W ,et al .Clin Infect Dis. 2007;45(2):

46. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Combination Therapy
An inhaled corticosteroid combined with a long- acting beta2-agonist is more effective than the individual components in improving lung function and health status and reducing exacerbations in moderate to very severe COPD.
Addition of a long-acting beta2-agonist/inhaled glucorticosteroid combination to an anticholinergic (tiotropium) appears to provide additional benefits.

47. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Systemic Corticosteroids
Chronic treatment with systemic corticosteroids should be avoided because of an unfavorable benefit-to-risk ratio.

48. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Phosphodiesterase-4 Inhibitors
In patients with severe and very severe COPD (GOLD 3 and 4) and a history of exacerbations and chronic bronchitis, the phospodiesterase-4 inhibitor (PDE-4), roflumilast, reduces exacerbations treated with oral glucocorticosteroids.

49. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Theophylline
Theophylline is less effective and less well tolerated than inhaled long-acting bronchodilators and is not recommended if those drugs are available and affordable.
There is evidence for a modest bronchodilator effect and some symptomatic benefit compared with placebo in stable COPD. Addition of theophylline to salmeterol produces a greater increase in FEV1 and breathlessness than salmeterol alone.
Low dose theophylline reduces exacerbations but does not improve post-bronchodilator lung function.

50. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Other Pharmacologic Treatments
Influenza vaccines can reduce serious illness. Pneumococcal polysaccharide vaccine is recommended for COPD patients 65 years and older and for COPD patients younger than age 65 with an FEV1 < 40% predicted.
The use of antibiotics, other than for treating infectious exacerbations of COPD and other bacterial infections, is currently not indicated.

51. Antitussives: Not recommended.
Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Other Pharmacologic Treatments
Alpha-1 antitrypsin augmentation therapy: not recommended for patients with COPD that is unrelated to the genetic deficiency.
Mucolytics: Patients with viscous sputum may benefit from mucolytics; overall benefits are very small.
Antitussives: Not recommended.
Vasodilators: Nitric oxide is contraindicated in stable COPD. The use of endothelium-modulating agents for the treatment of pulmonary hypertension associated with COPD is not recommended.

52. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Rehabilitation
All COPD patients benefit from exercise training programs with improvements in exercise tolerance and symptoms of dyspnea and fatigue.
Although an effective pulmonary rehabilitation program is 6 weeks, the longer the program continues, the more effective the results.
If exercise training is maintained at home the patient's health status remains above pre- rehabilitation levels.

53. Ain Shams Univ. & Aeromedical Inst.
Cardio-pulmonary Exercise Test in Assessment of COPD Patients Undergoing Rehabilitation Programme
Ain Shams Univ. & Aeromedical Inst.
2001
Mohammed Ali , Mona Mansour , Tarek Safwat , Ayman Farghaly

54. (2) Group II Twenty-five patients
(1) Group I Twenty five patients
pulmonary rehabilitation and received anabolic steroid ( Nandrolone deconoate 50mg / three-weeks for twelve weeks)
(2) Group II Twenty-five patients
only pulmonary rehabilitation and no anabolic steroid.
(3) Group III Twenty five patients
considered as a control group,

55. Cardio-Pulmonary exercise test;-
 a) It was done for all COPD patients included in this study before and after the exercise training program.
b) There was no reported complications during and after testing.
c) The cardiopulmonary exercise system supplied by computer with color monitor, gas analyzer, keyboard, colored printer connected with treadmill and E.C.G monitor. It uses Bruce protocol with incremental increase in the work load every three minutes.

56. Exercise Training Program
After primary assessment measures, the selected COPD patients were enrolled into a program of exercise training that was planned according to exercise rehabilitation program done by Vogiatzis et al.,1999.
Taking the following into consideration:-
(1) Warm up and cool down
(2) Aerobic exercise (endurance) i.e. Not allow patient to be exhausted.
(3) Modality:- patients were submitted to lower limb exercise in the form of walking on flat, treadmill, cycling and upper limb exercise in the form of lifting objects, arm rotator and cycling.
(4) Frequency:- three Times weekly.

57. Comparison between the three groups as regards,
CPET Parameters
(1) Time of test stage ( in minutes):
Before program
Mean ± SD
After program Mean ± SD
Paired
t-test
P-value
Group I
1.37 ± 0.53
3.816± 1.355
8.327
0.000
Group II
1.27 ±
3.728 ±
7.33
Group III
1.424 ±
1.340 ± 0.660
0.725
0.476
ANOVA
0.470
24.816
0.627

58. Comparison between the three groups as regards,
(2) Work Load (in watt):
Before program Mean ± SD
After program Mean ± SD
Paired
t-test
P-value
Group I
61.84 ± ±
12.585
0.000
Group II
60.80 ± ±
6.48
Group III
59.0 ± 10.29
57.17 ± 12.66
1.52
0.142
ANOVA
0.043
34.411
0.958

59. Comparison between the three groups as regards,
(3) Maximum Oxygen Consumption (ml/minute) (VO2 max.):
Before program Mean ± SD
After program Mean ± SD
Paired
t-test
P-value
Group I
± 446.8
± 8.352
4.651
0.001
Group II ±
± 589.9
3.542
0.002
Group III ± ±
0.171
0.866
ANOVA
0.127
14.816
0.881
0.000

60. Comparison between the three groups as regards,
(4) Maximum Oxygen Consumption Percent of Predicted (VO2 max.%):
Before program Mean ± SD
After program Mean ± SD
Paired
t-test
P-value
Group I
65.76 ± 14.45
97.76 ± 33.05
4.351
0.000
Group II
66.80 ±
88.44 ±
6.098
Group III
66.36 ±
65.64 ±
1.717
0.099
ANOVA
2.827
8.246
0.66
0.001

61. Comparison between the three groups as regards,
(5) Normalized VO2 (VO2 per Kg body weight):
Before program Mean ± SD
After program Mean ± SD
Paired
t-test
P-value
Group I
± 5.517 ±
3.573
0.002
Group II ± ±
2.654
0.014
Group III
± 9.329 ±
1.717
0.099
ANOVA
0.791
9.426
0.457
0.000

62. Comparison between the three groups as regards,
(6) Oxygen Pulse at maximum exercise (VO2 /HR) in ml/beat:
Before program Mean ± SD
After program Mean ± SD
Paired
t-test
P-value
Group I
14.24 ± 3.929
20.64 ± 9.699
2.784
0.01
Group II
17.60 ± 8.426
20.28 ±
1.033
0.312
Group III
18.36 ± 9.429
17.24 ± 4.40
1.63
0.11
ANOVA
2.056
2.917
0.135
0.061

63. Comparison between the three groups as regards,
(9) Maximum Minute Ventilation (VE max in liters/min):
Before program Mean ± SD
After program Mean ± SD
Paired
t-test
P-value
Group I
57.32 ± 20.68
68.54 ± 21.25
2.844
0.009
Group II
± 17.6
71.09 ± 20.42
4.629
0.000
Group III
41.52 ± 23.21
44.54 ± 17.62
1.87
0.08
ANOVA
4.277
18.552
0.18

64. Comparison between the three groups as regards,
[2] FVC% (% of predicted):-
Before program Mean ± SD
After program Mean ± SD
Paired
t-test
P-value
Group I
54.52 ±
58.52 ±
2.316
0.029
Group II
57.8 ±
58.84 ± 9.800
0.869
0.393
Group III
53.81 ± 8.88
54.67 ±
0.841
0.352
ANOVA
1.736
1.379
0.184
0.259

65. Comparison between the three groups as regards,
[3] FEV1 (in Liters):-
Before program Mean ± SD
After program Mean ± SD
Paired
t-test
P-value
Group I
1.407 ± 0.346
1.623 ± 0.347
4.32
0.01
Group II
± 0.327
1.580 ±
3.962
0.04
Group III
1.364 ±
1.42 ± 0.391
1.998
0.067
ANOVA
0.295
2.205
0.746
0.118

66. Conclusion Pulmonary rehabilitation is a multidisciplinary
program that attempts to return the patient to the
highest possible functional capacity.
• Evidence supports the use of lower extremity exercise
training as it improves exercise tolerance.
• Upper extremity strength and endurance training
is recommended.
• Pulmonary rehabilitation improves dyspnoea,
improves quality-of-life scores, and reduces the
number of hospitalizations and days in the hospital;
the effects on survival are not definite.

67. Thank you