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

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 .

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

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

What can cause COPD? Smoking is the primary risk factor Long-term smoking is responsible for 80-90 % 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

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

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

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.

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

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

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

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

COPD Mortality Worldwide 1990 2020 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

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.

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.

Barrel shaped Chest Emphysematous Chest

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

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

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.

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)

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

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

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

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

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

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

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.

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.

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

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

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