1. Chronic obstructive pulmonary disease (COPD) Professor Bill MacNee
Chronic obstructive pulmonary disease (COPD) describes a spectrum of respiratory conditions, all of which are associated with airflow obstruction.
Since the British Thoracic Society published its Guidelines for the management of COPD,1 in 1997, there has been a considerable increase in interest in the diagnosis and management of this condition. The guidelines were based on current published evidence and reflected the views of various individuals and organisations, including respiratory and public health physicians, GPs, nurses, geriatricians and members of the British Lung Foundation (BLF).
The next anticipated guidelines on COPD are the Global Obstructive Lung Disease (GOLD) guidelines.
Reference:
1. British Thoracic Society. BTS Guidelines for the management of chronic obstructive pulmonary disease. Thorax 1997; 52 (suppl 5): S1–S28.

2. 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.
© 2014 Global Initiative for Chronic Obstructive Lung Disease

3. Chronic Bronchitis Bronchiolitis Small airways disease Emphysema
Normal
COPD
COUGH and SPUTUM
Bronchiolitis
Small airways disease
AIRWAYS
OBSTRUCTION
BREATHLESSNESS
Emphysema

4. COPD:Quality Issues Diagnosis and assessment Therapy
Reduction exacerbations

5. indoor/outdoor pollution
Diagnosis of COPD
The diagnosis requires spirometry;
a post-bronchodilator FEV1/(FVC) <0.7 confirms the presence of airflow limitation that is not fully reversible.
Fixed ratio FEV1/FVC <0.7 may over diagnose COPD in elderly
EXPOSURE TO RISK
FACTORS
SYMPTOMS
cough
tobacco
sputum
occupation
shortness of breath
indoor/outdoor pollution è è è
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.
SPIROMETRY

6. Assessment of COPD Assess symptoms
Assess degree of airflow limitation using spirometry
Assess risk of exacerbations
Assess comorbidities

7. Medical Research Council (MRC) Breathlessness Scale
Grade 1 2 3 4 5
Degree of breathless-ness related to activities
Not troubled by breathlessness except on strenuous exercise.
Short of breath when hurrying or walking up a slight hill.
Walks slower than contemporaries on level ground because of breathlessness or has to stop for breath when walking at own pace.
Stops for breath after walking about 100m or after a few minutes on level ground.
Too breathless to leave the house, or breathless when dressing or undressing.

8. COPD Assessment Test (CAT)
Patients read the two statements for each item, and decide where on the scale they fit
Scores for each of the 8 items are summed to give single, final score (minimum 0, maximum 40)
This is a measure of the overall impact of a patient’s condition on their life
The CAT was developed using the accepted methods for the development of psychometric assessment instruments. The CAT contains 8 items, covering:
Cough
Phlegm 
Chest tightness 
Breathlessness going up hills/stairs 
Activity limitation at home 
Confidence leaving the home 
Sleep and energy
Patients read the two statements for each item, which describe the best and worst scenario, and decide where on the scale (0-5) they fit. Scores for each of the 8 items are summed to give single, final score (minimum 0, maximum 40) – this is a measure of the overall impact of a patient’s condition on their life. Also, scores for the individual items within the questionnaire will provide insight into the relative influence that the different components of COPD have on its overall impact on a patient’s life – thus, they will highlight problematic areas, which can be explored further during consultation and ultimately addressed through intervention.
Expert guidance on interpretation2:
Minimal relevant clinical change: Research is currently ongoing to define ranges of CAT score severity and to better understand the minimal clinically relevant change (often referred to as the Minimum Clinically Important Difference or MCID) in a CAT score from one visit to the next. However, based on the strong correlation of the CAT with the SGRQ, we currently believe that a difference or change of 2 or more units suggests a clinically significant difference or change in health status. We emphasise that this needs to be confirmed by further scientific studies, but the expert steering committee are confident that it is a reasonable indicative value of the MCID based upon current knowledge.
Difference between stable and exacerbating states: We already know that CAT scores in patients with moderate-severe exacerbations are approximately 5 units higher than in those who are not exacerbating.1 Based on what we know from other studies, this is likely to be the size of change in CAT score when a patient gets an exacerbation. Research studies have shown that it may take many weeks for patients to recover fully from a single moderate-severe exacerbation and some patients may never recover fully. Therefore another potential application of the CAT may be to assess the degree of recovery following an acute exacerbation by re-assessing the CAT score 2-3 months after the event
References
1 Jones P et al. Eur Respir J 2009; 34:
2 COPD Assessment Test Healthcare Professional User Guide: Expert Guidance on frequently asked questions. Jones PW, Jenkins C, Bauerle, O (on behalf of the CAT Development Steering Group). Issue 1: September 2009
1 Jones P et al. Eur Respir J 2009; 34:

9. In patients with FEV1/FVC < 0.70:
Severity of Airflow Limitation
Severity of COPD
In patients with FEV1/FVC < 0.70:
Mild FEV1 > 80% predicted
Moderate % < FEV1 < 80% predicted
Severe % < FEV1 < 50% predicted
Very Severe FEV1 < 30% predicted
*Based on Post-Bronchodilator FEV1

10. Assess Risk of Exacerbations
To assess risk of exacerbations use history of exacerbations and spirometry:
Two or more exacerbations within the last year or an FEV1 < 50 % of predicted value are indicators of high risk.
One or more hospitalizations for COPD exacerbation should be considered high risk.
© 2014 Global Initiative for Chronic Obstructive Lung Disease

11. Assess COPD Comorbidities
COPD patients are at increased risk for:
Cardiovascular diseases
Osteoporosis
Respiratory infections
Anxiety and Depression
Diabetes
Lung cancer
Bronchiectasis
These comorbid conditions may influence mortality and hospitalizations and should be looked for routinely, and treated appropriately.
© 2014 Global Initiative for Chronic Obstructive Lung Disease

12. Manage Stable COPD: Goals of Therapy
Relieve symptoms
Improve exercise tolerance
Improve health status
Prevent disease progression
Prevent and treat exacerbations
Reduce mortality
Reduce
symptoms
risk
© 2014 Global Initiative for Chronic Obstructive Lung Disease

13. © 2014 Global Initiative for Chronic Obstructive Lung Disease
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
Combination long-acting beta2-agonists + anticholinergic in one inhaler
Methylxanthines
Inhaled corticosteroids
Combination long-acting beta2-agonists + corticosteroids in one inhaler
Systemic corticosteroids
Phosphodiesterase-4 inhibitors
© 2014 Global Initiative for Chronic Obstructive Lung Disease

14. 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.

15. 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.
Inhaled corticosteroids are associated with an increased risk of pneumonia.
Addition of a long-acting beta2-agonist/inhaled glucorticosteroid combination to an anticholinergic (tiotropium) provides additional benefits.

16. Therapeutic Options: Systemic corticosteroids
Chronic treatment with systemic corticosteroids should be avoided because of an unfavorable benefit-to-risk ratio.

17. Therapeutic Options: Theophylline
Theophylline is less effective and less well tolerated than inhaled long-acting bronchodilators.
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.

18. 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.

19. NICE 2010-Inhaled therapies in COPD
Breathlessness and exercise limitation
SABA or SAMA as required*
FEV1 < 50%
Exacerbations or persistent breathlessness
FEV1 ≥ 50%
LABA
LAMA
Discontinue SAMA
________
Offer LAMA in preference to regular SAMA four times a day
LABA + ICS in a combination inhaler
________
Consider LABA + LAMA if ICS declined or not tolerated
LAMA
Discontinue SAMA
________
Offer LAMA in preference to regular SAMA four times a day
Persistent exacerbations or breathlessness
LABA + ICS in a combination inhaler
________
Consider LABA + LAMA if ICS declined or not tolerated
NOTES FOR PRESENTERS:
This slide shows the treatment algorithm included within the full guideline (Algorithm 2a) and is reproduced on page 9 of your QRG.
On pages 12 and 13 of your QRG you will also find a useful table which summarises the recommendations for managing symptoms and conditions in stable COPD.
LAMA + LABA + ICS
in a combination inhaler
* SABAs (as required) may continue at all stages
Offer
Consider

20. (C) (D) (A) (B) Combined Assessment of COPD ICS + LABA ICS + LABA or
Recommended First Choice
(GOLD classification of airflow limitation)
Risk
(Exacerbation / year)
Risk 4
≥ 2 or
> 1 leading
to hospital
admission
1 (not leading
to hospital
admission)
ICS + LABA or
LAMA
ICS + LABA
and/or
LAMA
(C)
(D) 3 2
SAMA prn or
SABA prn
LABA or
LAMA
(A)
(B) 1
2 CAT < 10
2 CAT  10
Symptoms
Breathlessness
mMRC 0 - 1
mMRC  2
© 2014 Global Initiative for Chronic Obstructive Lung Disease

21. Inhalers Nebulisers Be sure to: teach the technique and recheck
be familiar with different types of inhalers
change inhalers if a patient is having trouble coping with a certain type
encourage the use of spacer devices when needed.
The correct delivery system is as important as the drug used.
Nebulisers
nebuliser assessments trials should be done by secondary care respiratory physicians (this gives an added benefit to the patient of having the nebuliser maintained)
consider a nebuliser if the patient has excessive or distressing shortness of breath despite maximum therapy.
nebulised therapy should not continue to be prescribed without confirming improvement in one or more of the following:
• a reduction in symptoms and/or
• an increase in activities of daily living or exercise capacity.

22. Pulmonary rehabilitation: improves exercise tolerance
Pulmonary rehabilitation benefits all patients with COPD, particularly those with severe to very severe COPD or an MRC breathlessness score of 3 or more.
All patients with repeated exacerbations or who are admitted to hospital with an exacerbation should be fast tracked for pulmonary rehabilitation.
Pulmonary rehabilitation:
improves exercise tolerance
improves the quality of life
reduces symptoms
reduces the number of exacerbations
reduces hospital admissions
available in all CHPs (In Edinburgh, CHP home-based rehabilitation is available).

23. Oxygen therapy SBOT - short-burst oxygen therapy
There is no good evidence to support the use of short burst oxygen therapy.
LTOT - Long-term oxygen therapy
LTOT can prolong life. It is indicated in patients with hypoxaemia (PaO2 < 7.3 kPa) when in a stable condition. Secondary care assessment is required for the provision of long-term oxygen therapy.
Consider long-term oxygen therapy in patients with:
severe airflow obstruction (FEV1 < 40% predicted)
cyanosis
polycythemia
raised JVP or peripheral oedema
pulmonary hypertension
O2 saturation of < 92% while breathing air.
Patients who continue to smoke will rarely be considered for long-term
oxygen therapy.
Consider ambulatory oxygen therapy in mobile patients on long-term

24. Consequences of COPD Exacerbations
Negative
impact on
quality of life
Impact on
symptoms
and lung
function
EXACERBATIONS
Accelerated
lung function
decline
Increased
economic
costs
Increased
Mortality
© 2013 Global Initiative for Chronic Obstructive Lung Disease

25. Manage Exacerbations: Key Points
Short-acting inhaled beta2-agonists with or without short-acting anticholinergics are usually the preferred bronchodilators for treatment of an exacerbation.
Systemic corticosteroids and antibiotics can shorten recovery time, improve lung function (FEV1) and arterial hypoxemia (PaO2), and reduce the risk of early relapse, treatment failure, and length of hospital stay.
A dose of 40 mg prednisone per day for 5 days is recommended .
© 2014 Global Initiative for Chronic Obstructive Lung Disease

26. Manage Exacerbations: Treatment Options
Antibiotics should be given to patients with:
Three cardinal symptoms: increased dyspnea, increased sputum volume, and increased sputum purulence.
Two cardinal symptoms if one of which is increased sputum purulence. ventilation.
© 2014 Global Initiative for Chronic Obstructive Lung Disease

28. respiratory physician
CRT
SAS
LUCS/GP
respiratory physician
front door
RNS
smoking cessation
IMPACT
pulmonary rehab

29. Referral for Specialist Opinion
Consider referral if:
diagnosis is unclear
patient has severe COPD (FEV1 < 30% of predicted)
cor pulmonale (fluid retention or peripheral oedema)
increasing shortness of breath
rapidly decreasing FEV1
for assessment for O2 therapy if oxygen saturation (92% or less) while breathing air
chest x-ray shows bullae in the lung
patient is less than 40years old
symptoms are disproportionate to pulmonary function
patient has frequent infections/exacerbations
for assessment for nebuliser.