2. Chronic Obstructive Pulmonary Disease Dr. Pawan K. Mangla, M.D., INTENSIVIST & PULMONOLOGIST ISIC & PSRI HOSPITAL Brought to you by IJCP Group of Publications and eMedinewS ( a Daily Medical News Paper)

3. 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

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

5. “Despite this burden, COPD is a “Cindrella” conditions that receives limited recognition from both patients and physicians” Respiratory Medicine 2002; 96: S 1 -S 31

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

7. 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

8. 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  1 antitrypsin

9. 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

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

11. 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

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

13. Spirometry Diagnosis Assessing severity Assessing prognosis Monitoring progression

14. Spirometry FEV 1 – Forced expired volume in the first second FVC – Total volume of air that can be exhaled from maximal inhalation to maximal exhalation FEV 1 /FVC% - The ratio of FEV 1 to FVC, expressed as a percentage.

15. COPD classification based on spirometry GOLD 2003 SPIROMETRY is not to substitute for clinical judgment in the evaluation of the severity of disease in individual patients. Severity Postbronchodilator FEV 1 /FVC Postbronchodilator FEV 1 % predicted At risk>0.7>80 Mild COPD<0.7>80 Moderate COPD<0.750-80 Severe COPD<0.730-50 Very severe COPD <0.7<30

16. Stage 0: At Risk GOLD Guidelines for COPD Diagnosis Chronic cough/sputum PFTs within normal limits No symptoms Treatment Avoid risk factors (smoking cessation)

17. GOLD Guidelines for COPD Stage I: Mild Diagnosis FEV 1 >80% predicted FEV 1 /FVC <70% With/without symptoms Treatment Avoid risk factors Short-acting bronchodilator PRN

18. Stage II: Moderate GOLD Guidelines for COPD Diagnosis  50%  FEV 1 <80% predicted FEV 1 /FVC <70% With/without symptoms Treatment Avoid risk factors Regular therapy with  1 bronchodilators Inhaled corticosteroids if significant symptoms and lung function response Rehabilitation

19. Stage III:Severe GOLD Guidelines for COPD Diagnosis 30%  FEV 1 < 50% predicted FEV 1 /FVC < 70% With/without symptoms Treatment Avoid risk factors Regular therapy with  1 bronchodilators Rehabilitation Inhaled corticosteroids if significant symptoms and lung function response or if repeated exacerbations

20. Pharmacotherapy for Stable COPD Bronchodilators Short-acting  2 - agonist – Salbutamol Long-acting  2 - agonist - Salmeterol and Formoterol Anticholinergics – Ipratropium, Tiiotropium Methylxanthines - Theophylline Steroids Oral – Prednisolone Inhaled - Fluticasone, Budesonide

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

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

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

24. “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

25. 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)

26. Mode of Action (Contd.) Airways are narrowed in COPD therefore vagal cholinergic tone has greater effect on airway resistance (Resistance  1/radius 4 ) Therefore, the need for anticholinergic drugs that will act as muscarinic receptor antagonist and block the acetylcholine induced bronchoconstriction

27. 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 PaO 2 Drugs of Today 2002; 38(9): 585-600

28. “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

29. Leading Causes of Death, US (1998) Causes of Death 1.Heart disease 2.Cancer 3.Cerebrovascular disease (stroke) 4.COPD and allied conditions 5.Accidents 6.Pneumonia and influenza 7.Diabetes 8.Suicide 9.Nephritis 10.Chronic liver disease All other causes of death Number 724,269 538,947 158,060 114,381 94,828 93,307 64,574 29,264 26,295 24,936 469,314 Global Obstructive Lung Disease (GOLD) Initiative website (www.goldcopd.com), accessed April 2, 2001.

30. 0.0 0.5 1.0 1.5 2.0 2.5 3.0 Coronary Heart Disease Stroke Other CVD COPD All Other Causes - 59% - 64% - 35%+ 163%- 7% 1965–1998 Percent Increases in Adjusted Death Rates, US, 1965 – 1998 Proportion of 1965 Rate Global Obstructive Lung Disease (GOLD) Initiative website (www.goldcopd.com), accessed April 2, 2001.

31. COPD: Risk Factors Exposures Smoking (generally ≥90%) Passive smoking Ambient air pollution Occupational dust/chemicals Childhood infections (severe respiratory, viral) Socioeconomic status Host factors Alpha1-antitrypsin deficiency (<1%) Hyperresponsive airways Lung growth

32. Differential Diagnosis Chronic Bronchitis Emphysema Asthma COPD Airflow Obstruction

33. Thanks