1. Habib GHEDIRA, MD, Prof. Medical Faculty of Tunis
COPD Consensus GOLD Global Initiative for chronic Obstructive Lung Disease
Habib GHEDIRA, MD, Prof.
Medical Faculty of Tunis

2. Percent Change in Age-Adjusted Death Rates, U.S., 1965-1998
Proportion of 1965 Rate
3.0
Coronary
Heart
Disease
Stroke
Other CVD
COPD
All Other
Causes
2.5
2.0
1.5
1.0
0.5
–59%
–64%
–35%
+163%
–7%
Source: NHLBI/NIH/DHHS

3. Definition of COPD
COPD is a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients.
Its pulmonary component is characterized by airflow limitation that is not fully reversible.
The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases.

4. Risk Factors for COPD Lung growth and development Oxidative stress
Genes
Exposure to particles
Tobacco smoke
Occupational dusts, organic and inorganic
Indoor air pollution from heating and cooking with biomass in poorly ventilated dwellings
Outdoor air pollution
Lung growth and development
Oxidative stress
Gender
Age
Respiratory infections
Socioeconomic status
Nutrition
Comorbidities

5. COPD ASTHMA COPD : Pathology Airflow Limitation Small airway narrowing
Alv macrophage
Ep cells
CD8+ cell
(Tc1)
Neutrophil
Cigarette smoke
Small airway narrowing
Alveolar destruction
COPD
ASTHMA
Allergens Y
Ep cells
Mast cell
CD4+ cell
(Th2)
Eosinophil
Bronchoconstriction
AHR
Airflow Limitation
Reversible
Irreversible
Source: Peter J. Barnes, MD

6. Squamous metaplasia of epithelium No basement membrane thickening
Changes in Large Airways of COPD Patients
Mucus hypersecretion
Neutrophils in sputum
Squamous metaplasia of epithelium
No basement membrane thickening
Goblet cell
hyperplasia
↑ Macrophages
↑ CD8+ lymphocytes
Changes in large airways of COPD patients. The epithelium often shows squamous metaplasia and there is goblet cell and submucosal gland hyperplasia, resulting in mucus hypersecretion. The airway wall is infiltrated with macrophages and CD8+ lymphocytes, whereas neutrophils predominate in the airway lumen and around submucosal glands. Airway smooth muscle and basement membrane are minimally increased compared to the findings in asthma.
Mucus gland hyperplasia
Little increase in
airway smooth muscle
Source: Peter J. Barnes, MD 6

7. Changes in Small Airways in COPD Patients
Inflammatory exudate in lumen
Disrupted alveolar attachments
Changes in small airways in COPD patients. The airway wall is thickened and infiltrated with inflammatory cells, predominately macrophages and CD8+ lymphocytes, with increased numbers of fibroblasts. In severe COPD there are also lymphoid follicles. The lumen is often filled with an inflammatory exudate and mucus. There is peribronchial fibrosis and airway smooth muscle may be increased, resulting in narrowing of the airway.
Thickened wall with inflammatory cells
- macrophages, CD8+ cells, fibroblasts
Peribronchial fibrosis
Lymphoid follicle
Source: Peter J. Barnes, MD 7

8. Alveolar wall destruction
Changes in the Lung Parenchyma in COPD Patients
Alveolar wall destruction
Loss of elasticity
Changes in the lung parenchyma in COPD patients. There is loss of elasticity and alveolar wall destruction, and accumulation of inflammatory cells, predominantly macrophages and CD8+ lymphocytes. The destructive changes reduce the pulmonary capillary bed. The left panel shows a scanning electron micrograph of a patient with emphysema demonstrating the enlargement of alveoli and destruction of the alveolar walls.
Destruction of pulmonary
capillary bed
↑ Inflammatory cells
macrophages, CD8+ lymphocytes
Source: Peter J. Barnes, MD 8

9. indoor/outdoor pollution
Diagnosis of COPD
EXPOSURE TO RISK
FACTORS
SYMPTOMS
cough
tobacco
sputum
occupation
shortness of breath
indoor/outdoor pollution è è è
SPIROMETRY

10. Spirometry: Normal and Patients with COPD

11. 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

12. Therapy at Each Stage of COPD
I: Mild
II: Moderate
III: Severe
IV: Very Severe
FEV1
80%
50%
30%
Add long term oxygen if chronic respiratory failure. Consider surgery
Add inhaled glucocorticosteroids if repeated exacerbations
Add regular treatment with one or more long-acting bronchodilators* (when needed);
Add rehabilitation
* ß2- agonists, anticholinergics and methylxanthines
Active reduction of risk factor(s); influenza vaccination
Add short-acting bronchodilator (when needed)

13. Questions ? ~ Réponses !