Download Management of COPD

Chronic Obstructive Pulmonary
Disease (COPD)
Omer Alamoudi, MD, FRCP,FCCP,FACP
Professor, consultant Pulmonologist
dramoudi@yahoo.com
Definition of COPD
COPD is a chronic obstructive pulmonary
disease that is characterized by airflow
limitation that is not fully reversible.
The airflow limitation is usually both
progressive and associated with an abnormal
inflammatory response
 COPD is a preventable and treatable disease
Chronic Obstructive Pulmonary disease
(COPD)
 Chronic bronchitis
 Emphysema
COPD
 Definitions
Chronic bronchitis: Cough and sputum
production for at least 3 months in each of
two consecutive years in albescence of other
endobronchial disease such as bronchiectasis
Emphysema: overinflation of the distal
airspaces with destruction of alveolar septa
Prevalence of COPD worldwide and in KSA
Prevalence/Risk Factors
Cigarette Smoking
 Cigarette smoking is the primary cause of
COPD.
 Approximately 90% of COPD patients have a
smoking history
 The WHO estimates 1.1 billion smokers
worldwide, increasing to 1.6 billion by 2025.
 In low- and middle-income countries, rates are
• increasing
.
at an alarming rate
Smoking Prevalence Among Doctors
Country
Male%
Female%
UK
8
5
USA
9
7
Germany
9
6
Korea
46
28
China
42
35
S. Arabia
38
15
Global Burden of Disease (1990–2020)
2020
1990
Lower respiratory tract
infections
1
Diarrhoeal diseases
2
Conditions during perinatal
period
3
Unipolar major depression
4
Ischaemic heart disease
5
Cerebrovascular disease
6
Tuberculosis
7
Measles
8
Road traffic accidents
1
Ischaemic heart disease
2
Unipolar major depression
3
Road traffic accidents
4
Cerebrovascular disease
5
COPD
6
Lower respiratory tract infections
7
Tuberculosis
8
War
9
9
Diarrhoeal diseases
Congenital anomalies
10
10
HIV
Malaria
11
11
Conditions during perinatal period
COPD
12
12
Violence
COPD Prevalence in KSA
COPD Prevalence in KSA (Contd.)
 According to one report released by the executive
office of the GCC Health Ministers Council, Saudi
Arabia is the world’s fourth largest importer of
cigarettes.
 During the year of 2004, the kingdom imported
41,000 tons of tobacco at a value of SR 1.45 billion.
Table 3. Ranking of the 10 most frequent diagnoses
among hospitalized patients at KAUH
Diagnosis
Diabetes mellitus
Ischemic heart diseases
Bronchial asthma
Chronic liver disease
Congestive heart failure
Hypertension
Sickle cell anemia
COPD
Chronic renal failure
Cerebrovascular accident
No
%
570
493
311
293
203
153
141
132
116
108
10.5
8.6
5.8
5.4
3.8
2.8
2.6
2.4
2.1
2.0
Risk Factors
Risk Factors for COPD
Host Factors
Genes (e.g. alpha1-antitrypsin deficiency)
Hyperresponsiveness
Exposure
Tobacco smoke
Occupational dusts and chemicals
Infections
Socioeconomic status
Risk Factors for COPD
Nutrition
Infections
Socio-economic
status
Aging Populations
15
Pathogenesis of COPD
Pathogenesis of COPD
NOXIOUS AGENT
(tobacco smoke, pollutants, occupational
agent)
Genetic factors
Respiratory
infection
Other
COPD
Source: Peter J. Barnes, MD
Pathogenesis of
COPD
Cigarette smoke
Biomass particles
Particulates
Host factors
Amplifying mechanisms
LUNG INFLAMMATION
Anti-oxidants
Oxidative
stress
Anti-proteinases
Proteinases
COPD PATHOLOGY
Repair
mechanisms
Causes of Airflow Limitation
 Irreversible
Fibrosis and narrowing of the airways
Loss of elastic recoil due to alveolar destruction
Destruction of alveolar support that maintains
patency of small airways
Airway Pathology in COPD
Airway pathology in COPD
Airway pathology in COPD
Diagnosis of COPD
Diagnosis of COPD
 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.
 The diagnosis should be confirmed by spirometry.
A post-bronchodilator FEV1/FVC < 0.70 confirms
the presence of airflow limitation that is not fully
reversible.
 Comorbidities are common in COPD and should be
actively identified.
25
Diagnosis of COPD
SYMPTOMS
cough
sputum
shortness of breath
EXPOSURE TO RISK
FACTORS
tobacco
occupation
indoor/outdoor pollution

SPIROMETRY
Diagnosis of COPD
 Signs
 Hands
Flapping tremor, dilated veins, collapsing pulse,
warm hands (CO2 retention)
Cyanosis, clubbing of the finger (ca lung)
 Chest (signs of hyperinflation)
Barrel chest, use of accessory ms, decreased
expansion, absence cardiac dullness, tracheal tug
Hyperesonant on percussion
Diagnosis of COPD
 Sign of pulmonary HTN
Increased JVP, left parasternal heave, Loud P2,
Hepatomegaly, Ascitis, lower limb edema
 Fundus examination
Papilloedema
 Extrapulmonary manifestation
Ms wasting
Signs of COPD
Diagnosis of COPD: Spirometry
 Spirometry should be performed after the
administration of an adequate dose of a shortacting inhaled bronchodilator to minimize
variability.
 A post-bronchodilator FEV1/FVC < 0.70 confirms
the presence of airflow limitation that is not fully
reversible.
32
Diagnosis of COPD / Spirometry
Spirometry: Normal and Patients
with COPD
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
The Effect of Smoking on Lung Function
FEV1 (% of value at age 25 y)
Never smoked or not
susceptible to smoking
100
75
Smoked regularly and
susceptible to its effects
50
Stopped at 45
DISABILITY
Stopped at 65
25
DEATH
0
25
50
Age (y)
Adapted from Fletcher & Peto 1977
75
Diagnosis of COPD/ chest X-ray
Diagnosis of COPD/ HRCT scan
Diagnosis of COPD
 CBC
 ESR
WBC (increased with infection)
Hb (secondary Polycthemia)
Increased with
infection
malignancy
Diagnosis of AECOPD
Diagnosis of AECOPD
 Diagnosis of AECOPD was based on ATS
criteria
Major
Increased dyspnea
Increased sputum production
Purulent sputum
Minor
Cough, wheeze, sore throat, and cold
and nasal discharge
Diagnosis of AECOPD/sputum culture
 Pathogens isolated during exacerbation
 Bacterial
Moraxella catarrhalis
Pseudomonas
Haemophilus influenzae
 Viral
Influenza
 Atypical bacteria
Mycoplasma
Chlamydia
Differential Diagnosis
COPD VS Asthma
Differential Diagnosis:
COPD and Asthma
COPD
• Onset in mid-life
•
Symptoms slowly
progressive
ASTHMA
• Onset early in life (often
childhood)
• Symptoms vary from day to day
•
• Long smoking history
• Dyspnea during exercise •
• Largely irreversible airflow
•
limitation
•
Symptoms at night/early morning
Allergy, rhinitis, and/or eczema
also present
Family history of asthma
Largely reversible airflow
limitation
COPD and Co-Morbidities
COPD patients are at increased risk for:
• Myocardial infarction, angina
• Osteoporosis
• Respiratory infection
• Depression
• Diabetes
• Lung cancer
Pulmonary Hypertension in COPD
Chronic hypoxia
Pulmonary vasoconstriction
Muscularization
Pulmonary hypertension
Cor pulmonale
Intimal
hyperplasia
Fibrosis
Obliteration
Edema
Death
Source: Peter J. Barnes, MD
Management of COPD and Exacerbation
Management of COPD
Prevention
 Smoking cessation: is the single most effective — and
cost effective — intervention in most people to reduce
the risk of developing COPD and stop its progression
 Controlling pollution: 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.
50
Management of COPD
Smoking cessation
 Counseling delivered by physicians
 Numerous effective pharmacotherapies for smoking
cessation are available



Nicotine chewing gum, transcutaneous patches,
nicotine inhalers or nasal spray
Buproprion (aminoketone) (reduce nicotine
withdrawal symptoms)
 Epilepsy, tremor, insomnia, tachycardia
51
Nortiptyline
Management of COPD
Bronchodilators
Anticholinergics
 Ibratropium bromide (short acting)
 Improve nocturnal O2 saturation
 Improve quality of sleep
 Doses: 40 ug 1 -2 puffs q6h
Mainly used during exacerbation and symptomatic
patients
52
Management of COPD
Bronchodilators
Tiotropium bromide (long acting anticholinergic)
 Once daily
 No systemic cholinergic effect
M3 receptors antagonist
Dose: 18 ug/day
 Used in combination with LAB ± ICS or alone in
stable COPD
 Decrease symptoms, improve exercise tolerance
Decrease exacerbation
53
Management of COPD
Bronchodilators
 ß2 -agonists (Salbutamol, Terbutaline)
Rapid relief of symptoms
Dose: 120 ug, 2 puffs q4 - 6h
Tachycardia, tremors
 Methylxanthines (Theophylline)
 week bronchodilator effect
Monitor serum level (55 -110 umol/l)
Hepatic disease, heart failure, drugs; erythromycin,
54
ciprofloxacin increase serum level
Management of COPD
Long Acting Bronchodilators (LAB)


LAB is more effective and convenient than treatment
with short-acting bronchodilators
 Salmeterol (50 ug)
 Formoterol (9 ug)
Doses: q12h
It should be added with Ibratropium or tiotropium if
further improvement in symptoms is required
55
Management of COPD
Glucocorticosteroids

Long term use of ICS treatment is appropriate for:
● symptomatic COPD patients with an FEV1 < 50%
predicted (stage 111,1V)
● repeated exacerbations
● Allergy


Budesonide 800 ucg BD
Fluticasone 500 ucg BD

Chronic treatment with oral corticosteroids should be
avoided because of an unfavorable benefit-to-risk ratio
56
Management of COPD
Other Pharmacologic Treatments
Antibiotics: Only used to treat infectious exacerbations of
COPD

Respiratory stimulants (improve ABG)
Doxapram
Almitrine

Mucolytic agents, Antitussives: Not recommended in
stable COPD
57
Management of COPD
Pharmacotherapy: Vaccines

Influenza vaccines can reduce serious illness and should
be given yearly

Pneumococal polysaccharide vaccine may be given
although there is no conclusive evidence to support is it
use in COPD
58
Management of COPD
Non-Pharmacologic Treatments

Rehabilitation: All COPD patients benefit from exercise
training programs, improving with respect to both
exercise tolerance and symptoms of dyspnea and fatigue

Oxygen Therapy: LTOT (> 15 hours per day) to patients
with chronic respiratory failure has been shown to
increase survival
PO2: 55 mmHg or less
PO2: 59 mmHg + Polycythemia, Corpulmonale
59
Management of COPD
Surgical management
 Bullectomy
 Resection bulla allow expansion of the surrounding lung
tissue
 Lung Volume Reduction Surgery
 FEV1 < 35%
 Lung transplant
 Age <65
 FEV<35%
 Pao2<55mmHg, PaCO2 >55mmHg
 Secondary pulmonary HTN, absence of IHD
Management COPD Exacerbations

Antibiotics
 2nd generation cephalosporin
 Amoxicillin / clavulinate
 Quinolones

Inhaled bronchodilators, combination of
 Ibratropium
 B2 agonist
61
Management COPD Exacerbations
 Corticosteroid
 IV methyl prednisone
 Oral prednisone
Should be used in moderate to severe COPD
 Hydration
 Chest physiotherapy
62
Management COPD Exacerbations

Noninvasive mechanical ventilation
Decreases the need for endotracheal intubation

Mechanical ventilation
Deterioration of level of consciousness
PaO2 40 mmHg, pH < 7.25

Medications and education to help prevent future
exacerbations should be considered as part of follow-up