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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
Disease Trajectory of aPatients with COPD Symptoms Exacerbations Exacerbations Deterioration Exacerbations End of Life
“Despite this burden, COPD isa “Cindrella” conditions thatreceives limited recognitionfrom both patients andphysicians” Respiratory Medicine 2002; 96: S1-S31
Obstructive Airway Disease Asthma COPDExplosion in Little research research (? neglect)Revolution in Few advances in therapy therapy
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
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 α1 antitrypsin
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
Key Indicators for COPD DiagnosisChronic cough Present intermittently or every day often present throughout the day; seldom only nocturnalChronic sputum production Present for many years, worst in winters. Initially mucoid – becomes purulent with exacerbationDyspnoea that is Progressive (worsens over time) Persistent (present every day) Worse on exercise Worse during respiratory infectionsAcute bronchitis Repeated episodesHistory of exposure to risk Tobacco smoke (including beedi)factors occupational dusts and chemical smoke from home cooking and heating fuel
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
Algorithm for Diagnosis at Primary Care Pt reporting with respiratory symptoms Assess by - H/o exposure to risk factors - Physical examination Sputum for AFB +ve -ve Treat as TB Provisional Diagnosis of COPD Treat as COPD Poor response refer to secondary care National Guidelines for Management of COPD at Primary Care Level
Spirometry FEV1 – Forced expired volume in the first second FVC – Total volume of air that can be exhaled from maximal inhalation to maximal exhalation FEV1/FVC% - The ratio of FEV1 to FVC, expressed as a percentage.
COPD classification based on spirometry GOLD 2003Severity Postbronchodilator Postbronchodilator FEV1/FVC FEV1% predictedAt risk >0.7 >80Mild COPD <0.7 >80Moderate COPD <0.7 50-80Severe COPD <0.7 30-50Very severe <0.7 <30COPD SPIROMETRY is not to substitute for clinical judgment in the evaluation of the severity of disease in individual patients.
Management based on GOLD Post-bronchodilator FEV1(% predicted)
“Bronchodilator medications are central tothe symptomatic management of COPD” GOLD Report 2003
How Do Bronchodilators Work? Reverse the increased bronchomotor tone Relax the smooth muscle Reduce the hyperinflation Improve breathlessness
“All guidelines recommend inhaledbronchodilator as first line therapy.The ATS suggest initial therapy withan anticholinergic drug if regulartherapy is needed” Chest 2000; 117: 23S-28S
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)
Mode of Action (Contd.) Airways are narrowed in COPD therefore vagal cholinergic tone has greater effect on airway resistance (Resistance α1/radius4) Therefore, the need for anticholinergic drugs that will act as muscarinic receptor antagonist and block the acetylcholine induced bronchoconstriction
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 PaO2 Drugs of Today 2002; 38(9): 585-600
“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
Algorithm for the management of COPD Mild Short acting bronchodilator – as requiredassess with symptoms and spirometry Tiotropium Long acting beta agonist Tiotropium+LABA LABA + tiotropium Add -Inhaled steroids Severe -Theophylline