Obstructive Lung Diseases
A group of diseases characterized by reduction of expiratory flow rates:
• Bronchial Asthma: a chronic inflammatory disorder of the
airways characterized by bronchial hyper-responsiveness to a variety
of stimuli which lead to episodes of wide spread bronchial narrowing
which is largely reversible either spontaneously or with treatment.
• Chronic Bronchitis: chronic cough with expectoration for at least 6
months in a year or 3 months/Y for 2 successive years, not due to lung disease
• Emphysema: persistent abnormal dilatation of the air spaces
distal to the terminal bronchioles , accompanied by destruction of the
elastic tissues of the lungs.
• Cystic Fibrosis.
Pulmonary Disease (COPD)
* Encompasses chronic bronchitis, emphysema
and mixed cases.
* Preventable and treatable disease with some
significant extrapulmonary effects that may
contribute to the severity in individual patients.
* Pulmonary component characterized by
airflow limitation that is not fully reversible.
* Airflow limitation progressive and associated
with abnormal inflammatory response of the
lung to noxious particles or gases.
GLOBAL INITIATIVE FOR
CHRONIC OBSTRUCTIVE LUNG
Burden of COPD
A leading cause of morbidity and mortality
Burden expected to increase due to
continued exposure to risk factors and the
aging of the world’s population.
associated with significant economic
Severity of Airflow Limitation in COPD
In patients with FEV1/FVC < 0.7:
Two exacerbations or more within the last year
or an FEV1 < 50 % of predicted value
are indicators of high risk
Mild COPD ≥80
Moderate COPD 50–80
Severe COPD 30–50
Very severe COPD <30
Or chronic respiratory failure
FEV1 % Predicted:
Pulmonary Functions in COPD
–Decreased FEV1, FEV1/FVC, FEF25-75%
–Increased Total Lung Capacity
–Increased Residual Volume
DLCO—decreased in emphysema due
to lung destruction
Chest X-ray: Seldom diagnostic but valuable to exclude
alternative diagnoses and establish presence of
Diffusing Capacity: to characterize severity.
Oximetry and Arterial Blood Gases:
in advanced cases.
Alpha-1 Antitrypsin Level: required when:
• COPD develops under 45.
• COPD develops in non- smoker.
• Strong family history of COPD.
N: > 150 mg/dL . In disease: < 45 mg/dL
IV: Very SevereIII: SevereII: ModerateI: Mild
Therapy at Each Stage of COPDTherapy at Each Stage of COPD
* Regular treatment with long-acting bronchodilators
* Inhaled glucocorticosteroids if repeated
Active reduction of risk factor(s); influenza vaccination
short-acting bronchodilator (when needed)
* Long term oxygen if
* Surgical treatments
Reduction of exposures in the workplace.
Reduce indoor air pollution eg, from heating in poorly
Smoking cessation has the greatest capacity to improve
the natural history of COPD.
Bronchodilators are central to the symptomatic
management of COPD.
Inhaled bronchodilators are preferred over oral
Bronchodilators are prescribed on an as-needed or on a
regular basis to prevent or reduce symptoms.
The principal bronchodilator treatments are beta2-
agonists, anticholinergics, theophylline or combination
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 side effects compared to increasing the
dose of a single bronchodilator.
Long-term treatment with inhaled corticosteroids added to
long-acting bronchodilators is recommended for patients
with high risk of exacerbations.
Regular treatment with inhaled corticosteroids (ICS)
improves symptoms, lung function and quality of life
and reduces frequency of exacerbations for COPD
patients with an FEV1 < 60% predicted.
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
Addition of a long-acting beta2-agonist/inhaled steroid
combination to an anticholinergic appears to provide
Chronic treatment with systemic
corticosteroids should be avoided
because of an unfavorable benefit-to-
Theophylline is less effective and less well tolerated than
inhaled long-acting bronchodilators and is not
recommended if those drugs are available and affordable.
There is evidence for a modest bronchodilator effect and
some symptomatic benefit.
In patients with severe and
very severe COPD(GOLD 3
and 4), the selective
(PDE-4), roflumilast [Daxas],
It has also an anti-inflammatory
Dose: one tab (0.5 mg) PO
Influenza vaccine can reduce serious illness.
Pneumococcal polysaccharide vaccine recommended
for COPD patients 65 years and older.
Other Pharmacologic Treatments
Mucolytics: Only in patients with viscid sputum; overall
benefits are very small.
Antitussives: Not recommended.
Alpha-1 antitrypsin augmentation (replacement) therapy:
• The only specific therapy for
1 antitrypsin deficiency.
• Prepared from pooled plasma of
• Given as weekly IV infusion (60
• Not well tolerated (fever, chills,
flu like symptoms.
• Very expensive.
The long-term administration of oxygen
(> 15 hours per day) to patients with chronic respiratory
failure increases survival in patients with severe, resting
Reversal of hypoxaemia supersedes concerns about CO2
The therapeutic goal is to maintain Sa,O2 >90% during
rest, sleep and exertion.
All COPD patients benefit from exercise training
programs with improvements in exercise tolerance
and symptoms of dyspnea and fatigue.
Although an effective pulmonary rehabilitation
program is 6 weeks, the longer the program
continues, the more effective are the results.
Sleep in COPD is associated with oxygen
desaturation, predominantly due to the disease itself
(rather than sleep apnoea).
Desaturation during sleep may be greater than
during maximum exercise.
Sleep quality is markedly impaired in COPD.
Control of cough, dyspnoeal improves sleep quality.
Nocturnal oxygen therapy is rarely indicated.
Hypnotics should be avoided.
Bullectomy and Lung volume reduction surgery
are more efficacious than medical therapy among
patients with upper-lobe predominant emphysema
and low exercise capacity.
In appropriately selected patients with very severe
COPD, lung transplantation has been shown to
improve quality of life and functional capacity.
An exacerbation of COPD is:
“an acute event characterized by a worsening
of the patient’s respiratory symptoms that is
beyond normal day-to-day variations and
leads to a change in medications.”
Management of Exacerbations
Most exacerbations are precipitated by respiratory tract
Diagnosis relies exclusively on the clinical presentation.
quality of life
Consequences Of COPD Exacerbations
Check inhalation technique
Consider use of spacer devices
↑ Dose and/or frequency of SABA and/or anticholinergic MDI with spacer or hand-held
nebuliser as needed
Consider adding LABA
Corticosteroids Prednisone 30–40 mg per os q day for 7 - 10 days
Consider using an inhaled corticosteroid
May be initiated in patients with altered sputum characteristics (Volume and/or
Choice should be based on local bacteria resistance patterns
Supplemental oxygen to prevent tissue hypoxia by maintaining
arterial oxygen saturation (SaO2) at >90%.
If patient tolerates oral medications, prednisone 30–40 mg per os q day for 10 days
If patient can not tolerate, give the equivalent dose i.v.
Cardiovascular disease (including ischemic
heart disease, heart failure, atrial fibrillation,
and hypertension): the most frequent and
most important disease coexisting with COPD.
Benefits of cardioselective beta-blocker
treatment in heart failure outweigh potential
risk even in patients with severe COPD.
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