3. Chronic Obstructive Pulmonary Disease (COPD) is a
preventable and treatable disease with some significant
extra pulmonary 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.
Definition
4. COPD -A Neglected Disease
COPD does not kill as suddenly & unexpectedly as a myocardial infarction
More frequent in the lower socioeconomic class
Self inflicted disease-Smoker’s own fault
Limited success with primary & secondary prevention
Not so rewarding therapy
Clinically relevant only at the end of productive life
5. Burden of COPD- Global
COPD - 6th as cause of death in 1990
3rd as cause of death in 2020
Ischemic heart
disease (6.3
Million)
Cerebrovascular Accidents
(4.4 Million)
Lung Cancer
(0.9 Million)
Road traffic
Accidents (1.0
Million)
Measles
(1. 1 Million)
Tuberculosis
(2.0 Million)
Lower Respiratory
infection (4.3 Million)
Chronic obstructive
pulmonary Disease
(2.2 Million)
Perinatal Disease
(2.4 million)
Diarrheal Disease
( 2.9 Million)
22.9%
22.9% 22.9%
22.9%
3.3%
3.6%
4 % 7.3 %
8.7 %
8 %
6. Burden & Prevalence of COPD are
projected to increase
in the coming decades
Continued exposure to risk factors Changing age structure
Burden of COPD….contd
+
7. Risk Factors for COPD : Environmental factors
Wood fire : Biomass fuels
Environmental
Factors
Industrial pollution sulfur di
oxide particulars < 10 um
Cigarette, pipe, cigar smoking,
tobacco and cannabis
Car exhaust pollution
Mining : coal, silica &
gold cadmium fumes.
Influenza virus :
adenovirus and HIV
Bacterial infection :
streptococcus or heemophilus
8. Risk Factors for COPD : Host Factors
Airway hyperresponsiveness (AHR)
‘Dutch hypothesis’
Genetic factors :
(X1-antitrypsin deficiency
Host factors
Atopy :
Mast cell coated with IgE and allergen
(house dust mite)
Gender controversial
Premature baby
Small for dates
Low birth weight
Impaired lung
growth
Diet deficient in
Antioxidant vitamins (A, C & E)
Fist oil & protein
17. Why Early Diagnosis?
•Mostly irreversible disease if diagnosed late
•Significant morbidity
•Not so rewarding treatment
Early diagnosis-Effective intervention
for smoking cessation
•Lung function reversible if diagnosed early
18. Why Accurate?
Because most of the commonly used modalities
in diagnosing COPD do not help much in accurate
diagnosis of COPD
19. Medical History
Exposure to risk factors – Smoking, others
Symptoms pattern.
Frequent “winter colds”.
Co-morbidities – CAD, Malignancy, Osteoporosis.
Impact of disease on patient’s life
Social & family support.
Possibilities for reducing risk factors, esp smoking
cessation.
Diagnosing COPD
20. Chronic Cough
Dyspnea
Progressive(worsens over time)
Usually worse with exercise
Persistent (present every day)
Intermittent, unproductive.
Chronic sputum
production
Any pattern of chronic sputum
Production may indicate COPD
H/O exposure
to risk factors
Tobacco smoke
Occupational dusts and chemicals
Smoke from home cooking and
Heating fuels
Consider COPD if any of these is present
in a patient > 40 yrs of Age.
21. Additional Symptoms
Weight loss and
anorexia
S/O advanced COPD
(R/O TB, Br CA)
Chest tightness/
Wheezing
Non specific. More
common in severe & very
severe COPD
Ankle edema Cor Pulmonale
Depression
22. Physical Examination
Rarely diagnostic- low sensitivity & specificity.
•Absence of physical signs till development of
significant disease.
•Resp rate – increased, shallow breaths.
•Use of accessory muscles of resp.
•Pedal edema.
•Central cyanosis or bluish discoloration of mucosa.
24. Confirming Airflow Limitation
Spirometry is a GOLD STANDARD
Best Standardized, most reproducible &
most objective measurement
of airflow limitation
Early Diagnosis of COPD
25. Normal Borderline Mild Moderate Severe
Airway obstruction
35 40 45 50 55 60
Normal Hypoxemia
Normal Hyper
inflation
Resting
dyspnea
Cough & sputum Exertional
dyspnea
Symptoms
Spirometry
ABG
Chest x-Ray
AGE
Early Diagnosis of COPD
27. “Early Diagnosis” with Spirometry
45 Yrs Male
PME
History
Clinical Exam
Chest X-Ray
Spirometry
COPD – Stage I
Smoking Index - 300
Slight morning cough
NAD
FEV1 – 2.45 L (82 %)
FEV1/FVC - < 70 %
Counselling on
smoking cessation
Patient Quit
Smoking
Early Diagnosis
Smoking
Cessation
NAD
28. Stage of COPD
Stage – I
FEV1/FVC < 0.70
FEV1 > 80% Chronic cough
with Sputum +
Stage – II
FEV1/FVC < 0.70
FEV1 - 50% - 80%
Symptomatic
Stage – III FEV1/FVC < 0.70
FEV1 30 - 50%
↑↑ Symptomatic
Stage – IV FEV1/FVC < 0.70
FEV1 < 30%
Chronic respiratory failure +
Mild COPD
Moderate COPD
Severe COPD
Very Severe COPD
30. ABG
Alpha-1 Antitrypsin Def Screening
Young age < 45 yrs.
Strong family history.
Sperm level < 15-20%.
Bronchodilator reversibility testing.
Diagnosis
31. HRCT / Spiral CT
Indications
• Diagnosis of emphysema in asymptomatic COPD
• Bronchogenic CA
• PTE / Bronchiectases
• Before lung volume reduction surgery
Echocardiography
• Cor pulmonale
Diagnosis
32. Exercise Testing
• 6 min walk distance
• For determining effort tolerance
Sleep studies
BMI monitoring
Diagnosis
33. Differential Diagnosis of COPD
S/
No.
Disease Onset of Disease Symptoms of disease
01. COPD Onset in Mild – life
Symptoms slowly
progressive.
Commonly long
smoking history rarely
ά1- antitrypsin
deficiency rarely
primary ciliary
dyskinesia.
Dyspnea during
exercise largely
irreversible airflow
limitation.
02. Asthma Onset early in life
(often childhood).
Symptoms vary from
day to day. Symptoms
at night/ early
morning.
Allergy, rhinitis, or
eczema also present
family history of
Asthma. Respond to
β2-agonists: reversible
airflow limitation.
34. Smoking Most important risk factor
Smoking cessation
Most beneficial
management
step for COPD
Only intervention
that reduces
accelerated
decline in lung
function
Primary Prevention
35. Fletcher C, Peto R: BMJ 1977
Annual Decline in Lung Function
100
75
50
25
0
25 50 75
Age ( Years)
Stopped smoking
aged 60 yr
Stopped smoking
aged 50 yr
Susceptible
smoker
(10-20%)
Death
Disability
Non smoker
Non-susceptible
smoker
36. Smoking Cessation
ASK Systematically identify all tobacco users at every visit.
ADVICE
ASSESS Determine willingness to make a quit attempt.
Strongly urge all tobacco users to quit.
ASSIST Aid the patient with a quit plan.
ARRANGE Schedule follow-up contact
J Am Med Assoc 2000;283:3244-54
37. Even a brief (3 min) period of counselling to
urge a smoker to quit results in smoking
cessation rates of 5 – 10 %
Wilson DH, etal . “Sick of Smoking’’: evaluation of a
targeted minimal smoking cessation intervention in general
practice. Med J Aug 1990 ; 152 (10) : 518 – 21
SMOKING CESSATION
38. Transdermal skin patches
Nasal spray
Micro tablets for sublingual use
Inhalator with a cartridge containing nicotine Chewing gum
Nicotine replacement products
40. Bronchodilator in Stable COPD
Bronchodilator medications are central to symptom
management in COPD.
The choice between β2- agonists, anticholinergic,
theophylline, or combination therapy depends on availability
and individual response in terms of symptom relief and side
effects.
Combining bronchodilators may improve efficacy and
decrease the risk of side effects compared to increasing the
dose of a single bronchodilator.
Bronchodilators are prescribed on an as-needed or on
a regular basis to prevent or reduce symptoms.
Long – acting inhaled bronchodilators are more effective
and convenient.
41. The aerosol route is the safest, fastest and
most effective way to administer drugs in
patients suffering with asthma and COPD
and should be the method of choice in all
patients.
(GINA guidelines, GOLD guidelines)
42. • Jet, Ultrasonic and small volume nebulisers
• Pressurized metered dose inhalers
(pMDIs), with or without spacers (static and
non static)
• Dry powder inhalers (DPIs)
- Unit dose and Multidose
- Multi dose
AEROSOL GENERATION DEVICES
43. ADVANTAGES:
• Easy to use if technique proper
• Convenient – multiple doses in a
small canister
• Cheap – relatively cheaper to
manufacture
DISADVANTAGES:
• Co-ordination problems
• Cold Freon effect
• Increased oropharyngeal deposition
• CFC propellant – harms environment
Pressurized METERED DOSE INHALER
44. • No co-ordination required
• No cold - freon effect
• Reduced oropharyngeal deposition
• Increased drug deposition in the lungs
• As an alternative to nebulisers
SPACER
45. ADVANTAGES:
• Breath actuated – no co-ordination
skills required
• Easy and convenient to use
• No propellant – environmentally
friendly
DRY POWDER INHALERS
46. DISADVANTAGES:
• Requires a good inspiratory effort
• Carries a single dose at a time
• Capsule and drug life reduced by
moisture and humidity
• Reservoir multi-dose DPIs: Pure drug
Cohesion and static forces can reduce
dose uniformity
DRY POWDER INHALERS
47. • ASK THE PATIENT
• Assess the inhaler technique
• Prime importance to correct inhaler
technique
• Age
• Level of comprehension and cooperation
• Dosage of Inhaled steroids
• Acute severe attack
Which is the Best Inhaler
Device?
48. Therapy at each stage of COPD.
FVC1/FVC < 0.70
FEV1 > 80% predicted.
FEV1/FVC < 0.70
50% < FEV1< 80% predicted.
FEV1/FVC < 0.70
30% < FEV1< 50%
predicted.
FEV1/FVC < 0.70
FEV1< 30%
predicted or FEV1 < 50%
predicted plus chronic
respiratory failure..
Active reduction of risk factors (s); influenza vaccination
Add short- acting bronchodilator (when needed)
Add regular treatment with one or more long- acting
bronchodilators (when needed); add rehabilitation.
Add inhaled Glucocorticosteriods
if repeated exacerbations.
Add LTOT.
Consider surgical
treatments.
I: Mild II: Moderate III: Severe IV: Very Severe
50. High flow systems
Complete inspiratory
demand of patient
Low flow systems
Room air used to
provide part of
inspired atmosphere
OXYGEN DELIVERY SYSTEMS
51. Nasal cannula
Flow rate 1-6L/min
FiO2 24-44%
Simple masks
Flow rate 6-8L/min
FiO2 40-60%
DEVICES IN LOW FLOW
SYSTEM
52. Continuous Oxygen
Resting PaO2 < 55 mm Hg
Hematocrit > 56%
Dependent edema
P pulmonale
Resting PaO2 of 55-59 mm Hg
LONG TERM OXYGEN THERAPY
53. ADV
Moderate cost
Wide availability
Fair portability
Little maint.
ADV
Low cost
Good availability
Ease of use
GAS O2 CONCENTRATOR LIQUID
ADV
Light wt
Excellent
portability
Ease of refilling
DISADV
Heavy wt
Refilling difficulty
Frequent refills
required
DISADV
Heavy wt
Poor portability
Reg maint. req
DISADV
High cost
Incompatibility
of parts
Mod maint
MODES OF OXYGEN DELIVERY
54. PULMONARY
REHABILITATION
‘Pulmonary rehabilitation is a multidisciplinary program of care for
patients with chronic respiratory impairment that is individually
tailored and designed to optimize physical and social performance and
autonomy.’
The principal goals of pulmonary rehabilitation are to:
(1) Reduce symptoms, disability and handicap;
(2) Improve health – related quality of life;
(3) Improve functional independence, with maximal ability to perform a
range of everyday activities;
(4) Increase physical, social and emotional well-being in every day
activities.
56. Holistic approach by multidisciplinary team:
Sleep studies for selected patients
Pulmonary Rehabilitation
Exercise and physical training
Nutritional advice
Psychological assessment: Depression
Disease Education
Social & behavioral intervention
57. Nutrition in COPD
Nutritional assessment
• Body weight & recent weight loss
• Body mass index (BMI)
• Skin fold thickness
• Fat free mass (FFM)
Body Mass index (BMI)
< 25 kg/m2 in COPD patients associated
with increased mortality.
< 21 kg/m2 in normal Caucasians is
underweight at < 90% ideal body weight.
Dietary Assessment
• Calorie intake.
• Vitamin intake.
• Protein intake.
Treatment Options
• Improved diet and exercise.
• Antioxidants vitamin supplement.
• High calorie liquid supplement.
• Anabolic steroid.
• Recombinant human growth hormone (rhGH).
58.
59. Long Term Domiciliary Oxygen Therapy (LTOT)
Improves survival, reduces secondary polycythemia & prevents
progression of pulmonary hypertension
Crokett A J, et al. (Cochrane Review). Cochrane Library Issue, issue4, 2000.
60. Take Home Messages
Follow five A’S in Smoking cessation
Diagnose early by Spirometry
Regular drug therapy
Pulmonary Rehabilitation
Familiarisation with GOLD International Guidelines
