..

1. 1

2. Part 1

3. By

4. 4
Learning the COPD Guidelines by
Case Studies

5. 5

6.  A 75-year-old woman with a 50 pack - year history
of tobacco use presents to her primary care
physician with a complaint of worsening shortness
of breath over the past 6 months.
 She has no documented history of asthma or
COPD.
6

7. Which symptom is most consistent with the
diagnosis of COPD?
 Dyspnea that is progressive, persistent, and worse
with exertion.
 FEV1/FVC greater than 70% predicted.
 Chronic cough present only at night.
 COPD Assessment Test (CAT) score of 5. 7

8. Which symptom is most consistent with the
diagnosis of COPD?
A) Dyspnea that is progressive, persistent, and worse
with exertion.
B) FEV1/FVC greater than 70% predicted.
C) Chronic cough present only at night.
D) COPD Assessment Test (CAT) score of 5. 8

9. Answer: A
Answer A is correct as dyspnea that is progressive,
persistent and worse with exertion is a hallmark
symptom of COPD.
Answer B is incorrect as spirometry findings of an
FEV1/FVC less than 70% predicted are required for a
diagnosis of COPD.
9

10.  Answer C is incorrect because while a chronic
cough is usually present as a symptom of COPD,
this cough is rarely only nocturnal and is most
often present throughout the day.
 The CAT has a score range of 5–40, with higher
scores indicating worse COPD. A CAT score of 5 is
within the upper limit of normal scores, therefore
Answer D is incorrect
10

11. 11

13. Smoking History
No. of Packs/dayNo. of Packs/day
XX
No. of Years smokedNo. of Years smoked
……………………………………………………
COPD patientsCOPD patients
~ 20 pack-years~ 20 pack-years
No. of Packs/dayNo. of Packs/day
XX
No. of Years smokedNo. of Years smoked
……………………………………………………
COPD patientsCOPD patients
~ 20 pack-years~ 20 pack-years
20

14. 14

15. What is the next investigation
required to confirm your provisional
diagnosis?
15

16. 16
Diagnosis of COPD

17. 17

18. 18
 Spirometry should be performed after the
administration of an adequate dose of a short-acting
inhaled bronchodilator to minimize variability.
 A post-bronchodilator FEV1/FVC < 0.70 confirms the
presence of airflow limitation.
 Prebronchodilator and Postbronchodilator testing
should be performed to determine the degree of
reversibility of any airflow obstruction.

19. Results
Prebronchodilat
or
Postbronchodilator
FEV1 52%
Of Predicted
58%
of Predicted
FVC 80%
of predicted
82 %
of Predicted
FEV1/FVC
Ratio
52% 53%

20.  You interpret these measurements as obstructive lung
disease consistent with partially reversible airflow
obstruction.
 Postbronchodilator FEV1/FVC ratio in liters remains at
or below 0.70, but the FEV1 does not increase by more
than 12% and 200 mL.
20

21. 53%
82%
Petty TL. Spirometry made simple. National Lung Health Education Program Web site.
Simple.htm. Published January 1999.AccessedOctober 1, 2008.

22. Bronchodilator
Reversibility
Testing in COPD

23. Spirometry
• Definition for Reversibility:
– FEV1 and/or FVC >12% and >200 mL ATS/ERS,2005
– FEV1 >12% and >200 mL GOLD,2010

24. 24

25. 25

26. 26

27. 27

28. 28

29. 29FEV1 used to grade the severity

30. If you test one smoker with cough every day
You will diagnose one patient With COPD
a week

31. Case Scenario 2
31

32.  A 60-year-old man with chronic obstructive pulmonary
disease (COPD) has been using inhaled albuterol 2 puffs
four times per day as needed.
 His symptoms have worsened during the past year, and
now he has persistent symptoms and shortness of breath,
even while walking around his one-level house.
 His Modified Medical Research Council (mMRC) score is 2.
32

33. How could you Assess COPD
symptoms?
33

34. Assessment of Symptoms
• Best way to assess symptoms is to use validated
questionnaires:
– Modified Medical Research Council dyspnea scale. 
MMRC
– COPD Assessment Test  CAT

35. 35

36. 36

37. 37
0-1 = less
breathlessness
>2 = more
breathlessness

38. 38
Cough
Sputum
Chest tightness
Walking up hill
ADLs
Leaving the house
Sleep
Energy levels

39.  COPD Assessment Test (CAT) measures health
status impairment in COPD .
 Measures not just breathlessness but also cough,
sputum production, chest tightness, limitation of
activities, sleep, energy level, and confidence to
leave house
39

40. 40

41. 41

42. COPD Assessment Test (CAT)

43. 43

44.  His spirometry shows a forced expiratory volume in 1
second (FEV1) of 70% of predicted and an
FEV1/forced vital capacity (FEV1/ FVC) of 60% of
predicted.
 He has had no previous COPD exacerbations. Which
medication is best to initiate?
44

45. Which medication is best to initiate?
 Inhaled fluticasone.
 Inhaled tiotropium.
 Inhaled fluticasone/salmeterol.
 Oral roflumilast.
45

46. Which medication is best to initiate?
 Inhaled fluticasone.
 Inhaled tiotropium.
 Inhaled fluticasone/salmeterol.
 Oral roflumilast.
46

47. 47

48. Sir William Osler
Listen to the
patient; he is
telling you
the diagnosis.

50. 50

51. 51

52. 52

53. 53

54. 54

55. Scenario
Step 1: assess mMRC or CAT. mMRC=2
– Right side, more symptoms
Step 2: assess exacerbation hx = 0
– Lower side, Low risk
– Assessment Score = B

57. 57

58.  This patient is in GOLD patient group B. A single
Long acting bronchodilator is first choice for
medication treatment.
 Answer A is incorrect as an ICS is recommended
only in patient group C or D and should never be
used as monotherapy in COPD.
58

59.  Tiotropium is an LA bronchodilator
(anticholinergic) that would be appropriate to
initiate in this patient, making Answer B the
correct choice.
 A LABA would also be appropriate, but it was not
one of the choices.
59

60.  Answer C is incorrect as ICS/LABA combination is
not recommended for treatment unless a patient is
in Group C or D.
 Answer D is incorrect as roflumilast is only
indicated in severe COPD with (FEV1 less than 50%
of predicted) & associated with chronic
bronchitis and a history of frequent exacerbations.
60

62. 62

63. About pharmacotherapeutic agents for COPD,
which
of the following is a LAMA that can be used as
once
daily medication?
 Aclidinium.
 Vilanterol.
 Tiotropium.
 Roflumilast. 63

64. About pharmacotherapeutic agents for COPD,
which
of the following is a LAMA that can be used as
once
daily medication?
 Aclidinium.
 Vilanterol.
 Tiotropium.
 Roflumilast. 64

65. 65
LAMA
DPI HandiHaler/
SMI Respimat
Spiriva®
(tiotropium)
DPI Breezhaler Seebri®
(glycopyrronium
)
DPI Genuair Eklira®
(aclidinium)
DPI Ellipta Incruse®
(umeclidinium)
LAMA inhalers for COPD

66. 66
LAMA
DPI HandiHaler/
SMI Respimat
Spiriva®
(tiotropium)
DPI Breezhaler Seebri®
(glycopyrronium
)
DPI Genuair Eklira®
(aclidinium)
DPI Ellipta Incruse®
(umeclidinium)
LAMA inhalers for COPD

67. 67

68. 68

70. 70

71. 71

72. 72

73. About pharmacotherapeutic agents for COPD,
which
of the following is a LABA that can be used as
once
daily medication?
 Levalbuterol.
 Salmeterol.
 Formoterol.
 Indacaterol. 73

74. About pharmacotherapeutic agents for COPD,
which
of the following is a LABA that can be used as
once
daily medication?
 Levalbuterol.
 Salmeterol.
 Formoterol.
 Indacaterol. 74

75. 75
LABA
DPI Diskus Serevent®
(salmeterol)
DPI Aerolizer Foradil®
(formoterol)
DPI Breezhaler Onbrez®
(indacaterol)
SMI Respimat Striverdi®
(Olodaterol)

76. 76
Serevent®
(salmeterol)

77. 77

78. 78

79. 79

80. 80

81. 81

82. 82

83. 83

84. 84
Case Scenario 3

85. A 51-year-old woman with a 30 pack - year
history of tobacco use diagnosed as a COPD and
categorised as Group A, which of the following
therapeutic strategies is recommended 1st
choice ?
 Long-acting beta2-agonist taken regularly.
 Short-acting bronchodilator either SABA or
SAMA.
 Long acting antimscarinic agent taken
regularly.
85

86. A 51-year-old woman with a 30 pack - year
history of tobacco use diagnosed as a COPD and
categorised as Group A, which of the following
therapeutic strategies is recommended 1st
choice ?
 Long-acting beta2-agonist taken regularly.
 Short-acting bronchodilator either SABA or
SAMA.
 Long acting antimscarinic agent taken regularly.
 Short-acting bronchodilator and SR
theophylline..
86

87. 87

89. 89

90. 90

91. 91

92. 92

93. 93

94. 94

95. 95

96. Since the patient has reduced smoking to
only 5 cigarettes per day, smoking cessation
will have no relevant effect on lung
function decline?
96

97. Since the patient has reduced smoking to
only 5 cigarettes per day, smoking cessation
will have no relevant effect on lung
function decline?
97

98. 98

99. Smoking Is the Single Most Important
Risk Factor for COPD
Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Global Initiative for
Chronic Obstructive Lung Disease (GOLD) 2008. Available from: http://www.goldcopd.org.

101. 101

102. 10

103. 103
Fletcher-Peto Diagram: 1977

104. Adapted from Fletcher CM, Peto R. Brit Med J. 1977;1:1645-1648.
Accelerated Lung-Function Decline
in COPD
0
20
40
60
80
100
20 3030 40 50 60 70 80 90
FEV1
(%)
Age (years)
Death
Disability
Symptoms
Nonsmoker
COPD

105. Bucket and Spoon?
Maximum at age 25:
start with a bucketful
Maximum at age 25:
start with a bucketful
Lose FEV1 at a spoonful
(about 25 ml) per year:
natural ageing process
~ 1 litre over 40 years
Lose FEV1 at a spoonful
(about 25 ml) per year:
natural ageing process
~ 1 litre over 40 years

106. Average Decrease in FEV1 /
year
Males Females
Former
smokers
30 ml/year 22 ml/year
Current
smokers
66 ml/year 54 ml/year
Anthonisen NR, et.al. Am J Respir Crit Care Med 166:675-9, 2002.

107. COPD progression
Age (year)
FEV1%ofvalueatage25yr
100
75
50
25
5025 75
Death
Disability
Adapted from:Fletcher C,et al.Br Med J.1977;1:1645-1648
Nonsmokers
20-30 ml/year
COPD
60
mL/year
symptoms

108. AgeAge 40-5040-50 50-5550-55 55-6055-60 60-7060-70
Age (years)
Death
Disability
Symptoms
Not SusceptibleSusceptible
Smokers
Stopped smoking
at 45 (mild COPD)
Stopped smoking
at 65 (severe COPD)
30 40 50 60 70 80 90
0
20
40
60
80
20
100
Adapted from Fletcher CM, Peto R. BMJ
1977

109. 10

110.  There is no ‘safe’ level of
smoking : No matter
how small is it
 Smoking Even Just One
Cigarette a Day Is Bad
for You
110

111. No Safe Level of Smoking : Even low-
intensity smokers are at increased
risk of earlier death
111

112. 112

113. 113

114. 114

115.  Smoking cessation is the single most
effective and cost-effective intervention to
reduce the risk of developing COPD and stop
its progression (Evidence A)
 Intermittent quitting provides less benefit.

116. Non pharmacological
management of COPD

117. Non pharmacological
management of COPD
117
Patient group Essential Recommended Depending on
local guidelines
A
Smoking cessation
(can include
pharmacologic
treatment)
Physical activity
Flu vaccination
Pneumococcal
vaccination
B - D
Smoking cessation
(can include
pharmacologic
treatment)
Pulmonary
Rehabilitaion
Physical activity
Flu vaccination
Pneumococcal
vaccination

118. 118

119. The Role of Health Professionals
In Tobacco Control

120. 120

121. 121
 Brief Counseling Intervention
– 5 A’s for Brief Smoking Cessation Counseling
(U.S. Department of Health and Human Services)
•Ask
•Advise
•Assess
•Assist
•Arrange

122. 122
5 As

123. 123

124. A smoking aware practice
Adapted from Litt J, et al. Asia Pacific Fam Med. 2003; 2: 175-9
Increase in
quit rate
GP time
A ‘no-smoking practice’
Brief intervention
Moderate intervention
Intense
interventio
n
>5 mins
<1 mins
2-5 mins
2 fold
3 fold
4 fold
5-7 fold

125. (Ockene, et.al., 2000)
Brief interventions during medical
visits are cost-effective and could
potentially reach most smokers
Unfortunately, brief
interventions are not
consistently delivered!

126. 126
Lung Age - The Concept

127. Using "Lung Age" for Smoking
Cessation
127
Telling patients their lung age, or
the age of the average healthy person with similar
lung function to theirs, was an incentive
for smokers to quit smoking and may be
a strategy for general practitioners to use

128. 128
 ‘All health professionals should understand the
principles of Brief Intervention for smoking
cessation.
 It is to be routine practice to consider the need
for Brief Intervention at every patient contact’

129. 129

130. 130

131. 131