5. 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.
6.
7. COPD is the only chronic disease that is rapidly
increasing in prevalence on a worldwide basis
12. COPD is a Cinderella Condition
Limited recognition
from patients
Limited recognition
from physicians
QuickT ime™ and a
T IF F (Uncompressed) decompressor
are needed to see this picture.
COPD is
Underestimated
Underdiagnosed
Undertreated
13. Physician Specialty Seen Most Often
Respiratory
Specialist,
22% Internal Medicine,
15%
General/Family
Medicine,
52%
Cardiologist,
3%
Other,
2%
Not Sure,
5%
Allergist,
1%
14. Under diagnosis of COPD in the United States
Over 12 million people in the
United States have been
diagnosed with COPD; another
12 million are estimated to be
undiagnosed1
Data from NHANES III indicate
that approximately 24 million US
adults have evidence of impaired
lung function indicative of
COPD2,3
Most (70%) of patients with
undiagnosed COPD are <65
years
70%
<Age 65
30%
≥Age
65
Percent With Undiagnosed COPD
1. NHLBI; available at http://www.nhlbi.nih.gov/health/public/lung/copd/index.html. 3. Mannino DM, et al. Proc Am Thorac Soc.
2007;4:502-306
2. Mannino DM, et al. MMWR Surveill Summ. 2002:1-16.
15. An estimated 210 million people worldwide have
COPD
More than 3 million people died of COPD in 2005 ,
this represented 5% of all deaths worldwide
COPD disproportionately affects the world's
poorest
WHO , 2009.
COPD: Global Burden
16. COPD Is Deadly But Treatable -- And Preventable
disease , responsible for a large human and
economic burden around the world
Encourage the health care community to take a
more active role in developing programs for
COPD prevention
Stimulate effective management programs to
treat those with the disease
18. Common preventable & treatable disease
Characterized by persistent airflow limitation that is
usually progressive
Associated with an enhanced chronic inflammatory
response in the airways & the lung to noxious
particles or gases
Exacerbations & comorbidities contribute to the
overall severity in individual patients
Definition of COPD 2014
19. 19
COPD is used to describe emphysema, chronic
bronchitis or a combination of the two.
20. Burden of COPD
COPD is a leading cause of morbidity & mortality
worldwide
The burden will increase in coming decades due to
continued exposure to risk factors & the aging of the
world’s population
COPD is associated with significant economic
burden
21. Prevalence
Buist AS, McBurnie MA, Vollmer WM, et al. International variation in the prevalence of COPD (the BOLD Study):
a population-based prevalence study. Lancet. 2007;
11.8% 8.5%10.1% overall
22. Chapman KR, et al. Chest. 2001.
COPD Misdiagnosis Is Common in
Women
Hypothetical Male Patient With
COPD Symptoms
Hypothetical Female Patient
With COPD Symptoms
Diagnosed as COPD by
65% of physicians
Diagnosed as COPD by
49% of physicians
65%
49%
COPD symptoms in women were most
commonly misdiagnosed as asthma
27. 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 30 40 50 60 70 80 90
Age (years)
Death
Disability
Symptoms
Nonsmoker
COPD
28. 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.
29. Fletcher & Peto, BMJ 1977;1:1645
Susceptibility
Genes
Protective
Genes
PULMONARY FUNCTION DECLINE OVER TIME
MODEL: BETWEEN INDIVIDUAL VARIATION IN
SUSCEPTIBILITY TO CIGARETTE SMOKE
30. Not only smoking but smoke
Air pollution resulting from the burning of wood and
other biomass fuels is estimated to kill two million
women and children each year.
40. COPD comprises pathological changes in four
different compartments of the lungs
1. Central airways
2. Peripheral airways
3. Lung parenchyma
4. Pulmonary vasculature
40
41. PATHOLOGY
COPD comprises major pathological changes in the
following four different compartments of the lung,
which are variably present in individuals with the
disease:
1. Central airways (cartilaginous airways >2mm of internal
diameter)
2. Peripheral airways (noncartilaginous airways <2mm
internal diameter)
3. Lung parenchyma (respiratory bronchioles, alveoli and
capillaries)
4. Pulmonary vasculature
41
42. Mucus gland hyperplasia
Goblet cell
hyperplasia
Mucus hypersecretion Neutrophils in sputum
Squamous metaplasia of epithelium
↑ Macrophages
No basement membrane thickening
Little increase in
airway smooth muscle
↑ CD8+ lymphocytes
Changes in Large Airways of COPD
Patients
Source: Peter J. Barnes, MD
43. Disrupted alveolar attachments
Inflammatory exudate in lumen
Peribronchial fibrosis
Lymphoid follicle
Thickened wall with inflammatory cells
- macrophages, CD8+ cells, fibroblasts
Changes in Small Airways in COPD
Patients
Source: Peter J. Barnes, MD
44. Alveolar wall destruction
Loss of elasticity
Destruction of pulmonary
capillary bed
↑ Inflammatory cells
macrophages, CD8+ lymphocytes
Source: Peter J. Barnes, MD
Changes in Lung Parenchyma in COPD
45. 45
Lung parenchyma (respiratory bronchioles,
alveoli and capillaries)
Alveolar wall destruction, apoptosis of epithelial and
endothelial cells. There are two major types :
1) Centrilobular emphysema:
dilatation & destruction of respiratory bronchioles;
most commonly seen in smokers
2) Panacinar emphysema:
destruction of alveolar sacs as well as respiratory
bronchioles; most commonly seen in alpha-1
antitrypsin deficiency
51. -Chronic Bronchitis predominant
-Airway obstruction is the main problem
Normal
Elastic Recoil
Chronic Bronchitis
Elastic Recoil
Increased airway resistance
due to thickened wall and
secretions
Airway supported
by connective
tissue
52. -Emphysema Predominant
-This results in a loss of the elastic recoil of the lungs on expiration
-This also results in loss of tethering or support of the most distal
portions of the airway leading to collapse on expiration
Normal
Elastic Recoil
Airway supported
by connective
tissue
Decreased
Elastic Recoil
= Lower Flow
Loss of support = Airway
collapses= Air gets trapped in lung
55. Alveolar Emptying in COPD
In COPD, airflow is limited because small airways are narrowed,
alveoli lose their elasticity, and supportive structures are lost.
56. COPD is a Complex Disease
Progressive Loss of Lung Function
Reduced Quality of Life
Exacerbations
Mortality
Broncho-
constriction
Inflammation
Structural
Changes
Airflow
Limitation &
Hyperinflation
67. What is Progression of COPD?
*GOLD Guidelines. Am J Respir Crit Care Med.
0
At Risk
I
Mild
II
Moderate
III
Severe
IV
Very Severe
Health
Prevalent Disease
Progressive Disease
Death
???
Incident Disease
69. Natural History of COPDLungFunction
Time (Years)
Exacerbation
Exacerbation
Exacerbation
Never smoked
Smoker
Fletcher C. Br Med J. 1977
70. Frequent exacerbations are associated with
increased mortality
A = No exacerbations B = 1-2 exacerbations C = 3 or more exacerbations
Soler-Cataluna JJ, et al. Thorax 2005;60:925-931.
p < 0.0001
1.0
Probabilityofsurviving
0.8
0.6
0.4
0.2
0.0
0 10 20 30 40 50 60
Time (months)
A
B
C
p = 0.069
p < 0.0002
71. COPD is:
a multi- component disease
with systemic involvement & inflammation
Respiratory system
Systemic
inflammation
Target organs
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
COPD is: More than just a lung disorder
72. Barnes PJ (2010) Chronic Obstructive Pulmonary Disease: Effects beyond the Lungs.
Mechanism linking COPD to systemic manifestations
73. Declining lung function
Symptoms
Exacerbations
Decreased exercise tolerance
Deteriorating health status
and increasing morbidity
Mortality
Airflow
limitation
Systemic
component
Structural
changes
Mucociliary
dysfunction
Airway
inflammation
Agusti. Respir Med 2005
Agusti et al. Eur Respir J 2003
Bernard et al. Am J Respir Crit Care Med 1998
COPD is a multicomponent disease with
inflammation at its core leading to mortality
80. Effects of Exercise on Hyperinflation
VT
IRVERV
IC
RV
Normal
Years - Decades
Progression
Rest
Static
Hyperinflation
Air Trapping
at Rest
Seconds - Minutes
Exercise
Dynamic
Hyperinflation
Air Trapping
During Exercise
81. 81
Dynamic hyperinflation in patients with emphysema during exercise.
Note that V T increases with exercise. Note also that the expiratory
phase decreases progressively with continued exercise indicating
progressive air trapping .
82. Despite its heterogeneity, the pathophysiological
hallmark of COPD is expiratory flow limitation and
Lung hyperinflation
Dyspnea (breathlessness) and exercise intolerance are
the most common symptoms in COPD and progress
relentlessly as the disease advances.
82
84. o Many patients with COPD remain undiagnosed until the
more advanced stages of the disease.
o Delayed diagnosis results in patients suffering
symptoms and limitations that could otherwise be
alleviated by treatment.
Diagnosis of COPD
Early diagnosis of COPD can be challenging
85. The COPD patient
Generally over 40
years
A smoker or ex-
smoker
Presentation with:
– cough
– excessive sputum
production
– shortness of
breath
Dyspnea is the reason
most patients seek
medical attention.
1. BTS, 1997; 3. GOLD, 2003
94. Obstructive Pattern
FEV1: < 80% predicted
● FVC: can be normal or reduced – usually to
a lesser degree than FEV1
FEV1/FVC: <70% predicted
FEV1 used to grade the severity
96. FEV1: Normal or mildly reduced –
usually to a lesser degree than FVC
FVC: < 80% predicted
FEV1/FVC: Normal or increased > 0.7
Restrictive Pattern
97. Mixed Obstructive and Restrictive
Volume,liters
Time, seconds
Restrictive and mixed obstructive-restrictive are difficult to diagnose by spirometry
alone; full pulmonary function tests are usually required
FEV1 = 0.5L
FVC = 1.5L
FEV1/FVC = 0.30
Normal
Obstructive - Restrictive
105. Algorithm for Interpreting Spirometry Results
105
Petty TL. Spirometry made simple. National Lung Health Education Program website.
http://www.nlhep.org/resources/SpirometryMadeSimple.htm. Published January 1999.
Acceptable spirogram
Restrictive
defect
Is FVC low?
Yes
Further
testing
Normal
Yes
Obstructive defect
Is FVC low?
Near-total reversal with
use of beta agonist?
Yes
Mixed
obstructive/
restrictive defect
or hyperinflation
No
Pure obstruction
No
Is FEV1/FVC ratio low?
No
Yes No
Asthma COPDFurther testing
108. Spirometry is required for the diagnosis of COPD
SPIROMETRY REQUIRED TO DIAGNOSE COPD
Presence of a post-bronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow limitation and thus of COPD.
Key Indicators to Consider COPD Diagnosis:
1
• SYMPTOMS
• Dyspnea-progressive (worsens over time and with exercise)
• Chronic cough
• Sputum
2
• HISTORY OF EXPOSURE TO RISK FACTORS
• Tobacco smoke
• Smoke from home cooking/heating fuels
• Occupational dusts and chemical
3
• FAMILY HISTORY OF COPD
Adapted from GOLD 2014
110. The ATS/ERS guidelines (2005) suggest that other
measures, in addition to the degree of airflow obstruction, can
be useful in predicting treatment outcomes such as
• Body mass index
• Degree of airflow Obstruction
• Dyspnea
• Exercise capacity measured by the
6-minute walk test
These parameters, when combined, have been shown to
predict a higher risk of death than lung function alone.
BODE Index
112. Composite scores
The cutoff values for the assignment of points are shown for each
variable. The total possible values range from 0 to 10, with higher
scores indicating a greater risk of death.
Approximate 4 Year Survival Interpretation
0-2 Points: 80%
3-4 Points: 67 %
5-6 Points: 57%
7-10 Points: 18%
126. In patients with FEV1/FVC <0.70
GOLD 1 Mild FEV1>80%
GOLD 2 Moderate 50%<FEV1<80%
GOLD 3 Severe 30%<FEV1<50%
GOLD 4 Very severe FEV1<30%
Grading severity of airflow
Point out that FEV1/FVC ratio used to be the only factor in the old
classification system.
In a sense, we are using the same 1-4 ratios of FEV1 as the old
system here, but it is now one of three factors in the new classification
system
Low
risk
Hig
h
Risk
127. Combined Assessment of COPD
Assess symptoms
Assess degree of airflow limitation using
spirometry
Assess risk of exacerbations
Assess comorbidities
COPD Assessment Test (CAT)
or
mMRC Breathlessness scale
130. Patients read the two
statements for each item, and
decide where on the scale
they fit
Scores for each of the
8 items are summed to give
single, final score (minimum 0,
maximum 40)
This is a measure of the
overall impact of a patient’s
condition on their life
1 Jones P et al. Eur Respir J 2009; 34: 648-654
COPD Assessment Test (CAT)
132. COPD Assessment Test (CAT)
Aim of the COPD Assessment
Test(CAT) is to grade the impact
of COPD on health status.
133. Assess risk of exacerbations
History of exacerbations (Two or more
exacerbations in the preceding year).
Spirometry (GOLD 3 or GOLD 4 categories).
Combined Assessment of COPD
Adapted from GOLD 2014
134. 1) Assess symptoms first
2) Assess risk of exacerbations next
3) When assessing risk, choose the highest risk
according to GOLD grade or exacerbation
history
Patient is now in one of four categories
Adapted from GOLD 2014
Combined Assessment of COPD
135. Combined Assessment of COPD
(C) (D)
(A) (B)
mMRC 0-1
CAT < 10
mMRC > 2
CAT > 10
Symptoms
(mMRC or CAT score))
If mMRC 0-1 or CAT < 10:
Less Symptoms (A or C)
If mMRC > 2 or CAT > 10:
More Symptoms (B or D)
Assess symptoms first
www.goldcopd.org
136. Risk
(GOLDClassificationofAirflowLimitation)
Risk
(Exacerbationhistory)
> 2
1
0
(C) (D)
(A) (B)
mMRC 0-1
CAT < 10
4
3
2
1
mMRC > 2
CAT > 10
Symptoms
(mMRC or CAT score))
If GOLD 1 or 2 and only
0 or 1 exacerbations per
year:
Low Risk (A or B)
If GOLD 3 or 4 or two or
more exacerbations per
year:
High Risk (C or D)
Assess risk of exacerbations next
www.goldcopd.org
Combined Assessment of COPD
138. Global Strategy for Diagnosis, Management and
Prevention of COPD. Updated 2011
Risk
(GOLDClassificationofAirflowLimitation)
Risk
(Exacerbationhistory)
> 2
1
0
(C) (D)
(A) (B)
mMRC 0-1
CAT < 10 or CCQ<1
4
3
2
1
mMRC > 2
CAT > 10 or
CCQ>1
Symptoms
A: Les symptoms, low risk
B: More symtoms, low risk
C: Less symptoms, high risk
D: More Symtoms, high risk
139. GOLD 2011 Combined assessment of COPD
Less symptoms
High risk
Less symptoms
Low risk
More symptoms
low risk
More symptoms
high risk
GOLD 1
GOLD 2
GOLD 3
GOLD 4
(GOLDClassificationofAirflowLimitation)
Symptoms
≥2
or
1 (not leading
to hospital
admission)
0
RISK
(EXACERBATIONHISTORY)
Adapted from GOLD 2014
≥1 leading
to hospital
admission
Breathlessness
mMRC 0–1 mMRC ≥ 2
CAT < 10 CAT≥10
Risk
141. Manage Stable COPD: Pharmacologic
Therapy
Patient Recommended 1st choice Alternative choice
Other Possible
Treatments
A
SAMA prn
or
SABA prn
LAMA
or
LABA
or
SABA & SAMA
Theophylline
B
LAMA
or
LABA
LAMA & LABA
SABA and/or SAMA
Theophylline
C
ICS + LABA
or
LAMA
LAMA & LABA or
LAMA & PDE4-inh. or
LABA & PDE4-inh.
SABA and/or SAMA
Theophylline
D
ICS + LABA
and/or
LAMA
ICS + LABA & LAMA or
ICS+LABA & PDE4-inh. or
LAMA & LABA or
LAMA & PDE4-inh.
Carbocysteine
SABA and/or SAMA
Theophylline
From the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2011. http://www.goldcopd.org.
146. Smoking cessation is the single most effective
and cost-effective intervention to reduce the
risk of developing COPD and stop its
progression (Evidence A)
148. Age 40-50 50-55 55-60 60-70
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
153. Expiratory flow-limitation and lung hyperinflation that are only partially
reversible to bronchodilator therapy are pathophysiological hallmarks of COPD
154. V
BD
Air flowDeflation
Improvement in flow – FEV1
Improvement in volumes – FVC and IC
Bronchodilator therapy deflates the lung
BD = bronchodilator; V = ventilation; FEV1= forced expiratory volume in 1 second;
FVC= forced vital capacity; IC = inspiratory capacity
155. Bronchodilators work by:
Eur Respir Rev 2006; 15: 99, 37–41
Relieve dyspnea by
deflating the lungs
Allowing improved lung
emptying with each
breath
Improvement in
exercise tolerance
Reduces
the elastic
load on the
inspiratory
muscles.
158. The use of bronchodilators is now recommended
as the cornerstone of maintenance treatment of
COPD , since this disease is no longer regarded
as one characterised by irreversible airflow
limitation but rather as a disease with at least
partial reversibility of airflow limitation.
15
8
159. Short-acting and long-acting bronchodilators form
the cornerstone of pharmacologic management.
Unlike asthmatic patients who experience dyspnea
when acute bronchospasm occurs, patients with
COPD most commonly experience dyspnea due to
increased respiratory demands, such as occurs with
exertion.
15
9
160. Besides bronchodilatation , inhaled bronchodilators,
probably by reducing hyperinflation both at rest and
during exercise (a so-called pharmacological volume
reduction effect), offer beneficial effects on real world
outcomes important for the patient, such as symptoms
(dyspnoea), exercise tolerance (endurance),
exacerbation/hospitalisation rate and health-related
quality of life.
16
0
161. Bronchodilator effect :
Indacaterol > Formoterol or Salmeterol
Indacaterol = Tiotropium (Evidence A)
There is no evidence to recommend one
class of long acting bronchodilators over
the another for initial treatment. In the
individual patient, the choice should be in
the patient's perception of symptom relief.
Manage Stable COPD:
Pharmacologic Therapy
163. The overall approach to the management of
stable COPD is a stepwise increase in
treatment, depending on disease severity.
Bronchodilators (especially inhaled ) form the
cornerstone of pharmacologic treatment for
COPD
16
3
COPD treatment options
166. Inhaled corticosteroids (ICS) are now very widely
used in high doses in the management of COPD
patients , in sharp contrast to the situation in
asthma
16
6
170. ICS/LABA combination therapy
Inhaled steroids not licensed for use in
COPD except as combination
– ICS must be used in combination with LABA
for patients with COPD
– ICS monotherapy only FDA approved for
treatment of asthma, not COPD
17
0
171. Since COPD is usually progressive recommendations
for the pharmacological treatment of COPD reflect the
following general principles:
1. Treatment tends to be cumulative with more
medications being required as the disease state
worsens.
2. Regular treatment needs to be maintained at the same
level for long periods of time unless significant side
effects occur or the disease worsens.17
1
180. 18
0
Asthma
Asthma is a heterogeneous disease, usually characterized by chronic airway
inflammation. It is defined by the history of respiratory symptoms such as wheeze,
shortness of breath, chest tightness and cough that vary over time and in intensity,
together with variable expiratory airflow limitation. [GINA 2014]
COPD
COPD is a common preventable and treatable disease, characterized by persistent
airflow limitation that is usually progressive and associated with enhanced chronic
inflammatory responses in the airways and the lungs to noxious particles or gases.
Exacerbations and comorbidities contribute to the overall severity in individual
patients. [GOLD 2015]
Asthma-COPD overlap syndrome (ACOS) [a description]
Asthma-COPD overlap syndrome (ACOS) is characterized by persistent airflow
limitation with several features usually associated with asthma and several features
usually associated with COPD. ACOS is therefore identified by the features that it
shares with both asthma and COPD.
Definitions
