COPD ILLNESS

1. COPD
Islam Ibrahim, MD, FACP, FCCP,
Associate professor of Pulmonary and Critical
care medicine,
University of California San Diego, USA.
Consultant ICU, IMC, KSA.
imibrahim@ucsd.edu
iibrahim@imc.med.sa

2. (COPD)
DEFINITION
•A common, preventable and treatable
disease that is characterized by persistent
respiratory symptoms and airflow
limitation that is due to airway and/or
alveolar abnormalities usually caused by
significant exposure to noxious particles
or gases.

6. Symptoms

7. Pathology
•Airways
•parenchyma
•vasculature.

8. Chronic
inflammation

14. Gas trapping - Hyperinflation
Airflow limitation
Pathology

15. Gas exchange
Hypoxemia
Hypercapnia

16. Gas exchange
hypoxemia
Hypercapnia

17. Pathology
Pulmonary Vasculature

18. Pathology
pulmonary
Vasculature
Hypoxic vasoconstriction

19. Pathology
pulmonary
Vasculature
Pulmonary hypertension.
Hypoxic vasoconstriction

20. Pathology
pulmonary
Vasculature
Right ventricular hypertrophy
Pulmonary hypertension.
Hypoxic vasoconstriction

21. Pathology
pulmonary
Vasculature
Right ventricular hypertrophy
Pulmonary hypertension.
Hypoxic vasoconstriction
Right-side cardiac failure.

23. COPD
Diagnosis

24. COPD
Diagnosis

25. COPD
Diagnosis

26. COPD
Diagnosis

28. COPD
diagnosis

29. Lung volumes

30. D L C O

31. Diagnosis Severity

32. Diagnosis Severity

33. COPD Phenotypes
• Alpha-1 antitrypsin deficiency
• Emphysema/ hyperinflation
• Frequent exacerbators
• Mild airway obstruction but disproportionately severe dyspnea
• Rapid lung function decline
• Comorbidities
• Persistent inflammation, CRP, fibrinogen, WBC
• Chronic bacterial airway colonization
• Lung cancer phenotype
• Severe pulmonary hypertension
• Non-smokers
• Overlap of symptoms between asthma and COPD

34. COPD Severity
exacerbation risk
>2 exacerbations / year

35. GOLD 3 and 4
Deteriorating
airflow

36. GOLD 3 and 4
Deteriorating
airflow

37. Differential
diagnosis
• Asthma
• Congestive Heart Failure
• Bronchiectasis
• Tuberculosis
• Obliterative Bronchiolitis
• Diffuse Panbronchiolitis
• Alpha-1 antitrypsin deficiency

41. COPD
Diagnosis

43. Stable COPD
management strategy

44. stable COPD
management
strategy
> Health status
• < symptoms
• > exercise tolerance

45. stable COPD
management
strategy
> Health status
• < symptoms
• > exercise tolerance
REDUCE RISK
• < COPD progression
• < exacerbations
• < mortality

46. COPD
PREVENTION
Smoking
cessation

47. PREVENTION
AND
MAINTENANCE
THERAPY
Smoking
cessation
Inhaler
technique

48. PREVENTION
AND
MAINTENANCE
THERAPY
Smoking
cessation
Inhaler
technique
Influenza
vaccination
Pneumococcal
vaccination

49. PREVENTION
AND
MAINTENANCE
THERAPY
Smoking
cessation
Inhaler
technique
Influenza
vaccination
Pneumococcal
vaccination
Pulmonary
rehabilitation

50. PREVENTION
AND
MAINTENANCE
THERAPY
Smoking
cessation
Inhaler
technique
Influenza
vaccination
Pneumococcal
vaccination
Pulmonary
rehabilitation
Oxygen
therapy

51. PREVENTION
AND
MAINTENANCE
THERAPY
Smoking
cessation
Inhaler
technique
Influenza
vaccination
Pneumococcal
vaccination
Pulmonary
rehabilitation
oxygen
therapy
non-invasive
ventilation

52. PREVENTION
AND
MAINTENANCE
THERAPY
Smoking
cessation
Inhaler
technique
Influenza
vaccination
Pneumococcal
vaccination
Pulmonary
rehabilitation
oxygen therapy
non-invasive
ventilation
surgical or
bronchoscopic interventional treatments

54. Brief strategies to help the patient willing to quit

55. Brief strategies to help the patient willing to quit
• ASK:
• ADVISE:
• ASSESS:
• ASSIST:
• counseling
• pharmacotherapy
• ARRANGE:
• follow up

56. Treating tobacco
dependence
cost effective
Effective treatments exist
• should be offered Evidence A
• Documentation at every visit.
counseling is effective- every contact
• Practical
• social support
• pharmacotherapies
• varenicline,
• bupropion
• nicotine
• gum
• inhaler,
• nasal spray
• patch
Financial incentive programs

57. PHARMACOLOGIC
THERAPY FOR
STABLE COPD

58. PHARMACOLOGIC
THERAPY FOR
STABLE COPD
Reduce
Symptoms
Exacerbations

59. PHARMACOLOGIC
THERAPY FOR
STABLE COPD
Reduce
Symptoms
Exacerbations
Improve
Exercise tolerance
Health status.

60. PHARMACOLOGIC
THERAPY FOR
STABLE COPD
Reduce
Symptoms
Exacerbations
Improve
Exercise tolerance
Health status.
Modify decline in lung function.
No evidence

61. Inhalation drugs

62. Individually
tailored
Cost,
Patient’s
preference.
Inhalation drugs

63. Proper technique
Check at each visit
Individually tailored
Cost,
Patient’s
preference.
Inhalation drugs

64. Adherence
Proper technique
Check at each visit
Individually tailored
Cost, Patient’s preference.
Inhalation drugs

65. Beta 2
Agonists
SABA
• Formoterol
• Salmeterol
• Indacaterol
• Oladaterol
• Vilanterol
LABA

66. Beta 2
Agonists
Adverse
effects.
Sinus
tachycardia
tremors

67. Anti muscarinic
M3 muscarinic receptors
in airway smooth muscle.

68. Anti muscarinic
M3 muscarinic receptors
in airway smooth muscle.
SAMA
Ipratropium
Oxitropium

69. Anti muscarinic
M3 muscarinic receptors
in airway smooth muscle.
SAMA
Ipratropium
Oxitropium
LAMA
Tiotropium
Aclidinium
Glycopyrronium
Umeclidinium

70. Anti
muscarinic
Adverse effects.

71. Regular Use of SABA

72. Methylxanthines

73. Methylxanthines
Toxicity

74. Combination
bronchodilator
therapy

75. SABA and
SAMA
Salbutamol /
ipratropium
Superior

76. LABA- LAMA
formoterol - tiotropium
• bigger impact on FEV1 than
either component alone
1

77. Comb.
LABA- LAMA
Formoterol / aclidinium
Formoterol / glycopyrronium
Indacaterol / glycopyrronium
Vilanterol / umeclidinium
Olodaterol / tiotropium

78. LABAs and LAMAs > SABAs
• Evidence A
1 bronchodilator - escalate to 2
• Evidence A
Inhaled bronchodilators > oral
• Evidence A
Theophylline is not recommended
• Evidence B
Bronchodilators.

79. LABAs and LAMAs > short acting
agents
• Evidence A
1 bronchodilator - escalate to 2
• Evidence A
Inhaled bronchodilators > oral
• Evidence A
Theophylline is not recommended
• Evidence B
Bronchodilators.

80. LABAs and LAMAs > short acting
agents
• Evidence A
1 bronchodilator - escalate to 2
• Evidence A
Inhaled bronchodilators > oral
• Evidence A
Theophylline is not recommended
• Evidence B
Bronchodilators.

81. LABAs and LAMAs > short acting
agents
• Evidence A
1 bronchodilator - escalate to 2
• Evidence A
Inhaled bronchodilators > oral
• Evidence A
Theophylline is not recommended
• Evidence B
Bronchodilators.

82. Anti inflammatory
agents

83. Anti inflammatory agents
•ICS Long term monotherapy
•is not recommended
•Evidence A

84. ICS / LABAs
for
patients with
exacerbations
Evidence A

85. Combination
LABA - ICS
Formoterol /
beclomethasone
Formoterol / budesonide
Formoterol / mometasone
Salmeterol / fluticasone
Vilanterol / fluticasone

86. Anti inflammatory
therapy in stable COPD

87. EVIDENCE
ICS - LABA > individual components Evidence A
Regular ICS > pneumonia Evidence A
ICS/LAMA/LABA improves lung function Evidence A
ICS/LAMA/LABA reduces exacerbations Evidence B

88. EVIDENCE
ICS - LABA > individual components Evidence A
Regular ICS > pneumonia Evidence A
ICS/LAMA/LABA improves lung function Evidence A
ICS/LAMA/LABA reduces exacerbations Evidence B

89. EVIDENCE
ICS - LABA > individual components Evidence A
Regular ICS > pneumonia Evidence A
ICS/LAMA/LABA improves lung function Evidence A
ICS/LAMA/LABA reduces exacerbations Evidence B

90. EVIDENCE
ICS - LABA > individual components Evidence A
Regular ICS > pneumonia Evidence A
ICS/LAMA/LABA improves lung function Evidence A
ICS/LAMA/LABA reduces exacerbations Evidence B

91. EVIDENCE
ICS - LABA > individual components Evidence A
Regular ICS > pneumonia Evidence A
ICS/LAMA/LABA improves lung function Evidence A
ICS/LAMA/LABA reduces exacerbations Evidence B

92. anti
inflammatory
agents

93. anti
inflammatory
agents
Long term –oral corticosteroids

94. anti
inflammatory
agents
is not recommended
Long term –oral corticosteroids

95. anti
inflammatory
agents
Evidence A
is not recommended
Long term –oral corticosteroids

96. Anti Inflamatory
Phosphodiesterase-4 inhibitors
Roflumilast

97. Anti Inflamatory
Phosphodiesterase-4 inhibitors
Roflumilast

98. WHO ?
Severe airflow obstruction
Exacerbations despite comb.

99. Bronchodilators in stable COPD
Regular Inhaled bronchodilators Evidence A
SABA or SAMA Evidence A
SABA and SAMA are superior Evidence A
LABAs and LAMAs Evidence A
LAMAs < exacerbation LABAs Evidence A
LABA - LAMA > monotherapy Evidence A
LABA - LAMA > ICS/LABA Evidence B
Tiotropium improves exercise performance Evidence B
Theophylline small bronchodilator effect Evidence A

100. Mucolytics
NAC

101. Mucolytics
NAC

102. Simvastatin

103. Simvastatin

105. Antibiotics

106. Long term azithromycin and erythromycin
reduces exacerbations
Evidence A
Antibiotics

107. Long term azithromycin and erythromycin
reduces exacerbations
Evidence A
increased bacterial resistance
Evidence A
Antibiotics

108. Evidence B
Alpha 1 antitrypsin
augmentation therapy
• slow down the progression
of emphysema

109. alpha-1 antitrypsin augmentation therapy
severe deficiency emphysema
Evidence B

110. other
pharmacologic
treatments.
Evidence
B
opioids - dyspnea -severe disease
Evidence
B
primary pulmonary hypertension Drugs
are not recommended
Evidence
C
Antitussives not recommended

113. Pulmonary Rehabilitation
Evidence A Improves
• Dyspnea,
• Health status
• Exercise tolerance
reduces hospitalizations Evidence B

114. Oxygen therapy
Evidence A
increases survival

115. NPPV
< hospitalization
(PaCO₂ ≥ 52
Evidence B
< morbidity and mortality

118. lung
transplantation
Evidence C
Very severe COPD
> quality of life
> functional capacity.

120. PALLIATIVE, END-OF-LIFE & HOSPICE CARE
•Symptom control
•Palliative approaches
•less than 6 months to live.

121. PALLIATIVE,
END-OF-LIFE
& HOSPICE
CARE
Opiates
oxygen
Evidence A
fans
Evidence C
nutritional supplementation Evidence B