Its a slideshow helpful to understand Chronic Obstructive Pulmonary Disease & its management.

1. Clinical Discussion on
Chronic Obstructive Pulmonary Disease
DR. NAIM AL FUAD KHAN
INTERNE DOCTOR, MEDICINE UNIT -1

2. What is COPD?
 Chronic Obstructive Pulmonary disease(COPD) is
defined as a preventable and treatable disease
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.

3. Classification
 The spectrum of COPD includes-
a) Chronic Bronchitis
b) Emphysema

4. Chronic Bronchitis
Chronic bronchitis is defined as cough and sputum for
at least 3 consecutive months in each of 2 consecutive
years.
(e.g. if a person have cough and sputum production in
August, September, October of 2022 and then also in
January, February and march of 2023, this condition is
consistent with the definition, In case of any gap among
the months or between the year, it would be
inconsistent with the definition)

5. Emphysema
Emphysema is abnormal permanent enlargement of the
airspaces distal to the terminal bronchioles,
accompanied by destruction of their walls

6. Aetiology
There are some Environmental factors as well Host
factors responsible for the condition

7. Environmental Factors
1)Tobacco smoke
2) Indoor air pollution(e.g.cooking with biomass fuels)
3) Occupational exposures such as coal dust, silica and cadmium
4) Low birth weight(interferes with maximally attained lung
function in young adult life)
5) Lung growth(Childhood infections or indirect smoking may
interfere with lung functions in adult life)
6) Infections: Recurrent infections such as persistent adenovirus
infection predisposes to decline in FEV1, HIV infection is
associated with emphysema

8. Host Factors
a) Genetic factors: alpha-1 antitrypsin deficiency; other
COPD susceptible genes are likely to be identified
b) Airway hyper activity

9. Pathophysiology
COPD has both pulmonary and systemic components
Those are given below:

10. Clinical features
Symptoms:
a) Cough and sputum production: It is usually the first symptom.
haemoptysis may be associated with exacerbations
b) Breathlessness: usually prompts presentation to a health
professional.
Breathlessness should be quantified for future reference.

11. Clinical feature(contd.)
Signs:
Physical signs are often non specific and poorly correlate with
lung function.
a) Breath sound: vesicular with prolonged expiration
b) Cracles: May be accompanied by infections
c) Features of right heart failure may develop(pitting peripheral
edema, raised jugular venous pressure)

12. Clinical features(Contd.)
Two classical phenotypes have been described regarding the
presentation of COPD
a) Pink Puffers: Typically thin and breathless and maintain a
normal PaCO2 until late stage of disease
b) Blue Bloaters: These patients develop hypercapnia earlier
and may develop oedema and secondary polycythaemia

13. Additional clinical features in severe disease
 Weight loss
 Muscle mass loss
 Anorexia
 Ankle swelling(cor pulmonale)
 Depression/anxiety

14. Clinical indicators for considering a diagnosis of COPD
Dyspnea that is-
 Progressive over time
 Worse with exercise
 Persistent
Recurrent wheeze
Chronic cough- May be intermittent and and may be unproductive
Recurrent lower respiratory tract infections
History of risk factors
 Tobacco smoke
 Occupational dust, vapors, fumes etc

15. Differential Diagnosis of COPD
COPD-
 Symptoms slowly progressive
 History of tobacco smoking or other risk factors
Asthma-
 Variable airflow obstruction
 Symptoms vary widely from day to day
 Symptoms worsen at night/early morning
 Allergy, Rhinitis, and/or eczema also present
 Often occurs in children
 Family history of asthma

16. D/D of COPD
Congestive heart failure-
 Chest x-ray shows dilated heart, pulmonary edema
 Pulmonary function tests indicate volume restriction,
not airflow obstruction

17. D/D of COPD
Bronchiectasis-
 Large volumes of purulent sputum
 Commonly associated with bacterial infection
 Chest x-ray/HRCT shows bronchial dilatation

18. D/D of COPD
Tuberculosis-
 Onset in all ages
 Chest x-ray shows lung infiltrate
 Microbiological confirmation
 High local prevalence of tb

19. D/D of COPD
Obliterative bronchiolitis
 Can occur in children
 Seen after lung or bone marrow transplantation
 HRCT on expiration shows hypodense areas
Diffuse panbronchiolitis
 Predominantly seen in Asian descent
 Most patients are male and non smokers
 Almost all have chronic sinusitis
 Chest x-ray and HRCT show diffuse small centrilobular nodular
opacities and hyperinflation

20. Investigations
Spirometry:
Forced spirometry by far the most reproducible and objective
measurement of airflow obstruction .
Preparation:
 supervisor needs optimal training
 Maximal patient effort is required
Performance:
 The pause between inspiration and expiration should be less
then 1 second
 Both FVC and FEV1 should be the largest value obtained from
any of three technically satisfactory attempt and should vary
by no more than 5% or 150 ml, whichever is greater

21. Spirometry
Bronchodilatation:
Dosage protocol:
 400mcg SABA or
 160mcg short acting anti cholinergic(e.g. ipratropium)
 Or two combined
FEV1 should be measured 10-15 minutes after SABA
Or 30-45 minutes after administration of short acting anti
cholinergic or combination drugs

22. Spirometry
Evaluation:
 The presence of a post bronchodilator FEV1/FVC< 0.7 confirms the
presence of non fully reversible airflow obstruction
GOLD GRADES and severity of airflow obstruction in COPD:
GOLD 1: MILD FEV1>=80% predicted
GOLD 2: MODERATE 50%<=FEV1<80%
predicted
GOLD 3: SEVERE 30%<=FEV1<50%
predicted
GOLD 4: VERY SEVERE FEV1<30% predicted

23. Dyspnea assessment
Dyspnea is assessed by modified MRC dyspnea scale
which is stated below:
mMRC Grade 0 mMRC Grade 1 mMRC Grade 2 mMRC Grade 3 mMRC Grade 4
I only get
breathless with
strenous exercise
I get short of
breath when
hurrying on the
level or walking up
a slight hill
I walk slower than
people of the same
age on the level
because of
breathlessness and
have to stop for
breath
I stop for breath
after walking 100
meters or after a
few minutes on the
level
I am too breathless
to leave the house
or I am breathless
when I am dressing
or undressing

25. GOLD ABE Assessment Tool
Spirometrically
confirmed
diagnosis
Assessment of
airflow
obstruction
Assessment of
symptoms/risk
of exacerbation
Post
bronchodilaror
FEV1/FVC<0.7
Exacerbation
history
More than or
equal 2
moderate
GOLD
1
>= 80
GOLD 2 50-79
GOLD 3 30-49
GOLD 4 <30

27. Treatment
Prevention and Maintenance therapy:
 Smoking cessation
 Vaccinations
1. Influenza vaccine is recommended in people with COPD
2. SARS-CoV-2 Vaccination in recommended by WHO
3. CDC recommends Pneumococcal conjugate vaccine (20
valent or 15 valent) it has been shown to reduce incidents of
community acquired pneumonia and exacerbations in COPD
4. dTpa is also recommended

28. Pharmacological Therapy for Stable
COPD
Bronchodilators:
They increase FEV1 and other spirometric variables. Acts by
altering airway smooth muscle tone and improves expiratory
flow and also tend to reduce dynamic hyperinflation at rest and
during exercise.
Commonly prescribed are:
Beta2 agonists:
SABA(effects wear off 1-6 hours after administration)
LABA(effects are more than 12 hours after administration)
Adverse effects include sinus tachycardia, exaggeration of
somatic tremor

29. Treatment(contd)
Anti muscarinic drugs:
 Short acting anti muscarinic drugs(SAMA)e.g:
Ipratropium, oxitropium
 Long acting anti muscarinic drugs(LAMA) e.g.
tiotropium, aclidinium,glycopyrronium
Side effects: Main side effect is dryness of the mouth

30. Treatment(contnd.)
Methyxanthines:
Controversy remains about the effects of xanthine
derivatives.
They act as non selective phosphodiesterase inhibitors.
(Theophylline is commonly used methyxanthine)
Combination bronchodilator:
Combinations increase degree of bronchodilation
Such as SABA+SAMA , LABA+ LAMA
Studies showed that LABA+LAMA combination therapy
results in low rate of exacerbation

31. Treatment
Anti inflammatory therapy:
Inhaled corticosteroids:
An ICS combined with LABA is more effective than the
individual components
But regular treatment with ICS increase the risk of
pneumonia in very severe disease
Tripple inhaled therapy of LAMA+LABA+ICS improves
lung function, symptoms and health status and reduces
exacerbations

32. Factors to consider when initiating ICS treatment
Strongly favors use:
 History of hospitalization for exacerbations of COPD
 More than or equal 2 moderate exacerbation per year
 Blood eosinophil more than or equal to 300 cells/microlitre
 History of concomitant asthma
Favors use:
 1 moderate exacarbation of COPD per year
 Blood eosinophils 100 to less than 300
Against use:
Repeated pneumonia events
Blood eosinophills less than 100
History of mycobacterium infection

33. Other pharmacological therapies

34. Interventional Therapy in stable COPD
 Lung volume reduction surgery
 Bullectomy
 Transplantation
 Bronchoscopic Interventions

35. Management of COPD

36. Goals for treatment of Stable COPD

37. Initial Pharmacological Treatment

38. Initial pharmacological management
according to group
 Group-A
All patient should be offered bronchodilators based on its effect on
breathlessness
 Group-b
Treatment should be with LAMA+LABA
 Group E
LABA+LAMA is the choice, If eos>300 LABA+LAMA+ICS is recommended

39. Followup Pharmacological Treatment

40. Acute exacerbations of COPD
Presentation: Increasing cough, breathlessness or wheeze, Decreased exercise
capacity
D/D: Acute exacerbation of asthma
Acute pulmonary edema

43. Thank You