This is my 27th powerpoint............its on CASE STUDY ON COPD......... This powerpoint contains precise details on COPD...and its management....along with newer drugs introduction.... At the same time, I have also include SOAP ANALYSIS on a patient that was suffering with COPD, that I encountered in my ward rounds ............So , through this powerpoint, members can get a precise idea on the disease, and also get an idea on how to deal with cases related to COPD............... Do go through this...and submit ur reviews! Thank you, Vishnu.

1. PRESENTED BY,
VISHNU.R.NAIR,
NATIONAL COLLEGE OF PHARMACY(NCP).

2. COPD: A BRIEF INSIGHT

3. “ COPD refers to a group of LUNG DISEASES, that
block airflow, and make breathing difficult(includes
CHRONIC BRONCHITIS & EMPHYSEMA)”. . .

4. 1. TWO-THIRDS of men, and ONE-FOURTH of women have emphysema at
death(as per US statistics)
2. COPD is the FOURTH LEADING CAUSE of DEATH in the US
3. It is the sixth leading cause of death worldwide. . .

5. 1. Tobacco abuse
2. ALPHA-1-ANTITRYPSIN DEFICIENCY
3. CYSTIC FIBROSIS
4. Air pollution
5. Occupational exposure
6. Bronchiectasis. . .

6. A. OF CHRONIC BRONCHITIS:
- Chronic Bronchitis is defined as “excessive mucus production, with airway
obstruction and hyperplasia of mucus-producing glands”
- Endothelial damage impairs mucociliary response(that clears bacteria and
mucus)  increased inflammation and secretions occur  body responds by
REDUCING VENTILATION and INCREASING CARDIAC OUTPUT causes
HYPOXEMIA, POLYCYTHEMIA  HYPERCAPNIA and respiratory acidosis
develops  leads to PULMONARY ARTERY CONSTRICTION and COR
PULMONALE.
- Increased CO retention occurs
- Such people are known as “BLUE BLOATERS”. . .

7. B. OF EMPHYSEMA:
- EMPHYSEMA is defined as “destruction of airways, that are
distal to terminal bronchiole”.
- Gradual destruction of alveolar septae & pulmonary
capillary bed  reduces ability of lungs to OXYGENATE
BLOOD  Body compensates by reducing CARDIAC
OUTPUT & causing HYPERVENTILATION Causes
LIMITED BLOOD FLOW Rest of the body suffers from
tissue hypoxia and pulmonary cachexia causes muscle
wasting and weight loss such people are identified as
“PINK PUFFERS”. . .

8. 1. SOB(especially during EXERTION)
2. Chest-tightedness
3. Wheezing
4. Chronic productive cough
5. Cyanosis
6. Weight loss. . .

9. 1. PFTs
2. Chest X-RAY
3. ABG ANALYSIS
4. SPUTUM TESTS.
5. HEMATOLOGICAL TESTS.

10. 1. To ALLEVIATE the disability associated with AIRWAY OBSTRUCTION
2. To reduce ADRs associated with the therapy given
3. To reduce MORBIDITY & MORTALITY
4. To avoid PROGRESSION into COMPLICATIONS
5. To improve HRQoL. . .

11. I. BETA-2 AGONISTS:
- Drugs  potentiate beta-2-receptors on bronchial smooth muscles reduce
muscle tone in lungs, along with relieving of BRONCHOSPASM, by relaxing
smooth muscles of bronchi improves ventilation, and reduces airway resistance
- ADRs:
i. Tremor
ii. Nervousness
iii. Tachycardia
- Drugs include:
i. TERBUTALINE SULPHATE(BRICANYL)
ii. ALBUTEROL(PROVENTIL)

12. iii. SALMETEROL
iv. FORMOTEROL . . .
II. METHYLXANTHINES:
- Drug  increases CYCLIC-AMP LEVELS by blocking PDE-3 relaxes
bronchial smooth muscles(bronchodilatation)
- ADRs:
i. Tremor
ii. Tachycardia
- Drugs include:
i. THEOPHYLLINE(THEO-24) iv. AMINOPHYLLINE. . .
ii. ETIDOPHYLLINE
iii. ACEBROPHYLLINE

13. III. ANTI-CHOLINERGICS:
- Usually have slow effects, and used in combination with corticosteroids, or beta-
agonists for LONG TERM MAINTENANCE THERAPY OF COPD
- Drug  blocks action of ACETYLCHOLINE  causes relaxation of bronchial
smooth muscle
- ADRs:
i. Constipation
ii. Blurred vision
- Drugs include:
i. IPRATROPIUM BROMIDE(ATROVENT)
ii. TIOTROPIUM BROMIDE(SPIRIVA). . .

14. IV. CORTICOSTEROIDS:
- Used to ACCELERATE RECOVERY from COPD EXACERBATION
- ANTI-INFLAMMATORY PROPERTY of drugs in concern is EXPLOITED HERE
- ADRs:
i. Cataract
ii. Glaucoma
iii. Weight gain
iv. High risk of infections, etc . . .
- Drugs include:
i. METHYLPREDNISOLONE(MEDROL)
ii. PREDNISOLONE
iii. BUDESONIDE(INHALATION)

15. V. PHOSPHODIESTERASE-4 INHIBITORS:
- Reduce exacerbations, and improve dyspnea
- Improve lung function in patients with severe COPD
- Drug includes ROFLUMILAST(DALIRESP)
- ROFLUMILAST  blocks PDE-4 increases CYCLIC AMP in lung cells 
reduces frequency of exacerbations and worsening of symptoms from severe
COPD
- ADRs:
i. Weight loss
ii. Anorexia
iii. Backache. . .

16. VI. ELECTROLYTE SUPPLEMENTS:
- MAGNESIUM  replenishes stores that become depleted in periods of
ADRENERGIC EXCESS(like asthma, COPD, etc)
- MAGNESIUM SULPHATE is used
- Drug  counteracts CALCIUM-MEDIATED SMOOTH MUSCLE
CONTRACTION produces BRONCHODILATATION,
- ADRs:
i. Hypothermia
ii. Flushing
iii. Hypocalcemia. . .

17. VII. ANTIMICROBIAL THERAPY:
- Mainly effective in COPD exacerbation, under the following CONDITIONS:
1. Increased dyspnea
2. Increased sputum volume
3. Increased sputum purulence
- Treatment is based on MOST LIKELY OFFENDING MICROBES
- ORGANISMS include:
1. H.influenzae
2. Moraxella catarrhalis
3. S.pneumoniae
4. H.parainfluenzae
- Therapy should be started within 24 HOURS OF SYMPTOMS, and INITIATED
FOR 7-10 DAYS.

18. - For UNCOMPLICATED COPD EXACERBATIONS, use the following:
i. MACROLIDES( AZITHROMYCIN, CLARITHROMYCIN)
ii. 2nd / 3rd GENERATION CEPHALOSPORINS
iii. DOXYCYCLINE
- For COMPLICATED COPD EXACERBATIONS(including RESISTANCE), use
the following:
i. AMOXICILLIN+ CLAVULANATE
ii. FLUOROQUINOLONES(LEVOFLOXACIN, GEMIFLOXACIN,
MOXIFLOXACIN). . .

19. VII. NEWER DRUGS FOR COPD:
1. ACLIDINIUM(TUDORZA PRESSAIR):
- LONG ACTING SELECTIVE M3-ANTAGONIST (LAMA)
2. INHALED INDACATEROL(ARCAPTA NEOHALER):
- LABA(LONG ACTING BETA-2-AGONIST)
3. UMECLIDINIUM BROMIDE(ANDRO ELLIPTA):
- LAMA
4. VILANTEROL INHALED(ANDRO ELLIPTA):
- LABA
5. GLYCOPYRROLATE INHALED(SEEBRI NEOHALER):
- LAMA. . .

20. I. LUNG THERAPIES:
- Oxygen therapy
- Pulmonary rehabilitation programs
II. SURGERY:
- Lung volume reduction therapy
- Lung transplantation
III. HOME REMEDIES FOR COPD:
- FOR EMPHYSEMA:
1. Stop smoking
2. MUSTARD OIL+ CAMPHOR chest massage combination, to reduce chest
tightedness and breathing difficulties

21. - FOR CHRONIC BRONCHITIS:
1. Onion juice consumption
2. Turmeric powder+ a glass of milk every morning
3. Almonds(crushed)+ lemon juice. . .
IV. PATIENT COUNSELLING TIPS:
1. Avoid smoking
2. Avoid exposure to allergens & pollution
3. Avoid fermented foods
4. Have raisins+ honey
5. Focus on eating well, with justifiable diet
6. Avoid oily& fried foods
7. Annual vaccination with inactivated influenza vaccine. . .

22. SOAP ANALYSIS ON
COPD

23.  SEVERE COPD
 EMPHYSEMA
 RESPIRATORY FAILURE
 COR PULMONALE. . .

24. I. PATIENT DETAILS:
Name: Mrs.X
Age: 65 yrs
Sex: Female
IP NO.: 198044
Department: Pulmonology
Weight: 48 kgs
Height: 160 cm
BMI: 18.92
DOA : 15/10/2016
DOD: 21/10/2016. . .

25. II. REASON FOR ADMISSION:
Patient had c/o :
1.Breathlessness(for 2 days)
2. Fever(For 1 week)
3. Cough(For 1 week)
4. 1 episode of vomiting. . .
III. PAST MEDICAL HISTORY:
1. K/C/O COPD(on DOMICILIARY OXYGEN for 25 years)
2. K/C/O RESPIRATORY FAILURE. . .
3. H/O TB (15 years back, took Rx for 1 year). . .
IV. FAMILY HISTORY: Nil. . .
V. KNOWN ALLERGIES: Allergic to cold. . .

26. VI. FOOD HABITS: Non-vegetarian
VII. SOCIAL HABITS: Non-smoker, non-alcoholic. . .

27. I. VITALS CHART:
DATE 15/10 16/10 17/10 18/10 19/10 20/10 21/10
TEMP(in
degree F)
N N N N N N N
B.P(in mm
Hg)
110/70 100/60 110/70 140/80 130/80 130/80 130/70
PULSE(in
beats/min)
118 100 112 112 86 102 74
FBS(in
mg/dl)
105
RR(in
breaths/mi
n)
24 26 24 22 22 22 22
SPO2(in %) 99 96 90 95 90 92 94

28. II. HEMATOLOGICAL ANALYSIS:
1. Hb: 8 g/dl
2. TLC: 12,600 cells/cumm
3. ESR: 80 mm/hr
4. Platelets: 6,50,000 cells/cumm
5. RBC : 4,21,000 cells/cumm
6. DLC:
i. Polymorphs: 73%
ii. Lymphocytes: 20%
iii. Eosinophils: 7%. . .

29. III. LFT ANALYSIS:
i. Total bilirubin: 0.49 mg%
ii. Albumin: 3 g/dl
iii. Globulin: 3.9 g/dl
iv. Total protein: 6.9 g/dl
v. SGPT: 35 IU/L
vi. SGOT: 53 IU/L. . .

30. IV. RFT ANALYSIS:
i. Urea: 14 mg%
ii. Uric acid: 1.5 mg/dl
iii. Serum creatinine: 0.9 mg/dl. . .
V. ELECTROLYTES:
i. Sodium: 134 mEq/L
ii. Potassium: 3.4 mEq/L
iii. Calcium: 7.52 mEq/L. . .

31. VI. OTHERS:
1. Edema: positive
2. Pallor: positive
3. JVP: Increased
4. RS: Crepts(++)
5. Clubbing: +ve
6. B/L wheeze: +ve
7. HR-CT of thorax:
- Shows diffuse emphysematous changes in B/L lung field, & pleural thickening in
left lower lobe & right middle lobe. . .

32. 1. DIAGNOSIS:
- Severe COPD
- Emphysema
- Respiratory failure
- Cor pulmonale. . .
2. ASSESSMENT, IF THERAPY INDICATED:
i. To treat current conditions of severe COPD, emphysema and Cor-pulmonale
ii. To improve HRQoL

33. 3. ASSESSMENT OF CURRENT MEDICATIONS:
i. INJ. LASIX(FUROSEMIDE); 40 mg i.v; stat(D1):
- INDICATION: Diuretic, to treat edema & right ventricular volume filling
changes(for Cor Pulmonale)
ii. INJ. EFCORLIN( HYDROCORTISONE); 100 mg i.v; stat(D1):
- INDICATION: Corticosteroid, to treat inflammation associated with COPD
- Also reduces COPD exacerbations
iii. INJ.PAN (PANTOPRAZOLE); 40 mg i.v; stat(D1):
- INDICATION: PPI, that works to reduce gastric irritation(generalized).
iv. INJ. EMESET(ONDANSETRON); 4 mg i.v; stat(D1):
- INDICATION: Anti-emetic, that works to reduce emesis(N&V)
v. INJ. IVPRED(METHYLPREDNISOLONE); 4 mg i.v, (D1-D6):
- INDICATION: Corticosteroid, to attenuate COPD exacerbations; anti-
inflammatory.

34. vi. T.MUCINAR(ACETYLCYSTEINE); 5 mg OD; (D1-D7):
- INDICATION: Potent MUCOLYTIC, that reduces mucus viscosity.
vii. T. MONTEK-AB( MONTELUKAST+ACEBROPHYLLINE); 5 mg OD; (D2-D4):
- INDICATION: Leukotriene receptor antagonist+ bronchodilator combination,
that work to reduce inflammatory processes, and enhance bronchodilatation, by
relaxation of bronchial smooth muscles.
viii. T. DULCOLAX(BISACODYL SULFATE) ; 5 mg OD; (D3-D4):
- INDICATION: Increases laxative property, helps to treat constipation.
ix. NEB. SALBAIR-I(SALBUTAMOL+ IPRATROPIUM BROMIDE); (500+2.5 mcg)
Q6H; (D1-D7):
- INDICATION: Combination of beta-2-agonist and anticholinergic medications,
used for LONG TERM MAINTENANCE OF COPD.
x. T. ZOLFRESH(ZOLPIDEM); 5 mg OD, HS; (D3-D7):
- INDICATION: Produces SEDATION(induces sleep).

35. xi. INJ. MONOCEF(CEFTRIAXONE), 1 g i.v, BD; (D1):
- INDICATION: 3RD generation cephalosporin, used to treat COPD
EXACERBATION.
xii. C. LIVOGEN(FERROUS FUMARATE+ FOLIC ACID), 1500 mcg OD; (D4-D7):
- INDICATION: To treat ANEMIA(justifiable in this patient, who is with 8g/dl Hb
count).
xiii. NEB.FORACORT(BUDESONIDE+ FORMOTEROL), (400+6 mcg) BD; (D1-
D7):
- INDICATION: Bronchodilator+ corticosteroid combination, used in the long term
management of COPD
xiv. T. AZEE(AZITHROMYCIN), 500 mg OD, (D2-D5)
- INDICATION: Macrolide antibiotic, that is bacteriostatic, and exploited for COPD
exacerbation
- Use of this drug is justified here, since the patient is not resistant to this drug,
which is a major complication of antimicrobial therapy in COPD patients.

36. xv. ATPRO DHA POWDER(PROTEIN POWDER); 2 tsp TID; (D3-D7):
- INDICATION: Protein supplement, justifiable in COPD patients, since patients
with SEVERE COPD will be malnourished. . .
xvi. BIPAP (NON-INVASIVE VENTILATOR); (D1-D7):
- INDICATION: Used in respiratory failure and COPD exacerbation. . .

37. DRUG DOSE 15/10 16/10 17/10 18/10 19/10 20/10 21/10
Inj.Lasix 40 mg i.v
stat
Y
Inj.
Efcorlin
100 mg i.v
stat
Y
Inj.Pan 40 mg i.v
stat
Y
Inj.Emese
t
4 mg i.v
stat
Y
Inj. Ivpred 4 mg i.v Y Y Y Y Y Y
T.
Mucinar
600 mg Y Y Y Y Y Y Y
T. Montek-
AB
5 mg OD Y Y Y
T.
Dulcolax
5 mg Y Y
T. Azee 500 mg Y Y Y Y

38. INJ.MON
OCEF
1 g i.v BD Y
C.
LIVOGEN
1500 mcg
OD
Y Y Y Y
NEB.
FORACO
RT
(400+6)
mcg
Y Y Y Y Y Y Y
NEB.SAL
BAIR-I
(500+2.5)
mcg BD
Y Y Y Y Y Y Y
ATPRO
DHA
2 tsp TID Y Y Y Y Y
BIPAP Y Y Y Y Y Y Y

39. PROGRESS CHART:
15/10/2016:
- Edema (+ve), crepts(+ve), B/L wheezing(+ve)
16/10/2016:
- Patient felt better, reduced edema, crepts(+ve)
17/10/2016:
- Persistent cough, blood transfusion done, slept well
18/10/2016:
- Persistent cough, reduced breathlessness, c/o no motions for 2 days
19/10/2016:
- Symptomatically better, crepts(+ve)
20/10/2016:
- Patient felt better and no fresh complaints
21/10/2016:
- Patient felt better, and was discharged appropriately. . .

40. DISCHARGE SUMMARY:
A 65 yr old female, with k/c/o COPD, respiratory failure, emphysema, H/O TB,
allergic to cold, was presented with high breathlessness, exacerbation for 2 days,
cough & fever for 1 week, with 1 episode of vomiting.
Patient was diagnosed to have severe COPD, emphysema, respiratory failure, Cor-
pulmonale, and anemia.
Patient was treated with i.v antibiotics, steroids, inhalers and bronchodilators.
Patient felt symptomatically better at the time of discharge. . .

41. DISCHARGE ADVICE:
1. DUOLIN(R/C) , TID for 1 week
2. T. PAN (DSR), 40 mg OD, for 1 week
3. Cap. Livogen , 800 mcg for 1 week
4. T.Montek, 5 mg OD, for 1 week
5. Increase protein and calorie intake
6. Avoid exposure to allergenic environments
7. Review after 1 week. . .

42. DRUG-BASED COUNSELLING:
1. Patient should have proper knowledge on how to use ROTAHALERS
2. Avoid dose missing
3. Use ROTAHALERS TID, with a time interval of 4 hrs, between each
administration
4. Avoid overdosing, since the contents in ROTAHALERS have potentiality to
cause severe ADRs
5. Consume PAN-DSR 30 mins before food
6. Medication adherence is necessary to prevent disease worsening. . .

43. DISEASE-BASED COUNSELLING:
1. Avoid contact with allergens & polluted environment
2. Avoid fermented foods
3. Avoid dairy products
4. Avoid stress
5. Do breathing exercises(especially deep breathing)
6. Avoid oily& fried foods
7. Steam inhalation with eucalyptus/lavender essential oils
8. Chest massage with mustard oil+ camphor
9. Increase intake of calories
10. Keeping air purifiers also helps
11. Consume raisins with honey
12. Drink ginger tea/ green tea with little black pepper powder+ honey daily. . .

44. THANK YOU!!!!!