Chronic obstructive pulmonary disease (COPD) refers to a group of lung diseases including emphysema and chronic bronchitis that cause airflow blockage and breathing problems. COPD is usually caused by smoking and long-term exposure to other lung irritants. It progressively worsens over time and is characterized by symptoms like shortness of breath, cough, wheezing, and mucus production. While incurable, COPD can be managed through lifestyle changes, medications, oxygen therapy, pulmonary rehabilitation, and sometimes surgery to improve quality of life. Proper treatment aims to control symptoms and prevent exacerbations that can further damage the lungs.

1. Chronic Obstructive
Pulmonary Disease
(COPD)
Presented by: Dr. Serena Rambaran M.D

2. What is COPD?
Chronic obstructive pulmonary disease, or COPD, refers to a group of diseases that
cause airflow blockage and breathing-related problems. It includes emphysema and
chronic bronchitis.
Chronic bronchitis is inflammation of the lining of the bronchial tubes, which carry air
to and from the air sacs (alveoli) of the lungs. It's characterized by daily cough and
mucus (sputum) production.
Emphysema is a condition in which the alveoli at the end of the smallest air passages
(bronchioles) of the lungs are destroyed as a result of damaging exposure to cigarette
smoke and other irritating gases and particulate matter.
Although COPD is a progressive disease that gets worse over time, COPD is treatable.
With proper management, most people with COPD can achieve good symptom
control and quality of life, as well as reduced risk of other associated conditions.

3. How your lungs are affected?
Air travels down your windpipe (trachea) and into your lungs through two large
tubes (bronchi). Inside your lungs, these tubes divide many times — like the branches
of a tree — into many smaller tubes (bronchioles) that end in clusters of tiny air sacs
(alveoli).
The air sacs have very thin walls full of tiny blood vessels (capillaries). The oxygen in
the air you inhale passes into these blood vessels and enters your bloodstream. At the
same time, carbon dioxide — a gas that is a waste product of metabolism — is
exhaled.
Your lungs rely on the natural elasticity of the bronchial tubes and air sacs to force
air out of your body. COPD causes them to lose their elasticity and over-expand,
which leaves some air trapped in your lungs when you exhale.

4. Inemphysema,the
innerwallsofthelungs'
airsacs(alveoli)are
damaged,causingthem
toeventuallyrupture.
Thiscreatesonelarger
airspaceinsteadof
manysmallonesand
reducesthesurface
areaavailableforgas
exchange.

5. Bronchitisisan
inflammationofthelining
ofyourbronchialtubes,
whichcarryairtoand
fromyourlungs.People
whohavebronchitisoften
coughupthickened
mucus,whichcanbe
discolored.

6. In COPD, less air flows in and out of the airways because of one or more of the
following:
The airways and air sacs lose their elastic quality.
The walls between many of the air sacs are destroyed.
The walls of the airways become thick and inflamed.
The airways make more mucus than usual, which tends to clog them.

7. Causes
The main cause of COPD in developed countries is tobacco smoking. In the
developing world, COPD often occurs in people exposed to fumes from burning fuel
for cooking and heating in poorly ventilated homes.
In countries like Canada, smoking causes about 80-90% of COPD cases.
Only some chronic smokers develop clinically apparent COPD, although many smokers
with long smoking histories may develop reduced lung function. Some smokers
develop less common lung conditions. They may be misdiagnosed as having COPD
until a more thorough evaluation is performed.

8. Risk Factors
Exposure to tobacco smoke. The most significant risk factor for COPD is long-term
cigarette smoking. The more years you smoke and the more packs you smoke, the
greater your risk. Pipe smokers, cigar smokers and marijuana smokers also may be at
risk, as well as people exposed to large amounts of secondhand smoke.
People with asthma. Asthma, a chronic inflammatory airway disease, may be a risk
factor for developing COPD. The combination of asthma and smoking increases the
risk of COPD even more.
Occupational exposure to dusts and chemicals. Long-term exposure to chemical
fumes, vapors and dusts in the workplace can irritate and inflame your lungs.
Exposure to fumes from burning fuel. In the developing world, people exposed to
fumes from burning fuel for cooking and heating in poorly ventilated homes are at
higher risk of developing COPD.
Genetics. The uncommon genetic disorder alpha-1-antitrypsin deficiency is the
cause of some cases of COPD. Other genetic factors likely make certain smokers more
susceptible to the disease.

9. Signs and Symptoms
COPD symptoms often don't appear until significant lung damage has occurred, and they usually
worsen over time, particularly if smoking exposure continues.
Shortness of breath, especially during physical activities
Wheezing
Chest tightness
A chronic cough that may produce mucus (sputum) that may be clear, white, yellow or greenish
Frequent respiratory infections
Lack of energy
Unintended weight loss (in later stages)
Swelling in ankles, feet or legs
People with COPD are also likely to experience episodes called exacerbations, during which their
symptoms become worse than the usual day-to-day variation and persist for at least several days.

10. Complications
Respiratory infections. People with COPD are more likely to catch colds, the flu and
pneumonia. Any respiratory infection can make it much more difficult to breathe and
could cause further damage to lung tissue.
Heart problems. For reasons that aren't fully understood, COPD can increase your
risk of heart disease, including heart attack
Lung cancer. People with COPD have a higher risk of developing lung cancer.
High blood pressure in lung arteries. COPD may cause high blood pressure in the
arteries that bring blood to your lungs (pulmonary hypertension).
Depression. Difficulty breathing can keep you from doing activities that you enjoy.
And dealing with serious illness can contribute to the development of depression.

11. Diagnosis
COPD is commonly misdiagnosed. Many people who have COPD may not be
diagnosed until the disease is advanced.
Tests may include:
Lung (pulmonary) function tests. These tests measure the amount of air you can
inhale and exhale, and whether your lungs deliver enough oxygen to your blood.
During the most common test, called spirometry, you blow into a large tube
connected to a small machine to measure how much air your lungs can hold and how
fast you can blow the air out of your lungs. Other tests include measurement of lung
volumes and diffusing capacity, six-minute walk test, and pulse oximetry.
Chest X-ray. A chest X-ray can show emphysema, one of the main causes of COPD.
An X-ray can also rule out other lung problems or heart failure.
CT scan. A CT scan of your lungs can help detect emphysema and help determine if
you might benefit from surgery for COPD. CT scans can also be used to screen for lung
cancer.

12. Diagnosis
Arterial blood gas analysis. This blood test measures how well your lungs are
bringing oxygen into your blood and removing carbon dioxide.
Laboratory tests. Lab tests aren't used to diagnose COPD, but they may be used to
determine the cause of your symptoms or rule out other conditions. For example, lab
tests may be used to determine if you have the genetic disorder alpha-1-antitrypsin
deficiency, which may be the cause of COPD in some people. This test may be done if
you have a family history of COPD and develop COPD at a young age.

13. COPD can be Managed
Stop smoking
Take the right medications
Recognize, treat, & prevent flare-ups
Keep your body strong through exercise and healthy eating
Manage stress and anxiety

14. Treatment
Medicationscanhelpwithsymptoms,possiblyimprovelungfunctionandincreasequalityoflife.
Butonlyiftakenproperlyandasprescribed
The medication will:
Manage shortness of breath
Improve health status
Improve exercise tolerance
Reduce ‘flare-ups’
Types of medication include:
Rescue – short acting bronchodilators
Daily – long acting bronchodilators
Corticosteroids
Oxygen

15. How does the medication work ?
Bronchodilators
Relax muscles in the airways
Treat shortness of breath, some cough, wheezing, exercise tolerance
Types: Inhaled
Corticosteroids
Reduce inflammation in the airways
Treat shortness of breath, cough, wheeze due to inflammation in the airways
Can reduce flare ups
Types: Inhaled or oral

16. Reliever/Rescue Medications
Used when you feel short of breath and need relief fast
Fast-Acting: start to feel relief within 5-10 minutes
Short-Acting: only last 4-6 hours
Intended to be used as needed
Carry with you at all times
Ventolin (salbutamol)
Bricanyl (terbutaline)
Atrovent (ipratropium)
Combivent (ipratropium + salbutamol)

17. Long-Acting Bronchodilators
Last longer (12-24 hrs)
Taken on a regular basis – once or twice a day
Immediate effects may not be noticed
Some side effects with these medications
Dry mouth, heart flutter, lightheadedness, increase in eye pressure
Consider risk versus benefit

18. Aclidinium (Tudorza Pressair)
Arformoterol (Brovana)
Formoterol (Perforomist)
Indacaterol (Arcapta Neoinhaler)
Tiotropium (Spiriva)
Salmeterol (Serevent)
Umeclidinium (Incruse Ellipta)

19. Inhaled steroids
Inhaled corticosteroid medications can reduce airway inflammation and help prevent
exacerbations. Side effects may include bruising, oral infections and hoarseness.
These medications are useful for people with frequent exacerbations of COPD.
Examples of inhaled steroids include:
Fluticasone (Flovent HFA)
Budesonide (Pulmicort Flexhaler)

20. Some medications combine bronchodilators and inhaled steroids. Examples of these
combination inhalers include:
Fluticasone and vilanterol (Breo Ellipta)
Fluticasone, umeclidinium and vilanterol (Trelegy Ellipta)
Formoterol and budesonide (Symbicort)
Salmeterol and fluticasone (Advair HFA, AirDuo Digihaler, others)

21. Combination inhalers that include more than one type of bronchodilator also are
available. Examples of these include:
Aclidinium and formoterol (Duaklir Pressair)
Albuterol and ipratropium (Combivent Respimat)
Formoterol and glycopyrrolate (Bevespi Aerosphere)
Glycopyrrolate and indacaterol (Utibron)
Olodaterol and tiotropium (Stiolto Respimat)
Umeclidinium and vilanterol (Anoro Ellipta)

22. Technique
The basics:
Sit up with your back straight, or stand up.
Breathe out until away from your inhaler.
Seal your lips around the mouthpiece.
Breath in and hold your breath for as long as you can, (5-10 seconds).
Rinse your mouth with water (don't swallow it). Rinsing your mouth can cut down on
some side
effects.
Every inhaler is different – check instructions

23. Oral steroids
For people who experience periods when their COPD becomes more severe, called
moderate or severe acute exacerbation, short courses (for example, five days) of oral
corticosteroids may prevent further worsening of COPD. However, long-term use of
these medications can have serious side effects, such as weight gain, diabetes,
osteoporosis, cataracts and an increased risk of infection.

24. Phosphodiesterase-4 inhibitors
A medication approved for people with severe COPD and symptoms of chronic
bronchitis is roflumilast (Daliresp), a phosphodiesterase-4 inhibitor. This drug
decreases airway inflammation and relaxes the airways. Common side effects include
diarrhea and weight loss.

25. Theophylline
When other treatment has been ineffective or if cost is a factor, theophylline
(Elixophyllin, Theo-24, Theochron), a less expensive medication, may help improve
breathing and prevent episodes of worsening COPD. Side effects are dose related and
may include nausea, headache, fast heartbeat and tremor, so tests are used to
monitor blood levels of the medication.

26. Antibiotics
Respiratory infections, such as acute bronchitis, pneumonia and influenza, can
aggravate COPD symptoms. Antibiotics help treat episodes of worsening COPD, but
they aren't generally recommended for prevention. Some studies show that certain
antibiotics, such as azithromycin (Zithromax), prevent episodes of worsening COPD,
but side effects and antibiotic resistance may limit their use.

27. Lung therapies
Oxygen therapy. If there isn't enough oxygen in your blood, you may need supplemental
oxygen. There are several devices that deliver oxygen to your lungs, including lightweight,
portable units that you can take with you to run errands and get around town.
Some people with COPD use oxygen only during activities or while sleeping. Others use
oxygen all the time. Oxygen therapy can improve quality of life and is the only COPD therapy
proved to extend life. Talk to your doctor about your needs and options.
Pulmonary rehabilitation program. These programs generally combine education, exercise
training, nutrition advice and counseling. You'll work with a variety of specialists, who can
tailor your rehabilitation program to meet your needs.
Pulmonary rehabilitation after episodes of worsening COPD may reduce readmission to the
hospital, increase your ability to participate in everyday activities and improve your quality of
life. Talk to your doctor about referral to a program.

28. In-home noninvasive ventilation therapy
Evidence supports in-hospital use of breathing devices such as bilevel positive airway
pressure (BiPAP), but some research now supports the benefit of its use at home. A
noninvasive ventilation therapy machine with a mask helps to improve breathing and
decrease retention of carbon dioxide (hypercapnia) that may lead to acute respiratory
failure and hospitalization. More research is needed to determine the best ways to
use this therapy.

29. Surgery
Surgery is an option for some people with some forms of severe emphysema who aren't
helped sufficiently by medications alone. Surgical options include:
Lung volume reduction surgery. In this surgery, your surgeon removes small wedges of
damaged lung tissue from the upper lungs. This creates extra space in your chest cavity so
that the remaining healthier lung tissue can expand and the diaphragm can work more
efficiently. In some people, this surgery can improve quality of life and prolong survival.
Endoscopic lung volume reduction — a minimally invasive procedure — has recently been
approved by the U.S. Food and Drug Administration to treat people with COPD. A tiny one-
way endobronchial valve is placed in the lung, allowing the most damaged lobe to shrink so
that the healthier part of the lung has more space to expand and function.

30. Lung transplant. Lung transplantation may be an option for certain people who meet
specific criteria. Transplantation can improve your ability to breathe and to be active.
However, it's a major operation that has significant risks, such as organ rejection, and
you'll need to take lifelong immune-suppressing medications.
Bullectomy. Large air spaces (bullae) form in the lungs when the walls of the air sacs
(alveoli) are destroyed. These bullae can become very large and cause breathing
problems. In a bullectomy, doctors remove bullae from the lungs to help improve air
flow.

31. Avoiding Exacerbations.
Evenwithongoingtreatment,youmayexperiencetimeswhensymptomsbecomeworsefordays
orweeks.Thisiscalledanacuteexacerbation,anditmayleadtolungfailureifyoudon'treceive
prompttreatment.
To prevent irritation and infection of the airways, instruct the patient to:
Avoid exposure to cigarette, pipe, and cigar smoke as well as to dusts and powders.
Avoid use of aerosol sprays.
Stay indoors when the pollen count is high.
Stay indoors when temperature and humidity are both high
Use air conditioning to help decrease pollutants and control temperature
Avoid exposure to persons known to have colds or other respiratory tract infection
Avoid enclosed, crowded areas during cold and flu season.
Obtain immunization against influenza and streptococcal pneumonia.