Chronic Obstructive Pulmonary Disease (COPD) is a progressive lung disease characterized by limited airflow. It is caused most often by smoking or long-term exposure to lung irritants. Symptoms include shortness of breath, cough, wheezing, and fatigue. Diagnosis involves spirometry testing showing reduced airflow. Treatment focuses on bronchodilators, inhaled corticosteroids, pulmonary rehabilitation, oxygen therapy, and managing exacerbations. The goal is improving symptoms, lung function and quality of life.

1. Chronic Obstructive Pulmonary
Disease (COPD)

2.  Chronic obstructive pulmonary disease (COPD) is a leading
cause of morbidity and mortality worldwide.
 COPD is the most prevalent manifestation of obstructive
lung disease and mainly comprises chronic bronchitis and
emphysema.
 Chronic obstructive pulmonary disease (COPD) is a disease
state characterized by airflow limitation that is not fully
reversible.The airflow limitation is usually both progressive
and associated with an abnormal inflammatory response of
the lungs to noxious particles or gases.
(Pharmacotherapy principles and practice by dipirio)

3.  COPD has been defined (National Institute for
Health and Clinical Excellence, 2010) as:
 Airflow obstruction with a reduced FEV1/FVC ratio of less
than 0.7.
 If FEV1 is ≥ 80% of predicted normal, a diagnosis of COPD
should only be made in the presence of respiratory
symptoms, for example breathlessness or cough.

4. COPD: An umbrella term
• Umbrella term used to describe progressive lung diseases
which include:
• Emphysema
• Chronic bronchitis
COPD is also known as:
 Chronic Obstructive Lung Disease (COLD)
 Chronic Lower Respiratory Disease (CLRD)

5. Types of COPD
 Emphysema
 Permanent and destructive enlargement of airspaces
distal to the terminal bronchioles without obvious
fibrosis and with loss of normal architecture
 Always involves clinically significant airflow limitation.
 “pink puffer”
 Chronic Bronchitis
 Presence of a cough productive of sputum not
attributable to other causes on most days for at least 3
months over 2 consecutive years
 May be present in the absence of airflow limitation.
 “blue bloater”

6. Etiology
 Most cases of COPD are caused by inhaling pollutants; that
includes tobacco smoking (cigarettes, pipes, cigars, etc.), and
second-hand smoke.
 Fumes, chemicals and dust found in many work environments
are contributing factors for many individuals who develop
COPD.
 Genetics can also play a role in an individual’s development of
COPD—even if the person has never smoked or has ever been
exposed to strong lung irritants in the workplace.

7. Sign & Symptoms
 Symptoms of COPD can be different for each person, but
the common symptoms are:
 Shortness of breath
 Frequent coughing (with and without sputum or phlegm)
 Increased breathlessness
 Feeling tired, especially when exercising or doing daily
activities
 Wheezing
 Tightness in the chest

8. Pathogenesis of COPD
 Increased number of activated polymorphonuclear cells
and macrophages produce elastases (such as human
leukocyte elastase), resulting in lung destruction.
 Increased oxidative stress caused by free radicals in
cigarette smoke, the oxidants released by phagocytes,
and polymorphonuclear leukocytes all may lead to
apoptosis or necrosis of exposed cells

9. Classification of COPD

10. Risk Factors
Smoking
 COPD most often occurs in people 40 years of
age and older who have a history of smoking.
These may be individuals who are current or
former smokers. While not everybody who
smokes gets COPD, most of the individuals who
have COPD (about 90% of them) have smoked.
However, only one in five smokers will get
significant COPD.

11. Environmental Factors
 COPD can also occur in those who have had long
term exposure and contact with harmful pollutants in
the workplace. Some of these harmful lung irritants
include certain chemicals, dust, or fumes. Heavy or
long-term contact with secondhand smoke or other
lung irritants in the home, such as organic cooking
fuel, may also cause COPD. Individuals who have
worked for many years around these irritants are at
risk for developing mild COPD

12. Genetic Factors
 Even if an individual has never smoked or been exposed to
pollutants for an extended period of time, they can still
develop COPD. Alpha-1 Antitrypsin Deficiency (AATD) is
the most commonly known genetic risk factor for
emphysema. Alpha-1 Antitrypsin related COPD is caused by a
deficiency of the Alpha-1 Antitrypsin protein in the
bloodstream. Without the Alpha-1 Antitrypsin protein, white
blood cells begin to harm the lungs and lung deterioration
occurs. The World Health Organization and the American
Thoracic Society recommends that every individual diagnosed
with COPD be tested for Alpha-1.

13.  Alpha 1-antitrypsin deficiency is a genetic condition
that is responsible for about 2% cases of COPD.
 In this condition, the body does not make enough of
a protein, alpha 1-antitrypsin.
 This protein protects the lungs from damage caused
by protease enzymes, such as elastase and trypsin,
that can be released as a result of an inflammatory
response to tobacco smoke.
 Almost 90% of COPD deaths occur in low- and
middle-income countries, where effective strategies
for prevention and control are not always
implemented or accessible.

14. Physical Exam
 RR, HR, O2 saturation
 Gen: Barrel-chest, accessory muscle use
 CV: Quiet heart sounds
 Resp: Decreased breath sounds, wheezing, rhonchi, crackles
 CBC:  Hgb/Hct
 ABG: pH, pCO2
 Chemistry: HCO3

15. Diagnosis
• A simple diagnostic test called "spirometry“ measures how much
air a person can inhale and exhale, and how fast air can move
into and out of the lungs
• Spirometry can detect
COPD long before its
Symptoms appear.

16. Pharmacotherapy Plans

18. 1.Bronchodilators:
A. 𝜷𝟐 agonists

19. Anticholinergics

20. Recommendations
 Inhaled therapy is preferred.
 The choice between beta2-agonists, anticholinergics, theophylline, or
combination therapy depends on the availability of medications and each
patient’s individual response in terms of symptom relief and side
effects.
 Bronchodilators are prescribed on an as-needed or on a regular basis to
prevent or reduce symptoms.
 LA inhaled bronchodilators are convenient and more effective at
producing maintained symptom relief than short-acting bronchodilators.
 LA inhaled bronchodilators reduce exacerbations and related
hospitalizations and improve symptoms and health status, and
tiotropium improves the effectiveness of pulmonary rehabilitation.
 Combining bronchodilators of different pharmacological classes
may improve efficacy and decrease the risk of side effects compared to
increasing the dose of a single bronchodilator

21. Methyl xanthines

22. Recommendations
 Methylxanthines are less effective and less well tolerated
than inhaled long-acting bronchodilators and are not
recommended if those drugs are available and
affordable.
 Addition of theophylline to salmeterol produces a
greater increase in FEV1 and relief of breathlessness than
salmeterol alone. Low-dose theophylline reduces
exacerbations but does not improve post- bronchodilator
lung function.

23. Inhaled corticosteroids

24. Recommendations
• In COPD patients with FEV1 < 60% predicted, regular treatment
with inhaled corticosteroids improves symptoms, lung function,
and quality of life, and reduces the frequency of exacerbations.
• Inhaled corticosteroid therapy is associated with an
increased risk of pneumonia.
• Withdrawal from treatment with inhaled corticosteroids
may lead to exacerbations in some patients.
• Based on efficacy and side effects, inhaled bronchodilators
are preferred over oral bronchodilators.
• Long-term monotherapy with inhaled corticosteroids is
not recommended.
• Long-term treatment with oral corticosteroids is also not
recommended

25. Other pharmacological treatments
 Vaccines
 Alpha-1AntitrypsinAugmentationTherapy
 Antibiotics
 Mucolytics

26. Mucolytic agents
 Patients with viscous sputum may benefit from
mucolytics (e.g. carbocysteine), but overall
benefits are very small.

27. Vaccines
 Influenza vaccines can reduce serious illness and death in
COPD patients.
 Vaccines containing inactivated viruses are recommended,
and should be given once each year.
 Pneumococcal polysaccharide vaccine is recommended for
COPD patients 65 years and older, and has been shown to
reduce community-acquired pneumonia in those under age
65 with FEV1< 40% predicted.
Alpha-1 Antitrypsin AugmentationTherapy
Not recommended for patients with COPD that is unrelated to
alpha-1 antitrypsin deficiency.

28. Antibiotics
 Not recommended except for treatment of infectious
exacerbations and other bacterial infections.
 Drugs include doxycycline, trimethoprim-
sulfamethoxazole and amoxicillin-clavulanate
potassium.
 Treatment with augmented penicillins,
fluoroquinolones, third-generation
cephalosporins or aminoglycosides may be
considered in patients with more severe exacerbations

29. Non pharmacological treatments
 Rehabilitation
 Oxygen therapy
 Ventilatory support
 Surgical treatments
 Palliative Care, End-of-life Care, and Hospice Care

30. Rehabilitation
 Patients at all stages of disease benefit from exercise training
programs with improvements in exercise tolerance and
symptoms of dyspnea and fatigue.
 Benefits can be sustained even after a single pulmonary
rehabilitation program.
 The minimum length of an effective rehabilitation program is
6 weeks; the longer the program continues, the more
effective the results.

31. Oxygen therapy
 Long-term administration of oxygen (> 15 hours per day) to
patients with chronic respiratory failure has been shown to
increase survival in patients with severe, resting hypoxemia.
 Long-term oxygen therapy is indicated for patients who have:
o PaO2 between 7.3 kPa (55 mmHg) and 8.0 kPa (60 mmHg).

32. Ventilatory support
 Combination of non-invasive ventilation with long-term
oxygen therapy may be of some use in a selected subset
of patients, particularly in those with pronounced
daytime hypercapnia.
 It may improve survival but does not improve quality of
life.

33. Surgical treatment
 Advantage of lung volume reduction surgery (LVRS)
over medical therapy is more significant among patients
with upper-lobe predominant emphysema and low
exercise capacity prior to treatment.
 LVRS is costly relative to health-care programs not
including surgery.
 In appropriately selected patients with very severe
COPD, lung transplantation has been shown to
improve quality of life and functional capacity.