Chronic Obstructive Pulmonary Disease (COPD) is a major cause of mortality and morbidity worldwide. It is characterized by airflow limitation caused by an abnormal inflammatory response to noxious particles or gases. COPD is expected to be the third leading cause of death by 2020. Spirometry is important for diagnosing and assessing the severity of COPD. Bronchodilators are central to symptomatic management, with long-acting anticholinergics and long-acting beta agonists as first-line therapy. Combination therapy may provide increased bronchodilation compared to monotherapy.

1. Chronic Obstructive
Pulmonary Disease

2. Why COPD is Important ?
COPD is the only chronic disease that is showing
progressive upward trend in both mortality and
morbidity
It is expected to be the third leading cause of death
by 2020
Approximately 14 million Indians are currently
suffering form COPD*
Currently there are 94 million smokers in India
10 lacs Indians die in a year due to smoking related
diseases
*The Indian J Chest Dis & Allied Sciences 2001; 43:139-47

3. Disease Trajectory of a
Patients with COPD
Symptoms
Exacerbations
Exacerbations
Deterioration
Exacerbations
End of Life

4. “Despite this burden, COPD is
a “Cindrella” conditions that
receives limited recognition
from both patients and
physicians”
Respiratory Medicine 2002; 96: S1-S31

5. Obstructive Airway Disease
Asthma COPD
Explosion in Little research
research (? neglect)
Revolution in Few advances in
therapy
therapy

6. New Definition
Chronic obstructive pulmonary disease (COPD) is
a preventable and treatable disease state
characterised by airflow limitation that is not fully
reversible.
The airflow limitation is usually progressive and is
associated with an abnormal inflammatory
response of the lungs to noxious particles or
gases, primarily caused by cigarette smoking.
Although COPD affects the lungs, it also produces
significant systemic consequences.
ATS/ERS 2004

7. Risk Factors
Smoke from home cooking and heating
fuel
Occupational dust and chemicals
Gender: More common in men. M:F
ratio is 5%:2.7% (in India)
Increasing age
Others: Infection, nutrition and
deficiency of α1 antitrypsin

8. Pathophysiology of COPD
Increased mucus production and
reduced mucociliary clearance -
cough and sputum production
Loss of elastic recoil - airway
collapse
Increase smooth muscle tone
Pulmonary hyperinflation
Gas exchange abnormalities -
hypoxemia and/or hypercapnia

9. Key Indicators for COPD Diagnosis
Chronic cough Present intermittently or every day
often present throughout the day;
seldom only nocturnal
Chronic sputum production Present for many years, worst in
winters. Initially mucoid – becomes
purulent with exacerbation
Dyspnoea that is Progressive (worsens over time)
Persistent (present every day)
Worse on exercise
Worse during respiratory infections
Acute bronchitis Repeated episodes
History of exposure to risk Tobacco smoke (including beedi)
factors occupational dusts and chemical
smoke from home cooking and
heating fuel

10. Physical signs
Large barrel shaped
chest (hyperinflation)
Prominent accessory
respiratory muscles in
neck and use of
accessory muscle in
respiration
Low, flat diaphragm
Diminished breath sound

11. Algorithm for Diagnosis at Primary Care
Pt reporting with respiratory symptoms
Assess by
- H/o exposure to risk factors
- Physical examination
Sputum for AFB
+ve -ve
Treat as TB Provisional Diagnosis
of COPD
Treat as COPD Poor response refer
to secondary care
National Guidelines for Management of COPD at Primary Care Level

12. Spirometry
Diagnosis
Assessing severity
Assessing prognosis
Monitoring
progression

13. Spirometry
FEV1 – Forced expired volume in the
first second
FVC – Total volume of air that can be
exhaled from maximal inhalation to
maximal exhalation
FEV1/FVC% - The ratio of FEV1 to
FVC, expressed as a percentage.

14. COPD classification based on spirometry
GOLD 2003
Severity Postbronchodilator Postbronchodilator
FEV1/FVC FEV1% predicted
At risk >0.7 >80
Mild COPD <0.7 >80
Moderate COPD <0.7 50-80
Severe COPD <0.7 30-50
Very severe <0.7 <30
COPD
SPIROMETRY is not to substitute for clinical judgment in the
evaluation of the severity of disease in individual patients.

15. Pharmacotherapy for Stable
COPD
Bronchodilators Steroids
Short-acting β2- Oral – Prednisolone
agonist – Salbutamol Inhaled - Fluticasone,
Budesonide
Long-acting β2-
agonist - Salmeterol
and Formoterol
Anticholinergics –
Ipratropium, Tiiotropium
Methylxanthines -
Theophylline

16. Management based on GOLD
Post-
bronchodilator
FEV1
(% predicted)

17. “Bronchodilator medications are central to
the symptomatic management of COPD”
GOLD Report 2003

18. How Do Bronchodilators Work?
Reverse the increased
bronchomotor tone
Relax the smooth muscle
Reduce the hyperinflation
Improve breathlessness

19. “All guidelines recommend inhaled
bronchodilator as first line therapy.
The ATS suggest initial therapy with
an anticholinergic drug if regular
therapy is needed”
Chest 2000; 117: 23S-28S

20. Mode of Action
Cholinergic tone is the only
reversible component of COPD
Normal airway have small
degree of vagal cholinergic
tone (no perceptible effect
due to patent airways)

21. Mode of Action (Contd.)
Airways are narrowed in COPD
therefore vagal cholinergic tone has
greater effect on airway resistance
(Resistance
α1/radius4)
Therefore, the need for
anticholinergic drugs that will act as
muscarinic receptor antagonist and
block the acetylcholine induced
bronchoconstriction

22. Mode of Action (Contd.)
Anticholinergics may also reduce
mucus hypersecretion
Anticholinergic have no effect on
pulmonary vessels, and therefore do
not cause a fall in PaO2
Drugs of Today 2002; 38(9): 585-600

23. “Patients with moderate to severe symptoms of
COPD require combination of
bronchodilators”
“Combining bronchodilators with different
mechanisms and durations of actions may
increase the degree of bronchodilation for
equivalent or lesser side effects’’
GOLD Report 2003

24. Algorithm for the management of COPD
Mild Short acting bronchodilator – as required
assess with symptoms and spirometry
Tiotropium Long acting beta agonist
Tiotropium+LABA LABA + tiotropium
Add
-Inhaled steroids
Severe -Theophylline