The document outlines a comprehensive roadmap for managing chronic obstructive pulmonary disease (COPD) according to the 2014 guidelines, covering assessment of symptoms, severity, and exacerbations. It details treatment options, including smoking cessation, pharmacological therapies, and surgical interventions, emphasizing the importance of patient-specific factors. Additionally, it discusses the genetic aspect of alpha-1 antitrypsin deficiency and emerging therapies, highlighting the need for a tailored approach to COPD management.

1. DR.Y.SAI KRISHNA

2. ROAD MAP
 APPROACH TO A CASE OF COPD
 2014 GUIDELINES OF COPD MANAGEMENT
A) Management of Stable COPD
B) Management of COPD exacerbations
 NEWER THERAPIES

3. Approach
COPD SHOULD BE CONSIDERED
Over the age of 35 to 40
Shortness of breath with chronic cough and sputum
production,
Frequent winter colds
H/O exposure to risk factors for the disease.
STEPS
 Assessment of symptoms
 Assessment of degree of airflow obstruction by spirometry
and other investigations.
 Assessment of risk of exacerbations
 Assessment of comorbidities

4. Assessment of symptoms
 COPD assessment test ( An 8 item measurement of
health status in COPD)
 Clinical COPD Questionnaire ( Self administered
questionnaire to measure clinical control in patients
with COPD)
 Modified British Medical Reasearch Questionnaire

5. Assessment of severity (GOLD)

6. OTHER INVESTIGATIONS
Chest X-ray: Seldom diagnostic but valuable to
exclude alternative diagnoses and establish presence
of significant comorbidities.
Lung Volumes and Diffusing Capacity: Help to
characterize severity, but no role in management.
Oximetry and Arterial Blood Gases: to evaluate
need for supplemental oxygen therapy.
Alpha-1 Antitrypsin Deficiency Screening:
Perform when COPD develops in patients of Caucasian
descent under 45 years or with a strong family history
of COPD.

7. BODE Index
 APPROXIMATE 4 YEAR SURVIVAL INTERPRETATION
 0-2 Points: 80%
 3-4 Points: 67%
 5-6 Points: 57%
 7-10 Points: 18%

8. Assessment of risk of exacerbations
To assess risk of exacerbations use history of
exacerbations and spirometry:
 Two or more exacerbations within the last year or an
FEV1 < 50 % of predicted value are indicators of high
risk.
 One or more hospitalizations for COPD exacerbation
should be considered

9. ABG Measurements(in hospital): PaO2 < 8.0 kPa with or without
PaCO2 > 6.7 kPa when breathing room air indicates respiratory
failure.
Chest radiographs: useful to exclude alternative diagnoses.
ECG: may aid in the diagnosis of coexisting cardiac problems.
Whole blood count: identify polycythemia, anemia or bleeding.
Purulent sputum during an exacerbation: indication to begin
empirical antibiotic treatment.
Biochemical tests: detect electrolyte disturbances, diabetes, and
poor nutrition.
Spirometric tests: not recommended during an exacerbation.
Manage Exacerbations: Assessments
© 2014 Global Initiative for Chronic Obstructive Lung Disease

10. PATIENT CHARECTERSTIC SPIROMETRIC
CLASSIFICATION
EXACERBATION
PER YEAR
CAT mMRC
A
Low Risk
Less
Symptoms
GOLD 1-2 ≤ 1 < 10 0-1
B
Low Risk
More
Symptoms
GOLD 1-2 ≤ 1 > 10 > 2
C
High Risk
Less
Symptoms
GOLD 3-4 > 2 < 10 0-1
D
High Risk
More
Symptoms
GOLD 3-4 > 2 > 10 > 2
Combined assessment of COPD

11. Assess COPD Comorbidities
• Cardiovascular diseases
• Osteoporosis
• Respiratory infections
• Anxiety and Depression
• Diabetes
• Lung cancer
• Bronchiectasis

12. A1 Antitrypsin deficiency
 Alpha 1-antitrypsin deficiency (α1-antitrypsin deficiency, A1AD) is
a genetic disorder that causes defective production of (A1AT), leading
to decreased A1AT activity in the blood and lungs and deposition of
excessive abnormal A1AT protein in liver cells
 Severe A1AT deficiency causes panacinar emphysema or COPD in
adult life in many people with the condition (especially if they are
exposed to cigarette smoke) along with various other conditions such
as
Cirrhosis, Asthma, Wegener’s Granulomatosis, Pancreatitis,
Gallstones, Bronchiectasis, Emphysema, Autoimmune hepatitis,
Cancer

13.  The serum levels of some of the common genotypes are
 PiMM: 100% (normal)
 PiMS: 80% of normal serum level of A1AT
 PiSS: 60% of normal serum level of A1AT
 PiMZ: 60% of normal serum level of A1AT
 PiSZ: 40% of normal serum level of A1AT
 PiZZ: 10-15% (severe alpha 1-antitrypsin deficiency)
 Treatment
Lung-affected A1AD patients may receive intravenous infusions of
alpha-1 antitrypsin, derived from donated human plasma. This
augmentation therapy is thought to arrest the course of the
disease and halt any further damage to the lungs.

14. 2014

16. GOLD 2014

17. Managing stable COPD:
Stop smoking
 Encouraging patients with COPD to stop smoking is one
of the most important components of their management
 All COPD patients still smoking, regardless of age,
should be encouraged to stop, and offered help to do so,
at every opportunity
 Record a smoking history, including pack years smoked
 Offer nicotine replacement therapy, varenicline or
bupropion (unless contraindicated) combined with a
support programme to optimise quit rates

18. Anti smoking therapy
 Nicotine replacement therapy– Transdermal patches,
gums, sprays, lozenges, inhalers
 Bupropion (Zyban) ( Anti depressant)
 Nicotinic receptor partial agonist - Varenicline
(Chantix), Cystisine
 Psychosocial approaches – Cognitive behavioral therapy
VACCINES
Influenza vaccines and Pneumococcal polysaccharide
vaccine is recommended for COPD patients
 65 years or more
 younger than age 65 with FEV1< 40% predicted

19. Pulmonary rehabitilation
 It is divided into
 Pharmacological
 Non – pharmacological
 Non pharmacological includes exercises, nutritional plan
 Exercise is the cornerstone of pulmonary rehabilitation programs.
Although, exercise training does not directly improves lung function, it
causes improvement in physical condition. There are three basic types
of exercises to be considered. Aerobic exercise tends to improve the
body's ability to use oxygen by decreasing the heart rate and blood
pressure. Strengthening or resistance exercises can help build strength
in the respiratory muscles. Stretching and flexibility exercises like yoga
can enhance breathing coordination.

21. Oxygen: titrate to improve the patient’s hypoxemia with a
target saturation of 88-92%.
Bronchodilators: Short-acting inhaled beta2-agonists with
or without short-acting anticholinergics are preferred.
Systemic Corticosteroids: Shorten recovery time,
improve lung function (FEV1) and arterial hypoxemia (PaO2),
and reduce the risk of early relapse, treatment failure, and
length of hospital stay. A dose of 40 mg prednisone per day for 5
days is recommended .
Manage Exacerbations: Treatment Options
© 2014 Global Initiative for Chronic Obstructive Lung Disease

22. Alpha-1 antitrypsin augmentation therapy: not
recommended for patients with COPD that is unrelated to the
genetic deficiency.
Mucolytics: Patients with viscous sputum may benefit from
mucolytics; overall benefits are very small.
Antitussives: Not recommended.
Vasodilators: Nitric oxide is contraindicated in stable COPD. The
use of endothelium-modulating agents for the treatment of
pulmonary hypertension associated with COPD is not
recommended.
Therapeutic Options: Other
Pharmacologic Treatments
© 2014 Global Initiative for Chronic Obstructive Lung Disease

23.  The phospodiesterase-4 inhibitor Roflumilast may be useful to
reduce exacerbations for patients with FEV1 < 50% of predicted,
chronic bronchitis, and frequent exacerbations
 Theophylline –
Theophylline is less effective and less well tolerated than inhaled
long- acting bronchodilators and is not recommended if those
drugs are available and affordable.
There is evidence for a modest bronchodilator effect and some
symptomatic benefit in stable COPD. Addition of theophylline
to salmeterol produces a greater increase in FEV1 and a
decrease in breathlessness than salmeterol alone.
Low dose theophylline reduces exacerbations but does not
improve post-bronchodilator lung function.

24. Role of Antibiotics
 Antibiotics should be given to patients with 3 cardinal
symptoms
 A) Increased Dyspnoea
 B) Increased sputum volume
 C) Increased sputum prevalence
 And people who are on mechanical ventilation
assistance

25. NEJM Aug 25th 2011
 Adding Azithromycin, at a dose of 250 mg daily, for 1 year to
the usual treatment of patients who have an increased risk of
acute exacerbations of COPD
 Advantages
 1) Decreased the number of exacerbations per year
 2) the incidence of colonization with selected respiratory
pathogens
 3) Increased the quality of life
 Disadvantages
 1) Increased hearing loss in a small % of patients
 2) Prolonged QTc

26. Oxygen Therapy: The 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.
Ventilatory Support: Combination of noninvasive
ventilation (NIV) with long-term oxygen therapy may
be of some use in a selected subset of patients,
particularly in those with pronounced daytime
hypercapnia.
Therapeutic Options: Other Treatments
© 2014 Global Initiative for Chronic Obstructive Lung Disease

28. Advantages Of NIPPV
 Decreases need for invasive ventilation and may be
associated with improved outcome.
 CPAP alone can reduce work of breathing in COPD during
weaning and during sleep.
 BiPAP weaning may be better than weaning on pressure
support via an ETT.
 A lower rate of treatment failure ;lower mortality rate.
 Greater improvements in the 1-hour
post-treatment pH and PaCO2 levels

29. Indication and Relative contraindication for NIPPV
 Selection Criteria:
 Moderate to severe dyspnea with the use of accessory muscles,
paradoxical breathing.
 Moderate to severe acidosis PH  7.35 and/or PaCO2 > 45
mmHg
or PaO2/FiO2 < 200
 RR > 25 breaths/min,accessory muscle
 Exclusion Criteria:
 Respiratory arrest. Cardiovascular instability.
 Burns Extreme obesity.
 Craniofacial trauma. APACHE score >29
 High aspiration risk(. Cannot protect the airway )

30. Indications of IIPPV:
 Hypoxemia that has not corrected with NIPPV
 Exclusion criteria of NIPPV
 Sever acidosis PH<7.25 and/or PaCO2 >60 mmHg
 Impending respiratory arrest
 Respiratory rate > 36 breaths/minute
 Use of all accessory muscles
 Thoracoabdominal paradox
 Even minor mental state changes
 Patient's subjective sense of exhaustion
 Cardiovascular instability

31. Management of a COPD patient on ventilator
 Use low tidal volumes to prevent stretching of the lung
parenchyma and VIL (Ventilator induced injury)
 Another adverse effect of invasive mechanical ventilation in
COPD is the generation or aggravation of PEEPi
 Auto (intrinsic) PEEP — Incomplete expiration prior to the initiation
of the next breath causes progressive air trapping . This
accumulation of air increases alveolar pressure at the end of
expiration, which is referred to as auto-PEEP.
 Auto-PEEP develops commonly in high minute ventilation expiratory
flow limitation (obstructed airway) and expiratory resistance
(narrow airway).
 Once auto-PEEP is identified, steps should be taken to stop or
reduce the pressure build-up. When auto-PEEP persists despite
management of its underlying cause, applied PEEP may be helpful if
the patient has an expiratory flow limitation (obstruction).

32.  Applied (extrinsic) PEEP —
 A small amount of applied PEEP (3 to 5 cmH2O) is used in most
mechanically ventilated patients to mitigate end-expiratory
alveolar collapse. A higher level of applied PEEP (>5 cmH2O) is
sometimes used to improve hypoxemia or reduce VILI in
patients with acute lung injury, acute respiratory distress
syndrome, or other types of hypoxemic respiratory failure.
 Complications
 Decrease in systemic venous return
 Pulmonary baotrauma can be caused. Pulmonary barotrauma is
lung injury that results from the hyperinflation of alveoli past
the rupture point.
 Raised ICP
 Renal functions and electrolyte imbalances, due to decreased
venous return metabolism of certain drugs are altered and acid-
base balance is impeded

34. Lung volume reduction surgery (LVRS) is more
efficacious than medical therapy among patients
with upper-lobe predominant emphysema and low
exercise capacity.
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.
Surgical Treatments
© 2014 Global Initiative for Chronic Obstructive Lung Disease

35. LVRS Lung Transplantation
 Patient Factors Favoring LVRS over
Lung Transplantation
 • Age > 65 yr
 • Chronic medical conditions: Chronic
active viral hepatitis B, hepatitis C with
biopsy-proven histologic evidence of liver
disease, or HIV infection
 • Organ system dysfunction precluding
appropriate immunosuppressive therapy:
renal insufficiency, liver dysfunction,
neuropathy, significant osteoporosis,
uncontrolled diabetes
 • Refractory gastroesophageal reflux
disease
 • Malignancy
 • Inability to maintain long-term follow-up
 • Psychiatric conditions
 • Lack of social support
 Patient Factors Favoring Lung
Transplantation over LVRS
 • FEV1 ⩽ 20% predicted and either
homogeneous disease or DlCO ⩽
20% predicted
 • Lack of emphysema on HRCT
 • TLC < 100% predicted
 • RV < 150% predicted
 • PaCO2 > 60 mm Hg
 • PaO2 < 45 mm Hg
 • 6MWD ⩽ 140 m, < 3 min
unloaded pedaling on cycle
ergometer
 • Pulmonary hypertension
 • Clinically significant
bronchiectasis and/or recurrent
pulmonary infections

36. Newer modalities
 A new study called the STASCOPE study funded by the National Heart
Lung and Blood Institute is being conducted to determine if
Simvastatin might reduce swelling in the lungs in patients with
COPD.
 If it is found that Simvastatin reduces lung inflammation, there is a
possibility that the statin drug could also the limit the number or
severity of the exacerbations.
 Beta Blockers may reduce mortality and exacerbations when added
to established inhaled stepwise therapy for COPD, independently of
CVD and cardiac drugs, and without adverse effects on pulmonary
function.

37. Asthma COPD Overlap Syndrome (ACOS)
 A chapter on Asthma and COPD Overlap Syndrome (ACOS)
is in preparation by the Global Initiative for Chronic
Obstructive Lung Disease (GOLD).
 major criteria for ACOS:
 a physician diagnosis of asthma and COPD in the same
patient,
 history or evidence of atopy, for example, hay fever, elevated
total IgE,
 age 40 years or more,
 smoking >10 pack-years, postbronchodilator FEV1 <80%
predicted and FEV1/FVC <70%.
 A ≥15% increase in FEV1 or ≥12% and ≥200 ml increase in
FEV1 postbronchodilator treatment with albuterol would be
a minor criteria