Chronic obstructive pulmonary disease (COPD) is characterized by persistent airflow limitation that is usually progressive. It includes chronic bronchitis and emphysema. COPD is diagnosed based on spirometry showing airflow limitation. Symptoms include breathlessness, cough, and wheezing. Management involves reducing risk factors, managing stable COPD with bronchodilators and rehabilitation, and treating exacerbations with bronchodilators and glucocorticoids. The severity of COPD is classified based on lung function, and treatment is escalated based on severity from short-acting bronchodilators to long-term oxygen for very severe COPD.

1. Chronic obstructive pulmonary disease
(COPD)
Dr. Narendra Meena
MD Medicine
GGS Medical college Faridkot

2. COPD, a common preventable and treatable disease, is
characterized by persistent airflow limitation that is usually
progressive and associated with an enhanced chronic
inflammatory response in the airways and the lung to noxious
particles or gases.

3. COPD includes
• Chronic Bronchitis
• Emphysema

4. Chronic bronchitis
Defined as a chronic productive cough for three
months in each of two successive years in a
patient in whom other causes of chronic cough
have been excluded.

5. Emphysema
• Abnormal and permanent enlargement of the
airspaces distal to the terminal bronchioles
that is accompanied by destruction of the
airspace walls, without obvious fibrosis.

6. PATHOLOGY

7. Airways
 Chronic inflammation
 Increased numbers of goblet cells
 Mucus gland hyperplasia
 Fibrosis
 Narrowing and reduction in the number of small airways
 Airway collapse due to the loss of tethering caused by alveolar
wall destruction in emphysema

9. Lung Parenchyma
• Emphysema affects the structures distal to the terminal
bronchiole, consisting of the respiratory bronchiole, alveolar
ducts, alveolar sacs, and alveoli, known collectively as the
acinus.

10. Normal Acinus

11. Subtype of emphysema.
Centrilobular emphysema (Proximal acinar)
• Abnormal dilation or destruction of the respiratory
bronchiole, the central portion of the acinus. It is commonly
associated with cigarette smoking,

12. Panacinar emphysema
• Refers to enlargement or destruction of all parts of the acinus.
• Seen in alpha-1 antitrypsin deficiency and in smokers

13. Paraseptal emphysema
• Distal acinar - the alveolar ducts are predominantly
affected.

14. Emphysema

15. Pulmonary vasculature
• Intimal hyperplasia and smooth muscle hypertrophy or
hyperplasia thought to be due to chronic hypoxic
vasoconstriction of the small pulmonary arteries
• Destruction of alveoli due to emphysema can lead to loss of
the associated areas of the pulmonary capillary bed and
pruning of the distal vasculature

16. Risk Factors for COPD
• Genes
• Exposure to particles
• Tobacco smoke
• Occupational dusts, organic
and inorganic
• Indoor air pollution from
heating and cooking with
biomass in poorly ventilated
dwellings
• Outdoor air pollution
• Lung growth and
development
• Oxidative stress
• Gender
• Age
• Respiratory infections
• Socioeconomic status
• Nutrition

17. SYMPTOMS
BREATHLESSNESS:
• First symptom that bring patient to hospital.
• FEV1 declined by 1-1.5L when patient presents to hospital.
• Often assosciated with cough and expectoration.
• Varies in severity as mild,moderate,severe.
• Depends upon:temp.,occupation,position.

18. COUGH:
• First symptom to come but often ignored as smoker’s cough.
• a/w expectoration<60ml/day.
• More in morning hrs.

19. WHEEZE:
• Not characteristic feature but present.
• Due to turbulent airflow in large airways.
• Its presence indicates use of bronchodilator in management.

20. CHEST PAIN:
• Not characteristic feature of disease.
• May indicate underlying ischemic heart disease or GERD.
• Pleuritic chest pain d/t pneumothorax,infection,pulmonary
infarction.

21. • Other symptoms include:depression,weight loss,haemoptysis
• Haemoptysis if present then r/o bronchogenic ca.

22. PHYSICAL SIGNS
GENERAL PHYSICAL EXAMINATION:
• Tar stained fingers
• Cyanosis
• Flapping tremors
• When a COPD patient develops clubbing ,always suspect
and rule out bronchiectasis and bronchogenic carcinoma.

23. RESPIRATORY SYSTEM
INSPECTION:
Barrel-shaped chest ,
Accessory respiratory muscle participate ,
Prolonged expiration during quiet breathing.
Expiration through pursed lips
Paradoxical retraction of the lower interspaces during
inspiration (ie, hoover's sign)
Tripod Position

24. Tripod Position
• Patients with end-stage
COPD may adopt positions
that relieve dyspnea, such
as leaning forward with
arms outstretched and
weight supported on the
palms or elbows.

25. PALPATION:
Decreased fremitus vocalis
PERCUSSION :
Hyperresonant ,
Depressed diaphragm,
Decreasd hepatic and cardiac dullness.
AUSCULTATION:
Prolonged expiration,
Reduced breath sounds;
The presence of wheezing during quiet breathing
Crackle can be heard if infection exist.

26. SYSTEMIC MANIFESTATIONS OF COPD

27. COPD Diagnosis
SPIROMETRY:
• Spirometry is used to measure the forced vital capacity (FVC),
i.e. maximal volume of air forcibly exhaled from the point of
maximal inhalation; the volume of air exhaled during the first
second of this maneuver (FEV1), and the ratio of these two
measurements (FEV1/FVC).
• The presence of a postbronchodilator FEV1<80% of the
predicted value in combination with a FEV1/FVC <70%
confirms the presence of airflow limitation that is not fully
reversible.

28. Spirometry: Normal and COPD
0
5
1
4
2
3
Liter
1 65432
FVC
FVC
FEV1
FEV1
Normal
COPD
3.900
5.200
2.350
4.150 80 %
60 %
Normal
COPD
FVCFEV1 FVCFEV1/
Seconds

29. Additional 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 not essential to patient management.
Oximetry and Arterial Blood Gases: Pulse oximetry can be used to
evaluate a patient’s oxygen saturation and 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.
© 2015 Global Initiative for Chronic Obstructive Lung Disease

30. Exercise Testing: Objectively measured exercise impairment,
assessed by a reduction in self-paced walking distance (such as
the 6 min walking test) or during incremental exercise testing in a
laboratory, is a powerful indicator of health status impairment
and predictor of prognosis.
Composite Scores: Several variables (FEV1, exercise tolerance
assessed by walking distance or peak oxygen consumption, weight
loss and reduction in the arterial oxygen tension) identify patients
at increased risk for mortality.
© 2015 Global Initiative for Chronic Obstructive Lung Disease

31. Posteroanterior (PA) and lateral chest radiograph in a patient with severe
chronic obstructive pulmonary disease (COPD). Hyperinflation, depressed
diaphragms, increased retrosternal space, and hypovascularity of lung
parenchyma is demonstrated.
COPD Radiology

32. Differential Diagnosis:
COPD and Asthma
COPD
• Onset in mid-life
• Symptoms slowly progressive
• Long smoking history
• Dyspnea during exercise
• Largely irreversible airflow
limitation
ASTHMA
• Onset early in life (often
childhood)
• Symptoms vary from day to
day
• Symptoms at night/early
morning
• Allergy, rhinitis, and/or eczema
also present
• Family history of asthma
• Largely reversible airflow
limitation

33. GOLD criteria for Severity of Airflow Limitation
in COPD
In patients with FEV1/FVC < 0.70:
GOLD 1: Mild FEV1 > 80% predicted
GOLD 2: Moderate 50% < FEV1 < 80% predicted
GOLD 3: Severe 30% < FEV1 < 50% predicted
GOLD 4: Very Severe FEV1 < 30% predicted
*Based on Post-Bronchodilator FEV1
© 2015 Global Initiative for Chronic Obstructive Lung Disease

34. MANAGEMENT

35. Four Components of COPD
Management(Accordindg to GOLD
Guidelines)
1.Assess and monitor disease
2.Reduce risk factors
3.Manage stable COPD
– Education
– Pharmacologic
– Non-pharmacologic
4.Manage exacerbations

36. Management of Stable COPD
• Reduction of exposure to
tobacco smoke
occupational dusts and chemicals
indoor and outdoor air pollutants
• Smoking cessation is the single most effective — and cost
effective — intervention in most people to reduce the risk
of developing COPD and stop its progression.

37. Management of Stable COPD
 For patients with COPD, health education plays an important role
in smoking cessation , ability to cope with illness and health status.
 None of the existing medications for COPD have been shown to
modify the long-term decline in lung function that is the hallmark
of this disease.
 Therefore, pharmacotherapy for COPD is used to decrease
symptoms and/or complications.

38. Pharmacotherapy: Bronchodilators
• Bronchodilator medications are central to the symptomatic
management of COPD .
• The principal bronchodilator treatments are
ß2-agonists,
anticholinergics, and
methylxanthines
• Regular treatment with long-acting bronchodilators is more
effective and convenient than treatment with short-acting
bronchodilators.

39. Pharmacotherapy: Glucocorticosteroids
 Chronic treatment with systemic glucocorticosteroids should be
avoided.

40. Phosphodiesterase-4 Inhibitors:ROFLUMILAST
Used in pts.with
• severe and very severe COPD (GOLD 3 and 4)
• history of exacerbations
• chronic bronchitis

41. Pharmacotherapy: Vaccines
influenza vaccines
Pneumococcal polysaccharide vaccine is recommended
 for COPD patients 65 years and older
 COPD patients younger than age 65 with an FEV1 < 40%
predicted.

42. Other Pharmacologic Treatments
 Antibiotics: Only used to treat infectious exacerbations of
COPD
 Antioxidant agents: No effect of n-acetylcysteine on
frequency of exacerbations, except in patients not treated
with inhaled glucocorticosteroids
 Mucolytic agents, Antitussives, Vasodilators: Not
recommended in stable COPD

43. Non-Pharmacologic Treatments
 Rehabilitation: All COPD patients benefit from exercise
training programs, improving with respect to both exercise
tolerance and symptoms of dyspnea and fatigue.
 Oxygen Therapy: The long-term administration of oxygen
(> 15 hours per day) to patients with chronic respiratory
failure has been shown to increase survival.

44. COPD Exacerbations
An exacerbation of COPD is defined as:
An event in the natural course of the disease characterized by
a change in the patient’s baseline dyspnea, cough, and/or
sputum that is beyond normal day-to-day variations, is acute
in onset, and may warrant a change in regular medication in a
patient with underlying COPD.

45.  The most common causes of an exacerbation are infection of
the tracheobronchial tree and air pollution.
But the cause of about one-third of severe exacerbations cannot
be identified.

46. Management COPD Exacerbations
 Inhaled bronchodilators ( inhaled ß2-agonists with or without
anticholinergics)
 oral glucocorticosteroids are effective treatments for
exacerbations of COPD.
 Noninvasive mechanical ventilation in exacerbations improves
respiratory acidosis, increases pH, decreases the need for
endotracheal intubation, and reduces PaCO2, respiratory rate,
severity of breathlessness, the length of hospital stay, and
mortality.
 Medications and education to help prevent future
exacerbations should be considered as part of follow-up, as
exacerbations affect the quality of life and prognosis of
patients with COPD

47. IV: Very SevereIII: SevereII: ModerateI: Mild
Therapy at Each Stage of COPD
 FEV1/FVC < 70%
 FEV1 > 80%
predicted
 FEV1/FVC < 70%
 50% < FEV1 < 80%
predicted
 FEV1/FVC < 70%
 30% < FEV1 < 50%
predicted
 FEV1/FVC < 70%
 FEV1 < 30%
predicted
or FEV1 < 50%
predicted plus
chronic respiratory
failure
Add regular treatment with one or more long-acting
bronchodilators (when needed); Add rehabilitation
Add inhaled glucocorticosteroids if
repeated exacerbations
Active reduction of risk factor(s); influenza vaccination
Add short-acting bronchodilator (when needed)
Add long term
oxygen if chronic
respiratory failure.
Consider surgical
treatments

48. Surgery
In rare cases, surgery may benefit some people who have
COPD. Surgery usually is a last resort for people who have
severe symptoms that have not improved from taking
medicines.
Surgeries for people who have COPD that's mainly related
to emphysema include
Bullectomy
Lung volume reduction surgery
Lung Transplant

49. THANKS