COPD INTRODUCTION SINGS AND SYMPTOMS MANAGEMENT PHARMACOLOGICAL TREATMENT NON PHARMACOLOGICAL TREATMENT CAUSES

1. CHRONIC OBSTRUCTIVE
PULMONARY DISEASE

2. OUTLINE
• Introduction
• Causes
• Symptoms
• Diagnosis
• Levels of severity
• Pharmacological Management
• Surgical Management
• Non- pharmacological management
• Complications

3. INTRODUCTION
• A group of diseases that obstruct airflow and make it difficult to
breathe
• Largely misdiagnosed
• Many people who have COPD may not be diagnosed until the
disease is advanced
• COPD patients commonly present with comorbidities which
reduce quality of life

4. • In patients with mild to moderate COPD, cardiovascular
diseases are the leading cause of hospitalization and the second
leading cause after lung cancer
• In severe and very severe COPD, respiratory failure and
pneumonia are the leading causes of morbidity and mortality
• However, even in these patients, cardiovascular diseases remain
a major concern

5. • Caused by emphysema and chronic bronchitis
• Emphysema
-damage to the alveoli walls causing to merge into one giant air
sac
-Oxygen cannot be absorbed and causes the lungs to stretch and
loose its elasticity
-Air is trapped in the lungs and cannot be breathed out
• Damage to the lungs by COPD cannot be reversed

6. • Chronic bronchitis
-Characterized by coughing, shortness of breadth and
mucus that lingers for between 3 months and 2 years
-Results from cilia lining the bronchial tubes being lost
leading to inability to expel mucus

7. CAUSES
• Tobacco
• Second-hand smoking
• Asthma
• Dust
• Smoke
• Chemicals
• Genetic

8. SYMPTOMS
• Persistent cough
• Coughing up lots of mucus
• Shortness of breadth
• Wheezing
• Chest-tightness
• Frequent colds or flu
• Blue fingernails
• Low energy
• Weight loss
• Swollen ankles, feet or legs

9. DIAGNOSIS
• Lung function tests
- Spirometry (FEV1)
- Pulse oximetry
• Chest X-ray
• CT Scan
• Arterial blood gas
• Laboratory test for alpha-1-antitrypsin deficiency in individuals
with a family history

10. • Consider a COPD diagnosis for a patient ≥ 40 years of age who
has:
1. Respiratory symptoms including:
-dyspnoea (progressive, persistent and worse with exercise
- Chronic cough and
- Increased sputum production AND
2. One of the following:
- History of exposure to cigarette smoke
- History of environmental/occupational exposure to smoke, dust
or gas/fumes
- Frequent respiratory infection
- Family history of COPD

11. • Consider alternative diagnoses
• Asthma and asthma-COPD overlap syndrome (ACOS) are the 2
primary preferential diagnoses to rule out
• When breathlessness is out of proportion to spirometry results,
consider heart failure by measuring B-type natriuretic peptide
(BNP) levels
• Consider tuberculosis when there is excessive weight loss

12. FEATURES OF ASTHMA, COPD AND ACOS
Feature Asthma COPD ACOS
Age of onset childhood ≥ 40 years Age ≥ 40 years but may have
symptoms in childhood
Pattern of respiratory
symptoms
Vary over time, limit
activity, worse
during night or early
morning;
triggered by exercise,
laughter,
exposure to allergens,
respiratory
illness
Chronic and
continuous,
particularly
during exercise,
with “better” or
“worse” days
Symptoms (including exertional
dyspnea) are persistent but
variability may be prominent
Lung function Record of variable airflow
limitation
(e.g., BD reversibility, AHR)
FEV1 may improve
with therapy but
post-BD FEV1/FVC
< 0.7 persists
Airflow limitation not fully
reversible
but often with current or
historical
variability
Lung function
between symptoms
May be normal Persistent airflow
limitation
Persistent airflow limitation

13. Feature Asthma COPD ACOS
Past/family
history
Allergies and childhood
asthma
Exposure to noxious
particles and
gases (e.g., tobacco)
Asthma diagnosis (current/
previous), allergies and/or
noxious
exposures
Time course Improves spontaneously
or with
treatment, but may result
in fixed
airflow limitation
Slowly progressive over
years
despite treatment
Symptoms typically persistent
but
significantly improved by
treatment;
progression is usual and
treatment
needs are high
Chest X-ray Normal Hyperinflation and other
changes
of COPD
Similar to COPD
Exacerbations Occur but the risk can be
considerably reduced by
treatment
Reduced by treatment.
Comorbidities contribute
to impairment
More common than in COPD
and are reduced by treatment;
comorbidities can contribute
to impairment

14. LEVELS OF SEVERITY OF COPD
COPD
Severity
Symptoms FEV1 (%
predicted)
History of
exacerbations
Comorbidities
Mild • Breathlessness on moderate
exertion
• Recurrent chest infections
• Little or no effect on daily
activities
≥ 80 Frequency
increases
with severity
Exist across all
severity levels
(e.g., cardiovascular
disease,
skeletal muscle
dysfunction,
metabolic
syndrome,
osteoporosis,
anxiety or
depression, lung
cancer,
peripheral vascular
disease
and sleep apnea)
Moderate • Increasing dyspnea
• Breathlessness walking 100 m on
level ground
• Increasing limitation of daily
activities
• Cough and sputum production
• Exacerbations requiring
corticosteroids and/or
antibiotics
50 – 79
Severe • Dyspnea on minimal exertion
• Daily activities severely curtailed
• Expiring regular sputum
production
• Chronic cough
30-49
Very severe <30

15. TREATMENT
• Bronchodilators
• Inhaled corticosteroids (Eg. Fluticasone, budesonide)
• Combination inhalers (Eg. Budesonide-formoterol)
• Oral steroids (for moderate to severe acute exacerbations)
• Antibiotics (some respiratory infections like bronchitis,
pneumonia and influenza can aggravate COPD symptoms
• Roflumilast (PDE4 enzyme inhibitor) for people with severe
COPD and chronic symptoms of bronchitis
- Reduces airway inflammation and relaxes the airways
• Theophylline (when other treatments have been ineffective or
cost is a factor

16. • Flu or pneumonia vaccines
• Oxygen therapy

17. STEPWISE TREATMENT APPROACH
• STEP 1: For symptom relief
-SABA or SAMA monotherapy and SABA+LAMA when
symptoms are frequent
• STEP 2: For symptom relief and to prevent exacerbations
-LABA or LAMA monotherapy and LABA+LAMA when
symptoms are frequent
• STEP 3: To prevent exacerbations
-Triple Therapy: LAMA + LABA + ICS
NB: Use the lowest step that achieves optimal control based
on the severity of COPD

18. SURGICAL INTERVENTIONS
• Bullectomy (Removal of large air spaces that form when air
sacs collapse
• Lung volume reduction surgery (Removal o small wedges of
damaged lung tissue from the upper lungs
-Creates extra space in the chest cavity so that the remaining
healthier lung tissue can expand for diaphragm to be efficient
• Lung transplant

19. NON-PHARMACOLOGICAL MANAGEMENT
• Smoking cessation
• Physical activity
• Breathing clean air
• Pulmonary rehabilitation (education, exercise training, nutrition
advice and counselling
• Healthy diet rich in fruits and vegetables

20. COMPLICATIONS
• Respiratory infections
• Heart problems
• Lung cancer
• High blood pressure in pulmonary arteries
• Depression

21. REFERENCES
• Global Strategy for the Diagnosis, Management and Prevention of COPD,
Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2016.
Available from: http://goldcopd.org/.
• The COPD-X Plan: Australian and New Zealand Guidelines for the
Management of Chronic Obstructive Pulmonary Disease (Concise Version).
2015. Available at: copdx.org.au/,
• Woodruff PG, Barr RG, Bleecker E, Christenson SA, Couper D, Curtis JL, et
al. Clinical Significance of Symptoms in Smokers with Preserved Pulmonary
Function. N Engl J Med. 2016 May 12;374(19):1811–21.
• O’Donnell DE, Hernandez P, Kaplan A, Aaron S, Bourbeau J, Marciniuk D,
et al. Canadian Thoracic Society recommendations for management of
chronic obstructive pulmonary disease - 2008 update - highlights for primary
care. Can Respir J. 2008 Feb;15 Suppl A:1A–8A.