COPD

1. Dr.S.Yuvarajan,
MD,DNB,FCCP(USA),EDRM
Prof&Head,DeptofRespiratoryMedicine
LeadConsultant,InterventionalPulmounit
SMVMCH,Puducherry

2. Case scenario
• 58 yr Old Male came with chief complaints of
Breathlessness on exertion -5 yrs,
Progressive,MMRC grade 2
Increased for the past 1 week(MMRC 3)
No Ort./No PND
Cough -10 days
-Mucoid sputum
-No Diurnal/Postural variation

3. • Spirometry showed very severe obstruction with FEV1 <30
percent with no reversibility after bronchodilator.
• Patient had no exacerbation for the past 1 year

4. • COPD Group D(ABCD assessment tool)
• COPD Grade 4 Group B(Refined ABCD)

5. • 3 Exacerberations requiring hospital admission
• Now ?

6. • COPD Group D( ABCD assessment tool)
• COPD Grade 4 Group D(Refined ABCD assessment
tool)

7. Diagnostic Delays
• Often there is diagnostic delay
• Early diagnosis is the key to optimize the therapy
• Undiagnosed patients have an increased risk of
exacerbations and pneumonia, compared to their
non-COPD.

8. • Use of a targeted approach (focused case-finding
methods) may help to find these undiag- nosed
COPD patients.

9. Under Treatment
• COPD often remains undertreated, with a gap
between guideline recom- mendations and real
world practice.
• >65% of COPD patients were receiving no main-
tenance therapy,(As per Medical & Pharmacy
Claims,USA)
• Three quarters of patients with a modified Medical
Research Council (mMRC) dyspnea score <2 but ≥2
exacerbations/year -under-treated (UK)

10. Exacerberation frequency
• Many patients have >2 Exacerberations/Year.
• 22% Moderate COPD-Frequent Exacerberations
(Eclipse Study).
Earlier identification and treatment of patients who
protect lung function, reduce CV risk .

11. • COPD patients with CV disease are 4 times more
likely to have a subsequent CV event if they
exacerbate .
• 10 times more likely to have a subsequent CV
disease if exacerbation requires hospitalisation

12. Assessment of
and Quantification of Future Risk
• Perform thorough phenotyping, assessment of
underlying biological traits and risk prediction of all
patients.
• Different COPD phenotypes-Different Interventions.
• Thorough assessment will enable accurate individual
prediction of future risk of exacerbations, disease
progression, mortality and CV risk, with the goal to guide
therapy.

13. Assessment of COPD
• Symptomatology/Exacerberation H/O
• Spirometry/Other Lung function tests
• BMI
• Blood Eosinophil count
• Chest imaging
• CV assessment
• Identification of Comordities
• Smoking Exposure/Physical activity

14. • Dyspnoea scale
• MMRC
• CAT scoring
Symptom assessment to guide pharmacological
therapies

15. Post bronchodilator spirometry
• To confirm the diagnosis along with clinical
assessment.
• Longitudinal spirometry results can be used to
mea- sure lung function decline and response to
therapy and can help guide therapy interventions

16. BMI
• Associated with COPD prognosis
• Used in various risk prediction tools and models.
• Low BMI-Increased risk of Pneumonia& Mortality
• Obesity –Associated with comordities,Frequent
exacerberations,Poor therapeutic Response

17. BEC(Blood Eosinophil count)
• Marker of steroid responsiveness in COPD
• Patients with high BEC have less exacerberations
with ICS/LABA vs LABA alone.
• Real-life data also showed that elevated BEC was
associated with better outcomes for those on triple
therapy vs Dual therapy.
• The value of BEC aids to tailor treatments to
specific COPD phenotypes and endotypes .

18. Chest imaging
• Chest x ray /CT chest to exclude other Resp
pathologies.
• CT chest may be necessary for assessment before
LVRS,Lung cancer,Bronchiectasis.
• Standard CT scans can identify airway wall
thickening, and can discriminate between emphy-
sematous and non-emphysematous phenotypes .

19. CV risk assessment and Other
comorbidities
• 2 fold higher risk of CV disease vs non copd groups
• Deaths due to CV persay is higher than Resp Failure
in COPD .
• Prognosis following Acute Cardiac event is worse in
known COPD patients.
• Anxiety/Depression,GERD,DM,Osteoporosis are
common comorbidities in COPD and may be
encountered at any level of severity.

20. Risk Prediction tools
• BODE,DOSE-In predicting clinical worsening and
mortality.
• The risk of developing COPD in adulthood can be
identified using lifetime lung function trajectory
patterns and is 57% greater in those individuals
with a parental history.
• May be used to guide therapy and highlight those
most at risk of exacerbations, disease progression,
and mortality within the target population.

21. BURDEN OF COPD

22. • India contributes to 22% of Global COPD Burden, but 35% of
global COPD DALYs
Measure Global India
Percentage of
Global
India’s Global
Ranking
COPD
Prevalence 251.6 million 55.3 million 21.98% 1st
Deaths 2.9 million 848,165 28.90% 2nd
DALYs 63.4 million 22.4 million 35.27% 1st
India State-Level Disease Burden Initiative CRD Collaborators. Lancet Glob Health. 2018;6(12):e1363–e1374.
BURDEN OF COPD

24. Downward spiral of COPD
exacerbations
• AECOPD are a ‘gateway’ to
• Accelerated decreases in lung function
• Worsened quality of life
• The next, and more frequent, AECOPD
• Increased healthcare utilization, including emergency
department visits and hospitalizations
• Increased mortality
• Upto 50% exacerbations underreported by pts
• Exacerbations are a trigger (‘opportunity’) for clinicians
to consider the diagnosis of COPD or to optimize
management
• Early treatment optimization can prevent trapping into
downward spiral
Criner GJ, et al. Chest 2015; 147:883-893.
JR Hurst et al. Eur J Intern Med 73, 1-6. 2020.
Bourbeau J, et al. Can J Resp Crit Care Med 2017; 1:222.

25. Distribution of COPD pts as per GOLD
– Indian study
10%, 9.7%
11%, 57%
44%, 23%
35%, 10%
Bajpai J et al. J Family Med Prim Care. 2019;8(7):2364–2368.
80% of patients had moderate to severe COPD → Needs combination therapy
GOLD Grade FEV1
(% predicted )
I ≥ 80
II 50-79
III 30- 49
IV < 30

26. SPIROMIC study reveals under
treatment of symptomatic COPD pts
Labaki WW et a. BRN Rev. 2019;5(4):233-48
Inhaler management in about 50% of
patients with COPD is not aligned with
GOLD recommendations, with half of
these being under-treated

29. Are we still using this classification?

33. Active case finding
• Identify individuals ≥40 years of age (with or without
a pre-existing COPD diagnosis)
• History of smoking or relevant environmental
exposure(Biomass exposure)
• At increased risk of exacerbations, morbidity, and
mortality and with scope for COPD management
optimization.
• Identify those with greater cardiovascular risk

34. Diagnostic Delays
• Often there is diagnostic delay
• Early diagnosis is the key to optimize the therapy
• Undiagnosed patients have an increased risk of
exacerbations and pneumonia, compared to their
non-COPD.

35. • Use of a targeted approach (focused case-finding
methods) may help to find these undiag- nosed
COPD patients.

39. Ideal screening tool

40. Problems with Spirometry
• Cumbersome to reach target /outreach areas
• Effort dependent
• Good technician needed
• Lack of awareness among the Primary care
physicians.
• General practioners knows ECG reading better than
Spirometry

41. Ways to Overcome
• We can use COPD-6/Vitalograph for screening the
target population..
• FEV1,FEV6 and its ratio can be measured by this.
• Usual cut off is 0.75-0.8.
• Requires less effort as patient is needed to blow for 6
sec only ..
• But always remember spirometry is gold standard

44. mMRC Vs CAT score
mMRC –Widely used scale in patients with chronic resp diseases
Unidimentional scale quantifies only Dyspnoea
CAT- Multidimentional specifically designed for COPD
Controversies remain regarding the ideal CAT score cutoff-point
equivalent to an mMRC value or the extent of agreement
between the two scores.

73. (Part I)