Overview of COPD about pathophysiology, epidemiology, types and treatment of stable copd and exacurbation

1. PPE III/IV
PHAR 660/665
Zeinab Noormonavar
4/19/2021
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3. Outline
 Recall the pathophysiology, diagnosis, symptoms, epidemiology, causes
and types of COPD.
 Identify the classification and pharmacological treatment modalities.
 Learn the different drugs used.
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4. Definition
• The Global Initiative forChronic Obstructive Lung Disease (GOLD), a
project initiated by the National Heart, Lung, and Blood Institute (NHLBI)
and the World Health Organization (WHO), defines COPD as follows:
COPD is a common, preventable, and treatable disease that is characterized by
persistent respiratory symptoms and airflow limitation that is due to airway and/or
alveolar abnormalities usually caused by significant exposure to noxious particles
or gases.
Chronic inflammation causes structural changes, small airways narrowing, and
destruction of lung parenchyma.
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5. Epidemiology
5
3rdleading cause of death
worldwide
More than 12 million
have been diagnosed.
With another 12 million
who probably have the disease
and don’t know it.
Average time for readmission is
12 days post discharge
6 %of all deaths globally
In the US, more than 120,000 die
each year of COPD.
That equates to One death
every Four minutes.
15%of people over the age
of 65 have COPD
Not including those who have not
been diagnosed.
Increase prevalence of Lung
Cancer
Increase frequency of
hospitalization
and office visit.

6. Types of COPD
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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.
Abnormal and
permanent
enlargement of
the airspaces
distal to the
terminal
bronchioles that is
accompanied by
destruction of the
airspace walls,
without obvious
fibrosis.
The chronic inflammation is associated with
airway responsiveness that leads to
recurrent episodes of wheezing,
breathlessness, chest tightness, and
coughing, particularly at night or in the early
morning.

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Mild
Moderate
Severe
Very Severe

12. Non PharmacologicalTreatment
• Avoidance of risk factor(s), such as smoking
• Annual influenza vaccination
• Pneumococcal vaccination
• Regular physical activity
• Regular review/correction of inhaler technique
• Long-term oxygen therapy if chronic hypoxemia
• Pulmonary rehabilitation
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More info aboutVaccines:
https://www.uptodate.com/contents/image?imageKey=ID%2F82634&topicKey=PULM%2F120326&search=copd%20management&source=
outline_link&selectedTitle=6~150

13. Treatment Guideline
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14. Short acting
Bronchodilator
Beta Agonist
(SABA)
Albuterol
(PRN)
VENTOLIN
Levalbuterol
(PRN)
XOPENEX
Muscarinic
Antagonist
(SAMA)
Ipratropium
(80 mcgTID, for 12
wks)
ATROVENT
SE: Tremor,
Insomnia
and
Nervousness
SE: Sinusitis,
exacerbation
and
Bronchitis
Combination therapy increased the mean peak
FEV1 more than either agent alone, but did not
alter the frequency of exacerbations.
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15. Long Acting
Bronchodilator
Beta Agonist
(LABA)
Salmeterol: 1 inhalation (50 mcg/actuation) twice daily
Indacaterol: Inhale contents of 1 capsule (75
mcg/capsule) once daily
Vilanterol: Not available as monotherapy
Olodaterol*: 2 inhalations (2.5 mcg/actuation) once
daily
Arformoterol: Inhale contents of 1 vial (15 mcg/2 mL) twice
daily via standard jet nebulizer (solution for nebulizer)
Formoterol: 1 to 2 inhalations (12 to 24 mcg total dose)
twice daily (also available as solution and capsule)
Muscarinic Antagonist
(LAMA)
Tiotropium: 2 inhalations* (2.5 mcg/actuation) once
daily
(18 mcg/capsule once daily)
Aclidinium: 1 inhalation (400 mcg/actuation) twice daily
EKLIRA
Umeclidinium: 1 inhalation (62.5 mcg/actuation) once
daily
Glycopyrolate: Inhale contents of 1 capsule (15.6 mcg/capsule)
twice daily or (50 mcg/capsule) once daily
Inhale contents of 1 vial (25 mcg/1 mL) twice daily as solution for
nebulizer
SE: Resting
tachycardia,
Somatic tremor
SE: Dry mouth,
Urinary retention
All agents except * contain lactose and may
contain milk protein, which may put patients
with milk protein allergy at risk.
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16. CombinationTherapy
LABA /LAMA
Aclidinium
400 mcg
Formoterol
12 mcg
Glycopyrrolate
15.6 mcg
Indacaterol
27.5 mcg
Glycopyrrolate
50 mcg
Indacaterol
110 mcg
Glycopyrrolate
9 mcg
Formoterol
4.8 mcg
Tiotropium
2.5 mcg
Olodaterol
2.5 mcg per
actuationn
Umeclidinium
62.5 mcg
Vilanterol
25 mcg
ANORO
ELLIPTA
LABA/LAMA/GCS
Fluticasone
100 mcg
Umeclidinium
62.5 mcg
Vilanterol
25 mcg
Budesonide
160 mcg
Glycopyrrolate
9 mcg
Formoterol
4.8 mcg
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17. CombinationTherapy
LABA/ ICS
Budesonide-Formoterol
2 inhalations twice daily
(160/4.5
microg/inhalation)
SYMBICORT
Fluticasone propionate-
Salmeterol
2 inhalations twice daily
(115/21 microg/inhalation))
FLUDALT DUO
Fluticasone furoate-
Vilanterol
1 inhalation once daily
(100/25
microg/inhalation)
RELVAR ELLIPTA
Mometasone-
Formoterol
2 inhalations twice daily
(100/5 microg/inhalation)
(200/5 microg/inhalation)
Fluticasone propionate-
Salmeterol
(1 inhalation twice daily
(250/50
microg/inhalation)
(500/50
microg/inhalation)

18. Inhaler
Devices
Dry Powder
Inhaler (DPI)
Meter Dose
Inhaler (MDI)
Nebulizer
Soft Mist
Inhaler (SIM)
17  https://www.youtube.com/watch?v=Lx_e5nXfi5w
 https://www.youtube.com/watch?v=bxC48vQEfZI
 https://www.youtube.com/watch?v=U1NV10RuV6Y

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For 3-5
days
For 5-7 days

20. Summary Take Home Message
• The diagnosis of COPD requires
spirometric confirmation.
• Treatment decisions should be based
not just on the patient’s lung
function, but also on symptoms and
exacerbation history.
• GOLD emphasizes a patient-specific
approach.
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22. • Patients with higher annual rates of
exacerbations after initiation of ICS-
containing therapy had a significantly faster
FEV1 decline (5.8 ml/year).
• This was similar for patients on non-ICS
containing therapy (5.7 ml/year).
• Patients with a BEC of ≥350 cells/µL who
continue to have exacerbations under
treatment with long-acting bronchodilators
need additional treatment with ICS to
prevent excess decline associated with these
exacerbations.
• New ICS users with a high BEC may benefit
more than those with a low BEC when first
started on ICS.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7476283/
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23. References
1. https://pubmed.ncbi.nlm.nih.gov/11223724/
2. https://www.uptodate.com/contents/chronic-obstructive-pulmonary-disease-
definition-clinical-manifestations-diagnosis-and-
staging?search=epidemiology%20of%20COPD&source=search_result&selecte
dTitle=1~150&usage_type=default&display_rank=1
3. http://www.goldcopd.org/
4. https://www.catestonline.org/
5. https://www.researchgate.net/figure/Algorithm-for-antibiotic-treatment-of-
acute-exacerbations-of-COPD-Modified-from-Desai-H_fig3_286307367
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24. ThankYou