Chronic Obstructive Pulmonary Disease
Dr. Pawan K . Mangla , M.D.,INTENSIVIST & PULMONOLOGIST
ISIC & PSRI HOSPITAL
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Why COPD is Important ?
COPD is the only chronic disease that is showing progressive upward trend in both mortality and morbidityIt is expected to be the third leading cause of death by 2020Approximately 14 million Indians are currently suffering form COPD*Currently there are 94 million smokers in India10 lacs Indians die in a year due to smoking related diseases
*The Indian J Chest Dis & Allied Sciences 2001; 43:139-47
Disease Trajectory of a Patients with COPD
Symptoms
Exacerbations
Exacerbations
ExacerbationsDeterioration
End of Life
“Despite this burden, COPD is a “Cindrella” conditions that receives limited recognition from both patients and physicians”
Respiratory Medicine 2002; 96: S1-S31
Obstructive Airway Disease
Asthma
Explosion in
research
Revolution in
therapy
COPD
Little research
(? neglect)
Few advances in
therapy
New DefinitionChronic obstructive pulmonary disease (COPD) is a preventable and treatable disease state characterised by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and is associated with an abnormal inflammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking.Although COPD affects the lungs, it also produces significant systemic consequences.
ATS/ERS 2004
Risk FactorsSmoke from home cooking and heating fuelOccupational dust and chemicalsGender: More common in men. M:F ratio is 5%:2.7% (in India)Increasing ageOthers: Infection, nutrition and deficiency of 1 antitrypsin
Pathophysiology of COPD
Increased mucus production and reduced mucociliary clearance - cough and sputum productionLoss of elastic recoil - airway collapseIncrease smooth muscle tonePulmonary hyperinflationGas exchange abnormalities - hypoxemia and/or hypercapnia
Key Indicators for COPD DiagnosisChronic cough Present intermittently or every
day often present throughout the day; seldom only nocturnal
Chronic sputum production Present for many years, worst in winters. Initially mucoid – becomes purulent with exacerbation
Dyspnoea that is Progressive (worsens over time)Persistent (present every day)Worse on exerciseWorse during respiratory infections
Acute bronchitis Repeated episodes
History of exposure to risk factors
Tobacco smoke (including beedi) occupational dusts and chemical smoke from home cooking and heating fuel
Physical signs
Large barrel shaped chest (hyperinflation)Prominent accessory respiratory muscles in neck and use of accessory muscle in respirationLow, flat diaphragmDiminished breath sound
Algorithm for Diagnosis at Primary Care
Pt reporting with respiratory symptoms
Assess by
- H/o exposure to risk factors- Physical examination
Sputum for AFB
Treat as TB
+ve -ve
Provisional Diagnosis of COPD
Treat as COPD Poor response refer to secondary care
National Guidelines for Management of COPD at Primary Care Level
Spirometry
Diagnosis
Assessing
severity
Assessing
prognosis
Monitoring
progression
Spirometry
FEV1 – Forced expired volume in the first secondFVC – Total volume of air that can be exhaled from maximal inhalation to maximal exhalationFEV1/FVC% - The ratio of FEV1 to FVC, expressed as a percentage.
COPD classification based on spirometry GOLD 2003
SPIROMETRY is not to substitute for clinical judgment in the evaluation of the severity of disease in individual patients.
Severity Postbronchodilator FEV1/FVC
Postbronchodilator FEV1% predicted
At risk >0.7 >80
Mild COPD <0.7 >80
Moderate COPD
<0.7 50-80
Severe COPD <0.7 30-50
Very severe COPD
<0.7 <30
Stage 0: At Risk
GOLD Guidelines for COPD
DiagnosisChronic cough/sputumPFTs within normal limitsNo symptoms
TreatmentAvoid risk factors(smoking cessation)
GOLD Guidelines for COPDStage I: Mild
DiagnosisFEV1 >80% predictedFEV1/FVC <70%
With/without symptoms
TreatmentAvoid risk factorsShort-acting bronchodilator PRN
Stage II: Moderate
GOLD Guidelines for COPD
Diagnosis50% FEV1 <80% predictedFEV1/FVC <70%
With/without symptoms
TreatmentAvoid risk factorsRegular therapy with 1 bronchodilatorsInhaled corticosteroids if significant symptoms and lung function responseRehabilitation
Stage III:Severe
GOLD Guidelines for COPD
Diagnosis30% FEV1 < 50% predictedFEV1/FVC < 70%
With/without symptoms
TreatmentAvoid risk factorsRegular therapy with 1 bronchodilatorsRehabilitationInhaled corticosteroids if significant symptoms and lung function response or if repeated exacerbations
Pharmacotherapy for Stable COPD
BronchodilatorsShort-acting 2-agonist – Salbutamol
Long-acting 2-agonist - Salmeterol and Formoterol
Anticholinergics – Ipratropium, Tiiotropium
Methylxanthines - Theophylline
SteroidsOral – Prednisolone
Inhaled - Fluticasone, Budesonide
Post-bronchodilator
FEV1(% predicted)
Management based on GOLD
“Bronchodilator medications are central to the symptomatic
management of COPD”
GOLD Report 2003
How Do Bronchodilators Work?
Reverse the increased bronchomotor tone
Relax the smooth muscle
Reduce the hyperinflation
Improve breathlessness
“All guidelines recommend inhaled bronchodilator as first line therapy. The ATS suggest initial therapy with an anticholinergic drug if regular therapy is needed”
Chest 2000; 117: 23S-28S
Mode of Action
Cholinergic tone is the only reversible component of COPDNormal airway have small degree of vagal cholinergic tone (no perceptible effect due to patent airways)
Mode of Action (Contd.)
Airways are narrowed in COPD therefore vagal cholinergic tone has greater effect on airway resistance (Resistance1/radius4)Therefore, the need for anticholinergic drugs that will act as muscarinic receptor antagonist and block the acetylcholine induced bronchoconstriction
Mode of Action (Contd.)
Anticholinergics may also reduce mucus hypersecretion
Anticholinergic have no effect on pulmonary vessels, and therefore do not cause a fall in
PaO2
Drugs of Today 2002; 38(9): 585-600
“Patients with moderate to severe symptoms of COPD require combination
of bronchodilators”
“Combining bronchodilators with different mechanisms and durations of actions may increase the degree of bronchodilation for
equivalent or lesser side effects’’
GOLD Report 2003
Leading Causes of Death, US (1998)
Causes of Death
1. Heart disease
2. Cancer
3. Cerebrovascular disease (stroke)
4. COPD and allied conditions
5. Accidents
6. Pneumonia and influenza
7. Diabetes
8. Suicide
9. Nephritis
10. Chronic liver disease
All other causes of death
Number
724,269
538,947
158,060
114,381
94,828
93,307
64,574
29,264
26,295
24,936
469,314Global Obstructive Lung Disease (GOLD) Initiative website (www.goldcopd.com), accessed April 2, 2001.
0.0
0.5
1.0
1.5
2.0
2.5
3.0Coronary
HeartDisease
Stroke OtherCVD
COPD All OtherCauses
- 59% - 64% - 35% + 163% - 7%
1965–1998 1965–1998 1965–1998 1965–1998 1965–1998
Percent Increases in Adjusted Death Rates, US, 1965 – 1998
Pro
po
rtio
n o
f 19
65 R
ate
Global Obstructive Lung Disease (GOLD) Initiative website (www.goldcopd.com), accessed April 2, 2001.
COPD: Risk Factors
Exposures Smoking (generally ≥90%) Passive smoking Ambient air pollution Occupational dust/chemicals Childhood infections (severe respiratory, viral) Socioeconomic status
Host factors Alpha1-antitrypsin deficiency (<1%) Hyperresponsive airways Lung growth
Differential Diagnosis
ChronicBronchitis Emphysema
Asthma
COPDCOPD
Airflow Obstruction
Thanks