copd management.. chronic obstructive pulmonary disease

1. Pratap Sagar Tiwari, MD, Internal
medicine

2. • A clinical diagnosis of COPD should be
considered in any patient who has dyspnea,
chronic cough or sputum production and a
history of exposure to risk factors of the disease.
• Spirometry is required to make the diagnosis in
this clinical context; the presence of a post
bronchodilator FEV1/FVC <0.70 confirms the
presence of persistent airflow limitation and thus
of COPD.
• FEV1:the volume of air forcefully expired during the 1st sec after taking a full
breath
• Forced vital capacity (FVC):the total volume of air expired with maximal
force

3. Treatment line begins after assessment of
severity of the condition
Postbronchodilator FEV1/FVC <0.7 defines Airflow limitation
Low
risk
High
Risk
3 yr mortality =24%

4. • 0-1 = less
breathlessne
ss
• >2= more
breathlessne
ss

5. Variable 0 1 2 3
FEV1
O
≥ 65 50-64 36-49 ≤ 35
Dist walked
in 6 min (m)
E
≥ 350 250-349 150-249 ≤ 149
MRC
Dyspnoea
scale*
0-1 2 3 4
Body mass
index
> 21 ≤ 21
BODE score 0-2 =mortality rate of around 10% at 52 mnt
BODE score 7-10=mortality rate of around 80% at 52 mn

6. • Chronic stable phase COPD
• COPD on Acute exacerbation

7. • Only three interventions—smoking
cessation, oxygen therapy in chronically
hypoxemic patients, and lung volume
reduction surgery in selected patients with
emphysema—have been demonstrated to
influence the natural history of patients
with COPD.
• All other current therapies are directed at
improving symptoms and decreasing the
frequency and severity of exacerbations.

8. • Smoking cessation
• Bronchodilators

9. There are 4 principal pharmacologic approaches to the
problem:
1. Bupropion.
2. Nicotine replacement therapy available
as gum, transdermal patch, inhaler, and
nasal spray; and
3. Varenicline, a nicotinic acid receptor
agonist/antagonist.
4. Nortriptyline

10. • Anticholinergics
• B2 Agonists
Inhaled bronchodilators are the
mainstay of COPD management
Note:
• However no evidence that regular bronchodilator
use slows deterioration of lung function.
• Anticholinergics have a greater bronchodilating
effect than b2 agonists.

11. • Side effects: tremor and tachycardia
SABA Inhaler /mdi For nebuliser DOA (hr)
Salbutamol 100,200 mcg 5 mg/ml 4-6
Levalbuterol
Albuterol
Pirbuterol
Terbutaline
LABA Inhaler (mcg) Oral DOA (hr)
Salmeterol 25-50 12
Formeterol
Bambuterol
Indacarterol
10-20 mg od

12. • Side effects: urinary retention, and dry mouth,tremor and
tachycardia
SAA Inhaler For nebuliser
mg/ml
DOA (HR)
Ipratropium 20,40
MDI
0.25-0.5 6-8
Oxitropium 100
MDI
1.5 7-9
LAA Inhaler
(mcg)
Oral DOA (hr)
Tiotropium 18 DPI 24

13. • Inhaled Glucocorticoids
• Oral Glucocorticoids
• In COPD, inhaled GCs are used as part of a
combined regimen, but should NOT be used as
sole therapy for COPD (ie, without long-acting
BDs).
• Regular Rx improves symptoms, lung function
and quality of life and reduce frequency of
exacerbations in COPD with FEV1 <60% but
however doesnot modify long term decline of
FEV1 nor mortality .

14. • Their use has been A/W ↑ rates of
oropharyngeal candidiasis & an ↑ rate of
loss of bone density.
• A trial of inhaled GC should be considered
in patients with frequent exacerbations,
defined as ≥2/yr, and in pts who
demonstrate a significant amount of acute
reversibility in response to inhaled BD.

15. • The chronic use of oral GCs for Rx of
COPD is not recommended because of an
unfavorable benefit/risk ratio.
• The chronic use of oral GCs is a/W
significant side effects, including
osteoporosis, weight gain, cataracts,
glucose intolerance, & ↑ risk of infection.

16. • Theophylline produces modest improvements in
expiratory flow rates and vital capacity and a
slight improvement in arterial o2 and Co2 levels
in patients with moderate to severe COPD.
• Nausea is a common SE; tachycardia and tremor
have also been reported.
• MX are less effective and less well tolerated than
long acting inhaled bronchodilators and is not
recommended if others r available & affordable.
• Addition of low dose slow release theophylline
may be given along with long acting BDs.

17. • Once a day dosage :No direct bronchodilator
activity but has shown to improve FEV1 in pts
treated with salmeterol or tiotropium.
• Roflumilast ↓ moderate to severe
exacerbations treated with CSs by 15-20 % in
pts with ch bronchitis, severe and very severe
COPD and a Hx of A/E.
• S/e: nausea, pain abodmen, diarrhea
insomnia
• Note: Roflumilast & Theophylline shouldnot be
given together.

18. • All Patients with COPD should receive the
influenza vaccine annually.
• Polyvalent pneumococcal vaccine is also
recommended, (in pt ≥65 yrs old or <65 +
Fev1 <40 %)

19. Not recommended in stable copd by ATS, BTS,
ETS,GOLD
1. Mucokinetics and antioxidants (n-
acetylcysteine)
2. Antitussive
3. vasodilators like nitric oxide
4. Drugs to treat pulmonary hypertension
(ETA)
5. Nedochromil (mast cell stabilizer)
6. Monteleukast (leukotriene modifier)
7. Antibiotics

20. • Specific treatment in the form of IV a1AT
augmentation therapy is available for
individuals with severe a1AT deficiency.
• Eligibility for a1AT augmentation therapy
requires a serum a1AT level <11 uM
(approximately 50 mg/dL).

21. • Supplemental O2 is the only pharmacologic therapy
demonstrated to unequivocally decrease mortality rates
in patients with COPD.
1. PaO2 ≤ 7.3 kPa (55 mmhg) or SaO2 <88%, with or
without hypercapnia confirmed twice over a 3 week
period.
2. PaO2 :7.3 -8.0 kPa(55-60 mmhg) or SaO2 of 88%, if
there is evidence of pulmonary HTN, peripheral edema
s/o CCF, or polycythemia (HCT>55%).

22. • Surgery to reduce the volume of lung in patients with
emphysema was first introduced with minimal success in
the 1950s and was reintroduced in the 1990s.
• Patients are excluded if they have significant pleural
disease, a pulmonary artery systolic pressure >45
mmHg, extreme deconditioning, congestive heart failure,
or other severe comorbid conditions. Patients with an
FEV1 <20% of predicted and either diffusely distributed
emphysema on CT scan have an increased mortality rate
after the procedure and thus are not candidates for
LVRS.
• Patients with upper lobe–predominant emphysema and a
low postrehabilitation exercise capacity are most likely to
benefit from LVRS.

23. • COPD is currently the second leading indication for lung
transplantation.
• Current recommendations are that candidates for lung
transplantation should be <65 years; have severe
disability despite maximal medical therapy; and be free of
comorbid conditions such as liver, renal, or cardiac
disease.

25. Clinical
diagnosis
Spirometry
Gold severity
stage
Drugs a/t
stages

26. Stage Management
All - Avoidance of risk factor(s)
- Influenza vaccination
- Pneumococcal vaccination
Stage 1 Short-acting bronchodilator when needed
Stage 2 Short-acting bronchodilator when needed
Regular treatment with one or more long-acting bronchodilators
Stage 3 Short-acting bronchodilator when needed
Regular treatment with one or more long-acting bronchodilators
Inhaled glucocorticoids if significant symptoms, lung function response,
or if repeated exacerbations
Stage 4 Short-acting bronchodilator when needed
Regular treatment with one or more long-acting bronchodilators
Inhaled glucocorticoids if significant symptoms, lung function response, or
if repeated exacerbations
Treatment of complications
Long-term oxygen therapy if chronic respiratory failure
Consider surgical treatments

27. 1. Global strategy for the diagnosis, management,
and prevention of copd . Updated 2014
2. Harrison's Principles of Internal medicine .18th
edition
3. Davidson's Principles and practice of Medicine
.21st edition.
4. Uptodate version 20.3
5. Mercksmannual

28. • The goal of treatment in COPD AE is minimize the impact
of current exacerbation and to prevent the development
of subsequent exacerbations.
Signs of Severity

29. • The Global Initiative for COPD(GOLD), a report produced
by the National Heart, Lung, and Blood Institute (NHLBI)
and the WHO, defines an exacerbation of COPD as an
acute increase in symptoms beyond normal day-to-day
variation. This generally includes an acute increase in
one or more of the following cardinal symptoms:
1. Cough increases in frequency and severity
2. Sputum production increases in volume and/or changes
character
3. Dyspnea increases

30. • Haemophilus influenzae
• Moraxella catarrhalis
• Streptococcus pneumoniae
• Pseudomonas aeruginosa
• Enterobacteriaceae
• Haemophilus parainfluenzae
• Staphylococcus aureus
(Note: Despite the frequent implication of bacterial
infection, chronic suppressive or "rotating" antibiotics are
not beneficial in patients with COPD and is not
recommended.)
Most common cause is viral upper RTI

32. American Thoracic Society/European Respiratory Society (ATS/ERS)
• Inadequate response of symptoms to outpatient management
• Marked increase in dyspnea
• Inability to eat or sleep due to symptoms
• Worsening hypoxemia
• Worsening hypercapnia
• Changes in mental status
• Inability to care for oneself (ie, lack of home support)
• Uncertain diagnosis
• High risk comorbidities including pneumonia, cardiac arrhythmia,
heart failure, diabetes mellitus, renal failure, or liver failure
• In addition, there is general consensus that acute respiratory
acidosis justifies hospitalization.

33. • Typically, patients are treated with an
inhaled b-agonist, often with the
addition of an anticholinergic agent.
• Patients are often treated initially with
nebulized therapy, as such treatment
is often easier to administer in older
patients or to those in respiratory
distress.

34. Antibiotics
• Inexpensive common oral antibiotics usually adequate
.Broader spectrum if not responsive.
Glucocorticoids
• Among patients admitted to the hospital, the use of
glucocorticoids has been demonstrated to reduce the
length of stay, hasten recovery, and reduce the chance of
subsequent exacerbation or relapse for a period of up to
6 months.
• The GOLD guidelines recommend 30–40 mg of oral
prednisolone or its equivalent for a period of 10–14 days.

35. • Target Pao2: 60-70 mmhg
• Nasal cannulae can provide flow rates up to 6 L
/min with an associated FiO2 of approximately
40 % .
• Simple facemasks can provide an FiO2 up to 55
% using flow rates of 6 to 10 L per minute.
• Venturi masks can deliver an FiO2 of 24, 28, 31,
35, 40, or 60 percent.
• Non-rebreathing masks with a reservoir, one-way
valves, and a tight face seal can deliver an
inspired oxygen concentration up to 90 %.

38. • cardiovascular instability,
• impaired mental status or inability to cooperate,
• copious secretions or the inability to clear secretions,
• craniofacial abnormalities
• extreme obesity,
• or significant burns.

41. • End of slides