ECI COPD Educator Course. www.copdegypt.org

1. COPD
Definition
Epidemiology
Prevalence
Pathophysiology

2. GOLD Definition
 COPD, a common preventable and treatable disease, is
characterized by persistent airflow limitation that is
usually progressive and associated with an enhanced
chronic inflammatory response in the airways and the
lung to noxious particles or gases.
 Exacerbations and comorbidities contribute to the
overall severity in individual patients.
GOLD 2013

3. ATS/ ERS Definition
 Chronic obstructive pulmonary disease (COPD) is a
slowly progressive disease involving the airways or
pulmonary parenchyma (or both) that results in airflow
obstruction.
 Manifestations of COPD range from dyspnea, poor
exercise tolerance, chronic cough with or without
sputum production, and wheezing to respiratory failure
or cor-pulmonale.
 Exacerbations of symptoms and concomitant chronic
diseases may contribute to the severity of COPD in
individual patients.
Ann Intern Med. 2011;155:179-191.

4. Definition : Airflow Limitation
 The chronic airflow limitation characteristic of COPD is
caused by a mixture of small airway disease (obstructive
bronchiolitis) and parenchymal destruction (emphysema),
the relative contributions of which vary from person to
person
Global initiative for chronic obstructive pulmonary disease updated 2013

5. Definitions
Emphysema pathological term which is destruction of
the gas exchanging surfaces of the lung (alveoli).
 Chronic bronchitis is the presence of cough and
sputum production for at least 3 months in each of two
consecutive years.
GOLD 2013

6. Epidemiology
COPD is a leading cause of morbidity and mortality
worldwide and results in an economic and social burden
that is both substantial and increasing.
COPD is the result of cumulative exposures over decades
GOLD 2013

7. Epidemiology
Studies to improve the global understanding of COPD
prevalence and prognosis include:
▫ Burden of Obstructive Lung Disease (BOLD) Initiative 1 (now complete
in China, Turkey, Austria, South Africa, Iceland, Poland, Germany,
Norway, Canada, Philippines, USA and Australia) 2
▫ Latin-American Project for the Investigation of Pulmonary
Obstruction (PLATINO) (in Brazil, Chile, Mexico and
Uruguay) 3
1-Buist et al COPD 2005; 2-BOLD 2007; 3-Menezes et al LANCET 2005

8. Epidemiology
The BOLD Study: a population-based prevalence
study
 9425 Participants from 12 sites , aged 40 years and
older.
The prevalence of stage II or higher COPD was 10・1%
(SE 4・8) overall, 11・8% (7・9) for men, and 8・5% (5
・8) for women.
Generally, the prevalence of COPD that is GOLD stage II
or higher increased steadily with age for men and women
in every site.
The prevalence increased with increasing pack-years.
Lancet 2007; 370: 741–50

9. Epidemiology
The Global Burden of Disease Study projected
that COPD, which ranked sixth as the cause of
death in 1990, will become the third leading
cause of death worldwide by 2020; a newer
projection estimated COPD will be the fourth
leading cause of death in 2030
And the seventh leading cause of DALYs
lost worldwide in 2030.
GOLD 2013

10. Epidemiology
COPD prevalence by gender and age groups
60
50
40
Prevalence %
30 Male
Female
20
10
0
40-49 50-59 60-69 70+
Prevalence of COPD According to GOLD Stage I and Higher COPD
Chest 2007;131;29-36

11. Epidemiology
Factors Influence disease development and progression
 Genes
 Age and Gender
 Lung Growth and Development
 Exposure to particles
▫ Tobacco smoke
▫ Occupational dusts, organic and inorganic
▫ Indoor air pollution from heating and cooking with biomass
in poorly ventilated dwellings
▫ Outdoor air pollution
 Socioeconomic status
 Respiratory Infections
Chronic Bronchitis
Asthma / Bronchial Hyperreactivity
GOLD 2013

12. Epidemiology
Factors Influence disease development and progression
Cigarette smoking is the most commonly encountered
risk factor for COPD
100 Never smoked or not
susceptible to smoke
FEV1 (% of value at age 25)
80
Smoked regularly
60 and susceptible
to its effects
Stopped at 45
40 Disability
20
Death Stopped at 65
0
25 50 75
Adapted from Fletcher C, et al. Br Med J 1977 Age (years)

13. Epidemiology
Genes
The genetic risk factor that is best documented is a
severe hereditary deficiency of alpha-1
antitrypsin, a major circulating inhibitor of serine
proteases.
Genetic factors with environmental factors could
influence susceptibility to develop airflow limitation
Gender
In the past most studies showed that COPD were
greater among men
But now studies shows prevalence is almost equal
which reflects changing patterns of tobacco
smoking

14. Prevalence of COPD
Other Risk Factors
Comorbid conditions
Under-diagnosis
Complex disease

15. COPD has the third highest overall
lifetime risk after diabetes and asthma
Gershon AS et al. Lancet 2011; 378: 991–96

16. COPD: Prevalence Rates
Country/region Extrapolated Population estimated
Prevalence use
Egypt 3,777,886 76,117,421
Gaza strip 65,762 1,324,991
Jordan 278,497 5,611,202
Kuwait 112,047 2,257,549
Lebanon 187,472 3,777,218
Saudi Arabia 1,280,313 25,795,938
United Arab Emirates 125,267 2,523,915
West Bank 114,710 2,311,204
Yemen 993,881 20,024,867
http://www.rightdiagnosis.com/c/copd/stats-country.htm last accessed 20/3/2013

17. 17
COPD in Egypt
Statistical analysis of COPD prevalence in Egypt showed
that 3 millions from the egyptian population have
COPD.1
In different studies prevalence were from 3.3% up to
10%. 1,2
Prevalence rate in men was ~6.7 % while it was ~1.5% in
woman1
1-BREATHE Study, Prevalence of COPD in middle east and north Africa. E-poster, ERS Sep 2011
2- E-poster Burden of COPD in some African and Asian countries V.Kiri et al, Sep 2007

18. Air pollution is a major problem in Asia
SO2 : Sulfur Dioxide NO2 : Nitrogen dioxide.
PM 10 :particulate matter 10 microns and less TSP :Total suspended particulates
Thorax 2007;62:748-749

19. Biomass smoke exposure and the
risk of COPD
Am J Respir Crit Care Med Vol 182. pp 693–718, 2010

21. TORCH : Overall, 27% of the deaths were adjudicated as
due to cardiovascular causes, 35% to pulmonary causes,
and 21% to cancer
Unknown
Other 7% Respiratory
10%
35%
Respiratory
Cancer Cardiac
21%
Cancer
Other
Unknown
Cardiac
27%
N Engl J Med 2007;356:775-89.

22. COPD Uncovered
75% stated they had ≥1 comorbid condition
The most commonly reported conditions were
hypertension, asthma, arthritis, anxiety,
depression and diabetes.
Fletcher et al. BMC Public Health 2011, 11:612

23. Probability of Cardiovascular
event
Thorax 2010;65:719e725

24. Prevalence of CVD in COPD
BCMJ, Vol. 50, No. 5, June 2008, page(s) 246-251

25. Clinical consequences of
Osteoporosis
• Acute and chronic pain • Bulging abdomen, reflux and other Gl symptoms
• Kyphosis • Breathing difficulties
• Loss of height • Depression
• Loss of mobility • Loss of Independence
REDUCED QUALITY OF LIFE

26. Prevalence of osteoporosis in
COPD
Rev Osteoporos Metab Miner 2012 4;2:69-75

27. GOLD staging and osteoporosis
The prevalence of osteoporosis was greater than
50% regardless of GOLD stage
COPD 2008, 5:291–297

28. Reported prevalence of chronic obstructive
pulmonary disease and relative Underdiagnosis
in selected population studies
Lancet 2009; 374: 721–32

29. COPD prevalence and GOLD
severity stages by gender and age
M: men
W:women;
T:total
Thorax 2009;64:863-868

30. Recent trends in COPD prevalence in
Spain: a repeated cross-sectional survey
1997-2007
Eur Respir J.2010 Oct;36(4):758-65

32. International COPD network
(ICON) study
 Twelve territories across the Asia-Pacific region, Africa, eastern
Europe, and Latin America
 Total of 600 GPs (50 from each territory)
 Survey demonstrated that the GPs’ understanding of COPD was
variable across the territories, with large numbers of GPs having
very limited knowledge of COPD and its management.
 A consistent finding across all territories was the underutilization of
spirometry (median 26%; range 10%–48%) and reliance on X-rays
(median 14%; range 5%–22%) for COPD diagnosis
International Journal of COPD 2012:7 271–282

33. Perceived prevalence of chronic obstructive
pulmonary disease (COPD) in each territory
International Journal of COPD 2012:7 271–282

34. Parameters considered by GPs for ongoing
treatment of COPD in different territories
International Journal of COPD 2012:7 271–282

35. Gender Bias Can Impede
Diagnosis
Survey of 192 primary care physicians
▫ Provided a case of male patient and female patient
with same history and physical exam
▫ Asked about provisional diagnosis
Physicians Provisional diagnosis (%)
Male Patient Female Patient
COPD 65 49
Asthma 32 44

36. The Changing Face of COPD
Younger More women
 70% of patients with COPD  In 2004 women
are <65 years old, accounting accounted for 63% of
for: all self reported COPD
▫ 67% of COPD office visits cases
▫ 43% of hospitalizations

37. Conclusions
The Prevalence de COPD is between 10 - 15 %.
Most patients have not been diagnosed.
Cigarette smoking and biomass are major risk factors for
the disease.
Co-morbid conditions prevalence are increasing.
COPD is a disease of younger patie nts, and increased
number of women.
Different therapies including smoking cessation, and
pharmacotherapy impact the disease.

38. Pathophysiology
Inhaled cigarette smoke and other noxious particles such
as smoke from biomass fuels cause lung inflammation, a
normal response that appears to be modified in patients
who develop COPD.
This chronic inflammatory response may induce
parenchymal tissue destruction (resulting in
Emphysema) and disrupt normal repair and defense
mechanisms (resulting in small airway fibrosis)

39. Pathophysiology
Inflammatory Cells
COPD is characterized by a specific pattern of inflammation involving
Neutrophils ,Macrophages, Cytotoxic Lymphocytes
Oxidative stress
A number of studies have indicated that oxidative stress has a
significant role in the pathogenesis of COPD.
Biomarkers of oxidative stress are increased in the breath and sputum
of COPD patients.
 Protease-antiprotease imbalance
This imbalance is at least partly due to the secretion of proteases by
macrophages and neutrophils associated with the chronic
inflammatory response

40. Pathophysiology
Although both COPD and asthma are associated with
chronic inflammation of the respiratory tract, there are
differences in the inflammatory cells and mediators
involved In the two diseases, which in turn account lor
differences in physiological effects, symptoms, and
response to therapy.
Some patients with COPD have features consistent with
asthma and may have mixed inflammatory pattern with
increased eosinophils.

41. Distribution of Direct Costs of
COPD by Severity
100%
90%
80%
70%
Equipment aids
60%
50% Oxygen therapy
40% Outpatient care
30%
Medicines
20%
10% Hospitalizations
0%
<40% 40-59% 60-79% >80% Mean