Chronic Obstructive

Pulmonary Disease
Why COPD is Important ?
COPD is the only chronic disease that is
showing progressive upward trend in both
mortality and morbidity
It is expected to be the third leading cause of
death by 2020
Approximately 14 million Indians are
currently suffering form COPD*
Currently there are 94 million smokers in India
10 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
Deterioration
Exacerbations

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 COPD

Explosion in Little research

research (? neglect)

Few advances in
Revolution in
therapy therapy
 New Definition
Chronic 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 Factors
Smoke from home cooking and
heating fuel
Occupational dust and chemicals
Gender: More common in men.
M:F ratio is 5%:2.7% (in India)
Increasing age
Others: Infection, nutrition and
deficiency of α 1 antitrypsin
Pathophysiology of COPD
Increased mucus production and
reduced mucociliary clearance -
cough and sputum production
Loss of elastic recoil - airway
collapse
Increase smooth muscle tone
Pulmonary hyperinflation
Gas exchange abnormalities -
hypoxemia and/or hypercapnia
Key Indicators for COPD
Diagnosis
Chronic cough
Chronic sputum production
Dyspnoea that is
Acute bronchitis
History of exposure to risk
factors
Present intermittently or every day
often present throughout the day;
seldom only nocturnal
Present for many years, worst in
winters. Initially mucoid –
becomes purulent with
exacerbation
Progressive (worsens over time)
Persistent (present every day)
Worse on exercise
Worse during respiratory infections
Repeated episodes
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 respiration
Low, flat diaphragm
Diminished 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

+ve -ve

Treat as TB 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 second
FVC – Total volume of air that can
be exhaled from maximal
inhalation to maximal exhalation
FEV1/FVC% - The ratio of FEV1 to
FVC, expressed as a percentage.
 COPD classification based on
spirometry

GOLD 2003
Severity Postbronchodilato Postbronchodilator
r FEV1/FVC FEV1% predicted
At risk >0.7 >80
Mild COPD <0.7 >80
Moderate <0.7 50-80
COPD
Severe COPD <0.7 30-50
Very severe <0.7 <30
COPD

SPIROMETRY is not to substitute for clinical judgment in the

evaluation of the severity of disease in individual patients.
Pharmacotherapy for Stable
COPD
Bronchodilators Steroids
Short-acting β 2- Oral – Prednisolone
agonist – Salbutamol Inhaled - Fluticasone,
Long-acting β 2- Budesonide
agonist - Salmeterol
and Formoterol
Anticholinergics –
Ipratropium, Tiiotropium
Methylxanthines -
Theophylline
 Management based on GOLD

Post-
bronchodilator
FEV1
(% predicted)
“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
COPD
Normal 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 (Resistance
α 1/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
Drugsof Today2002; 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

 Algorithm for the management of
COPD

Mild Short acting bronchodilator – as required

assess with symptoms and

Tiotropium Long acting beta agonist

Tiotropium+LAB LABA + tiotropium

A
spirometry

Add
-Inhaled steroids
Severe -Theophylline