Chronic Obstructive Pulmonary Disease (COPD

Chronic Obstructive Pulmonary Disease (COPD)
Mohamed Awad Tageldin
Prof . and Consultant of Thoracic Diseases Ain Shams Faculty of Medicine
Former Minister of Health and Population Former President of Ain Shams University
President of the Egyptian Society of Chest Diseases and Tuberculosis
Definition Of Copd
. 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.
Airflow limitation of COPD
. 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
Definition Of Copd
. 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.
Airflow limitation of COPD
. 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
COPD Burden
. 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
. Under-recognition and under-diagnosis of COPD still affect the accuracy of mortality data.
. Morbidity from COPD may be affected by other comorbid chronic conditions that are related to COPD and may have impact on patient’s health status as well as interfere with COPD management e.g. Cardiovascular diseases
. It is clear that COPD is one of the most important causes of death in most countries
Newer projections
. Newer Projections estimated COPD will be the fourth leading cause of death in 2030
. And the seventh leading cause of DALYs lost worldwide in 2030.
COPD Prevalence
. COPD is a common disease with a steadily increasing prevalence and mortality.1
. And despite its considerable social and economic importance, population-based epidemiological studies of its prevalence have lagged behind those of other common health problems.3
. Globally, COPD affects around 210 million people, and half of these are thought to be aged 40-651
. About 400,000 deaths occur each year from COPD in industrialized countries. 2
. Meta-analysis of epidemiological investigations based on spirometry testing showed a COPD prevalence of 9–10%. 3
. Only 19% of these patients had already been diagnosed and treated. 3
Early diagnosis of COPD
can be challenging
. Patients with mild COPD and a smoker’s cough may experience little impact on breathing ability and no obvious additional abnormal symptoms.
. Often, recognition of COPD does not occur until the disease has progressed to moderate or severe stages, by which time patients’ symptoms have worsened; they have a poor QoL and a rapidly declining condition.
. Factors contributing to this include:
- Low awareness of COPD
- Low awareness of the initial symptoms of the
disease among the general population
- Acceptance of these symptoms as a consequence
of aging or smoking
- Despite spirometry is a vital tool, it is
widely underutilized, even if available in
disease at point of diagnosis
Mapel DW et al. International Journal of COPD 2011:6 573–581
Purpose: This study was conducted to determine COPD severity at the time of diagnosis as
confirmed by spirometry in patients treated in a US managed care setting.
Patients and methods: All patients with one or more inpatient stays, one or more emergency
department visits, or two or more outpatient visits with diagnosis codes for COPD during1994 –2006 were identified from the Lovelace Patient Database. From this group, a subset of
continuously enrolled patients with evidence in claims of a first available pulmonary function
test or pulmonary clinic visit
and a confirmatory claim for a COPD diagnosis was selected.
Medical chart abstraction was undertaken for this subset to gather information for diagnosis
and severity staging of each patient based on the Global Initiative for Chronic Obstructive Lung
Disease (GOLD) criteria for COPD.
Results: Of the 12,491 patients with a primary or secondary COPD diagnosis between 1994
and 2006, there were 1520 continuously enrolled patients who comprised the study cohort.
Among the 648 eligible records from patients with evidence of a pulmonary function test, 366
were identified by spirometry as having COPD of GOLD stage I or higher (average percentage
of predicted forced expiratory volume in 1 second: 60%): 19% were diagnosed at the stage of
mild disease (GOLD stage I); 50% at moderate disease (GOLD stage II); and 31% at severe
or very severe disease (GOLD stage III or IV, respectively).
The majority of patients in these
groups were not receiving maintenance treatment.
Conclusion: The results demonstrate a very low incidence of early-stage diagnosis, confirmed
by a pulmonary function test,
of COPD in a large US sample and support calls for increased
screening for COPD and treatment upon diagnosis.
. Patients restrict their activities to avoid breathlessness1,2
.This ultimately leads to gradual deterioration of the patient´s health-related quality of life (HRQoL)3, increased dependency and social isolation1
The GOLD guideline recommends long-acting bronchodilators as first-line maintenance treatment in COPD.
GOLD 2013
Combined assessment of COPD
. Assess symptoms first
. Assess risk of exacerbations next
. Patient is now in one of four categories:
Management of COPD
Objectives of COPD Management
- Prevent disease progression
- Relieve symptoms
- Improve exercise tolerance
- Improve health status
- Prevent and treat exacerbations
- Prevent and treat complications
- Reduce mortality
Minimize side effects from treatment
Management of Stable COPD
All Stages of Disease Severity
. Avoidance of risk factors
- smoking cessation
- reduction of indoor pollution
- reduction of occupational exposure
. Influenza vaccination
Manage Stable COPD: Key Points
.The overall approach to managing stable COPD should be individualized to address symptoms and improve quality of life.
. For patients with COPD, health education plays an important role in smoking cessation and can also play a role in improving skills, ability to cope with illness and health status.
. None of the existing medications for COPD have been shown to modify the long-term decline in lung function that is the hallmark of this disease . Therefore, pharmacotherapy for COPD is used to decrease symptoms and/or complications
Bronchodilators
. Bronchodilator medications are central to the symptomatic management of COPD .
.They are given on an as-needed basis or on a regular basis to prevent or reduce symptoms and exacerbations.
.The principal bronchodilator treatments are ß2- agonists, anticholinergics, and methylxanthines used singly or in combination .
. Regular treatment with long-acting bronchodilators is more effective and convenient than treatment with short-acting bronchodilators .
Bronchodilators in Stable COPD
. Inhaled therapy is preferred.
.The choice between Anticholinergic, Beta2-agonist, theophylline or combination therapy depends on availability and individual response in terms of symptoms relief and side effects.
.Theophylline is effective in COPD
.Bronchodilators are prescribed on an as- needed or on a regular basis to prevent or reduce symptoms.
. Long-acting inhaled bronchodilators are more convenient.
. Combining bronchodilators may improve efficacy and decrease the risk of side effects compared to increasing the dose of a single bronchodilator
Glucocorticosteroids
The addition of regular treatment with inhaledv glucocorticosteroids to bronchodilator treatment is appropriate for symptomatic COPD patients with an FEV1 Managing Stable DiseaseICS
Long term use of ICS (> six months) did not significantly reduce the rate of decline in FEV1 in COPD patients.
There was no statistically significant effect on mortality in COPD patients.
Long term use of ICS reduced the mean rate of exacerbations in those studies where pooling of data was possible
ICS slowed the rate of decline in quality of life, as measured by the St George’s Respiratory Questionnaire
Glucocorticosteroids
. Chronic treatment with systemic glucocorticosteroids should be avoided because of an unfavorable benefit-to-risk ratio .
Managing Stable Disease
Pulmonary Rehabilitation
Rehabilitation relieves dyspnea and fatigue, improves emotional function and enhances patients’ sense of control over their condition. These improvements are moderately large and clinically significant. Rehabilitation forms an important component of the management of COPD.
Bronchodilators are the cornerstone
of COPD treatment
.Target air flow limitation, bronchodilating by altering airway smooth muscle tone
. Improve emptying of the lung
. Reduce hyperinflation at rest and during exercise
Oxygen Therapy
The long-term administration of oxygen (> 15 hours per day) to patients with chronic respiratory failure has been shown to increase survival. It can also have a beneficial effect on hemodynamics, hematologic characteristics, exercise capacity, lung mechanics and mental state.

. Long-term home oxygen therapy improved survival in a selected group of COPD patients with severe hypoxaemia (arterial PaO2 less than 55 mm Hg (8.0 kPa)). Home oxygen therapy did not appear to improve survival in patients with mild to moderate hypoxaemia or in those with only arterial desaturation at night.
. PaO2 breathing room air.
. PaO2 56 mm Hg, or SaO2 > 89 percent, while awake.
. PaO2 56 mm Hg, or SaO2 > 89 percent during the day, while at rest.
. PaO2 is 56-59 mm Hg or whose SaO2 =
89%, if there is evidence of:
- Dependent edema suggesting
congestive heart failure;
- Pulmonary hypertension or cor pulmonale,artery“P”pulmonale on EKG (P wave greater than 3 mm instandard leads II, III, or AVF); or
Erythrocythemia with a hematocrit greater than 56 percent
Other pharmacological treatment
Vaccines
. Influenza vaccines can reduce serious illness and death in COPD patients by about 50%. Vaccines containing killed or live, inactivated viruses are recommended as they are more effective in elderly patients with COPD. The strains are adjusted each year for appropriate effectiveness and should be given once (in Autumn) or twice (in Autumn and Winter) each year. A pneumococcal vaccine containing 23 virulent serotypes has been used, but sufficient data to support its general use in COPD patients are lacking.
Non pharmacological treatment
Rehabilitation
Improves exercise capacity.
Reduces the perceived intensity of breathlessness.
Can improve health-related quality of life.
Reduces the number of hospitalizations and days in the hospital.
Reduces anxiety and depression associated with COPD.
Surgical treatment
Bullectomy
. Indicated when the bullea occupy 50% or more of the hemithorax and produce definite displacement of the adjacent lung .
Lung volume reduction surgery (LVRS)
. Is indicated when FEV1 200% predicted.
Lung Transplantation
. Criteria for referral for lung transplantation include:
. FEV1 . PaCO2 > 50 mmHg and secondary pulmonary hypertension
Mucolytics
In participants with chronic bronchitis or COPD, treatment with mucolytics was associated with a small reduction in acute exacerbations and a reduction in total number of days of disability. Benefit may be greater in individuals who have frequent or prolonged exacerbations, or those who are repeatedly admitted to hospital with exacerbations with COPD. They should be considered for use, through the winter months at least, in patients with moderate or severe COPD in whom inhaled corticosteroids (ICS) are not prescribed.