COPD

DR.K.K.SHYAMALA
ASSOCIATE PROFESSOR
DEPT OF PULMONARY MEDICINE
DR.B.R.AMC

22/04/2020
Contents
Introduction
Etiology/ Risk Factors
Pathophysiology
Pathology
Clinical features
Diagnosis
Management
Complication
 Definition : GOLD (Global Initiative for
Chronic Obstructive Lung Disease)

Common, preventable and treatable disease that is characterized by persistent

respiratory symptoms and airflow limitation that is due to airway and /or alveolar

abnormalities usually caused by significant exposure to noxious particles or

gases and influenced by host factors including abnormal lung development.

Significant comorbidities may have an impact on morbidity and mortality

Epidemology : Global Burden

COPD – 4 th leading cause of morbidity and mortality world wide

Globally – 3 million deaths annually

Economic and Social burden
 ETIOLOGY
Smoking and pollutants
Host factors

PATHOBIOLOGY
. Impaired lung growth
Accelerated decline
Lung injury
Lung and systemic inflammation

PATHOLOGY
Small airway abnormalities
Emphysema CLINICAL
AIRFLOW
Systemic effects MANIFESTATION
LIMITATION
Symptoms
Persistent airflow
Exacebration
limitation
Comorbidities
© 2020 Global Initiative for Chronic Obstructive Lung Disease
Risk factors
Age – ageing increases copd risk, usually occurs above 40yrs
Gender – Equal incidence
Genetic factors- alpha 1 antitrypsin deficiency
Lung growth and development – during gestation and childhood
Exposure to particles
Tobacco smoke exposure – cigarette smokers
- Environmental tobacco smoke
Contd
Occupational exposures (organic and inorganic dusts, chemical agents and fumes
Air Pollution – Indoor – Biomass gas, burning of wood, heating in poorly ventilated
- Outdoor - small effect
Socio economic status – poverty , low SE –( crowding, poor nutrition, infections,
indoor and outdoor pollutants)
Asthma and airway reactivity
Chronic Bronchitis
Infections- history of childhood infection – increased respiratory symptoms in
adulthood
Pathology, Pathogenesis and
Pathophysiology
Exposure results in Chronic inflammation.
Pathological changes occur in airways, lung parenchyma, and Pulmonary
vasculature
Systemic inflammation may be present
Pathogenesis: Mechanism:
◦ Inflammation is modification of normal inflammatory response of
respiratory tract.
◦ Oxidative stress
◦ Protease and antiprotease imbalance
◦ Inflammatory cells- activated neutrophils, increased lymphocytes and
sometimes eosinophils – release inflammatory mediators – chemotactic factors
and proinflammatory cytokines
 Pathophysiology
Airflow limitation and gas trapping: extent of inflammation, fibrosis and luminal exudates in
small airways
Reduction of FEVI1 and FEV1/FVC ratio (characteristic of COPD)
Hyperinflation as a result of gas trapping
Gas exchange abnormalities- VA / Q mismatch
Hypoxemia and hypercapnia
Mucus hypaersecretion – increased number of goblet cells, enlarged submucosal glands
Pulmonary hypertension – late response- hypoxic vasoconstriction of small pulmonary arteries,
intimal hyperplasia, later smooth muscle hypertrophy/hyperplasia, endothelial cell dysfunction, loss
of capillary bed in emphysema - result in right ventricular hypertrophy and right heart failure
Exacebration
Systemic features – inflammatory mediators – skeletal muscle wasting and cachexia, IHD,
Osteoporosis, normocytic anaemia, diabetes, and metabolic syndrome
© 2020 GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE
© 2020 GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE
© 2020 GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE
Physical Examination

Low sensitivity and specificity

Absence of physical signs does not exclude the diagnosis
© 2020 GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE
 ASSESSMENT

The Presence and severity of the spirometric abnormality

Current nature and magnitude of of the Patient’s symptoms

History of moderate and severe exacebrations

Presence of comorbidities
© 2020 GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE
© 2020 GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE
© 2020 GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE
Assessment of Exacebration risk – An exacerbation of copd is
defined as an acute worsening of respiratory symptoms that
results in additional therapy.

Assessment of concomitant diseases- IHD, Osteoporosis,

skeletal muscle dysfunction, normocytic anaemia, Cachexia,
cancers
© 2020 GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE
Other investigations
Alpha 1 antitrypsin deficiency screening
Additional investigations
◦ Imaging – CXR, CT scan
◦ Lung volumes and diffusing capacity
◦ Oximetry and ABG
◦ Exercise testing
◦ Biomarkers- CRP, Procalcitonin, Eosinophils
◦ ECG
◦ ECHO
Chest radiograph and CT
Management
Medical
◦ Pharmacological
◦ Non pharmacological – Rehabilitation , Education
- Oxygen therapy, ventilator support

Surgical - Bullectomy, Lung volume reduction surgery, Lung transplantation

Preventive Aspects
Identify and Reduce risk factor exposure
◦ Smoking cessation
◦ Vaccinations : Pneumococcal and Influenza
 Drugs
 Bronchodilators
◦ Beta agonist
- Short acting- (SABA) - Salbutamol, levosalbutamol, Terbutaline
- Long acting (LABA) -Formoterol, Aformeoterol, Salmeterol, Indacterol

◦ Anticholinergics – Block the bronchoconstrictor effect of acetylcholine on M3 receptors in airway

smooth muscle
◦ - Short acting – SAMA- Ipratropium, Oxitropium
- Long acting - LAMA –Tiotropium, Glycopyrronium bromide, Umeclidinium

◦ Methylxanthines – Aminophylline, Theophylline – modest bronchodilator - Toxicity

◦ Phosphodiesterase – 4 inhibitors - Roflumilast

Mucolytics & Antioxidants– carbocysteine, N-acetycylcysteine
Antiinflammatory agents - Eaxacebrations, moderate to severe COPD
◦ Corticosteroids - Inhaled (ICS)– Fluticasone, Budesonide, mometasone etc
- Oral
If Blood eosinophil < 100, risk of pneumonia – not recommended,
Eos 100-300 – consider use
Eos >300 cells, h/o or concomitant asthma – strong recommendation
Antibiotics: - Azithromycin, Erythromycin, Moxifloxacin – reduces exacebratiions over
one year
Alpha 1 antitrypsin augmentation therapy
Vasodilators - Pulmonary hypertension
© 2020 GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE
© 2020 GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE
© 2020 GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE
© 2020 GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE
© 2020 GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE
 Management of acute Exacebrations
As the symptoms are not specific to COPD relevant differential diagnosis should
be considered
Exacebrations precipitated by several factors- Respiratory infections
Goal – minimize current exacerbation and prevent subsequent events
SABA with or without SAMA are initial bronchodilators
Miantenance therapy with long acting bronchodilators initiated before discharge
Systemic corticosteroids and oxygenation – improve lung function and recovery

Antibiotics
Methylxanthines not recommended
NIV – Preferred when no absolute contraindications
Summary
Chronic Obstructive Pulmonary Disease is a common, preventable and treatable
disease that is characterized by persistent respiratory symptoms and airflow
limitation that is due to airway and or /alveolar abnormalities usually caused by
significant exposure to noxious particles or gases.
The most common respiratory symptoms include dyspnea, cough and /or sputum
production. These symptoms may be underreported by patients.
The main risk factor for COPD is tobacco smoking but environmental exposures
biomass fuel exposure and air pollution, genetic abnormalities, abnormal lung
development and accelerated aging
Acute exacerbations
Associated comorbidities may increase morbidity and mortality
Any Questions ?
Thank you