DR. VAIBHAV PARASHAR

• Fourth leading cause of death and fifth most common cause of disability worldwide by 2020.• Major cause of chronic morbidity and mortality

throughout the world.• In 1998, Global Initiative for Chronic Obstructive Lung

Disease(GOLD) was implemented as an international collaborative effort to improve awareness, diagnosis and treatment of COPD.

DEFINITION

GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE(GOLD)• A disease state characterized by airflow

limitation that is not fully reversible.• COPD includes EMPHYSEMA CHRONIC BRONCHITISALSO KNOWN AS COAD AND COLD.

CHRONIC BRONCHITIS• Persistent cough that produces sputum and mucus for atleast

three consecutive months per year, in two consecutive years.

PATHOPHYSIOLOGY OF CHRONIC BRONCHITIS

NORMAL EPITHELIUM OF RESPIRATORY TRACT

BRONCHIAL EPITHELIUM IN CHRONIC BRONCHITIS

EMPHYSEMAEMPHYSEMA IS CHARACTERIZED BY DESTRUCTION OF GAS EXCHANGING AIRSPACES i.e. RESPIRATORY BRONCHIOLES,ALVEOLAR DUCTS AND ALVEOLI.CLASSIFIED AS CENTRICINAR EMPHYSEMA AND PANACINAR EMPHYSEMA.

PATHOPHYSIOLOGY OF EMPHYSEMA

RISK FACTORS

MANAGEMENT OF COPD

• FOUR COMPONENTS ASSESSMENT AND MONITORING OF THE DISEASE REDUCTION OF THE RISK FACTORS MANAGEMENT OF STABLE COPD MANAGEMENT OF EXACERBATIONS

ASSESSMENT AND MONITORING•HISTORY•PHYSICAL FINDINGS •INVESTIGATIONS

• COUGH• SPUTUM PRODUCTION• EXERTIONAL DYSPNOEA• WHEEZING AND CHEST TIGHTNESS

SYMPTOMS

DYSPNOEA-: PROGRESSIVE,USUALLY WORSE WITH EXERCISE,PERSISTENT DESCRIBED BY PATIENT AS AN INCREASED EFFORT TO BREATHE,HEAVINESS,AIR HUNGER OR GASPING.

MODIFIED MRC SCALE I only get breathless with strenuous exercise – GRADE 0 I get short of breath when hurrying on the level or walking up a slight hill. - GRADE 1• I walk slower than people of the same age on the level because of breathlessness, or I have to stop for breath when walking on my own pace on the level.-GRADE 2• I stop for breath after walking about 100 meters or after a few minutes on the level. -GRADE 3• I am too breathless to leave the house or I am breathless when dressing or undressing. - GRADE 4

PHYSICAL FINDINGS• INSPECTION- CYANOSIS CHEST WALL ABNORMALITIES-BARREL SHAPED CHEST AND PROTRUDING ABDOMEN. RESTING RESPIRATORY RATE>20 BREATHE PER MINUTE AND SHALLOW BREATHING.• PATIENTS WITH PREDOMINANT EMPHYSEMA ARE THIN AND ACYANOTIC AT

REST(pink puffers)WHILE PATIENTS WITH CHRONIC BRONCHITIS ARE HEAVY AND CYANOTIC(blue bloaters).

• SITTING IN TRIPOD POSITION.• ADVANCED DISEASE-SYSTEMIC WASTING WITH SYSTEMIC WEIGHT

LOSS,BITEMPORAL WASTING AND DIFFUSE LOSS OF SUBCUTANEOUS ADIPOSE TISSUE.

• PARADOXICAL INWARD MOVEMENT OF THE RIB CAGE WITH INSPIRATION(hoover’s sign)

• CLUBBING • PALPATION AND PERCUSSION- UNHELPFUL.• AUSCULTATION- REDUCED BREATH SOUNDS, INSPIRATORY CRACKLES,HEART SOUNDS ARE BEST HEARD OVER THE XIPHOID AREA.

DIFF. DIAGNOSIS• ASTHMA-MAJOR DIFFERENTIAL DIAGNOSIS. DIFF. OF ASTHMA FROM COPD ASTHMA COPDAGE OF ONSET <30 >40FAMILY HISTORY COMMON UNCOMMONETIOLOGY POSSIBLE FAMILY HIST. LONG SMOKING OF ALLERGY AND ASTHMA HISTORY OR HISTORY OF EXPOSURE TO DUST OR SMOKECOUGH UNCOMMON COMMONDYSPNOEA EPISODIC/NOCTURNAL PROGRESSIVE OVER YEARS; ATTACKS DAYTIME EXERTIONAL AIRFLOW LIMITATION MORE REVERSIBLE NOT REVERSIBLE

CONTD…• BRONCHIECTASIS-- LARGE VOLUMES OF PURULENT SPUTUM.- COMMONLY ASSOCIATED WITH BACTERIAL INFECTION.- BRONCHIAL DILATION AND CHEST WALL THICKENING ON CXR/CT.• CONGESTIVE HEART FAILURE-- CXR SHOWS DILATED HEART AND PULMONARY OEDEMA.- PFT INDICATES VOLUME RESTRICTION NOT AIRFLOW LIMITATION.• TUBERCULOSIS- - ONSET ALL AGES - CXR SHOWS LUNG INFILTERATION - MICROBIOLOGICAL CONFIRMATION

DIAGNOSIS• PULMONARY FUNCTION TEST(SPIROMETRY)-SHOWS

EVIDENCE OF AIRFLOW LIMITATION.SPIROMETRIC CLASSIFICATION OF COPD SEVERITY BASED ON POST BRONCHODILATOR FEV1(GOLD CRITERIA)

CONTD….• CHEST X-RAY-OFTEN NORMAL .• CLASSIC FEATURES---SEVERE OVERINFLATION OF THE LUNGS WITH LOW FLATTENED DIAPHRAGMS.-LARGE RETROSTERNAL AIRSPACE ON THE LAT. Film.

CONTD…• Hb LEVEL AND PCV-ELEVATED.• ARTERIAL BLOOD GAS TEST-IT IS USED TO DETERMINE THE

NEED FOR OXYGEN.RECOMMENDED IN THOSE WITH FEV1<35% AND THOSE WITH PEROPHERAL OXYGEN SATURATION<92% AND IN CCF.

• ELECTROCARDIOGRAM- IN ADVANCED CORPULMONALE THE ‘P’ WAVE IS TALLER AND THERE MAY BE RIGHT BUNDLE BRANCH BLOCK AND THE CHANGES OF RIGHT VENTRICULAR HYPERTROPHY.

• ECHOCARDIOGRAM-TO ASSESS CARDIAC FUNCTION.• alpha1-ANTITRYPSIN LEVELS-NRML RANGE 2-4g/L.

Rx.

Contd…REDUCE RISK FACTORS:-QUIT SMOKING-ELIMINATION OR REDUCTION OF VARIOUS SUBSTANCES IN THE WORKPLACE-AVOID EXPOSURE TO OUTDOOR/INDOOR POLLUTIONSTRATEGIES TO QUIT SMOKING:ASK: EVERY PATIENT AT EVERY CLINIC VISITADVISE: TO QUITASSESS: WILLING TO QUITASSIST: AID THE PATIENT IN QUITTING-PROVIDE COUNSELLING,PHARMACOTHERAPY AND SOCIAL SUPPORT.

CONTD…• PHARMACOTHERAPY FOR SMOKING CESSATION:- WHEN COUNSELLING NOT SUFFICIENT TO HELP PATIENT QUITTING.- NICOTINE REPLACEMENT THERAPY: NICOTINE GUM,INHALER,NASAL SPRAY,TRANSDERMAL PATCH OR SIBLINGUAL TABLET.- BUPROPIONE AND NORTRIPTYLINE INCREASES LONG TERM ABSTINENCE RATES. - CLONIDINE- USE LIMITED BY SIDE EFFECTS.

PHARMACOTHERAPY

• Bronchodilators:- CENTRAL TO SYMPTOM MANAGEMENT IN COPD.- INHALED ROUTE IS PREFERRED.- CHOICE DEPENDS ON AVAILABILITY AND INDIVIDUAL RESPONSE IN TERMS OF SYMPTOM RELIEF AND SIDE EFFECTS.- SHORT ACTING BRONCHODILATORS, β2- AGONISTS SALBUTAMOL AND TERBUTALINE OR THE ANTICHOLINERGIC IPRATROPIUM BROMIDE CAN BE USED IN PATEINTS WITH MILD DISEASES.- LONG ACTING BRONCHODILATORS, β2 AGONISTS SALMETEROL AND FORMOTEROL OR THE ANTICHOLINERGIC TIOTROPIUM BROMIDE ARE MORE APPROPRIATE IN MODERATE TO SEVERE DISEASE.- ORAL BRONCHODILATOR THERAPY – THEOPHYLLINE PREPARATIONS.

CONTD...• CORTICOSTEROIDS:-REGULAR INHALED GLUCOCORTICOSTEROIDS DOES NOT MODIFY LONG TERM DECLINE OF FEV1.INHALED STEROIDS ARE BECLOMETHASONE,FLUTICASONE,TRIAMCINOLONE.APPROPRIATE FOR:- SYMPTOMATIC COPD PATIENTS WITH AN FEV1<50%

PREDICTED(STAGE III: SEVERE COPD AND STAGE IV: VERY SEVERE COPD) AND

- REPEATED EXACERBATIONS- REDUCE THE FREQUENCY OF EXACERBATIONS.- INHALED GLUCOCORTICOSTEROIDS COMBINED WITH A LONG ACTING

B AGONIST IS MORE EFFECTIVE THEN THE INDIVIDUAL COMPONENTS.- LONG TERM USE OF ORAL STEROIDS IS NOT RECOMMENDED IN COPD.ORAL CORTICOSTEROIDS ARE PREDNISOLONE METHYL PREDNISOLONE AND BUDESONIDE.

CONTD..

NARCOTICS(MORPHINE)-EFFECTIVE FOR TREATING DYSPNEA IN COPD PATIENTS WITH ADVANCED DISEASE.α1 ANTITRYPSIN AUGMENTATION THERAPY:-YOUNG PATIENTS WITH SEVERE α1 ANTITRYPSIN DEFICIENCY AND ESTABLISHED EMPHYSEMA.-VERY EXPANSIVE-NOT WIDELY AVAILABLE-NOT RECOMMENDED FOR COPD UNRELATED TO α1 ANTITRYPSIN DEFICIENCY.

• PULMONARY REHABILITATION:-EXERCISE TRAINING-NUTRITIONAL COUNSELLING-DISEASE EDUCATION

CONTD..• OXYGEN THERAPY:-LONG TERM OXYGEN THERAPY(LTOT) >15 hrs. A DAY TO PATIENTS WITH CHRONIC RESPIRATORY FAILURE INCREASE SURVIVAL.-PROVIDED BY AN OXYGEN CONCENTRATOR.-INDICATIONS:-STAGE IV: VERY SEVERE COPD WITH PaO2 <55 mmHg OR SaO2 <88% with or without hypercapnia. PaO2 55-6- mmHg + pulmonary hypertension,peripheral oedema,peripheral oedema or nocturnal hypoxaemia.GOAL-TO INCREASE THE BASELINE PaO2 TO ATLEAST 60mmHg AT REST AND/OR TO PRODUCE SaO2 AT LEAST 90%.

CONTD..• SURGICAL INTERVENTION:-BULLECTOMY: YOUNG PATIENTS IN WHOM LARGE BULLAE COMPRESS SURROUNDING NORMAL LUNG TISSUE WHO OTHERWISE HAVE MINIMAL AIRFLOW LIMITATION AND A LACK OF GENERALISED EMPHYSEMA MAY BE CONSIDERED FOR BULLECTOMY.-LUNG VOLUME REDUCTION SURGERY(LVRS)-INDICATED IN PATIENTS WITH PREDOMINANTLY UPPER LOBE EMPHYSEMA WITH PRESERVED GAS TRANSFERENCE MAY BENEFIT FROM LVRS.IN THIS SURGERY PERIPHERAL EMPHYSEMATOUS LUNG TISSUE IS RESECTED.

CONTD..• OTHER MEASURES:PATIENTS WITH COPD SHOULD GET

ANNUAL INFLUENZA VACCINATION AND PNEUMOCOCCAL VACCINATION.

• OBESITY,POOR NUTRITION DEPRESSION AND SOCIAL ISOLATION SHOUL BE IDENTIFIED AND CORRECTED.

MONITORING AND FOLLOW UP• ROUTINE FOLLOW-UP IS ESSENTIAL BECAUSE EVEN WITH THE BEST AVAILABLE CARE

LUNG FUNCTION CAN BE EXPECTED TO WORSEN OVER TIME.FOLLOW UP VISITS SHOULD INCLUDE A INQUIRY ABOUT CHANGES IN SYMPTOMS SINCE THE LAST VISIT INCLUDES COUGH AND SPUTUM,BREATHLESSNESS,FATIGUE,ACTIVITY LIMITATION AND SLEEP DISTURBANCES.• SMOKING STATUS-DETERMINE CURRENT SMOKING STATUS AND SMOKING

EXPOSURE.• MONITOR MEDICAL TREATMENT-DOSAGE OF VARIOUS MEDICATIONS,INHALER

TECHNIQUE,EFFECTIVENESS OF CURRENT REGIMEN SHOULD BE MONITORED BY ASKING THE PATIENT SUCH QUESTIONS-

-HAVE YOU NOTICED A DIFFERENCE SINCE STARTING THIS TREATMENT.-IF YOU ARE FEELING BETTER- ARE YOU LESS BREATHLESS? CAN YOU DO MORE? DO YO SLEEP BETTER? DESCRIBE WHAT DIFFERENCE IT HAS MADE TO YOU? DO YOU FEEL ANY DIFFICULTY AFTER TAKING THE MEDICATIONS?• MONITOR EXACERBATION HISTORY-EVALUATE THE SEVERITY AND LIKELY CAUSES OF

EXACERBATIONS .INCREASED SPUTUM VOLUME,ACUTELY WORSENING DYSPNEA AND THE PRESENCE OF PURULENT SPUTUM SHOULD BE NOTED.

EXACERBATIONS OF COPD• EXACERBATION OF COPD IS AN ACUTE EVENT CHARACTERIZED BY A

WORSENING OF THE PATIENT’S RESPIRATORY SYMPTOMS SUCH AS SHORTNESS OF BREATH,QUANTITY AND COLOUR OF PHLEGM.EXACERBATION MAY BE TRIGERRED BY AN RESPIRATORY INFECTIONS WHICH MAY BE BACTERIAL AOR VIRAL OR BY ENVIRONMENTAL POLLUTANTS.

• CONDITIONS THAT MAY AGGRAVATE EXACERBATINS INCLUDE PNEUMONIA,PULMONARY EMBOLISM,PNEUMOTHORAX AND PLEURAL EFFUSION.

• DIAGNOSIS:DIAGNOSIS OF AN EXACERBATION RELIES EXCLUSIVELY ON THE CLINICAL PRESENTATION OF THE PATIENT COMPLAINING OF AN ACUTE CHANGE OF SYMPTOMS(BASELINE DYSPEA,COUGH AND SPUTUM PRODUCTION) THAT IS BEYOND NORMAL DAY TO DAY VARIATION.

ASSESSMENT OF EXACERBATION• ASSESSMENT OF AN EXACERBATION IS BASED ON PATIENT’S

MEDICAL HISTORY AND CLINICAL SIGNS OF SEVERITY.• IN THE MEDICAL HISTORY WE SHOULD LOOK FOR--SEVERITY OF COPD BASED ON DEGREE OF AIRFLOW LIMITATION.-DURATION OF WORSENING OR NEW SYMPTOMS.-NUMBER OF PREVIOUS EPISODES.-PRESENT TREATMENT REGIMEN.-PREVIOUS USE OF MECHANICAL VENTILATION.• SIGNS OF SEVERITY--USE OF ACCESSORY RESPIRATORY MUSCLES.-PARADOXICAL CHEST WALL MOVEMENTS.-WORSENING OR NEW ONSET CENTRAL CYANOSIS.-DEVELOPMENT OF PERIPHERAL EDEMA.-DETERIORATED MENTAL STATUS.

CONTD..• TESTS THAT CAN BE CONSIDERED TO ASSESS THE SEVERITY OF AN

EXACERBATION ARE-PULSE OXIMETRY- IT IS USEFUL FOR TRACKING OR ADJUSTING SUPPLEMENTAL OXYGEN THERAPY.ASSESSMENT OF ACID BASE STATUS IS NECESSARY BEFORE INITIATING MECHANICAL VENTILATION.-AN ECG MAY AID IN THE DIAGNOSIS OF COEXISTING CARDIAC PROBLEMS.-CBC MAY IDENTIFY POLYCYTHEMIA,ANEMIA OR LEUCOCYTOSIS.-THE PRESENCE OF PURULENT SPUTUM DURING AN EXACERBATION CAN BE SUFFICIENT INDICATION FOR STARTING EMPIRICAL ANTIBIOTIC TREATMENT.

TREATMENT OF EXACERBATIONS• WHEN A PATIENT COMES TO THE EMERGENCY DEPARTMENT THE FIRST

ACTION IS TO PROVIDE SUPPLEMENTAL OXYGEN THERAPY AND TO DETERMINE WHETHER THE EXACERBATION IS LIFE THREATENING.IF SO,THE PATIENT IS ADMITTED TO ICU IMMEDIATELY OTHERWISE THE PATIENT CAN BE MANAGED IN THE EMERGENCY DEPARTMENT.

• INDICATIONS FOR HOSPITAL ADMISSION:-MARKED INCREASE IN INTENSITY OF SYMPTOMS SUCH AS SUDDEN DEVELOPMENT OF RESTINF DYSPNEA.-SEVERE UNDERLYING COPD.-ONSET OF NEW PHYSICAL SIGNS(CYANOSIS,PEROPHERAL EDEMA)-FAILURE OF AN EXACERBATION TO RESPOND TO INITIAL MEDICAL MANAGEMENT.-PRESENCE OF SERIOUS COMORBIDITIES(HERAT FAILURE OR NEWLY OCCURING ARRYTHMIAS)-OLDER AGE

THERAPEUTIC COMPONENTS OF HOSPITAL MANAGEMENT

• RESPIRATORY SUPPORT-OXYGEN THERAPY-VENTILATORY SUPPORT NONINVASIVE VENTILATION INVASIVE VENTILATION• PHARMACOLOIC TREATMENT-BRONCHODILATORS-CORTICOSTEROIDS-ANTIBIOTICS

MANAGEMENT OF SEVERE BUT NOT LIFE THREATENING EXACERBATIONS• ASSESS SEVERITY OF SYMPTOMS, BLOOD GASES CHEST RADIOGRAPH.• ADMINISTER SUPPLEMENTAL OXYGEN THERAPY AND OBTAIN SERIAL

ARTERIAL BLOOD GAS MEASUREMENT.• BRONCHODILATORS-INCREASE DOSES AND FREQUENCY OF SHORT ACTING BRONCHODILATORS.-COMBINE SHORT ACTING beta2 AGONISTS AND ANTICHOLINERGICS.-ADD ORAL OR IV CORTICOSTEROIDS.-CONSIDER ANTIBIOTICS WHEN SIGNS OF BACTERIAL INFECTION.-CONSIDER NON INVASIVE MECHANICAL VENTILATION.-AT ALL TIMES:MONITOR FLUID BALANCE AND NUTRITION.IDENTIFY AND TREAT ASSOCIATED CONDITIONS(HEART FAILURE,ARRYTHMIAS)CLOSELY MONITOR CONDITION OF THE PATIENT.

INDICATIONS FOR ICU ADMISSION• SEVERE DYSPNEA THAT RESPONDS INADEQUATELY TO INITIAL

EMERGENCY THERAPY.• CHANGES IN THE MENTAL

STATE(CONFUSION,LETHARGY,COMA)• PERSISTENT OR WORSENING HYPOXAEMIA(PaO2<40mmHg)

AND /OR SEVERE/WORSENING RESPIRATORY ACIDOSIS(Ph<7.25) DESPITE SUPPLEMENTAL OXYGEN AND NONINVASIVE VENTILATION.

• NEED FOR INVASIVEMECHANICAL VENTILATION.

DISCHARGE CRITERIA• PATIENT IS ABLE TO USE LONG ACTING BRONCHODILATORS

WITH OR WITHOUT INHALED CORTICOSTEROIDS.• INHALED SHORT ACTING beta2 AGONIST THERAPY IS

REQUIRED NO MORE FREQUENTLY THAN EVERY 4 HOURS.• PATIENT IS ABLE TO WALK ACROSS ROOM.• PATIENT IS ABLE TO EAT AND SLEEP WITHOUT FREQUENT

AWAKENING BY DYSPNEA.• PATIENT HAS CLINICALLY STABLE FOR12-24 HRS.• ARTERIAL BLOOD GASES HAVE BEEN STABLE FOR 12-24

HOURS.• PATIENT FULLY UNDERSTANDS USE OF MEDICATIONS.• PATIENT,FAMILY AND PHYSICIAN ARE CONFIDENT THAT

PATIENT CAN MANAGE SUCCESSFULLY AT HOME.

FOLLOW UP• THERE SHOULD BE FOLLOW UP VISIT AFTER 4-6 WEEKS AFTER

DISCHARGE FROM HOSPITAL IF EVERYTHING IS NORMAL.• THE FOLLOWING THINGS SHOULD BE ASSESSED--ABILITY TO COPE IN THE ENVIRONMENT.-MEASUREMENT OF FEV1-REASSESSMENT OF INHALER TECHNIQUE.-REASSESS NEED FOR LONG TERM OXYGEN THERAPY OR HOME NEBULIZER.-CAPACITY TO DO PHYSICAL ACTIVITIES.-STATUS OF COMORBIDITIES.

COPD AND COMORBIDITIES• CARDIOVASCULAR DISEASES: ISCHAEMIC HEART

DISEASE,HYPERTENSION,HEART FAILURE.• ANXIETY AND DEPRESSION.• OSTEOPOROSIS• METABOLIC SYNDROME AND DIABETES• INFECTIONS