CHRONIC

OBSTRUCTIVE
PULMONARY
DISEASE

Melito A. Vergara II, MD

First Year Resident
Department of Family & Community Medicine
Manila Doctors Hospital
 Definition of COPD
COPD is a preventable and treatable
disease with some significant
extrapulmonary effects that may contribute
to the severity in individual patients.

Its pulmonary component is characterized

by airflow limitation that is not fully
reversible.

The airflow limitation is usually progressive

and associated with an abnormal
inflammatory response of the lung to
noxious particles or gases
I: Mild COPD • FEV1/FVC < 0.7
• FEV1 ≥ 80% predicted
II: Moderate • FEV1/FVC < 0.7
• 50% ≤ FEV1 < 80%
COPD predicted
III: Severe • FEV1/FVC < 0.7
• 30% ≤ FEV1 < 50%
COPD predicted
IV: Very Severe • FEV1/FVC < 0.7
• FEV1 < 30% predicted or
COPD FEV1 < 50% predicted plus
chronic respiratory failure
At this stage,
the patient may not be
aware that their
lung function is abnormal
Symptoms usually
progress at this stage,
with shortness
of breath typically
developing on exertion.
Shortness of breath
typically worsens at this
stage and often limits
patients’ daily
activities. Exacerbations
are especially seen
beginning at this stage.
At this stage, quality of
life is very appreciably
impaired
and exacerbations may be
life-threatening
Of the six
Of the six leading
causes of death in the
leading causes
United States, only
COPD has been
of death in the
increasing steadily since
United States,
1970

only COPD has

been increasing
steadily since
1970
 COPD Mortality by Gender,
U.S., 1980-2000
70
Number Deaths x 1000

60

50 Men

40
Women
30

20

10

0
1980 1985 1990 1995 2000
Risk Factors for COPD

Nutrition

Infections

Socio-
economic
status
 Pathogenesis of
Cigarette smoke COPD
Biomass particles
Particulates
Host factors
Amplifying mechanisms

LUNG INFLAMMATION
Anti-oxidants
Anti-proteinases

Oxidative
stress Proteinases

Repair
mechanisms

COPD
PATHOLOGY
Changes in the Lung Parenchyma in COPD Patients

Alveolar wall destruction

Loss of elasticity

Destruction of pulmonary
capillary bed
 ASTHMA
COPD
Allergens Cigarette smoke

Y Y
Y

Ep cells Mast cell Alv macrophage Ep cells

CD4+ cell Eosinophil CD8+ cell Neutrophil

(Th2) (Tc1)
Bronchoconstricti Small airway narrowing
on Alveolar destruction

Reversible Airflow Limitation Irreversible

 COPD and Asthma
COPD ASTHMA
Onset in mid-life
Symptoms slowly
progressive
Long smoking history
Dyspnea during exercise
Largely irreversible
airflow limitation
Onset early in life (often
childhood)
Symptoms vary from day
to day
Symptoms at night/early
morning
Allergy, rhinitis, and/or
eczema also present
Family history of asthma
Largely reversible airflow
limitation
 Four Components of COPD
Management
 Assess and monitor disease

 Reduce risk factors

 Manage stable COPD

• Education
• Pharmacologic
• Non-pharmacologic

 Manage exacerbations
 Management of Stable COPD
Assess and Monitor COPD: Key Points
 A clinical diagnosis of COPD should be considered in
any patient who has dyspnea, chronic cough or
sputum production, and/or a history of exposure to
risk factors for the disease.

 The diagnosis should be confirmed by spirometry. A

post-bronchodilator FEV1/FVC < 0.70 confirms the
presence of airflow limitation that is not fully
reversible.

 Comorbidities are common in COPD and should be

actively identified.
 Diagnosis of COPD

EXPOSURE TO RISK
SYMPTOMS FACTORS
cough tobacco
sputum occupation
shortness of breath
indoor/outdoor pollution
➨

SPIROMETRY
 Management of Stable COPD
Reduce Risk Factors: Key Points

• Reduction of total personal exposure to

tobacco smoke, occupational dusts and
chemicals, and indoor and outdoor air
pollutants are important goals to prevent the
onset and progression of COPD.

• Smoking cessation is the single most effective

— and cost effective — intervention in most
people to reduce the risk of developing COPD
and stop its progression.
 Brief Strategies to Help the
Patient Willing to Quit Smoking
 ASK Systematically identify all tobacco
users at every visit.
 ADVISE Strongly urge all tobacco
users to quit.
 ASSESS Determine willingness to make a
quit attempt.
 ASSIST Aid the patient in quitting.

 ARRANGE Schedule follow-up contact.

 Management of Stable COPD
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.
 Therapy at Each Stage of COPD
I: Mild II: Moderate III: Severe IV: Very Severe

 FEV1/FVC < 70%

 FEV1/FVC < 70%  FEV1 < 30%

 FEV1/FVC < 70% predicted
 FEV1/FVC < 70% or FEV1 < 50%
 30% < FEV1 < 50%
 50% < FEV1 < 80% predicted predicted plus
 FEV1 > 80% chronic respiratory
predicted predicted
failure
Active reduction of risk factor(s); influenza vaccination
Add short-acting bronchodilator (when needed)
Add regular treatment with one or more long-acting
bronchodilators (when needed); Add rehabilitation
Add inhaled glucocorticosteroids if
repeated exacerbations
Add long term
oxygen if chronic
respiratory failure.
Consider surgical
treatments
 Management of Stable COPD
Other Pharmacologic Treatments
 Antibiotics: Only used to treat infectious
exacerbations of COPD

 Antioxidant agents: No effect of n-

acetylcysteine on frequency of
exacerbations, except in patients not
treated with inhaled glucocorticosteroids

 Mucolytic agents, Antitussives,

Vasodilators: Not recommended in stable
COPD
 Management of Stable COPD
Non-Pharmacologic Treatments
 Rehabilitation: All COPD patients benefit from
exercise training programs, improving with
respect to both exercise tolerance and
symptoms of dyspnea and fatigue.

 Oxygen Therapy: The long-term

administration of oxygen (> 15 hours per day)
to patients with chronic respiratory failure has
been shown to increase survival.
Management COPD Exacerbations
• An exacerbation of COPD is defined as:

• “An event in the natural course of the

disease characterized by a change in the
patient’s baseline dyspnea, cough, and/or
sputum that is beyond normal day-to-day
variations, is acute in onset, and may
warrant a change in regular medication in
a patient with underlying COPD.”
Manage COPD Exacerbations
The most common causes of an exacerbation are
infection of the tracheobronchial tree and air pollution,
but the cause of about one-third of severe
exacerbations cannot be identified.

Patients experiencing COPD exacerbations with

clinical signs of airway infection (e.g., increased
sputum purulence) may benefit from antibiotic
treatment.

Inhaled bronchodilators (particularly inhaled ß2-

agonists with or without anticholinergics) and oral
glucocortico-steroids are effective treatments for
exacerbations of COPD.
 KEY POINTS
 Better dissemination of COPD guidelines and their
effective implementation in a variety of health care
settings is urgently required.
 In many countries, primary care practitioners treat
the vast majority of patients with COPD and may be
actively involved in public health campaigns and in
bringing messages about reducing exposure to risk
factors to both patients and the public.
 KEY POINTS
 Spirometric confirmation is a key
component of the diagnosis of COPD
and primary care practitioners should
have access to high quality spirometry.

 COPD is increasing in prevalence in many

countries of the world.

 COPD is treatable and preventable

Global Initiative for Chronic
bstructive
Oung
L isease
D
THANK YOU!