copd slides

8/6/2019 COPD Slides

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CHRONICCHRONIC

OBSTRUCTIVEOBSTRUCTIVE

PULMONARYPULMONARY

DISEASEDISEASE

Melito A. Vergara II, MDMelito A. Vergara II, MD

First Year ResidentFirst Year Resident

Department of Family & Community MedicineDepartment of Family & Community Medicine

Manila Doctors HospitalManila Doctors Hospital


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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


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I: Mild COPD FEV1/FVC < 0.7 FEV1 80% predicted

At this stage,

the patient may not beaware that their

lung function is abnormal

II: Moderate

COPD

FEV1/FVC < 0.7

50% FEV1 < 80%predicted

Symptoms usuallyprogress at this stage,with shortness

of breath typically

developing on exertion.

III: SevereCOPD

FEV1/FVC < 0.7 30% FEV1 < 50%

predicted

Shortness of breathtypically worsens at thisstage and often limitspatients daily

activities. Exacerbationsare especially seen

beginning at this stage.

IV: Very Severe

COPD

FEV1/FVC < 0.7

FEV1 < 30% predicted or

FEV1 < 50% predicted plus

chronic respiratory failure

At this stage, quality oflife is very appreciablyimpaired

and exacerbations may be

life-threatening


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Of the six leadingcauses of death in theUnited States, onlyCOPD has been

increasing steadily since1970

Of the sixleading causesof death in theUnited States,only COPD hasbeen increasing

steadily since1970


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0

10

20

30

40

50

60

70

1980 1985 1990 1995 2000

M en

Women

Number

Deathsx

1000

COPD Mortality by Gender,U.S., 1980-2000


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Risk Factors for COPD

NutritionNutrition

InfectionsInfections

Socio-Socio-

economiceconomic

statusstatus


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LUNG INFLAMMATIONLUNG INFLAMMATION

OxidativeOxidative

stressstress ProteinasesProteinases

RepairRepair

mechanismsmechanisms

Anti-proteinasesAnti-proteinasesAnti-oxidantsAnti-oxidants

Host factors

Amplifying mechanisms

Cigarette smokeCigarette smokeBiomass particlesBiomass particles

ParticulatesParticulates

Pathogenesis ofCOPD

COPDCOPD

PATHOLOGYPATHOLOGY


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Alveolar wall destruction

Loss of elasticity

Destruction of pulmonary

capillary bed

Changes in the Lung Parenchyma in COPD Patients


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YYYYYY

Mast cellMast cell

CD4+ cellCD4+ cell

(Th2)(Th2)EosinophilEosinophil

AllergensAllergens

Ep cellsEp cells

BronchoconstrictiBronchoconstricti

onon

Alv macrophageAlv macrophage Ep cellsEp cells

CD8+ cellCD8+ cell

(Tc1)(Tc1)NeutrophilNeutrophil

Cigarette smokeCigarette smoke

Small airway narrowingSmall airway narrowingAlveolar destructionAlveolar destruction

COPDCOPDASTHMAASTHMA

Airflow LimitationAirflow LimitationReversible Irreversible


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COPD and AsthmaCOPD and AsthmaCOPD ASTHMA

Onset in mid-life

Symptoms slowlyprogressive

Long smoking history

Dyspnea during exercise

Largely irreversibleairflow limitation

Onset early in life (oftenchildhood)

Symptoms vary from dayto daySymptoms at night/earlymorning

Allergy, rhinitis, and/oreczema also present

Family history of asthma

Largely reversible airflowlimitation


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Four Components of COPDFour Components of COPD

ManagementManagement

Assess and monitor disease

Reduce risk factors

Manage stable COPD Education

Pharmacologic

Non-pharmacologic

Manage exacerbations


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Management of Stable COPD

Assess and Monitor COPD: Key Points

A clinical diagnosis of COPD should be considered inany patient who has dyspnea, chronic cough orsputum production, and/or a history of exposure torisk factors for the disease.

The diagnosis should be confirmed by spirometry. Apost-bronchodilator FEV1/FVC < 0.70 confirms thepresence of airflow limitation that is not fullyreversible.

Comorbidities are common in COPD and should beactively identified.


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Diagnosis of COPD

SYMPTOMS

coughcough

sputumsputum

shortness of breathshortness of breath

EXPOSURE TO RISKFACTORS

tobaccotobaccooccupationoccupation

indoor/outdoor pollutionindoor/outdoor pollution

SPIROMETRYSPIROMETRY


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Reduce Risk Factors: Key Points

Reduction of total personal exposure totobacco smoke, occupational dusts andchemicals, and indoor and outdoor airpollutants 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 COPDand stop its progression.


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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.

M t f St bl COPD


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Manage Stable COPD: Key Points

The overall approach to managing stable COPDshould be individualized to address symptoms andimprove quality of life.

For patients with COPD, health education plays an

important role in smoking cessation and can also playa role in improving skills, ability to cope with illnessand health status.

None of the existing medications for COPD have been

shown to modify the long-term decline in lungfunction that is the hallmark of this disease.Therefore, pharmacotherapy for COPD is used todecrease symptoms and/or complications.

Th t E h St f COPD


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IV: Very Severe III: Severe II: Moderate I: Mild

Therapy at Each Stage of COPD

FEV1/FVC < 70%

FEV1 > 80%predicted

FEV1/FVC < 70%

50% < FEV1 < 80%predicted

FEV1/FVC < 70%

30% < FEV1 < 50%

predicted

FEV1/FVC < 70%

FEV1 < 30%

predictedorFEV

1< 50%

predicted pluschronic respiratoryfailure

Addregular treatment with one or more long-acting

bronchodilators (when needed); AddrehabilitationAddinhaled glucocorticosteroids ifrepeated exacerbations

Active reduction of risk factor(s); influenza vaccination

Addshort-acting bronchodilator (when needed)

Addlong termoxygenif chronicrespiratory failure.

Considersurgicaltreatments


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Other Pharmacologic Treatments Antibiotics: Only used to treat infectious

exacerbations of COPD

Antioxidant agents: No effect of n-

acetylcysteine on frequency ofexacerbations, except in patients nottreated with inhaled glucocorticosteroids

Mucolytic agents, Antitussives,Vasodilators: Not recommended in stableCOPD


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Non-Pharmacologic Treatments Rehabilitation: All COPD patients benefit from

exercise training programs, improving withrespect to both exercise tolerance andsymptoms of dyspnea and fatigue.

Oxygen Therapy: The long-termadministration of oxygen (> 15 hours per day)to patients with chronic respiratory failure has

been shown to increase survival.


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Management COPD Exacerbations

An exacerbation of COPD is defined as:

An event in the natural course of the

disease characterized by a change in thepatients baseline dyspnea, cough, and/orsputum that is beyond normal day-to-dayvariations, is acute in onset, and maywarrant a change in regular medication ina patient with underlying COPD.

b


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The most common causes of an exacerbation are

infection of the tracheobronchial tree and air pollution,but the cause of about one-third of severeexacerbations cannot be identified.

Patients experiencing COPD exacerbations withclinical signs of airway infection (e.g., increasedsputum purulence) may benefit from antibiotictreatment.

Inhaled bronchodilators (particularly inhaled 2-agonists with or without anticholinergics) and oralglucocortico-steroids are effective treatments forexacerbations of COPD.

Manage COPD Exacerbations


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KEY POINTSKEY POINTS

Better dissemination of COPD guidelines and theirBetter dissemination of COPD guidelines and their

effective implementation in a variety of health careeffective implementation in a variety of health care

settings is urgently required.settings is urgently required.

In many countries, primary care practitioners treatIn many countries, primary care practitioners treat

the vast majority of patients with COPD and may bethe vast majority of patients with COPD and may be

actively involved in public health campaigns and inactively involved in public health campaigns and in

bringing messages about reducing exposure to riskbringing messages about reducing exposure to risk

factors to both patients and the public.factors to both patients and the public.


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KEY POINTSKEY POINTS

Spirometric confirmation is a keySpirometric confirmation is a keycomponent of the diagnosis of COPDcomponent of the diagnosis of COPDand primary care practitioners shouldand primary care practitioners should

have access to high quality spirometry.have access to high quality spirometry.

COPD is increasing in prevalence in manycountries of the world.

COPD is treatable and preventable


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lobal Initiative for Chronic

bstructive

ung

isease

lobalInitiative for Chronic

bstructive

ung

isease

G

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LD

G

O

LD


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THANK YOU!THANK YOU!

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