Chronic Obstructive Pulmonary Disease

Why COPD is Important ?

COPD is the only chronic disease that is showing progressive upward trend in both mortality and morbidity It is expected to be the third leading cause of death by 2020 Approximately 14 million Indians are currently suffering form COPD* Currently there are 94 million smokers in India 10 lacs Indians die in a year due to smoking related diseases
*The Indian J Chest Dis & Allied Sciences 2001; 43:139-47

Disease Trajectory of a Patients with COPD

Symptoms

Exacerbations Exacerbations Exacerbations

Deterioration

End of Life

Despite this burden, COPD is a Cindrella conditions that receives limited recognition from both patients and physicians
Respiratory Medicine 2002; 96: S1-S31

Obstructive Airway Disease

Asthma Explosion in research Revolution in therapy COPD Little research (? neglect) Few advances in therapy

New Definition
Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease state characterised by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and is associated with an abnormal inflammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking. Although COPD affects the lungs, it also produces significant systemic consequences.
ATS/ERS 2004

Risk Factors
Smoke from home cooking and heating fuel Occupational dust and chemicals Gender: More common in men. M:F ratio is 5%:2.7% (in India) Increasing age Others: Infection, nutrition and deficiency of 1 antitrypsin

Pathophysiology of COPD
Increased mucus production and reduced mucociliary clearance cough and sputum production Loss of elastic recoil - airway collapse Increase smooth muscle tone Pulmonary hyperinflation Gas exchange abnormalities hypoxemia and/or hypercapnia

Key Indicators for COPD Diagnosis

Chronic cough Present intermittently or every day often present throughout the day; seldom only nocturnal Present for many years, worst in winters. Initially mucoid becomes purulent with exacerbation Progressive (worsens over time) Persistent (present every day) Worse on exercise Worse during respiratory infections Repeated episodes Tobacco smoke (including beedi) occupational dusts and chemical smoke from home cooking and heating fuel

Chronic sputum production

Dyspnoea that is

Acute bronchitis History of exposure to risk factors

Physical signs
Large barrel shaped chest (hyperinflation) Prominent accessory respiratory muscles in neck and use of accessory muscle in respiration Low, flat diaphragm Diminished breath sound

Algorithm for Diagnosis at Primary Care

Pt reporting with respiratory symptoms Assess by - H/o exposure to risk factors - Physical examination

Sputum for AFB +ve Treat as TB -ve Provisional Diagnosis of COPD Poor response refer to secondary care

Treat as COPD

National Guidelines for Management of COPD at Primary Care Level

Spirometry
Diagnosis Assessing severity Assessing prognosis Monitoring progression

Spirometry
FEV 1 Forced expired volume in the first second FVC Total volume of air that can be exhaled from maximal inhalation to maximal exhalation FEV 1 /FVC% - The ratio of FEV1 to FVC, expressed as a percentage.

COPD classification based on spirometry

GOLD 2003
Severity At risk Mild COPD Moderate COPD Severe COPD Very severe COPD Postbronchodilator FEV 1 /FVC >0.7 <0.7 <0.7 <0.7 <0.7 Postbronchodilator FEV 1 % predicted >80 >80 50-80 30-50 <30

SPIROMETRY is not to substitute for clinical judgment in the evaluation of the severity of disease in individual patients.

Pharmacotherapy for Stable COPD

Bronchodilators Short-acting 2agonist Salbutamol Long-acting 2agonist - Salmeterol
and Formoterol

Steroids Oral Prednisolone Inhaled - Fluticasone,

Budesonide

Anticholinergics
Theophylline

Ipratropium, Tiiotropium

Methylxanthines -

Management based on GOLD

Postbronchodilator FEV1 (% predicted)

Bronchodilator medications are central to

the symptomatic management of COPD GOLD Report 2003

How Do Bronchodilators Work?

Reverse the increased bronchomotor tone Relax the smooth muscle Reduce the hyperinflation Improve breathlessness

All guidelines recommend inhaled bronchodilator as first line therapy. The ATS suggest initial therapy with an anticholinergic drug if regular therapy is needed
Chest 2000; 117: 23S-28S

Mode of Action
Cholinergic tone is the only reversible component of COPD Normal airway have small degree of vagal cholinergic tone (no perceptible effect due to patent airways)

Mode of Action

(Contd.)

Airways are narrowed in COPD therefore vagal cholinergic tone has greater effect on airway resistance (Resistance 1/radius 4 ) Therefore, the need for anticholinergic drugs that will act as muscarinic receptor antagonist and block the acetylcholine induced bronchoconstriction

Mode of Action

(Contd.)

Anticholinergics may also reduce mucus hypersecretion Anticholinergic have no effect on pulmonary vessels, and therefore do not cause a fall in PaO2
Drugs of Today 2002; 38(9): 585-600

Patients with moderate to severe symptoms of COPD require combination of bronchodilators

Combining bronchodilators with different mechanisms and durations of actions may increase the degree of bronchodilation for equivalent or lesser side effects
GOLD Report 2003

Algorithm for the management of COPD

Mild
assess with symptoms and spirometry

Short acting bronchodilator as required

Tiotropium Tiotropium+LABA

Long acting beta agonist LABA + tiotropium

Severe

Add -Inhaled steroids -Theophylline