COMPARISON OF FEV1 WITH SIX MINUTE WALK TEST IN COPD PATIENTS

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

1.1 DEFINITION: Chronic obstructive pulmonary disease (COPD) is a lung disease

characterized by chronic obstruction of lung airflow that interferes with normal breathing and is
not fully reversible. The more familiar terms 'chronic bronchitis' and 'emphysema' are no longer
used, but are now included within the COPD diagnosis.

1.2 TYPES OF COPD: There are two main forms of COPD:

1) Chronic bronchitis.
2) Emphysema.

CHRONIC BRONCHITIS:

Bronchitis is an inflammation of the bronchial tubes, the airways that carry air to your lungs. It
causes a cough that often brings up mucus. It can also cause shortness of breath, wheezing, a low
fever, and chest tightness. There are two main types of bronchitis: acute and chronic.

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Chronic bronchitis is one type of COPD (chronic obstructive pulmonary disease). The inflamed
bronchial tubes produce a lot of mucus. This leads to coughing and difficulty breathing. Cigarette
smoking is the most common cause. Breathing in air pollution, fumes, or dust over a long period
of time may also cause it.

EMPHYSEMA:

Emphysema is a condition that forms part of chronic obstructive pulmonary disease (COPD) and
involves the enlargement of the air sacs in the lung.
The alveoli at the end of the bronchioles of the lung become enlarged because of the breakdown
of their walls. The fewer and larger damaged sacs that result mean there is a reduced surface area
for the exchange of oxygen into the blood and carbon dioxide out of it.
The damage is permanent - not reversible - and it causes reduced respiratory function and
breathlessness. The damage takes a number of forms - the sacs can be destroyed, narrowed,
collapsed, stretched or over-inflated.

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1.3 EPIDEMOLOGY:

According to the World Health Organization,COPD is the fourth leading cause of death in the
world, with approximately 2.75 million deaths per annum, or 4.8% of deaths. In France, the
mortality rate is approximately 40 deaths per 100,000 population 

1.4 ETIOLOGY:
Tobacco smoking is by far the main risk factor for COPD. It is responsible for 40% to 70% of
COPD cases and exerts its effect by causing an inflammatory response, cilia dysfunction, and
oxidative injury. Air pollution and occupational exposure are other common etiologies.
Oxidative stress and an imbalance in proteinases and antiproteinases are also important factors in
the pathogenesis of COPD, especially in patients with alpha-1 antitrypsin deficiency, who have
panacinar emphysema that usually presents at an early age

1.5 PATHOPHYSIOLOGY:
PATHOPHYSIOLOGY OF CHRONIC BRONCHITIS
Chronic bronchitis is chronic inflammation of the lower airways characterized by excessive
secretion of mucus, hypertrophy of mucous glands, and recurring infection, progressing to
narrowing and obstruction of airflow. Emphysema is the enlargement of the air spaces distal to
the terminal bronchioles, with breakdown of alveolar walls and loss of elastic recoil of the lungs.
The two conditions may overlap, resulting in subsequent derangement of airways dynamics (e.g.,
obstruction to airflow). In pulmonary emphysema, lung function progressively deteriorates for
many years before the illness becomes apparent. The most common cause of COPD is cigarette
smoking. Air pollution, occupational exposures, allergens, and infections may also act as
irritants. Alpha1-antitrypsin deficient is an infrequent cause. Complications include respiratory
failure, pneumonia or other overwhelming respiratory infection, right heart failure (cor
pulmonale), arrhythmias, and depression

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COMPARISON OF FEV1 WITH SIX MINUTE WALK TEST IN COPD PATIENTS

PATHOPHYSIOLOGY OF EMPHYSEMA

When irritants, such as tobacco smoke or dusts, are inhaled into the lungs they come into contact
with the alveoli, causing oxidative damage that triggers an inflammatory response. It is
postulated that Cytokines released in association with the inflammation may then be involved in
reducing the elasticity of the alveolar walls (Septa), eventually leading to rupture. Despite
decades of study, the specific details of causality and pathophysiology currently remain unclear.
Long-term continued exposure to irritants thus leads to accumulation of damage to the alveolar
walls so that large cavities, known as Bullae, are formed. Since these Bullae present a lower total
surface area for gaseous exchange than the many smaller alveolar spaces in a healthy lung, the
ability of the lungs to exchange O2 and CO2 is considerably diminished.
Additionally, since the disease compromises the elasticity of the alveolar septa, inspired air
becomes trapped during exhalation, so that the tidal volume of the lungs is decreased.

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 COMPARISON OF FEV1 WITH SIX MINUTE WALK TEST IN COPD PATIENTS

The resulting inability to absorb enough O2 and release enough CO2 means that the Emphysema
patient may not finish breathing out before they feel the need to breathe in. This leads to
Breathlessness, which becomes especially apparent with increased activity or exercise.
In late-stage Emphysema patients, the effect of decreased O2 levels and increased CO2 levels
often leads to other medical issues including headaches, fatigue, weight loss, muscle wasting,
osteoporosis, depression, and heart failure.

1.6 CLINICAL MANIFESTATIONS:

 An ongoing cough or a cough that produces a lot of mucus (often called "smoker's
cough")
 Shortness of breath, especially with physical activity.
 Wheezing (a whistling or squeaky sound when you breathe)
 Chest tightness.

1.7 RISK FACTORS:

1. Smoking
2. Air pollution
3. Occupational dusts & chemicals like
a. Industrial dusts
b. Gases
c. Chemicals
4. Age
5. Genetics

1.8 DIAGNOSIS:
Spirometry is a simple test to measure the amount of air a person can breathe out, and
the amount of time taken to do so.
A spirometer is a device used to measure how effectively and how quickly the lungs
can be emptied.

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 COMPARISON OF FEV1 WITH SIX MINUTE WALK TEST IN COPD PATIENTS

Spirometry measurements used for diagnosis of COPD include:

• FVC (forced vital capacity): maximum volume of air that can be exhaled
during a forced maneuver.
• FEV1 (forced expired volume in one second): volume expired in the first
second of maximal expiration after a maximal inspiration. This is a measure of
how quickly the lungs can be emptied.
• FEV1/FVC: FEV1 expressed as a percentage of the FVC, gives a clinically
useful index of airflow limitation.
The ratio FEV1/FVC is between 70% and 80% in normal adults; a value less than 70%
indicates airflow limitation and the possibility of COPD.
FEV1 is influenced by the age, sex, height, and ethnicity, and is best considered as a
percentage of the predicted normal value.

Lung Function Tests

Lung function tests measure how much air you can breathe in and out, how fast you can breathe
air out, and how well your lungs deliver oxygen to your blood.
The main test for COPD is spirometry (spi-ROM-eh-tre). Other lung function tests, such as a
lung diffusion capacity test, also might be used. (For more information, go to the Health
Topics Lung Function Tests article.)

Other Tests

Your doctor may recommend other tests, such as:

 A chest x ray or chest CT scan. These tests create pictures of the structures inside your
chest, such as your heart, lungs, and blood vessels. The pictures can show signs of COPD. They
also may show whether another condition, such as heart failure, is causing your symptoms.
 An arterial blood gas test. This blood test measures the oxygen level in your blood using
a sample of blood taken from an artery. The results from this test can show how severe your
COPD is and whether you need oxygen therapy.

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1.9 TREATMENT
Goals:

 Relieving your symptoms

 Slowing the progress of the disease
 Improving your exercise tolerance (your ability to stay active)
 Preventing and treating complications
 Improving your overall health.

1.10NON PHARMACOLOGICAL TREATMENT:

1)Lifestyle Changes
 Quit Smoking and Avoid Lung Irritants

Quitting smoking is the most important step you can take to treat COPD. Talk with your doctor
about programs and products that can help you quit.

If you have trouble quitting smoking on your own, consider joining a support group. Many
hospitals, workplaces, and community groups offer classes to help people quit smoking. Ask
your family members and friends to support you in your efforts to quit.

Also, try to avoid secondhand smoke and places with dust, fumes, or other toxic substances that
you may inhale.

For more information about how to quit smoking, go to the Health Topics Smoking and Your
Heart article and the National Heart, Lung, and Blood Institute's "Your Guide to a Healthy
Heart." Although these resources focus on heart health, they include basic information about how
to quit smoking.

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Other Lifestyle Changes

If you have COPD, you may have trouble eating enough because of your symptoms, such as
shortness of breath and fatigue. (This issue is more common with severe disease.) As a result,
you may not get all of the calories and nutrients you need, which can worsen your symptoms and
raise your risk for infections.

Talk with your doctor about following an eating plan that will meet your nutritional needs. Your
doctor may suggest eating smaller, more frequent meals; resting before eating; and taking
vitamins or nutritional supplements.

Also, talk with your doctor about what types of activity are safe for you. You may find it hard to
be active with your symptoms. However, physical activity can strengthen the muscles that help
you breathe and improve your overall wellness.

2.Pulmonary Rehabilitation
Pulmonary rehabilitation (rehab) is a broad program that helps improve the well-being of people
who have chronic (ongoing) breathing problems.
Rehab may include an exercise program, disease management training, and nutritional and
psychological counseling. The program's goal is to help you stay active and carry out your daily
activities.
Your rehab team may include doctors, nurses, physical therapists, respiratory therapists, exercise
specialists, and dietitians. These health professionals will create a program that meets your
needs.
3.Oxygen Therapy
If you have severe COPD and low levels of oxygen in your blood, oxygen therapy can help you
breathe better. For this treatment, you're given oxygen through nasal prongs or a mask.
You may need extra oxygen all the time or only at certain times. For some people who have
severe COPD, using extra oxygen for most of the day can help them:
 Do tasks or activities, while having fewer symptoms
 Protect their hearts and other organs from damage

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 Sleep more during the night and improve alertness during the day
 Live longer

4.Surgery
Surgery may benefit some people who have COPD. Surgery usually is a last resort for people
who have severe symptoms that have not improved from taking medicines.
Surgeries for people who have COPD that's mainly related to emphysema include bullectomy
(bul-EK-toe-me) and lung volume reduction surgery (LVRS). A lung transplantmight be an
option for people who have very severe COPD.

5.Bullectomy
When the walls of the air sacs are destroyed, larger air spaces called bullae (BUL-e) form. These
air spaces can become so large that they interfere with breathing. In a bullectomy, doctors
remove one or more very large bullae from the lungs.

6.Lung Volume Reduction Surgery

In LVRS, surgeons remove damaged tissue from the lungs. This helps the lungs work better. In
carefully selected patients, LVRS can improve breathing and quality of life.

7.Lung Transplant
During a lung transplant, your damaged lung is removed and replaced with a healthy lung from a
deceased donor.
A lung transplant can improve your lung function and quality of life. However, lung transplants
have many risks, such as infections. The surgery can cause death if the body rejects the
transplanted lung.
If you have very severe COPD, talk with your doctor about whether a lung transplant is an
option. Ask your doctor about the benefits and risks of this type of surgery.

8.Vaccines
Flu Shots
The flu (influenza) can cause serious problems for people who have COPD. Flu shots can reduce
your risk of getting the flu. Talk with your doctor about getting a yearly flu shot.

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Pneumococcal Vaccine
This vaccine lowers your risk for pneumococcal pneumonia (NU-mo-KOK-al nu-MO-ne-ah) and
its complications. People who have COPD are at higher risk for pneumonia than people who
don't have COPD. Talk with your doctor about whether you should get this vaccine.

1.11 PHARMACOLOGICAL TREATMENT:

 Short acting beta 2 agonist
 Albuterol- 2 inhalations
 Albuterol sulphate – 2 inhalations, 2.5 inhaled
 Levalbuterol tartrate – 2 inhalations
 Long acting beta 2 agonist
 Alformeterol – 15mcg inhaled BID
 Formeterol - 12 mcg inhaled BID
 Solmeterol - 50 mcg inhaled BID
 Short acting anticholinergics
 Ipratropium - 2 inhalations QID, 500 Mcg inhaled QID
 Long acting anticholinergics
 Tiotropium – 18 mcg inhaled OD
 Short acting combination bronchodilators
 Albuterol – 2 inhalations QID
 Sulfate/ipratropium 2.5 mcg inhaled QID
 Inhaled corticosteroids
 Beclomethasone diproplanate - 40-320 mcg inhaled BID
 Budesonide - 360-720 mcg inhaled BID
 Ciclesonide - 80-320 mcg inhaled BID
 Corticosteroids/long acting beta 2 agonist combination products
 Budesonide/formeterol - 2 inhalation BID
 Fluticisone/solmeterol - 1 inhalation BID

Mechanism of actions:

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1)Beta2 Agonists: The primary mechanism of action of beta2 agonists is to stimulate beta2
adrenergic receptors, causing an increase in cyclic adenosine monophosphate, smooth-
muscle relaxation, and bronchodilation. Inhaled beta2 agonists have a fairly rapid onset of
action. Short-acting beta2 agonists such as albuterol have a duration of action of 4 to 6 hours,
while long-acting beta2 agonists (salmeterol, formoterol, and arformoterol) have a duration
of action of 12 hours or longer. Long-acting beta2 agonists provide more sustained
improvement over short-acting bronchodilators in pulmonary function, dyspnea, and overall
health status in patients with moderate to severe COPD. Based on current clinical standards,
regular treatment with long-acting bronchodilators is more effective than short-acting
bronchodilators and is more convenient for the patient.
Adverse effects of beta2 agonists include exaggerated somatic tremors, resting sinus
tachycardia, palpitations, insomnia, and hypokalemia.Tolerance to adverse events typically
occurs with continued use. Overall, beta2 agonists are generally well tolerated and produce
favorable results in COPD patients.
2) Anticholinergics: Inhaled anticholinergic medications are regularly utilized in the
management of patients with COPD. Ipratropium is a short-acting anticholinergic, and
tiotropium is a long-acting, once-daily agent. In patients with moderate to severe COPD,
tiotropium provides more sustained improvements on pulmonary function, activity-related
dyspnea, and overall health status as compared to ipratropium or placebo. Inhaled
anticholinergics are poorly absorbed, which limits the chances for adverse systemic
effects.The main adverse effect of anticholinergic agents is dry mouth. Other side effects
may include urinary retention, increased intraocular pressure, and pharyngeal irritation. have
been recent reports of a potential increase in the risk of stroke, cardiovascular events, or
mortality in patients with COPD receiving anticholinergic medications Data from a recently
published randomized, placebo-controlled trial, however, do not substantiate these risks. The
FDA is reviewing available data on tiotropium. Currently, inhaled anticholinergic agents
remain an important treatment option for patients with COPD.
3)Methylxanthines: Theophylline is not considered first-line therapy in COPD due to the
potential side effects, various drug interactions, and need for strict monitoring. It may be
used as additive therapy to inhaled bronchodilators in select patients. Low-dose theophylline

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decreases the frequency of exacerbations in COPD patients but does not increase
postbronchodilator lung function.
Toxicity of methylxanthines is dose related. Adverse effects include insomnia, headaches,
nausea, and heartburn. At higher serum concentrations, there is the potential for more serious
side effects including arrhythmias, tachycardia, hypokalemia, and seizures.Additionally,
theophylline is metabolized by CYP450 enzymes, which can lead to increased risk of various
drug and disease interactions.
Combination Bronchodilator Treatment: Combining different types of bronchodilators may
increase the degree of bronchodilation without increasing side effects. Combining a short-
acting beta2 agonist and an anticholinergic may result in improved changes in forced
expiratory volume in 1 second (FEV1) as compared to the individual drugs alone.
4)Glucocorticosteroids:
Inhaled Glucocorticosteroids: Inhaled glucocorticosteroids are recommended in patients with
stage III COPD who experience repeated exacerbations (≥ three exacerbations in the last
three years) while taking a long-acting bronchodilator. Inhaled glucocorticosteroids do not
improve the long-term decrease in FEV1 or significantly reduce mortality in COPD, but
regular treatment has been shown to reduce the frequency of exacerbations. The combination
of an inhaled glucocorticosteroid and a long-acting beta2 agonist is more effective than the
individual drugs in decreasing the frequency of exacerbations and improving lung function
and overall health. Fluticasone/salmeterol 250/50 mcg is approved for the reduction of
exacerbations in patients with COPD who have had a history of exacerbations.
Budesonide/formoterol is also available as a combination product, although it is not currently
approved for use in COPD.
Long-term treatment with inhaled glucocorticosteroids may increase susceptibility to
pneumonia. Other adverse effects of inhaled glucocorticosteroids are dose related. Patients
using inhaled glucocorticosteroids should be instructed to rinse their mouth after each use to
decrease the risk of developing localized effects such as candidiasis and dysphonia.
Absorption of inhaled glucocorticosteroids over a prolonged period of time may be
associated with systemic symptoms such as cataracts or decreased bone mineral density

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5)Oral Glucocorticosteroids: It has often been recommended to use a short-term treatment,

usually two weeks, of oral glucocorticosteroids to predict the potential for benefit of long-
term treatment with oral or inhaled glucocorticosteroids in COPD patients.41 More recent
studies, however, suggest that this is a poor indicator of long-term response and thus is not
recommended due to a lack of evidence.
Due to insufficient data showing substantial benefit and the known side effects of long-term
glucocorticosteroid therapy, including myopathy, weight gain, and immunosuppression,
long-term treatment with glucocorticosteroids is not recommended in COPD patients.
1.12 PATIENT COUNSELLING:
1. Smoking cessation—and the earlier the better—is the sole intervention shown to
decrease disease progression
2. Vaccination is critical. All pharmacists need to promote annual immunizations
with influenza vaccine and pneumococcal vaccines.
3. Proper usuage of inhaler.
4. Counsel patients that Pulmonary hypertension is a common COPD complication

REFERENCE:
https://online.epocrates.com/diseases/724/COPD/Etiology
https://www.nhlbi.nih.gov/health/health-topics/topics/copd/treatment
https://www.uspharmacist.com/article/management-strategies-in-stable-copd

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