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Program Certificate of Excellence in Family Medicine

Course Pulmonology

Module Obstructive & Restrictive Airway Diseases

Topic COPD

Credit Hours 1 CME Credit Hour

Total
Educational 2 Educational Hour
Hours

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

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Prof. Nasir Shah

MCPS, FCPS, MRCGP [INT], FRCGP [INT]

Professor and Head, Department of Family Medicine

University of Health Sciences Lahore

Dean Family Medicine Faculty, College of Physicians and

Surgeons Pakistan

Convener National Family Medicine Committee of

Pakistan

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

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 CHRONIC OBSTRUCTIVE ®
PULMONARY DISEASE ©

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

COPD l DEFINITION ®
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A Preventable & Treatable disease, characterized by:
• Progressive airflow limitation (partially reversible), due to;
• Abnormal inflammatory response of the lungs to toxic particles
and gases

Primarily caused by Cigarette smoking!

(Both Active & Passive)

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

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COPD l DEFINITION ®
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Repeated injury and repair causes Structural & Physiologic
changes in:
• Central & Peripheral airways
• Lung parenchyma
• Alveoli
• Pulmonary vasculature

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

COPD l EPIDEMIOLOGY ®
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THIRD leading cause of death in 2020

COPD in Smokers COPD in Non-smokers

40 – 70 % 12.2 %

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

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COPD l SPECTRUM OF CONDITIONS ®
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MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

COPD l SPECTRUM OF CONDITIONS ®

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Chronic Bronchitis
• Chronic productive cough for 3 months during each of 2
consecutive years (other causes of cough being excluded)

Emphysema
• Abnormal, permanent enlargement of air spaces distal to
terminal bronchioles, accompanied by destruction of their walls
and without obvious fibrosis

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

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MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

FEATURES l SYMPTOMS ®
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COMMON SYMPTOMS
1. Chronic productive cough
- Worse in morning
- Colourless sputum
2. Breathlessness
- Use MRC Dyspnoea Scale to grade breathlessness
3. Frequent winter bronchitis
4. Wheezing
- May occur during exercise and exacerbations

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

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MRC DYSPNOEA SCALE ®
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GRADE DEGREE OF BREATHLESSNESS RELATED TO PHYSICAL ACTIVITY
1 Not troubled by breathlessness EXCEPT on Strenuous Exercise
2 SOB when Hurrying or walking up a Slight Hill
Walks Slower than contemporaries on level ground because of
3 breathlessness OR has to Stop For Breath when walking at own
pace
Stops for breath after walking 100m OR after a Few Minutes on
4
level ground
Too Breathless to leave the house OR breathless on
5
Dressing/Undressing
MRC - Medical Research Council

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

FEATURES l SYMPTOMS ®
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UNCOMMON SYMPTOMS
1. Fatigue
2. Cyanosis
Chest pain & Hemoptysis are
3. Anorexia
Uncommon symptoms of COPD
4. Weight loss
5. Hemoptysis Think of Alternative diagnosis!
6. Ankle swelling
7. Waking at night
8. Morning headaches
9. Effort intolerance (Muscle loss)

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

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FEATURES l SIGNS ®
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There may be no signs at all, or;
• Cyanosis • Hyper-inflated chest
• Cachexia • Hyper-resonant chest
• Raised JVP • Use of accessory muscles
• Tachypnoea • Wheeze or Quite breath sounds
• Peripheral oedema • Poor chest expansion on inspiration
• Pursing of lips on expiration • Paradoxical movements of lower ribs
(Pursed lip breathing)

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

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MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

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COPD l CAUSES/RISK FACTORS ®
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Strong Risk Factors
• Cigarette Smoking
• Advanced Age
• Genetic Factors (Alpha-1 Antitrypsin Deficiency)

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

COPD l CAUSES/RISK FACTORS ®

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Weak Risk Factors
• Male sex
• Indoor air pollution
• Outdoor air pollution
• Occupational exposures
• Low socioeconomic status
• Developmentally abnormal lung
(Low birth weight, respiratory infections)

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

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HUKKAH ®
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MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

DOMESTIC SMOKE ®
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MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

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COOKING INSIDE ROOM ®
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MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

DOMESTIC SMOKE ®
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MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

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OCCUPATIONAL SMOKE ®
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MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

DIAGNOSIS ®
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Diagnosis is based on:
1. History
2. Examination
3. Spirometry

Investigations that SHOULD BE advised during initial diagnostic,

other than spirometry:
1. CXR (Chest X-ray)
2. FBC (Full Blood Count)

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

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DIAGNOSIS l CHEST X-RAY ®
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Prominent features:

• Hyperinflation
• Depressed diaphragm
• Increased retrosternal space, and
• Hypovascularity of lung parenchyma

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

DIAGNOSIS l CHEST X-RAY ®

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MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

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DIAGNOSIS l SPIROMETRY ®
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Post-bronchodilator FEV1/FVC < 0.70 confirms presence of
persistent airflow limitation

Perform spirometry:
1. At Diagnosis
2. To Reconsider diagnosis, if exceptionally good response to
treatment
3. To Monitor disease progression

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

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MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

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SPIROMETRY l EXCEPTIONS ®
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For Older people:
• Think about alternative diagnoses or investigations, if;
- FEV1/FVC ratio below 0.7 but do not have typical
symptoms of COPD

For Younger people:

• Think about a diagnosis of COPD, even when their FEV1/FVC
ratio is above 0.7, if;
- Symptoms of COPD are present

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

WHAT TO LOOK FOR IN SPIROMETRY ®

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MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

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SEVERITY OF COPD ®
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In patients with FEV-1/FVC ratio > 70:

FEV1 ≥80% predicted Mild COPD

FEV1 ≥50% and <80% predicted Moderate COPD

FEV1 ≥30% and <50% predicted Severe COPD

FEV1 <30% predicted Very severe COPD

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

COPD l DIFFERENTIAL DIAGNOSIS ®

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• Asthma
• Anaemia
• Lung cancer
• Tuberculosis
• Heart Failure
• Bronchiectasis
• Interstitial lung disease

Refer for specialist review if diagnostic uncertainty

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

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ADDITIONAL INVESTIGATIONS ®
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To rule out other causes, NOT to diagnose COPD

1. CT Chest : Rule out lung cancer

2. Pulse Oximetry : Assess need for O2 therapy
3. Sputum Culture : If purulent sputum is persistent
4. ECG/Echo/BNP/ANP : cor pulmonale
5. Alpha-1 Antitrypsin : If early onset COPD/family history
6. TLCO (Transfer factor for carbon monoxide)

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

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MANAGEMENT OF COPD

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

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NON-PHARMACOLOGICAL MANAGEMENT ®
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1. Smoking cessation
2. Exercise/ Pulmonary rehabilitation
3. Optimize treatment for comorbidities
4. Pneumococcal and influenza vaccinations
5. Co-develop a personalized self-management plan
6. Nutrition
i. Encourage weight loss if obese
ii. Encourage healthy diet if under-weight
iii. Refer to Nutritionist

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

SMOKING CESSATION ®
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Most important therapeutic intervention for COPD
• Document smoking history and Pack-years
• Nicotine replacement therapy Watch lecture on Smoking cessation in
Classroom:
• Varenicline or Bupropion CVS/Metabolic Syndrome/Smoking
• Support programmes

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

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PULMONARY REHABILITATION ®
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Multidisciplinary support programme
Individually tailored and designed to optimize each patient’s
circumstances

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

DRUGS FOR COPD ®

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1. Anticholinergics 3. Inhaled Corticosteroid (ICS)
• Ipratropium (SAMA)
• Tiotropium (LAMA) 4. Xanthine Derivatives
• Theophylline
2. Beta 2 agonists
• Salbutamol (SABA)
• Salmeterol (LABA) 5. PDE-4 inhibitor
• Roflumilast

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

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STEP WISE APPROACH ®
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Step – 1: Initiate to;
• Relieve breathlessness & Exercise limitation

SABA or SAMA

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

STEP WISE APPROACH ®

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Step – 2: Add, if;
LABA + LAMA
• No Asthma features
• Asthma features
LABA + ICS

• Known Asthma or Atopy

• High Eosinophil count
• Substantial variation in FEV1 (at least 400ml)
• Diurnal variation in PEFR ( at least 20%)

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

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LAMA ®
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MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

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MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

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STEP WISE APPROACH ®
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Step – 3: Start, if;
• 1 Severe exacerbation, requiring hospitalization, or
• 2 moderate exacerbations in a year

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

LABA + LAMA + ICS ®

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MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

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COPD ®
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• If FEV1 >50% predicted consider either LABA or LAMA
- If such patients are breathless or have exacerbations;
• LABA +ICS or
• LABA + LAMA (if ICS CI/not tolerated)

• If FEV1 <50% predicted consider either LABA+ICS or LAMA

- If such patients are breathless or have exacerbations;
• LAMA plus LABA+ICS irrespective of their FEV1

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

ADD-ON THERAPY ®
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1. Oral Mucolytic Therapy
2. Oral Prophylactic Antibiotics
3. Long-term Oral Steroids
4. Theophylline
5. Roflumilast
6. LTOT (Long Term Oxygen Therapy)

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

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ORAL MUCOLYTIC THERAPY ®
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Carbocisteine – Stop if no symptomatic improvement

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

ORAL PROPHYLACTIC ANTIBIOTICS ®

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Azithromycin 250mg 3 times/week, only if:
• Smoker/Ex-smoker
• Optimized inhaler therapies
• Undertaken pulmonary rehabilitation
Azithromycin 250mg OD or
• >4 exacerbations per year, with sputum production or
500mg 3times/week
hospitalizations OR
Erythromycin 500mg BD
For 1 Year
Ref: GOLD (Global Initiative for
COPD) Guidelines 2020

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

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ORAL PROPHYLACTIC ANTIBIOTICS ®
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Check:
• Microscopy, Culture & Sensitivity to exclude resistant
organisms/Pseudomonas aeruginosa
• LFTs & ECG (for prolonged QT)

• Review after 3 months, then every 6 months

• Continue, if Benefits > Risks

• Alternative: Doxycycline 100mg OD

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

ORAL STEROIDS ®
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• Avoid if possible
• If unavoidable, use lowest possible dose
• Bone protection

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

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THEOPHYLLINE ®
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A Xanthine derivative / PDE Inhibitor (Non-selective)
• Relaxes smooth muscles of respiratory tract

• Use if;
- LABA/LAMA is ineffective or
- Unable to use inhaled medication
• Increased drug-drug interaction: (Reduce the dose)
- Antibiotics (Quinolones and Macrolides)
- Cimetidine

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

ROFLUMILAST ®
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Adjunct to bronchodilators, with frequent exacerbations

Refer to specialist for initiation!

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

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LONG TERM OXYGEN THERAPY ®
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Assess need for O2 and Refer people with:

• Cyanosis
• Raised JVP
• Polycythaemia
• O2< 92% on room air
• Peripheral oedema (swelling)
• Very severe airflow obstruction (FEV1 < 30% predicted)

• Beware of CO2 retainers

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

VACCINATION IN COPD ®
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Influenza vaccine – Yearly
Pneumococcal vaccine – 1 year

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

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ACUTE EXACERBATION ®
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• Rest
• Optimize inhalers/Nebulizer
• Oral antibiotics e.g., Amoxicillin
• Oral steroids (short course)

• Oxygen with care (beware of CO2 retainers)

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

PROGNOSIS ®
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Poor prognostic factors:
• Smoker
• Low BMI
• Multi-morbidity/ frailty
• Chronic hypoxia and/ or corpulmonale
• Low FEV1 and/ or meets criteria for Long Term Oxygen Therapy
(LTOT)
• Severe/ frequent exacerbations ± hospital admissions
• Breathless (MRC4/ 5), high symptom burden ± decreased
exercise capacity

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

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REFERENCES ®
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• https://www.nice.org.uk/guidance
• https://www.patient.co.uk
• GOLD (Global Initiative for COPD)
• Oxford Handbook of General Medicine, 2020
• BTS (British Thoracic Society) Guidelines on COPD

MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

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MCPS - MRCGP[INT] - CEFM | Pulmonology | Obstructive and Restrictive Lung Diseases | COPD

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