COPD

Dr Muhammad Asim
Consultant Pulmonologist
Northwest General Hospital and Research Center, Peshawar
MBBS, MRCP(UK), FRCP(glasg.)
CCT (Pulmonology/Internal Medicine)
Fellow of the Higher Education Academy(UK)
Postgraduate certificate in medical education (UK)
Objectives
 Recognize COPD as a preventable cause of
morbidity & mortality
 Discuss the disastrous consequences of Tobacco
use
 Describe the pulmonary & extra-pulmonary
manifestations of COPD
 Construct a management plan
 Employ smoking cessation advice as part of every
patient encounter
Definition - COPD

 GOLD:
 Common, preventable, and treatable
 Persistent respiratory symptoms
 Airflow limitation due to airway and alveolar
abnormalities
 Caused by significant exposure to noxious particles
or gases.
Chronic Bronchitis

Cough and sputum for at least 3 consecutive

months in each of 2 consecutive years
Emphysema

Abnormal permanent enlargement of the airspaces

distal to the terminal bronchioles, accompanied by
destruction of their walls and without obvious
fibrosis
Risk factors - Environmental
•Tobacco smoke
•Indoor air pollution: cooking with biomass fuels
•Occupational exposures, such as coal, silica
•Low birth weight
•Lung growth: childhood infections or maternal
smoking
•Infections: recurrent infection
•HIV infection
•Cannabis
Host factors

 Genetic factors: α1-antitrypsin deficiency

 Other COPD susceptibility genes ?
 Airway hyper-reactivity
Cigarette smoking
 Most significant risk factor
 Tremendous health & socioeconomic consequences
 Can effect almost any organ system
 Nearly all smokers suffer an accelerated decline in
lung function

 Calls for a 5 minute discussion on Smoking &

tobacco !!
Cigarette smoking
 Every health care worker

 Strong advocate against tobacco use

Pathophysiology

Susceptible host

Destruction of lung Inflammatory cell

parenchyma infiltration/
Inflammation
Inhalational
exposures
 bronchoconstriction,
mucosal edema Increased Protease activity

 Tissue destruction and

mucus hypersecretion
Clinical features
 Cough
 Sputum
 Breathlessness
 Wheezing
 Functional limitation
 Repeated “Chest infections”
 Fatigue
Clinical features -Systemic
Signs
 Clubbing – Absent
 Cyanosis
 Signs of Hypercapnea
 JVP ?
 Distant breath sounds
 Wheeze
 Edema
Advanced stages
 Chronic respiratory failure
 Cor pulmonale
 Pulmonary hypertension
 Infections
Two classical phenotypes
 Pink puffers’ : thin and breathless, and maintain a
normal PaCO2 until the late stage of disease.

 Blue bloaters develop hypercapnia earlier and may

develop oedema and secondary polycythaemia. In
practice, these phenotypes often overlap.
Investigations
 Baseline – CBC, U, Creatinine, Blood sugar, LFTs,
Urine
 Chest Radiograph
 Spirometry
 OPTIONAL:
 Lung volumes
 Cardio pulmonary exercise testing
 CT
Pulse Oximetry
Management - Goals

 Improving breathlessness
 Reducing exacerbations
 Improving health status and prognosis.
Reducing exposure

 Smoking cessation
 Non-smoking cooking devices or alternative fuels
should be encouraged.
 Occupational exposure
Bronchodilators
 Preferably inhaled
 Short acting vs long acting
 Salbutamol, Salmeterol, Formeterol, Indacterol
 Ipratropium, Tiotropium

 Oral – Theophyllin
Combined inhaled glucocorticoids and
bronchodilators

 Improves lung function

 Reduces the frequency and severity of
exacerbations and improves quality of life.

 An increased risk of pneumonia, particularly in the

elderly.
Oral / Systemic Steroids

 Useful during exacerbations but maintenance

therapy contributes to osteoporosis and impaired
skeletal muscle function, and should be avoided.
Pulmonary rehabilitation
 Exercise

 Multidisciplinary programmes - physical training,

disease education and nutritional counselling
reduce symptoms, improve health status and
enhance confidence.
Oxygen therapy
 Long-term domiciliary oxygen therapy (LTOT)
improves survival in selected patients with COPD
complicated by severe hypoxaemia (arterial PaO2
<7.3 kPa (55 mmHg)

 Patients should be instructed to use oxygen for a

minimum of 15 hours/ day
Other measures

 Annual influenza vaccination

 Pneumococcal vaccination.
 Obesity, poor nutrition, depression and social
isolation should be identified and, if possible,
improved.
Palliative care
 End of life care
 Pain relief
 Morphine
 Advanced directives
 Code status
Acute exacerbations
 an increase in symptoms and deterioration in lung
function and health status.

 More frequent as the disease progresses and are

usually triggered by bacteria, viruses or a change in
air quality.
Acute exacerbations
 Respiratory failure
 Fluid retention
 Altered mental status
 Thromboembolism
 Acute coronary syndromes
 Heart failure
Acute exacerbations
 Controlled Oxygen therapy
 Venturi mask
 High concentrations of oxygen may cause
respiratory depression and worsening acidosis
 Non-Invasive ventilation
Never withhold oxygen from a seriously ill
hypoxic patient due to fear of cause
hypercapnic respiratory failure
Bronchodilators
 Nebulized Salbutamol & Ipratropium
 Frequency depends on severity
Glucocorticoids
 Oral prednisolone reduces symptoms and improves
lung function. Doses of 30 mg for 10 day.

 Prophylaxis against osteoporosis

Antibiotics

 The role of bacteria in exacerbations remains

controversial and there is little evidence for the
routine administration of antibiotics.

 Clinical scenario, White cells, CRP, Procalcitonin

Additional therapy
 Address fluid overload
 Heart failure
 Look for other causes e.g ACS, PE, Pneumonia,
Aspiration
Discharge

 Clinically stable on their usual maintenance

medication.
• A 68 year old male with COPD for the past 8 years presents to
clinic for follow up. He is managed with ICS and LABA. He has a
pulse of 78/m, BP 120/70 mmHg, SpO2 of 87 & R/R of 24/m.
There are decreased breath soundsand expiratory wheezes. His
chest xray shows hyperinflated lungs. ABGs show PaO2 of 53
mmHg and PaCO2 30 mm HG. CBC is normal. What intervention
would decrease mortality of this patient?

• a. BiPAP
• b. LTOT
• c. anticoagulation
• d. Nitric oxide inhalation
• e. Chest physiotherapy
• A 55 year old woman with history of COPD is admitted to
the Emergency Department with breathlessness. This is
her first admission with an exacerbation of COPD. Blood
gases taken on room air shortly after admission are as
follows: pH 7.29, PCO2 60 mmHg, PO2 60 mmHg
• What should her target oxygen saturations be?

• A. 94-98%
• B. 88-92%
• C. 92-94%
• D. >98%
• E. 91 – 93%
• 60 year old man presents to clinic with productive cough, shortness of
breath on exertion and wheezing. He has 35 pack years history of
smoking. His Pulse is 88/m, BP 140/80mmHg, SpO2 97% on room air and
R/R is 22 /m. There are bilateral reduced breath sounds & expiratory
wheeze. CXR shows hyperinflated lungs. Spirometry shows FEV1 55% of
predicted and FEV1/FVC ratio of 70. What is the best intervention to
improve survival in this patient?

A. Short courses of oral steroids

B. Overnight CPAP
C. Azithromycin alternate day
D. Smoking cessation
E. surgery
 A 75 year old man with COPD presents to the ER with 3 days history of
worsening breathlessness, cough & sputum production. He has diffuse
wheezes on exam. The Oxygen saturations are 84 % on room air. He is
started on controlled oxygen, an IV line is passed, bloods are sent & a
chest xray is requested. An ECG is also being done. What is the next best
step in his management ?

A. IV steroids
B. IV Aminophyllin
C. IV Ceftriaxone
D. IV MgSO4
E. Nebulization with Salbutamol & Ipratropium
 An 80 year old gentleman comes to the clinic for advice regarding
vaccination. He has COPD for the last 15 years, well controlled diabetes &
HTN. He has one exacerbation of COPD 6 months ago which required
admission. What is/ are the most important vaccination(s) for this patient?

A. Annual influenza & pneumococcal

B. Enteric fever
C. Meningococcal
D. Yellow fever
E. H. influenza
• Thank you, Any question?.