A New and update

Diagnosis and management of stable COPD

Sumardi
Division of Pulmonary and Critical Care
Internal Medicine Departement
Faculty of Medicine
Gadjah Mada University
Sardjito Genaral Hospital
Yogyakarta
 COPD IS A MAJOR BURDEN ON HEALTHCARE
RESOURCES AND THE ECONOMY
■ COPD is a leading cause of morbidity and mortality
■ COPD affects 210 million people worldwide1 and causes 3
million deaths annually (5% of all deaths worldwide)2
■ It is predicted to become the third leading cause of global
mortality by 20303
■ The economic burden of COPD is high, with costs increasing
as the disease progresses
■ Severe COPD costs are up to 17 times higher than mild COPD4
■ High costs are associated with treatment of exacerbations and loss
of productivity in the workplace 4
1. Diette GB, Orr P, McCormack MC et al. Population Health Management 2010;13:21-26.
2. WHO. COPD Fact Sheet No 315. 2011. Available from www.who.int/mediacentre/factsheets/fs315/en/index.html
3. WHO. Chronic respiratory diseases. Accessed 2011. http://www.who.int/respiratory/copd/burden/en/index.html
4. Wouters EFM. Respir Med 2003;97:S3-S14.
Percent change in age-adjusted
death rates, U.S., 1965-1998
Definition of COPD
Global Initiative for Chronic Obstructive Lung Disease
(GOLD) defines COPD as:

“a common preventable and treatable disease is characterised by

persistent airflow limitation that is usually progressive and
associated with an enhanced chronic inflamatory response in the
airways the lung to noxious particles or gases. Exacerbations and
comorbidities contribute to the overall severity in individual
patients.

Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Global
Initiative for Chronic Obstructive Lung Disease (GOLD) 2016. Available from www.goldcopd.org
 COPD has pulmonary and systemic components

Inhaled substances +
Genetic susceptibility

Airway Mucociliary Structural Systemic

inflammation dysfunction changes
inflammation

Airway limitation

Breathlessness Weight changes

Bronchitis: coughing, sputum Co-morbidities
production (e.g. diabetes, cardiovascular disease, renal, GI
Emphysema: hyperinflation, tract, Osteoporosis)
wheezing
Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Global Initiative for Chronic Obstructive Lung Disease
(GOLD) 2016 Available from www.goldcopd.org
Key indicators for COPD
■ Dyspnea
Progressive, worse with exercise, persistent
■ Chronic cough
■ Chronic sputum production
■ History exposure to risk factors
■ Tobacco smoke
■ Smoke from home cooking and heating fuels
■ Occupational dust and chemicals
■ Family history of COPD
 X-ray results

For Illustration purposes only

■ Emphysematous changes seen in both lung fields in keeping with COPD

■ No focal active lung lesion seen
 COPD is diagnosed based on symptoms, risk
factors and spirometry

SYMPTOMS RISK FACTORS

Dyspnea Tobacco
Chronic cough + Occupational hazards
Sputum production Indoor/outdoor pollution

Spirometry;
The presence of FEV1/FVC < 0.70 confirms the
presence of the persistent airflow limitation and thus of
COPD.
Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Global Initiative for Chronic Obstructive Lung
Disease (GOLD) 2014. Available from www.goldcopd.org
Penilaian COPD

• Penilaian gejala
• Severity pemeriksaan spirometri
• Resiko eksaserbasi
• Adanya komorbid
Stage of COPD
•Base on spirometry: FEV1/FVC < 70%
Stage Air flow obstruction Sign
I Mild Chronic cough FEV1 > 80%
Sputum production

Dyspnea on
II Moderate exertion
50% < FEV1 <
80%
Dyspnea
III Severe
Exercise capacity↓
30% < FEV1 < 50%

Quality of life ↓

FEV1 < 30% or

IV Very severe Quality of life ↓ ↓
Exacerbations FEV1 < 50% plus
maybe life- chronic respiratory
threatening failure
 GOLD Guideline

Assess COPD comorbidities

COPD patients are at increased risk for:
 Cardiovascular diseases
 Osteoporosis
 Respiratory infections
 Anxiety and Depression
 Diabetes
 Lung cancer
 Bronchiectasis

These comorbid conditions may influence mortality and hospitaliza-

tions and should be looked for routinely, and treated appropriately

Adapted from Global Strategy for the Diagnosis, Management and Prevention of Chronic
Obstructive Pulmonary Disease. GOLD: 2016
The newest assessment of COPD

≥ 1,
MRS

(Tak
MRS)
 GOALs OF COPD MANAGEMENT

PATIENT CHARACTERISTICS

Prevent and treat symptom Prevent and treat exacerbations

Improve exercise tolerance Prevent and treat complications
Improve health status Prevent disease progression

Reduce mortality

MANAGEMENT PLAN

Adapted from:
1. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Global Initiative for Chronic Obstructive Lung Disease
(GOLD) 2016. Available from www.goldcopd.org
2. Postma D, Anzueto A, Calverley P et al . Prim Care Respir J 2011; 20:205-209.
Risk Factors for COPD

Nutrition

Infections

Socio-economic
status

Aging Populations
Gene, Gender, Comorbidities
Management of COPD Non-
pharmacological
 Global Strategy for Diagnosis, Management and Prevention of COPD

Pilihan Terapi: Pengobatan PPOK

Beta2-agonists
Short-acting beta2-agonists
Long-acting beta2-agonists
Anticholinergics
Short-acting anticholinergics

Long-acting anticholinergics
Combination short-acting beta2-agonists + anticholinergic in one inhaler
Combination long-acting beta2-agonist + anticholinergic in one inhaler
Methylxanthines
Inhaled corticosteroids
Combination long-acting beta2-agonists + corticosteroids in one inhaler

Systemic corticosteroids
Phosphodiesterase-4 inhibitors (systemic)

© 2014 Global Initiative for Chronic Obstructive Lung Disease

 Global Strategy for Diagnosis, Management and Prevention of COPD
Manage Stable COPD: Pharmacologic Therapy
RECOMMENDED FIRST CHOICE

C D
GOLD 4

Exacerbations per year

ICS + LABA ICS + LABA 2 or more
or
or and/or
> 1 leading
LAMA LAMA to hospital
GOLD 3
admission

A B 1 (not leading
GOLD 2 to hospital
SAMA prn LABA
admission)
or or
GOLD 1 SABA prn LAMA
0

CAT < 10 CAT > 10

mMRC 0-1 mMRC > 2
© 2015 Global Initiative for Chronic Obstructive Lung Disease
 Management of COPD Pharmacological
First alternatives
C D
ICS + LABA and LAMA
LAMA and LABA
GOLD 4 or 2 or more
or ICS + LABA and PDE4-inh
LAMA and PDE4-inh or
or

Exacerbations per year

or LAMA and LABA > 1 leading
GOLD 3 LABA and PDE4-inh or to hospital
LAMA and PDE4-inh. admission
A B
GOLD 2 LAMA 1 (not leading
or to hospital
LAMA and
LABA admission)
LABA
GOLD 1 or
SABA and SAMA 0

CAT < 10 CAT > 10

mMRC 0-1 mMRC > 2
© 2014 Global Initiative for Chronic Obstructive Lung Disease
 Management of COPD
Pharmacological
Patient Recommended Alternative choice Other Possible
First choice Treatments
LAMA
SAMA prn or
A or LABA Theophylline
SABA prn or
SABA and SAMA
LAMA
SABA and/or SAMA
B or LAMA and LABA
Theophylline
LABA
ICS + LABA LAMA and LABA or
or LAMA and PDE4-inh. or SABA and/or SAMA
C
LAMA LABA and PDE4-inh. Theophylline

ICS + LABA and LAMA or

ICS + LABA
ICS+LABA and PDE4-inh. Carbocysteine
and/or
D or SABA and/or SAMA
LAMA
LAMA and LABA or Theophylline
LAMA and PDE4-inh.
Global initiative for chronic Obstructive Lung Disease , Jan 27,2014
Bronchodilators
• Beta2-agonist and anticholinergic, long acting preferred over
short acting (evidence A)
• Combination of Beta2-agonist & anticholinergic (short or
Long acting) maybe considered IF symptoms not improved
with single agents (B)
• Based on Efficacy and side effect, Inhaled bronchodilators
are preferred over oral (A)
• Based on relatively low efficacy and side effect, theophylline
is not recommended unless other long-term treatment
bronchodilator are not available or not affordable (B)
GOLD 2016
Mechanism actions of Muscarinic antagonist
and B2-agonist

Clin Chest 2014

Therapeutic Options:
Long-acting Bronchodilators
• Long-acting inhaled bronchodilators are convenient and
more effective for symptom relief than short-acting
• Long-acting inhaled bronchodilators reduce exacerbations
and related hospitalizations and improve symptoms and
health status
• Combining bronchodilators of different pharmacological
classes may improve efficacy and decrease the risk of side
effects compared to increasing the dose of a single
bronchodilator

GOLD 2016
LABA+LAMA Combination
• Combination of a LABA and LAMA shown a significant
increase in lung function than a single one
• Combination of Beta2-agonist & Anticholinergic (short or
Long acting) maybe considered IF symptoms not improved
with single agents (B)
• Pharmacological management according to Individual
assessment of symptoms, airflow limitation & Risk of
exacerbation → Combination LABA + LAMA

GOLD 2016
Combination ICS/Bronchodilator
• ICS combined with LABA is recommended for patients
with severe and very severe COPD and frequent
exacerbations that are not adequately controlled by
LABA (Evidence A)
• This combination therapy is associated with an
increased risk of pneumonia (Evidence A)
• Long-term treatment ICS should not be prescribed
outside their indications, due to risk of pneumonia and
possibility increase risk of fractures
GOLD 2016
FEV1 decline in COPD:
Potentially reversible mechanisms

Smooth muscle Mucus

contraction hypersecretio
n
Cholinergic
tone

Loss of alveolar attachment

Peribronchial fibrosis

1. Celli BR, et al. Am J Respir Crit Care Med 2008; 178: 332–38;
2. Beaucage F, Decramer M, et al. Am J Respir Crit Care Med .2008; 177: A401.
Conclusion .....
• COPD is a leading cause of morbidity & mortality in the world, with
high of the burden of disease and economic impact
• Airway obstruction - air trapping linked to symptoms, decrease
capacity → inactivity and disability
• Bronchodilator → reduced symptoms and increasing the
exercise capacity
• Long-acting bronchodilators prefer and most effective for using as
long-term treatment
• Early treatment (GOLD II /B) is indicated
• Combination Bronchodilator → optimal effect
Conclusion
• The choice of bronchodilator treatments depends
on availability and individual patient response in
terms of symptom relief and side effects

• Combining bronchodilators of different

pharmacological classes may improve efficacy and
decrease the risk of side effects compared to
increasing the dose of a single bronchodilator
FOR YOUR KINDNESS ATTENTION