GLOBAL INITIATIVE FOR

CHRONIC OBSTRUCTIVE LUNG

DISEASE
2023
SHEEHAN JALANIE BERNADETTE E. ALCID, MD
ABIGAIL C. LACAMBRA, MD
DEFINITION AND OVERVIEW
WHAT IS COPD?

• heterogenous lung condition

• chronic respiratory symptoms
• dyspnea
• cough
• sputum production
• exacerbations
• abnormalities in the:
• airway: bronchitis/ bronchiolitis
• alveoli: emphysema
• persistent, often progrressive, airflow obstruction
DEFINITION AND OVERVIEW
CAUSES AND RISK FACTORS

• gene(G)-environment(E) occuring over the lifetime (T) of the individual (GETomics)

• Main environmental exposures

• tobacco smoking
• inhalation of toxic particles, gases from household
• outdoor air pollution
• environmental and host factors

• SERPINA1 gene: genetic risk factor that lead to alpha 1 antitrypsin deficiency
DEFINITION AND OVERVIEW
DIAGNOSTIC CRITERIA
• CONFIRMATORY: non-fully reversible airflow limitation measured by
spirometry (FEV1/FVC <0.7 post bronchodilation)

CLINICAL PRESENTATION
• dyspnea
• activity limitation
• cough with or without sputum production
• acute respiratory events
PATHOGENESIS
ENVIRONMENTAL RISK FACTORS
• cigarette smoking
• biomass exposure
• occupational exposures
• air pollution

GENETIC FACTORS
TRAJECTORIES OF LUNG FUNCTION: DEVELOPMENT & AGING
PATHOPHYSIOLOGY
• airflow obstruction and gas
trapping
• pulmonary gas exchange
abnormalities
• pulmonary hypertension
• exacerbation : (trigger)
infection & environment
EVIDENCE SUPPORTING PREVENTION AND MAINTENANCE THERAPY

PHARMACOTHERAPIES FOR
SMOKING CESSATION
1. Nicotine replacement products
2. pharmacological products
SMOKING
bupoprion and nortriptyline CESSATION
VACCINATIONS IS THE KEY
1. influenza vaccine
2. pneumococcal vaccine
3. other vaccines
REHABILITATION, EDUCATION AND SELF-MANAGEMENT

PULMONARY REHABILITATION

• comprehensive intervention -->

patient tailored therapy
• tele-rehabilitation
SUPPORTIVE, PALLIATIVE, END-OF-LIFE AND HOSPICE CARE

RELIEVING DYSPNEA
major goal of COPD care

Vitamin C, E
Zinc
Selenium

Cognitive behavioral
therapy
Mind-body interventions
OTHER TREATMENTS

> 15 hours per day

Oxygen Therapy

noninvasive positve pressure

ventilation
stardard of care in decreasing
mortality and morbidity

CPAP
COPD + OSA
INTERVENTIONAL AND SURGICAL THERAPIES FOR COPD
INTERVENTIONAL AND SURGICAL THERAPIES FOR COPD
COPD AND COMORBIDITIES

• Cardiovascular diseases are common and important comorbidities in

COPD
• Lung cancer is a major cause of death
• Osteoporosis and depression/anxiety are frequent
• Gastroesophageal reflux: increase risk of exacerbation and poorer health
status
COPD
DIAGNOSIS AND ASSESSMENT
OBJECTIVES:
• To be able to discuss the diagnosis and assessment of
patient with COPD according to the latest CPG guidelines
and Harrison’s 21st edition

• To be able to talk through the management and other

beneficial treatment on COPD patients according to their
current COPD status
DIAGNOSIS AND
ASSESSMENT
• CLINICAL PRESENTATION
• DIFFERENTIAL DIAGNOSIS OF COPD
• MEDICAL HISTORY
• PHYSICAL EXAMINATION
• SPIROMETRY
• INITIAL ASSESSMENT
• ADDITIONAL INVESTIGATIONS
CLINICAL PRESENTATION
 DIFFERENTIAL
DIAGNOSIS OF COPD
MEDICAL HISTORY
• Exposure to risk factors: smoking and environmental factors (household/
outdoor)
• Past Medical History: prematuriy, low birth weight, maternal smoking during
pregnancy, passive smoking exposure, asthma, allergy, sinusitis, nasal polyps,
respiratory infections in childhood, hiv tuberculosis
• Family history (COPD or chronic respiratory disease)
• Pattern of symptom development: increased breathlessness, winter colds
• History of exacerbations or previous hospitalizations:
• Presence of comorbidities
• Impact of disease on patient’s life
• Social and family support
• Possibilities of reducing risk factors, especially smoking cessation
PHYSICAL EXAMINATION
• Rarely diagnostic in COPD
• Airflow obstruction – usually not present until significant impairment of lung
function has occurred; detection on physical examination has low specificit and
sensitivity.

• Lung hyperinflation, cyanosis:

• May be present in COPD but the absence does not exclude the diagnosis
SPIROMETRY
INITIAL ASSESSMENT

1. Confirm diagnosis by
Spirometry
2. Determine the four
fundamental aspects to
guide COPD therapy
 Severity of airflow limitation
 Nature and magnitude of
current symptoms
 Previous history of moderate
and severe exacerbations
 Presence and type of other
comorbidities
(multimorbidity)
PHARMACOLOGICAL
THERAPY FOR STABLE
COPD
Apremilast
Crisaborole
Roflumilast
MANAGEMEN
T OF STABLE
COPD
ATHMA – COPD OVERLAP

ASTHMA COPD
 PHARMACOLOGICAL TREATMENT OF
STABLE COPD
• Basic principles for appropriate inhalation device choice
• Dry powdered inhalers: appropriate only if the patient can make forceful and deep inhalation. If
there is doubt, choose an alternative device
• Metered dose inhaler/ soft mist inhaler: needs coordination, check if patient can inhale slowly
and deeply from the device; if there is doubt, may add a spacer or choose an alternative device

• Use of bronchodilators:
• LABA and LAMA preferred
• SABA – occasional dyspnea and for immediate relief of symptoms in patients already on LAMA
as maintenance
• Initiation of treatment: LAMA + LABA
• Inhaled > Oral bronchodilator
• Theophylline are not recommended unless other LABA/ LAMA are not available
 PHARMACOLOGICAL TREATMENT OF
STABLE COPD
• Use of Anti- Inflammatory Agents
• Long term monotherapy with ICS is not advised
• LABA + LAMA + (ICS- if warranted) >> LABA + ICS
• Patients with severe to very severe airflow limitation, chronic bronchitis and exacerbation =
add PDE4 inhibitors + LAMA/LABA with or without ICS
• Azithromycin

• Other pharmacologic treatments

• Alpha 1 anti trypsin augmentation therapy
• Drugs approved for primary pulmonary hypertension are not recommended with a
pulmonary hypertension secondary to COPD
• Severe COPD with dyspnea- low dose long acting oral and parenteral opioids
 NON- PHARMACOLOGICAL
TREATMENT OF STABLE COPD
OXYGEN THERAPY
 MANAGEMENT
OF
EXACERBATIONS
 MANAGEMENT OF EXACERBATIONS
• Exacerbation:
• dyspnea and/or cough and sputum that worsen over < 14 days + tachypnea +/-
tachycardia
• increased local and systemic inflammation caused by airway infection, pollution, or other
insults to the lungs.

• Goals of treatment: minimize the negative impact of the current exacerbation

and to prevent subsequent events.

• SABA with or without SAMA – recommended as initial bronchodilators to treat

an exacerbation
 MANAGEMENT OF EXACERBATIONS
• Maintenance with LABA is started as soon as possible

• Antibiotics: shorten recovery time, reduce the risk or early relapse, treatment
failure and hospitalization duration; duration of therapy should be 5 days

• Methyxanthines are not recommended due to increased side effect profiles

• Non invasive mechanical ventilation: COPD with acute respiratory failure

• Improves gas exchange, reduce work of breathing and need for intubatin, decrease
hospitalization and improves survivial

• Exacerbation recovery time: 4-6 weeks

Treatment Options
 COPD CLASSIFICATION BASED ON
SEVERITY OF EXACERBATION
1. No respiratory failure: 2. Acute Respiratory Failure, non-life threatening:
a) RR: ≤ 24 breaths/min; a) RR >24 cpm
b) HR < 95 BPM b) (+) use of accessory muscles
c) No use of accessory respiratory muscles c) No change in mental status
d) No change in mental status d) O2 improved with use of O2 mask (fio2 >35%)
e) Hypoxemia improved with supplemental oxygen e) Increased Paco2 (50-60 mmhg)
via mask (24-35% fio2)
f) No increase in Paco2

3. Acute Respiratory Failure, life threatening:

a) RR > 24 cpm
b) (+) use of accessory muscles
c) Acute change in mental status
d) Hypoxemia not improved with O2 use (fio2 >40%)
e) Paco2 >60 mmhg
f) Acidosis at ≤ 7.25
COPD
HARRISON’S 21ST EDITION
 STABLE PHASE COPD
• 2 MAIN GOALS:
• Provide symptomatic relief (reduce respiratory symptoms, improve exercise tolerance,
improve health stauts)
• Reduce future risk (prevent disease progression, prevent and treat exacerbations and reduce
mortality)

• 3 interventions demonstrating improved survival of patients:

• Smoking cessation
• Oxygen therapy in chronically hypoxemic patients
• Lung volume reduction surgery (LVRS)

• Reduces mortality:
• LAMA + LABA + ICS
• Inhaled LAMA

• Non pharmacologic:
• Pulmonary rehabilitation
• Lung Volume Reduction Surgery
 LUNG VOLUME REDUCTION SURGERY

• Upper lobe–predominant  FEV1 < 20% od predicted

emphysema  Diffusely distributed emphysema

on CT scan
• Low post rehabilitation  Diffusing capacity of lung for carbon
exercise capacity monoxide (DLCO) <20% of
predicted
 COPD EXACERBATIONS
• Exacerbations are episodic acute worsening
of respiratory symptoms, including increased
dyspnea, cough, wheezing, and/ or change in
When to admit?
the amount and character of sputum.  Presence of respiratory
• +/- FEVER, MYALGIAS, SORE THROAT
acidosis and hypercarbia (>45)
 New or worsening hypoxemia
• Strongest single predictor of exacerbation:
history of a previous exacerbation
 Severe underlying disease
 Living conditions not
• The single greatest risk factor for
hospitalization with an exacerbation is a conducive to careful
history of previous hospitalization. observation and delivery of
• Risk factors: severe airflow obstruction,
prescribed treatment
elevated ratio of the diameter of the
pulmonary artery to aorta on chest CT Scan,
GERD
 COPD EXACERBATIONS- TREATMENT

• Bronchodilators
• Antibiotics
• Bacteria: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and
Chlamydia pneumoniae
• Systemic glucocorticoids
• reduces the length of stay, hastens recovery, and reduces the chance of subsequent
exacerbation or relapse
• 30 – 40 mg oral prednisolone or its given equivalent typically for a period of 5-10 days in
outpatients
• Oxygen: goals to maintain ≥ 90%
• Mechanical Ventilatory Support
MECHANICAL VENTILATORY SUPPORT
 Cardiovascular instability

Invasive (conventional) mechanical  Impaired mental status

ventilation (ET) – 17-30% mortality
 Inability to cooperate
rate
• severe respiratory distress despite  Copious secretions or the inability
initial therapy to clear secretions
• life-threatening hypoxemia  Craniofacial abnormalities ir trauma
• severe hypercarbia and/or acidosis (effective fitting of mask, extreme
obesity or significant burns)
• Markedly impaired mental status
• Respiratory arrest
• Hemodynamic instability
FOLLOWING HOSPITALIZATION FOR
COPD:
• 20% - Re-hospitalized in the subsequent 30 days
• 45%- hospitalized in the next year
• 20%- mortality in the following year
THANK
YOU!