Obstructive Lung Diseases

A group of diseases characterized by reduction of expiratory flow rates:

• Bronchial Asthma: a chronic inflammatory disorder of the airways characterized by bronchial hyper-responsiveness to a variety of stimuli which lead to episodes of wide spread bronchial narrowing

which is largely reversible either spontaneously or with treatment.

• Chronic Bronchitis: chronic cough with expectoration for at least 6 months in a year or 3 months/Y for 2 successive years, not due to lung disease

• Emphysema: persistent abnormal dilatation of the air spaces distal to the terminal bronchioles , accompanied by destruction of the elastic tissues of the lungs.

• Bronchiectasis.

• Cystic Fibrosis.

Chronic Bronchitis

Emphysema

Bronchial Asthma

Chronic Obstructive Pulmonary Disease (COPD)

Chronic Obstructive Pulmonary Disease (COPD)

* Encompasses chronic bronchitis, emphysema and mixed cases.

* Preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients.

* Pulmonary component characterized by airflow limitation that is not fully reversible.

* Airflow limitation progressive and associated with abnormal inflammatory response of the lung to noxious particles or gases.

* Encompasses chronic bronchitis, emphysema and mixed cases.

* Preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients.

* Pulmonary component characterized by airflow limitation that is not fully reversible.

* Airflow limitation progressive and associated with abnormal inflammatory response of the lung to noxious particles or gases.

GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG

DISEASE (GOLD)

January 2013

http://www.goldcopd.org

Burden of COPDBurden of COPD

A leading cause of morbidity and mortality worldwide.

Burden expected to increase due to continued exposure to risk factors and the aging of the world’s population.

associated with significant economic burden.

A leading cause of morbidity and mortality worldwide.

Burden expected to increase due to continued exposure to risk factors and the aging of the world’s population.

associated with significant economic burden.

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Risk FactorsHost factors Exposures

Genetic factors Airway hyperreactivity

SmokingOccupationEnvironmental pollutionRecurrent bronchopulmonary infections

Airways Disease• Luminal Plugs• Mucosal Inflammation• Muscle Spasm• Bronchial wall fibrosis (Remodelling)

Parenchymal Destruction• Loss of alveolar attachments• Decrease of elastic recoil

AIRFLOW LIMITATION

Diagnosis Clinical diagnosis based on:

– Dyspnoea.

– Chronic cough.

– Exposure to risk factors.

Spirometric diagnosis:

post-bronchodilator FEV1/FVC < 0.7 (persistent airflow limitation)

Why post-bronchodilator? To minimize variability and exclude BA

1 2 3 4 5 6

1

2

3

4

Volu

me,

liters

Time, sec

FVC5

1

FEV1 = 4L

FVC = 5L

FEV1/FVC = 0.8

Volu

me,

liters

Time, seconds

5

4

3

2

1

1 2 3 4 5 6

FEV1 = 1.8L

FVC = 3.2L

FEV1/FVC = 0.56

Severity of Airflow Limitation in COPDIn patients with FEV1/FVC < 0.7:

Two exacerbations or more within the last year or an FEV1 < 50 % of predicted value

are indicators of high risk

Mild COPD 80

Moderate COPD 50–80

Severe COPD 30–50

Very severe COPD <30

Or chronic respiratory failure

FEV1 % Predicted:

Pulmonary Functions in COPD Spirometry

– Decreased FEV1, FEV1/FVC, FEF25-75%

Lung volumes– Increased Total Lung Capacity– Increased Residual Volume– Increased RV/TLC

DLCO—decreased in emphysema due to lung destruction

Additional InvestigationsAdditional Investigations

Chest X-ray: Seldom diagnostic but valuable to exclude alternative diagnoses and establish presence of significant comorbidities. 

Diffusing Capacity: to characterize severity.

Oximetry and Arterial Blood Gases:

in advanced cases.

Alpha-1 Antitrypsin Level: required when:

• COPD develops under 45.

• COPD develops in non- smoker.

• Strong family history of COPD. 

N: > 150 mg/dL . In disease: < 45 mg/dL

Chest X-ray: Seldom diagnostic but valuable to exclude alternative diagnoses and establish presence of significant comorbidities. 

Diffusing Capacity: to characterize severity.

Oximetry and Arterial Blood Gases:

in advanced cases.

Alpha-1 Antitrypsin Level: required when:

• COPD develops under 45.

• COPD develops in non- smoker.

• Strong family history of COPD. 

N: > 150 mg/dL . In disease: < 45 mg/dL

IV: Very Severe III: Severe II: Moderate I: Mild

Therapy at Each Stage of COPDTherapy at Each Stage of COPD

* Regular treatment with long-acting bronchodilators

* Inhaled glucocorticosteroids if repeated exacerbations

Active reduction of risk factor(s); influenza vaccinationshort-acting bronchodilator (when needed)

* Long term oxygen if chronic respiratory failure. * Surgical treatments

Risk Reduction

Reduction of exposures in the workplace.

Reduce indoor air pollution eg, from heating in poorly ventilated home.

Smoking cessation has the greatest capacity to improve

the natural history of COPD.

Bronchodilators are central to the symptomatic management of COPD. Inhaled bronchodilators are preferred over oral bronchodilators.

Bronchodilators are prescribed on an as-needed or on a regular basis to prevent or reduce symptoms.

The principal bronchodilator treatments are beta2- agonists, anticholinergics, theophylline or combination therapy.

Bronchodilators

Long-acting inhaled bronchodilators are convenient and more effective for symptom relief than short-acting bronchodilators.

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 side effects compared to increasing the dose of a single bronchodilator.

Bronchodilators

Long-term treatment with inhaled corticosteroids added to long-acting bronchodilators is recommended for patients with high risk of exacerbations.

Long-term treatment with inhaled corticosteroids added to long-acting bronchodilators is recommended for patients with high risk of exacerbations.

Regular treatment with inhaled corticosteroids (ICS) improves symptoms, lung function and quality of life and reduces frequency of exacerbations for COPD patients with an FEV1 < 60% predicted.

Inhaled Corticosteroids

An inhaled corticosteroid combined with a long-acting beta2-agonist is more effective than the individual components in improving lung function and health status and reducing exacerbations in moderate to very severe COPD.

Addition of a long-acting beta2-agonist/inhaled steroid combination to an anticholinergic appears to provide additional benefits.

Combination Therapy

Chronic treatment with systemic corticosteroids should be avoided because of an unfavorable benefit-to-risk ratio.

Systemic Corticosteroids

Theophylline

Theophylline is less effective and less well tolerated than inhaled long-acting bronchodilators and is not recommended if those drugs are available and affordable.

There is evidence for a modest bronchodilator effect and some symptomatic benefit.

In patients with severe and very severe COPD(GOLD 3 and 4), the selective hospodiesterase-4 inhibitor (PDE-4), roflumilast [Daxas], reduces xacerbations.It has also an anti-inflammatory activity.Dose: one tab (0.5 mg) PO once daily.

Phosphodiesterase-4 Inhibitors

Influenza vaccine can reduce serious illness. Pneumococcal polysaccharide vaccine recommended for COPD patients 65 years and older.

Other Pharmacologic Treatments

Mucolytics: Only in patients with viscid sputum; overall benefits are very small.

Antitussives: Not recommended.

Alpha-1 antitrypsin augmentation (replacement) therapy:

• The only specific therapy for 1 antitrypsin deficiency. • Prepared from pooled plasma of healthy donors.• Given as weekly IV infusion (60 mg/Kg).• Not well tolerated (fever, chills, flu like symptoms.• Very expensive.

The long-term administration of oxygen

(> 15 hours per day) to patients with chronic respiratory failure increases survival in patients with severe, resting hypoxemia.

Reversal of hypoxaemia supersedes concerns about CO2 retention.

The therapeutic goal is to maintain Sa,O2 >90% during rest, sleep and exertion.

Oxygen Therapy

All COPD patients benefit from exercise training programs with improvements in exercise tolerance and symptoms of dyspnea and fatigue.

Although an effective pulmonary rehabilitation program is 6 weeks, the longer the program continues, the more effective are the results.

Rehabilitation

Sleep Sleep in COPD is associated with oxygen

desaturation, predominantly due to the disease itself (rather than sleep apnoea).

Desaturation during sleep may be greater than during maximum exercise.

Sleep quality is markedly impaired in COPD.

Control of cough, dyspnoeal improves sleep quality.

Nocturnal oxygen therapy is rarely indicated.

Hypnotics should be avoided. 

Bullectomy and Lung volume reduction surgery

are more efficacious than medical therapy among patients with upper-lobe predominant emphysema and low exercise capacity.

In appropriately selected patients with very severe COPD, lung transplantation has been shown to improve quality of life and functional capacity.

Surgical Treatments

An exacerbation of COPD is:

“an acute event characterized by a worsening of the patient’s respiratory symptoms that is beyond normal day-to-day variations and leads to a change in medications.”

Management of ExacerbationsManagement of Exacerbations

Most exacerbations are precipitated by respiratory tract infections.

Diagnosis relies exclusively on the clinical presentation.

Impact on symptoms

and lungfunction

Negativeimpact on

quality of life

Consequences Of COPD Exacerbations

Increasedeconomic

costs

Acceleratedlung function

decline

IncreasedMortality

EXACERBATIONS

Patient educationCheck inhalation technique

Consider use of spacer devices

Bronchodilators Dose and/or frequency of SABA and/or anticholinergic MDI with spacer or hand-held nebuliser as needed

Consider adding LABA

Corticosteroids Prednisone 30–40 mg per os q day for 7 - 10 daysConsider using an inhaled corticosteroid

Antibiotics May be initiated in patients with altered sputum characteristics (Volume and/or Purulence)

Choice should be based on local bacteria resistance patterns

Amoxicillin/ampicillin, cephalosporins

Doxycycline

Macrolides

   

Out-Patient Treatment

In-Patient Treatment

Add:

Supplemental oxygen to prevent tissue hypoxia by maintaining arterial oxygen saturation (SaO2) at >90%.

Ventilatory support

CorticosteroidsIf patient tolerates oral medications, prednisone 30–40 mg per os q day for 10 days

If patient can not tolerate, give the equivalent dose i.v.

Cardiovascular disease (including ischemic heart disease, heart failure, atrial fibrillation, and hypertension): the most frequent and most important disease coexisting with COPD. Benefits of cardioselective beta-blocker treatment in heart failure outweigh potential risk even in patients with severe COPD. 

Manage Comorbidities

Manage Comorbidities