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Chronic Obstructive Pulmonary Disease (COPD) Omer Alamoudi, MD, FRCP,FCCP,FACP Professor, consultant Pulmonologist [email protected] Definition of COPD COPD is a chronic obstructive pulmonary disease that is characterized by airflow limitation that is not fully reversible. The airflow limitation is usually both progressive and associated with an abnormal inflammatory response COPD is a preventable and treatable disease Chronic Obstructive Pulmonary disease (COPD) Chronic bronchitis Emphysema COPD Definitions Chronic bronchitis: Cough and sputum production for at least 3 months in each of two consecutive years in albescence of other endobronchial disease such as bronchiectasis Emphysema: overinflation of the distal airspaces with destruction of alveolar septa Prevalence of COPD worldwide and in KSA Prevalence/Risk Factors Cigarette Smoking Cigarette smoking is the primary cause of COPD. Approximately 90% of COPD patients have a smoking history The WHO estimates 1.1 billion smokers worldwide, increasing to 1.6 billion by 2025. In low- and middle-income countries, rates are • increasing . at an alarming rate Smoking Prevalence Among Doctors Country Male% Female% UK 8 5 USA 9 7 Germany 9 6 Korea 46 28 China 42 35 S. Arabia 38 15 Global Burden of Disease (1990–2020) 2020 1990 Lower respiratory tract infections 1 Diarrhoeal diseases 2 Conditions during perinatal period 3 Unipolar major depression 4 Ischaemic heart disease 5 Cerebrovascular disease 6 Tuberculosis 7 Measles 8 Road traffic accidents 1 Ischaemic heart disease 2 Unipolar major depression 3 Road traffic accidents 4 Cerebrovascular disease 5 COPD 6 Lower respiratory tract infections 7 Tuberculosis 8 War 9 9 Diarrhoeal diseases Congenital anomalies 10 10 HIV Malaria 11 11 Conditions during perinatal period COPD 12 12 Violence COPD Prevalence in KSA COPD Prevalence in KSA (Contd.) According to one report released by the executive office of the GCC Health Ministers Council, Saudi Arabia is the world’s fourth largest importer of cigarettes. During the year of 2004, the kingdom imported 41,000 tons of tobacco at a value of SR 1.45 billion. Table 3. Ranking of the 10 most frequent diagnoses among hospitalized patients at KAUH Diagnosis Diabetes mellitus Ischemic heart diseases Bronchial asthma Chronic liver disease Congestive heart failure Hypertension Sickle cell anemia COPD Chronic renal failure Cerebrovascular accident No % 570 493 311 293 203 153 141 132 116 108 10.5 8.6 5.8 5.4 3.8 2.8 2.6 2.4 2.1 2.0 Risk Factors Risk Factors for COPD Host Factors Genes (e.g. alpha1-antitrypsin deficiency) Hyperresponsiveness Exposure Tobacco smoke Occupational dusts and chemicals Infections Socioeconomic status Risk Factors for COPD Nutrition Infections Socio-economic status Aging Populations 15 Pathogenesis of COPD Pathogenesis of COPD NOXIOUS AGENT (tobacco smoke, pollutants, occupational agent) Genetic factors Respiratory infection Other COPD Source: Peter J. Barnes, MD Pathogenesis of COPD Cigarette smoke Biomass particles Particulates Host factors Amplifying mechanisms LUNG INFLAMMATION Anti-oxidants Oxidative stress Anti-proteinases Proteinases COPD PATHOLOGY Repair mechanisms Causes of Airflow Limitation Irreversible Fibrosis and narrowing of the airways Loss of elastic recoil due to alveolar destruction Destruction of alveolar support that maintains patency of small airways Airway Pathology in COPD Airway pathology in COPD Airway pathology in COPD Diagnosis of COPD Diagnosis of COPD A clinical diagnosis of COPD should be considered in any patient who has dyspnea, chronic cough or sputum production, and/or a history of exposure to risk factors for the disease. The diagnosis should be confirmed by spirometry. A post-bronchodilator FEV1/FVC < 0.70 confirms the presence of airflow limitation that is not fully reversible. Comorbidities are common in COPD and should be actively identified. 25 Diagnosis of COPD SYMPTOMS cough sputum shortness of breath EXPOSURE TO RISK FACTORS tobacco occupation indoor/outdoor pollution SPIROMETRY Diagnosis of COPD Signs Hands Flapping tremor, dilated veins, collapsing pulse, warm hands (CO2 retention) Cyanosis, clubbing of the finger (ca lung) Chest (signs of hyperinflation) Barrel chest, use of accessory ms, decreased expansion, absence cardiac dullness, tracheal tug Hyperesonant on percussion Diagnosis of COPD Sign of pulmonary HTN Increased JVP, left parasternal heave, Loud P2, Hepatomegaly, Ascitis, lower limb edema Fundus examination Papilloedema Extrapulmonary manifestation Ms wasting Signs of COPD Diagnosis of COPD: Spirometry Spirometry should be performed after the administration of an adequate dose of a shortacting inhaled bronchodilator to minimize variability. A post-bronchodilator FEV1/FVC < 0.70 confirms the presence of airflow limitation that is not fully reversible. 32 Diagnosis of COPD / Spirometry Spirometry: Normal and Patients with COPD Classification of COPD Severity by Spirometry Stage I: Mild FEV1/FVC < 0.70 FEV1 > 80% predicted Stage II: Moderate FEV1/FVC < 0.70 50% < FEV1 < 80% predicted Stage III: Severe FEV1/FVC < 0.70 30% < FEV1 < 50% predicted Stage IV: Very Severe FEV1/FVC < 0.70 FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure The Effect of Smoking on Lung Function FEV1 (% of value at age 25 y) Never smoked or not susceptible to smoking 100 75 Smoked regularly and susceptible to its effects 50 Stopped at 45 DISABILITY Stopped at 65 25 DEATH 0 25 50 Age (y) Adapted from Fletcher & Peto 1977 75 Diagnosis of COPD/ chest X-ray Diagnosis of COPD/ HRCT scan Diagnosis of COPD CBC ESR WBC (increased with infection) Hb (secondary Polycthemia) Increased with infection malignancy Diagnosis of AECOPD Diagnosis of AECOPD Diagnosis of AECOPD was based on ATS criteria Major Increased dyspnea Increased sputum production Purulent sputum Minor Cough, wheeze, sore throat, and cold and nasal discharge Diagnosis of AECOPD/sputum culture Pathogens isolated during exacerbation Bacterial Moraxella catarrhalis Pseudomonas Haemophilus influenzae Viral Influenza Atypical bacteria Mycoplasma Chlamydia Differential Diagnosis COPD VS Asthma Differential Diagnosis: COPD and Asthma COPD • Onset in mid-life • Symptoms slowly progressive ASTHMA • Onset early in life (often childhood) • Symptoms vary from day to day • • Long smoking history • Dyspnea during exercise • • Largely irreversible airflow • limitation • Symptoms at night/early morning Allergy, rhinitis, and/or eczema also present Family history of asthma Largely reversible airflow limitation COPD and Co-Morbidities COPD patients are at increased risk for: • Myocardial infarction, angina • Osteoporosis • Respiratory infection • Depression • Diabetes • Lung cancer Pulmonary Hypertension in COPD Chronic hypoxia Pulmonary vasoconstriction Muscularization Pulmonary hypertension Cor pulmonale Intimal hyperplasia Fibrosis Obliteration Edema Death Source: Peter J. Barnes, MD Management of COPD and Exacerbation Management of COPD Prevention Smoking cessation: is the single most effective — and cost effective — intervention in most people to reduce the risk of developing COPD and stop its progression Controlling pollution: Reduction of total personal exposure to tobacco smoke, occupational dusts and chemicals, and indoor and outdoor air pollutants are important goals to prevent the onset and progression of COPD. 50 Management of COPD Smoking cessation Counseling delivered by physicians Numerous effective pharmacotherapies for smoking cessation are available Nicotine chewing gum, transcutaneous patches, nicotine inhalers or nasal spray Buproprion (aminoketone) (reduce nicotine withdrawal symptoms) Epilepsy, tremor, insomnia, tachycardia 51 Nortiptyline Management of COPD Bronchodilators Anticholinergics Ibratropium bromide (short acting) Improve nocturnal O2 saturation Improve quality of sleep Doses: 40 ug 1 -2 puffs q6h Mainly used during exacerbation and symptomatic patients 52 Management of COPD Bronchodilators Tiotropium bromide (long acting anticholinergic) Once daily No systemic cholinergic effect M3 receptors antagonist Dose: 18 ug/day Used in combination with LAB ± ICS or alone in stable COPD Decrease symptoms, improve exercise tolerance Decrease exacerbation 53 Management of COPD Bronchodilators ß2 -agonists (Salbutamol, Terbutaline) Rapid relief of symptoms Dose: 120 ug, 2 puffs q4 - 6h Tachycardia, tremors Methylxanthines (Theophylline) week bronchodilator effect Monitor serum level (55 -110 umol/l) Hepatic disease, heart failure, drugs; erythromycin, 54 ciprofloxacin increase serum level Management of COPD Long Acting Bronchodilators (LAB) LAB is more effective and convenient than treatment with short-acting bronchodilators Salmeterol (50 ug) Formoterol (9 ug) Doses: q12h It should be added with Ibratropium or tiotropium if further improvement in symptoms is required 55 Management of COPD Glucocorticosteroids Long term use of ICS treatment is appropriate for: ● symptomatic COPD patients with an FEV1 < 50% predicted (stage 111,1V) ● repeated exacerbations ● Allergy Budesonide 800 ucg BD Fluticasone 500 ucg BD Chronic treatment with oral corticosteroids should be avoided because of an unfavorable benefit-to-risk ratio 56 Management of COPD Other Pharmacologic Treatments Antibiotics: Only used to treat infectious exacerbations of COPD Respiratory stimulants (improve ABG) Doxapram Almitrine Mucolytic agents, Antitussives: Not recommended in stable COPD 57 Management of COPD Pharmacotherapy: Vaccines Influenza vaccines can reduce serious illness and should be given yearly Pneumococal polysaccharide vaccine may be given although there is no conclusive evidence to support is it use in COPD 58 Management of COPD Non-Pharmacologic Treatments Rehabilitation: All COPD patients benefit from exercise training programs, improving with respect to both exercise tolerance and symptoms of dyspnea and fatigue Oxygen Therapy: LTOT (> 15 hours per day) to patients with chronic respiratory failure has been shown to increase survival PO2: 55 mmHg or less PO2: 59 mmHg + Polycythemia, Corpulmonale 59 Management of COPD Surgical management Bullectomy Resection bulla allow expansion of the surrounding lung tissue Lung Volume Reduction Surgery FEV1 < 35% Lung transplant Age <65 FEV<35% Pao2<55mmHg, PaCO2 >55mmHg Secondary pulmonary HTN, absence of IHD Management COPD Exacerbations Antibiotics 2nd generation cephalosporin Amoxicillin / clavulinate Quinolones Inhaled bronchodilators, combination of Ibratropium B2 agonist 61 Management COPD Exacerbations Corticosteroid IV methyl prednisone Oral prednisone Should be used in moderate to severe COPD Hydration Chest physiotherapy 62 Management COPD Exacerbations Noninvasive mechanical ventilation Decreases the need for endotracheal intubation Mechanical ventilation Deterioration of level of consciousness PaO2 40 mmHg, pH < 7.25 Medications and education to help prevent future exacerbations should be considered as part of follow-up