Chronic obstructive pulmonary disease

(COPD)
• Chronic Obstructive Pulmonary Disease (COPD) is characterized
by airflow limitation that is NOT fully reversible.

The airflow limitation is usually

Associated with an
abnormal inflammatory
response of the lung to
Progressive noxious particles or
gases, commonly
smoking.
 Indoor/ outdoor air Respiratory infections
SMOKING pollution in early childhood

Low socioeconomic Alpha1-antitrypsin

status deficiency
 Inflammation of Lung parenchyma.

Imbalance
Increased oxidative between
stress caused by proteinases
free radicals in and anti-
cigarette smoke
proteinases
Symptoms
chronic cough ˃ 3 Chronic sputum
months production

Sensation of
heaviness in the chest
Dyspnea
Signs
use of accessory
Hyperinflation of the
muscles of
chest
respiration

wheezing, prolonged signs of hypoxemia

expiratory phase, may include cyanosis
and rhonchi. and tachycardia.
second jugular
heart venous
sound distention

lower
hepato
extremity
edema megaly
 Post-bronchodilator
labs FEV1/FVC < 0.70
confirms the presence
•Look for secondary
polycythemia: Hct
of persistent airflow >55%
limitation

•ABG:pH, pCO2,
•Measure alpha1-
pO2 antitrypsin AAT levels
•( Core pulmonale, respir. in all patients with a
diagnosis of COPD .
Failure)
COPD assessment must consider the following aspects separately:
1. Severity of spirometric abnormality (Degree of Airflow limitation GOLD1-4)
2. Magnitude of patient’s symptoms (COPD Assessment Questionnaire CAT
or modified British Medical research Council mMRC)
3. Risk of future exacerbations
mMRC CAT
scale score
Manage stable COPD Manage acute exacerbations
 Non-
pharmacological
therapy
 Risk factor prevention
&Smoking cessation
 Vaccination
Brief 3 minute period of
 Pulmonary counseling improve smoking
rehabilitation cessation rate.
 Long term O2 therapy“ Offer this at EVERY visit”
 Surgery
Non-pharmacologic therapy
1. Smoking cessation & reduction of exposure to risk factors
• For all patient groups (A-E)
• Cigarette smoking is the most commonly encountered & easily identifiable risk factor for
COPD.
• Reduction of exposure to occupational dusts, fumes, gases, indoor & outdoor air
pollutants should be addressed.
Non-pharmacologic therapy
2. Pulmonary rehabilitation
• Exercise training
• Nutrition counseling
• Education

Benefits of Pulmonary Rehabilitation in COPD

• Improves both exercise tolerance & dyspnea
• Reduce the frequency of hospitalization and number of days in hospital.
Non-pharmacologic therapy
3. Long-term oxygen therapy

> 15 hrs/ day

• Initiation in patient with chronic respiratory failure

OR with one of the following criteria:

a. PaO2 ˂ 55 mm Hg or SaO2 ˂ 88%

OR
b. PaO2 between 55-60 mm Hg, with right heart failure, or
polycythemia (Hct > 55%)

GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention

Non-pharmacologic therapy
4. Surgical treatment
1. Lung Volume Reduction Surgery (LVRS)
• Surgical procedure in which parts of the lung are resected to
reduce hyperinflation making respiratory muscles more
efficient.

2. Bullectomy
 Removal of large bulla that
doesn’t contribute to gas
exchange to reduce
compression to adjacent
parenchyma.
3. Lung transplantation

GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention

Bronchodilator Anti- others
Inflammatory Antibiotics
β2-Agonists Cortico-
steroids
Alpha 1 anti
Anti- trypsine
(PDE-4) augmentation
cholinergics therapy
Inhibitors

Methyl Mucolytics and

Anti-Oxidant
xanthines
Treatment of stable COPD
I. Bronchodilators
Bronchodilators: They are the mainstay in COPD, and commonly
given on a regular basis to prevent or reduce symptoms.
• Inhaled therapy is preferred
• Combination bronchodilators of different pharmacological
classes may improve efficacy and decrease the risk of side
effects compared to increasing the dose of a single
bronchodilator.
Treatment of stable COPD
I. Bronchodilators
They are the mainstay in COPD
A. Beta 2 agonists
 Short-acting Beta2-agonists
 Albuterol (Salbutamol) (Ventolin®) (Rescue Medication that
should be prescribed to all patients for immediate symptom
relief)
 Fenoterol (Berotec®)
Twice
 Long-acting Beta2-agonists daily
 Salmeterol (Serevent®), formoterol (Foradil®)
Indacaterol (Arcapta™, Onbrez®) (once daily dosing): ultra long acting B2
agonist with duration of action of 24 hrs
Olodaterol (Striverdi®) and vilanterol (once daily dosing): improve lung
function and symptoms.
*Vilanterol is only available in combination inhalers.
Adverse effects of B2A: hypokalemia, tremors, tachycardia & palpitation
Treatment of stable COPD

I. Bronchodilators

B. Anticholinergics
• Short-acting muscarinic antagonists (SAMAs), ipratropium (every
6-8 hrs) (Atrovent®) and oxitropium
• long-acting muscarinic antagonists (LAMAs), tiotropium (once
daily) (Spiriva®), aclidinium (twice daily), glycopyrronium
bromide and umeclidinium (once daily)
• LABA & LAMA combination significantly improve lung
function, dyspnea, & reduce exacerbation reduce
exacerbation, increase FEV1 & reduce symptoms as
compared to monotherapy.
• Major adverse effect: dry mouth
Treatment of stable COPD

I. Bronchodilators

C. Methylxanthines (Theophylline)
• It has anti-inflammatory affect, and improves respiratory muscle
function, stimulates the respiratory center, and promotes
bronchodilation .
Its use is limited due to a narrow therapeutic index, multiple drug
interactions, and adverse effects.
• Addition of theophylline to salmeterol produces a greater improvement
in FEV1 and breathlessness than salmeterol alone
• Theophylline is NOT recommended unless other long-term treatment
bronchodilators are unavailable or unaffordable.
Adverse effects: anxiety, tremors, insomnia, nausea, cardiac arrhythmia,
seizures
Treatment of stable COPD
II. Anti-inflammatory drugs (CS)
For symptomatic patients with moderate to very severe COPD and frequent
exacerbations (NOT recommended as monotherapy).
For patients with blood eosinophil count > 300 cells/μL.
Inhaled corticosteroids (ICS) Fluticasone (Flixotide™, Flovent®), Budesonide
(Pulmicort®), Beclomethasone (Beclosone®, Vanceril)
• Triple inhaled therapy of ICS/LAMA/LABA improves lung function, symptoms &
reduces exacerbations compared to ICS/LABA, LABA/LAMA or LAMA
monotherapy.
Adverse effects: pneunomenia, oropharyngeal candidiasis and hoarse voice.
 These can be minimized by rinsing the mouth after use and by using a spacer
device with metered-dose inhalers.
 Oral Corticosteroids
 Long-term treatment with oral corticosteroids is NOT recommended
Treatment of stable COPD
III. PHOSPHODIESTERASE Inhibitors (PDE-4 inhibitor)

• The principal action is by reducing

inflammation, thus improves lung
function and reduces exacerbations.
• It is a once daily oral medication with NO
direct bronchodilator activity.
• E.g., Roflumilast (DALIRESP®)
• For patients with chronic bronchitis,
severe COPD and history of
exacerbations.
• Side effects: nausea, abdominal pain ,
diarrhea, sleep disturbance, weight loss.
• Used with caution in patients with
depression.
Treatment of stable COPD
IV. Vaccinations

• Influenza
• Recommended for all COPD patient (A-E). Reduces serious
illness and death in COPD patients
• Give once yearly
• Pneumococcal vaccine PCV13 & PPSV23 (Prevenar 13®,
Pneumovax®23)
• Recommended for all COPD patient groups (A-E)≥ 65 years and
younger patients with comorbid conditions such as chronic
cardiac or lung disease.

• COVID-19 vaccine
• The WHO and CDC recommend SARS-Cov-2 (COVID-19) for
people with COPD.
Treatment of stable COPD
V. Other therapies

• Alpha-1 Antitrypsin Augmentation Therapy

• IV augmentation therapy can be used only for individuals with
AAT deficiency.
Weekly transfusion of AAT to maintain adequate enzyme plasma
levels.
The therapy is very expensive and not recommended for patients
with COPD unrelated to AAT deficiency
• Antibiotics
• Recent studies have shown that regular use of macrolide antibiotics
(azithromycin and erythromycin) reduces exacerbation rate.
• Side effects
Treatment of stable COPD
V. Other therapies

• Mucolytic, Antioxidant agents

N-acetylcysteine (NAC) or carbocysteine or erdosteine
• In select COPD patients, regular treatment with mucolytics
reduces exacerbations and modestly improve health status

• Antitussives
• Regular use is contraindicated in stable COPD since cough has
a significant protective role by promoting clearance of
secretions.

GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention

Chief Complaint

“My wife says I need to get my lungs checked. Ever since we moved, I’m
having a hard time breathing.”

HPI

Dwayne Morrison is a 59-year-old man who is presenting to a new

provider at

the family medicine clinic today with complaints of increasing shortness of

breath. He points out that he first noticed some difficulty catching his
breath at his job 3 years ago. He had been able to heavy loads up and
down a flight of stairs daily for the last 35 years without any problem.
However, his shortness of breath began to make this very difficult.
Coincidently at that time, he accepted a managerial position at his
company that significantly reduced his carry activity level. After taking this
position, he no longer noticed any problems, but admits that he avoids
He noticed significant shortness of breath again after he moved to
Colorado from a lower elevation 2 months ago to be closer to his
grandchildren. His shortness of breath is worst when he is outside
playing with his grandchildren(MmRC grade 1). His previous physician
had placed him on salmeterol/fluticasone (Advair Diskus) one
inhalation twice daily 2 years ago. He thinks his physician initiated the
medication for the shortness of breath, but he is not entirely sure. He
is hoping to get a good medication that will help relieve his shortness
of breath because the gardening season is right around the corner,
and he enjoys this hobby.
PMH
• CAD (MI 7 years ago, resulting in stent placement at that time;
additional stent placed 2 years ago; normal echocardiogram
and stress test 3 months ago)
• Chronic bronchitis × 8 years (has had one exacerbation in the
last 12 months; received oral antibiotic treatment but was not
hospitalized)
• Cervical radiculopathy
FH
• Father with COPD (smoked a pipe for 40 years). Mother with
coronary artery disease and cerebrovascular disease.
SH
• He lives with his wife, who is a nurse. He has a 40 pack-year
history of smoking. When he had an MI at age 52, he quit smoking
temporarily. At present, he continues to smoke five to six
cigarettes per day. He drinks two to three beers most nights of the
workweek.
Meds
• Aspirin 81 mg PO once daily
• Bupropion SR 150 mg PO twice daily
• Clopidogrel 75 mg PO once daily
• Fluticasone/salmeterol 100/50, one inhalation BID
• OTC ibuprofen 200 mg PO four to six times daily PRN
• Rosuvastatin 20 mg PO once daily
• Metoprolol succinate 50 mg PO once daily

Allergy
• NKDA
ROS:(+) Chronic cough with sputum production; (+) exercise intolerance
Physical Examination
Gen: WDWN man in NAD
VS: BP 110/68, P 60, RR 16, T 37°C; Wt 82 kg, Ht 5′9″; pulse ox 93% on RA
Skin: Warm, dry; no rashes
HEENT: Normocephalic; PERRLA, EOMI; normal sclerae; mucous membranes are
moist; TMs intact; oropharynx clear
Neck/Lymph Nodes: Supple without lymphadenopathy
Lungs: Decreased breath sounds; no rales, rhonchi, or crackles
CV: RRR without murmur; normal S1 and S2
Abd: Soft, NT/ND; (+) bowel sounds; no organomegaly
Genit/Rect: No back or flank tenderness; normal male genitalia
MS/Ext: No CCE; pulses 2+ throughout
Neuro: A & O × 3; CN II–XII intact; DTRs 2+; normal mood and affect
Labs

What’s the important lab test for

COPD?
HCt Value; if HCt >55%, the patient has secondary
polycythemia.
Labs

Pulmonary Function Tests (During Clinic Visit Today)

Prebronchodilator FEV1 = 2.6L (predicted is 4.02 L)
FVC = 4.5 L
Postbronchodilator FEV1 = 2.75 L
CAT Assesment score <10
1a.Create a list of this patient’s drug-related problems.

Clopidogrel Drug therapy related problems

Fluticasone/Salmeterol
Ibuprofen

1.Unnecessary
3. Wrong Dose
drug therapy (Drug 4. Drug
2. Wrong drug. (too low or too
use without Interactions.
Nitrates
high).
indication).
ACEI/ARBs

7. Need additional
5. Adverse drug drug therapy
6. Noncompliance.
reaction. (Untreated
Indication).
2. What objective information indicates the presence and severity of COPD?

 Presence:
Postbronchodilator
FEV1/FVC=2.75/4.5= 0.6 (<0.7)

 Severity:
FEV1/Predicted FEV1=
(2.75/4.02)*100 = 68
3. What subjective information (eg, patient history) suggests the diagnosis of
COPD in this patient?

1. Age 59 years old (>40)

2. Family History of COPD
3. Chronic cough with sputum production.
4. History of Exposure to Risk Factors: Smoking
5. Dyspnea: Exercise intolerance.
4. How would you stage and classify this patient’s COPD?
4. How would you stage and classify this patient’s COPD?
4. How would you stage and classify this patient’s COPD?
5. What are the desired goals of pharmacotherapy for the treatment of COPD in this patient?

(a) Smoking cessation.

(b) Reducing symptoms.

(c) Improving exercise tolerance.

(d) Minimizing the rate of decline in lung function.

(e) Maintaining or improving quality of life.

(f) Preventing exacerbations.
6. What nonpharmacologic therapies would be useful to improve this patient’s COPD
symptoms?

Non-
pharmacological
therapy
 Risk factor prevention
&Smoking cessation
In this patient:
 Vaccination
 Risk factor prevention
Brief 3 minute period of
 Pulmonary counseling improve smoking
&Smoking cessation
rehabilitation cessation rate.
 Vaccination
 Long term O2 therapy “ Offer this at EVERY visit”
 Surgery
6. What nonpharmacologic therapies would be useful to improve this patient’s COPD
symptoms?
7. What pharmacotherapeutic alternatives are available for the treatment of this patient’s
COPD based on the most recent GOLD guideline recommendations?
8. Should home oxygen therapy be considered for the patient at this time? Why or why not?

 NO. Because oxygen therapy is initiated in patients with chronic

respiratory failure
 OR with one of the following criteria:
• a. PaO2 ˂ 55 mm Hg or SaO2 ˂ 88%
OR
• b. PaO2 between 55-60 mm Hg, with heart failure, or polycythemia
(Hct > 55%)
9. Evaluate the patient’s current COPD regimen, and develop recommendations to continue or
change the current COPD medications at his clinic visit today.
Make sure to include specific doses, route, frequency, and duration of therapy.

 He should omit the ICS and continue on any bronchodilator.

 He can use LABA as he’s already using Salmeterol

Salmeterol Formoterol Indacaterol Olodaterol Vilanterol

Route Inhalation

Frequency Twice Daily Once Daily

Duration of Lifelong
therapy
10. What clinical parameters will you monitor to assess the COPD pharmacotherapy regimen in
this patient?

 Review smoking status.

 Symptoms (CAT and mMRC)

 Exacerbation frequency & severity.

 Severity of spirometric abnormality (Degree of Airflow limitation GOLD1-4) annually

11. What laboratory tests can be performed and how often should they be performed to assess
the efficacy of the current COPD regimen as well as progression of the patient’s lung disease?

 Spirometry annually to assess disease progression

 CBC (HCt Value)
 ABG: pH, PaCO2 (normal: 38-42 mm Hg), PaO2
(normal: 75-100 mm Hg)
12. What information should be provided to the patient to enhance adherence,
ensure successful therapy, and minimize adverse effects?

 Check patient’s compliance on therapy.

 Discuss with the patient the risk of exacerbation if
he stopped his medications.
 Check if he uses the inhalers correctly and tell him
about the frequency, precautions, purpose of drug.
 Smoking Cessation: discuss with him the 5 Rs:
Relevance, Risk, Reward, Roadblocks, Repetition.
ABG: pH, PaCO2 (normal: 38-42 mm Hg),
PaO2 (normal: 75-100 mm Hg)
*
Thank You
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