MANAGEMENT OF COPD
Goals of treatment
• Symptomatic relief
• Prevention of complications
• Removal of risk-factors
• Treatment of complications & Ac
Exacerbations
• Reduce the rate of decline in lung
function
• Prevent morbidity and mortality
• Rehabilitation of patient

MANAGEMENT OF COPD
Steps of therapy
I (Mild) Short acting BDs
II (Moderate) Regular BD (one / more)
III (Severe) - Bronchodilators
- Inhaled corticosteroids
- Rx of complications
Tobacco cessation and pulmonary rehabilitation
are important at all stages

Guidelines on Smoking Cessation
The “5A” Strategy for Physicians
1. ASK about tobacco use
2. ASSESS the status and severity of use
3. ADVISE to stop
4. ASSIST in smoking cessation
5. ARRANGE follow-up programme

Bronchodilators
1. Anticholinergics
Tiotropium - Long acting
Ipratropium - Short acting
2. Beta-agonists
Long acting – Maintenance
(Salmeterol, Formoterol)
Short acting – Rescue
(Salbutamol)
3. Combinations (1+2)
4. Oral: Theophyllines
PDE4 inhibitors (Roflumilast)

Inhalational Treatment
Preferred route for both controller and reliever
therapy
Advantages: Local effect,
immediate response
Minimal dosage,
few side effects
Available as : Dry powder (DPIs),
Metered dose liquid inhalers MDIs);
Nebulizers
Devices: Spacers (to increase drug delivery)

Side effects of inhalation drugs
Local side effects:
throat irritation,
voice change, thrush (candida
infection), vocal cord dysphonia
Systemic side effects of drugs: Rare
may be growth retardation in
young children
cataracts, other steroid effects

Metered Dose Inhalers

Dry powder inhalers

Anticholinergics
1. Cause effective bronchodilatation
2. Reduce rate & severity of acute
exacerbations
3. Improve quality of life
4. Long acting
5. Side effects: Dryness, blurred
vision, urinary retention (if BPH)

Corticosteroids
1. Oral/parenteral for acute exacerbations
2. Inhaled for moderate to severe COPD
• Improve lung function
• Reduce exacerbations
• Improve symptoms & Q.O.L.
• Reduce airway reactivity
Side effects:
• Loss of bone mineral density
• Increased skin bruising

Complications of COPD
1. Acute exacerbations
Severe airway obstruction
Acute change in baseline lung function
Marked exercise tolerance
Nocturnal hypoxemia
2. Pulmonary hypertension and
Chronic cor pulmonale
3. Respiratory failure

Symptoms of COPD Exacerbation
• Increase in cough
• Chest pain
• Increase in breathlessness
• Increase in sputum volume and change in its
colour (to green, yellow, blood streaked)
• Fever
• Increased tiredness
• Increase in oxygen requirement (for those on
long-term oxygen therapy)

Management of Acute Exacerbations
1. Increase the dose and/or frequency of
current bronchodilator therapy
2. Add new bronchodilators
3. Bronchodilator nebulization
4. Parenteral theophyllines
5. Systemic glucocorticoids
6. Antibiotics for infections
7. Maintenance of oxygenation
8. NIV or Assisted Ventilation for refractory
respiratory failure (Hypoxaemia and/ or
hypercapnia)

Supplemental Oxygen
• Hypoxemia common in hospitalized pts.
• Small increase in FiO2 - good response
However, this can worsen hypercapnia
due to:
– Release of hypoxic vasoconstriction 
Increased dead-space
– Loss of hypoxic respiratory drive
• Domicilliary long term-term oxygen therapy
for COPD with chronic respiratory failure

Assisted Respir Supports
• Non-invasive ventilation (NIV) in case there is
failure to respond to supportive therapy and
controlled oxygen supplementation
Initiate as early as possible
RR > 24 and hypercapnia with acidosis
(pH <7.35) are the classic indications
No benefit in milder exacerbations
• Intubation and Mechanical ventilation if NIV is
contraindicated, has failed, or is not tolerated

Chronic Cor Pulmonale
Definition: Alterations in the structure and/or
function of the right ventricle secondary to diseases
of the lung, chest wall or lung vasculature – (which
are not secondary to the diseases of the left heart or
congenital heart diseases).
Manifests with features of pulmonary hypertension
and right heart overload/ failure:
Generalized anasarca, congested liver,
ascites, cyanosis, loud P-2, cardiomegaly (rt.)
Diagnosis: H/O COPD
CXR, ECG, ECHO

Treatment of cor pulmonale
1. Long term oxygen therapy
2. Removal of fluid retention –
diuretics
3. Maintenance of CO2 levels
4. Digoxin, if arterial fibrillation
5. Vasodilators - may be hazardous
(Lower systemic and pulm. BP)
6. Treatment of COPD

Other complications
1. Rupture of blebs/bullae: Pneumothorax,
pneumomediastinum, subcutaneous emphysema
2. Polycythemia (due to chronic hypoxemia)
3. Increased coagulation problems
In situ thrombosis
Pulmonary thromboembolism
5. Hyperuricemia (and occasionally gout)
6. Systemic manifestations

Systemic manifestations of COPD
1. General
Wasting, weight loss,
Nutritional anomalies, anemia
2. Musculoskeletal
Skeletal muscle dysfunction,
Osteoporosis
Reduced exercise tolerance, performance
3.Cardiovascular
Ischemic heart disease
Cardiac failure, Stroke

4. Endocrinal
Diabetes,
Metabolic syndrome
Dysfunction of pituitary,
thyroid, gonads and adrenals
5. Neuropsychiatric
Depression
Disordered sleep
Anxiety
Cognitive function decline

Long term Maintenance and
Prophylaxis Treatment
• Keep off smoking
• Bronchodilators
• Inhaled corticosteroids
• Use/avoidance of other drugs (e.g.
antibiotics, mucolytics ,sedatives)
• Prophylactic vaccination (influenza)
• Pulmonary rehabilitation (multidisciplinary
supports and management)

Pulmonary Rehabilitation
• Structured, multi-disciplinary programme tailored to
one’s needs to improve quality of life, lung function
and reduce breathlessness
Components
• Exercise training
• Nutritional counseling
• Education on lung disease or condition and how to
manage it
• Energy-conserving techniques
• Breathing strategies
• Psychological counseling and/or group support

Pulmonary Eosinophilic Disorders
Normal E counts: Differential: ≤5%, AEC: ≤0.5×109/l
Eosinophilia:
• Mild: AEC 0.5-1.5×109/l
• Moderate: AEC 1.5-5.0×109/l
• Severe: AEC >5.0×109/l
• Hyper Eosinophilic Syndrome (HES):
AEC: >1.5×109/l lasting for 6 months
Lack of evidence for known causes of eosinophilia
Signs and symptoms of organ
involvement/dysfunction

Pulm eosinophilic disorders: Classification
A. Primary pulmonary eosinophilia
Predominant involving lung.
Acute eosinophilic pneumonia
Chronic eosinophilic pneumonia
Systemic disease with lung disease
Churg-Strauss syndrome
Idiopathic hypereosinophilic syndrome
B. Lung disorders with associated eosinophilia
1. Interstitial lung disease, Sarcoidosis, Langerhans cell
histiocytosis, Connective tissue disease
2. Asthma
3. Bronchiolitis obliterans-organizing pneumonia
4. Neoplasms:, Hematological malignancies, Solid organ tumors

C. Secondary pulmonary eosinophilia
1. Infections: Parasitic infestations
Transient passage (Löffler’s syndrome)
Ancylostoma, ascaris, strongyloides
paragonimiasis, echinococcosis
Trichinella, Visceral larva migrans
Disseminated strongyloidiasis Schistosomiasis
• Fungal infections: Coccidiomycosis, Histoplasmosis
• Other infections: Tuberculosis, Brucellosis
3. Tropical pulmonary eosinophilia
4. Allergic bronchopulmonary aspergillosis
5. Hypersensitivity pneumonia
6. Drugs, toxins and radiation

Drugs causing eosinophilic lung disease
1. Antimicrobials: Para-amino salicyclic acid, Nitrofurantoin
Penicillin, Tetracycline, Streptomycin, Isoniazid
Sulfonamide,Tetracycline, Minocycline,Dapsone + pyrimethamine
2. Antineoplastic and immunosuppressives
Bleomycin, Methotrexate, Melphalan, Gold salts
Azathioprine, Penicillamine, Beclomethasone
3. Nonsteroidal anti-inflammatory drugs (NSAIDs):
Aspirin, Naproxen, Piroxicam, Nimesulide, Phenylbutazone
4. Cardiovascular and antidiabetics:
Amiodarone, Hydralazine, Thiazides, Clofibrate, Sulfonylureas
5. Miscellaneous: Carbamazepine, Phenytoin, Dantrolene,
Methylphenidate, Imipramine, Cocaine or heroin exposure
Iodinated contrast media, L-tryptophan.

Churg Strauss Syndrome
Now known as Allergic Granulomatosis with Angiitis
Include i) asthma, ii) paranasal sinusitis,
iii) monoarthropathy or polyarthropathy,
iv) migratory or transient pulmonary infiltrates,
v) peripheral blood eosinophilia greater than 10%, and
vi) extravascular eosinophils in a blood vessel on a
biopsy specimen.
D/D: Wegener’s granulomatosis, polyarteritis nodosa,
tuberculosis, fungal infections,
allergic bronchopulmonary aspergillosis,
Tmt.: Corticosteroids and cytotoxic medications

Tropical Pulmonary Eosinophilia
• Immunological hyper-responsiveness to human filarial
parasite- W. bancrofti & Brugia malayi
• Transmitted through mosquito bites
• Symptoms: Cough, breathlessness, wheeze, usually
nocturnal symptoms. Systemic organ involvement.
• Diagnosis: Absolute eosinophil count – more than
3000/cmm; demonstration of parasites
• Chest X-ray: Reticulo-nodular shadow
• Elevated serum IgE and anti-falarial antibodies
• Tmt: Diethylcarbamazine (6mg/kg per day for 3 weeks)

Hypersensitivity Pneumonias
• Type 3 immunological response to sensitizing antigens
(Cf. type 1 for asthma)
• Presentation delayed 4-6 hrs or more after exposure
• Symptoms: Cough, fever, breathlessness, malaise etc
• Types: Farmer’s lung, Byssinosis, Baggasosis
Psittacosis, Pigeon breeder lung, Grain lung,
Air-conditioner lung, compost lung etc
Diagnosis: History of exposure-symptom relationship
CXR; Non-specific. Eosinophilia, Antibodies
Tmt: Removal of offending antigens
Symptomatic and anti-inflammatory treatment