HERE YOU CAN GET FULL INFORMATION ABOUT CHRONIC OBSTRUCTIVE PULMONARY DISEASE....

1. DR. VAIBHAV PARASHAR

2. • Fourth leading cause of death and fifth most common
cause of disability worldwide by 2020.
• Major cause of chronic morbidity and mortality
throughout the world.
• In 1998, Global Initiative for Chronic Obstructive Lung
Disease(GOLD) was implemented as an international
collaborative effort to improve awareness, diagnosis and
treatment of COPD.

3. DEFINITION
GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE
LUNG DISEASE(GOLD)
• A disease state characterized by airflow
limitation that is not fully reversible.
• COPD includes
EMPHYSEMA
CHRONIC BRONCHITIS
ALSO KNOWN AS COAD AND COLD.

4. CHRONIC BRONCHITIS
• Persistent cough that produces sputum and mucus for atleast
three consecutive months per year, in two consecutive years.

5. PATHOPHYSIOLOGY OF
CHRONIC BRONCHITIS

6. NORMAL EPITHELIUM OF
RESPIRATORY TRACT

7. BRONCHIAL EPITHELIUM IN
CHRONIC BRONCHITIS

8. EMPHYSEMA
EMPHYSEMA IS CHARACTERIZED BY DESTRUCTION OF GAS
EXCHANGING AIRSPACES i.e. RESPIRATORY
BRONCHIOLES,ALVEOLAR DUCTS AND ALVEOLI.CLASSIFIED AS
CENTRICINAR EMPHYSEMA AND PANACINAR EMPHYSEMA.

9. PATHOPHYSIOLOGY OF
EMPHYSEMA

10. RISK FACTORS

11. MANAGEMENT OF COPD
• FOUR COMPONENTS
ASSESSMENT AND MONITORING OF THE DISEASE
REDUCTION OF THE RISK FACTORS
MANAGEMENT OF STABLE COPD
MANAGEMENT OF EXACERBATIONS

12. ASSESSMENT AND
MONITORING
•HISTORY
•PHYSICAL FINDINGS
•INVESTIGATIONS

13. •
•
•
•
COUGH
SPUTUM PRODUCTION
EXERTIONAL DYSPNOEA
WHEEZING AND CHEST TIGHTNESS

14. SYMPTOMS
DYSPNOEA-: PROGRESSIVE,USUALLY WORSE WITH
EXERCISE,PERSISTENT DESCRIBED BY PATIENT AS AN INCREASED
EFFORT TO BREATHE,HEAVINESS,AIR HUNGER OR GASPING.
MODIFIED MRC SCALE
I only get breathless with strenuous exercise – GRADE 0
I get short of breath when hurrying on the level or
walking up a slight hill.
- GRADE 1
• I walk slower than people of the same age on the
level because of breathlessness, or I have to stop for
breath when walking on my own pace on the level.-GRADE 2
• I stop for breath after walking about 100 meters or
after a few minutes on the level.
-GRADE 3
• I am too breathless to leave the house or I am
breathless when dressing or undressing.
- GRADE 4

15. PHYSICAL FINDINGS
• INSPECTION- CYANOSIS
CHEST WALL ABNORMALITIES-BARREL SHAPED CHEST AND
PROTRUDING
ABDOMEN.
RESTING RESPIRATORY RATE>20 BREATHE PER MINUTE AND SHALLOW
BREATHING.
• PATIENTS WITH PREDOMINANT EMPHYSEMA ARE THIN AND ACYANOTIC AT
REST(pink puffers)WHILE PATIENTS WITH CHRONIC BRONCHITIS ARE HEAVY AND
CYANOTIC(blue bloaters).
• SITTING IN TRIPOD POSITION.
• ADVANCED DISEASE-SYSTEMIC WASTING WITH SYSTEMIC WEIGHT
LOSS,BITEMPORAL WASTING AND DIFFUSE LOSS OF SUBCUTANEOUS ADIPOSE
TISSUE.
• PARADOXICAL INWARD MOVEMENT OF THE RIB CAGE WITH
INSPIRATION(hoover’s sign)
• CLUBBING
• PALPATION AND PERCUSSION- UNHELPFUL.
• AUSCULTATION- REDUCED BREATH SOUNDS,
INSPIRATORY CRACKLES,HEART SOUNDS ARE BEST HEARD OVER THE XIPHOID
AREA.

16. DIFF. DIAGNOSIS
• ASTHMA-MAJOR DIFFERENTIAL DIAGNOSIS.
DIFF. OF ASTHMA FROM COPD
ASTHMA
COPD
AGE OF ONSET
FAMILY HISTORY
ETIOLOGY
<30
COMMON
POSSIBLE FAMILY HIST.
OF ALLERGY AND ASTHMA
COUGH
DYSPNOEA
UNCOMMON
EPISODIC/NOCTURNAL
ATTACKS
>40
UNCOMMON
LONG SMOKING
HISTORY OR HISTORY OF
EXPOSURE TO DUST OR
SMOKE
COMMON
PROGRESSIVE OVER YEARS;
DAYTIME EXERTIONAL
MORE REVERSIBLE
NOT REVERSIBLE
AIRFLOW
LIMITATION

17. CONTD…
•
-
BRONCHIECTASISLARGE VOLUMES OF PURULENT SPUTUM.
COMMONLY ASSOCIATED WITH BACTERIAL INFECTION.
BRONCHIAL DILATION AND CHEST WALL THICKENING ON
CXR/CT.
• CONGESTIVE HEART FAILURE- CXR SHOWS DILATED HEART AND PULMONARY OEDEMA.
- PFT INDICATES VOLUME RESTRICTION NOT AIRFLOW
LIMITATION.
• TUBERCULOSIS- ONSET ALL AGES
- CXR SHOWS LUNG INFILTERATION
- MICROBIOLOGICAL CONFIRMATION

18. DIAGNOSIS
• PULMONARY FUNCTION TEST(SPIROMETRY)-SHOWS
EVIDENCE OF AIRFLOW LIMITATION.
SPIROMETRIC CLASSIFICATION OF COPD SEVERITY BASED ON
POST BRONCHODILATOR FEV1(GOLD CRITERIA)

19. CONTD….
• CHEST X-RAY-OFTEN NORMAL .
• CLASSIC FEATURES--SEVERE OVERINFLATION OF THE LUNGS WITH LOW FLATTENED
DIAPHRAGMS.
-LARGE RETROSTERNAL AIRSPACE ON THE LAT. Film.

20. CONTD…
• Hb LEVEL AND PCV-ELEVATED.
• ARTERIAL BLOOD GAS TEST-IT IS USED TO DETERMINE THE
NEED FOR OXYGEN.RECOMMENDED IN THOSE WITH
FEV1<35% AND THOSE WITH PEROPHERAL OXYGEN
SATURATION<92% AND IN CCF.
• ELECTROCARDIOGRAM- IN ADVANCED CORPULMONALE THE
‘P’ WAVE IS TALLER AND THERE MAY BE RIGHT BUNDLE
BRANCH BLOCK AND THE CHANGES OF RIGHT VENTRICULAR
HYPERTROPHY.
• ECHOCARDIOGRAM-TO ASSESS CARDIAC FUNCTION.
• alpha1-ANTITRYPSIN LEVELS-NRML RANGE 2-4g/L.

21. Rx.

22. Contd…
REDUCE RISK FACTORS:
-QUIT SMOKING
-ELIMINATION OR REDUCTION OF VARIOUS SUBSTANCES IN THE
WORKPLACE
-AVOID EXPOSURE TO OUTDOOR/INDOOR POLLUTION
STRATEGIES TO QUIT SMOKING:
ASK: EVERY PATIENT AT EVERY CLINIC VISIT
ADVISE: TO QUIT
ASSESS: WILLING TO QUIT
ASSIST: AID THE PATIENT IN QUITTING-PROVIDE
COUNSELLING,PHARMACOTHERAPY AND SOCIAL SUPPORT.

23. CONTD…
• PHARMACOTHERAPY FOR SMOKING CESSATION:
- WHEN COUNSELLING NOT SUFFICIENT TO HELP PATIENT QUITTING.
- NICOTINE REPLACEMENT THERAPY: NICOTINE GUM,INHALER,NASAL
SPRAY,TRANSDERMAL PATCH OR SIBLINGUAL TABLET.
- BUPROPIONE AND NORTRIPTYLINE INCREASES LONG TERM
ABSTINENCE RATES.
- CLONIDINE- USE LIMITED BY SIDE EFFECTS.

24. PHARMACOTHERAPY
• Bronchodilators:
- CENTRAL TO SYMPTOM MANAGEMENT IN COPD.
- INHALED ROUTE IS PREFERRED.
- CHOICE DEPENDS ON AVAILABILITY AND INDIVIDUAL RESPONSE IN TERMS
OF SYMPTOM RELIEF AND SIDE EFFECTS.
- SHORT ACTING BRONCHODILATORS, β2- AGONISTS SALBUTAMOL AND
TERBUTALINE OR THE ANTICHOLINERGIC IPRATROPIUM BROMIDE CAN BE
USED IN PATEINTS WITH MILD DISEASES.
- LONG ACTING BRONCHODILATORS, β2 AGONISTS SALMETEROL AND
FORMOTEROL OR THE ANTICHOLINERGIC TIOTROPIUM BROMIDE ARE
MORE APPROPRIATE IN MODERATE TO SEVERE DISEASE.
- ORAL BRONCHODILATOR THERAPY – THEOPHYLLINE PREPARATIONS.

25. CONTD...
• CORTICOSTEROIDS:
-REGULAR INHALED GLUCOCORTICOSTEROIDS DOES NOT MODIFY LONG
TERM DECLINE OF FEV1.INHALED STEROIDS ARE
BECLOMETHASONE,FLUTICASONE,TRIAMCINOLONE.
APPROPRIATE FOR:
- SYMPTOMATIC COPD PATIENTS WITH AN FEV1<50% PREDICTED(STAGE
III: SEVERE COPD AND STAGE IV: VERY SEVERE COPD) AND
- REPEATED EXACERBATIONS
- REDUCE THE FREQUENCY OF EXACERBATIONS.
- INHALED GLUCOCORTICOSTEROIDS COMBINED WITH A LONG ACTING B
AGONIST IS MORE EFFECTIVE THEN THE INDIVIDUAL COMPONENTS.
- LONG TERM USE OF ORAL STEROIDS IS NOT RECOMMENDED IN
COPD.ORAL CORTICOSTEROIDS ARE PREDNISOLONE METHYL
PREDNISOLONE AND BUDESONIDE.

26. CONTD..
NARCOTICS(MORPHINE)-EFFECTIVE FOR TREATING DYSPNEA IN
COPD PATIENTS WITH ADVANCED DISEASE.
α1 ANTITRYPSIN AUGMENTATION THERAPY:
-YOUNG PATIENTS WITH SEVERE α1 ANTITRYPSIN DEFICIENCY AND
ESTABLISHED EMPHYSEMA.
-VERY EXPANSIVE
-NOT WIDELY AVAILABLE
-NOT RECOMMENDED FOR COPD UNRELATED TO α1 ANTITRYPSIN
DEFICIENCY.
• PULMONARY REHABILITATION:
-EXERCISE TRAINING
-NUTRITIONAL COUNSELLING
-DISEASE EDUCATION

27. CONTD..
• OXYGEN THERAPY:
-LONG TERM OXYGEN THERAPY(LTOT) >15 hrs. A DAY TO PATIENTS
WITH CHRONIC RESPIRATORY FAILURE INCREASE SURVIVAL.
-PROVIDED BY AN OXYGEN CONCENTRATOR.
-INDICATIONS:
-STAGE IV: VERY SEVERE COPD WITH
PaO2 <55 mmHg OR SaO2 <88% with or without hypercapnia.
PaO2 55-6- mmHg + pulmonary hypertension,peripheral
oedema,peripheral oedema or nocturnal hypoxaemia.
GOAL-TO INCREASE THE BASELINE PaO2 TO ATLEAST 60mmHg AT REST
AND/OR TO PRODUCE SaO2 AT LEAST 90%.

28. CONTD..
• SURGICAL INTERVENTION:
-BULLECTOMY: YOUNG PATIENTS IN WHOM LARGE BULLAE COMPRESS
SURROUNDING NORMAL LUNG TISSUE WHO OTHERWISE HAVE
MINIMAL AIRFLOW LIMITATION AND A LACK OF GENERALISED
EMPHYSEMA MAY BE CONSIDERED FOR BULLECTOMY.
-LUNG VOLUME REDUCTION SURGERY(LVRS)-INDICATED IN PATIENTS
WITH PREDOMINANTLY UPPER LOBE EMPHYSEMA WITH PRESERVED
GAS TRANSFERENCE MAY BENEFIT FROM LVRS.IN THIS SURGERY
PERIPHERAL EMPHYSEMATOUS LUNG TISSUE IS RESECTED.

29. CONTD..
• OTHER MEASURES:PATIENTS WITH COPD SHOULD GET
ANNUAL INFLUENZA VACCINATION AND PNEUMOCOCCAL
VACCINATION.
• OBESITY,POOR NUTRITION DEPRESSION AND SOCIAL
ISOLATION SHOUL BE IDENTIFIED AND CORRECTED.

30. MONITORING AND FOLLOW UP
• ROUTINE FOLLOW-UP IS ESSENTIAL BECAUSE EVEN WITH THE BEST AVAILABLE CARE
LUNG FUNCTION CAN BE EXPECTED TO WORSEN OVER TIME.
FOLLOW UP VISITS SHOULD INCLUDE A INQUIRY ABOUT CHANGES IN SYMPTOMS SINCE
THE LAST VISIT INCLUDES COUGH AND SPUTUM,BREATHLESSNESS,FATIGUE,ACTIVITY
LIMITATION AND SLEEP DISTURBANCES.
• SMOKING STATUS-DETERMINE CURRENT SMOKING STATUS AND SMOKING
EXPOSURE.
• MONITOR MEDICAL TREATMENT-DOSAGE OF VARIOUS MEDICATIONS,INHALER
TECHNIQUE,EFFECTIVENESS OF CURRENT REGIMEN SHOULD BE MONITORED BY
ASKING THE PATIENT SUCH QUESTIONS-HAVE YOU NOTICED A DIFFERENCE SINCE STARTING THIS TREATMENT.
-IF YOU ARE FEELING BETTER- ARE YOU LESS BREATHLESS?
CAN YOU DO MORE?
DO YO SLEEP BETTER?
DESCRIBE WHAT DIFFERENCE IT HAS MADE TO
YOU?
DO YOU FEEL ANY DIFFICULTY AFTER TAKING THE
MEDICATIONS?
• MONITOR EXACERBATION HISTORY-EVALUATE THE SEVERITY AND LIKELY CAUSES OF
EXACERBATIONS .INCREASED SPUTUM VOLUME,ACUTELY WORSENING DYSPNEA
AND THE PRESENCE OF PURULENT SPUTUM SHOULD BE NOTED.

31. EXACERBATIONS OF COPD
• EXACERBATION OF COPD IS AN ACUTE EVENT CHARACTERIZED BY A
WORSENING OF THE PATIENT’S RESPIRATORY SYMPTOMS SUCH AS
SHORTNESS OF BREATH,QUANTITY AND COLOUR OF
PHLEGM.EXACERBATION MAY BE TRIGERRED BY AN RESPIRATORY
INFECTIONS WHICH MAY BE BACTERIAL AOR VIRAL OR BY
ENVIRONMENTAL POLLUTANTS.
• CONDITIONS THAT MAY AGGRAVATE EXACERBATINS INCLUDE
PNEUMONIA,PULMONARY EMBOLISM,PNEUMOTHORAX AND
PLEURAL EFFUSION.
• DIAGNOSIS:DIAGNOSIS OF AN EXACERBATION RELIES EXCLUSIVELY
ON THE CLINICAL PRESENTATION OF THE PATIENT COMPLAINING OF
AN ACUTE CHANGE OF SYMPTOMS(BASELINE DYSPEA,COUGH AND
SPUTUM PRODUCTION) THAT IS BEYOND NORMAL DAY TO DAY
VARIATION.

32. ASSESSMENT OF
EXACERBATION
• ASSESSMENT OF AN EXACERBATION IS BASED ON PATIENT’S
MEDICAL HISTORY AND CLINICAL SIGNS OF SEVERITY.
• IN THE MEDICAL HISTORY WE SHOULD LOOK FOR-SEVERITY OF COPD BASED ON DEGREE OF AIRFLOW LIMITATION.
-DURATION OF WORSENING OR NEW SYMPTOMS.
-NUMBER OF PREVIOUS EPISODES.
-PRESENT TREATMENT REGIMEN.
-PREVIOUS USE OF MECHANICAL VENTILATION.
• SIGNS OF SEVERITY-USE OF ACCESSORY RESPIRATORY MUSCLES.
-PARADOXICAL CHEST WALL MOVEMENTS.
-WORSENING OR NEW ONSET CENTRAL CYANOSIS.
-DEVELOPMENT OF PERIPHERAL EDEMA.
-DETERIORATED MENTAL STATUS.

33. CONTD..
• TESTS THAT CAN BE CONSIDERED TO ASSESS THE SEVERITY OF AN
EXACERBATION ARE
-PULSE OXIMETRY- IT IS USEFUL FOR TRACKING OR ADJUSTING
SUPPLEMENTAL OXYGEN THERAPY.ASSESSMENT OF ACID BASE STATUS
IS NECESSARY BEFORE INITIATING MECHANICAL VENTILATION.
-AN ECG MAY AID IN THE DIAGNOSIS OF COEXISTING CARDIAC
PROBLEMS.
-CBC MAY IDENTIFY POLYCYTHEMIA,ANEMIA OR LEUCOCYTOSIS.
-THE PRESENCE OF PURULENT SPUTUM DURING AN EXACERBATION
CAN BE SUFFICIENT INDICATION FOR STARTING EMPIRICAL
ANTIBIOTIC TREATMENT.

34. TREATMENT OF
EXACERBATIONS
• WHEN A PATIENT COMES TO THE EMERGENCY DEPARTMENT THE
FIRST ACTION IS TO PROVIDE SUPPLEMENTAL OXYGEN THERAPY
AND TO DETERMINE WHETHER THE EXACERBATION IS LIFE
THREATENING.IF SO,THE PATIENT IS ADMITTED TO ICU IMMEDIATELY
OTHERWISE THE PATIENT CAN BE MANAGED IN THE EMERGENCY
DEPARTMENT.
• INDICATIONS FOR HOSPITAL ADMISSION:
-MARKED INCREASE IN INTENSITY OF SYMPTOMS SUCH AS SUDDEN
DEVELOPMENT OF RESTINF DYSPNEA.
-SEVERE UNDERLYING COPD.
-ONSET OF NEW PHYSICAL SIGNS(CYANOSIS,PEROPHERAL EDEMA)
-FAILURE OF AN EXACERBATION TO RESPOND TO INITIAL MEDICAL
MANAGEMENT.
-PRESENCE OF SERIOUS COMORBIDITIES(HERAT FAILURE OR NEWLY
OCCURING ARRYTHMIAS)
-OLDER AGE

35. THERAPEUTIC COMPONENTS OF HOSPITAL
MANAGEMENT
• RESPIRATORY SUPPORT
-OXYGEN THERAPY
-VENTILATORY SUPPORT
NONINVASIVE VENTILATION
INVASIVE VENTILATION
• PHARMACOLOIC TREATMENT
-BRONCHODILATORS
-CORTICOSTEROIDS
-ANTIBIOTICS

36. MANAGEMENT OF SEVERE BUT NOT
LIFE THREATENING EXACERBATIONS
• ASSESS SEVERITY OF SYMPTOMS, BLOOD GASES CHEST
RADIOGRAPH.
• ADMINISTER SUPPLEMENTAL OXYGEN THERAPY AND OBTAIN SERIAL
ARTERIAL BLOOD GAS MEASUREMENT.
• BRONCHODILATORS
-INCREASE DOSES AND FREQUENCY OF SHORT ACTING
BRONCHODILATORS.
-COMBINE SHORT ACTING beta2 AGONISTS AND ANTICHOLINERGICS.
-ADD ORAL OR IV CORTICOSTEROIDS.
-CONSIDER ANTIBIOTICS WHEN SIGNS OF BACTERIAL INFECTION.
-CONSIDER NON INVASIVE MECHANICAL VENTILATION.
-AT ALL TIMES:
MONITOR FLUID BALANCE AND NUTRITION.
IDENTIFY AND TREAT ASSOCIATED CONDITIONS(HEART
FAILURE,ARRYTHMIAS)
CLOSELY MONITOR CONDITION OF THE PATIENT.

37. INDICATIONS FOR ICU
ADMISSION
• SEVERE DYSPNEA THAT RESPONDS INADEQUATELY TO INITIAL
EMERGENCY THERAPY.
• CHANGES IN THE MENTAL
STATE(CONFUSION,LETHARGY,COMA)
• PERSISTENT OR WORSENING HYPOXAEMIA(PaO2<40mmHg)
AND /OR SEVERE/WORSENING RESPIRATORY
ACIDOSIS(Ph<7.25) DESPITE SUPPLEMENTAL OXYGEN AND
NONINVASIVE VENTILATION.
• NEED FOR INVASIVEMECHANICAL VENTILATION.

38. DISCHARGE CRITERIA
• PATIENT IS ABLE TO USE LONG ACTING BRONCHODILATORS
WITH OR WITHOUT INHALED CORTICOSTEROIDS.
• INHALED SHORT ACTING beta2 AGONIST THERAPY IS
REQUIRED NO MORE FREQUENTLY THAN EVERY 4 HOURS.
• PATIENT IS ABLE TO WALK ACROSS ROOM.
• PATIENT IS ABLE TO EAT AND SLEEP WITHOUT FREQUENT
AWAKENING BY DYSPNEA.
• PATIENT HAS CLINICALLY STABLE FOR12-24 HRS.
• ARTERIAL BLOOD GASES HAVE BEEN STABLE FOR 12-24
HOURS.
• PATIENT FULLY UNDERSTANDS USE OF MEDICATIONS.
• PATIENT,FAMILY AND PHYSICIAN ARE CONFIDENT THAT
PATIENT CAN MANAGE SUCCESSFULLY AT HOME.

39. FOLLOW UP
• THERE SHOULD BE FOLLOW UP VISIT AFTER 4-6 WEEKS AFTER
DISCHARGE FROM HOSPITAL IF EVERYTHING IS NORMAL.
• THE FOLLOWING THINGS SHOULD BE ASSESSED-ABILITY TO COPE IN THE ENVIRONMENT.
-MEASUREMENT OF FEV1
-REASSESSMENT OF INHALER TECHNIQUE.
-REASSESS NEED FOR LONG TERM OXYGEN THERAPY OR HOME
NEBULIZER.
-CAPACITY TO DO PHYSICAL ACTIVITIES.
-STATUS OF COMORBIDITIES.

40. COPD AND COMORBIDITIES
• CARDIOVASCULAR DISEASES: ISCHAEMIC HEART
DISEASE,HYPERTENSION,HEART FAILURE.
• ANXIETY AND DEPRESSION.
• OSTEOPOROSIS
• METABOLIC SYNDROME AND DIABETES
• INFECTIONS