1. COPD
WHAT IS IT?

2. Definition of COPD
COPD is a preventable and treatable disease with some significant
extrapulmonary effects that may contribute to the severity in
individual patients.
Its pulmonary component is characterized by airflow limitation that
is not fully reversible.
The airflow limitation is usually progressive and associated with an
abnormal inflammatory response of the lung to noxious particles
or gases.

6. Disease Trajectory of
Patients with COPD
Symptoms
Exacerbations
Exacerbations
Deterioration
Exacerbations
End of Life

7. SYMPTOMS
• The most common symptoms of COPD are
breathlessness, or a 'need for air', excessive sputum
production, and a chronic cough.
• Others include wheezing, tiredness and chest
tightness
• However, COPD is not just simply a "smoker's cough",
but a under-diagnosed, life threatening lung disease
that may progressively lead to death.
• COPD develops slowly, it may take years before
shortness of breath is noticed. Most of the time, COPD
diagnosed among middle aged people 40 years old
above

8. EPIDEMIOLOGY
• According to the latest WHO estimates (2004),
currently 64 million people have COPD and 3
million people died of COPD.
• Prevalence and morbidity
data greatlyunderestimate the total burden of
COPD because the disease is usually not
diagnosed until it is clinically apparent and
moderately advanced.
• In the Philippines, COPD is one of the 10
leading cause of death (DOH)

9. BURDEN
• COPD is a leading cause of morbidity and mortality
worldwide and results in an economicand social
burden that is both substantial and increasing.
• The burden of COPD is projected to increase in the
coming decades due to continued exposure to COPD
risk factors and the changing age structure of the
world’s population.
• Most of the information available on COPD
prevalence, morbidity and mortality comes from high-
income countries. Even in those countries, accurate
epidemiologic data on COPD are difficult and
expensive to collect. It is known that almost 90% of
COPD deaths occur in low- and middle-income
countries.

10. BURDEN
• At one time, COPD was more common in men, but
because of increased tobacco use among women in
high-income countries and the higher risk of exposure
to indoor air pollution (such as biomass fuel used for
cooking and heating) in low-income countries, the
disease now affects men and women almost equally.
• In 2002 COPD was the fifth leading cause of death.
Total deaths from COPD are projected to increase by
more than 30% in the next 10 years unless urgent
action is taken to reduce the underlying risk factors,
especially tobacco use. Estimates show that COPD
becomes in 2030 the third leading cause of death
worldwide.

11. Burden of Tobacco Use
• WB estimates in 1993 that global net social cost of
smoking was US$200B each year. This huge
economic burden is now shifting from developed to
developing countries.
• About 75% of today's tobacco users live on developing
countries. By 2030, estimates are developing
countries shall account to 70% of all tobacco deaths.
• In Vietnam, tobacco spending 1.5x higher than
education, 5x higher than health expenditure. Even
homeless children in India spent significant portion of
income purchasing tobacco.

12. Burden of Tobacco Use
• In India, 1M die every year due to tobacco related
diseases.
• In the Philippines, researchers estimate total annual
cost of illness for just four smoking related diseases -
cerebrovascular diseases, coronary artery disease,
COPD, and lung cancer - at US$2B, while real costs
may be as high as US$6.05B each year.

14. Of the six
leading causes
of death in the
United States,
only COPD has
been
increasing
steadily since
1970
Source: Jemal A. et al. JAMA 2005

15. COPD Mortality by Gender,
U.S., 1980-2000
Number Deaths x 1000
70
60
50 Men
40
Women
30
20
10
0
1980 1985 1990 1995 2000
Source: US Centers for Disease Control and Prevention, 2002

16. COPD Mortality by Gender
U.S., 1999-2006
Between 1999
and 2006,
death rates for
COPD have
declined among
U.S. men.
There has been
no significant
change among
death rates
among U.S.
women.
Source: US Centers for Disease Control and Prevention, 2011

17. RISK FACTORS

18. PRIMARY SUSPECT

19. Risk Factors for COPD
 Genes  Lung growth and
 Exposure to particles development
 Tobacco smoke  Oxidative stress
 Occupational dusts,  Gender
organic and
 Age
inorganic
 Indoor air pollution  Respiratory
from heating and infections
cooking with biomass  Socioeconomic
in poorly ventilated status
dwellings
 Nutrition
 Outdoor air pollution
 Comorbidities

20. MANAGEMENT
• An effective COPD management plan includes four
components:
– (1) assess and monitor disease;
– (2) reduce risk factors;
– (3) manage stable COPD;
– (4) manage exacerbations.

21. Changes in Small Airways in COPD Patients
Inflammatory exudate in lumen
Disrupted alveolar attachments
Thickened wall with inflammatory cells
- macrophages, CD8+ cells, fibroblasts
Peribronchial fibrosis
Lymphoid follicle
Source : Peter J. Barnes,
MD
Pathogenesis, Pathology, Pathophysiology

22. Changes in the Lung Parenchyma in COPD
Patients
Alveolar wall destruction
Loss of elasticity
Destruction of pulmonary
capillary bed
↑ Inflammatory cells
macrophages, CD8+ lymphocytes
Source : Peter J. Barnes,

23. Air Trapping in COPD
Normal Mild/moderate Severe
COPD COPD
Inspiration
small
airway
alveolar attachments loss of elasticity loss of alveolar attachments
Expiration
closure
↓ Health Dyspnea Air trapping
status ↓ Exercise capacity Hyperinflation
Source : Peter J. Barnes,

24. DIAGNOSIS AND TREATMENT
• COPD is confirmed by a simple diagnostic test called
"spirometry" that measures how much air a person
can inhale and exhale, and how fast air can move into
and out of the lungs. Because COPD develops slowly,
it is frequently diagnosed in people aged 40 or older.
• COPD is not curable. Various forms of treatment can
help control its symptoms and increase quality of life
for people with the illness. For example, medicines
that help dilate major air passages of the lungs can
improve shortness of breath.

25. COPD and Co-morbidities
COPD patients are at increased risk for:
• Myocardial infarction, angina
• Osteoporosis
• Respiratory infection
• Depression
• Diabetes
• Lung cancer
• Extrapulmonary (systemic) effects: Weight
loss, Nutritional abnormalities, Skeletal muscle
dysfunction

26. Diagnosis of COPD
EXPOSURE TO RISK
SYMPTOMS FACTORS
cough tobacco
sputum occupation
shortness of breath
indoor/outdoor pollution
SPIROMETRY

27. Physical signs
• Large barrel shaped
chest (hyperinflation)
• Prominent accessory
respiratory muscles in
neck and use of
accessory muscle in
respiration
• Low, flat diaphragm
• Diminished breath sound

28. Spirometry: Normal and Patients with COPD
Diagnosis
Assessing severity
Assessing prognosis
Monitoring progression

29. 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
SPIROMETRY is not to substitute for clinical judgment in the
evaluation of the severity of disease in individual patients.

30. Therapy at Each Stage of COPD
I: Mild II: Moderate III: Severe IV: Very Severe
Add long term
oxygen if chronic
respiratory failure.
Consider surgery
Add inhaled
glucocorticosteroids if repeated
exacerbations
Add regular treatment with one or more long-
acting bronchodilators* (when needed);
Add rehabilitation
Active reduction of risk factor(s); influenza vaccination
Add short-acting bronchodilator (when needed)
* ß2- agonists, anticholinergics and methylxanthines

31. LIMITATIONS
1. The limited reach of individual and small
group programs;
2. Low penetration of programs to some
segments of the population; and
3. The desire to develop programs to
achieve change in populations.

32. National collaborative approach to tobacco control issues,
nominating a range of government, non-government and
community partnerships and linkages, under six key
strategy areas:
• Strengthening community action
• Promoting cessation of tobacco use
• Reducing availability and supply of
tobacco
• Reducing tobacco promotion
• Regulating tobacco; and
• Reducing exposure to environmental
tobacco smoke

33. – Agenda Setting
– Increasing the salience of tobacco control issues
– Facilitating acceptance of tobacco control policy
initiatives to achieve structural change
– Behaviour change
– Increased preparedness to quit
– Prompting quit action
– Prompting supportive action for quitters
– Providing reinforcement for ex-smokers and never
smokers.

34. TOBACCO INDUSTRY
• Massive infrastructure
• Billion dollar budgets
• Ingenious product marketing

35. ANTI- TOBACCO INDUSTRY
• Quit campaigns • Fragmented
• Health departments - infrastructure
State/Territory and • Cooperative rather than
Commonwealth coordinated approach
• Cancer councils • Limited funding
• National Heart • Smokers targeted
Foundation through multiple
• Action on Smoking and approaches with varying
Health research to support
• Peak medical bodies
• Quitline
• Pharmaceutical
companies

36. % of smokers
10,0
20,0
30,0
40,0
50,0
60,0
0,0
R
U
S
G
EO
C
H
N
AR
G
G
ER
PH
I
AU
T
SU
I
PO
L
C
ZE
BR
A
KO
R
N
ED
JP
N
M
E
X
SY
R
Country
U
SA
U
K
PO
R
N
O
R
R
SA
Percent of Smokers
M
A
L
IT
A
KG
Z
TH
A
AU
S
C
AN
SW
E
SI
N

37. In Asia, most men smoke
1) CHN 70,2 %
2) RUS 63,0 %
3) GEO 57,5 %
4) SYR 46,0 %
5) JPN 43,3 %
6) KGZ 41,4 %

38. In Europe, most women smoke
1) BRA 30,0 %
2) RUS 30,0 %
3) NED 28,0 %
4) CZE 28,0 %
5) GER 28,0 %
6) AUT 26,0 %

39. Warning labels on cigarette packs
Are available in all surveyed countries!
But:
No COPD warning in most countries!
Except: NOR, CZE, USA, CAN, JPN, THA, AUS, RSA

40. Smoking can damage health
• Is known throughout all countries
• But smoke of indoor heating and cooking
with biomass fuels is not recognized to be
harmful!

41. Awareness in %
0,0
100,0
10,0
20,0
30,0
40,0
50,0
60,0
70,0
80,0
90,0
ITA
NOR
NED
SWE
AUS
AUT
GER
CAN
POL
SUI
CZE
UK
USA
JPN
CHN
Country
THA
SYR
PHI
MAL
POR
BRA
KGZ
GEO
RSA
RUS
MEX
Awareness of COPD is low in public
ARG
SIN
KOR

42. Patients don’t seek help
• Smokers showing symptoms of COPD like
– Coughing,
– Sputum production
– Shortness of breath
• Smokers do not relate these signs to
smoking or COPD
• And do not seek medical treatment

43. GPs generally do not diagnose or
treat COPD
• The awareness of COPD among GPs is quite high
• The opinion of the interviewed ICC members revealed
that only few GPs would diagnose COPD
• As a consequence, GPs do normally not treat COPD
• Only in Austria, Italy, The Netherlands and Canada,
more than 80 % of GPs will diagnose and treat COPD

44. % of GPs with spirometer
0
10
20
30
40
50
60
70
80
90
KO
R
AU
T
AU
S
SU
I
PO
L
G
ER
C
AN
JP
N
N
ED
U
K
M
E
X
PO
R
N
O
R
SW
E
SI
N
AR
G
Country
IT
A
U
SA
R
SA
R
U
S
PH
I
M
A
L
C
ZE
BR
A
TH
A
C
H
N
KG
Z
G
EO
Most GPs do not have access to spirometry
SY
R

45. Not in all countries treatment costs will
be covered by health insurances
•In most of the developed countries, health insurances
•No full coverage in Mexico, Argentina, Brazil, Russia,
•Large population can’t afford treatment

46. Huge information about COPD is
available
• In nearly all surveyed countries COPD patient
organizations exist
• Guidelines for diagnosis and treatment exist
• The GOLD guidelines are mainly known by specialists
• Many GPs don’t know the GOLD guidelines or don’t
follow them

47. Biggest Unmet Needs
• Awareness among patients about disease and risk factors (e.g. smoking)
• Lack of smoking cessation programs
• More anti-smoking campaigns are needed (TV etc.)
• Need for a better approach to prevention and treatment of cigarette smoking
• Lack of early diagnosis
• Huge number of undiagnosed/untreated COPD patients
• Diagnosis among GPs (spirometry needed)
• Differentiation between asthma and COPD unclear to many GPs
• Treatment algorithms are not followed/known by GPs
• No proper disease management by GPs
• Lack of rehabilitation facilities
• Funding of all drugs needed for treatment
• Lack of lung specialists
• More access to oxygen therapy
• Governmental programs to fight COPD

48. Public
• Percentage of smokers is too high
• More effective anti-smoking campaigns are needed
• Raise public awareness of COPD
• Drive patients with symptoms to GPs
• Enable smoking cessation programs

49. Physicians
• Increase knowledge regarding diagnosis, treatment
and management of COPD among GPs
• Follow GOLD guidelines
• Spirometry is needed
• More rehabilitation centres needed
• More specialists needed

50. Government
• Increase coverage for medical treatment
• Make medications available for poor patients
• Smoking bans in public areas needed
• COPD labeling on cigarette packs needed

51. Environment:
Behavioral: Economic
Smoking Cessation Diagnosis (Spirometric confirma
Health seeking transport and work
Rehabilitation Policy
Depression/ helplessness Healthcare organization
diet
tobacco
physical activity
COPD Access to Support groups
Govt/ Community Programs
Education/ Advertising
Medication Availability
Non Modifiable:
Age, Sex, Genes

52. Better outcomes for Chronic Conditions

53. Further Readings
• Global Initiative for Chronic Obstructive Lung Disease. Spirometry for Healthcare
Providers. (2007)
• Manual of Pulmonary Function Testing. Gregg l. Ruppel. Ninth Edition.
• Interpretation of Pulmonary Function Tests. Robert E. Hyatt. Second Edition
• Burden of Obstructive Lung Disease (BOLD) and participated in by the COPD Foundation
of the Philippines and the COPD Council of the Philippine College of Chest Physicians