2. American Thoracic Society, British Thoracic Society and European Respiratory
Society: Chronic bronchitis (clinical) and Emphysema (pathological).
Global Initiative for Chronic Obstructive Lung Disease (GOLD): airflow
limitation that is not fully reversible and is progressive and associated with an
abnormal inflammatory response of the lungs to noxious particles or gases.
Emphysema Normal
William MacNee. ABC of chronic obstructive pulmonary disease. Pathology, pathogenesis, and pathophysiology. BMJ. 2006 May 20; 332(7551): 1202–1204.
Definition of COPD
3. When to consider COPD in individuals over 40?
• Progressive and persistent dyspnea, which is worse with exercise.
• Chronic cough, which may be intermittent and unproductive.
• Chronic productive cough (any pattern of chronic sputum production).
• History of exposure to risk factors like tobacco smoke, domestic smoke and
occupational dust.
• Family history of COPD
Perform SpirometryAny of the above key indicators
Source: At-A-Glance Outpatient Management Reference for Chronic Obstructive Pulmonary Disease (COPD).
http://www.goldcopd.org/uploads/users/files/WatermarkedAt-A-Glance%202016(1).pdf Accessed on 08/07/2016
5. • Chronic Lower Respiratory Diseases (CLRD) are the 3rd leading cause of death
in US (2013)
• CLRD including asthma: 149,205
• CLRD excluding asthma: 136,627
Source: Deaths: Final Data for 2013, tables 9, 10, 11. http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_02.pdf Accessed on 08/07/2016
Source: Chronic Respiratory Diseases. Burden of COPD. http://www.who.int/respiratory/copd/burden/en/ Accessed on 08/07/2016
• More than 90% of COPD deaths occur in low- and
middle-income countries in 2005.
Global Burden of Disease Study 2013 Collaborators Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and
chronic diseases and injuries in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;386:743–800.
• One of the leading cause of disability worldwide.
• COPD is an iceberg disease.
Regan EA, et al. Clinical and Radiologic Disease in Smokers With Normal Spirometry. JAMA Intern Med. 2015 Sep;175(9):1539-49.
Source: Morbidity and Mortality: 2012 Chart Book on cardiovascular,
Lung, and Blood Diseases.
http://www.nhlbi.nih.gov/files/docs/research/2012_ChartBook.pdf
Accessed on 08/07/2016
Numbers in COPD
Source: Summary Health Statistics Tables for U.S. Adults: National Health Interview
Survey, 2014, Table A-2
http://ftp.cdc.gov/pub/Health_Statistics/NCHS/NHIS/SHS/2014_SHS_Table_A-
2.pdf Accessed on 08/07/2016.
• Adults diagnosed with chronic bronchitis in 2013: 8.7 million
• Adults diagnosed with emphysema in 2013: 3.4 million
6. Source: Trends in COPD (Chronic Bronchitis and Emphysema): Morbidity and Mortality.
http://www.lung.org/assets/documents/research/copd-trend-report.pdf Accessed on 08/07/2016
• Prevalence rates increase with age. • Prevalence rates from 1980-2011
Sourc: Chronic Obstructive Pulmonary Disease Surveillance — United States, 1971–2000.
http://www.cdc.gov/mmwr/pdf/ss/ss5106.pdf Accessed on 08/07/2016
Source: COPD Surveillance—United States, 1999-2011.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3707177/pdf/chest_144_1_284.pdf Accessed on 08/07/2016
Disease prevalence
7. Age-adjusted death rates for selected causes of
death for all ages, by sex: United States, 2003-2013
Source: Health. United States. 2014, table 18. http://www.cdc.gov/nchs/data/hus/hus14.pdf#018
Males
Females
Source: Disease Statistics. National Heart, Lung and Blood Institute.
http://www.nhlbi.nih.gov/about/documents/factbook/2012/chapter4#4_1
Males Females
Mortality
9. COPD death rates among people aged 55 years
and over in relation to smoking (Australia)
Source: How many die from COPD? COPD is a major leading cause of death in Australia. http://www.aihw.gov.au/copd/mortality/
10. Modified version of Fletcher and Peto’s. from Daniel Kotz, et al Efficacy of confrontational counselling for smoking cessation in smokers with previously undiagnosed mild to
moderate airflow limitation: study protocol of a randomized controlled trial. BMC Public Health. 2007; 7: 332.. C Fletcher, R Peto. The natural history of chronic airflow obstruction.
Br Med J. 1977 June 25; 1(6077): 1645–1648.
Lung function and smoking
11. Genes may play a role in COPD
Hersh CP, et al. Family history is a risk Factor for COPD. Chest. 2011 Aug;140(2):343-50.
Salvi SS and Barnes PJ. Chronic obstructive pulmonary disease n non-smokers. Lancet. 2009 Aug 29;374(9691):733-43.
13. Assessment of COPD
• Symptoms
• Degree of airflow limitation (using spirometry)
• Risk of exacerbations
• Comorbidities
• Symptoms assessed by a questionnaire containing 8 questions.
Source: How is your COPD? Take the COPD AssessmentTestTM (CAT). http://www.catestonline.org/english/indexEN.htm Accessed on 08/07/2016
Modified from Source: At-A-Glance Outpatient Management Reference for Chronic Obstructive Pulmonary Disease
(COPD). http://www.goldcopd.it/materiale/2015/GOLD_Pocket_2015.pdf Accessed on 08/07/2016
14. Source: How is your COPD? Take the COPD AssessmentTestTM (CAT). http://www.catestonline.org/english/indexEN.htm Accessed on 08/07/2016
15. Assessment of COPD
• Symptoms
• Degree of airflow limitation (using spirometry)
• Risk of exacerbations
• Comorbidities
• Symptoms assessed by a questionnaire containing 8 questions.
Source: How is your COPD? Take the COPD AssessmentTestTM (CAT). http://www.catestonline.org/english/indexEN.htm Accessed on 08/07/2016
• Degree of airflow limitations discussed in the next slide.
Modified from Source: At-A-Glance Outpatient Management Reference for Chronic Obstructive Pulmonary Disease
(COPD). http://www.goldcopd.it/materiale/2015/GOLD_Pocket_2015.pdf Accessed on 08/07/2016
16. Classification of Severity of Airflow Limitation
in COPD (Based on Post-Bronchodilator FEV1)
In patients with FEV1/FVC < 0.70 (Normal: > 0.70 of predicted ratio)
GOLD 1 Mild FEV1 ≥ 80% predicted
GOLD 2 Moderate 50% ≤ FEV1 < 80% predicted
GOLD 3 Severe 30% ≤ FEV1 < 50% predicted
GOLD 4 Very severe FEV1 < 30% predicted
Normal FEV1 and FVC volumes depends on the age, height
and gender of the person.
Modified from Source: At-A-Glance Outpatient Management Reference for Chronic Obstructive Pulmonary Disease
(COPD). http://www.goldcopd.org/uploads/users/files/WatermarkedAt-A-Glance%202016(1).pdf Accessed on 08/07/2016
17. Assessment of COPD
• Symptoms
• Degree of airflow limitation (using spirometry)
• Risk of exacerbations
• Comorbidities
• Symptoms assessed by a questionnaire containing 8 questions.
Source: How is your COPD? Take the COPD AssessmentTestTM (CAT). http://www.catestonline.org/english/indexEN.htm Accessed on 08/07/2016
• Degree of airflow limitations discussed in the next slide.
• Risk of exacerbations:
Low Risk: ≤ 1 per year and no hospitalization for exacerbation
High Risk: ≥ 2 per year or ≥ 1 with hospitalization
Modified from Source: At-A-Glance Outpatient Management Reference for Chronic Obstructive Pulmonary Disease
(COPD). http://www.goldcopd.it/materiale/2015/GOLD_Pocket_2015.pdf Accessed on 08/07/2016
19. Exacerbation
Celli BR, MacNee W; ATS/ERS Task Force. Standards for the diagnosis and treatment of patients with COPD: a summary
of the ATS/ERS position paper. Eur Respir J. 2004;23(6):932-946.
O'Reilly JF, et al. Defining COPD exacerbations: impact on estimation of incidence and burden in primary care. Prim Care
Respir J 2006; 15: 346–353.
Causes of exacerbation: Bacterial (55%) and viral respiratory
infections, inflammatory (eosinohilic) and air pollution. But in some
cases of exacerbations the cause remains unknown.
Common bacterial causes include Haemophilus influenza, Haemohilus
parainfluenza, Streptococcus pneumoniae and Moraxella catarrhalis.
Less common causes include Pseudomonas aeruginosa,
Enterobacteriaceae and Staphylococcus aureus.
The most common viral cause is Rhinovirus.
Budev MM and Wiedemann HP. Acute bacterial exacerbation of chronic bronchitis.
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/pulmonary/acute-bacterial-exacerbation-chronic-
bronchitis/
Bafadhel M, et al. Acute exacerbations of chronic obstructive pulmonary disease: identification of biologic clusters and their biomarkers.
Am J Respir Crit Care Med. 2011 Sep 15;184(6):662-71.
Bafadhel M, et al. Acute exacerbations of chronic obstructive pulmonary disease: identification of biologic clusters and their biomarkers. Am J Respir Crit Care Med. 2011 Sep
15;184(6):662-71.
Agusti A, et al. Prevention of exacerbations in chronic obstructive pulmonary disease: knowns and unknowns. J COPD F. 2014; 1(2): 166-184. doi:
http://dx.doi.org/10.15326/jcopdf.1.2.2014.0134 - See more at: http://journal.copdfoundation.org/jcopdf/id/1041/Prevention-of-Exacerbations-in-Chronic-Obstructive-Pulmonary-
Disease-Knowns-and-Unknowns#sthash.gXOGSqp9.dpuf
Wedzicha JA, Donaldson GC. Exacerbations of chronic obstructive pulmonary disease. Respir Care. 2003 Dec;48(12):1204-13; discussion 1213-5.
An exacerbation of COPD is an increase from the patient's baseline
dyspnea, cough and/or sputum beyond day-to-day variability
warranting a change in management strategy.
20. Exacerbation
Mild: Can be controlled with an increase in dosage of regular
medication
Moderate: Requires treatment with systemic corticosteroids and/or
antibiotics
Severe: Requires hospitalization or evaluation in the ED and can lead
to respiratory failure
Evensen AE. Management of COPD exacerbation. Am Fam Physician. 2010 Mar 1;81(5):607-13.
Laue J, Reierth E and Melbye H. When should acute exacerbations of COPD be treated with systemic corticosteroids and antibiotics in primary
care: a systematic review of current COPD guidelines. NPJ Prim Care Respir Med. 2015 Feb 19;25:15002.
Burge S and Wedzicha JA. COPD exacerbations: definitions and classifications. Eur Respir J Suppl. 2003 Jun;41:46s-53s.
21. But the most reliable predictor of an exacerbation is the previous history
of exacerbation.
Exacerbation
Suissa S, Dell'Aniello S, Ernst P. Long-term natural history of chronic obstructive pulmonary disease: severe exacerbations and mortality. Thorax. 2012 Nov;67(11):957-63.
22. Assessment of COPD
• Symptoms
• Degree of airflow limitation (using spirometry)
• Risk of exacerbations
• Comorbidities
• Symptoms assessed by a questionnaire containing 8 questions.
Source: How is your COPD? Take the COPD AssessmentTestTM (CAT). http://www.catestonline.org/english/indexEN.htm Accessed on 08/07/2016
• Degree of airflow limitations discussed in the next slide.
• Risk of exacerbations:
Low Risk: ≤ 1 per year and no hospitalization for exacerbation
High Risk: ≥ 2 per year or ≥ 1 with hospitalization
• Comorbidities: Cardiovascular diseases, osteoporosis, depression and anxiety,
skeletal muscle dysfunction, metabolic syndrome, and lung cancer among other
diseases affect the morbidity and mortality of COPD.
Modified from Source: At-A-Glance Outpatient Management Reference for Chronic Obstructive Pulmonary Disease
(COPD). http://www.goldcopd.it/materiale/2015/GOLD_Pocket_2015.pdf Accessed on 08/07/2016
24. Systemic effects and comorbidities of COPD
P. J. Barnes, and B. R.. Systemic manifestations and comorbidities of COPD. Celli Eur Respir J 2009;33:1165-1185
26. Assessment of COPD
• Symptoms
• Degree of airflow limitation (using spirometry)
• Risk of exacerbations
• Comorbidities
• Symptoms assessed by a questionnaire containing 8 questions.
Source: How is your COPD? Take the COPD AssessmentTestTM (CAT). http://www.catestonline.org/english/indexEN.htm Accessed on 08/07/2016
• Degree of airflow limitations discussed in the next slide.
• Risk of exacerbations:
Low Risk: ≤ 1 per year and no hospitalization for exacerbation
High Risk: ≥ 2 per year or ≥ 1 with hospitalization
• Comorbidities: Cardiovascular diseases, osteoporosis, depression and anxiety,
skeletal muscle dysfunction, metabolic syndrome, and lung cancer among other
diseases affect the morbidity and mortality of COPD.
Modified from Source: At-A-Glance Outpatient Management Reference for Chronic Obstructive Pulmonary Disease
(COPD). http://www.goldcopd.it/materiale/2015/GOLD_Pocket_2015.pdf Accessed on 08/07/2016
27. Combined Assessment of COPD
Patient Characteristic Spirometric
classification
Exacerbations
per year
CAT*
A
Low risk
Less symptoms
GOLD 1-2 ≤1 < 10
B
Low risk
More symptoms
GOLD 1-2 ≤1
≥ 10
C
High risk
Less symptoms
GOLD 3-4 ≥2 < 10
D
High risk
More symptoms
GOLD 3-4 ≥2 ≥ 10
Modified from Source: At-A-Glance Outpatient Management Reference for Chronic Obstructive Pulmonary Disease
(COPD). http://www.goldcopd.it/materiale/2015/GOLD_Pocket_2015.pdf Accessed on 08/07/2016
*CAT: COPD assessment test http://www.catestonline.org/images/pdfs/CATest.pdf
28. Management of COPD
Patient
group
Recommended first
choice
Alternative choice
A
SA anticholinergic prn
or
SA beta2-agonist prn
LA anticholinergic
or
LA beta2-agonist
or
SA anticholinergic and
SA beta2-agonist
B
LA anticholinergic
or
LA beta2-agonist
LA anticholinergic and
LA beta2-agonist
C
LA beta2-agonist
or
ICS + LA anticholinergic
LA anticholinergic and
LA beta2-agonist
or
LA anticholinergic and
PDE-4 inhibitor
or
LA beta2-agonist and PDE-4 inhibitor
D
LA beta2-agonist
and/or
ICS + LA anticholinergic
ICS + LA anticholinergic and
LA beta2-agonist
or
ICS + LA beta2-agonist and PDE-4 inhibitor
or
LA anticholinergic and
LA beta2-agonist
or
LA anticholinergic and
PDE-4 inhibitor
Modified from Source: At-A-Glance Outpatient
Management Reference for Chronic Obstructive
Pulmonary Disease (COPD).
http://www.goldcopd.it/materiale/2015/GOLD_Pocket_20
15.pdf Accessed on 08/07/2016
29. How the interventions help?
Kim V and Criner GJ. Chronic bronchitis and chronic obstructive
pulmonary disease. Am J Respir Crit Care Med. 2013 Feb 1;187(3):228-37.
30. Treatment of exacerbation is bronchodilators, oxygen therapy,
antibiotics and/or inhaled/systemic corticosteroid therapy.
Pavord ID, et al. Exacerbations of COPD. Int J Chron Obstruct Pulmon Dis. 2016 Feb 19;11 Spec Iss:21-30
Source: Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease updated 2016.
http://www.goldcopd.org/uploads/users/files/WatermarkedGlobal%20Strategy%202016(1).pdf Accessed on 08/07/2016
.
But use of antibiotics in mild to moderate COPD exacerbation is
fraught with controversy.
Puhan M, et al. Where is the supporting evidence for treating mild to moderate chronic obstructive pulmonary disease
exacerbations with antibiotics? A systematic review. BMC Med 2008; 6: 28.
Systemic corticosteroid use is associated with several adverse effects,
especially in patients with co-morbidities.
Bach PB, et al. Management of acute exacerbations of chronic obstructive pulmonary disease: a summary and
appraisal of published evidence. Ann Intern Med 2001; 134: 600–620.
In spite of the above facts, antibiotics and corticosteroids are used in
almost all cases of acute exacerbation of COPD.
Laue J, Reierth E and Melbye H. When should acute exacerbations of COPD be treated with systemic corticosteroids and
antibiotics in primary care: a systematic review of current COPD guidelines. NPJ Prim Care Respir Med. 2015 Feb
19;25:15002.
Treatment of acute exacerbation of COPD
Oxygen therapy has a demonstrable beneficial effect in the
management of exacerbation of COPD
Simon E Brill, Jadwiga A Wedzicha. Oxygen therapy in acute exacerbations of chronic obstructive pulmonary disease. Int
J Chron Obstruct Pulmon Dis. 2014; 9: 1241–1252.
31. Moderate or Severe
At least two or three cardinal symptoms*
Simple (no major risk factors**) Complicated (≥ 1 major risk factors**)
Treat for 5 days with
β-lact/Doxy/Bactrim/Cephalosporin
(2nd or 3rd gen)/Macrolides
Treat for 5 days with
β-lact+lactamase/fluroquinolone
Clinical improvement in 72 hours?
• Change to oral antibiotics
• Vaccinate for influenza and pneumo
• Smoking cessation
• Reevaluate history/exam/data
• Sputum culture
• Broaden antibiotic coverage
* Increased dyspnea, sputum and sputum purulence
** FEV1 <50% predicted, >3 exacerbations/year, comorbid diseases, antibiotic use in the past 3 months
YES NO
Antibiotics in acute exacerbation of COPD
Anthonisen NR, al. Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease. Ann Intern Med. 1987 Feb;106(2):196-204.
Source: Kelly Cunningham Sponsler, J. Daniel Markley and Joshua LaBrin. What Is the Appropriate Use of Antibiotics In Acute Exacerbations of COPD? The Hospitalist. January 26, 2012. http://www.the-hospitalist.org/article/what-is-the-appropriate-use-of-antibiotics-in-acute-exacerbations-of-copd/?singlepage=1 Accessed on 08/07/20166
32. Empirical selection of antibiotics in exacerbation of COPD
Source: What Is the Appropriate Use of Antibiotics In Acute Exacerbations of COPD? http://www.the-hospitalist.org/article/what-is-the-appropriate-use-of-antibiotics-in-acute-exacerbations-of-
copd/?singlepage=1 Accessed on 08/07/2016
33. Prevention of acute exacerbation of COPD
http://dx.doi.org/10.15326/jcopdf.1.2.2014.0134 - See
more at:
http://journal.copdfoundation.org/jcopdf/id/1041/Pr
evention-of-Exacerbations-in-Chronic-Obstructive-
Pulmonary-Disease-Knowns-and-
Unknowns#sthash.gXOGSqp9.dpuf Accessed on
08/07/2016
Inhibitor of
phosphodiesterase type 4
34. Conclusions
• COPD is a disease, which is significant for prevalence, morbidity,
mortality, and economic burden (both on the individual and the
healthcare system).
• It is a disease that is largely preventable.
• Unfortunately, once acquired, the course is relentless leading to
considerable morbidity and ultimately to death.
• Co-morbidities play a significant role on the outcome of the disease.
• Acute exacerbations are a natural course of the disease.
• Antibiotics, steroids, bronchodilators and oxygen therapy are the
main stay in treating the exacerbations.
• Control of risk factors is essential to prevent exacerbations.
• Maintaining a baseline disease process involves risk prevention and
non-pharmacological as well as pharmacological methods.
• Medication compliance, smoking cessation and vaccination has
proven highly beneficial in keeping the disease under control.
