COPD
Mohammad Ruhal Ain
R Ph, PGDPRA, M Pharm (Clin. Pharm)
Department of Clinical Pharmacy
Define !
Definition
 COPD?
•syndrome of chronic limitation in expiratory airflow encompassing emphysema or
chronic bronchitis. Airflow obstruction may be accompanied by airway
hyperresponsiveness and may be not be fully reversible.
 Emphysema
•abnormal permanent enlargement of the airspaces distal to the terminal
bronchioles, accompanied by destruction of their walls and without obvious fibrosis
Chronic Bronchitis?
•consists of persistent cough plus sputum production for most days out of 3 months
in at least 2 consecutive years
Emphysema
Destruction of the
alveolar wall damages
pulmonary capillaries
by tearing, fibrosis, or
thrombosis
Inelastic
collapsible
bronchioles
Enlarged air sacs due
to destruction of
alveolar walls (bullae)
Abnormal permanent
Abnormal
enlargement
of permanent
the air spaces
distal
to the terminal
enlargement
of the air
bronchioles accompanied by
spaces distal to the
destruction of their walls and
terminal
bronchioles
without
obvious
fibrosis
accompanied by
destruction of their
walls and without
obvious fibrosis
Walls of individual
sacs torn (repair not
possible)
Bronchiole
Air passage
narrowed by plugged
and swollen mucous
membrane
Mucus and pus
impede action
of respiratory
cilia
Chronic
Bronchitis
Presence of chronic
productive cough for
3 months in each of
2 successive years in a
patient in whom other
causes of chronic cough
have been excluded
Inflammation: COPD vs Asthma

Inflammation is an important component in the pathogenesis
of asthma and COPD

The inflammatory response in asthma and COPD is markedly
different, although some cell types are present in both
diseases

The predominant inflammatory cells in asthma include
 Eosinophils
 Mast cells
 CD4+ T lymphocytes

The predominant inflammatory cells in COPD include
 Neutrophils
 CD8+ T lymphocytes
 Macrophages

The role of these cells in COPD is not fully understood
Asthma
COPD
Sensitizing agent
Noxious agent
Asthmatic airway inflammation
CD4+ T-lymphocytes
Eosinophils
Completely
reversible
COPD airway inflammation
CD8+ T-lymphocytes
Macrophages
Neutrophils
Airflow
limitation
Completely
irreversible
Differential Diagnosis:
COPD and Asthma
ASTHMA
COPD
•
•
•
•
•
Onset in mid-life
Symptoms slowly
progressive
Long smoking history
Dyspnea during exercise
Largely irreversible
airflow limitation
•
•
•
•
Onset early in life (often childhood)
Symptoms vary from day to day
Symptoms at night/early morning
Allergy, rhinitis, and/or eczema also present
• Family history of asthma
• Largely reversible airflow limitation
COPD: Risk Factors
• Exposures
– Smoking (generally ≥90%)
– Passive smoking
– Ambient air pollution
– Occupational dust/chemicals
– Childhood infections (severe respiratory, viral)
– Socioeconomic status
• Host factors
– Alpha1-antitrypsin deficiency (<1%)
– Hyperresponsive airways
– Lung growth
Diagnosis of COPD
EXPOSURE TO RISK
FACTORS
SYMPTOMS
shortness of breath
chronic cough
sputum
tobacco
occupation
indoor/outdoor pollution
è
SPIROMETRY: Required to establish
diagnosis
Spirometric Diagnosis of COPD
 COPD is confirmed by post–
bronchodilator FEV1/FVC < 0.7
 Post-bronchodilator FEV1/FVC
measured 15 minutes after 400µg
salbutamol or equivalent
GOLD Guidelines for COPD
Stage 0: At Risk
Diagnosis
Treatment

Chronic cough/sputum


PFTs within normal
limits

No symptoms
Avoid risk factors
(smoking cessation)
GOLD Guidelines for COPD
Stage I: Mild
Diagnosis
Treatment

FEV1 >80% predicted

Avoid risk factors

FEV1/FVC <70%

Short-acting
bronchodilator PRN

With/without
symptoms
GOLD Guidelines for COPD
Stage II: Moderate
Diagnosis

50%  FEV1 <80%
predicted

FEV1/FVC <70%

With/without
symptoms
Treatment

Avoid risk factors

Regular therapy with
 1 bronchodilators

Inhaled corticosteroids if
significant symptoms
and lung function
response

Rehabilitation
GOLD Guidelines for COPD
Stage III:Severe
Diagnosis

30%  FEV1 < 50%
predicted

FEV1/FVC < 70%

With/without symptoms
Treatment

Avoid risk factors

Regular therapy with
 1 bronchodilators

Rehabilitation

Inhaled corticosteroids if
significant symptoms
and lung function
response or if repeated
exacerbations
GOLD Guidelines for COPD
Stage IV: Very Severe
Diagnosis
Treatment

FEV1 < 30% predicted

Avoid risk factors

FEV1/FVC < 70%


Respiratory failure
Regular therapy with
1 bronchodilators

Right-side-of-the-heart
failure

Inhaled corticosteroids if
significant symptoms and
lung function response or
repeated exacerbations

Rehabilitation

Treatment of complications

Long-term O2 therapy for
hypoxic respiratory failure

Evaluate for surgical
treatment
Case: S.H. is a 50-year-old male smoker with a recent diagnosis
of COPD. Spirometry showed FEV1/FVC 60%; prebronchodilator FEV1 70% of predicted; and post bronchodilator
FEV1 72% of predicted.
The gold standard in diagnosing COPD patient is ?
I.Spirometry
II.Xray
III.ABG
Assessment-Dx
The diagnosis of COPD is based on
I. A history of exposure to risk factors
II. The presence of airflow limitation that is not fully
reversible, with or without the presence of symptoms.
For the diagnosis and assessment
of COPD, spirometry is the gold
standard.
FEV1/FVC less than 70% of predicted
An FEV1/FVC ratio less
+
than 70% is the hallmark of COPD
a postbronchodilator FEV1 less than 80%
= airflow limitation
Bronchodilator reversibility testing is generally
performed only once, at the time of diagnosis,
to rule out the diagnosis of asthma
Assessment
S.H. is a 50-year-old male smoker with a recent diagnosis of COPD. Spirometry
showed FEV1/FVC 60%; pre-bronchodilator FEV1 70% of predicted; and post
bronchodilator FEV1 72% of predicted.
The gold standard in diagnosing COPD patient is ?
I.Spirometry
II.Xray
III.ABG
When to use ABG?
I.Patient with stable COPD
II.Patient with FEV1 >70 %
III.Patient with FEV1<50 % with and or clinical signs suggestive of respiratory
failure or right heart failure.
Assessment
S.H. is a 50-year-old male smoker with a recent diagnosis
of COPD. Spirometry showed FEV1/FVC 60%; pre
bronchodilator FEV1 70% of predicted; and post
bronchodilator FEV1 72% of predicted.
History of exposure to risk factors may play a role in S.H
condition , what’s the most common risk factor
I. tobacco smoke
II. occupational dusts and chemicals,
III. and smoke from home cooking and heating fuels
Note: ALL of the above considered to be a risk factor
Plan
Therapy Goals
I.Relieve symptoms
II.Improve exercise tolerance.
III.Improve health status.
Relieve symptoms
I.Prevent and treat exacerbations.
II.Prevent disease progression
III.Prevent and treat complications.
IV.Reduce mortality.
V.Minimize adverse effects from treatment.
Reduce risk
Case: S.H. is a 50-year-old male smoker with a
recent diagnosis of COPD. Spirometry showed
FEV1/FVC 60%; pre-bronchodilator FEV1 70%
of predicted; and post bronchodilator FEV1
72% of predicted.
Q. Which of the following is the severity
classification (stage) of S.H.’s COPD
A. Stage I: Mild.
B. Stage II: Moderate.
C. Stage III: Severe.
D. Stage IV: Very severe.
FEV1/FVC always less than 70% in patient with COPD
Patient has post bronchodilator FEV1 72% of predicted
Global Initiative for Chronic Obstructive Lung Disease Workshop
Executive Summary: Global Strategy for the Diagnosis, Management,
and Prevention of Chronic Obstructive Pulmonary Disease. National
Institutes of Health National Heart,
Lung and Blood Institute, 2013update
Case: S.H. is a 50-year-old male smoker with a
recent diagnosis of COPD. Spirometry showed
FEV1/FVC 60%; pre-bronchodilator FEV1 70%
of predicted; and post bronchodilator FEV1
72% of predicted.
Q. Which of the following is the severity
classification (stage) of S.H.’s COPD
A. Stage I: Mild.
B. Stage II: Moderate.
C. Stage III: Severe.
D. Stage IV: Very severe.
Plan
Q.Which one of the following pharmacotherapy options
is most appropriate for S.H. to be started on?
A.Albuterol MDI 2 puffs every 4–6 hours as needed.
B.Albuterol MDI 2 puffs every 4–6 hours as needed plus
formoterol inhale 1 capsule 2 times/day.
C.Albuterol MDI 2 puffs every 4–6 hours as needed plus
salmeterol/fluticasone 50/500 1 puff 2 times/day.
D.Albuterol MDI 2 puffs every 4–6 hours as needed plus
salmeterol/fluticasone 50/500 1 puff 2 times/ day plus
home oxygen.
Plan
Q: Which one of the following pharmacotherapy options
is most appropriate for S.H. to be started on?
A. Albuterol MDI 2 puffs every 4–6 hours as needed.
B. Albuterol MDI 2 puffs every 4–6 hours as needed plus
formoterol inhale 1 capsule 2 times/day.
C. Albuterol MDI 2 puffs every 4–6 hours as needed plus
salmeterol/fluticasone 50/500 1 puff 2 times/day.
D. Albuterol MDI 2 puffs every 4–6 hours as needed plus
salmeterol/fluticasone 50/500 1 puff 2 times/ day plus
home oxygen.
Plan
Complete the following sentence
•…………. Is the most important component of COPD
management?
MCQ
Q: Other pharmacologic treatments for COPD
a. Smoking cessation
b. Influenza vaccine annually
c. Pneumococcal vaccine
d. α1-Antitrypsin augmentation therapy in patient
with Severe hereditary α1-antitrypsin deficiency
and established emphysema
D. All of the above
Plan
Complete the following sentence
•…………. Is the most important component of COPD
management? (Smoke caesation)
MCQ
Q: Other pharmacologic treatments for COPD
a. Smoking cessation
b. Influenza vaccine annually
c. Pneumococcal vaccine
d. α1-Antitrypsin augmentation therapy in patient
with Severe hereditary α1-antitrypsin deficiency
and established emphysema
D. All of the above
True or false?
Q. Bronchodilator medications are central to the symptomatic management of COPD ?
True
False
Q. The preferred route for bronchodilators in the management of COPD is by
inhalation ?
True
False
Q. Regular treatment with LABAs is more effective and convenient than with SABAs for
treating COPD patient ?
True
False
Q. Combining bronchodilators with different mechanisms and durations of action
may improve efficacy with the same or fewer adverse effects compared with
increasing the dose of a single bronchodilator?
True
False
Q. All bronchodilators have been shown to improve exercise capacity, but they may
not significantly improve FEV1 in patient with COPD?
True
False
Q. LABAs improve health status and decrease COPD exacerbations.
True
False
True or false?
Q. Bronchodilator medications are central to the symptomatic management of COPD ?
True
Q. The preferred route for bronchodilators in the management of COPD is by
inhalation ?
True
Q. Regular treatment with LABAs is more effective and convenient than with SABAs for
treating COPD patient ?
True
Q. Combining bronchodilators with different mechanisms and durations of action
may improve efficacy with the same or fewer adverse effects compared with
increasing the dose of a single bronchodilator?
True
Q. All bronchodilators have been shown to improve exercise capacity, but they may
not significantly improve FEV1 in patient with COPD?
True
Q. LABAs improve health status and decrease COPD exacerbations.
True
MCQ
Q. Treatment with a long-acting anticholinergic in
patients with COPD
I. Delays first exacerbation
II. Reduces the overall number of COPD
exacerbations
III. Improves the effectiveness of pulmonary
rehabilitation
IV. All of the above .
MCQ
Q. In COPD patients , ICS is appropriate for
I. Patients with an FEV1 less than 50% (stages
III and IV) of predicted and repeated
exacerbations
II.Patient with FEV1/FVC < 70% and 50% ≤
FEV1< 80% of predicted (stage II Moderate)
III.Patient FEV1/FVC < 70% FEV1 ≥ 80% of
predicted (Stage 1 mild)
MCQ
Q. In COPD patients , ICS is appropriate for
I. Patients with an FEV1 less than 50% (stages
III and IV) of predicted and repeated
exacerbations
II.Patient with FEV1/FVC < 70% and 50% ≤
FEV1< 80% of predicted (stage II Moderate)
III.Patient FEV1/FVC < 70% FEV1 ≥ 80% of
predicted (Stage 1 mild)
Q. Regarding the use of ICS in COPD
I. ICSs decrease the frequency of
exacerbations
II. ICSs alone do not modify the progressive
decline in FEV
III. ICSs alone do not decrease mortality.
IV. ICSs Increased incidence of pneumonia
V. All of the above
Q. Regarding the use of ICS in COPD
I. ICSs decrease the frequency of
exacerbations
II. ICSs alone do not modify the progressive
decline in FEV
III. ICSs alone do not decrease mortality.
IV. ICSs Increased incidence of pneumonia
V. All of the above
True or false
Q. In stable COPD patient , An ICS combined with a
LABA is more effective than the individual
components?
True
False
Q. In stable COPD , An ICS-LABA combination
reduces the rate of decline of FEV1
True
False
Q. In stable COPD , Chronic treatment with OCSs
should be avoided because of an unfavorable benefitrisk ratio
True
False
True or false
Q. In stable COPD patient , An ICS combined with a
LABA is more effective than the individual
components?
True
False
Q. In stable COPD , An ICS-LABA combination
reduces the rate of decline of FEV1
True
False
Q. In stable COPD , Chronic treatment with OCSs
should be avoided because of an unfavorable benefitrisk ratio
True
False
Case: K.R. is a 60-year-old man with COPD who
smokes ½ pack/day (cut down from 2 packs/day). He
has had a gradual worsening in shortness of breath.
Spirometry shows FEV1/FVC 55% and FEV1 63%. His
current COPD medications are tiotropium (Spiriva)
once daily and albuterol HFA as needed.
Which one of the following is the most appropriate
course of action?
A. Add salmeterol 1 puff 2 times/day.
B. Change tiotropium to salmeterol 1 puff 2
times/day.
C. Add fluticasone 110 mcg 2 puffs 2 times/day.
D. Discontinue tiotropium and start Advair 250/50.
Case: K.R. is a 60-year-old man with COPD who
smokes ½ pack/day (cut down from 2 packs/day). He
has had a gradual worsening in shortness of breath.
Spirometry shows FEV1/FVC 55% and FEV1 63%. His
current COPD medications are tiotropium (Spiriva)
once daily and albuterol HFA as needed.
Which one of the following is the most appropriate
course of action?
A. Add salmeterol 1 puff 2 times/day.
B. Change tiotropium to salmeterol 1 puff 2
times/day.
C. Add fluticasone 110 mcg 2 puffs 2 times/day.
D. Discontinue tiotropium and start Advair 250/50.
Case: A 60-year-old man with mild chronic obstructive
pulmonary disease (COPD) has been using albuterol HFA
(ProAir) 2 puffs 4 times/day as needed. His symptoms have
worsened during the past few months, and now, he has
persistent symptoms and shortness of breath, even while
walking around his house. His spirometry showed a forced
expiratory volume in 1 second (FEV1) of 70% of predicted and
an FEV1/forced vital capacity (FEV1/FVC) of 60% of
predicted. Which one of the following
Q. Which Medications is best to initiate
A. Fluticasone (Flovent).
B. Tiotropium (Spiriva).
C. Montelukast (Singulair).
D. Omalizumab (Xolair).
Case: A 60-year-old man with mild chronic obstructive
pulmonary disease (COPD) has been using albuterol HFA
(ProAir) 2 puffs 4 times/day as needed. His symptoms have
worsened during the past few months, and now, he has
persistent symptoms and shortness of breath, even while
walking around his house. His spirometry showed a forced
expiratory volume in 1 second (FEV1) of 70% of predicted and
an FEV1/forced vital capacity (FEV1/FVC) of 60% of
predicted. Which one of the following
Q. Which Medications is best to initiate
A. Fluticasone (Flovent).
B. Tiotropium (Spiriva).
C. Montelukast (Singulair).
D. Omalizumab (Xolair).
Q. Side effects of anti cholinergic (eg ,Ipratropium
bromide , tiotropium ) include the following except
I.Dry mouth , headache , Blurred vision
II.Flushed skin , Tachycardia
III.Hypokalemia
Q. Difference between ipratopium and tiotropium
include the following
I.Tiotropium half life is longer than ipratropium
II.Ipratropium availbale as nebulization as well as
inhlation
III.Duration of Tiotropium is more than 24 hr
while ipratropium is 8 hrs
IV.All of the above
Q. Side effects of anti cholinergic (eg ,Ipratropium
bromide , tiotropium ) include the following except
I.Dry mouth , headache , Blurred vision
II.Flushed skin , Tachycardia
III.Hypokalemia
Q. Difference between ipratopium and tiotropium
include the following
I. Tiotropium half life is longer than ipratropium
II. Ipratropium availbale as nebulization as well as
inhlation
III. Duration of Tiotropium is more than 24 hr
while ipratropium is 8 hrs
IV. All of the above
Logbook Question
•GG is a 52-year-old man who complains to his physician of
increasing shortness of breath and when walking his dog.
•He has been experiencing several months of persistent, very
productive cough that is particularly bothersome when he
wakes up in the morning.
•His medical history generally is unremarkable, except for
smoking 2 packs per day of cigarettes for the past 20 years.
•On physical examination, he is noted to be a moderately
obese male who is slightly cyan- otic. Coarse breath sounds
are noted on auscultation. Spirometry results indicate a
forced expiratory capacity at 1 second (FEV 1 ) that is 65%
of predicted, which improves slightly after administration of
an inhaled short-acting -agonist. An initial diagnosis of
chronic obstructive pulmonary disease (COPD) is made.
Write SOAP note
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