COPD

Chronic Obstructive Pulmonary

Disease

Dr.dr.Tahan P.H., SpP., DTCE., MARS

Penyakit Dalam FK-UWKS
15-06-12
Introduction
Chronic Obstructive Pulmonary Disease (COPD) is
one of the top five causes of global mortality

COPD affects 210 million people worldwide and

causes 3 million deaths annually (5% of all
deaths worldwide)1
It is predicted to become the third leading cause
of global mortality by 20302
The economic burden of COPD is high, with costs
increasing as the disease progresses
- Costs associated with severe COPD are up to 17 times
higher than those associated with mild COPD 3
- High costs are associated with treatment of
exacerbations, such as hospitalisation3
- Indirect costs include loss of productivity in the workplace
owing to symptoms3
 Worldwide Prevalence of COPD

Other Asia and islands Male/1000

Female/100
Middle Eastern Crescent
0

Latin America and Caribbean

Sub-Saharan Africa

India

Established market economies

Former Socialist economies

0 2 4 6 8 10 12

Adapted from the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary
Disease, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2005.
COPD Misdiagnosis Is Common in Women

Hypothetical Male Patient

With
COPD Symptoms
Diagnosed as COPD by
65% of physicians
65%

49%
Hypothetical Female
Patient With COPD
Diagnosed Symptoms
as COPD by
49% of physicians

COPD symptoms in women were

most commonly misdiagnosed as
asthma
Chapman KR, et al. Chest. 2001;119:1691-1695.
COPD Is an Increasingly Common Cause
of Death Worldwide

Cause of Death Rank in 2002 Rank in 2030

Ischaemic heart disease 1 1

Cerebrovascular disease 2 2

Lower respiratory infections 3 5

HIV/AIDS 4 3
COPD 5 4
Perinatal conditions 6 9
Diarrhoeal diseases 7 16
Tuberculosis 8 23

Trachea, bronchus, lung cancers 9 6

Mathers CD, et al. PLoS Med. 2006;3:2011-2030.
Road traffic accidents 10 8
 What is COPD?
Global Initiative for Chronic Obstructive Lung
Disease (GOLD) defines COPD as (2009):
a preventable and treatable disease with some
significant extrapulmonary effects that may
contribute to the severity in individual patients. Its
pulmonary component is characterised by airflow
limitation that is not fully reversible. The airflow
limitation is usually progressive and associated with
abnormal inflammatory response of the lung to
noxious particles or gases
Key points:
- COPD is preventable and treatable
- Airway limitation is not fully reversible and is usually
progressive
- Extrapulmonary (systemic) effects play a significant
role
- Associated with chronic inflammation in response to
inhaled
COPD IS CAUSED BY INHALATION OF NOXIOUS
SUBSTANCES
Mucociliary Apparatus
 COPD has pulmonary and systemic components

Inhaled substances
+
Genetic
susceptibility

Airway MucociliaryStructural Systemic

inflammation
dysfunction changes
inflammation
Airway limitation

Breathlessness Weight changes

onchitis: coughing, sputum production Co-morbidities
mphysema: hyperinflation, wheezing (e.g. diabetes,
NYC/DAXAS/10/012
WHAT IS THE ROLE OF INFLAMMATION IN
COPD?
 COPD Is a Disease Characterised
by Inflammation
Cigarette
smoke

Epithelial cells

Monocyte Macrophage Neutrophil

/Dendritic
cell
Proteases
Fibroblast
Fibrosis CD8 +

Tc
Obstructiv cell Mucus
e Emphysema hypersecre
 Chronic Inflammation plays a central role
in COPD

Smoke Pollutants
Key inflammatory cells
Neutrophils
CD8+ T-lymphocyte
Inflammation
Macrophages

Chronic inflammation
Structural changes
Systemic Bronchoconstri Acute
inflammat ction, exacerbatio
ion oedema, n
mucus,
emphysema
Airflow
limitation
om Barnes PJ, in Stockley, et al (editors), Chronic Obstructive Pulmonary Disease. Oxford, England: Blackwell Publishing; 2007:860.
NYC/DAXAS/10/012
 COPD inflammation is different from asthma
inflammation

COPD Asthma
Noxious
Neutrophil Onset Sensitising
agent agent
s Eosinophils
Inflammatory cells
CD8+ T- CD4+ T-
lymphocyte lymphocyte
s s
Macropha Mast cells
Not
ges
fully Reversi
Airflow limitation
reversi ble
ble
From the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive
Pulmonary Disease, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2009. Available from:
http://www.goldcopd.org.
NYC/DAXAS/10/012
 Airway Inflammation occurs from COPD onset and
increases with disease severity
Airways with measurable cells (%)

Neutrophi Macrophages CD8+ cells

ls
GOLD stage GOLD stage II GOLD stage
I dan III IV
apted from Hogg JC et al, 2004.
NYC/DAXAS/10/012
 How is COPD diagnosed
and managed?

NYC/DAXAS/10/012
 COPD is diagnosed based on symptoms,
risk factors and spirometry

RISK FACTORS
SYMPTOMS Tobacco
Cough Occupational
Sputum production + hazards
Shortness of breath Indoor/outdoor
pollution

Spirometry

From the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive
Pulmonary Disease, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2009. Available from:
http://www.goldcopd.org.
NYC/DAXAS/10/012
 Classification of cough
Cough is classified into acute
and chronic
and
Clinically subdivided into
productive and dry cough.
Productive cough
is present at an expectoration
rate of
30 ml/24 hours,
Classification of cough

Acute cough is defined as one

lasting less than three weeks

Chronic cough is defined as one

lasting greater than eight weeks
Acute Cough ... < 3 weeks

Differential Diagnosis

URTI : Sinusitis viral / bacterial

URTI triggering exacerbations of
Chronic Lung Disease eg Asthma;
COPD
Pneumonia
Left Ventricular Heart Failure
Foreign Body Aspiration
 INITIAL ASSESSMENT OF SEVERITY OF ACUTE ASTHMA IN
ADULTS
SYMPTOMS SEVERE AND
MILD MODERATE LIFE-THREATENING
Physical No No Yes, may have
Exhaustion paradoxical chest
wall movement
Pulse rate < 100 / min 100 120 / min > 120 / min
Central cyanosis absent May be present Likely to be
present
Wheeze variable Moderate Often quiet
intensity
Peak expiratory . 75% 50 75% < 50 %
flow
(% predicted)

Arterial Blood Test not If initial response Yes

Gas necessary is poor
 GOALS OF COPD MANAGEMENT

Relieve symptoms Improve

Improve exercise tolerance current
Improve health status control

Prevent and treat exacerbations Reduce future

Prevent disease progression risks
Prevent and treat complications
Reduce mortality
Adapted from the Global Strategy for the Diagnosis, Management, and Prevention of Chronic
Obstructive Pulmonary Disease, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2009.
Available from: http://www.goldcopd.org.
NYC/DAXAS/10/012
 Continued smoking leads to rapid decline
of FEV1
10
0
Smoked Never
regularly smoked or
FEV1 (% of value at

7 and not
5 susceptibl susceptible
e to its to smoke
age 25)

Disabili
effects
ty
5
0 Stopped at
45
Disabilit
y
2
5
Death Stopped at
0 65
2 50 75
5 Age
Adapted from Fletcher C and Peto R , 1977.
NYC/DAXAS/10/012
 What are exacerbations ?

NYC/DAXAS/10/012
 What are exacerbations?
Global Initiative for Chronic Obstructive Lung
Disease (GOLD) defines an exacerbation as:
an event in the natural course of the disease
characterized by a change in the patients
baseline dyspnea, cough, and/or sputum that
is beyond normal day-to-day variations, is
acute in onset and may warrant a change in
regular medication1
May be mild, moderate or severe in nature. More
severe exacerbations can require hospitalisation
and are associated with a prolonged recovery
period2
Commonly caused by bacterial/viral infections of
the lungs and airways1
Associated with increases in markers of
 frequent exacerbations drive disease progression

Patients with frequent exacerbations

Increased mortalit
ower quality of life
rate

Increased Increased risk of

inflammation recurrent exacerbatio

Faster disease Increased likelihood

progression of hospitalisation
Adapted from Wedzicha JA et al, 2007; Donaldson GC et al, 2006.
NYC/DAXAS/10/012
 Cough and sputum production indicate an
increased risk of exacerbations

Number of
Chronic exacerbations
3
inflammation

Chronic cough 2
and sputum
p<0.000
1 1
equent exacerbations
0
Patients WITH Patients
chronic cough WITHOUT
and sputum chronic cough
Adapted from Burgel PR et al, 2009.
NYC/DAXAS/10/012
 Definitions of Exacerbations

COPD exacerbations were classified in clinical

studies as follows:
Severe COPD exacerbation
Requiring hospitalisation and/or leading
to death
Moderate COPD exacerbation
Initiation of oral or parenteral
glucocorticosteroid therapy is required

Calverley PMA et al, 2009. Fabbri L,et al, 2009.

NYC/DAXAS/10/012
 Pulmonary and Systemic
Inflammation in Exacerbations

TRIG
GERS Viruses
Pollutants
Bacteria
Inflamed
COPD airways

EFFECT Greater
S airway
inflammatio
n Bronchoconstrictio
Systemic n
inflammation oedema, mucus
Expiratory flow
Exacerbatio limitation
Cardiovascula
Dynamic
r n
hyperinflation
Reprintedcomorbidity symptoms
from The Lancet, 370, Wedzicha JA, Seemungal TA, COPD exacerbations: defining their cause and
prevention, 786-796, Copyright 2007, with permission from Elsevier. 28
 FACTORS PRECIPITATING ACUTE
FAILURE

Sputum retention
Bronchospasm
Infection
Pneumothorax
Large bullae
Uncontrolled O2 - administration
Pulmonary embolism
Left-ventricular failure
End-stage disease
 PATHO- PHYSIOLOGY.

FACTORS AFFECTING AIR-FLOW

Mucosal edema
Hypertrophy of mucosa
Increased secretions
Increased bronchospasm
incr. Airway tortuosity
More airway turbulance
Loss of lung recoil
 PATHO-PHYSIOLOGY.contd

AIR-FLOW OBSTRUCTION

PROLONGED EXPIRATION

PULMONARY HYPERINFLATION
DUE TO AIR-TRAPPING

INCREASED WORK OF BREATHING

DYSPNOEA
 PATH-PHYSIO..CONTD

ALVEOLAR DISTORTION
AND DESTRUCTION

LOSS OF
HYPOXIA CAUSING
CAPILLARY BED
PULMONARY

VASOCONSTRICTION

PULMONARY HYPERTENSION

SECONDARY VASCULAR CHANGES

 Pharmacological treatments should be added stepwise as
copd progresses
Stage IV:
Stage III: Very Severe
Stage II: Severe FEV1/FVC<0.70
Stage I: Moderate
Mild FEV1 <30%
FEV1/FVC<0.70 FEV1/FVC<0 predicted or
FEV1/FVC<0.70 .70 FEV1 <50%
50% FEV1 <80%
FEV1 80% predicted 30% FEV1 predicted plus
predicted <50% chronic
predicted respiratory
Active reduction of risk factor(s); influenza vaccination failure
Add short-acting bronchodilator (when needed)
Add regular treatment with one or more
long-acting
bronchodilators (when Add inhaledneeded); Add
rehabilitation glucocorticosteroids if
repeated exacerbations
Add long-term
oxygen if chronic
respiratory failure
From the Global Strategy for the Diagnosis, Management, and Prevention of Chronic
Obstructive Pulmonary Disease, Global Initiative for Chronic Obstructive Lung Disease Consider surgical
(GOLD) 2009. Available from: http://www.goldcopd.org.
NYC/DAXAS/10/012
procedures
 MANAGEMENT NONINVASIVE

# BRONCHODILATORS
ROUTINELY GIVEN
HELP RESIDUAL BRONCHODILATION
AND MUCO-CILIARY CLEARANCE

[ I.V.AMINOPHYLLINE / B2-AGONIST /
IPRATROPIUM ]

CONTD
 CONSERVATIVE MANAGEMENT .contd

# ANTIBIOTICS
# STEROIDS AVOID IN ARF DUE TO
INFECTION
# OTHER
* STEAM / PHYSIOTHERAPY /
ENCOURAGE COUGH
* GENERAL HYDRATION
* DIURETICS / LOW DIGOXIN IF LVF
* HEPARIN S /C FOR D V T / PULM
EMBOLISM
 MANAGEMENT - NON CONSERVATIVE.
1. INVASIVE TECHNIQUES FOR SPUTUM
CLEARANCE
OROPHARYNGEAL / NASOPHARYNGEAL
SUCTION
NASO-PHARYNGEAL AIR-WAY
THERAPEUTIC AND DIAGNOSTIC F O B
MINI TRACHEOSTOMY/ CRICOTHYROTOMY
FOR SUCTION
ENDOTRACHEAL INTUBATION
* FOR BETTER ACCESS
* FOR VENTILATORY
SUPPORT
TRACHEOSTOMY
 Emphysema
The fourth leading cause of death in the US
34 million people in the US suffer from
emphysema
Current treatment is limited in efficacy
 Bronchoscopic Lung Volume
Reduction for Emphysema

The Concept of lung Volume Reduction

Lung volume Reduction
1. Removal of the most destroyed hyperinflated
poorly perfused areas of the lung can enhance
the
function of the remaining normal lung and
leads to func(onal and symptoma(c
improvement
2. Applicable in heterogeneous emphysema (upper
lobe predominant)
Multiple retrospective and prospective studies
reported success with surgical lung volume
reduction
 SUMMARY

COPD is a debilitating disease that presents a

huge healthcare and economic burden around
the world
The major risk factor for developing COPD is
tobacco smoking
COPD encompasses damage to the airways,
and chronic pulmonary and systemic
inflammation
The symptoms of COPD include breathlessness,
chronic cough and sputum production
 Chronic inflammation in the airways and
systemic circulation contributes to the pathology
of COPD
COPD-specific inflammation is characterised by
increased neutrophils, CD8+ T-lymphocytes and
macrophages, as well as cytokines and other
inflammatory mediators
Inflammatory processes activated in asthma are
different from COPD-specific inflammation
Chronic inflammation is present from the onset
of COPD and increases with disease progression.
Airway inflammation increases during
exacerbations
Effective COPD management should include
Exacerbations are attacks in which symptoms
increase beyond daily variations

Patients with frequent exacerbations have a

poor prognosis and increased risk of
mortality

Inflammation is increased during

exacerbations

The symptoms of chronic cough and sputum

production are associated with an increased
risk of exacerbations
 COPD is diagnosed based on medical history,
exposure to risk factors and assessment of lung
function by spirometry

GOLD guidelines recommend seven goals for

COPD management, including reducing the
frequency of exacerbations

Non-pharmacological management of COPD

includes smoking cessation

GOLD guidelines recommend stepwise addition of

pharmacological treatments based on the
 The Downward Spiral in COPD
COPD Lung
Mucous inflammation
hypersecretion Airway
Exacerbation obstruction
Continued Impaired
smoking mucous clearance
Exacerbation Submucousal gland
Alveolar hypertrophy
destruction Exacerbation
Hypoxaemia

DEATH
From the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease,
Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2008. Available from: http://www.goldcopd.org.
THANK-YOU