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Defining COPD
‘Chronic Obstructive Pulmonary Disease (COPD) is a common, preventable and treatable disease that
is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually
caused by significant exposure to noxious particles or gases’
Defining COPD
Chronic Obstructive
Pulmonary Disease
(COPD) is now the
preferred term for the
conditions in patients
with airflow limitation
previously diagnosed
as having chronic
bronchitis and
emphysema
NICE National Institute for Health and Care Excellence
Reference: NICE. Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update). June
2010. Available from www.nice.org.uk [Accessed November 2015]
Aetiology
COPD results from a gene-environment interaction
Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. Available from: http://goldcopd.org. © 2016 Global Strategy for Diagnosis, Management and Prevention of COPD all rights reserved. Use is by express license from the owner
Pathogenesis
COPD is characterised by an intense
inflammatory response by the airways
and alveoli to inhaled substances
such as tobacco smoke
Reference: Sinden NJ and Stockley RA. Thorax. 2010;65:930–6
Pathogenesis
6
Tobacco smoking produces lung inflammation in everyone yet only 20–30% of heavy smokers
develop COPD suggesting that the inflammatory response is exaggerated and amplified in
those with increased genetic predisposition or environmental risk factors
Reference: Hogg J. Airway Pathology Chapter 6. Asthma and COPD Basic Mechanisms and Clinical Management. Ed Barnes P. Academic Press 2008
Pathogenesis The inflammatory response …
… is characterised by increased numbers of
…
Neutrophils
Macrophages
T lymphocytes
in addition to increased concentrations of
Leukotrienes
Interleukins
TNF
Oxidative stress
TNF tumour necrosis factor
Reference: Sinden NJ and Stockley RA. Thorax. 2010;65:930–6
Pathological Changes
This chronic cycle of inflammatory injury and repair leads to
structural changes within the airway and alveoli
Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. Available from: http://goldcopd.org. © 2016 Global Strategy for Diagnosis, Management and Prevention of COPD all rights reserved. Use is by express license from the owner
Inflammation in Asthma v COPD
Although Asthma and COPD are both
associated with chronic inflammation of the
respiratory tract, there are differences in the
inflammatory cells involved in the two
diseases, which in turn account for differences
in symptoms and response to treatment
Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. Available from: http://goldcopd.org.
Phenotypes
The term phenotype in the field of COPD is defined as:
“A single or combination of disease attributes that describe
differences between individuals with COPD”
The relative contributions of
chronic bronchitis and
emphysema vary from patient to
patient (NICE 2010)
Reference: Miravitlles M, et al. Arch Bronconeumol. 2012;48:86–98; NICE. Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in
adults in primary and secondary care (partial update). June 2010
Phenotypes
What is the main pathology on the inside?
Reference: Miravitlles M, et al. Arch Bronconeumol. 2012;48:86–98
Phenotypes
Identifying the peculiarities of the different phenotypes of
COPD will allow us to implement a more personalized
treatment regime, in which the characteristics of the
patients, together with their severity will be key to
choosing the best treatment option
Reference: Miravitlles M, et al. Arch Bronconeumol. 2012;48:86–98
Matching Pathology to Symptoms C
hro
nic
Bro
nchitis
Main symptom typically excessive phlegm production
Typically reports phlegm production worse in the mornings but reduces as the day goes on
Typically reports a history of frequent chest infections
‘Scooped’ out
appearance
on spirometry
Reference: Miravitlles M, et al. Arch Bronconeumol. 2012;48:86–98
Matching Pathology to Symptoms E
mphysem
a Main symptom typically breathlessness
Typically does not report excessive phlegm production
Typically does not report a history of frequent chest infections
‘Steeple’
appearance on
spirometry
Reference: Miravitlles M, et al. Arch Bronconeumol. 2012;48:86–98
Multiple symptoms of COPD have a real impact on patient well-
being
SYMPTOMS1–4
Shortness of breath
Cough
Wheezing
Chest tightness
Sputum production
Worse in morning
Fatigue
Reference:
1. Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. Available from: http://goldcopd.org. [date last accessed
July 2017]2. O'Donnell DE. Eur Respir Rev. 2006;15:37–41; 3. Rennard S, et al. Eur Respir J. 2002;20:799–805; 4. Kessler R, et al. Eur Respir J. 2011;37:264–72; 5. Cleland JA, et al. Fam Pract.
2007;24:217–23
IMPACT ON WELL-BEING1–5
Activity/exercise limitation
Anxiety and depression
Apprehension about future events
Lack of confidence about steps to take action
Risk of increasing social isolation
Loss of independence
The FEV1
• Severity According to FEV1 as a % of predicted
• > 80%
• Mild
• 50–80%
• Moderate
• 30–50%
• Severe
• < 30%
• Very severe
Management Goals
1. Reduce symptoms
2. Reduce frequency and severity of acute exacerbations
3. Improve health status and exercise tolerance
References: NICE. Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary secondary care (partial update). June 2010; Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. Available from: http://goldcopd.org. © 2016 Global Strategy for Diagnosis, Management and Prevention of COPD all rights reserved. Use is by express license from the owner.
Smoking Cessation
Smoking cessation is the key intervention for all
COPD patients who continue to smoke
References: NICE. Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary & secondary care (partial update) June 2010 Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. Available from: http://goldcopd.org. © 2016 Global Strategy for Diagnosis, Management and Prevention of COPD all rights reserved. Use is by express license from the owner
References: NICE. Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary & secondary care (partial update). June 2010 Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. Available from: http://goldcopd.org. © 2016 Global Strategy for Diagnosis, Management and Prevention of COPD all rights reserved. Use is by express license from the owner
Pulmonary Rehabilitation
All COPD patients appear to benefit from rehabilitation and
maintenance of physical activity, improving their exercise tolerance
and experiencing decreased dyspnoea and fatigue
Vaccination
Pneumococcal vaccination and an annual influenza vaccine
should be offered to all patients with COPD
References: NICE. Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary & secondary care (partial update). June 2010 Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. Available from: http://goldcopd.org. © 2016 Global Strategy for Diagnosis, Management and Prevention of COPD all rights reserved. Use is by express license from the owner
Aim of pharmacologic therapy in COPD
Reduce symptoms
Reduce frequency
and
severity
of
exacerbations
Improve health
status and
exercise tolerance
Reference: Global initiative for chronic Obstructive Lung Disease (GOLD 2017). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Updated 2016. Last accessed April 2017. http://goldcopd.org/gold-reports/
There are 2 main groups of medication that are used in the management of
COPD
Bronchodilators Corticosteroids
Pharmacology
29
References: Asthma and COPD: Basic Mechanisms and Clinical Management. 2nd Ed Peter Barnes Academic Press 2008; Lippincott’s Illustrated Reviews: Pharmacology 5th
edition, Harvey et al 2014; Basic and Clinical Pharmacology 12th edition Katzung et al 2012 LANGE basic; Sparrow J 2010 Pharmacological Management of COPD in The
Management of COPD in Primary and Secondary Care Ed Lynes M&K Update
Bronchodilators • Medications that increase the FEV1 or change other
spirometric variables, usually by altering airway smooth muscle tone, are termed bronchodilators, since the improvements in expiratory flow reflect widening of the airways
Reference: Global initiative for chronic Obstructive Lung Disease (GOLD 2017). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Updated 2016. Last accessed April 2017. http://goldcopd.org/gold-reports/
Bronchodilators • Bronchodilators improve emptying of the lungs, tend to
reduce dynamic hyperinflation at rest and during exercise and improve exercise performance
Reference: Global initiative for chronic Obstructive Lung Disease (GOLD 2017). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Updated 2016. Last accessed April 2017. http://goldcopd.org/gold-reports/
Short-acting
(SABA)
Long-acting
(LABA)
Salbutamol
Terbutaline
Formoterol
Indacaterol maleate
Olodaterol
Salmeterol
Short-acting
(SAMA)
Long-acting
(LAMA)
Ipratropium bromide Aclidinium bromide▼
Glycopyrronium bromide▼
Tiotropium bromide Umeclidinium bromide▼
Bronchodilators
Beta2 agonists
Anti-
muscarinics
Reference: MIMS. Available at www.mims.co.uk / [Accessed April 2017]
Inhaled corticosteroids
The effects of inhaled corticosteroids
on pulmonary and systemic
inflammation in patients with COPD
are controversial, and their role in the
management of stable COPD is
limited to specific indications
Reference: Global initiative for chronic Obstructive Lung Disease (GOLD 2017). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Updated 2016. Last accessed April 2017. http://goldcopd.org/gold-reports/
Inhaled corticosteroids
• Long-term treatment with inhaled corticosteroids is recommended for patients with severe and very severe COPD and frequent exacerbations that are not adequately controlled by long-acting bronchodilators
– Frequent exacerbations not adequately controlled by Long Acting Bronchodilators (≥2 per year) or
– ≥1 hospitalisation for exacerbation
Reference: Global initiative for chronic Obstructive Lung Disease (GOLD 2017). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Updated 2016. Last accessed April 2017. http://goldcopd.org/gold-reports/
Inhaled corticosteroids indications
• Increasing evidence suggests that patients with certain COPD phenotypes appear to benefit from ICS treatment including patients with:
• Asthma COPD Overlap Syndrome (ACOS)
• Frequent exacerbations
• Eosinophilia
Reference: Ernst P. et al. Eur Resp J. 2015;45:525–37