Update of COPD 2022_ Dr. Chandan Kumar Sheet_Calcutta Heart Clinic & Hospital .pdf

Stepwise approach to COPD

1. Update of COPD
2022
Dr. Chandan Kumar Sheet
MD (Pulmonary Medicine)
Consultant Pulmonary Medicine, Critical Care & Sleep Disorders
Calcutta Heart Clinic & Hospital
Saltlake, Kolkata

3. Overview
Introduction
Definition
Aetiology
Risk factors
Assessment
Differential diagnosis
Management

4. Introduction
3
rd
most common causes of death worldwide (GOLD 2022)
Both preventable & treatable public health challenge
COPD burden is going to increase in coming decades d/t
cont. exposure to COPD risk factors & aging of the
population.

5. Definition
COPD is a common, preventable and treatable disease that
is characterised by –
oPersistent respiratory symptoms and
oAirflow limitation that is due to airway and /or alveolar
abnormalities
oUsually caused by significant exposure to noxious
particles or gases
oInfluenced by host factors including abnormal lung
development.

6. Aetiology
Complex interplay of -
long-term exposure to noxious gases & particles,
combined with a variety of host factors including
genetics, airway hyperresponsiveness & poor lung
growth during childhood

7. Contributors to the disease pathology of COPD

8. Risk factors
Environmental
Tobacco smoking
Indoor air pollution
Occupational
Outdoor air pollution
Socio-economic status : poverty, low socio economic status
Infection: severe childhood resp. infection, TB, HIV

9. Lung growth & development : factors that affect lung growth
(LBW, resp. infection) -↑ risk
Genetic factor : α1-antitrypsin deficiency , MMP12, SOD3,
HMOX1(antioxidant), GSTMI(detoxifying)
Age & Gender :increase age & female sex –increase risk
Asthma & airway hyperresponsiveness greater decline of FEV1
Chronic bronchitis : ↑frequency of exacerbation
Risk factors
Host factors

10. Key Indicators For Considering a Diagnosis Of COPD
Age more than 40 years with the following symptoms –Consider COPD
Spirometry is must to diagnose COPD

11. Assessment of COPD
Spirometry : confirmation & grading
Grouping (ABCD) for treatment
based on symptoms : MMRC grade, COPD assessment test
(CAT) score & Exacerbation history
Presence of comorbidities & systemic effects
Composite score for prognosis

12. Spirometry
In patient with FEV1/FVC < 70%
GOLD StagingCategory FEV1
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
Classification of Airflow Limitation in COPD
(Based on Post Bronchodilator FEV1)

13. mMRC Grading

14. COPD Assessment Test (CAT)

15. ABCD Assessment tool

16. Presence of comorbidities
Cardiovascular
-HTN,
-IHD,
-Heart failure
-Arrhythmia
Osteoporosis
Anxiety, Depression
DM, metabolic syndrome
Obstructive sleep apnoea
Bronchiectasis
GERD
Lung Cancer

17. Composite score for prognosis

18. Differential Diagnosis of COPD

19. Goals for treatment of stable COPD

20. Pharmacotherapy Options for stable COPD
Bronchodilators
Methylxanthine
Anti inflammatory agents

21. Bronchodilators for stable COPD
Beta 2 agonist
-SABA
-LABA
Antimuscarinic drugs
-SAMA
-LAMA
Combined bronchodilators
-SABA+SAMA
-LABA+LAMA
-Ultra LABA + Ultra LAMA

22. SABA & LABA for stable COPD
oSalbutamol
oFormoterol
oSalmeterol
oIndacatrol
oVilanterol
DPI
DPI
MDI
NebuAvailable in India

23. SAMA & LAMA for stable COPD
Available in India
oIpratropium
oGlycopironium
oTiotropium
oUmeclidinium
DPI/MDI
Nebu
DPI
DPI/MDI

24. Combined bronchodilators for stable COPD
Available in India
oSalbutamol + Ipratropium
oFormoterol + Tiotropium
oFormoterol + Glycopironium
oIndacatrol + Glycopironium
oVilanterol + Umeclidinium
DPI /MDI /Nebu
DPI/MDI
DPI

25. BETA2 AGONISTS
Relax airway smooth muscle by stimulating beta2 adrenergic
receptor and increases cAMP
Produces functional antagonism to bronchoconstriction
ADVERSE EFFECTS
Sinus tachycardia and cardiac rhythm disturbances
Somatic tremor
hypokalemia

26. Antimuscarinic agents
Block the bronchoconstrictor effect of acetylcholine on M3 muscarinic
receptor
SAMA also block inhibitory neuronal receptor M2 which potentially causes
vagally induced bronchoconstriction
ADVERSE EFFECTS
Dryness of mouth
Urinary symptoms
Ipratropium report bitter metallic taste
Use of solutions with facemask precipitate acute glaucoma

27. BRONCHODILATORS IN STABLE COPD
Inhaled bronchodilators are the main component in stable COPD management
SOS use of SABA or SAMA improves FEV1 and symptoms
Combinations of SABA and SAMA are superior than SABA or SAMA alone
LABAs and LAMAs significantly improve lung function, dyspnea, health status, and
reduce exacerbation rates
LAMAs have a greater effect on exacerbation & hospitalizations reduction than LABA
Combination of LABA and LAMA increases FEV1, and reduces symptoms compared to
monotherapy
Combination treatment with LABA and LAMA reduces exacerbations compared to
monotherapy
Tiotropium improves the effectiveness of pulmonary rehabilitation in increasing
exercise performance .
Theophylline exerts a small bronchodilator effect in stable COPD and that is associated
with modest symptomatic benefits

28. Key points for use of bronchodilators
LABA + LAMAs are preferred over short-acting agents.
SABA or SAMA only if
-occasional dyspnea (Evidence A),
-for immediate relief of symptoms in patients already on long-acting
bronchodilators for maintenance therapy.
Patients may be started either LABA or LAMA therapy or LABA+LAMA
In patients with persistent SOB on one bronchodilator should be escalated to two
(Evidence A).
Inhaled bronchodilators are recommended over oral bronchodilators (Evidence A).
Theophylline is not recommended unless other long-term treatment bronchodilators
are unavailable or unaffordable (Evidence B).

29. Key points for inhalation of drugs
The choice of inhaler device has to be individually tailored
-patient's ability
-preference
-access
-cost
provide instructions and demonstrate the proper inhalation technique when
prescribing and re-check at each visit that

30. Methylxanthines
Act as non-selective phosphodiesterase inhibitors
causes bronchodilatation at concentration >10mg/l.
Theophylline, most commonly used methylxanthine, is metabolized by
cytochrome P450
MethylxanthinesOral InjectionDuration of Actin
AminophyllineSolution√ Variable, Up to 24 Hours
Theophylline Pill √ Variable, Up to 24 Hours
Doxofylline Pill √ Variable, Up to 24 Hours
AcebrophyllineSolutionx Variable, Up to 24 Hours

31. Adverse effects of Methylxanthines
Dose-related Toxicity, because their therapeutic ratio is small and most of the benefit
occurs only when near-toxic doses are given.
Palpitations caused by atrial and ventricular arrhythmias (which can prove fatal)
Grand mal convulsions (which can occur irrespective of prior epileptic history
Other side effects include headaches, insomnia, nausea, and heartburn, and these
may occur within the therapeutic range of serum levels of theophylline.
Significant interactions with commonly used medications such as ciprofloxacin (but not
ofloxacin), allopurinol, cimetidine (but not ranitidine), SSRI

32. Inhaled Corticosteroids
An ICS + LABA is more effective than the individual components in improving lung
function and health status and reducing exacerbations (Evidence A).
Regular treatment with ICS increases the risk of pneumonia especially in those
with severe disease (Evidence A).
Triple inhaled therapy of LABA/LAMA/ICS improves lung function, symptoms and
health status, and reduces exacerbations, compared to LABA/ICS, LABA/LAMA or
LAMA monotherapy (Evidence A).

33. Considerable Factors before ICS initiation in stable
COPD

34. ERS recommendation of ICS use

35. Combined ICS + Bronchodilators
Combinations Devices Duration of Action
Double Combination on Single Device
Formoterol / Beclomethasone DPI / MDI 12 Hours
Formoterol / Budesonide DPI / MDI 12 Hours
Formoterol / Mometasone MDI 12 Hours
Salmeterol / Fluticasone DPI / MDI 12 Hours
Vilanterol / Fluticasone DPI 24 Hours
Indacatrol / Mometasone DPI 24 Hours
Triple Combination on single device
Vilanterol / Umeclidinium / Fluticasone DPI 24 Hours
Formoterol / Glycopironium / BeclomethasoneDPI 12 Hours
Formoterol / Glycopironium / Budesonide DPI 12 Hours

36. Initial pharmacological treatment
LAMA +

37. GOLD 2022 Follow-up pharmacological treatment
Dyspnea
Exacerbations

38. PDE4 inhibitors
ReduceinflammationbyinhibitingthebreakdownofintracellularcAMP
Roflumilastisoncedailyoralmedicationwithnodirectbronchodilator
effect
Improveslungfunctions(EvidenceA)
ReducemoderatetosevereExacerbations(EvidenceA)
Adverseeffect
-Diarrhoea,nausea,lossofappetite,weightloss,abdominalpain,sleep
disturbancesandheadache

39. Oral Glucocorticosteroids
and
Long-term antibiotics
and
Mucoregulators and antioxidant agents
Long term oral glucocorticoids
-Numerous side effects (Evidence A)
-No Benefits ( Evidence C)
Long term azithromycin reduces exacerbations over 1 year ( Evidence A)
Treatment with azithromycin associated with
-increased bacterial resistance ( Evidence A)
-hearing impairments ( Evidence B)
Regular treatment with mucolytics like NAC reduces risk of exacerbations in
selected populations ( Evidence B)

40. Key points for use of other pharmacotherapy
Patients with severe hereditary alpha-1 antitrypsin deficiency and established
emphysema may be candidates for alpha-1 antitrypsin augmentation therapy
(Evidence B).
Antitussivescannot be recommended (Evidence C ).
Drugs approved for primary Pulmonary hypertension are not recommended for
COPD related PH (Evidence B).
Low-dose long acting oral and parenteral opioidsmay be considered for treating
dyspnea in severe COPD patients (Evidence B).

41. Non-pharmacological treatment
Patient GroupEssential Recommended Local Guideline
Category A oSmoking Cessation Physical ActivityoFlu Vaccine
oPneumococcal Vaccine
oPertussis Vaccine
oCOVID Vaccine
Category B, C, DoSmoking Cessation
oPulmonary Rehabilitation
Physical Activity

42. MANAGEMENT CYCLE

43. MANAGEMENT
OF STABLE
COPD

44. Asthma COPD Overlap ( ACO)

45. Diagnostic Criteria of ACO
Major Criteria Minor Criteria
1. Previous history of Asthma1. High total IgE > 100 IU
2. High Bronchodilator reversibility
(FEV1 ≥ 15 % and % ≥ 400 ml )
2. History of Atopy
3. Positive Bronchodilator
reversibility
(FEV1 ≥ 12 and % ≥ 200 ml
4. Blood Eosinophil >5%
Two Major Criteria
Or
1 major Criteria + 2 minor Criteria

46. Thank You!