(Chronic Obstructive (Chronic Obstructive Pulmonary Disease)Pulmonary Disease)

lobal Initiative for

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lobal Initiative for

Chronic

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isease

G O

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LDNovember 19, 2006World COPD Day, Kyoto Japan

What is chronic obstructive What is chronic obstructive pulmonary disease (COPD)?pulmonary disease (COPD)?

►Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease (COPD) is a disease state characterized by (COPD) is a disease state characterized by airflow limitation that is not fully reversible.airflow limitation that is not fully reversible.

►The airflow limitation is usually both The airflow limitation is usually both progressive and associated with an progressive and associated with an abnormal inflammatory response of the abnormal inflammatory response of the lung to noxious particles or gases.lung to noxious particles or gases.

►This definition does not use the terms This definition does not use the terms chronic bronchitis and emphysema* and chronic bronchitis and emphysema* and excludes asthma (reversible airflow excludes asthma (reversible airflow limitation).limitation).

Definition of COPD

Chronic Obstructive Pulmonary Disease (COPD) is a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by airflow limitation that is not fully reversible.

Its pulmonary component is characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases.

Definisi PPOK :Definisi PPOK :

►Adalah penyakit Adalah penyakit paru yang dapat dicegah paru yang dapat dicegah dan diobatidan diobati, ditandai oleh hambatan , ditandai oleh hambatan aliran udara yang tidak sepenuhnya aliran udara yang tidak sepenuhnya reversibel, bersifat progresif dan reversibel, bersifat progresif dan berhubungan dengan respons inflamasi berhubungan dengan respons inflamasi paru terhadap partikel atau gas yang paru terhadap partikel atau gas yang beracun / berbahaya, beracun / berbahaya, disertai efek disertai efek ekstraparu yang berkontribusi terhadap ekstraparu yang berkontribusi terhadap derajat berat penyakitderajat berat penyakit. (PDPI Revisi Juli . (PDPI Revisi Juli 2010)2010)

►Chronic bronchitis, defined as the Chronic bronchitis, defined as the presence of cough and sputum presence of cough and sputum production for at least 3 months in each production for at least 3 months in each consecutive years, is not necessarily consecutive years, is not necessarily associated with airflow limitation. associated with airflow limitation.

►Emphysema, defined as destruction of Emphysema, defined as destruction of the alveoli, is pathological term that is the alveoli, is pathological term that is sometimes (incorectly) used clinically.sometimes (incorectly) used clinically.

► Symptoms of COPD include:Symptoms of COPD include: Cough Cough Sputum productionSputum production Dyspnea on exertionDyspnea on exertion

Episodes of acute worsening of these Episodes of acute worsening of these symptoms often occursymptoms often occur

Chronic cough and sputum production often Chronic cough and sputum production often precede the development of airflow precede the development of airflow limitation by many years, although not all limitation by many years, although not all individuals with cough and sputum individuals with cough and sputum production go on to develop COPD.production go on to develop COPD.

Risk factors:Risk factors:What causes COPD?What causes COPD?

Tobacco smoke Tobacco smoke :: The most important risk factor The most important risk factor for COPD is cigarette smoking. Pipe, cigar, and for COPD is cigarette smoking. Pipe, cigar, and other types of tobacco smoking popular in other types of tobacco smoking popular in many countries are also risk factors for COPD.many countries are also risk factors for COPD.

Other documented causes of COPD include:Other documented causes of COPD include: Occupational dust and chemicals Occupational dust and chemicals (vapors, irritants, (vapors, irritants,

and fumes) when the exposures are sufficiently and fumes) when the exposures are sufficiently intense or prolonged.intense or prolonged.

Indoor airIndoor air pollution pollution from biomass fuel used for from biomass fuel used for cooking and heating in poorly vented dwelings.cooking and heating in poorly vented dwelings.

Outdoor air pollutionsOutdoor air pollutions, adds to the lungs’ total , adds to the lungs’ total burden of inhaled particles, although its specific role burden of inhaled particles, although its specific role in causing COPD is not well understood.in causing COPD is not well understood.

Passive exposure to cigarette smokePassive exposure to cigarette smoke also contributes to respiratory also contributes to respiratory symptoms and COPDsymptoms and COPD

Respiratory infections in early Respiratory infections in early childhood childhood are associated with reduced are associated with reduced lung function and increased lung function and increased respiratory symptoms in adulthood.respiratory symptoms in adulthood.

Risk Factors for COPD

NutritionNutrition

InfectionsInfections

Socio-Socio-economic economic statusstatus

Aging PopulationsAging Populations

SYMPTOMScoughcough

sputumsputumshortness of breathshortness of breath

EXPOSURE TO RISKFACTORS

tobaccotobaccooccupationoccupation

indoor/outdoor pollutionindoor/outdoor pollution

SPIROMETRYSPIROMETRY

Diagnosis of COPDDiagnosis of COPD

Diagnosing COPDDiagnosing COPD

A diagnosis of COPD should be A diagnosis of COPD should be considered in any individual who considered in any individual who presents characteristic symptoms and presents characteristic symptoms and a history of exposure to risk factors for a history of exposure to risk factors for the disease, especially cigarette the disease, especially cigarette smoking (figure 1)smoking (figure 1)

Figure 1: Key indicators for considering a COPD Figure 1: Key indicators for considering a COPD diagnosisdiagnosis

► Chronic cough : Chronic cough : Present intermittently or every day.Present intermittently or every day.Often present throughout the day; seldom only Often present throughout the day; seldom only nocturnalnocturnal

► Chronic sputum production:Chronic sputum production:Any pattern of chronic sputum production may Any pattern of chronic sputum production may indicate COPDindicate COPD

► Acute bronchitis:Acute bronchitis: Repeated episodesRepeated episodes► Dyspnea that is:Dyspnea that is: Progressive (worsens over time).Progressive (worsens over time).

Persistent (present every day)Persistent (present every day)Worse on exerciseWorse on exercise

Worse during respiratory infectionsWorse during respiratory infections..► History of exposure to risk factors:History of exposure to risk factors:

Tobacco smoke (including popular local preparations)Tobacco smoke (including popular local preparations)Occupational dusts and chemicals.Occupational dusts and chemicals.Smoke from home cooking and heating fuel.Smoke from home cooking and heating fuel.

The diagnosis should be confirmed by spirometry* (figure 2, The diagnosis should be confirmed by spirometry* (figure 2, page 9 and appendix I, page 24)page 9 and appendix I, page 24)

**Where spirometry is unavailable, the Where spirometry is unavailable, the diagnosis COPD should be made using all diagnosis COPD should be made using all available tools. available tools. Clinical symptoms and signs Clinical symptoms and signs (abnormal shortness of breath and increased (abnormal shortness of breath and increased forced expiratory time) can be forced expiratory time) can be used to help used to help with the diagnosiswith the diagnosis. A low peak flow is . A low peak flow is consistent with COPD but has poor specificity consistent with COPD but has poor specificity since it can be caused by other lung diseases since it can be caused by other lung diseases and by poor performance. In the interest of and by poor performance. In the interest of improving the accuracy of a diagnosis of improving the accuracy of a diagnosis of COPD, every effort should be made to COPD, every effort should be made to provide access to standardized spirometry.provide access to standardized spirometry.

When performing spirometry, measure:When performing spirometry, measure:► FForced orced VVital ital CCapacity (FVC) and apacity (FVC) and ► FForced orced EExpiratory xpiratory VVolume in one second olume in one second

(FEV(FEV11))

Calculate the FEVCalculate the FEV11/FVC ratio/FVC ratio

Spirometric results are expressed as % Spirometric results are expressed as % PredictedPredicted using appropriate normal values using appropriate normal values for the person’s sex, age, and height.for the person’s sex, age, and height.

Patients with COPD typically Patients with COPD typically show a show a decrease in both FEVdecrease in both FEV11 and FEV and FEV11 /FVC. /FVC. The degree of spirometric abnormality The degree of spirometric abnormality generally reflects the severity of COPD. generally reflects the severity of COPD. However, both symptoms and However, both symptoms and spirometry should be considered when spirometry should be considered when developing an individualized developing an individualized management strategy for each patient.management strategy for each patient.

Classification of COPD by Classification of COPD by SeveritySeverity

Stage 0:Stage 0: At Risk – Chronic cough and sputum At Risk – Chronic cough and sputum production; lung function is still normal.production; lung function is still normal.

Stage I:Stage I: Mild COPD – Mild airflow limitation (FEVMild COPD – Mild airflow limitation (FEV11 /FVC<70% but FEV/FVC<70% but FEV11≥≥80% predicted) and usually, but 80% predicted) and usually, but not always, chronic cough and sputum production.not always, chronic cough and sputum production.

At this stage, the individual may not be aware that At this stage, the individual may not be aware that his or her lung function is abnormal.his or her lung function is abnormal.

Stage II:Stage II: Moderate COPD Moderate COPD –– Worsening airflow limitation Worsening airflow limitation ((FEVFEV11 /FVC<70% , /FVC<70% , 50%50%≤≤FEVFEV11< 80% predicted), and < 80% predicted), and usually the progression of symptoms, with shortness of usually the progression of symptoms, with shortness of breath typically developing on exertion.breath typically developing on exertion.

Stage III:Stage III: Severe COPD – Further worsening of airflow Severe COPD – Further worsening of airflow limitation (FEVlimitation (FEV11 /FVC<70%, 30% /FVC<70%, 30% ≤ ≤ FEVFEV11<50%<50% predicted), predicted), increased shortness of breath, and repeated increased shortness of breath, and repeated exacerbation which have an impact on patients’ quality exacerbation which have an impact on patients’ quality for life.for life.• Exacerbations of symptoms, which have an impact on Exacerbations of symptoms, which have an impact on

a patient’s quality of life and prognosis, are especially a patient’s quality of life and prognosis, are especially seen in patients with FEVseen in patients with FEV11 < 50% predicted. < 50% predicted.

Stage IV:Stage IV: Very Severe COPD – Severe airflow limitation Very Severe COPD – Severe airflow limitation (FEV(FEV11 /FVC<70%, FEV /FVC<70%, FEV11 < 30% predicted) or FEV < 30% predicted) or FEV11 < 50% < 50% predicted plus the presence of chronic respiratory predicted plus the presence of chronic respiratory failure. Patients may have very severe (stage IV) COPD failure. Patients may have very severe (stage IV) COPD even if the FEVeven if the FEV11 is > 30% predicted, whenever these is > 30% predicted, whenever these complications are present.complications are present.

At this stage, quality of life is very appreciably At this stage, quality of life is very appreciably impaired and exacerbations may be life-threatening.impaired and exacerbations may be life-threatening.

Classification of COPD Severity by Spirometry

Stage I: Mild FEV1/FVC < 0.70 FEV1 > 80% predicted

Stage II: Moderate FEV1/FVC < 0.70 50% < FEV1 < 80% predicted

Stage III: Severe FEV1/FVC < 0.70 30% < FEV1 < 50% predicted

Stage IV: Very Severe FEV1/FVC < 0.70 FEV1 < 30% predicted or

FEV1 < 50% predicted plus chronic respiratory failure

Differential DiagnosisDifferential Diagnosis

Figure 3: Differential Diagnosis of COPDFigure 3: Differential Diagnosis of COPDDiagnosis Diagnosis Suggestive Features*Suggestive Features*COPD COPD Onset in mid-life.Onset in mid-life.

Symptoms slowly progressive.Symptoms slowly progressive.Long smoking historyLong smoking historyDispnea during exerciseDispnea during exerciseLargely irreversible airflow limitationLargely irreversible airflow limitation

Asthma Asthma Onset early in life (often childhood).Onset early in life (often childhood).Symptoms vary from day to daySymptoms vary from day to daySymptoms at night/early morningSymptoms at night/early morningAllergy, rhinitis, and/or eczema also present.Allergy, rhinitis, and/or eczema also present.Largely reversible airflow limitation.Largely reversible airflow limitation.

Congestive heart failure Congestive heart failure Fine basilar crackles on auscultationFine basilar crackles on auscultationChest X-ray show dilated heart, pulmonary Chest X-ray show dilated heart, pulmonary edema. edema. Pulmonary function tests indicate volume Pulmonary function tests indicate volume restriction, not airflow limitation.restriction, not airflow limitation.

Bronchiectasis Bronchiectasis Large volumes of purulent sputum.Large volumes of purulent sputum.Commonly associated with bacterial infection.Commonly associated with bacterial infection.Coarse crackles/clubbing on auscultation.Coarse crackles/clubbing on auscultation.Chest X-ray/CT show bronchial dilation, bronchial Chest X-ray/CT show bronchial dilation, bronchial wall thickening.wall thickening.

Tuberculosis Tuberculosis Onset all ages Onset all ages Chest X-ray show lung infiltrate or nodular Chest X-ray show lung infiltrate or nodular lesionslesionsMicrobiological confirmationMicrobiological confirmationHigh local prevalence of tuberculosisHigh local prevalence of tuberculosis

• Relieve symptoms • Prevent disease progression• Improve exercise tolerance• Improve health status• Prevent and treat complications• Prevent and treat exacerbations• Reduce mortalityCessation of cigarette smoking should be included as a

goal throughout the management program.

GOALS of COPD MANAGEMENTVARYING EMPHASIS WITH DIFFERING SEVERITY

Four Components of Care

Assess and Monitor Disease

Reduce Risk Factors

Manage Stable COPD

Manage Exacerbations

IV: Very Severe III: Severe II: Moderate I: Mild

Therapy at Each Stage of COPDTherapy at Each Stage of COPD

• FEV1/FVC < 70%

• FEV1 > 80% predicted

• FEV1/FVC < 70%

• 50% < FEV1 < 80%

predicted

• FEV1/FVC < 70%

• 30% < FEV1 < 50% predicted

FEV1/FVC < 70%

• FEV1 < 30% predicted

or FEV1 < 50% predicted plus chronic respiratory failure

Add regular treatment with one or more long-acting bronchodilators (when needed); Add rehabilitation

Add inhaled glucocorticosteroids if repeated exacerbations

Active reduction of risk factor(s); influenza vaccinationAdd short-acting bronchodilator (when needed)

Add long term oxygen if chronic respiratory failure. Consider surgical treatments

Regular nebulized bronchodilator therapy for a stable patient Regular nebulized bronchodilator therapy for a stable patient is not appropriate is not appropriate unless it has been shown to be better unless it has been shown to be better than conventional doses by metered dose inhaler.than conventional doses by metered dose inhaler.

Glucocorticosteroids:Glucocorticosteroids: Regular treatment with inhaled Regular treatment with inhaled glucocorticosteroids is only appropriate for patients with:glucocorticosteroids is only appropriate for patients with: Symptomatic improvement and a documented spirometric Symptomatic improvement and a documented spirometric

response to inhaled glucocorticosteroids or.response to inhaled glucocorticosteroids or. An FEVAn FEV11 <50% predicted and repeated exacerbations (for <50% predicted and repeated exacerbations (for

example, 3 in the last three years).example, 3 in the last three years).

Prolonged treatment with inhaled glucocorticosteroids may Prolonged treatment with inhaled glucocorticosteroids may relieve symptoms in this carefully selected group of relieve symptoms in this carefully selected group of patients but does not modify the long-term decline in FEVpatients but does not modify the long-term decline in FEV11. . The dose-response relationships and long-term safety of The dose-response relationships and long-term safety of inhaled glucocorticosteroids in COPD are not knowninhaled glucocorticosteroids in COPD are not known. Long-. Long-term treatment with glucocorticosteroid is not term treatment with glucocorticosteroid is not recommended.recommended.

Vaccines:Vaccines: Influenza vaccines reduce serious illness and Influenza vaccines reduce serious illness and death in COPD patients by 50%. Give once (in autumn) or death in COPD patients by 50%. Give once (in autumn) or twice (in Autumn and winter) each year. There is no twice (in Autumn and winter) each year. There is no evidence for recommending the general use of pneumococal evidence for recommending the general use of pneumococal vaccine for COPD.vaccine for COPD.

AntibioticsAntibiotics:: Not recommended except for treatment of Not recommended except for treatment of infectious exacerbations and other bacterial infections.infectious exacerbations and other bacterial infections.

Mucolytic (mucokinetic, Mucoregulator) Mucolytic (mucokinetic, Mucoregulator) AgentsAgents:: Patients with viscous sputum may benefit from Patients with viscous sputum may benefit from mucolytics, but overall benefits are very small. Use not mucolytics, but overall benefits are very small. Use not recommended.recommended.

AntitusivesAntitusives:: regulator use contraindicated in stable COPD. regulator use contraindicated in stable COPD.

Respiratory stimulants:Respiratory stimulants: Not recommended for regular use. Not recommended for regular use.

Non-pharmacologic treatment:Non-pharmacologic treatment: Includes Includes rehabilitation, oxygen therapy, and surgical interventions. rehabilitation, oxygen therapy, and surgical interventions.

Rehabilitation Rehabilitation programs should include, at a minimum: programs should include, at a minimum: Exercise trainingExercise training Nutrition counselingNutrition counseling Education.Education.

Surgical Treatment:Surgical Treatment: Bullectomy and lung Bullectomy and lung transplantation may be considered in transplantation may be considered in carefully selected patients with stage IV: Very carefully selected patients with stage IV: Very severe COPD. There is currently no sufficient severe COPD. There is currently no sufficient evidence that would support the widespread evidence that would support the widespread use of lung volume reduction surgery (LVRS).use of lung volume reduction surgery (LVRS).

There is no convincing evidence that mechanical There is no convincing evidence that mechanical ventilatory support has a role in the routine ventilatory support has a role in the routine management of stable COPD.management of stable COPD.

COPD EXACERBATIONSCOPD EXACERBATIONS

► COPD exacerbations defined:COPD exacerbations defined:

““An event in the natural course of the disease An event in the natural course of the disease characterized by characterized by a change in the patient’s a change in the patient’s baseline dyspnea, cough, and/or sputum that is baseline dyspnea, cough, and/or sputum that is beyond normal beyond normal day-to-day variations, is acute in day-to-day variations, is acute in onset, and may warrant a change in regular onset, and may warrant a change in regular medication in a patient with underlying COPD.”medication in a patient with underlying COPD.”

► Antibiotics with specific adviceAntibiotics with specific advice► Non Invasive Ventilation explained and Non Invasive Ventilation explained and

prioritisedprioritised► Care at home/follow upCare at home/follow up

How to assess the severity of an exacerbationHow to assess the severity of an exacerbation

► Lung function test (may be difficult for sick to Lung function test (may be difficult for sick to perform):perform): PEF < 100 L/min of FEVPEF < 100 L/min of FEV11 < 1 L indicates a severe < 1 L indicates a severe

exacerbation.exacerbation.► Arterial blood gas measurement (in hospital)Arterial blood gas measurement (in hospital)

PaOPaO22 < 8.0 kPa (60 mmHg) and or SaO < 8.0 kPa (60 mmHg) and or SaO22<< 90 with or 90 with or without PaCO2 > 6.7 kPa (50 mmHg) when breathing without PaCO2 > 6.7 kPa (50 mmHg) when breathing room air indicates respiratory.room air indicates respiratory.

PaOPaO22 < 6.7 kPa(50 mmHg), PaCO < 6.7 kPa(50 mmHg), PaCO2 2 > 9.3 Kpa (70 > 9.3 Kpa (70 mmHg) and pH < 7.30 suggest a life-threatening mmHg) and pH < 7.30 suggest a life-threatening episode that needs close monitoring or critical episode that needs close monitoring or critical management.management.

Chets X-rayChets X-ray:: Chest radiographs (posterior/anterior Chest radiographs (posterior/anterior plus lateral identify complications such as plus lateral identify complications such as pneumonia and alternative diagnoses that can pneumonia and alternative diagnoses that can mimic the symptoms of exacerbation.mimic the symptoms of exacerbation.

EGCEGC:: Aids in the diagnosis of right ventilator Aids in the diagnosis of right ventilator hypertrophy, arrhythmias, and ischemic episodes.hypertrophy, arrhythmias, and ischemic episodes.

Other laboratory testOther laboratory test:: Sputum culture and antibiogram to identify Sputum culture and antibiogram to identify

infection if there is no response to initial infection if there is no response to initial antibiotic treatmentantibiotic treatment

Biochemical test detect electrolyte disturbance Biochemical test detect electrolyte disturbance diabetes and poor nutrition.diabetes and poor nutrition.

Home care or Hospital care for End-stage COPD Home care or Hospital care for End-stage COPD patients ?patients ?

The risk of dying from an exacerbation of COPD is closely The risk of dying from an exacerbation of COPD is closely related to the development of respiratory acidosis, the related to the development of respiratory acidosis, the presence of serious comorbidities, and the need for presence of serious comorbidities, and the need for ventilatory supportventilatory support patients lacking these features are not patients lacking these features are not at high risk of dying, but those with severe underlying at high risk of dying, but those with severe underlying COPD often require hospitalization in any case. Attempts COPD often require hospitalization in any case. Attempts at managing such patients entirely in the community at managing such patients entirely in the community have met with limited success, but returning them to their have met with limited success, but returning them to their homes with increased social support and a supervised homes with increased social support and a supervised medical care program after an initial emergency room medical care program after an initial emergency room assessment has been much more successful. However, assessment has been much more successful. However, detailed cost-benefit analyses of these approaches have detailed cost-benefit analyses of these approaches have not been reported. not been reported.

Home management Home management

Bronchodilators Bronchodilators : : Increase dose and/or frequency of Increase dose and/or frequency of existing brochodilator therapy. If not already used, add existing brochodilator therapy. If not already used, add anticholinergics until symptoms improve.anticholinergics until symptoms improve.

Glucocorticostiroids Glucocorticostiroids : : If baseline FEVIf baseline FEV11<50% <50% predicted, add 40 mg oral prednisolone per day for 10 days to predicted, add 40 mg oral prednisolone per day for 10 days to the bronchodilator regimen. Nebulized abudesonide may be the bronchodilator regimen. Nebulized abudesonide may be an alternative to oral glucocorticostiroide may be an an alternative to oral glucocorticostiroide may be an alternative to oral glucocorticostiroids in the treatment of alternative to oral glucocorticostiroids in the treatment of nonacidotic exacerbations.nonacidotic exacerbations.

Antibiotics Antibiotics :: When symptoms of breatlessness and cough When symptoms of breatlessness and cough are increased and sputum is purulent and increased in are increased and sputum is purulent and increased in volume, provide antibiotic coverage of the major bacterial volume, provide antibiotic coverage of the major bacterial pathogens invoved in exacerbations, taking into account local pathogens invoved in exacerbations, taking into account local patterns of antibiotic sensitivity. patterns of antibiotic sensitivity.

Hospital ManagementHospital ManagementPatients with the characteristic listed in Figure 7 Patients with the characteristic listed in Figure 7 should be hospitalized.indications for referral should be hospitalized.indications for referral and the management of exacerbations of COPD and the management of exacerbations of COPD in the hospital depend on local resources and in the hospital depend on local resources and the facilities of the local hospital.the facilities of the local hospital.

Figure 7: Indications for Hospital Admission for exacerbations

• Marked increased in intensity of symptoms, such as sudden development of resting dyspnea

• Severe background COPD • Onset of new physical signs (e.g.,

cyanosis, peripheral edema)

• Failure of exacerbation to respond to initial medical management.

• Significant comorbidities• Newly occurring arrhytmias• Diagnostic uncertainty • Older age• Insufficient home support

COPD ComorbiditiesCOPD Comorbidities

Comorbid heterogeneityComorbid heterogeneity Common causeCommon cause

Heart failure Heart failure Lung cancerLung cancer

ComplicatingComplicating PneumoniaPneumonia

CoincidentialCoincidential Diabetes mellitusDiabetes mellitus Arthritis hip/kneeArthritis hip/knee DepressionDepression

COPD: An Increasing Public Health Problem Worldwide

COPD is increasing in prevalence in many countries of the world

COPD is treatable and preventable

The GOLD program offers a strategy to identify patients and to treat them according to the best medications available

COPD: An Increasing Public Health Problem Worldwide COPD can be prevented by avoidance

of risk factors, the most notable being tobacco smoke

Patients with COPD have multiple other conditions (comorbidities) that must be taken into consideration

GOLD has developed a global network to raise awareness of COPD and disseminate information on diagnosis and treatment