CHRONIC OBSTRUCTIVE

PULMONARY DISEASE (COPD)

MUHAMMAD ILYAS

DEPARTMENT OF PULMONOLOGY AND RESPIRATORY MEDICINE

FACULTY OF MEDICINE HASANUDDIN UNIVERSITY
 Definition of COPD

 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.

 The airflow limitation is usually progressive and associated

with an abnormal inflammatory response of the lung to
noxious particles or gases.
 EPIDEMIOLOGY
2020
1990

Ischaemic Lower Trachea, Road traffic

heart CVD COPD Respiratory bronchus accidents
disease Infections & lung cancer
Murray CJL et al. Lancet 1997; 349:1498-1504
 Risk Factors for COPD
Genes Lung growth & development
Exposure to particles Oxidative stress
● Tobacco smoke Gender
● Occupational dusts, organic Age
and inorganic Respiratory infections
● Indoor air pollution from Socioeconomic status
heating and cooking with
Nutrition
biomass in poorly ventilated
dwellings Comorbidities
● Outdoor air pollution
Risk Factors for COPD

Nutrition

Infections

Socio-economic
status

Aging Populations
Cellular Mechanisms of COPD
 Pathogenesis and Pathophysiology
 Pathogenesis
– Tobacco smoking is the main risk factor for COPD, although
other inhaled noxious particles and gases may contribute.
– In addition to inflammation, an imbalance of proteinases and
antiproteinases in the lungs, and oxidative stress are also
important in the pathogenesis of COPD.

 Pathophysiology
– The different pathogenic mechanisms produce the pathological
changes which, in turn, give rise to the physiological
abnormalities in COPD:
• mucous hypersecretion and ciliary dysfunction,
• airflow limitation and hyperinflation,
• gas exchange abnormalities,
• pulmonary hypertension,
ERS-ATS COPD Guidelines
• systemic effects.
 Asthma COPD
Sensitizing agent Noxious agent

COPD airway inflammation

Asthmatic airway inflammation
CD8+ T-lymphocytes
CD4+ T-lymphocytes
Macrophages
Eosinophils
Neutrophils

Small airway disease Parenchymal destruction

Airway inflammation Loss of alveolar attachments
Airway remodeling Decrease of elastic recoil

Completely Completely
reversible Airflow limitation irreversible
HISTOPATHOLOGY OF ASTHMA-COPD
Differential Diagnosis
 Asthma
 CHF
 Bronchiectasis
 Tuberculosis
 Obliterative bronchiolitis
• onset younger age, nonsmokers, h/o RA or fume exposure
 Diffuse panbronchiolitis
• Male nonsmokers, chronic sinusitis, centrilobular nodular
opacities and hyperinflation
 Diagnosis of COPD
EXPOSURE TO RISK
SYMPTOMS FACTORS
cough tobacco
sputum occupation
shortness of breath
è indoor/outdoor pollution

SPIROMETRY
Spirometry: Normal and Patients
with COPD
 Spirometric classification of COPD
severity using post-bronchodilator FEV 1
 Stage I (Mild): FeV1/FVC <0.7; FEV1 80% of
predicted
 Stage II (Moderate): FEV1/FVC <0.7; FEV1 50-
<80% of predicted
 Stage III (Severe): FEV1/FVC <0.7; FEV1 30-
<50%
 Stage IV (Very severe): FEV1/FVC <0.7; FEV1
<30% or <50% but chronic respiratory failure is
present.
Four Components of COPD Management

1. Assess and monitor disease

2. Reduce risk factors
3. Manage stable COPD
 Education
 Pharmacologic
 Non-pharmacologic

4. Manage exacerbations
 GOALS OF
2
COPD TREATMENT
SHORT TERM
GLOBAL GOLD GOALS
1
SMOKING IMMEDIATE BENEFITS
CESSATION 3 RELIEF OF SYMPTOMS
[ BREATHLESSNESS ]
LONG TERM
GOALS

PREVENT DISEASE PROGRESSIVE

REDUCE EXACERBATIONS

IMPROVE QUALITY OF LIFE

IMPROVE EXERCISE TOLERANCE

REDUCE MORTALITY
 Global Strategy for Diagnosis,
Management and Prevention of COPD

Combined assessment of COPD

Patient Characteristic Spirometric Exacerbations mMRC CAT
Classification per year
Sedikit gejala , risiko
A rendah GOLD 1-2 ≤1 0-1 < 10

SYM/030/Okt12-Okt13/RD
Banyak Gejala,
B GOLD 1-2 ≤1 >2 ≥ 10
risiko rendah
sedikit gejala, risiko
C GOLD 3-4 >2 0-1 < 10
tinggi
Banyak Gejala, ≥ 10
D GOLD 3-4 >2 >2
risiko tinggi
 Global Strategy for Diagnosis, Management and Prevention of COPD
Manage Stable COPD: Pharmacologic Therapy
(Medications in each box are mentioned in alphabetical order, and therefore not necessarily in order
of preference.)

Patient Recommended Alternative choice Other Possible

First choice Treatments

SABA prn LAMA or

A or LABA or Theophylline
SAMA prn SABA and SAMA

LABA
SABA and/or SAMA
B or LAMA and LABA
Theophylline
LAMA

ICS + LABA LAMA and LABA or

SABA and/or SAMA
C or LAMA and PDE4-inh. or
Theophylline
LAMA LABA and PDE4-inh.

ICS + LABA and LAMA or

ICS + LABA Carbocysteine
ICS+LABA and PDE4-inh. or
D and/or SABA and/or SAMA
LAMA and LABA or
LAMA Theophylline
LAMA and PDE4-inh.

Source: GOLD guideline 2013

 1
RELAX 3
2 AIRWAY SMOOTH
MUSCLE DECREASED
DECREASED INFLAMMATORY
PLASMA MEDIATOR
EXUDATION ? RELEASE ?

BRONCHODILATORS
IN COPD

5 4
IMPROVE DECREASED
RESPIRATORY NEUROTRANSMITTER
MUSCLE RELEASE ?
FATIGUE ?
Aerosol Delivery Devices in the
Treatment of Asthma-COPD

 Nebulizer
 Metered-Dose Inhalers
 Spacers and Valved Holding Chambers
 Dry-Powder Inhalers
 Management of Stable COPD
Other Pharmacologic Treatments
 Antibiotics: Only used to treat infectious
exacerbations of COPD
 Antioxidant agents: No effect of n-
acetylcysteine on frequency of
exacerbations, except in patients not treated
with inhaled glucocorticosteroids
 Mucolytic agents, Antitussives, Vasodilators:
Not recommended in stable COPD
 Managing stable COPD:
Stop smoking
– Encouraging patients with COPD to stop smoking is one of the
most important components of their management

– All COPD patients still smoking, regardless of age, should be

encouraged to stop, and offered help to do so, at every
opportunity

– Record a smoking history, including pack years smoked

– Offer nicotine replacement therapy, varenicline or bupropion

(unless contraindicated) combined with a support programme
to optimise quit rates

[2004]
 Differential Diagnosis:
COPD and Asthma
COPD
• Onset in mid-life
• Symptoms slowly
progressive
• Long smoking history
• Dyspnea during exercise
• Largely irreversible airflow
limitation
ASTHMA
• 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
 ASTHMA AND COPD
Similarities
1. Asthma and COPD are diseases of chronic
inflammation of the airways that causes
airflow obstruction.
2. Shortness of breath, wheeze and cough are
symptoms experienced by both asthma and
COPD patients.
3. Viral infections and exposure to tobacco
smoke, indoor air pollution, environmental
pollution, and occupational pollution can
all cause an asthma or COPD exacerbation.
4. Asthma and COPD are both diagnosed
through the use of breathing test called
spirometry.
Difference
1. Asthma is defined as an obstruction that is
reversible, where COPD is an obstruction
that is irreversible.
2. The inflammation occurring in asthma and
COPD are different. Asthma is primarily
caused by allergies, where COPD is caused
by bacteria.
3. Asthma and COPD respond differently to
anti-inflammatory medications due to the
differences in inflammation.
4. The goal of treatment is different; asthma is
treated to suppress chronic inflammation,
where COPD is treated to reduce symptoms.
 SUMMARY
 COPD can be prevented and can be treated. And to treat the
COPD patient, we need to assess Symptoms, Degree of airflow
limitation, Risk of exacerbation, and Comorbidities
 Combined assessment of symptoms and risk of exacerbations is
the basis for management of COPD
– FEV1 < 50% and Exacerbation ≥ 2 times/year or any
hospitalization for exacerbation of COPD would put a patient in
a high risk category
– the recommended pharmacological treatments are now
categorized as “recommended first choice option”, “alternative
options” and “other options”
 Treat COPD exacerbations to minimize impact and prevent the
development of subsequent exacerbations
THANK YOU