COPD: Chronic Obstructive Pulmonary Disease

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“COPD & Asthma Are Not the Same”

COPD: Chronic Obstructive

Pulmonary Disease

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The Global Initiative for

Chronic Obstructive Lung Disease (GOLD) Guidelines 2007

National Heart, Lung, and Blood Institute World Health Organization

Am J Respir Crit Care Med.2007,176:532-555

New 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.

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Classification

Classification of COPD Severity by Spirometry

Stage Characteristics

I: Mild COPD - FEV1/FVC <70%

- FEV₁≥80% predicted

- With or without chronic symptoms (cough, sputum production) II: Moderate COPD - FEV1/FVC <70%

- 50% ≤FEV1 <80% predicted III: Severe COPD - FEV1/FVC <70%

- 30% ≤FEV1<50% predicted IV: Very severe COPD - FEV₁/FVC <70%

- FEV1<30% predicted or FEV1<50% predicted plus respiratory failure or clinical signs of right heart failure

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Epidemiology

• The prevalence of COPD varies but it is directly related to the prevalence of TOBACCO smoking

• The prevalence is projected to increase in the coming decades due to continued exposure to COPD risk factors

• The disease is under-recognized and under- diagnosed

Epidemiology

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Of the six leading causes of death in the United States, only COPD has been increasing

steadily since 1970

Source: Jemal A. et al. JAMA2005

In Saudi Arabia?

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• According to one report released by the executive office of the GCC Health Ministers Council, Saudi Arabia is the world’s fourth largest importer of cigarettes.

• During the year of 2004, the kingdom imported 41,000 tons of tobacco at a value of SR 1.45 billion.

COPD Prevalence in KSA (Contd.)

• The estimated number of COPD patients in KSA is somewhere between:

357 Thousands Patients

214 Thousands Patients

• The number of currently diagnosed COPD patients in KSA doesn’t exceed 45,000 patients

COPD Prevalence in KSA (Contd.)

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• Risk factors

• Burden of COPD

Risk Factors for COPD

Nutrition Nutrition Infections Infections Socio

Socio--economic economic status

status

AGING AGING GENETIC

GENETIC RISK

RISK

FACTOR

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Burden of COPD

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How many lives are lost to COPD?

• In 2000, COPD was the 4

^th

leading cause of death in the USA after heart diseases, cancer, and

cerebrovascular diseases.

• Worldwide, 3 million people die from COPD every year.

• According to WHO, COPD kills more people than cancer, and as many people as HIV/AIDS.

www.goldcopd.org

Global Burden of Disease (1990–2020)

Lower respiratory tract infections

1

Diarrhoeal diseases 2 Conditions during perinatal period

3

Unipolar major depression 4 Ischaemic heart disease 5 Cerebrovascular disease 6

Tuberculosis 7

Measles 8

Road traffic accidents 9 Congenital anomalies 10

Malaria 11

COPD 12

1 Ischaemic heart disease 2 Unipolar major depression 3 Road traffic accidents 4 Cerebrovascular disease

5 COPD

6 Lower respiratory tract infections 7 Tuberculosis

8 War

9 Diarrhoeal diseases 10 HIV

11 Conditions during prenatal period 12 Violence

1990 2020

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Projected Global Mortality From COPD

0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.5

1990 2000 2010 2020

Murray CJL, Lopez AD.

Lancet. 1997;349:1498

4.0

M o rt a li ty ( × 10 )

6

Year

Burden of COPD: Key Points

• COPD is a leading cause of morbidity and mortality worldwide and results in an economic and social burden that is both substantial and increasing.

• COPD morbidity, and mortality vary across countries and across different groups within countries.

• The burden of COPD is projected to increase in the

coming decades due to continued exposure to COPD

risk factors and the changing age structure of the

world’s population.

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• Pathology

• Pathogenesis

• Pathophysiology

Small airways

Airway inflammation Airway remodeling

Pathologic Changes in COPD

Lung Parenchyma

Inflammation

Loss of alveolar attachments elastic recoil

AIRWAY LIMITATION

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LUNG INFLAMMATION LUNG INFLAMMATION

COPD PATHOLOGY COPD PATHOLOGY

Oxidative Oxidative

stress

stress Proteinases Proteinases

Host factors Amplifying mechanisms

Source: Peter J. Barnes, MD

Pathogenesis of COPD

Pathophysiological Features of COPD

Normal COPD

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Pathophysiological Features of COPD

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Hypoxemia Hypoxemia

Pulmonary Vasoconstriction Pulmonary Vasoconstriction

Pulmonary Arterial Hypertension Pulmonary Arterial Hypertension

Right Heart Failure (Cor Pulmonale) Right Heart Failure (Cor Pulmonale)

Pulmonary Hypertension in COPD

Systemic Effects of COPD

• Increased oxidative stress and altered

circulating levels of inflammatory mediators and acute-phase proteins

• Weight loss

• Muscle wasting

• Tissue depletion

• Reduced exercise capacity

Wouters EF, et al. Chest.2002;121(suppl 5):127S-130S.

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ASTHMA ASTHMA

Sensitizing agent COPD COPD

Noxious agent

Asthmatic airway inflammation CD4+ T-lymphocytes

Eosinophils Mast calls

COPD airway inflammation CD8 + T-lymphocytes

Macrophages Neutrophils

Airflow Limitation

Completely

reversible Incompletely

reversible

How to reach the diagnosis of COPD ?

§ History

§ Physical Examination

§ Spirometry

§ Radiology

§ Others

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SYMPTOMS cough cough sputum sputum dyspnea dyspnea

EXPOSURE TO RISK FACTORS

tobacco tobacco occupation occupation

indoor/outdoor pollution indoor/outdoor pollution

SPIROMETRY SPIROMETRY

Diagnosis of COPD Diagnosis of COPD

èè

§ Chronic cough:

ü Initially in the morning.

ü Often progresses to occur throughout the day.

ü Seldom only nocturnal.

§ Sputum production:

ü Any pattern of sputum production may indicate COPD.

ü The daily volume rarely exceeds 60 ml

Diagnosis : HISTORY

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§ Dyspnea

ü Most patients seek medical attention due to dyspnea

ü Initially may be noticed only with exertion

ü It progressively worsens, persistent,

Diagnosis : HISTORY

§ Wheezing:

ü Indicates airway narrowing

ü More during expiration

§ Early stages of COPD: may have an entirely normal physical examination

Physical Examination

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More Severe Disease

§ Signs of hyperinflation ü Barrel chest,

ü Enlarged lung volumes with poor diaphragmatic excursion

§ Signs of severe airflow obstruction:

ü Use of accessory muscles of respiration

Physical Examination

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Physical Examination

§ Decreased intensity of breath and heart sounds

§ Prolonged expiratory phase

§ Wheezes

§ Central cyanosis (lips and nail beds)

§ None of these signs are specific to COPD and do not correlate very well with the severity of the disease

§ Their presence should alert the physician to the

possible diagnosis of COPD.

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Physical Examination

Advanced Disease

Signs of Right Heart Failure (Cor Pulmonale )

§ Elevated jugular venous pressures

§ Right ventricular heave or third heart sound

§ Hepatic congestion, ascites, and peripheral edema as the right ventricle decompensated as a result of chronic pulmonary hypertension

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CLINICAL PATTERNS IN SEVERE COPD

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Wayne McLaren…Former Marlboro Man

Age 30…a robust young man

Age 51…riding into the sunset

• Diagnostic Measures: SPIROMETRY