CHRONIC

OBSTRUCTIVE
PULMONARY
DISEASE

Abegail A. Masangkay, M.D.

First Year Resident

June, 2019
 OBJECTIVES
General Objective
 To discuss Chronic Obstructive Pulmonary Disease
(COPD)

Specific Objectives
 To discuss the definition and criteria of COPD
 To explain the pathophysiology of COPD
 To enumerate the signs and symptoms of COPD
 To discuss the approach to a patient with COPD
 To discuss the diagnostic modalities and the
management of COPD based on clinical practice
guidelines
 OUTLINE
 Definition
 Epidemiology
 Causes
 RiskFactors
 Pathophysiology
 Manifestations
 Diagnostics
 Management
 Definition
 Common, preventable, treatable disease
 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
 Main characteristic: chronic airflow limitation
 Mixture of small airways disease (e.g.
obstructive bronchiolitis) and parenchymal
destruction (emphysema)

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Epidemiology
 4th leading cause of death in the world
 3rd leading cause of death by 2020
 Cause of more than 3 million deaths,
accounting for 6% of all deaths globally

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
COPD

Image Credits:
http://goldcopd.org
http://www.pinoycopd.com
 EPIDEMIOLOGY
Estimated Population Prevalence of Gold Stage II+ COPD*
by35%
pack years and sex, Manila, Philippines
30% 29%
25%
Never Smokers
0-10 pack years
25% 10-20 pack years
19% 19% 20+ pack years
20% 17% Total
15% 11% 12%
9% 9%
10%
7%7%8% 7% 7%
4%
5%
0%
Men Women All
* Post BD FEV1/FVC <70% and post BD FEV1 <80%
 Causes
 Tobacco smoke
 Indoor air pollution
 Occupational exposures
 Outdoor air pollution
 Genetic factors
 Age and sex
 Lung growth and development
 Socioeconomic status
 Asthma and airway hyper-reactivity
 Chronic bronchitis
 Infections

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Risk Factor
 Main risk factor: Tobacco smoking
 Others:
 Environmental exposures (biomass fuel
exposure, air pollution)
 Genetic abnormalities
 Abnormal lung development
 Accelerated aging

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
PATHOPHYSIOLOGICAL FEATURES OF COPD
Normal Emphysema
Airway
structural
changes

Alveolar destruction
Epithelial hyperplasia
Glandular hypertrophy
Goblet cell metaplasia
Airway fibrosis
PATHOPHYSIOLOGICAL FEATURES OF COPD

Muco-ciliary
dysfunction

Mucus hyper-secretion
Increased mucus viscosity
Reduced muco-ciliary transport
Mucosal damage
PATHOPHYSIOLOGICAL FEATURES OF COPD

Muco-ciliary
dysfunction

Mucus hyper-secretion
Increased mucus viscosity
Reduced muco-ciliary transport
Mucosal damage
INFLAMMATION IN ASTHMA AND COPD
COPD ASTHMA

Noxious Agent Sensitizing Agent

COPD Airway Asthmatic Airway

Inflammation Inflammation
CD8, T-lymphocytes CD4, T-lymphocytes
Macrophages, Neutrophils Eosinophils
 Manifestations
 Most common:
 dyspnea
 cough and/or
 sputum production
 Periods of acute worsening of respiratory
symptoms (exacerbations)

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Manifestations
 Concomitant chronic diseases occur
frequently in COPD patients, including
cardiovascular disease, skeletal muscle
dysfunction, metabolic syndrome,
osteoporosis, depression, anxiety, and
lung cancer

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Assessment
 Goal is to determine the:
 level of airflow limitation
 impact of disease on the patient’s
health status
 risk of future events (such as
exacerbations, hospital admissions, or
death), in order to guide therapy

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Assessment

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Assessment

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Diagnostics
 Spirometry:
 most reproducible and objective
measurement of airflow limitation
 required to make the diagnosis
 FEV1/FVC < 0.70 confirms the
presence of persistent airflow
limitation.

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Diagnostics
 Alpha-1 antitrypsin deficiency (AATD)
screening:
 WHO recommends that all patients with a
diagnosis of COPD should be screened
once especially in areas with high AATD
prevalence
 A low concentration (< 20% normal) is
highly suggestive of homozygous
deficiency
 Family members should also be screened

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Key Points
 Smoking cessation is key
 The effectiveness and safety of e-
cigarettes as a smoking cessation aid is
uncertain at present.
 Pharmacological therapy can reduce
COPD symptoms, reduce the frequency
and severity of exacerbations, and
improve health status and exercise
tolerance.

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Key Points
 Inhaler technique needs to be assessed regularly
 Influenza vaccination decreases the incidence of
lower respiratory tract infections
 Pneumococcal vaccination decreases lower
respiratory tract infections
 Pulmonary rehabilitation improves symptoms,
quality of life, and physical and emotional
participation in everyday activities.
 In patients with severe resting chronic hypoxemia,
long-term oxygen therapy improves survival

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Key Points
 In patients with stable COPD and resting or exercise-
induced moderate desaturation, long-term oxygen
treatment should not be prescribed routinely
 In patients with severe chronic hypercapnia and a
history of hospitalization for acute respiratory failure,
long-term non-invasive ventilation may decrease
mortality and prevent re-hospitalization
 In select patients with advanced emphysema
refractory to optimized medical care, surgical or
bronchoscopic interventional treatments may be
beneficial
 Palliative approaches are effective in controlling
symptoms in advanced COPD

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Smoking Cessation
 Has the greatest capacity to influence
the natural history of COPD
 Ask- Advise- Assess- Assist- Arrange
 Pharmacotherapy and nicotine
replacement reliably increase long-term
smoking abstinence rates
 Legislative smoking bans and counselling,
delivered by healthcare professionals
improve quit rates

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Treating Tobacco Use and
Dependence
 Three types of counseling have been
found to be effective: practical
counseling, social support of family and
friends as part of treatment, and social
support arranged outside of treatment
 First-line pharmacotherapies for tobacco
dependence: varenicline, bupropion
sustained release, nicotine gum, nicotine
inhaler, nicotine nasal spray and nicotine
patch
SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Vaccination
 Influenza vaccination reduces serious illness
and death in COPD patients
 PPSV23 has been shown to reduce the
incidence of community-acquired
pneumonia in COPD patients aged <65 years
with an FEV1 <40% predicted and in those
with comorbidities
 PCV13 has demonstrated significant efficacy
in reducing bacteremia and serious invasive
pneumococcal disease.

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Treatment

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the
Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Treatment

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Pharmacologic Therapy
A. Bronchodilators
 Increase FEV1 and/or change other
spirometric variables
 Most often given on a regular basis to
prevent or reduce symptoms.
 Toxicity is also dose-related
 Use of short acting bronchodilators on a
regular basis is NOT generally
recommended.
SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Pharmacologic Therapy
1. Beta2 agonists
 Relaxes airway smooth muscle by stimulating
beta2- adrenergic receptors  increases cyclic
AMP  functional antagonism to
bronchoconstriction
 The effect of SABAs usually wears off within 4 to 6
hours
 For single-dose, as-needed use in COPD, there
appears to be no advantage in routinely using
levalbuterol over conventional bronchodilators
 LABAs show duration of action of 12 or more hours
and do not preclude additional benefit from as-
needed SABA therapy
SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Pharmacologic Therapy
1. Beta2 agonists
 Formoterol and salmeterol are twice-daily LABAs
that significantly improve FEV1 and lung volumes,
dyspnea, health status, exacerbation rate and
number of hospitalizations, but have no effect on
mortality or rate of decline of lung function.
 Indacaterol is a once daily LABA that improves
breathlessness, health status and exacerbation
rate. Some patients experience cough following
the inhalation of indacaterol.
 Oladaterol and vilanterol are additional once
daily LABAs that improve lung function and
symptoms.
SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Pharmacologic Therapy
1. Beta2 agonists
 Adverse effects include:
 Resting sinus tachycardia
 Cardiac rhythm disturbances
 Somatic tremor
 Hypokalemia (especially with thiazide)

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Pharmacologic Therapy
B. Antimuscarinic drugs
 Block the bronchoconstrictor effects of acetylcholine
on M3 muscarinic receptors expressed in airway
smooth muscle
 SAMAs namely ipratropium and oxitropium, also
block the inhibitory neuronal receptor M2, which
potentially can cause vagally induced
bronchoconstriction
 LAMAs, such as tiotropium, aclidinium,
glycopyrronium bromide and umeclidinium have
prolonged binding to M3 muscarinic receptors, with
faster dissociation from M2 muscarinic receptors, thus
prolonging the duration of bronchodilator effect

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Pharmacologic Therapy
B. Antimuscarinic drugs
 Ipratropium, a short acting muscarinic
antagonist, alone provided small benefits
over short-acting beta2-agonist in terms
of lung function, health status and
requirement for oral steroids
 Clinical trials have shown a greater effect
on exacerbation rates for LAMA treatment
(tiotropium) versus LABA treatment.

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Pharmacologic Therapy
B. Antimuscarinic drugs
 Adverse effects include:
 Dryness of mouth
 Bitter, metallic taste (Ipatropium)
 Cardiovascular events

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Pharmacologic Therapy
C. Methylxanthines
 Controversy remains about the exact effects of
xanthine derivatives.
 Theophylline, the most commonly used
methylxanthine, is metabolized by cytochrome
P450 mixed function oxidases
 Addition of theophylline to salmeterol produces a
greater improvement in FEV1 and breathlessness
than salmeterol alone
 Therapeutic ratio is small and most of the benefit
occurs only when near-toxic doses are given

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Pharmacologic Therapy
D. Combination Bronchodilator Therapy
 Increase the degree of bronchodilation with a lower risk of
side-effects compared to increasing the dose of a single
bronchodilator
 Superior compared to either medication alone in improving
FEV1 and symptoms
 Study revealed that a combination LABA/LAMA decreased
exacerbations to a greater extent than an ICS/LABA
combination
 However, another study in a population with high
exacerbation risk (≥ 2 exacerbations and/or 1
hospitalization in the previous year) reported that ICS/LABA
decreased exacerbations to a greater extent than an
LABA/LAMA combination at higher blood eosinophil
concentrations

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
E. Anti-inflammatory Agents

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Pharmacologic Therapy
F. Inhaled Corticosteroids (ICS)
 COPD-associated inflammation has limited
responsiveness to corticosteroids
 Regular treatment increase risk for pneumonia
 Regular treatment with ICS alone does not modify
the long-term decline of FEV1 nor mortality in
patients with COPD
 In the TORCH trial, a trend toward higher mortality
was observed for patients treated with fluticasone
propionate alone compared to those receiving
placebo or salmeterol plus fluticasone propionate
combination

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Pharmacologic Therapy
F. Inhaled Corticosteroids (ICS)
 ICS + LABA is more effective than either
component alone in improving lung function,
health status and reducing exacerbations
 The magnitude of the effect of ICS (added on top
of regular maintenance bronchodilator treatment)
in preventing future exacerbations can be
predicted by blood eosinophil counts
 Effect of ICS containing regimens (ICS/LAMA/LABA
and ICS/LABA vs LABA/LAMA) is higher in patients
with high exacerbation risk (≥ 2 exacerbations and
/ or 1 hospitalization in the previous year)

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Pharmacologic Therapy
F. Inhaled Corticosteroids (ICS)
 Adverse effects include:
 Oral candidiasis
 Hoarse voice
 Skin bruising
 Pneumonia

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Pharmacologic Therapy
G. Triple Inhaled Therapy
 LABA + LAMA + ICS
 Single inhaler triple therapy had greater
clinical benefits compared to tiotropium
in patients with symptomatic COPD, FEV1
< 50%, and a history of exacerbations
 Single-inhaler triple therapy is more
beneficial compared with LABA/LAMA
combination therapy

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Pharmacologic Therapy
H. Oral Glucocorticoids
 May cause:
 Steroid myopathy  muscle weakness,
decreased functionality and respiratory
failure
 Plays a role in the acute management of
exacerbations, they have no role in the
chronic daily treatment in COPD because of
a lack of benefit balanced against a high
rate of systemic complications.

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Pharmacologic Therapy
I. Phosphodiesterase-4 (PDE4) inhibitors
 Reduces inflammation by inhibiting the
breakdown of intracellular cyclic AMP
 Roflumilast is a once daily oral medication
with no direct bronchodilator activity thus,
added to long-acting bronchodilators
 Effects greater in patients with a prior
history of hospitalization for an acute
exacerbation

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Pharmacologic Therapy
I. Phosphodiesterase-4 (PDE4) inhibitors
 Adverse effects include:
 Diarrhea
 Nausea
 Reduced appetite
 Weight loss
 Abdominal pain
 Sleep disturbance
 Headache.
 Depression.

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Pharmacologic Therapy
J. Antibiotics
 May reduce exacerbation rate
 Azithromycin (250 mg/day or 500 mg
three times per week) or Erythromycin
(500 mg two times per day) for one year
in patients prone to exacerbations
reduced the risk of exacerbations
compared to usual care.

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Pharmacologic Therapy
K. Mucolytic (mucokinetics,
mucoregulators) and antioxidant agents
(NAC, carbocysteine)
 In COPD patients not receiving inhaled
corticosteroids, regular treatment with
mucolytics such as erdosteine,
carbocysteine and N-acetylcysteine may
reduce exacerbations and modestly
improve health status.
SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Pharmacologic Therapy
L. Others
 Apha.-1 Antitrypsin Augmentation Therapy
 IV augmentation therapy may slow down
the progression of emphysema
 Antitussives
 No conclusive evidence regarding
benefits
 Vasodilators
 Do not improve outcomes
 May worsen oxygenation

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
Pharmacologic Therapy

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
Rehabilitation, Education and
Self-management
A. Pulmonary Rehabilitation
 A comprehensive intervention based on thorough
patient assessment followed by patient-tailored
therapies that include, but are not limited to,
exercise training, education, self-management
intervention aiming at behavior change, designed
to improve the physical and psychological
condition of people with chronic respiratory
disease and to promote the long-term adherence
to health-enhancing behaviors.
 Reduces hospitalization among patients who have
has a recent exacerbation
SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
Rehabilitation, Education and
Self-management
B. Education and Self-management
 Education alone has not been shown to
be effective
 Self-management intervention with
communication with a health care
professional improves health status and
decreases hospitalizations and
emergency department visits

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
Rehabilitation, Education and
Self-management
C. Integrated Case Program
 No demonstrated benefits at this time

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Supportive, Palliative, End-of-
life and Hospice Care
A. Symptom Control and Palliative Care
 Opiates, neuromuscular electrical stimulation
(NMES), oxygen and fans blowing are on to
the face can relieve breathlessness
 In malnourished patients, nutritional
supplementation may improve respiratory
muscle strength and overall health status
 Fatigue can be improved by self-
management education, pulmonary
rehabilitation, nutritional support and mind-
body intervention

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Other Treatments
A. Oxygen Therapy
 Key component of hospital treatment of an
exacerbation
 Supplemental oxygen should be titrated to
improve the patient’s hypoxemia with a target
saturation of 88-92%
 Blood gases should be checked frequently Venturi
masks (high-flow devices) offer more accurate
and controlled delivery of oxygen than do nasal
prongs high-flow oxygen therapy by nasal
cannula (HFNC) may be an alternative to
standard oxygen therapy or noninvasive positive
pressure ventilation
SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Other Treatments
B. Ventilatory Support
 Noninvasive ventilation (NIV) in the form of
noninvasive positive pressure ventilation
(NPPV) is the standard of care for decreasing
morbidity and mortality in patients
hospitalized with an exacerbation of COPD
and acute respiratory failure
 In patients with both COPD and obstructive
sleep apnea there are clear benefits
associated with the use of continuous positive
airway pressure (CPAP)

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Other Treatments

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Other Treatments
C. Surgical Interventions
 Lung volume reduction surgery (LVRS)
 A surgical procedure in which parts of the
lungs are resected to reduce hyperinflation,
making respiratory muscles more effective
pressure generators by improving their
mechanical efficiency
 Increases the elastic recoil pressure of the
lung and thus improves expiratory flow rates
and reduces exacerbations
 Improves survival in severe emphysema
patients with an upper lobe emphysema and
low post-rehabilitation exercise capacity
SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Other Treatments
C. Surgical Interventions
 Lung transplantation
 Shown to improve health status and
functional capacity but not prolong
 Bilateral lung transplantation has been
reported to provide longer survival
than single lung transplantation in
COPD patients, especially those < 60
years of age

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Other Treatments
C. Surgical Interventions
 Bullectomy
 Decreased dyspnea, improved lung
function and exercise tolerance
 Bronchoscopic Interventions

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Managing Exacerbations
Exacerbations
 Defined as an acute worsening of respiratory
symptoms that result in additional therapy
 They are classified as:
 Mild (treated with short acting
bronchodilators only, SABDs)
 Moderate (treated with SABDs plus antibiotics
and/or oral corticosteroids) or
 Severe (patient requires hospitalization or visits
the emergency room). Severe exacerbations
may also be associated with acute respiratory
failure

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
Managing Exacerbations

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Hospitalization
No respiratory failure
 Respiratory rate: 20-30 breaths per minute; no use of accessory
respiratory muscles; no changes in mental status; hypoxemia
improved with supplemental oxygen given via Venturi mask 28-
35% inspired oxygen (FiO2); no increase in PaCO2.
Acute respiratory failure – non-life-threatening:
 Respiratory rate: > 30 breaths per minute; using accessory
respiratory muscles; no change in mental status; hypoxemia
improved with supplemental oxygen via Venturi mask 25-30%
FiO2; hypercarbia i.e., PaCO2 increased compared with
baseline or elevated 50-60 mmHg.
Acute respiratory failure – life-threatening:
 Respiratory rate: > 30 breaths per minute; using accessory
respiratory muscles; acute changes in mental status; hypoxemia
not improved with supplemental oxygen via Venturi mask or
requiring FiO2 > 40%; hypercarbia i.e., PaCO2 increased
compared with baseline or elevated > 60 mmHg or the
presence of acidosis (pH ≤ 7.25)

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
 Non Pharmacologic
Management

SOURCE: Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019). Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Pulmonary Disease 2019
EBM
 MEDICAL ETHICS
 Autonomy
 Beneficence
 Non Maleficence
 REFERENCES
Global Initiative for Chronic Obstructive
Lung Disease (GOLD). (2019). Global
Strategy for the Diagnosis,
Management, and Prevention of Chronic
Obstructive Pulmonary Disease 2019
Kasper, Fauci, Haucer. 2015. Harrison’s
Principles of Internal Medicine.
Nineteenth edition