Chronic obstructive pulmonary disease (COPD)

By Abdulrahman M Al Jahhaaf, MD, Published on June 01, 2020 - 6 min read

Case history:

A 65 y/o male had visited you in your clinic for the first time. “I can’t sleep well because of my worsening cough”, the patient complaining. You started your clinical routine and you found out, he smoked 1 pack per day for 40 years and had a chronic cough for more than 4 years and did not seek medical care. Within the past 2 months, his cough was getting progressively worse and associated with yellowish-reddish sputum. His case was also associated withdifficulty breathing on minimum physical activity.

No fever, weight loss, night sweating. < To exclude PulmonaryTB and Lung malignancy.

No GIT complaints. < To exclude GERD.

Examination findings:
tachypnoeaPursed-lip breathing + Coughing + Tripod positionLung wheeze, hyper-resonance,coarse crackles and decreased breathing sound.
No other physical signs.
DDx:

COPD

Lung malignancy

Atypical Pulmonary TB

Tests to confirm COPD:
SpirometryDiagnostic: FEV1/FVC ratio <0.70, post bronchodilatorHigh sensitivity, High specificity
Chest radiologyTo excluded other pathology And to monitor for complications, i.e PnTXVariable sensitive, low specificity
Pulse oximetryFor monitoring.High sensitivity for blood oxygenation. Not specific for COPD
Blood gasesFor monitoring, if indicated.FEV1 <35%, pulse oximetry <92%,depressed level of consciousness or acute exacerbation of COPD
alpha-1 antitrypsinIf patient is < 45 y/o
Diffusing capacity for COFor monitoring the severity of emphysema.
Staging:

Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria:

  • 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.

Management plan for COPD:

Clinical goal:

  1. maximize blood oxygenation.
  2. Reduce GOLD stage.
  3. Reduce the risk of COPD exacerbation.
  4. Reduce the risk of pneumonia.
  5. Reduce the risk of cardiac complications.

Monitoring parameters:

  • FEV1 every 1 year.
  • OPD appointment every 1-6 month per GOLD stage.
    • COPD assessment.
    • Pulse oximetry.
    • Complication assessment.
    • Risk assessment.
    • Depression.

Therapeutic approach:

NOTE: add medications as per clinical response.
1Fewer manifestation and ≤1 exacerbation last year. Give either Long OR Short-acting; Anticholinergic OR beta-2 agonist.OPD every 6 mo+Smoking cessation.

+Pulmonary rehabilitation.

+Influenza and pneumococcal Vaccination.

2More manifestation and ≤1 exacerbation last year.Give Long + Short Anticholinergic OR beta-2 agonist

+/- Oxygen therapy

+/- 2nd Long-acting Anticholinergic OR beta-2 agonist

OPD every 3 mo
3fewer manifestation and ≥2 exacerbation last year. Give Long + Short Anticholinergic OR beta-2 agonist

+/- Oxygen therapy

+/- theophylline or aminophylline

+/-2nd Long-acting Anticholinergic OR beta-2 agonist

+/-inhaled corticosteroid

OPD every 1-3 mo
4More manifestation and ≥2 exacerbation last year. Give dual Long + 1 Short AnticholinergicOR beta-2 agonist

+/-inhaled corticosteroid

+/- Oxygen therapy

+/- theophylline or aminophylline

+/-phosphodiesterase-4 inhibitor

+/-lung transplantation

OPD every month
Medication details:
Long acting anticholinergic:
Tiotropium

Powder in capsules(=18 Mcg), OD, Inhalation, long term use

Or

inhalation solution (5 Mcg), OD, Inhalation, long term use

Hvizdos KM, Goa KL. Tiotropium bromide. Drugs. 2002;62(8):1195-1205. doi:10.2165/00003495-200262080-00008

Global strategy for the diagnosis, management, and prevention of COPD

Umeclidinium

Powder: 1 metered dose (=62.5 Mcg or 55) OD, inhalation, long term use.

Hvizdos KM, Goa KL. Tiotropium bromide. Drugs. 2002;62(8):1195-1205. doi:10.2165/00003495-200262080-00008

Global strategy for the diagnosis, management, and prevention of COPD

Short acting anticholinergic:
Ipratropium

2-4 metered doses of aerosol (20 Mcg/dose), QID/PRN, inhalation, long term use

Appleton S, Jones T, Poole P, et al. Ipratropium bromide versus short acting beta-2 agonists for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2006;2006(2):CD001387. Published 2006 Apr 19. doi:10.1002/14651858.CD001387.pub2

Global strategy for the diagnosis, management, and prevention of COPD

Long beta-2 agonist:
Salmeterol

1 puff (=50 Mcg),BID, inhalation, long term use. \ \ Kardos P, Wencker M, Glaab T, Vogelmeier C. Impact of salmeterol/fluticasone propionate versus salmeterol on exacerbations in severe chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2007;175(2):144-149. doi:10.1164/rccm.200602-244OC

Keating GM, McCormack PL. Salmeterol/fluticasone propionate: a review of its use in the treatment of chronic obstructive pulmonary disease. Drugs. 2007;67(16):2383-2405. doi:10.2165/00003495-200767160-00006

Global strategy for the diagnosis, management, and prevention of COPD

Short acting beta-2 agonist:
salbutamol

1-2 puffs (1 puff= 100 Mcg), QID/PRN, inhalation, long term

Global strategy for the diagnosis, management, and prevention of COPD

Oxygen therapy

venturi mask= 4 L/min

nasal cannula= 2L/min

Indications:

theophylline or aminophylline

theophylline

300-600 mg/day, PO, QID, long term use.

Note: Start with minimum dose and titrate up every 3 days with 200mg as per clinical response, adverse effect tolerance and serum concentrations.

Serum concentrations range from 5 to 20 Mcg/mL; monitor every 6-12 months.

Global strategy for the diagnosis, management, and prevention of COPD

aminophylline hydrate

225 to 450 mg, PO, BID, long term use.

Note: Start with minimum dose and titrate up slowly as per clinical response, adverse effect tolerance and serum concentrations.

Consult a specialist for accurate usage.

Global strategy for the diagnosis, management, and prevention of COPD

inhaled corticosteroid

fluticasone furoate

100 mg,inhalation, OD, long term use.

fluticasone propionate

500 mg, inhalation, BID, long term use.

Global strategy for the diagnosis, management, and prevention of COPD

phosphodiesterase-4 inhibitor

Roflumilast

250- 500 mg, PO, OD, long term use.

Start with 500 mg and reduce to 250 mg (sub-therapeutic dose) if adverse effects were not tolerated. Increase back to 500 mg after 1 month.

Sanford M. Roflumilast: in chronic obstructive pulmonary disease [published correction appears in Drugs. 2010 Aug 20;70(12):1627]. Drugs. 2010;70(12):1615-1627. doi:10.2165/11205930-000000000-00000

Calverley PM, Rabe KF, Goehring UM, et al. Roflumilast in symptomatic chronic obstructive pulmonary disease: two randomised clinical trials [published correction appears in Lancet. 2010 Oct 2;376(9747):1146]. Lancet. 2009;374(9691):685-694. doi:10.1016/S0140-6736(09)61255-1

Martinez FJ, Rabe KF, Sethi S, et al. Effect of Roflumilast and Inhaled Corticosteroid/Long-Acting β2-Agonist on Chronic Obstructive Pulmonary Disease Exacerbations (RE(2)SPOND). A Randomized Clinical Trial. Am J Respir Crit Care Med. 2016;194(5):559-567. doi:10.1164/rccm.201607-1349OC