COPD

AND
ASTHMA

Christopher Worsnop

Department of Respiratory and Sleep Medicine

COPD DEFINITION

• Progressive airflow limitation that is not

fully reversible.
• Inflammation in the airways, lung
parenchyma and pulmonary vessels.
• Neutrophils, macrophages, CD 8 cells.
• Proteinase - antiproteinase imbalance.
• Oxidative stress.
COPD NAMES

• COPD = chronic obstructive pulmonary

disease
• COAD = chronic obstructive airways
disease
• COLD = chronic obstructive lung disease
• CAL = chronic airflow limitation
They all mean the same thing.
Emphysema Asthma

Airflow
obstruction
Intrinsic
airways
COPD disease
COPD DIAGNOSIS

• Consider COPD in . . .
• any smoker
→ chronic cough
→ productive cough
→ dyspnoea
Respirology
2006; 11: 9
COPD DIAGNOSIS

• Spirometry
→ is the best measure of airflow
obstruction
→ FER = forced expiratory ratio
→ FER = FEV1/FVC or FEV1/VC
using the larger of FVC or VC
→ FER < 0.7 ⇒ airflow obstruction (this
varies slightly with age)
→ a reduced FEV1 alone does not
mean airflow obstruction
→ FEV1 is used for monitoring

→ Occasionally people with emphysema

on HRCT have normal spirometry.
REVERSIBILITY WITH SPIROMETRY

• An increase in FEV1 of > 12 % (and at

least 200 ml) is likely to be due to the
bronchodilator.
• If the FEV1 returns into the normal
range, the diagnosis is likely to be
asthma.
• Reversibility does not predict
symptomatic responses to
bronchodilators.
 MANAGEMENT OF COPD

• STOP SMOKING

• MEDICATIONS

• VACCINATIONS

• PULMNARY REHABILITATION
COPDX

Confirm the diagnosis and assess

severity
Optimize function
Prevent deterioration
Develop a support network and self-
management plan
Exacerbations – manage appropriately
STOP SMOKING
 Stopping smoking
slows the decline in lung function

100 Never smoked or not

FEV1 (% of value at age 25)

susceptible to smoke

75 Smoked regularly
and susceptible to Stopped at 45
its effects
50
Disability
25 Stopped at 65

Death
0
25 50 75
Age (years)

Adapted from: Fletcher et al, Br 1977.

Stages of change

• Pre Contemplation (40% of current

smokers - not ready now)
• Contemplation (40% - ambivalent)
• Preparation
• Action
• Maintenance
Current smoking
cessation strategies

• Non - pharm. • Pharmacological

- Willpower alone - Nicotine
- Doctor’s advice replacement
- Self-help materials therapy
- Intensive counselling
- Zyban

- Quit courses
 MEDICATIONS IN COPD

• Other treatments are for control of

symptoms
→ anticholinergics - ipratropium,
tiotropium
→β 2 agonists - short or long-acting
→ theophylline - rarely used now
→ combined bronchodilators
• Reversibility on spirometry does not
predict long term symptomatic
response.
• There are poor correlations between
symptoms, lung function and
pathology.
• FEV1 is not a good way to assess
response to treatment.
• Cease if no symptomatic benefit after
a reasonable trial (6-12 weeks), or
unacceptable side effects.
Anticholinergics

• Spiriva = tiotropium
Atrovent = ipratropium

• Long-acting more convenient, and less

dyspnoea, better exercise, less exacerbations
(NTT = 14), less mortality.
• Handihaler designed for COPD.
• Side effect = dry mouth in 14 %.
β 2 agonists

• Ventolin, Airomir = salbutamol

Bricanyl = terbutaline
Serevent = salmeterol
Oxis, Foradile = eformoterol

• Short-acting for prn use.

• Long-acting for regular use – less symptoms,
more exercise, better QOL
• Less QOL with higher doses
• Side effects = tremor, tachycardia.
INHALED CORTICOSTEROIDS

• Inhaled corticosteroids
→ the type of inflammation in COPD
does not respond well to steroids.
→ Four major studies ⇒ indications are:

> documented increase in FEV1 after 6 -

12 week trial
> severe COPD (FEV1 < 50 %) with
frequent exacerbations
Why give a trial of ICS in COPD?

• Any suggestion of asthma

> history of asthma, eczema, hayfever,
allergy
> some reversibility on spirometry

• The patient is keen for more

improvement in symptoms and exercise.
Combination treatment

• Inhaled fluticasone and salmeterol

(Seretide)
• In moderate to severe COPD
(FEV1 < 60 %) it has been shown to
reduce exacerbations, improve QOL and
FEV1.
• A small reduction in mortality with p =
0.052 in the TORCH study.
Theophyllines

• Benefits less well documented.

• Narrow therapeutic window.
• Significant side effects = nausea,
dysrhythmias, seizures, death.
• Drug interactions.
• Monitor blood levels.
Oral corticosteroids

• 5 – 10 % of patients will show an increase

in FEV1 after a short course of prednisolone
½ mg/kg/day.
• It is not possible to predict those who will
respond.
• This does not predict those who will
respond to ICS.
• There is no evidence that long term
prednisolone is of any benefit, but it does
have significant side effects.
VACCINES

• Influenza vaccine - reduces mortality,

hospital admissions and exacerbations.
- it does not prevent other URTI viruses.
- local side effects only.
- it is given yearly.
• Pneumococcal vaccine - no evidence
about its use in COPD, but it seems like
a good idea.
- it is given twice 5 years apart.
PULMONARY REHABILITATION

•There is good evidence that it improves

symptoms in COPD.
• Patients need to be well motivated.
• Two main components - improving
fitness, and education.
• A course is run over 6 - 8 weeks with
twice weekly visits, but the exercise needs
to be maintained at home.
• Usually supervised by physiotherapists.
• Variable cost to the patient.
HOME OXYGEN THERAPY

• Oxygen concentrator: 2 - 4 l/min. via

nasal prongs for > 16 hours/day IF
- when at his/her best and stable
- PO2 on air at rest < 55 mmHg OR
- PO2 < 60 if evidence of hypoxic
damage, i.e. cor pulmonale, pulmonary
hypertension, polycythaemia; AND
- no cigarettes for 3 months.
• This oxygen improves mortality, and
usually has no effect on symptoms.
Portable home oxygen

• This is designed to improve symptoms

and increase exercise.
• No cigarettes for 3 months.
• SpO2 < 88 % with exercise AND
- supplemental O2 prevents this
desaturation AND
- exercise is improved.
• The patient needs to be motivated to
lug a cylinder around.
Lung Volume Reduction Surgery

• Improves symptoms
• Improves quality of life
• Improves FEV1
• ? FEV1 after 5 years
• ? symptomatic benefit after 2-4 years

• Bullectomy is a separate issue

• Consider lung transplantation

Problems with LVRS

• Peri-operative morbidity & mortality

• Local experience
• Patients’ expectations
• Long-term outlook is unknown
• What is the best technique?
• ? cost ~$20,000
 Other treatments

• Chronic antibiotics - no benefit

• Mucolytics - minimal benefit
• Non-invasive ventilation – unproven

• Self management plans – no proven benefit

ACUTE COPD EXACERBATION

• The cause is often unknown

• Respiratory infections - bacterial, viral
- URTI, bronchitis, pneumonia
• Heart failure, arrhythmia
• Systemic infection, fever
• Anaemia
• Anxiety
• Anything that increases metabolic rate
Features of a COPD exacerbation

• Anthonisen criteria:
- increased dyspnoea
- increased sputum production
- sputum becoming discoloured
• Antibiotics to cover Strep and Gram
negatives have been shown to be useful
if all three criteria are present.
• CXR to look for pneumonia, and cover
atypical bacteria if there is pneumonia.
MANAGEMENT OF AN EXACERBATION

• Supplemental O2 - aim to keep SpO2 >

90 %, and/or PaO2 > 60 mmHg
- do not give high doses of O2 too
quickly
- consider the O2 concentration, flow rate
and patient’s inspiratory flow rate
• A high dose of O2 in COPD with
chronic hypercapnia may lead to a
further rise in PCO2 due to :
 Haldane effect – O2 displacing CO2
from Hb. .
 Worsening V/Q mismatch due to high
PO2 in parts of the lung overcoming
hypoxic vasoconstriction.
 Reduced ventilatory drive.
• Bronchodilators - anticholinergics and
β agonists
2
• Corticosteroids - inhaled, oral,
intravenous
- some benefit, but not great and must be
balanced with side effects.
• Antibiotics - if there is evidence of
infection
• Physical activity - to prevent
deconditioning
• Non-invasive ventilation - BiPAP, VPAP
 ASTHMA DEFINITION

• Variable airflow obstruction.

• Chronic inflammation of the airways
with bronchial hyper-responsiveness.
• Eosinophils, mast cells, CD 4 cells.
• Airway remodeling can occur and
may lead to fixed airflow obstruction.
ASTHMA DIAGNOSIS
• Variability over time:
→ > 12 - 15 % variation in FEV1
→ > 20 % variation in peak flows

• Variability with bronchodilator:

→ > 12 - 15 % increase in FEV1
→ > 20 % increase in peak flows

• Variability after challenge:

→ methacholine, histamine, exercise,
MANAGEMENT OF ASTHMA
www.nationalasthma.org.au
Goals of asthma management

→ reduce mortality
→ eliminate symptoms
→ maximize lung function
→ eliminate hyper-responsiveness
→ prevent airway remodeling
ASTHMA DIAGNOSIS
• There is no ‘gold standard' for the
diagnosis of asthma.

• The diagnosis of asthma is based on:

history
physical examination
supportive diagnostic testing, including
spirometry.
Establish the diagnosis

• Variability over time:

→ > 12 - 15 % variation in FEV1
→ > 20 % variation in peak flows
• Variability with bronchodilator:
→ > 12 % (& > 200 ml) increase in FEV1
→ > 20 % increase in peak flows
• Variability after challenge:
→ methacholine, histamine, exercise,
mannitol
Asthma severity

• Classification as mild, moderate or

severe is useful for clinical trials and
epidemiological studies, but is of
limited value in clinical practice.

• Management needs to be
individualized to achieve control.
• The important questions are:

> Does the patient really have asthma?

> Is the asthma persistent and warrant
ICS, or is it intermittent and ICS are not
needed? Most adults will need ICS.
> What are the goals of treatment?
> Is the patient’s asthma well
controlled?
Asthma Control

• No or minimal symptoms - dyspnoea,

wheeze, cough, chest tightness
• No nocturnal symptoms
• Activities are not restricted
• No or minimal use of relievers
• No exacerbations
• Peak flow variability < 20 %
• Spirometry is normal.
• ? bronchial hyper-reactivity
Initiating treatment

• Inhaled corticosteroids - ? start high

or low. Generally start with lower
doses.
• Start with a combination of ICS &
LABA - Seretide or Symbicort – except
maybe mild asthma.
• Long term treatment for most adults
∴ consider long term systemic effects.
• Local side effects - oral thrush,
dysphonia.
 Efficacy:safety ratio of inhaled
steroids

Airway effects: ICS & LABA

Effect Airway effects: ICS
Systemic effects

Dose µ g
1000 2000 (BDP/BUD)
Starting with a combination

• Many physicians now start treatment with a

combination.
• Some GPs start with a combination, but
some are reluctant because of the PBS
indications.
• There are several studies showing that
starting treatment with Seretide provides
quicker and better control of asthma.
• There is an impression that the less
medication changes, the better the
compliance will be.
Asthma medications

• Always check inhaler technique.

• Relievers: short acting β agonists -
salbutamol (Ventolin, Airomir, Epaq,
Asmol)
terbutaline - Bricanyl
long -acting β agonist with rapid onset
- eformoterol (Oxis, Foradile)

• MDI/DPI usually preferable to

nebulizers.
Inhaled corticosteroids

• Fluticasone (Flixotide Accuhaler 500, 250, 100

µ g; Flixotide MDI 250, 125, 50)
> double the potency of BDP/bud.
• Budesonide (Pulmicort Turbuhaler 400, 200, 100
µ g; 200, 100 µ g MDI; [nebs.])
• Beclomethasone (QVAR Autohaler 50, 100 µ g)
> double the lung deposition.
• Ciclesonide (Alvbeco MDI 80, 160 µ g)
> pro drug with minimal oral side effects
> once per day dosing
> 50 % lung deposition
Long acting β agonists

• Salmeterol (Serevent Accuhaler 50 µ g, MDI 25

µ g)
• Eformoterol (Oxis Turbuhaler 12 µ g; Foradile
Aerolizer 12 µ g)
• Always used with ICS.
• Consider a combination device: Seretide (salm. &
flut. Accuhaler 500/50, 250/50, 100/50, MDI 250/25,
125/25, 50/25); Symbicort (eform. & bud.
Turbuhaler 6/100, 6/200, 12/400).
• Symbicort can be used as i bd plus prn.
• Tremor and tachycardia with big doses.
Leukotriene receptor antagonist

• Montelukast (Singulair)
- one tablet per day.
- only on PBS for children
- not as good as ICS.
- useful for patients with throat side
effects with ICS.
- useful in exercise-induced asthma.
Avoiding triggers

• In general, this is difficult.

• House dust mite can be reduced to
acceptable levels, but measures are
extreme, and ? benefit of overall
asthma control.
• Obvious triggers on history should be
avoided.
• Some would consider allergy testing.
Asthma management plans

• Good evidence that they reduce

mortality and morbidity.
• Use common sense and individualize
the plan for the patient.
• Don’t make them too complicated.
• Patients tend not to use peak flow
meters, and may fabricate charts.
Education and review

• Asthma is a chronic condition in

adults.
• It is also variable, so requires review.
• It is unpredictable, so patients should
not under estimate their asthma: 1 - 2
die per day from asthma in Australia
• Does the patient really the dose of
ICS? Think of “back titrating”.
• Check inhaler technique.
ASTHMA EXACERBATIONS

• Think about a treatable cause and

predisposing factors:
> pneumonia, PE, pulmonary oedema,
PTX
> allergen exposure
> smoking
> poor medication use
> underestimation of asthma and
symptoms
> poorly managed asthma
• Often a specific treatable cause is not
found.
• Viruses (rhinovirus) can produce
exacerbations, but are not treatable or
preventable.
• Predisposing factors are important to
assess to try to reduce the chance of
another exacerbation, or at least reduce
its severity.
Treatment of exacerbations

• Assess the need for hospital admission.

• Possibly assess oxygen requirements.
• Increase beta agonist use (+ ipratopium)
• Increase steroids:
> prednisolone (or IV steroids)
- consider the side effect risk
- careful review is needed
- avoid complicated regimes
> Increase the puffs from a current
inhaler - logical if on submaximal ICS
- Symbicort is designed for this as
both drugs are at low doses
- this also applies to Seretide, except
many patients seem to be already
on large doses.
> Add an ICS to a combination inhaler
- possibly cumbersome
 asthma
Difficult to control asthma

¥ Is it asthma?
¥ Is it something else
- COPD, vocal cord dysfunction,
bronchiectasis, ABPA, Churg Strauss?
¥ Cardiac disease, ILD?
• Lack of fitness?
• Exacerbating factors …
- smoking, work, triggers, GOR,
medications.
• Does he/she use his medication?
• Does he/she use it properly?
Compliance

• “Compliance” has been replaced by

“acceptance” and “adherence”.
• They are probably over-estimated.
• Keep the treatment simple.
• Patients need to understand the purpose of
their treatment.
• Can patients take responsibility for their
treatment?
• Regular follow-up is needed.
• We need to be empathic.
Is there airway remodeling?

• Thickening of the basement membrane,

fibroblasts and myofibroblasts, collagen
deposition in the bronchial wall.
• This can lead to irreversible airflow
obstruction.
• It may be preventable with early
initiation of treatment, but this is
unproven and controversial.
COPD ? Asthma

COPD
&
asthma
COPD & ASTHMA SUMMARY

COPD ASTHMA
Not variable Variable
Neutrophils Eosinophils

DISEASE CONTROL
Stop smoking ICS & avoid triggers

AIM OF TREATMENT
Symptom control Reduce mortality
Prevent fixed obstruction
REFERENCES
• www.goldcopd.com

• ATS official statement on COPD. AM J Respir Crit Care Med

1995; 152: S77-S120.

• Barnes PJ. Chronic obstructive pulmonary disease. NEJM 2000;

343: 269-280.

• McKenzie DK, Frith PA, Burdon JGW, Town GI. The COPDX plan.
MJA 2003; 178: S1-S39.

• National Asthma Council Asthma Management Handbook, 2006

• www.nationalasthma.org.au

• www. Pulmonaryrehab.com.au

• www.copdx.org.au

• www.ginasthma.com