COPD Management Overview

COPD Management

• COPD is a common lung disease, causing restricted airflow and breathing issues. It's frequently called emphysema or chronic bronchitis.
• Globally, COPD is the 3rd leading cause of death.
• The majority (nearly 90%) of COPD deaths in those under 70 occur in low and middle-income countries.
• Tobacco smoking is a significant risk factor, contributing to over 70% of COPD cases in high-income countries and 30-40% in lower-middle-income countries.
• COPD is characterized by chronic respiratory symptoms (dyspnea, cough, sputum production) caused by abnormal airways (bronchitis, bronchiolitis) and/or alveoli (emphysema).
• The condition often progresses, leading to persistent airflow obstruction.

Intended Learning Outcomes

• Students will be able to describe the pathophysiology, diagnosis, signs, and symptoms of Chronic Obstructive Pulmonary Disease (COPD).
• Students will be able to explain mainstream medical management of COPD.
• Students will be able to conduct an appropriate physiotherapy assessment using the ICF framework.
• Students will be able to provide intervention and education for COPD patients.
• Students will be able to select appropriate outcome measures to evaluate COPD management program effectiveness.
• Students will be aware of the risks associated with supplemental oxygen administration to COPD patients.
• Students will identify global management guidelines for COPD.

Etiology of COPD

• Smoking and pollutants are significant COPD contributors, leading to impaired lung function, lung injury, and lung diseases.
• Inflammation of the airways and overproduction of mucus are key factors.
• Destruction of alveolar tissue, leading to emphysema, is a key COPD characteristic.
• COPD can be linked to comorbidities such as lung cancer and bronchiectasis.
• Genetic factors, such as alpha-1-antitrypsin (AAT) deficiency, are also involved. AATD patients under 45 should undergo genetic screening.

COPD Diagnosis/Spirometry

• Spirometry confirmation (FEV1/FVC <70%) is vital for diagnosis.
• Key symptoms, include progressive dyspnea over time (worsening with exercise), chronic cough, and sputum production.
• History of exposure to risk factors, genetic factors (AAT deficiency), family history, low birth weight, and childhood respiratory infection are also indicators.
• X-ray examination may show signs of hyperinflation.

COPD Grades and Severity

• GOLD (Global Initiative for Chronic Obstructive Lung Disease) grades categorize COPD severity based on FEV1 (forced expiratory volume in 1 second) percentage predicted values.
• Grade 1: Mild (FEV1>80% predicted)
• Grade 2: Moderate (50%<FEV1<80% predicted)
• Grade 3: Severe (30%<FEV1<50% predicted)
• Grade 4: Very Severe (FEV1<30% predicted)

COPD Symptoms

• Shortness of breath, particularly over several years
• Airway obstruction
• Over-inflated lungs
• Chronic cough
• Poor exercise tolerance
• Impaired gas exchange
• Right-heart failure from increased blood resistance may occur.

COPD-Related Complications/Associations

• 40%-70% of lung cancer patients also have COPD.
• COPD incidence is 4.3 times higher in males and 4.8 times higher in females compared to the general population.

COPD Assessment of Symptoms

• Shortness of breath assessment (Modified MRC dyspnea scale, VAS (Visual Analogue Scale), Borg scale, mMRC (modified Medical Research Council) scale, simple 0–10 score)
• CAT-COPD Assessment Test
• QOL questionnaires
• Frequency of exacerbations

Assessment for COPD Exacerbation

• Group A: 0 or 1 exacerbation (not leading to hospital admission)
• Group B: mMRC ≥2 or CAT ≥10 and no hospital admission
• Group C: >2 exacerbations and >1 leading to hospital admission
• Group D: mMRC ≥2 or CAT ≥10 and more than 1 hospital admission

COPD Exacerbation Types

• Type 1 exacerbation includes increased dyspnea, sputum production, and decreased PEFR (peak expiratory flow rate).
• Type 2 and 3 exacerbation are characterized by two or more of these factors, or one factor and signs of a common cold, respectively.

COPD Management of Acute Exacerbation

• Non-invasive ventilation
• Oral corticosteroids
• Antibiotic use
• Early pulmonary rehabilitation (within 3 weeks of discharge) is important.

COPD Management of Stable COPD

• Prevention (smoking cessation, nicotine replacement, monitoring exhaled CO level)
• Vaccination (COVID-19, influenza, and pneumococcal)
• Maintenance of stable COPD
• Non-pharmacological therapy (pulmonary rehabilitation, structured exercise programs, education)
• Pharmacological therapy (bronchodilators, inhaled corticosteroids, combination therapies (e.g., SABA+SAMA, LABA+LAMA, ICS/LAMA/LABA, mucolytic agents, antibiotics)
• Triple therapy inhaler use(e.g., fluticasone furoate/umeclidinium/vilanterol)
• Physiotherapists need to be knowledgeable about specific COPD medications and assist in proper inhaler usage.

COPD Non-Pharmacological Therapy

• Pulmonary rehabilitation programs
• Structured exercise programs.
• COPD self-management strategies
• Integrated care (long-term oxygen therapy, non-invasive positive pressure ventilation (NIPPV), nutrition, lung volume reduction)

COPD Management Goals

• Minimize hospitalizations
• Manage dyspnea.
• Increase physical activity.

COPD Assessment

• Respiratory function, functional capacity
• Assessment of inhaler technique/effectiveness

COPD Service Delivery

• COPD face-to-face supervision.
• Digital physiotherapy service.

COPD Stable Assessment

• Dyspnea assessment (mMRC scale)
• Spirometry
• BODE index
• CAT
• QOL questionnaires.
• 6MWT/Shuttle walk test

COPD BODE Index

• BODE index (0–10)
• BMI
• Predicted FEV1%
• MMRC dyspnea scale
• 6MWD
• Higher scores indicate a higher risk of mortality
• Distance-saturation product (DSP) is calculated as distance walked (during 6MWT) multiplied by the lowest SpO2 value.

COPD Post-Intervention Outcome Evaluation

• Short-term: improvement in shortness of breath, maintaining SpO2 during exercise.
• Long-term: improved 6-minute walk distance (6MWD), QoL, activity level, and reduced rate of lung function decline.

COPD Oxygen Therapy

• Oxygen therapy delivery can induce hypercapnia in COPD patients due to the removal of the hypoxic drive.
• Management of COPD oxygen therapy needs to maintain SpO2 between 88–92%.
• Oxygen therapy implications relate to VQ mismatch (hypoxic pulmonary vasoconstriction), Haldane effect, and loss of hypoxic drive.
• Long-term oxygen therapy (LTOT) is indicated for patients with severe COPD and low resting arterial oxygen tension

COPD Non-Pharmacological Therapy

• NIPPV (non-invasive positive-pressure ventilation) may improve hospitalization-free survival for selected COPD patients with persistent daytime hypercapnia.

COPD Pulmonary Rehabilitation

• Pulmonary rehabilitation uses a toolkit for health professionals

COPD Surgical Intervention

• Lung volume reduction surgery helps those with severe emphysema and exercise tolerance problems
• Transplantation
• Zephyr endobronchial valves

Electro-Muscle Stimulation in COPD

• Whether electrical muscle stimulation helps in lung function for COPD patients needs further study.

Physiotherapy Role in COPD Management

• Hospital ward (acute exacerbation management).
• Outpatient pulmonary rehabilitation (stable COPD).
• Community (prevention, education).
• Awareness of global demographics and management strategies.

COPD International Guidelines

• GOLD (Global Initiative for Chronic Obstructive Lung Disease)
• ACP (American College of Physicians)
• ACCP (American College of Chest Physicians).
• ATS (American Thoracic Society)
• ERS (European Respiratory Society)

COPD References

• Provided in the included text.