Obstructive Pulmonary Diseases

Obstructive Pulmonary Diseases
• For the respiratory system to succeed in oxygenating blood

and eliminating CO2,
– it must be able to ventilate the lung tidally and thus to freshen
alveolar gas;
– it must provide for perfusion of the individual alveolus in a
manner proportional to its ventilation;
– and it must allow adequate diffusion of respiratory gases
between alveolar gas and capillary blood.
– Furthermore, it must accommodate several fold increases in
the demand for oxygen uptake or CO2 elimination imposed by
metabolic needs or acid-base derangement.
• Given these multiple requirements for normal operation, it
is not surprising that many diseases disturb respiratory
function.
• think about the respiratory system as three
independently functioning components:
– the lung, including its airways;
– the neuromuscular system; and
– The chest wall, which includes everything that is
not lung or active neuromuscular system.
10/15/23
A Glossary of Spirometry
Terminology
• FVC- forced vital
capacity: the total
amount of air that can
be blown out after
inhaling as deeply as
possible and then
blowing out as hard
and forcefully and
long as possible. (unit
is in liters)
10/15/23
Terminology
• FEV1- forced
expiratory volume in
one second: the
amount of air
that is blown out in
the first second of
the forced vital
capacity manuever.
(unit is in liters)
10/15/23
Terminology
• FEFmax- forced expiratory
flow, maximum (also know
as PEF, peak expiratory
flow or PEFR, peak
expiratory flow rate): the
fastest flow that can be
forcefully blown out.
(unit is in liters/second,
although home peak flow
meters measure this in
liters/minute)
10/15/23
Terminology
• FEF25-75- forced
expiratory flow
between 25% and 75%
of the vital capacity
(also known as MMEF,
maximum mid-
expiratory flow):
the fastest flow that
can be forcefully blown
out within the middle
half of the forced vital
capacity manuever.
(unit is in liters/second)
10/15/23
Indications
1. Detect the presence or absence of lung
dysfunction suggested by clinicals and/or
laboratory tests
2. Quantify severity of know lung disease
3. Assess the change in lung function over the
time or F/U after Tx
4. Assess the potential effects or response to
env. or occup. Exposure
5. Assess the risk for surgery
6. Assess impairment and/or disability
10/15/23
Contraindication for Spirometry
• Hemoptysis
• Pneumothorax
• Cardiovascular instability eq. Severe hypertension,
hypotension, recent MI, pulmonary embolism
• Vascular aneurysm
• Recent surgery eq. Eye surgery, abdominal surgery
• Active respiratory infection eq. Active TB
• Pregnancy (relatively)
• Severe nausea ,vomiting
10/15/23
Complications
Spirometry is very safe, rarely seen

• Increase intracranial pressure
• Dizziness, vertigo, syncope
• Cough
• Bronchospasm
• Chest pain
• Pneumothorax
• Respiratory infection
10/15/23
Flow volume curve
10/15/23
Definition and diagnosis of
asthma
GINA Global Strategy for Asthma

Management and Prevention 2016
This slide set is restricted for academic and educational purposes only.
Use of the slide set, or of individual slides, for commercial or promotional
purposes requires approval from GINA.
© Global Initiative for Asthma

What is known about asthma?
• Asthma is a common and potentially serious chronic disease
that can be controlled but not cured
• Asthma causes symptoms such as wheezing, shortness of
breath, chest tightness and cough that vary over time in their
occurrence, frequency and intensity
• Symptoms are associated with variable expiratory airflow,
i.e. difficulty breathing air out of the lungs due to
– Bronchoconstriction (airway narrowing)
– Airway wall thickening
– Increased mucus
• Symptoms may be triggered or worsened by factors such as
viral infections, allergens, tobacco smoke, exercise and stress
GINA 2016
What is known about asthma?
• Asthma can be effectively treated
• When asthma is well-controlled, patients can
 Avoid troublesome symptoms during the day and night
 Need little or no reliever medication
 Have productive, physically active lives
 Have normal or near-normal lung function
 Avoid serious asthma flare-ups (also called exacerbations,
or severe attacks)
GINA 2016
Histopathology of a small airway in fatal asthma. The lumen is occluded with a
mucous plug, there is goblet cell metaplasia, and the airway wall is thickened,
with an increase in basement membrane thickness and airway smooth muscle.
(Courtesy of Dr. J. Hogg, University of British Colombia.)
PATHOPHYSIOLOGY
• Asthma is associated with a specific chronic
inflammation of the mucosa of the lower airways.
• One of the main aims of treatment is to reduce
this inflammation.
• The pathology of asthma: the airway mucosa is
infiltrated with activated eosinophils and T
lymphocytes, and there is activation of mucosal
mast cells.
• The degree of inflammation is poorly related to
disease severity
Definition of asthma
Asthma is a heterogeneous disease, usually characterized by
chronic airway inflammation.
It is defined by the history of respiratory symptoms such as

wheeze, shortness of breath, chest tightness and cough that vary
over time and in intensity, together with variable expiratory
airflow limitation.
GINA 2016
Diagnosis of asthma
• The diagnosis of asthma should be based on:
– A history of characteristic symptom patterns
– Evidence of variable airflow limitation, from
bronchodilator reversibility testing or other tests
• Document evidence for the diagnosis in the patient’s
notes, preferably before starting controller treatment
– It is often more difficult to confirm the diagnosis after
treatment has been started
• Asthma is usually characterized by airway
inflammation and airway hyperresponsiveness, but
these are not necessary or sufficient to make the
diagnosis of asthma.
GINA 2016
Patient with
respiratory symptoms
Are the symptoms typical of asthma?
YES
Detailed history/examination
for asthma
History/examination supports
asthma diagnosis?
YES
Perform spirometry/PEF
with reversibility test
Results support asthma diagnosis?
YES
Treat for ASTHMA
GINA 2016, Box 1-1 (1/4) © Global Initiative for Asthma

Patient with
NO
YES
for asthma
asthma diagnosis?
Further history and tests for
NO alternative diagnoses
YES Alternative diagnosis confirmed?
YES YES
Treat for ASTHMA Treat for alternative diagnosis

Patient with
NO
YES
for asthma
asthma diagnosis?
Repeat on another
NO
occasion or arrange
NO
YES other tests
Confirms asthma diagnosis?
YES NO YES
Consider trial of treatment for

most likely diagnosis, or refer
for further investigations

Patient with
NO
YES
for asthma
asthma diagnosis?
Clinical urgency, and
other diagnoses unlikely
Repeat on another
NO
occasion or arrange
NO
YES other tests
Confirms asthma diagnosis?
Empiric treatment with YES NO YES

ICS and prn SABA
Review response
Consider trial of treatment for
Diagnostic testing most likely diagnosis, or refer
within 1-3 months for further investigations

Diagnosis of asthma – symptoms
• Increased probability that symptoms are due to asthma if:
– More than one type of symptom (wheeze, shortness of breath, cough,
chest tightness)
– Symptoms often worse at night or in the early morning
– Symptoms vary over time and in intensity
– Symptoms are triggered by viral infections, exercise, allergen
exposure, changes in weather, laughter, irritants such as car exhaust
fumes, smoke, or strong smells
• Decreased probability that symptoms are due to asthma if:
– Isolated cough with no other respiratory symptoms
– Chronic production of sputum
– Shortness of breath associated with dizziness, light-headedness or
peripheral tingling
– Chest pain
– Exercise-induced dyspnea with noisy inspiration (stridor)
GINA 2016
Diagnosis of asthma – physical
examination
• Physical examination in people with asthma
– Often normal
– The most frequent finding is wheezing on auscultation,
especially on forced expiration
• Wheezing is also found in other conditions, for example:
– Respiratory infections
– COPD
– Upper airway dysfunction
– Endobronchial obstruction
– Inhaled foreign body
• Wheezing may be absent during severe asthma
exacerbations (‘silent chest’)
GINA 2016
Diagnosis of asthma – variable airflow
limitation
• Confirm presence of airflow limitation
– Document that FEV1/FVC is reduced (at least once, when FEV1 is low)
– FEV1/ FVC ratio is normally >0.75 – 0.80 in healthy adults, and
>0.90 in children
• Confirm variation in lung function is greater than in healthy individuals
– The greater the variation, or the more times variation is seen, the greater
probability that the diagnosis is asthma
– Excessive bronchodilator reversibility (adults: increase in FEV1 >12% and
>200mL; children: increase >12% predicted)
– Excessive diurnal variability from 1-2 weeks’ twice-daily PEF monitoring (daily
amplitude x 100/daily mean, averaged)
– Significant increase in FEV1 or PEF after 4 weeks of controller treatment
– If initial testing is negative:
• Repeat when patient is symptomatic, or after withholding bronchodilators
• Refer for additional tests (especially children ≤5 years, or the elderly)
GINA 2016, Box 1-2

Other Investigations
• Whole-body plethysmography: increased airway resistance and increased total lung capacity and
residual volume.
– Gas diffusion: normal, may be a small increase in gas transfer in some patients.
– Airway Responsiveness: increased AHR is measured by methacholine or histamine challenge with calculation
of the provocative concentration that reduces FEV1 by 20% (PC20) can be used in the differential diagnosis
of chronic cough and when the diagnosis is in doubt.
• Occasionally exercise testing is done to demonstrate the pos-texercise bronchoconstriction if there
is a predominant history of EIA.
• Allergen challenge is rarely necessary and should only be undertaken by a specialist if specific
occupational agents are to be identified.
• Hematologic Tests Blood tests are not usually helpful.
• Total serum IgE and specific IgE to inhaled allergens (radioallergosorbent test [RAST]) may be
measured in some patients.
• Imaging Chest roentgenography -usually normal
– in more severe patients may show hyperinflated lungs.
– In exacerbations, there may be evidence of a pneumothorax.
– Lung shadowing indicates pneumonia or eosinophilic infiltrates in patients with bronchopulmonary
aspergillosis.
• HRCT may show areas of bronchiectasis in patients with severe asthma, and thickening of the
bronchial walls, but these changes are not diagnostic of asthma.
• Skin prick tests to common inhalant allergens (house dust mite, cat fur, grass pollen) are positive in
allergic asthma and negative for intrinsic asthma
• Exhaled Nitric Oxide FeNO is now being used as a noninvasive test to measure airway
inflammation. The typically elevated levels in asthma are reduced by ICS, so this may be a test of
compliance with therapy.
Spirometry
Typical spirometric tracings
Volume
Normal
FEV1
Asthma
(after BD)
Normal
Asthma
(before BD) Asthma
(after BD)
Asthma
(before BD)
1 2 3 4 5 Volume
Time (seconds)
Note: Each FEV1 represents the highest of
three reproducible measurements
GINA 2016 © Global Initiative for Asthma

Assessment of asthma


Assessment of asthma
1. Asthma control - two domains
– Assess symptom control over the last 4 weeks
– Assess risk factors for poor outcomes, including low lung
function
2. Treatment issues
– Check inhaler technique and adherence
– Ask about side-effects
– Does the patient have a written asthma action plan?
– What are the patient’s attitudes and goals for their asthma?
3. Comorbidities
– Think of rhinosinusitis, GERD, obesity, obstructive sleep apnea,
depression, anxiety
– These may contribute to symptoms and poor quality of life
GINA 2016, Box 2-1

GINA assessment of symptom control
A. Symptom control Level of asthma symptom control

Well- Partly Uncontrolled
In the past 4 weeks, has the patient had:
controlled controlled
• Daytime asthma symptoms more
than twice a week?
Yes No
• Any night waking due to asthma?
Yes No None of 1-2 of 3-4 of

• Reliever needed for symptoms* these these these
more than twice a week?
*Excludes reliever taken before exercise, because many people take this routinely
Yes No
This classification
• Any activity limitation is the same as the GINA 2010-12 assessment
due to asthma?
of ‘current control’, except that lung function now appears only
Yes No in the assessment of risk factors
GINA 2016, Box 2-2A © Global Initiative for Asthma

GINA assessment of symptom control
A. Symptom control Level of asthma symptom control

Well- Partly Uncontrolled
In the past 4 weeks, has the patient had:
controlled controlled
• Daytime asthma symptoms more
than twice a week?
Yes No
• Any night waking due to asthma?
Yes No None of 1-2 of 3-4 of

• Reliever needed for symptoms* these these these
more than twice a week?
Yes No
• Any activity limitation due to asthma?
Yes No
B. Risk factors for poor asthma outcomes
• Assess risk factors at diagnosis and periodically
GINA 2016 Box 2-2B (1/4) © Global Initiative for Asthma
Assessment of risk factors for poor asthma
outcomes
Risk factors for exacerbations include:
• Ever intubated for asthma
• Uncontrolled asthma symptoms
• Having ≥1 exacerbation in last 12 months
• Low FEV1 (measure lung function at start of treatment, at 3-6 months
to assess personal best, and periodically thereafter)
• Incorrect inhaler technique and/or poor adherence
• Smoking
• Obesity, pregnancy, blood eosinophilia
GINA 2016, Box 2-2B (2/4) © Global Initiative for Asthma

outcomes
• Smoking
Risk factors for fixed airflow limitation include:
• No ICS treatment, smoking, occupational exposure, mucus
hypersecretion, blood eosinophilia

outcomes
• Smoking
Risk factors for fixed airflow limitation include:
• No ICS treatment, smoking, occupational exposure, mucus
hypersecretion, blood eosinophilia
Risk factors for medication side-effects include:
• Frequent oral steroids, high dose/potent ICS, P450 inhibitors

The role of lung function in asthma
• Diagnosis
– Demonstrate variable expiratory airflow limitation
– Reconsider diagnosis if symptoms and lung function are discordant
• Frequent symptoms but normal FEV 1: cardiac disease; lack of fitness?
• Few symptoms but low FEV1: poor perception; restriction of lifestyle?
• Risk assessment
– Low FEV1 is an independent predictor of exacerbation risk
• Monitoring progress
– Measure lung function at diagnosis, 3-6 months after starting treatment
(to identify personal best), and then periodically
– Consider long-term PEF monitoring for patients with severe asthma or
impaired perception of airflow limitation
• Adjusting treatment?
– Utility of lung function for adjusting treatment is limited by between-visit
variability of FEV1 (15% year-to-year)
GINA 2016
Assessing asthma severity
• How?
– Asthma severity is assessed retrospectively from the level of
treatment required to control symptoms and exacerbations
• When?
– Assess asthma severity after patient has been on controller treatment
for several months
– Severity is not static – it may change over months or years, or as
different treatments become available
• Categories of asthma severity
– Mild asthma: well-controlled with Steps 1 or 2 (as-needed SABA or
low dose ICS)
– Moderate asthma: well-controlled with Step 3 (low-dose ICS/LABA)
– Severe asthma: requires Step 4/5 (moderate or high dose ICS/LABA ±
add-on), or remains uncontrolled despite this treatment
GINA 2016
How to distinguish between uncontrolled
and severe asthma
Watch patient using their Compare inhaler technique with a device-
specific checklist, and correct errors;
inhaler. Discuss adherence recheck frequently. Have an empathic
and barriers to use discussion about barriers to adherence.
Remove potential
risk factors. Assess and
manage comorbidities
Consider treatment
step-up
Refer to a specialist or
severe asthma clinic

and severe asthma
If lung function normal during symptoms,

Confirm the diagnosis consider halving ICS dose and repeating
of asthma lung function after 2–3 weeks.

and severe asthma

Remove potential Check for risk factors or inducers such as

smoking, beta-blockers, NSAIDs, allergen
risk factors. Assess and exposure. Check for comorbidities such as
manage comorbidities rhinitis, obesity, GERD, depression/anxiety.
Consider treatment
step-up

and severe asthma


Consider step up to next treatment level.

Consider treatment Use shared decision-making, and balance
step-up potential benefits and risks.

and severe asthma



Consider step up to next treatment level.

Consider treatment Use shared decision-making, and balance
step-up potential benefits and risks.
If asthma still uncontrolled after 3–6 months

Refer to a specialist or on Step 4 treatment, refer for expert advice.
severe asthma clinic Refer earlier if asthma symptoms severe,
or doubts about diagnosis.

Treating asthma to control
symptoms and minimize risk


Goals of asthma management
• The long-term goals of asthma management are
1. Symptom control: to achieve good control of symptoms
and maintain normal activity levels
2. Risk reduction: to minimize future risk of exacerbations,
fixed airflow limitation and medication side-effects
• Achieving these goals requires a partnership between
patient and their health care providers
– Ask the patient about their own goals regarding their
asthma
– Good communication strategies are essential
– Consider the health care system, medication availability,
cultural and personal preferences and health literacy
GINA 2016
Key strategies to facilitate good
communication
• Improve communication skills
– Friendly manner
– Allow the patient to express their goals, beliefs and
concerns
– Empathy and reassurance
– Encouragement and praise
– Provide appropriate (personalized) information
– Feedback and review
• Benefits include:
– Increased patient satisfaction
– Better health outcomes
– Reduced use of health care resources
GINA 2016, Box 3-1

Reducing the impact of impaired
health literacy
• Health literacy affects health outcomes, including in asthma
– ‘The degree to which individuals have the capacity to obtain,
process and understand basic health information and services
to make appropriate health decisions’ (Rosas-Salazar, JACI 2012)
• Strategies for reducing the impact of impaired health
literacy
– Prioritize information (most important to least important)
– Speak slowly, avoid medical language, simplify numeric
concepts
– Use anecdotes, drawings, pictures, tables and graphs
– Use the ‘teach-back’ method – ask patients to repeat
instructions
– Ask a second person to repeat the main messages
– Pay attention to non-verbal communication
GINA 2016, Box 3-1

Treating to control symptoms and
•
minimize risk
Establish a patient-doctor partnership
• Manage asthma in a continuous cycle:
– Assess
– Adjust treatment (pharmacological and
non-pharmacological)
– Review the response
• Teach and reinforce essential skills
– Inhaler skills
– Adherence
– Guided self-management education
• Written asthma action plan
• Self-monitoring
• Regular medical review
GINA 2016
The control-based asthma
management cycle
Diagnosis
Symptom control & risk factors
(including lung function)
Inhaler technique & adherence
Patient preference
Symptoms
Exacerbations
Side-effects
Patient satisfaction
Lung function
Asthma medications
Non-pharmacological strategies
Treat modifiable risk factors
GINA 2016, Box 3-2

Stepwise management - pharmacotherapy
UPDATED!
Diagnosis
Symptom control & risk factors
(including lung function)
Inhaler technique & adherence
Patient preference
Symptoms
Exacerbations
Side-effects Asthma medications
Patient satisfaction Non-pharmacological strategies
Lung function Treat modifiable risk factors
STEP 5
STEP 4
Refer for *Not for children <12 years
STEP 3
PREFERRED STEP 1 STEP 2 add-on **For children 6-11 years, the
CONTROLLER treatment
e.g. preferred Step 3 treatment is
CHOICE
Med/high tiotropium,* medium dose ICS
omalizumab,
ICS/LABA mepolizumab* #
For patients prescribed
Low dose
BDP/formoterol or BUD/
Low dose ICS ICS/LABA** formoterol maintenance and
reliever therapy
Other Consider low Leukotriene receptor antagonists (LTRA) Med/high dose ICS Add tiotropium* Add low
controller dose ICS Low dose theophylline* Low dose ICS+LTRA High dose ICS dose OCS  Tiotropium by mist inhaler is
(or + theoph*) + LTRA an add-on treatment for
options (or + theoph*)
patients ≥12 years with a
As-needed short-acting beta2-agonist (SABA) As-needed SABA or history of exacerbations
RELIEVER low dose ICS/formoterol#
GINA 2016, Box 3-5 (2/8) (upper part)

Stepwise management –
additional components
• Provide guided self-management education

REMEMBER
• Treat modifiable risk factors and comorbidities
TO...
• Advise about non-pharmacological therapies and strategies
• Consider stepping up if … uncontrolled symptoms, exacerbations or risks,
but check diagnosis, inhaler technique and adherence first
• Consider stepping down if … symptoms controlled for 3 months
+ low risk for exacerbations. Ceasing ICS is not advised.
GINA 2016, Box 3-5 (3/8) (lower part)

Low, medium and high dose inhaled
corticosteroids
UPDATED!
Adults and adolescents

Inhaled corticosteroid
(≥12 years)
Total daily dose (mcg)
Low Medium High
Beclometasone dipropionate (CFC) 200–500 >500–1000 >1000

Beclometasone dipropionate (HFA) 100–200 >200–400 >400
Budesonide (DPI) 200–400 >400–800 >800
Ciclesonide (HFA) 80–160 >160–320 >320
Fluticasone furoate (DPI) 100 n.a. 200
Fluticasone propionate (DPI or HFA) 100–250 >250–500 >500
Mometasone furoate 110–220 >220–440 >440
Triamcinolone acetonide 400–1000 >1000–2000 >2000
– This is not a table of equivalence, but of estimated clinical comparability
– Most of the clinical benefit from ICS is seen at low doses
– High doses are arbitrary, but for most ICS are those that, with prolonged use, are
associated with increased risk of systemic side-effects
GINA 2016, Box 3-6 (1/2)

Low, medium and high dose inhaled
corticosteroids
Children 6–11Total
Inhaled corticosteroid
yearsdaily dose (mcg)
Low Medium High
Beclometasone dipropionate (CFC) 100–200 >200–400 >400
Beclometasone dipropionate (HFA) 50–100 >100–200 >200
Budesonide (DPI) 100–200 >200–400 >400
Budesonide (nebules) 250–500 >500–1000 >1000
Ciclesonide (HFA) 80 >80–160 >160
Fluticasone furoate (DPI) n.a. n.a. n.a.
Fluticasone propionate (DPI) 100–200 >200–400 >400
Fluticasone propionate (HFA) 100–200 >200–500 >500
Mometasone furoate 110 ≥220–<440 ≥440
Triamcinolone acetonide 400–800 >800–1200 >1200
– This is not a table of equivalence, but of estimated clinical comparability
– Most of the clinical benefit from ICS is seen at low doses
– High doses are arbitrary, but for most ICS are those that, with prolonged use, are associated with
increased risk of systemic side-effects
GINA 2016, Box 3-6 (2/2)
Reviewing response and adjusting
treatment
• How often should asthma be reviewed?
– 1-3 months after treatment started, then every 3-12 months
– During pregnancy, every 4-6 weeks
– After an exacerbation, within 1 week
• Stepping up asthma treatment
– Sustained step-up, for at least 2-3 months if asthma poorly controlled
• Important: first check for common causes (symptoms not due to asthma, incorrect
inhaler technique, poor adherence)
– Short-term step-up, for 1-2 weeks, e.g. with viral infection or allergen
• May be initiated by patient with written asthma action plan
– Day-to-day adjustment
• For patients prescribed low-dose ICS/formoterol maintenance and reliever regimen*
• Stepping down asthma treatment
– Consider step-down after good control maintained for 3 months
– Find each patient’s minimum effective dose, that controls both symptoms and
exacerbations
*Approved only for low dose beclometasone/formoterol and low dose budesonide/formoterol
GINA 2016
General principles for stepping down
• Aim controller treatment
– To find the lowest dose that controls symptoms and exacerbations, and minimizes the risk of side-
effects
• When to consider stepping down
– When symptoms have been well controlled and lung function stable for
≥3 months
– No respiratory infection, patient not travelling, not pregnant
• Prepare for step-down
– Record the level of symptom control and consider risk factors
– Make sure the patient has a written asthma action plan
– Book a follow-up visit in 1-3 months
• Step down through available formulations
– Stepping down ICS doses by 25–50% at 3 month intervals is feasible and safe for most patients
(Hagan et al, Allergy 2014)
– See GINA 2016 report Box 3-7 for specific step-down options
• Stopping ICS is not recommended in adults with asthma because of risk of
exacerbations (Rank et al, JACI 2013)
GINA 2016, Box 3-7

Treating modifiable risk factors
• Provide skills and support for guided asthma self-management
– This comprises self-monitoring of symptoms and/or PEF, a written asthma action plan and
regular medical review
• Prescribe medications or regimen that minimize exacerbations
– ICS-containing controller medications reduce risk of exacerbations
– For patients with ≥1 exacerbations in previous year, consider low-dose ICS/formoterol
maintenance and reliever regimen*
• Encourage avoidance of tobacco smoke (active or ETS)
– Provide smoking cessation advice and resources at every visit
• For patients with severe asthma
– Refer to a specialist center, if available, for consideration of add-on medications and/or
sputum-guided treatment
• For patients with confirmed food allergy:
– Appropriate food avoidance
– Ensure availability of injectable epinephrine for anaphylaxis
*Approved only for low dose beclometasone/formoterol and low dose budesonide/formoterol
GINA 2016, Box 3-8
Non-pharmacological interventions
• Avoidance of tobacco smoke exposure
– Provide advice and resources at every visit; advise against exposure of children to environmental tobacco
smoke (house, car)
• Physical activity
– Encouraged because of its general health benefits. Provide advice about exercise-induced
bronchoconstriction
• Occupational asthma
– Ask patients with adult-onset asthma about work history. Remove sensitizers as soon as possible. Refer for
expert advice, if available
• Avoid medications that may worsen asthma
– Always ask about asthma before prescribing NSAIDs or beta-blockers
• Remediation of dampness or mold in homes
– Reduces asthma symptoms and medication use in adults
• (Allergen avoidance) UPDATED!
– (Not recommended as a general strategy for asthma)
• See GINA Box 3-9 and online Appendix for details
This slide shows examples of interventions with high quality evidence

GINA 2016, Box 3-9
Guided asthma self-management and
skills training
Essential components are:
•Skills training to use inhaler devices correctly
•Encouraging adherence with medications,
appointments
•Asthma information
•Guided self-management support
– Self-monitoring of symptoms and/or PEF
– Written asthma action plan
– Regular review by a health care provider
GINA 2016
Global Strategy for Diagnosis, Management and
Prevention of COPD, 2017: Chapters
 Definition and Overview

 Diagnosis and Assessment
 Therapeutic Options
 Manage Stable COPD
 Manage Exacerbations
 Manage Comorbidities
Updated 2015
 Asthma COPD Overlap
Syndrome (ACOS)
© 2015 Global Initiative for Chronic Obstructive Lung Disease
Global Strategy for Diagnosis, Management and Prevention of COPD
Definition of COPD
 COPD, a common preventable and treatable
disease, is characterized by persistent airflow
limitation that is usually progressive and
associated with an enhanced chronic
inflammatory response in the airways and the
lung to noxious particles or gases.
 Exacerbations and comorbidities contribute to
the overall severity in individual patients.
Mechanisms Underlying Airflow

Limitation in COPD
Small Airways Disease Parenchymal Destruction

•Airway inflammation •Loss of alveolar attachments
•Airway fibrosis, luminal plugs •Decrease of elastic recoil
•Increased airway resistance
AIRFLOW LIMITATION
Burden of COPD
 COPD is a leading cause of morbidity and
mortality worldwide.
 The burden of COPD is projected to increase

in coming decades due to continued
exposure to COPD risk factors and the aging
of the world’s population.
 COPD is associated with significant economic

burden.
Risk Factors for COPD
Genes
Infections
Socio-economic
status
Aging Populations

Updated 2015
Syndrome (ACOS)
Diagnosis and Assessment: Key Points
• A clinical diagnosis of COPD should be

considered in any patient who has dyspnea,
chronic cough or sputum production, and a
history of exposure to risk factors for the
disease.
• Spirometry is required to make the diagnosis;
the presence of a post-bronchodilator FEV1/FVC
< 0.70 confirms the presence of persistent
airflow limitation and thus of COPD.
Diagnosis and Assessment: Key Points
• The goals of COPD assessment are to determine

the severity of the disease, including the severity of
airflow limitation, the impact on the patient’s health
status, and the risk of future events.
• Comorbidities occur frequently in COPD patients,
and should be actively looked for and treated
appropriately if present.

Diagnosis of COPD
EXPOSURE TO RISK
SYMPTOMS FACTORS
shortness of breath
tobacco
chronic cough occupation
sputum indoor/outdoor pollution

SPIROMETRY: Required to establish

diagnosis
Assessment of Airflow Limitation:

Spirometry
Spirometry should be performed after the
administration of an adequate dose of a short-acting
inhaled bronchodilator to minimize variability.
A post-bronchodilator FEV1/FVC < 0.70 confirms
the presence of airflow limitation.
Where possible, values should be compared to
age-related normal values to avoid overdiagnosis
of COPD in the elderly.

Spirometry: Normal Trace Showing FEV1
and FVC
5
FVC
4
Volume, liters
FEV1 = 4L
3
FVC = 5L
2
FEV1/FVC = 0.8
1
1 2 3 4 5 6
Time, sec
Spirometry: Obstructive Disease
5 Normal
4
Volume, liters
3
FEV1 = 1.8L
2 FVC = 3.2L Obstructive
FEV1/FVC = 0.56
1
1 2 3 4 5 6
Time, seconds

Assessment of COPD: Goals

Determine the severity of the disease, its
impact on the patient’s health status and the
risk of future events (for example
exacerbations) to guide therapy. Consider the
following aspects of the disease separately:
 current level of patient’s symptoms
 severity of the spirometric abnormality
 frequency of exacerbations
 presence of comorbidities.
Assessment of COPD
 Assess symptoms
 Assess degree of airflow
limitation using spirometry
 Assess risk of exacerbations
 Assess comorbidities
Symptoms of COPD
The characteristic symptoms of COPD are chronic and
progressive dyspnea, cough, and sputum production
that can be variable from day-to-day.
Dyspnea: Progressive, persistent and characteristically

worse with exercise.
Chronic cough: May be intermittent and may be

unproductive.
Chronic sputum production: COPD patients commonly

cough up sputum.
Assessment of COPD
 Assess symptoms
Assess degree of airflow limitation using spirometry
AssessCOPD
risk of exacerbations
Assessment Test (CAT)
Assess comorbidities
or
Clinical COPD Questionnaire (CCQ)
or
mMRC Breathlessness scale
Assessment of Symptoms
COPD Assessment Test (CAT): An 8-item

measure of health status impairment in COPD
(http://catestonline.org).
Clinical COPD Questionnaire (CCQ): Self-

administered questionnaire developed to
measure clinical control in patients with COPD
(http://www.ccq.nl).

Assessment of Symptoms
Breathlessness Measurement using the
Modified British Medical Research Council
(mMRC) Questionnaire: relates well to other
measures of health status and predicts future
mortality risk.

Modified MRC (mMRC)Questionnaire

Assessment of COPD
 Assess symptoms
 Assess degree of airflow limitation using
spirometry
Assess risk of exacerbations
Use spirometry for grading severity
according to spirometry, using four
grades split at 80%, 50% and 30% of
predicted value

Classification of Severity of Airflow

Limitation in COPD*
In patients with FEV1/FVC < 0.70:
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
*Based on Post-Bronchodilator FEV1 Disease

© 2015 Global Initiative for Chronic Obstructive Lung
Assessment of COPD
 Assess symptoms
spirometry
Use history of exacerbations and spirometry.
Two exacerbations or more within the last year
or an FEV1 < 50 % of predicted value are
indicators of high risk. Hospitalization for a COPD
exacerbation associated with increased risk of death.
Assess Risk of Exacerbations
To assess risk of exacerbations use history of

exacerbations and spirometry:
Two or more exacerbations within the last
year or an FEV1 < 50 % of predicted value
are indicators of high risk.
One or more hospitalizations for COPD
exacerbation should be considered high risk.

Combined Assessment of COPD
 Assess symptoms
spirometry
Combine these assessments for the

purpose of improving management of COPD
Prevention of COPD
Combined Assessment of
COPD
When assessing risk, choose the highest risk
according to GOLD grade or exacerbation
history. One or more hospitalizations for COPD
exacerbations should be considered high risk.)
Patient Characteristic Spirometric Exacerbations CAT mMRC

Classification per year
Low Risk
A GOLD 1-2 ≤1 < 10 0-1
Less Symptoms
Low Risk
B GOLD 1-2 ≤1 > 10 >2
More Symptoms
High Risk
C GOLD 3-4 >2 < 10 0-1
Less Symptoms
High Risk >2
D GOLD 3-4 >2 > 10
More Symptoms
Assess COPD Comorbidities

COPD patients are at increased risk for:
• Cardiovascular diseases
• Osteoporosis
• Respiratory infections
• Anxiety and Depression
• Diabetes
• Lung cancer
• Bronchiectasis
These comorbid conditions may influence mortality and
hospitalizations and should be looked for routinely, and
treated appropriately.

Differential Diagnosis:
COPD and Asthma
COPD ASTHMA
• Onset in mid-life • Onset early in life (often childhood)
• Symptoms slowly progressive • Symptoms vary from day to day
• Long smoking history • Symptoms worse at night/early morning
• Allergy, rhinitis, and/or eczema also present
• Family history of asthma

Additional Investigations
Chest X-ray: Seldom diagnostic but valuable to exclude
alternative diagnoses and establish presence of significant
comorbidities.
Lung Volumes and Diffusing Capacity: Help to characterize
severity, but not essential to patient management.
Oximetry and Arterial Blood Gases: Pulse oximetry can be
used to evaluate a patient’s oxygen saturation and need for
supplemental oxygen therapy.
Alpha-1 Antitrypsin Deficiency Screening: Perform when COPD
develops in patients of Caucasian descent under 45 years or
with a strong family history of COPD.
Additional Investigations
Exercise Testing: Objectively measured exercise
impairment, assessed by a reduction in self-paced walking
distance (such as the 6 min walking test) or during
incremental exercise testing in a laboratory, is a powerful
indicator of health status impairment and predictor of
prognosis.
Composite Scores: Several variables (FEV1, exercise
tolerance assessed by walking distance or peak oxygen
consumption, weight loss and reduction in the arterial
oxygen tension) identify patients at increased risk for
mortality.


Updated 2015
Syndrome (ACOS)
Therapeutic Options: Key Points
 Smoking cessation has the greatest capacity to

influence the natural history of COPD. Health care
providers should encourage all patients who smoke
to quit.
 Pharmacotherapy and nicotine replacement reliably
increase long-term smoking abstinence rates.
 All COPD patients benefit from regular physical
activity and should repeatedly be encouraged to
remain active.
Therapeutic Options: Key Points
 Appropriate pharmacologic therapy can reduce COPD

symptoms, reduce the frequency and severity of
exacerbations, and improve health status and
exercise tolerance.
 None of the existing medications for COPD has been
shown conclusively to modify the long-term decline
in lung function.
 Influenza and pneumococcal vaccination should be
offered depending on local guidelines.
Therapeutic Options: Smoking Cessation
 Counseling delivered by physicians and other health

professionals significantly increases quit rates over
self-initiated strategies. Even a brief (3-minute) period
of counseling to urge a smoker to quit results in
smoking quit rates of 5-10%.
 Nicotine replacement therapy (nicotine gum, inhaler,
nasal spray, transdermal patch, sublingual tablet, or
lozenge) as well as pharmacotherapy with varenicline,
bupropion, and nortriptyline reliably increases long-
term smoking abstinence rates and are significantly
more effective than placebo.
Brief Strategies to Help the
Patient Willing to Quit Smoking
• ASK Systematically identify all

tobacco users at every visit
• ADVISE Strongly urge all tobacco
users to quit
• ASSESS Determine willingness to
make a quit attempt
• ASSIST Aid the patient in quitting
• ARRANGE Schedule follow-up contact.
Therapeutic Options: Risk Reduction
 Encourage comprehensive tobacco-control policies with clear, consistent, and

repeated nonsmoking messages.
 Emphasize primary prevention, best achieved by elimination or reduction of
exposures in the workplace. Secondary prevention, achieved through surveillance
and early detection, is also important.
 Reduce or avoid indoor air pollution from biomass fuel, burned for cooking and
heating in poorly ventilated dwellings.
 Advise patients to monitor public announcements of air quality and, depending on
the severity of their disease, avoid vigorous exercise outdoors or stay indoors during
pollution episodes.

Therapeutic Options: COPD Medications
Beta2-agonists
Short-acting beta2-agonists
Long-acting beta2-agonists
Anticholinergics
Short-acting anticholinergics
Long-acting anticholinergics
Combination short-acting beta2-agonists + anticholinergic in one inhaler
Combination long-acting beta2-agonist + anticholinergic in one inhaler
Methylxanthines
Inhaled corticosteroids
Combination long-acting beta2-agonists + corticosteroids in one inhaler
Systemic corticosteroids
Phosphodiesterase-4 inhibitors
Therapeutic Options: Bronchodilators
 Bronchodilator medications are central to the

symptomatic management of COPD.
 Bronchodilators are prescribed on an as-needed or on a
regular basis to prevent or reduce symptoms.
The principal bronchodilator treatments are beta 2-
agonists, anticholinergics, theophylline or combination
therapy.
The choice of treatment depends on the availability of
medications and each patient’s individual response in
terms of symptom relief and side effects..
Therapeutic Options: Bronchodilators
 Long-acting inhaled bronchodilators are

convenient and more effective for symptom relief
than short-acting bronchodilators.
 Long-acting inhaled bronchodilators reduce
exacerbations and related hospitalizations and
improve symptoms and health status.
 Combining bronchodilators of different
pharmacological classes may improve efficacy and
decrease the risk of side effects compared to
increasing the dose of a single bronchodilator.
Therapeutic Options: Inhaled
Corticosteroids
 Regular treatment with inhaled corticosteroids
improves symptoms, lung function and quality of life
and reduces frequency of exacerbations for COPD
patients with an FEV1 < 60% predicted.
 Inhaled corticosteroid therapy is associated with an

increased risk of pneumonia.
 Withdrawal from treatment with inhaled

corticosteroids may lead to exacerbations in some
patients.
Therapeutic Options: Combination
Therapy
 An inhaled corticosteroid combined with a long-acting
beta2-agonist is more effective than the individual
components in improving lung function and health
status and reducing exacerbations in moderate to very
severe COPD.
 Combination therapy is associated with an increased
risk of pneumonia.
 Addition of a long-acting beta 2-agonist/inhaled
glucorticosteroid combination to an anticholinergic
(tiotropium) appears to provide additional benefits.
Therapeutic Options: Systemic
Corticosteroids
 Chronic treatment with systemic

corticosteroids should be avoided
because of an unfavorable benefit-to-
risk ratio.

Therapeutic Options:
Phosphodiesterase-4 Inhibitors
 In patients with severe and very severe

COPD (GOLD 3 and 4) and a history of
exacerbations and chronic bronchitis, the
phospodiesterase-4 inhibitor, roflumilast,
reduces exacerbations treated with oral
glucocorticosteroids.

Therapeutic Options: Theophylline
 Theophylline is less effective and less well tolerated than inhaled long-acting
bronchodilators and is not recommended if those drugs are available and
affordable.
 There is evidence for a modest bronchodilator effect and some symptomatic

benefit compared with placebo in stable COPD. Addition of theophylline to
salmeterol produces a greater increase in FEV1 and breathlessness than
salmeterol alone.
 Low dose theophylline reduces exacerbations but does not improve post-
bronchodilator lung function.

Therapeutic Options: Other
Pharmacologic Treatments
Influenza vaccines can reduce serious illness.

Pneumococcal polysaccharide vaccine is recommended
for COPD patients 65 years and older and for COPD
patients younger than age 65 with an FEV1 < 40%
predicted.
The use of antibiotics, other than for treating infectious

exacerbations of COPD and other bacterial infections, is
currently not indicated.

Therapeutic Options: Other
Pharmacologic Treatments
Alpha-1 antitrypsin augmentation therapy: not
recommended for patients with COPD that is unrelated
to the genetic deficiency.
Mucolytics: Patients with viscous sputum may benefit
from mucolytics; overall benefits are very small.
Antitussives: Not recommended.
Vasodilators: Nitric oxide is contraindicated in stable
COPD. The use of endothelium-modulating agents for
the treatment of pulmonary hypertension associated
with COPD is not recommended.
Therapeutic Options: Rehabilitation
 All COPD patients benefit from exercise training

programs with improvements in exercise tolerance
and symptoms of dyspnea and fatigue.
 Although an effective pulmonary rehabilitation
program is 6 weeks, the longer the program
continues, the more effective the results.
 If exercise training is maintained at home, the
patient's health status remains above pre-
rehabilitation levels.

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Obstructive Pulmonary Diseases

• For the respiratory system to succeed in oxygenating blood

Spirometry is very safe, rarely seen

GINA Global Strategy for Asthma

© Global Initiative for Asthma

It is defined by the history of respiratory symptoms such as

Treat for ASTHMA

GINA 2016, Box 1-1 (1/4) © Global Initiative for Asthma

Treat for ASTHMA Treat for alternative diagnosis

GINA 2016, Box 1-1 (2/4) © Global Initiative for Asthma

Consider trial of treatment for

Treat for ASTHMA Treat for alternative diagnosis

GINA 2016, Box 1-1 (3/4) © Global Initiative for Asthma

Empiric treatment with YES NO YES

Treat for ASTHMA Treat for alternative diagnosis

GINA 2016, Box 1-1 (4/4) © Global Initiative for Asthma

GINA 2016, Box 1-2

GINA 2016 © Global Initiative for Asthma

GINA Global Strategy for Asthma

© Global Initiative for Asthma

GINA 2016, Box 2-1

A. Symptom control Level of asthma symptom control

Yes No None of 1-2 of 3-4 of

GINA 2016, Box 2-2A © Global Initiative for Asthma

A. Symptom control Level of asthma symptom control

Yes No None of 1-2 of 3-4 of

GINA 2016, Box 2-2B (2/4) © Global Initiative for Asthma

GINA 2016, Box 2-2B (3/4) © Global Initiative for Asthma

GINA 2016, Box 2-2B (4/4) © Global Initiative for Asthma

GINA 2016, Box 2-4 (1/5) © Global Initiative for Asthma

If lung function normal during symptoms,

GINA 2016, Box 2-4 (2/5) © Global Initiative for Asthma

If lung function normal during symptoms,

Remove potential Check for risk factors or inducers such as

GINA 2016, Box 2-4 (3/5) © Global Initiative for Asthma

If lung function normal during symptoms,

Remove potential Check for risk factors or inducers such as

Consider step up to next treatment level.

GINA 2016, Box 2-4 (4/5) © Global Initiative for Asthma

Watch patient using their Compare inhaler technique with a device-

If lung function normal during symptoms,

Remove potential Check for risk factors or inducers such as

Consider step up to next treatment level.

If asthma still uncontrolled after 3–6 months

GINA 2016, Box 2-4 (5/5) © Global Initiative for Asthma

GINA Global Strategy for Asthma

© Global Initiative for Asthma

GINA 2016, Box 3-1

GINA 2016, Box 3-1

GINA 2016, Box 3-2

GINA 2016, Box 3-5 (2/8) (upper part)

• Provide guided self-management education

GINA 2016, Box 3-5 (3/8) (lower part)

Adults and adolescents

Beclometasone dipropionate (CFC) 200–500 >500–1000 >1000

GINA 2016, Box 3-6 (1/2)

GINA 2016, Box 3-7

This slide shows examples of interventions with high quality evidence

 Definition and Overview