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Chronic Obstructive Pulmonary Disease (COPD)

Updated : May 28, 2024





Background

A condition of progressive lung disease where it restricts airflow, which causes breathing difficulties is known as COPD. 

32 million individuals are affected by COPD, and it is the third leading cause of death in the US. COPD arises emphysema and chronic bronchitis that causes breathlessness in progressive lung diseases. 

Major cause of COPD is prolonged inhalation of pollutants, mainly from smoking. 

Epidemiology

NHIS finds 18 emphysema cases per 1000 persons and 34 chronic bronchitis cases per 1000. Global COPD prevalence is unclear, but it ranges from 7% to 19%. 

Burden of Obstructive Lung Disease study showed global obstructive lung disease prevalence at 10.1%, men at 11.8% and women at 8.5%. 

Underdiagnosed disease, patients seek care in late stages, which causes issues with diagnosis and treatment effectiveness. 

Anatomy

Pathophysiology

COPD causes chronic changes in large airways, small bronchioles, and lung parenchyma.  

Airway remodelling is a process characterized by the thickening of airway walls, increased mucus production, and fibrosis, which result in long-term inflammation in the airways. 

Etiology

Smoking causes macrophages to release chemicals that destroy respiratory tissue. Second-hand smoke harms lungs, worsens asthma, and raises risk of respiratory infections.  

Airway responsiveness in smoking patients increases risk of COPD, that occurs accelerated decline in lung function. 

Genetics

Prognostic Factors

The absolute mortality rates for US patients aged 25 and older due to COPD were 77.3 deaths per 100,000 males and 56.0 deaths per 100,000 females. 

It is found that heart disease, depression, underweight are linked to lower health-related quality of life in COPD. 

Clinical History

COPD affects older adults, mostly diagnosed individuals over 40 years old. 

 

Physical Examination

Respiratory Assessment 

Chest Examination 

Peripheral Examination 

Functional Assessment 

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Initial mild symptoms progress to worsen severity and frequency with cough, shortness of breath during exertion. 

Exposure to irritants, weather changes, or illnesses may trigger symptoms. 

Differential Diagnoses

Asthma 

Congestive Heart Failure 

Pulmonary Embolism 

Bronchiectasis 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

The use of Bronchodilator therapy, oxygen therapy and pulmonary rehabilitation is very effective in the treatment of COPD. 

Supportive care and preventive measures should be considered to improve the overall health and quality of life of patients. 

Medication with inhaled corticosteroids and Phosphodiesterase-4 (PDE-4) Inhibitors should be given to patients.  

Appointments with medical physicians and preventing recurrence of disorder is an ongoing life-long effort. 

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

Use of a non-pharmacological approach for treating COPD

Patients should stop smoking to prevent further damage to their lungs. 

Patients should avoid environments with high levels of smoke and always stay inside a smoke-free environment. 

Patient should stay in adequate conditions with good ventilation, air quality and a clean environment. 

Education should be given to individuals about cautious with activities that could cause pulmonary disease. 

Use of Anticholinergics drugs

Ipratropium bromide: It is used with a beta-2 agonist that enhances bronchodilation with 2 to 4 puffs administered every 6 to 8 hours. It has a slow onset and longer duration and is less ideal for as-needed use. 

Tiotropium: Quaternary ammonium compound causes bronchodilation through M3 receptor inhibition thus they have anticholinergic and antimuscarinic effects. 

Use of Xanthine Derivative

Theophylline metabolized by liver enzyme system which affected by age, heart conditions, liver issues. Monitor serum levels to prevent toxicity. 

Use of Phosphodiesterase-4 Inhibitors

Roflumilast inhibits PDE-4, which reduces exacerbations and symptoms in severe COPD patients. 

Use of Corticosteroids (Inhaled)

Fluticasone relaxes muscles, reduces inflammation, lowers hyperresponsiveness in airways, inhibiting bronchoconstriction. 

Use of Antibiotics

Cefuroxime: It is a second-gen cephalosporin, that binds to penicillin-binding proteins and inhibits transpeptidation for cell wall death. 

 

Use of Intervention with a procedure in treating COPD

Direct bronchoscopy administers bronchodilators for targeted airway relief. 

Bronchial Thermoplasty: Thermal energy delivered to airway walls reduces smooth muscle mass to improve airflow in patients. 

Endobronchial stents help manage severe airway blockage from COPD complications by maintaining airway openness and enhancing airflow. 

Use of phases in managing COPD

A detailed family history and physical examination of patient is conducted by healthcare specialist in diagnosis phase to identify signs and symptoms of pulmonary disease. 

The regular follow-up visits with the physician are required to check the improvement of patients and newly observed complaints. 

Long-term management phase is a very important phase which involves continuous monitoring, supportive care, and surveillance for late effects of treatment. 

Medication

 

formoterol

20

mg

inhaled by nebulizer twice a day
or
1 or 2 capsules inhaled every 12 hours (Do not exceed 4 capsules/day)



arformoterol

15

mcg

oral inhalation twice a day



indacaterol

1 capsule (75 mcg) is inhaled once a day



levalbuterol

Nebulization solution: 0.63 mg to 1.25mg oral inhalation every 1 hour for 2 to 3 doses or as needed
Metered-dose inhaler: 1 to 2 oral inhalations every 1 hour for 2 to 3 doses or as needed



ipratropium

Inhaler:

2

actuations

every 6 hrs


Do not exceed 12 actuations per day
Nebulizer: 2.5 mL every 6-8hours



epinephrine 

MD:

1 - 1

mcg/m²

Capsules

Aerosol

3 times a day

1 - 1

minutes

CM



Dose Adjustments

AD

roflumilast 

500

mcg

Tablet

Orally 

once a day

4

weeks



olodaterol/tiotropium 

Inhalation mouth spray:

Mouth spray

Inhalation

Each actuation=2.5mcg tiotropium(3.124mcg tiotropium bromide monohydrate) and 2.5mcg olodaterol(2.736mcg olodaterol hydrochloride
Chronic obstructive pulmonary disorder
Two inhalations orally every day at the same time



cefpodoxime 

200

mg

Orally 

every 12 hrs

10

days


Note: It is indicated for Acute Bronchitis & Acute Exacerbation of Chronic Bronchitis



glycopyrrolate inhaled and formoterol 

Mouth spray

Orally inhaled

twice a day

Two inhalations (Formoterol 18mcg/ Glycopyrrolate inhaled 9 mcg for each inhalation)
Do not exceed two inhalations per day



amoxicillin 

Mild/moderate/severe:

875

mg

every 12 hrs or 500mg every 8hrs



clarithromycin 

Acute exacerbation:

500 mg oral tablet immediate release every 12 hours for 5 to 7 days
Note: Not recommended for with risk infection of Pseudomonas



moxifloxacin 

chronic exacerbation
:


400mg orally/intravenous every day for five days



gemifloxacin 

320mg orally every day for five days



aclidinium and formoterol 

One inhalation orally twice a day. Do not exceed one inhalation per day



cefixime 

Indicated for Acute Exacerbations of Chronic Bronchitis:

400

mg/day

Orally 

Single dose or divided every 12hr



salbutamol 

Aerosol Metered dose inhaler
1 to 2 inhalations in 2-3 doses every hour, then every 2 to 4 hours



ciprofloxacin 

In the case of mild/moderate infections: 500 mg orally every 12 hours or 400 mg intravenously every 12 hours for 7-14 days
In the case of severe/complicated infections: 750 mg orally every 12 hours or 400 mg intravenously every 8 hours for 7-14 days
Limitations for usage: Reserve the fluoroquinolones for patients who are voided of available treatment options for chronic bronchitis



tetracycline 

A dose of 500 mg orally every 12 hours or 250 mg orally every 6 hours is indicated in chronic bronchitis infection



azithromycin 

3 days of 500 mg orally every day OR Instead, take 500 mg orally in a single dosage on Day 1, then 250 mg orally every day from Days 2 to 5



red clover 

Indicated for Cancer, skin sores, asthma, bronchitis :


4 mg of flower tops orally three times a day
Or
4 gm of flower tops in 150 ml of water;1 cup of tea orally three times a day
Or
1.5-3 ml of liquid extract orally three times a day;1:1 in 25% alcohol
1-2 ml of tincture orally three times a day;1:10 in 45% alcohol



red clover 

Indicated for Cancer, skin sores, asthma, bronchitis :


4 mg of flower tops orally three times a day
Or
4 gm of flower tops in 150 ml of water;1 cup of tea orally three times a day
Or
1.5-3 ml of liquid extract orally three times a day;1:1 in 25% alcohol
1-2 ml of tincture orally three times a day;1:10 in 45% alcohol



cefditoren 

Exacerbation of chronic bronchitis by acute bacteria Take 400 mg orally after every 12 hours up to 10 days



aclidinium 

inhaling 400 mcg (1 puff) orally two times daily



revefenacin 

Using a mouthpiece on a nebulizer, inhale 175 mcg orally every day
Administer every day at the same time
Do not exceed 175mg daily once



Dose Adjustments

Renal impairment
Any level of impairment: No change in dose is necessary.
Patients with COPD with substantial renal impairment should be monitored for systemic antimuscarinic side effects.

Hepatic impairment
Mild-to-severe: Safety has not been determined; individuals with any degree of hepatic impairment are not recommended

tiotropium 

It is indicated in the maintenance of bronchospasm that is linked to COPD, helping in COPD exacerbations
Spiriva Handihaler- 2 inhalations from a capsule orally each day through the HandiHaler device
Spiriva Respimat- 2 actuation of 2.5 mcg each, inhaled orally daily



indacaterol, inhaled/glycopyrrolate inhaled 

Indicated for long-term maintenance of COPD
Inhale the contents orally through one capsule every 12 hours by a neo haler device



umeclidinium bromide/vilanterol inhaled 

Indicated for long-term maintenance of COPD that includes emphysema and chronic bronchitis
62.5 mcg/25mcg as one actuation inhaled orally each day
Do not exceed more than one inhalation each day



budesonide inhaled/formoterol/glycopyrrolate inhaled 

2 inhalations orally two times daily
Dosage Modifications
Renal impairment
Study not carried out
Hepatic impairment
Study not carried out
Dosing Considerations
Limitations of use: Not suggested for in acute bronchospasm



albuterol/ipratropium 

Aerosol: Administer 100 mcg/20 mcg (1 metered-dose inhaler actuation) every six hours
Do not exceed more than six actuations daily.
Nebulizer: Administer 3ml inhalation every 6 hours.
Do not exceed 3ml every 4 hours.



batefenterol 

(off-label):

By using a dry powder inhaler, The administration of batefenterol at a dose of 300 µg for a duration of 42 days
Note: The dosage of 300 µg of batefenterol could be considered as the most suitable for clinical trials (phase III)



carbocisteine 

Indicated as mucolytic agent:

Administer 750 mg to 2.25 g daily in three to four divided doses



clenbuterol 

Take a dose of 20 mcg orally two times a day
Daily dose should not be more than 60 mcg



procaterol 

Inhaled a dose of 20 mcg up to 4 times daily



grepafloxacin 


Indicated for Chronic bronchitis
400 mg to 600 mg orally one time a day for nearly 10 days
Community-acquired pneumonia
600 mg orally one time a day for nearly 10 days
Uncomplicated gonorrhea
400 mg orally one time
Cervicitis or Nongonococcal urethritis
400 mg orally one time a day for nearly 7 days



loracarbef 

For one week, take 400 mg two times a day by oral route



rimiterol 

As metered-dose aerosol:
Inhaled dose of 250 to 500 mcg when required
Dose should not be more than 8 times in a day
Do not repeat dose in less than 1 hour



lomefloxacin 

Take 400 mg by oral route one time daily for ten days duration



abediterol 

It assesses four separate inhaled abediterol dosages at 0.625 ug, 2.5 ug, 5 ug & 10 ug Comparing the results to a placebo, it was evident that all doses considerably improved bronchodilation Comparing the doses of 2.5, 5, and 10 ug to the active comparator, further improvements were observed



ethylephedrine 

5 ml of this drug every 3 to 5 hours is recommended, which should be at most 30 ml daily
This drug is used for treating bronchial congestion and bronchospasm, which are associated with acute and chronic bronchitis



etophylline and theophylline 

115 mg of etophylline and 35 mg of theophylline is given once a day



almitrine 

It is used as a respiratory stimulant used in the therapy for acute respiratory failure such as COPD
The usual dose via oral administration given as a tablet is 50 -100 mg, which is divided into two doses per day
The usual dose via IV administration is 1-3 mg/kg per day, which is given in divided doses which is infused for over 2 hours



Dose Adjustments

Limited data is available

cefodizime 

Administer 1 to 2 g once or twice a day intramuscularly or intravenous infusion.
Maximum dose-4 g/day.

Renal impairment
CrCl 10 to 30ml/min-Administer 1 to 2 g every day.
CrCl<10ml/min- Administer 0.5 to 1 g every day.



acebrophylline 

Take a dose of 100 mg orally two times daily



albuterol/ipratropium 

Aerosol: 100mcg albuterol /20mcg ipratropium bromide (1 actuation of metered-dose inhaler) every 6 hours; should not exceed more than 6 actuations/day
Nebulizer solution: 3 mL is inhaled every 6hours; should not exceed more than 3 mL every 4hours



bromotheophylline 

Take one tablet/capsule after the breakfast with a glass of water. Dose can be repeated every six hours, should not exceed more than four capsules daily



glycopyrrolate 

solution

Inhalation

Using the nebulization system, inhale the contents of the vial two times a day
Capsules for inhalation
using an inhaler, inhale the capsule contents twice daily



dirithromycin 

500 mg is given orally once every day for one week



bitolterol 

Administer 2 inhaled aerosols dose at an interval of minimum 1 to 3 minutes followed by a third inhalation



ephedra sinica root 

Take a dose of 32 mg orally daily



enprofylline 

Administer 150mg twice a day, can increase the dose to 300mg to 450mg twice a day based on the patient's tolerance.



flurithromycin 

375

mg

Tablets

Orally 

twice a day

2

weeks



Dose Adjustments

Off-label

pf-00610355 

280

mcg