Doenças Pulmonares Obstrutivas2017

1
DOENÇAS PULMONARES
José Eduardo Oliveira

Serviço de Pneumologia / UCIP
Hospital de Braga
DOENÇAS PULMONARES
José Eduardo Oliveira
Serviço de Pneumologia / UCIP
Hospital de Braga
2013
Doenças Pulmonares
¤ Obstrutivas
■ Asma
■ Enfisema
■ Bronquite crónica
■ Bronquiectasias
■ Fibrose quistica
¤ Restritivas
■ Restritivas no parenquima pulmonar
■ Sarcoidose
■ Pneumoconiose
■ Doenças do conjuntivo
■ Fibrose pulmonar
■ ….
■ Restritivas no parede toracica
■ Cifoescoliose, # costais, Espondilite anquilosante
■ Pneumotorax, derrames pleurais, paquipleurite
■ Restritivas por doença neuromuscular
Doenças Pulmonares Obstrutivas
Causas mais comuns
◻ Asma brônquica
◻ Doença Pulmonar Obstrutiva Crônica (DPOC) -
Bronquite Crônica - Enfisema Pulmonar
ACOS (Asma - COPD Overlap Sindrome)
◻ Bronquiectasias
◻ Bronquiolites
Doença Pulmonar Obstrutiva Crónica
CODP
Global Strategy for Diagnosis, Management and Prevention of COPD
Definition of COPD
n 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.
n Exacerbations and comorbidities contribute to the

overall severity in individual patients.
© 2014 Global Initiative for Chronic Obstructive Lung Disease

7
GOLD Objectives
► To provide a non-biased review of the current

evidence for the assessment, diagnosis and treatment
of patients with COPD.
► To highlight short-term and long-term treatment

objectives organized into two groups:
➢ Relieving and reducing the impact of symptoms,
and
➢ Reducing the risk of adverse health events that
may affect the patient in the future.
► To guide symptoms assessment and health status

measurement.

DPOC
◻ Sintomas
¤ Dispnéia
¤ Sibilância
¤ Tosse
¤ Produção de expectoração
¤ Intolerância ao exercício
¤ Ansiedade e depressão
Bronquite crónica
◻ bronquite crônica:
¤ tosse produtiva (com expectoração) na maioria dos dias, por pelo
menos três meses ao ano, em dois anos consecutivos
Enfisema pulmonar
◻ Enfisema pulmonar:
¤ Alargamento anormal e permanente dos
espaços aéreos distais ao bronquiolo
terminal, com destruição da parede sem
fibrose
¤ os tecidos dos pulmões são gradualmente
destruídos, tornando-se hiperinsuflados
(muito distendidos).
◻
Fonte: GUYTON, A.C.; HALL, J.E. Tratado de Fisiologia Médica.9ªed. RJ: Guanabara
Koogan, 1997.
DPOC
DPOC x ASMA BRÔNQUICA
DPOC ASMA
Início após 40 anos Início na infância
Antecedente de atopias Antecedente de atopias

ausente presente
História familiar de asma História familiar de asma

ausente presente
DPOC x ASMA BRÔNQUICA
DPOC ASMA
Tabagismo
Tabagismo ausente
> 20 anos / maço
Melhoria variável com Melhoria acentuada com

tratamento tratamento
Obstrução parcialmente
Obstrução reversível
reversível
Diagnosis
◻ Diagnosis of COPD should be considered in any patient who
has the following:
¤ • symptoms of cough
¤ • sputum production or
¤ • dyspnoea or
¤ • history of exposure to risk factors for the disease.
◻ The diagnosis requires spirometry;

¤ post-bronchodilator FEV1/forced vital capacity <0.7 confirms the
presence of airflow limitation that is not fully reversible.
COPD Definition
► Chronic Obstructive Pulmonary Disease (COPD) is a

common, preventable and treatable disease that is
characterized by persistent respiratory symptoms and
airflow limitation that is due to airway and/or alveolar
abnormalities usually caused by significant exposure
to noxious particles or gases.

Chronic Obstructive Pulmonary Disease
(COPD)
► COPD is currently the fourth leading cause of death in
the world.1
► COPD is projected to be the 3rd leading cause of

death by 2020.2
► More than 3 million people died of COPD in 2012

accounting for 6% of all deaths globally.
► Globally, the COPD burden is projected to increase in

coming decades because of continued exposure to
COPD risk factors and aging of the population.
1. Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a
systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380(9859): 2095-128.
2. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med 2006; 3(11): e442.

Definition and Overview
OVERALL KEY POINTS (1 of 2):
► Chronic Obstructive Pulmonary Disease (COPD) is a

common, preventable and treatable disease that is
characterized by persistent respiratory symptoms and
airflow limitation that is due to airway and/or alveolar
abnormalities usually caused by significant exposure
to noxious particles or gases.
► The most common respiratory symptoms include

dyspnea, cough and/or sputum production. These
symptoms may be under-reported by patients.
► The main risk factor for COPD is tobacco smoking but

other environmental exposures such as biomass fuel
exposure and air pollution may contribute.

Factos acerca da DPOC
◻ A DPOC é a 4ª causa de morte nos Estados Unidos (a

seguir às doenças cardíacas, cancro e doenças cérebro-
vasculares).
◻ Em 2000, a OMS avaliou em 2,74 milhões o número
de mortes por DPOC no Mundo.
◻ Em 1990, DPOC foi classificada como a 12ª doença
em termos de peso para a saúde; em 2020, calcula-se
que seja a 5ª.
Prevalence
Prevalence of COPD
► Systematic review and meta-analysis (Halbert et al,

2006)
► Included studies carried out in 28 countries between

1990 and 2004
► Prevalence of COPD was higher in smokers and ex-

smokers compared to non-smokers
► Higher ≥ 40 year group compared to those < 40
► Higher in men than women.

Prevalence
Prevalence of COPD
► Estimated 384 million COPD cases in 2010.
► Estimated global prevalence of 11.7% (95% CI 8.4%–

15.0%).
► Three million deaths annually.
► With increasing prevalence of smoking in developing

countries, and aging populations in high-income
countries, the prevalence of COPD is expected to rise
over the next 30 years.
► By 2030 predicted 4.5 million COPD related deaths

annually.

Factos acerca da DPOC
▪ O fumo do cigarro é a principal causa de DPOC.
▪ Nos EUA 47,2 milhões de pessoas (28% dos homens e

23% das mulheres) fumam.
▪ A OMS avalia em 1,1 biliões os fumadores em todo o

mundo, prevendo-se que aumente para 1,6 bilhões em
2025. Nos países de rendimento baixo e médio, as taxas
estão a aumentar a um ritmo alarmante.
Alteração percentual das taxas de mortalidade ajustadas à
idade
E.U.A.: 1965-1998
Proporção da taxa de 1965
3.0
Doença AVC Outras DCV DPOC Todas
3.0
coronária as outras
2.5 causas
2.0 2.3
1.5 1.5
1.0
0.8
0.5
0.0
–59% –64% –35% +163% –7%
0
1965 - 1998 1965 - 1998 1965 - 1998 1965 - 1998 1965 - 1998
Murray and Lopez Lancet 1997
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CAUSAS DE MORTALIDADE
1990 2020
1. Dça Isquémica coronária 1. Dça Isquémica coronária
2. Dça Cerebro-vascular 2. Dça Cerebro-vascular
3. Infecções respiratórias 3. DPOC
4. Desinterias 4. Infecções respiratórias
5. Problemas neo-natais 5. Cancro do Pulmão
6. DPOC 6. Acidentes de Viação
7. Tuberculose 7. Tuberculose
8. Sarampo 8. Cancro do estômago
9. Acidentes de Viação 9. SIDA
10. Cancro do Pulmão 10. Auto agressões
Global Health Statistics

Epidemiologia, Factores de Risco
História natural
East
Itália 11%
Espanha (IBERPOC) 9.1%
Japão (NICE) 8.5%
EUA (NHANES III) 6.8%
Hong Kong 6.8%
Noruega 4.5%
Portugal 5.3%
0% 3% 6% 8% 11% 14%
Aspectos epidemiológicos
(norma DGS 028/2011 actualizada 2013)
30
• A prevalência da DPOC em Portugal atinge 14.2% nos indivíduos adultos com mais
de 40 anos de idade (Estudo BOLD Portugal)
• O número de internamentos por DPOC entre 2000 e 2008, aumentou cerca de 20%
representando um custo superior a 25 milhões de euros, o que equivale a um aumento de
39.2%. (DGS 2013)
• O custo por doente internado também aumentou 16% (DGS) .
De acordo com um estudo de 2006 efetuado em doentes internados, o custo médio

anual de um doente com DPOC muito grave atinge mais de 8.000 euros, enquanto os
estádios menos graves variam entre 2.000 e os 4.000 euros (DGS, 2013).
Definição de DPOC
É uma doença prevenivel e tratável com repercussões extra pulmonares

que podem contribuir para a gravidade da saúde individual.
O componente pulmonar caracteriza-se por limitação do fluxo aéreo que

não é completamente reversível.
A limitação do fluxo aéreo é habitualmente progressiva e associada a uma

resposta inflamatória anormal do pulmão a partículas e gases nocivos
Pontos Chave
◻ Limitação do fluxo aéreo é causada:
¤ Doença das pequenas vias aéreas (bronquiolite obstrutiva)
¤ Destruição do parênquima (enfisema)
◻ O contributo relativo de cada componente variável de

indivíduo para indivíduo
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
Pontos Chave
◻ A história natural da doença é variável de indivíduo para

indivíduo
◻ Geralmente progressiva, particularmente se a exposição a

factor de risco permanecer
Pontos Chave
◻ O impacto da DPOC no indivíduo depende

¤ Gravidade dos sintomas
■ Grau de dispneia
■ Diminuição da capacidade de exercício
■ Efeitos sistémicos
■ Co-morbilidades
¤ Não dependente do grau de obstrução funcional

Factores de Risco
Pontos Chave
◻ Em todo o mundo o fumo de tabaco é o factores de risco

mais frequentemente encontrado
◻ Factor de risco genético melhor documentado é o défice de

alfa 1 anti tripsina
¤ Funciona como modelo de outros potenciais factores de risco
genéticos
Factores de Risco
Pontos Chave
◻ Das várias exposições inalatórias, apenas o fumo de tabaco e

poeiras/químicos ocupacionais são por si só causa de DPOC. São
necessários mais estudos para explorar o papel de outros factores de
risco.
◻ A poluição indoor, em particular a resultante da combustão em

espaços fechados, está associada ao aumento de risco de DPOC nos
países em desenvolvimento, especialmente nas mulheres
Factores de risco para a DPOC
•Genéticos – alfa1 anti tripsina
•Exposição a particulas
•Tabaco
•Exposição profissional a partículas orgânica e inorgânicas
•Poluição indoor (fumos de combustão para aquecimento e fogão em locais
mal ventilados)
•Poluição outdoor
•Crescimento e desenvolvimento do pulmão
•Stress oxidativo
Alpha-1 antitrypsin deficiency (AATD)
AATD screening
► The World Health Organization recommends that all patients

with a diagnosis of COPD should be screened once especially
in areas with high AATD prevalence.
► AATD patients are typically < 45 years with panlobular basal

emphysema
► Delay in diagnosis in older AATD patients presents as more

typical distribution of emphysema (centrilobular apical).
► A low concentration (< 20% normal) is highly suggestive of

homozygous deficiency.

Risk Factors for COPD
Nutrition
Infections
Socio-economic status
Aging Populations
Diagnosis and Initial Assessment

Prevalência DPOC
◻ Dados recentes apontam para a evidência de que a
prevalência de DPOC ligeiro ou estadios mais
graves é apreciavelmente mais elevada em
¤ Fumadores ou ex-fumadores
¤ > 40 anos
¤ Sexo masculino
Patogenese
◻ As alterações patológicas características da DPOC
encontram-se:
¤ Vias aéreas proximais
¤ Vias aéreas periféricas
¤ Parênquima pulmonar
¤ Componente vascular pulmonar
◻ Incluem :
¤ Inflamação crónica e alterações estruturais resultantes de
processos repetidos de lesão e reparação
INFLAMAÇÃO
Doença das pequenas vias Destruição do parênquima
Inflamação das vias aéreas Perda das ligações alveolares

Remodelação das vias aéreas Diminuição da retracção elástica
LIMITAÇÃO DO FLUXO AÉREO

Alterações no parênquima
pulmonar na DPOC
Destruição da parede alveolar
Perda de elasticidade
Destruição do leito capilar

pulmonar
↑ Cel. inflamatórias
macrofagos, CD8+ linfocitos
Source: Peter J. Barnes, MD

ASMA DPOC
alergeneo Fumo cigarro
Y
Y Y
Cel epiteliais mastocitos macrofagos Cel epiteliais
CD4+ Eosinofilo CD8+ Neutrofilo

(Th2) (Tc1)
Broncoconstrição Inflamação peq. vias
HRB Destruição alveolar
Reversível Limitação fluxo aéreo Irreversível
Source: Peter J. Barnes, MD

47
Causas de limitação do fluxo aéreo
◻ Irreversível
¤ Fibrose e estreitamento das vias aéreas

¤ Perda da retracção elástica devida a destruição alveolar
¤ Destruição do suporte alveolar que mantém abertas as vias aéreas
◻ Reversível
¤ Acumulação de células inflamatórias, muco e exsudação de plasma

para os brônquios
¤ Contracção do músculo liso nas vias aéreas centrais e periféricas
¤ Hiperinsuflação dinâmica durante o exercício
Fisiopatologia
◻ As alterações fisiopatológicas características da doença
incluem :
¤ Hipersecreção de muco
¤ Limitação de fluxo aéreo
¤ “ Air-trapping”
¤ Alterações das trocas gasosas
¤ Cor pulmonale
Fisiopatologia
◻ As repercussões sistémicas da DPOC, particularmente na
doença grave incluem :
¤ Caquexia
¤ Perda de massa muscular
¤ Aumento de risco de doença cardio vascular
¤ Anemia
¤ Osteoporose
¤ Depressão
Avaliação e Monitorização da doença: Pontos-Chave
◻ A espirometria é “ gold standard” para

¤ Diagnóstico
¤ Monitorização
◻ Método mais reprodutível, estandardizado e objectivo de medição da

limitação aérea
◻ DPOC é uma doença habitualmente progressiva com agravamento

gradual da função respiratória ao longo do tempo, apesar de
tratamento indicado
Diagnóstico de DPOC
EXPOSIÇÃO A FACTORES
SINTOMAS DE RISCO
tosse
tabaco
expectoração
ocupação
dispneia
poluição interior / exterior
ESPIROMETRIA
53
Classification of severity of airflow limitation

Assessment of Exacerbation Risk
► COPD exacerbations are defined as an acute worsening of

respiratory symptoms that result in additional therapy.
► Classified as:
➢ Mild (treated with SABDs only)
➢ Moderate (treated with SABDs plus antibiotics and/or oral
corticosteroids) or
➢ Severe (patient requires hospitalization or visits the
emergency room). Severe exacerbations may also be
associated with acute respiratory failure.
► Blood eosinophil count may also predict exacerbation rates (in
patients treated with LABA without ICS).

Relatório do “Workshop” GOLD
Quatro Componentes do Tratamento da DPOC
1. Avaliar e monitorizar a doença

2. Reduzir os factores de risco
3. Tratar a DPOC estável

l Educação
l Farmacológico
l Não farmacológico
4. Tratar as exacerbações
Global Strategy for Diagnosis, Management and
Prevention of COPD, 2014: Chapters
n Definição e Panorâmica
n Diagnostico e Avaliação
n Terapêutica
n DPOC estado estável
n Exacerbações
n Comorbilidades
n Asthma COPD Overlap
Updated 2014 Syndrome (ACOS)

Manage Stable COPD: Goals of Therapy
▪ Relieve symptoms
▪ Improve exercise tolerance Reduce
▪ Improve health status symptoms
▪ Prevent disease progression

▪ Prevent and treat exacerbations Reduce
▪ Reduce mortality risk

Reduzir os Factores de Risco
Pontos Chave
n A cessação tabágica é a intervenção mais eficaz e com

melhor custo/eficácia para reduzir o risco de
desenvolver DPOC e interromper a sua progressão
(Evidência A).
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.
Reduzir os Factores de Risco Pontos
Chave
n O aconselhamento efectuado pelos médicos e outros
profissionais de saúde aumenta significativamente as taxas
cessação tabágica por auto iniciativa.
n Um aconselhamento breve ( 3 min) consegue que um fumador
deixe de fumar com taxas sucesso de cerca de 5 a 10 %
n 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.
62
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.
Reduzir os Factores de Risco
Poluição indoor e outdoor
n A redução de poluição indoor e outdoor requer a
combinação de medidas protectoras publicas e individuais
n A redução da exposição ao fumo resultante da combustão

de biomassa, particularmente entre as mulheres e as
crianças, é um ponto crucial para reduzir a prevalência de
DPOC no mundo
Evidence Supporting Prevention &
Maintenance Therapy
► Smoking cessation is key. Pharmacotherapy and nicotine replacement

reliably increase long-term smoking abstinence rates.
► The effectiveness and safety of e-cigarettes as a smoking cessation
aid is uncertain at present.
► Pharmacologic therapy can reduce COPD symptoms, reduce the
frequency and severity of exacerbations, and improve health status
and exercise tolerance.
► Each pharmacologic treatment regimen should be individualized and
guided by the severity of symptoms, risk of exacerbations, side-effects,
comorbidities, drug availability and cost, and the patient’s response,
preference and ability to use various drug delivery devices.
► Inhaler technique needs to be assessed regularly.
Maintenance Therapy
► Influenza vaccination decreases the incidence of lower respiratory

tract infections.
► Pneumococcal vaccination decreases lower respiratory tract
infections.
► Pulmonary rehabilitation improves symptoms, quality of life, and
physical and emotional participation in everyday activities.
► In patients with severe resting chronic hypoxemia, long-term oxygen
therapy improves survival.
► In patients with stable COPD and resting or exercise-induced
moderate desaturation, long-term oxygen treatment should not be
prescribed routinely. However, individual patient factors must be
considered when evaluating the patient’s need for supplemental
oxygen. © 2017 Global Initiative for Chronic Obstructive Lung Disease
Maintenance Therapy
► In patients with severe chronic hypercapnia and a history of

hospitalization for acute respiratory failure, long-term non-invasive
ventilation may decrease mortality and prevent re-hospitalization.
► In select patients with advanced emphysema refractory to optimized

medical care, surgical or bronchoscopic interventional treatments may
be beneficial.
► Palliative approaches are effective in controlling symptoms in

advanced COPD.

Therapeutic Options: Key Points
▪ Terapêutica farmacológica apropriada

▪ Reduz sintomas
▪ Reduz frequência e severidade de exacerbações
▪ Melhora globalmente a saúde e bem estar e a
tolerância ao exercício.
▪ Nenhuma medicação modificou no entanto o declínio da
função pulmonar.
▪ Vacinação para Influenza and vacinação pneumocócica

Vaccination
► Influenza vaccination can reduce serious illness (such as lower

respiratory tract infections requiring hospitalization)24 and
death in COPD patients.
► Pneumococcal vaccinations, PCV13 and PPSV23, are

recommended for all patients ≥ 65 years of age

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-agonists + anticholinergic in one inhaler
Methylxanthines
Inhaled corticosteroids
Combination long-acting beta2-agonists + corticosteroids in one inhaler
Systemic corticosteroids
Phosphodiesterase-4 inhibitors
Pharmacologic Therapy

Pharmacologic Therapy

Anti-inflammatory Therapy in Stable COPD

Other Pharmacologic Treatments

Rehabilitation, Education & Self-
Management

Tratamento da DPOC estável
Pontos Chave
◻ Os broncodilatores são os fármacos principais para o

tratamento sintomático da DPOC (Evidência A). São
administrados à medida da necessidade ou de forma
regular para prevenir ou reduzir os sintomas.
◻ Os principais fármacos broncodilatadores são b2-agonistas,
anticolinérgicos, teofilina e uma associação destes
fármacos (Evidência A).
◻ A terapêutica inalatória é a preferível.
Broncodilatadores na DPOC estável
◻ A associação de broncodilatadores pode melhorar a eficácia e diminuir

o risco de efeitos colaterais em alternativa ao aumento de dose de um
único broncodilatador.
◻ O tratamento com anticolinérgicos de curta acção reduz o nº de

exacerbações e melhora a resposta à reabilitação pulmonar
◻ Nos doentes em tratamento regular com broncodilatadores de acção

longa e sintomáticos a associação de teofilina pode ser benéfica
Management of Stable COPD
Pharmacotherapy: Bronchodilators
▪ Bronchodilator medications are central to the

symptomatic management of COPD (Evidence A).
▪ Bronchodilators are prescribed on an as-needed or on a
regular basis to prevent or reduce symptoms.
▪ The principal bronchodilator treatments are ß 2- agonists,
anticholinergics, and methylxanthines used singly or in
combination (Evidence A).
▪ Long-acting bronchodilators are more effective and
convenient than treatment with short-acting bronchodilators
(Evidence A).
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.
Pontos Chave
◻ O tratamento regular com corticosteróides inalados melhora os

sintomas, a função pulmonar e a qualidade de vidade doentes com
DPOC e reduz a frequência das exacerbações em doentes com FEV <
60% previsto.
◻ Suspensão dos corticoides inalados na DPOC pode ocasionar
exacerbações nalguns doentes.
◻ Corticoides inalados aumentam o risco de Pneumonia
◻ Não devem ser usados em monoterapia

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.
▪ Addition of a long-acting beta2-agonist/inhaled glucorticosteroid

combination to an anticholinergic appears to provide additional
benefits.
▪ Combination therapy is associated with an increased risk of

pneumonia.

Pharmacotherapy: 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.
Pontos Chave
◻ O tratamento crónico com corticosteróides sistémicos

deve ser evitado devido a uma relação risco-benefício
menos favorável (Evidência A).
◻ Todos os doentes com DPOC beneficiam com
programas de treino de exercício, melhorando quer a
tolerância ao exercício quer os sintomas de dispneia e
fadiga (Evidência A).
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.

Vacinas e antibióticos
◻ Nos doentes com DPOC a vacina anti gripal pode prevenir doença grave
( Evidencia A )
◻ A vacina anti pneumococica está recomendada em doentes com DPOC:

¤ >65 anos
¤ < 65 anos e FEV1 < 40% ( Evidencia B )
¤ Vacina de 23 serotipos / Vacina conjugada 13 serotipos
◻ O uso de antibióticos fora das exacerbações não está indicado

Pontos Chave
◻ Demonstrou-se que a administração de oxigénio de

longa duração (> 15 horas por dia) a doentes com
insuficiência respiratória crónica aumenta a
sobrevida (Evidência A).
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.
Tratamento da DPOC em função da gravidade
Estadio 1: DPOC ligeira

Estadio 2: DPOC moderada
Estadio 3: DPOC grave
Estadio 4 : DPOC muito grave
Avaliação combinada da DPOC –

Estratificação em Grupos de Gravidade
(A – B – C - D)
Níveis de Gravidade GOLD na DPOC
Ligeira Moderad Grave Muito

a Grave
VEMS/CVF % <70%
FEV1/FVC %
VEMS > 80% 50 – 80% 30 –50% < 30%

FEV1
Classification of COPD Severity
by Spirometry
Stage I: Mild FEV1/FVC < 0.70
FEV1 > 80% predicted
Stage II: Moderate FEV1/FVC < 0.70

50% < FEV1 < 80% predicted
Stage III: Severe FEV1/FVC < 0.70

30% < FEV1 < 50% predicted
Stage IV: Very Severe FEV1/FVC < 0.70

FEV1 < 30% predicted or
FEV1 < 50% predicted plus chronic respiratory
failure
Tratamento da DPOC :
Todos os estadios
◻ Evicção dos agentes nocivos
- cessação tabágica
- redução da poluição doméstica
- redução da exposição profissional
◻ Vacina anti-gripal
Tratamento da DPOC por Estadios
I: Ligeiro II: Moderado III: Grave IV: Muito Grave
n FEV1/FVC < 70%

n FEV1/FVC < 70% n FEV1/FVC < 70% n FEV1/FVC < 70%
n FEV1 < 30% vt
n FEV1 > 80% n 50% < FEV1 < 80% n 30% < FEV1 < 50% vt Ou FEV1 < 50% vt e
valor teórico( vt ) vt insuficiência respiratória
Redução activa de factores de risco e vacina antigripal
Mais broncodilatador acção curta sos
Mais tratamento regular com um ou mais broncodilatador acção longa Mais reabilitação
Mais Corticoides inalados se exacerbações de

repetição
Mais OLD se insuf.
respiratória crónica
Considerar tratamento
cirúrgico
Other Pharmacologic Treatments
▪ Antibiotics: Only used to treat infectious

exacerbations of COPD
▪ Antioxidant agents: No effect of n-acetyl-cysteine on

frequency of exacerbations, except in patients not
treated with inhaled glucocorticosteroids
▪ Mucolytic agents, Antitussives, Vasodilators: Not

recommended in stable COPD
Non-Pharmacologic Treatments
▪ Oxygen Therapy: The long-term administration of oxygen (> 15

hours per day) to patients with chronic respiratory failure has been
shown to increase survival in patients with severe, resting hypoxemia.
▪ Ventilatory Support: Combination of noninvasive ventilation (NIV)

with long-term oxygen therapy may be of some use in a selected
subset of patients, particularly in those with pronounced daytime
hypercapnia.
Non-Pharmacologic Treatment
► Education and self-management

► Physical activity
► Pulmonary rehabilitation programs
► Exercise training
► Self-management education
► End of life and palliative care
► Nutritional support
► Vaccination
► Oxygen therapy

Oxygen therapy
Long-term oxygen therapy is indicated for stable patients who

have:
► PaO2 at or below 7.3 kPa (55 mmHg) or SaO2 at or below

88%, with or without hypercapnia confirmed twice over a
three week period; or
► PaO2 between 7.3 kPa (55 mmHg) and 8.0 kPa (60
mmHg), or SaO2 of 88%, if there is evidence of pulmonary
hypertension, peripheral edema suggesting congestive
cardiac failure, or polycythemia (hematocrit > 55%).

99
Exercicio fisico
Nivel evidência C
grau recomendação I
Qualquer estadio
(dgs 028/2011)
COPD and Co-Morbidities
COPD patients are at increased risk for:

• Myocardial infarction, angina
• Osteoporosis
• Respiratory infection
• Depression
• Diabetes
• Lung cancer
Prevention of COPD, 2013: Major Chapters
n Definition and Overview

n Diagnosis and Assessment
n Therapeutic Options
n Manage Stable COPD
n Manage Exacerbations
UPDATED 2013
n Manage Comorbidities
GOLD 2017 Report: Chapters
1. Definition and Overview
2. Diagnosis and Initial Assessment
3. Evidence Supporting Prevention &

Maintenance Therapy
4. Management of Stable COPD
5. Management of Exacerbations
6. COPD and Comorbidities

COPD and Comorbidities
► COPD often coexists with other diseases (comorbidities) that may

have a significant impact on disease course.
► In general, the presence of comorbidities should not alter COPD

treatment and comorbidities should be treated per usual standards
regardless of the presence of COPD.
► Lung cancer is frequently seen in patients with COPD and is a main

cause of death.
► Cardiovascular diseases are common and important comorbidities in

COPD.

► Osteoporosis and depression/anxiety are frequent, important

comorbidities in COPD, are often under-diagnosed, and are
associated with poor health status and prognosis.
► Gastroesophageal reflux (GERD) is associated with an increased risk

of exacerbations and poorer health status.
► When COPD is part of a multimorbidity care plan, attention should be

directed to ensure simplicity of treatment and to minimize
polypharmacy.

Some common comorbidities occurring in patients with COPD with

stable disease include:
► Cardiovascular disease (CVD)
► Heart failure
► Ischaemic heart disease (IHD)
► Arrhythmias
► Peripheral vascular disease
► Hypertension
► Osteoporosis
► Anxiety and depression
► COPD and lung cancer
► Metabolic syndrome and diabetes
► Gastroesophageal reflux (GERD)
► Bronchiectasis
► Obstructive sleep apnea

COPD as part of multimorbidity
► An increasing number of people in any aging population will suffer from multi-
morbidity, defined as the presence of two or more chronic conditions, and
COPD is present in the majority of multi-morbid patients.
► Multi-morbid patients have symptoms from multiple diseases and thus

symptoms and signs are complex and most often attributable to several
causes in the chronic state as well as during acute events.
► There is no evidence that COPD should be treated differently when part of

multi-morbidity; however, it should be kept in mind that most evidence comes
from trials in patients with COPD as the only significant disease.
► Treatments should be kept simple in the light of the unbearable polypharmacy

that these patients are often exposed to.

Manage Comorbidities
COPD often coexists with other diseases

(comorbidities) that may have a significant impact
on prognosis. In general, presence of
comorbidities should not alter COPD treatment and
comorbidities should be treated as if the patient
did not have COPD.
Cardiovascular disease (including ischemic heart

disease, heart failure, atrial fibrillation, and hypertension)
is a major comorbidity in COPD and probably both the
most frequent and most important disease coexisting with
COPD. Benefits of cardioselective beta-blocker treatment
in heart failure outweigh potential risk even in patients
with severe COPD.


Osteoporosis and anxiety/depression: often under-diagnosed

and associated with poor health status and prognosis.
Lung cancer: frequent in patients with COPD; the most
frequent cause of death in patients with mild COPD.
Serious infections: respiratory infections are especially
frequent.
Metabolic syndrome and manifest diabetes: more frequent in
COPD and the latter is likely to impact on prognosis.

Prevention of COPD, 2014
Avaliação combinada da DPOC
Updated 2014

Calculator: BODE Index for COPD survival prediction
FEV1 % Predicted After Bronchodialator
>=65% (0 points)
50-64% (1 point)
36-49% (2 points)
<=35% (3 points)
6 Minute Walk Distance
>=350 Meters (0 points)
250-349 Meters (1 point)
150-249 Meters (2 points)
<=149 Meters (3 points)
MMRC Dyspnea Scale (4 is worst)
MMRC 0: Dyspneic on strenuous excercise (0 points)
MMRC 1: Dyspneic on walking a slight hill (0 points)
MMRC 2: Dyspneic on walking level ground; must stop occasionally due to
breathlessness (1 point)
MMRC 3: Must stop for breathlessness after walking 100 yards or after a few
minutes (2 points)
MMRC 4: Cannot leave house; breathless on dressing/undressing (3 points)
Body Mass Index
>21 (0 points)
<=21 (1 point)
Approximate 4 Year Survival Interpretation

0-2 Points: 80% 3-4 Points: 67% 5-6 Points: 57% 7-10 Points: 18%
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.

Avaliação da DPOC
1. Avaliar os sintomas
2. Avaliar a limitação do fluxo aéreo -
espirometria
3. Avaliar o risco de exacerbações
4. Avaliar comorbilidades

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
Assess risk of exacerbations
Use the COPD Assessment Test(CAT)
Assess comorbidities
or
mMRC Breathlessness scale
or
Clinical COPD Questionnaire (CCQ)
Assessment of Symptoms
COPD Assessment Test (CAT): An 8-item
measure of health status impairment in COPD
(http://catestonline.org).
Breathlessness Measurement using the Modified

British Medical Research Council (mMRC)
Questionnaire: relates well to other measures of
health status and predicts future mortality risk.

Assessment of Symptoms
Clinical COPD Questionnaire (CCQ): Self-
administered questionnaire developed to measure
clinical control in patients with COPD
(http://www.ccq.nl).

mMRC
123
Assessment of COPD
▪ Assess symptoms
▪ Assess degree of airflow limitation
using spirometry
Use spirometry
Assess for grading severity
risk of exacerbations
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

Assessment of COPD
▪ Assess symptoms
▪ Assess degree of airflow limitation using
spirometry
▪ Assess risk of exacerbations
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
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.
Exacerbador frequente

Combined Assessment of COPD
¨ Assess symptoms
¨ Assess degree of airflow limitation using
spirometry
¨ Assess risk of exacerbations
Combine these assessments for the purpose of
improving management of COPD

130

Assess symptoms first
If mMRC 0-1 or CAT < 10:
(C) (D) Less Symptoms (A or C)
If mMRC > 2 or CAT > 10:

More Symptoms (B or D)
(A) (B)
mMRC 0-1 mMRC > 2
CAT < 10 CAT > 10
Symptoms
(mMRC or CAT score))

Assess risk of exacerbations next
(GOLD Classification of Airflow Limitation)
If GOLD 1 or 2 and only

4 0 or 1 exacerbations per year:
(C) (D)
(Exacerbation history)
Low Risk (A or B)
>2
3
If GOLD 3 or 4 or two or
Risk
Risk
more exacerbations per year:
2 1 High Risk (C or D)
(A) (B) (One or more hospitalizations for
1 0 COPD exacerbations should be
considered high risk.)
mMRC 0-1 mMRC > 2
CAT < 10 CAT > 10
Symptoms

Use combined assessment
Patient is now in one of

4 four categories:
(C) (D)
>2
3 A: Less symptoms, low risk
Risk
Risk
B: More symptoms, low risk
2 1
(A) (B) C: Less symptoms, high risk
1 0
D: More symptoms, high risk
mMRC 0-1 mMRC > 2
CAT < 10 CAT > 10
Symptoms

4
(C) (D) >2
3
Risk
Risk
2
1
(A) (B)
1 0
mMRC 0-1 mMRC > 2

CAT < 10 CAT > 10
Symptoms
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 mMRC CAT

Classification per year
Low Risk
A GOLD 1-2 ≤1 0-1 < 10
Less Symptoms
Low Risk
B GOLD 1-2 ≤1 >2 ≥ 10
More Symptoms
High Risk
C GOLD 3-4 >2 0-1 < 10
Less Symptoms
High Risk
D GOLD 3-4 >2 >2 ≥ 10
More Symptoms
Manage Stable COPD: Non-pharmacologic
Patient Essential Recommended Depending on local

Group guidelines
Smoking cessation (can Flu vaccination

A include pharmacologic Physical activity Pneumococcal
treatment) vaccination
Smoking cessation (can

Flu vaccination
include pharmacologic
B, C, D Physical activity Pneumococcal
treatment)
vaccination
Pulmonary rehabilitation

Manage Stable COPD: Pharmacologic Therapy
(Medications in each box are mentioned in alphabetical order, and therefore not necessarily in
order of preference.)
Patient RecommendedFir Alternative choice Other Possible

st choice Treatments
LAMA
SAMA prn or
A or LABA Theophylline
SABA prn or
SABA and SAMA
LAMA
SABA and/or SAMA
B or LAMA and LABA
Theophylline
LABA
ICS + LABA LAMA and LABA or

SABA and/or SAMA
C or LAMA and PDE4-inh. or
Theophylline
LAMA LABA and PDE4-inh.
ICS + LABA and LAMA or

ICS + LABA Carbocysteine
ICS+LABA and PDE4-inh. or
D and/or SABA and/or SAMA
LAMA and LABA or
LAMA Theophylline
LAMA and PDE4-inh.
RECOMMENDED FIRST CHOICE
C D
GOLD 4
ICS + LABA ICS + LABA
or and/or >2
Exacerbations per year

LAMA LAMA
GOLD 3
A B
GOLD 2
SAMA prn LABA 1
or or
GOLD 1 SABA prn LAMA
0
mMRC 0-1 mMRC > 2

CAT < 10 CAT > 10
ALTERNATIVE CHOICE
C D
ICS + LABA and LAMA
GOLD 4 LAMA and LABA or
or ICS + LABA and PDE4-inh >2

LAMA and PDE4-inh or
or LAMA and LABA
GOLD 3 or
LABA and PDE4-inh
LAMA and PDE4-inh.
A B
GOLD 2 LAMA
or LAMA and LABA 1
LABA
GOLD 1 or
SABA and SAMA 0
mMRC 0-1 mMRC > 2

CAT < 10 CAT > 10
OTHER POSSIBLE TREATMENTS
C D
Carbocysteine
GOLD 4 SABA and/or SAMA
SABA and/or SAMA >2

Theophylline
GOLD 3 Theophylline
A B
GOLD 2
SABA and/or SAMA 1
Theophylline
GOLD 1 Theophylline
0
mMRC 0-1 mMRC > 2

CAT < 10 CAT > 10
Glossário
¨ SABA (Beta2 estimulante de acção curta)
▫ Salbutamol
▫ Terbutalina
▫ Fenoterol
¨ SAMA (Anti-colinergico de acção curta-antimuscarinico)
▫ Brometo de ipratrópio
¨ LABA (Beta2 estimulante de acção longa)
▫ Formoterol
▫ Salmeterol
▫ Indacaterol
▫ Olodaterol
▫ Vilanterol
¨ LAMA(Anti-colinergico de acção longa -antimuscarinico)
▫ Tiotrópio
▫ Glicopirrónio
▫ Aclidinio
▫ Umeclidinio
Treatment of Stable COPD


UPDATED 2013
Four Components of COPD
Management
1. Assess and monitor

disease
2. Reduce risk factors
3. Manage stable COPD

l Education
l Pharmacologic
l Non-pharmacologic
4. Manage exacerbations
Manage Exacerbations
An exacerbation of COPD is:

“an acute event characterized by a
worsening of the patient’s respiratory
symptoms that is beyond normal day-to-
day variations and leads to a change in
medication.”

Management of Exacerbations
► An exacerbation of COPD is defined as an acute worsening of

respiratory symptoms that results in additional therapy.
► Exacerbations of COPD can be precipitated by several factors. The

most common causes are respiratory tract infections.
► The goal for treatment of COPD exacerbations is to minimize the

negative impact of the current exacerbation and to prevent subsequent
events.
► Short-acting inhaled beta2-agonists, with or without short-acting

anticholinergics, are recommended as the initial bronchodilators to
treat an acute exacerbation.

► Maintenance therapy with long-acting bronchodilators should be

initiated as soon as possible before hospital discharge.
► Systemic corticosteroids can improve lung function (FEV1),

oxygenation and shorten recovery time and hospitalization duration.
Duration of therapy should not be more than 5-7 days.
► Antibiotics, when indicated, can shorten recovery time, reduce the risk
of early relapse, treatment failure, and hospitalization duration.
Duration of therapy should be 5-7 days.
► Methylxanthines are not recommended due to increased side effect

profiles.

► Non-invasive mechanical ventilation should be the first mode of

ventilation used in COPD patients with acute respiratory failure who
have no absolute contraindication because it improves gas exchange,
reduces work of breathing and the need for intubation, decreases
hospitalization duration and improves survival.
► Following an exacerbation, appropriate measures for exacerbation

prevention should be initiated (see GOLD 2017 Chapter 3 and Chapter
4).

COPD exacerbations are defined as an acute worsening of

respiratory symptoms that result in additional therapy.
► They are classified as:
➢ Mild (treated with short acting bronchodilators only, SABDs)

➢ Moderate (treated with SABDs plus antibiotics and/or oral
corticosteroids) or
➢ Severe (patient requires hospitalization or visits the emergency
room). Severe exacerbations may also be associated with acute
respiratory failure.

Management COPD Exacerbations
Key Points
An exacerbation of COPD is defined as:
“An event in the natural course of the disease

characterized by a change in the patient’s
baseline dyspnea, cough, and/or sputum that is
beyond normal day-to-day variations, is acute in
onset, and may warrant a change in regular
medication in a patient with underlying COPD.”
Consequences Of COPD Exacerbations
Negative Impact on
impact on symptoms
quality of life and lung
function
EXACERBATIONS
Accelerated Increased
lung function economic
decline costs
Increased
Mortality

Manage Exacerbations: Key Points

▪ The most common causes of COPD exacerbations are viral upper
respiratory tract infections and infection of the tracheobronchial
tree.
▪ Diagnosis relies exclusively on the clinical presentation of the
patient complaining of an acute change of symptoms that is
beyond normal day-to-day variation.
▪ (Rhinoviruses . Influenza, parainfluenza, coronavirus, and adenovirus
are also common
▪ (Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus
pneumoniae)
▪ The goal of treatment is to minimize the impact of the current
exacerbation and to prevent the development of subsequent
exacerbations.
Key Points
▪ The most common causes of an exacerbation are
infection of the tracheobronchial tree and air
pollution, but the cause of about one-third of severe
exacerbations cannot be identified (Evidence B).
▪ Patients experiencing COPD exacerbations with

clinical signs of airway infection (e.g., increased
sputum purulence) may benefit from antibiotic
treatment (Evidence B).
▪ Bacteria / Virus (???)

Exacerbação da DPOC
◻ Factores de mau prognostico:
■ Hipoxemia
■ Hipercapnia
■ Hipoalbuminemia (< 2,5 g/dl)
■ IMC < 20
■ Exacerbador frequente
■ Corticoterapia prolongada
■ Presença de HTP
Exacerbação da DPOC
◻ Exacerbador frequente - > 2 exacerbações por ano separadas por pelo
menos 4 semanas desde o fim da ultima exacerbação (ou 6 semanas de
tempo total de exacerbação)
◻ Prevenção das exacerbações

■ Cessação tabágica
■ Aderência ao tratamento e boa técnica inalatória
■ Terapêutica combinada (LAMA/LABA)
■ Programas de auto-controlo
■ Imunizações :
■ Gripe
■ Pneumonia
■ Contra lisados bacterianos
■ Mucolíticos
■ Roflumilaste
Infecções no doente com DPOC
Haemophilus influenzae
Moraxella catarrhalis
Streptococcus pneumoniae
Agentes bacterianos mais frequentes
Mycoplasma pneumoniae
Pseudomonas aeruginosa
Outras bactérias gram negativas
Rhinovirus
Coronavirus
Influenza A e B
Agentes víricos mais frequentes
Parainfluenza
RSV
Metapneumovirus
Que antibiótico escolher?
Características do doente Microorganismos prováveis Antibiótico a escolher
DPOC não complicada H. influenzae

-Idade < 65 anos S. pneumoniae Macrólido
M. catharralis Doxiciclina
-FEV1>50%previsto
H. parainfluenzae Cefalosporina 2ª ou 3ª geração
-< 4 exacerbações/ano M. pneumoniae Quinolona respiratória
-Sem comorbilidades Vírus
DPOC complicada H. influenzae

-Idade > 65 anos S. pneumoniae
M. catharralis Quinolona respiratória
-FEV1<50%previsto
H. parainfluenzae Amoxicilina/Ácido Clavulânico
-> 4 exacerbações/ano M. pneumoniae
-Com comorbilidades Bacilos gram negativos
H. influenzae
DPOC com S. pneumoniae
-Risco Pseudomonas M. catharralis
H. parainfluenzae Fluoroquinolona com actividade
-FEV1<35%previsto
M. pneumoniae contra Pseudomonas
-Uso atb ou CCT recorrente
-Bronquiectasias Bacilos gram negativos
Pseudomonas aeroginosa
Factores de risco para Pseudomonas aeruginosa
◻ Bronquiectasias
◻ Deterioração da função pulmona (FEV1 < 30 %)
◻ Tratamento antibiótico nos 3 meses precedentes ou mais
de 4 tratamentos antibióticos por ano
◻ Hospitalização recente
◻ Corticoide oral (prednisolona > 10 mg/dia nas 2 últimas
semanas
◻ Isolamento de Pseudomonas aeruginosa em exacerbação
prévia
◻ Colonização brônquica por Pseudomonas aeruginosa
Manage Exacerbations: Assessments

Arterial blood gas measurements (in hospital): PaO2 < 60 mm Hg with
or without PaCO2 > 50 mm Hg when breathing room air indicates
respiratory failure.
Chest radiographs: useful to exclude alternative diagnoses.
ECG: may aid in the diagnosis of coexisting cardiac problems.
Whole blood count: identify polycythemia, anemia or bleeding.
Purulent sputum during an exacerbation: indication to begin empirical
antibiotic treatment.
Biochemical tests: detect electrolyte disturbances, diabetes, and poor
nutrition.
Spirometric tests: not recommended during an exacerbation.

Manage Exacerbations: Treatment Options
Oxygen: titrate to improve the patient’s hypoxemia with a target saturation

of 88-92%.

Bronchodilators: Short-acting inhaled beta2-agonists with or without short-
acting anticholinergics are preferred.

Systemic Corticosteroids: Shorten recovery time, improve lung function
(FEV1) and arterial hypoxemia (PaO2), and reduce the risk of early relapse,
treatment failure, and length of hospital stay. A dose of 40 mg prednisone
per day for 5 days is recommended .

Oxygen: titrate to improve the patient’s hypoxemia with a target saturation

of 88-92%.

Bronchodilators: Short-acting inhaled beta2-agonists with or without
short-acting anticholinergics are preferred.

Systemic Corticosteroids: Shorten recovery time, improve lung function
(FEV1) and arterial hypoxemia (PaO2), and reduce the risk of early relapse,
treatment failure, and length of hospital stay. A dose of 40 mg prednisone
per day for 5 days is recommended.
Nebulized magnesium as an adjuvent to salbutamol treatment in the setting

of acute exacerbations of COPD has no effect on FEV1.
Antibiotics should be given to patients with:

• Evidência alta e recomendação forte nas agudizações
severas e muito severas
• Evidência alta e recomendação fraca nas exacerbações
leves/moderadas com expectoração purulenta e/ou PCR
elevada
▪ Three cardinal symptoms: increased dyspnea, increased sputum

volume, and increased sputum purulence.
▪ Who require mechanical ventilation.

Manage Exacerbations: Treatment
Options
Noninvasive ventilation (NIV) for patients hospitalized for

acute exacerbations of COPD:
▪ Improves respiratory acidosis, decreases respiratory rate,
severity of dyspnea, complications and length of hospital
stay.
▪ Decreases mortality and needs for intubation.
© 2015 Global Initiative for Chronic Obstructive Lung Disease GOLD Revision 2011
Manage Exacerbations: Indications for Hospital Admission
▪ Marked increase in intensity of symptoms

▪ Severe underlying COPD
▪ Onset of new physical signs
▪ Failure of an exacerbation to respond to initial
medical management
▪ Presence of serious comorbidities
▪ Frequent exacerbations
▪ Older age
▪ Insufficient home support

Tratamento das exacerbações
Indicações para hospitalização
▪ Aumento marcado da intensidade dos sintomas
▪ DPOC muito severa
▪ Aparecimento de sinais clínicos de novo
▪ Falência de resposta ao tratamento inicial de uma
exacerbação
▪ Comorbilidades sérias ou em descompensação
▪ Exacerbações frequentes
▪ Idade avançada
▪ Mau apoio domiciliário e familiar
Manage COPD Exacerbations
Key Points
▪ Inhaled bronchodilators (particularly

inhaled ß2-agonists with or without
anticholinergics) and oral glucocortico-
steroids are effective treatments for
exacerbations of COPD (Evidence A).

▪ Short-acting inhaled beta2-agonists with or without
short-acting anticholinergics are usually the preferred
bronchodilators for treatment of an exacerbation.
▪ Systemic corticosteroids and antibiotics can shorten
recovery time, improve lung function (FEV1) and
arterial hypoxemia (PaO2), and reduce the risk of early
relapse, treatment failure, and length of hospital stay.
▪ COPD exacerbations can often be prevented.

Key Points
▪ Noninvasive mechanical ventilation in exacerbations

improves respiratory acidosis, increases pH, decreases
the need for endotracheal intubation, and reduces
PaCO2, respiratory rate, severity of breathlessness,
the length of hospital stay, and mortality (Evidence A).
▪ Medications and education to help prevent future
exacerbations should be considered as part of follow-
up, as exacerbations affect the quality of life and
prognosis of patients with COPD.
Ventilação não invasiva na prática
Take home message
◻ Exacerbação da DPOC
¤ Quando : Início VNI precoce
¤ Onde : Urgência/Emergência; UCI; Enfermaria especializada
¤ Quem : Experiência com VNI; pode não necessitar de ratio 1:1 ou 1:2
¤ Bom prognóstico mesmo com resolução tardia e transição para VNI

crónica
Na EA DPOC a PaO2 deve manter-se entre 50-

65 mmHg (Sat O2 88–92%) para evitar a hipóxia
e a acidose
2008

▪ The most common causes of COPD exacerbations are viral upper
respiratory tract infections and infection of the tracheobronchial
tree.
▪ Diagnosis relies exclusively on the clinical presentation of the
patient complaining of an acute change of symptoms that is
beyond normal day-to-day variation.
▪ (Rhinoviruses . Influenza, parainfluenza, coronavirus, and adenovirus
are also common
▪ (Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus
pneumoniae)
▪ The goal of treatment is to minimize the impact of the current
exacerbation and to prevent the development of subsequent
exacerbations.

▪ Short-acting inhaled beta2-agonists with or without
short-acting anticholinergics are usually the preferred
bronchodilators for treatment of an exacerbation.
▪ Systemic corticosteroids and antibiotics can shorten
recovery time, improve lung function (FEV1) and
arterial hypoxemia (PaO2), and reduce the risk of early
relapse, treatment failure, and length of hospital stay.
▪ COPD exacerbations can often be prevented.

Consequences Of COPD Exacerbations
Negative Impact on
impact on symptoms
quality of life and lung
function
EXACERBATIONS
Accelerated Increased
lung function economic
decline costs
Increased
Mortality

Manage Exacerbations: Assessments
Arterial blood gas measurements (in hospital): PaO2 < 8.0 kPa(60
mmHg) with or without PaCO2 > 6.7 kPa (50 mm Hg), when breathing
room air indicates respiratory failure.
Chest radiographs: useful to exclude alternative diagnoses.
ECG: may aid in the diagnosis of coexisting cardiac problems.
Whole blood count: identify polycythemia, anemia or bleeding.
Purulent sputum during an exacerbation: indication to begin empirical
antibiotic treatment.
Biochemical tests: detect electrolyte disturbances, diabetes, and poor
nutrition.
Spirometric tests: not recommended during an exacerbation.

Oxygen: titrate to improve the patient’s hypoxemia with a target saturation of 88-92%.

Bronchodilators: Short-acting inhaled beta2-agonists with or without short-acting
anticholinergics are preferred.

Systemic Corticosteroids: Shorten recovery time, improve lung function (FEV1) and arterial
hypoxemia (PaO2), and reduce the risk of early relapse, treatment failure, and length of
hospital stay. A dose of 30-40 mg prednisolone per day for 10-14 days is recommended.

Antibiotics should be given to patients with:
▪Three cardinal symptoms: increased dyspnea,

increased sputum volume, and increased sputum
purulence.
▪Who require mechanical ventilation.

Manage Exacerbations: Treatment
Options
Noninvasive ventilation (NIV) for patients hospitalized for acute

exacerbations of COPD:
▪Improves respiratory acidosis, decreases respiratory rate,
severity of dyspnea, complications and length of hospital
stay.
▪Decreases mortality and needs for intubation.
© 2013 Global Initiative for Chronic Obstructive Lung Disease GOLD Revision 2011
WORLD COPD DAY
November 15, 2017
Raising COPD Awareness Worldwide


Updated 2015
n Asthma COPD Overlap
Syndrome (ACOS)
Definitions
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 2014]
COPD
COPD is a common preventable and treatable disease, characterized by persistent airflow
limitation that is usually progressive and associated with enhanced chronic inflammatory
responses in the airways and the lungs to noxious particles or gases. Exacerbations and
comorbidities contribute to the overall severity in individual patients. [GOLD 2015]
Asthma-COPD overlap syndrome (ACOS) [a description]
Asthma-COPD overlap syndrome (ACOS) is characterized by persistent airflow limitation
with several features usually associated with asthma and several features usually
associated with COPD. ACOS is therefore identified by the features that it shares with both
asthma and COPD.
GINA 2014, Box 5-1 © Global Initiative for Asthma

Usual features of asthma, COPD and ACOS
Feature Asthma COPD ACOS

Age of onset Usually childhood but can Usually >40 years Usually ≥40 years, but may
commence at any age have had symptoms as
child/early adult
Pattern of Symptoms vary over time Chronic usually continuous Respiratory symptoms
respiratory (day to day, or over longer symptoms, particularly including exertional dyspnea
symptoms period), often limiting during exercise, with ‘better’ are persistent, but variability
activity. Often triggered by and ‘worse’ days may be prominent
exercise, emotions
including laughter, dust, or
exposure to allergens
Lung function Current and/or historical FEV1 may be improved by Airflow limitation not fully
variable airflow limitation, -
therapy, but post-BD reversible, but often with
e.g. BD reversibility, AHR FEV1/FVC <0.7 persists current or historical
variability
Lung function May be normal Persistent airflow limitation Persistent airflow limitation
between
symptoms
GINA 2014, Box 5-2A (1/3) © Global Initiative for Asthma

Usual features of asthma, COPD and ACOS
(continued)
Feature Asthma COPD ACOS
Past history or Many patients have History of exposure to Frequently a history of
family history allergies and a personal noxious particles or gases doctor-diagnosed
- asthma
history of asthma in (mainly tobacco smoking or (current or previous),
childhood and/or family biomass fuels) allergies, family history of
history of asthma asthma, and/or a history of
noxious exposures
Time course Often improves Generally slowly progressive Symptoms are partly but
spontaneously or with over years despite treatment significantly reduced by
treatment, but may result in treatment. Progression is
fixed airflow limitation usual and treatment needs
are high.
Chest X-ray
- Usually normal Severe hyperinflation and Similar to COPD
other changes of COPD
Exacerbations Exacerbations occur, but Exacerbations can be Exacerbations may be more

risk can be substantially reduced by treatment. If common than in COPD but
reduced by treatment present, comorbidities are reduced by treatment.
contribute to impairment Comorbidities can contribute
to impairment.
GINA 2014, Box 5-2A (2/3) © Global Initiative for Asthma

Features that (when present) favor asthma or
COPD
Feature Favors asthma Favors COPD
Age of onset ❑ Before age 20 years ❑ After age 40 years
Pattern of ❑ Symptoms vary over minutes, hours or days ❑ Symptoms persist despite treatment
respiratory ❑ Worse during night or early morning ❑ Good and bad days, but always daily
symptoms ❑ Triggered by exercise, emotions including symptoms and exertional dyspnea
Syndromic laughter,of
diagnosis dust, or exposure
airways to allergens
disease ❑ Chronic cough and sputum preceded
onset of dyspnea, unrelated to triggers
The shaded columns list features that, when present, best distinguish between asthma and
Lung function ❑ Record of variable airflow limitation ❑ Record of persistent airflow limitation
COPD. (spirometry, peak flow) (post -BD FEV 1/FVC <0.7)
For a patient,❑count
Normalthebetween
number of check boxes in each column.
symptoms ❑ Abnormal between symptoms
▪ or 3 or more
Past history If boxesdoctor
❑ Previous are checked
diagnosisfor either asthma or ❑
of asthma COPD,
Previousthat diagnosis
doctor is of
diagnosis suggested.
COPD,
▪ If there❑are
family history similar
Family numbers
history of checked
of asthma, and other boxes
allergicin each chronic
column, the diagnosis
bronchitis of ACOS
or emphysema
should beconditions
considered.(allergic rhinitis or eczema) ❑ Heavy exposure to a risk factor: tobacco
smoke, biomass fuels
Time course ❑ No worsening of symptoms over time. ❑ Symptoms slowly worsening over time
Symptoms vary seasonally, or from year to (progressive course over years)
year ❑ Rapid -acting bronchodilator treatment
❑ May improve spontaneously, or respond provides only limited relief
immediately to BD or to ICS over weeks
Chest X -ray ❑ Normal ❑ Severe hyperinflation
GINA 2014, Box 5-2B (3/3) © Global Initiative for Asthma

Features that (when present) favor asthma or
COPD
Feature Favors asthma Favors COPD
Age of onset ❑ Before age 20 years ❑ After age 40 years
Pattern of ❑ Symptoms vary over minutes, hours or days ❑ Symptoms persist despite treatment
respiratory ❑ Worse during night or early morning ❑ Good and bad days, but always daily
symptoms ❑ Triggered by exercise, emotions including symptoms and exertional dyspnea
laughter, dust, or exposure to allergens ❑ Chronic cough and sputum preceded
onset of dyspnea, unrelated to triggers
Lung function ❑ Record of variable airflow limitation ❑ Record of persistent airflow limitation
(spirometry, peak flow) (post -BD FEV 1/FVC <0.7)
❑ Normal between symptoms ❑ Abnormal between symptoms
Past history or ❑ Previous doctor diagnosis of asthma ❑ Previous doctor diagnosis of COPD,
family history ❑ Family history of asthma, and other allergic chronic bronchitis or emphysema
conditions (allergic rhinitis or eczema) ❑ Heavy exposure to a risk factor: tobacco
smoke, biomass fuels
Time course ❑ No worsening of symptoms over time. ❑ Symptoms slowly worsening over time
Symptoms vary seasonally, or from year to (progressive course over years)
year ❑ Rapid -acting bronchodilator treatment
❑ May improve spontaneously, or respond provides only limited relief
immediately to BD or to ICS over weeks
Chest X -ray ❑ Normal ❑ Severe hyperinflation
GINA 2014, Box 5-2B (3/3) © Global Initiative for Asthma

Step 3 - Spirometry
Spirometric variable Asthma COPD ACOS

Normal FEV 1/FVC Compatible with asthma Not compatible with Not compatible unless
pre - or post -BD diagnosis (GOLD) other evidence of chronic
airflow limitation
Post -BD FEV 1/FVC <0.7 Indicates airflow Required for diagnosis Usual in ACOS
limitation; may improve by GOLD criteria
FEV 1 =80% predicted Compatible with asthma Compatible with GOLD Compatible with mild
(good control, or interval category A or B if post - ACOS
between symptoms) BD FEV 1/FVC <0.7
FEV 1 <80% predicted Compatible with asthma. Indicates severity of Indicates severity of
A risk factor for airflow limitation and risk airflow limitation and risk
exacerbations of exacerbations and of exacerbations and
mortality mortality
Post -BD increase in Usual at some time in Common in COPD and Common in ACOS, and
FEV 1 >12% and 200mL course of asthma; not more likely when FEV 1 is more likely when FEV 1 is
from baseline (reversible always present low, but consider ACOS low
airflow limitation)
Post -BD increase in High probability of Unusual in COPD. Compatible with
FEV 1 >12% and 400mL asthma Consider ACOS diagnosis of ACOS
from baseline
Stepwise approach to diagnosis and initial
treatment
For an adult who presents with

respiratory symptoms:
1. Does the patient have chronic
airways disease?
2. Syndromic diagnosis of asthma,
COPD and ACOS
3. Spirometry
4. Commence initial therapy
5. Referral for specialized
investigations (if necessary)
GINA 2014, Box 5-4 (1/6) © Global Initiative for Asthma

Step 1 – Does the patient have chronic
airways disease?

GINA
GINA 2014
2014, Box 5-4 (3/6) © Global Initiative for Asthma
Step 5 – Refer for specialized investigations if
needed
Investigation Asthma COPD

DLCO Normal or slightly elevated Often reduced
Arterial blood gases Normal between exacerbations In severe COPD, may be abnormal
between exacerbations
Airway Not useful on its own in distinguishing asthma and COPD.
hyperresponsiveness High levels favor asthma
High resolution CT scan Usually normal; may show air Air trapping or emphysema; may show
trapping and increased airway bronchial wall thickening and features of
wall thickness pulmonary hypertension
Tests for atopy (sIgE Not essential for diagnosis; Conforms to background prevalence;
and/or skin prick tests) increases probability of asthma does not rule out COPD
FENO If high (>50ppb) supports Usually normal. Low in current smokers
eosinophilic inflammation
Blood eosinophilia Supports asthma diagnosis May be found during exacerbations
Sputum inflammatory Role in differential diagnosis not established in large populations
cell analysis

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1

José Eduardo Oliveira

n Exacerbations and comorbidities contribute to the

© 2014 Global Initiative for Chronic Obstructive Lung Disease

► To provide a non-biased review of the current

► To highlight short-term and long-term treatment

► To guide symptoms assessment and health status

© 2017 Global Initiative for Chronic Obstructive Lung Disease

Início após 40 anos Início na infância

Antecedente de atopias Antecedente de atopias

História familiar de asma História familiar de asma

Melhoria variável com Melhoria acentuada com

◻ The diagnosis requires spirometry;

► Chronic Obstructive Pulmonary Disease (COPD) is a

© 2017 Global Initiative for Chronic Obstructive Lung Disease

► COPD is projected to be the 3rd leading cause of

► More than 3 million people died of COPD in 2012

► Globally, the COPD burden is projected to increase in

© 2017 Global Initiative for Chronic Obstructive Lung Disease

► Chronic Obstructive Pulmonary Disease (COPD) is a

► The most common respiratory symptoms include

► The main risk factor for COPD is tobacco smoking but

© 2017 Global Initiative for Chronic Obstructive Lung Disease

◻ A DPOC é a 4ª causa de morte nos Estados Unidos (a

► Systematic review and meta-analysis (Halbert et al,

► Included studies carried out in 28 countries between

► Prevalence of COPD was higher in smokers and ex-

► Higher ≥ 40 year group compared to those < 40

► Higher in men than women.

© 2017 Global Initiative for Chronic Obstructive Lung Disease

► Estimated 384 million COPD cases in 2010.

► Estimated global prevalence of 11.7% (95% CI 8.4%–

► Three million deaths annually.

► With increasing prevalence of smoking in developing

► By 2030 predicted 4.5 million COPD related deaths

© 2017 Global Initiative for Chronic Obstructive Lung Disease

▪ Nos EUA 47,2 milhões de pessoas (28% dos homens e

▪ A OMS avalia em 1,1 biliões os fumadores em todo o

Proporção da taxa de 1965

Global Health Statistics

Espanha (IBERPOC) 9.1%

Japão (NICE) 8.5%

EUA (NHANES III) 6.8%

Hong Kong 6.8%

• O custo por doente internado também aumentou 16% (DGS) .

De acordo com um estudo de 2006 efetuado em doentes internados, o custo médio

É uma doença prevenivel e tratável com repercussões extra pulmonares

O componente pulmonar caracteriza-se por limitação do fluxo aéreo que

A limitação do fluxo aéreo é habitualmente progressiva e associada a uma

¤ Doença das pequenas vias aéreas (bronquiolite obstrutiva)

¤ Destruição do parênquima (enfisema)

◻ O contributo relativo de cada componente variável de

Mechanisms Underlying Airflow

Small Airways Disease Parenchymal Destruction

◻ A história natural da doença é variável de indivíduo para

◻ Geralmente progressiva, particularmente se a exposição a

◻ O impacto da DPOC no indivíduo depende

¤ Não dependente do grau de obstrução funcional

◻ Em todo o mundo o fumo de tabaco é o factores de risco

◻ Factor de risco genético melhor documentado é o défice de

◻ Das várias exposições inalatórias, apenas o fumo de tabaco e

◻ A poluição indoor, em particular a resultante da combustão em

•Crescimento e desenvolvimento do pulmão