1

Global Strategy for Diagnosis, Management and Prevention of

Chronic Obstructive Pulmonary Disease

Revised 2011

Dr. Mashfiqul HasanResident, Phase A

Respiratory wing, Dept of MedicineBSMMU

2

lobal Initiative for Chronicbstructiveungisease

GOLD

© Global Initiative for Chronic Obstructive Lung Disease

WORLD COPD DAYNovember 14, 2012WORLD COPD DAYNovember 14, 2012

Raising COPD Awareness WorldwideRaising COPD Awareness Worldwide

4

“It’s Not Too Late.”

5

Evidence Category

Sources of Evidence

A Randomized controlled trials (RCTs). Rich body of data

B Randomized controlled trials(RCTs). Limited body of data

C Nonrandomized trialsObservational studies.

D Panel consensus judgment

Description of Levels of Evidence

6

Global Strategy for Diagnosis, Management and Prevention of COPD, 2011: Chapters

Definition and Overview

Diagnosis and Assessment

Therapeutic Options

Manage Stable COPD

Manage Exacerbations

Manage Comorbidities

Definition and Overview

Diagnosis and Assessment

Therapeutic Options

Manage Stable COPD

Manage Exacerbations

Manage Comorbidities

REVISED 2011

7

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

8

Mechanisms Underlying Airflow Limitation in COPD

Small Airways Disease• Airway inflammation• Airway fibrosis, luminal

plugs• Increased airway

resistance

Parenchymal Destruction• Loss of alveolar

attachments• Decrease of elastic recoil

AIRFLOW LIMITATION

9

Emphysema & chronic bronchitis Not included in the definition

Emphysema

Pathological term

Only one of several structural abnormalities

Chronic bronchitis

Independent disease entity

May precede or follow development of airflow limitation

Burden of COPD

Leading cause of morbidity and mortality worldwide

6th leading cause of death in 1990

Will be the 3rd leading cause of death by the year 2020

Risk Factors for COPD

• Lung growth and development • Gender• Age • Respiratory infections• Socioeconomic status• Asthma/Bronchial hyperreactivity• Chronic Bronchitis

• Genes• Exposure to particles Tobacco smoke Occupational dusts,

organic and inorganic Indoor air pollution from

heating and cooking with biomass in poorly ventilated dwellings

Outdoor air pollution

Risk Factors for COPD

Genes

Infections

Socio-economic status

Aging Populations

Global Strategy for Diagnosis, Management and Prevention of COPD, 2011: Chapters

Definition and Overview

Diagnosis and Assessment

Therapeutic Options

Manage Stable COPD

Manage Exacerbations

Manage Comorbidities

Definition and Overview

Diagnosis and Assessment

Therapeutic Options

Manage Stable COPD

Manage Exacerbations

Manage Comorbidities

REVISED 2011

SYMPTOMS

chronic coughshortness of breath

EXPOSURE TO RISKFACTORS

tobaccooccupation

indoor/outdoor pollution

SPIROMETRY : Required to establish diagnosis

Diagnosis of COPD

sputum

Spirometry: Normal Trace Showing FEV1 and FVC

1 2 3 4 5 6

1

2

3

4

Volu

me,

liters

Time, sec

FVC5

1

FEV1 = 4L

FVC = 5L

FEV1/FVC = 0.8

Spirometry: Obstructive Disease

Volu

me,

liters

Time, seconds

5

4

3

2

1

1 2 3 4 5 6

FEV1 = 1.8L

FVC = 3.2L

FEV1/FVC = 0.56

Normal

Obstructive

Assessment of COPD

1. Assess symptoms

2. Assess degree of airflow limitation using spirometry

3. Assess risk of exacerbations

4. Assess comorbidities

1. Assess symptomsAssess degree of airflow limitation using spirometryAssess risk of exacerbationsAssess comorbidities

COPD Assessment Test (CAT)

or

mMRC Breathlessness scale

Assessment of COPD

Modified MRC (mMRC)Questionnaire

21

1. Assess symptoms2. Assess degree of airflow limitation

Spirometry for grading severity

Assessment of COPD

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

1. Assess symptoms2. Assess degree of airflow limitation

using spirometry3. Assess risk of exacerbations

Assess comorbidities1. History of exacerbations and

2. Spirometry

Assessment of COPD

Combined Assessment of COPD

Risk

(GO

LD C

lass

ifica

tion

of A

irflow

Lim

itatio

n)

Risk

(Exa

cerb

ation

his

tory

)

> 2

1

0

(C) (D)

(A) (B)

mMRC 0-1CAT < 10

4

3

2

1

mMRC>2CAT >10

Symptoms(mMRC or CAT score))

Combined Assessment of COPDRi

sk(G

OLD

Cla

ssifi

catio

n of

Airfl

ow L

imita

tion)

Risk

(Exa

cerb

ation

his

tory

)

> 2

1

0

(C) (D)

(A) (B)

mMRC 0-1CAT < 10

4

3

2

1

mMRC>2CAT >10

Symptoms(mMRC or CAT score))

Patient is now in one ofFour categories:

A: Les symptoms, low risk

B: More symtoms, low risk

C: Less symptoms, high risk

D: More symptoms, high risk

Assess COPD Comorbidities

• Cardiovascular diseases• Skeletal muscle dysfunction• Osteoporosis• Anxiety and Depression• Metabolic syndrome• Lung cancer

May influence mortality and hospitalizations

Should be looked for routinely and treated appropriately

Additional Investigations

•Chest X-ray

•Lung Volumes and Diffusing Capacity

•Oximetry and Arterial Blood Gases

•Alpha-1 Antitrypsin Deficiency Screening

•Exercise Testing

Global Strategy for Diagnosis, Management and Prevention of COPD, 2011: Chapters

Definition and Overview

Diagnosis and Assessment

Therapeutic Options

Manage Stable COPD

Manage Exacerbations

Manage Comorbidities

Definition and Overview

Diagnosis and Assessment

Therapeutic Options

Manage Stable COPD

Manage Exacerbations

Manage Comorbidities

REVISED 2011

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Smoking cessation

• Greatest capacity to influence the natural history of COPD

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Treating tobacco use & dependence

• Warrants repeated treatment• Effective treatment exist & should be

offered• Smoking cessation counseling• Pharmacotherapies : varenicline,

bupropion, nicotine gum, inhaler, nasal spray, patch

• Cost effective

Brief Strategies to Help the Patient Willing to Quit Smoking

1. ASK Systematically identify all tobacco users at every visit

2. ADVISE Strongly urge all tobacco users to quit

3. ASSESS Determine willingness to make a quit attempt

4. ASSIST Aid the patient in quitting

5. ARRANGE Schedule follow-up contact

Pharmacological therapy for stable COPD

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

MethylxanthinesInhaled corticosteroids Combination long-acting beta2-agonists + corticosteroids in one inhaler

Systemic corticosteroidsPhosphodiesterase-4 inhibitors

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Bronchodilators in COPD

• Central to the symptom management• Inhaled : preferred• Choice depends on availability &

individual patient response• As needed or regular• Long acting : convenient, more

effective• Combination

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ICS in COPD

• Controversial • Limited to specific indications• Regular treatment with ICS improves

symptoms, lung function and quality of life in patients with FEV1 <60% predicted (Evidence A)

• Does not modify the long term decline of FEV1 nor mortality (Evidence A)

• Adverse effects

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Other pharmacological treatments

• Phosphodiesterase 4 inhibitors: Roflumilast• Vaccines• Antibiotics • Mucolytic & antioxidant agents• Immunoregulators • Antitussive • Vasodilators • Narcotics • Nedocromil & leukotriene modifier

Non-pharmacologic therapies : pulmonary rehabilitation

Improvements in exercise tolerance and symptoms of dyspnea and fatigue

Effective pulmonary rehabilitation program duration: 6 weeks

If exercise training is maintained at home the patient's health status remains above pre-rehabilitation levels

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Other treatments

• O2 therapy• Ventilatory support• Surgical treatments

– Lung volume reduction surgery– Bronchoscopic lung volume reduction– Lung transplantation– Bullectomy

Global Strategy for Diagnosis, Management and Prevention of COPD, 2011: Major Chapters

Definition and Overview

Diagnosis and Assessment

Therapeutic Options

Manage Stable COPD

Manage Exacerbations

Manage Comorbidities

Definition and Overview

Diagnosis and Assessment

Therapeutic Options

Manage Stable COPD

Manage Exacerbations

Manage Comorbidities

REVISED 2011

Relieve symptoms Improve exercise tolerance Improve health status

Prevent disease progression Prevent and treat exacerbations Reduce mortality

Reducesymptoms

Reducerisk

Goals of Therapy

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Identify & reduce exposure to risk factors

• Tobacco smoke– Key intervention (Evidence A)

• Occupational exposures– Avoid continued exposures (Evidence D)

• Indoor & outdoor air pollution– Biomass fuel– Efficient ventilation, non polluting

cooking device (Evidence B)

Manage Stable COPD: Non-pharmacologic

Patient Essential Recommended Depending on local guidelines

ASmoking cessation (can include pharmacologic

treatment)Physical activity

Flu vaccinationPneumococcal

vaccination

B, C, DSmoking cessation (can include pharmacologic

treatment)Pulmonary rehabilitation

Physical activityFlu vaccinationPneumococcal

vaccination

Manage Stable COPD: Pharmacologic

Patient First choice Second choice Alternative Choices

ASAMA prn

orSABA prn

LAMAor

LABA or

SABA and SAMA

Theophylline

BLAMA

orLABA

LAMA and LABA SABA and/or SAMATheophylline

CICS +

LABA or LAMA

LAMA and LABAPDE4-inh.

SABA and/or SAMATheophylline

DICS +

LABA orLAMA

ICS andLAMA orICS + LABA and LAMA or

ICS+LABA and PDE4-inh.orLAMA and LABA or

LAMA and PDE4-inh.

CarbocysteineSABA and/or SAMA

Theophylline

Exac

erba

tions

per

yea

r

> 2

1

0

mMRC 0-1CAT < 10

GOLD 4

mMRC>2CAT >10

GOLD 3

GOLD 2

GOLD 1

SAMA prnor

SABA prn

LABA or

LAMA

ICS + LABAor

LAMA

FIRST CHOICE

A B

DCICS + LABA

orLAMA

> 2

1

0

mMRC 0-1CAT < 10

GOLD 4

mMRC> 2CAT > 10

GOLD 3

GOLD 2

GOLD 1

LAMA orLABA or

SABA and SAMA

LAMA and LABA ICS and LAMA orICS + LABA and LAMA or

ICS + LABA and PDE4-inh orLAMA and LABA or

LAMA and PDE4-inh.

LAMA and LABA

SECOND CHOICE

A

DC

B

Exac

erba

tions

per

yea

r

> 2

1

0

mMRC 0-1CAT < 10

GOLD 4

mMRC> 2CAT >10

GOLD 3

GOLD 2

GOLD 1Theophylline

PDE4-inh.SABA and/or SAMA

Theophylline

CarbocysteineSABA and/or SAMA

Theophylline

SABA and/or SAMATheophylline

ALTERNATIVE CHOICES

A

DC

B

Exac

erba

tions

per

yea

r

47

Monitoring & follow up

• Disease progression & development of complications

• Monitor pharmacotherapy • Exacerbation history• Comorbidities

Global Strategy for Diagnosis, Management and Prevention of COPD, 2011: Chapters

Definition and Overview

Diagnosis and Assessment

Therapeutic Options

Manage Stable COPD

Manage Exacerbations

Manage Comorbidities

Definition and Overview

Diagnosis and Assessment

Therapeutic Options

Manage Stable COPD

Manage Exacerbations

Manage Comorbidities

REVISED 2011

• 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

Acute Exacerbation

Impact on symptoms

and lungfunction

Negativeimpact on

quality of life

Consequences Of COPD Exacerbations

Increasedeconomic

costs

Acceleratedlung function

decline

IncreasedMortality

EXACERBATIONS

• Respiratory tract infection (Bacterial or viral)

• Exposure to pollutants

• Interruption of maintenance therapy

• Overlaping

Precipitating factors

• Pulse oxymetry, ABG

• Chest radiograph

• ECG

• CBC

• Sputum for CS

• Biochemical tests

• Spirometry : Not recommended

Investigation for acute exacerbation

• Marked increase in the intensity of symptoms

• Onset of new physical signs

• Failure to respond to initial medical management

• Severe underlying COPD

• Frequent exacerbations

• Serious comorbidities

• Older age

• Insufficeint home support

Potential indications for hospital assessment and admission

• Pharmacologic treatment

• Respiratory support

Treatment of exacerbation

• Short acting bronchodilators

• Systemic corticosteroid

• Antibiotics

Pharmacologic treatment

• Short acting bronchodilators

• Short acting inhaled β2 agonist with or without short acting anticholinergic (Evidence C)

• No significant difference betweent MDI with or without spacer and nebuliser

• IV methylxanthines only to be used in selected cases (Evidence B)

Pharmacologic treatment

• Shorten recovery time, improve FEV1 & PaO2, reduce the risk of early relapse, treatment failure & length of hospital stay (Evidence A)

• 30-40 mg prednisolone for 10-14 days (Evidence D)

• Nebulised budesonide may be an alternative

Pharmacologic treatment: Coticosteroids

• Indications

• Increased dyspoea, sputum purulence, sputum volume (Evidence B)

• Increased sputum purulence with one other cardinal symptoms (Evidence C)

• Mechanical ventilation (Evidence B)

• Length of antibiotic therapy : 5-10 days (Evidence D)

• The choice of antibiotic

• Route of administration

Pharmacologic treatment: Antibiotics

• Appropriate fluid balance

• Diuretics

• Anticoagulants

• Treatment of comorbidities

• Nutrition

Pharmacologic treatment: others

Respiratory support

• Oxygen therapy– Key component of hospital treatment– Target saturation of 88-92%– ABG should be checked 30-60 minutes later– Venturi masks for accurate & controlled delivery

Ventilatory support

• Non-invasive

• Invasive

Indications for NIV

At least one of following:• Respiratory acidosis • Severe dyspnea with clinical signs suggestive

of respiratory muscle fatigue, increased work of breathing or both (Use of respiratory accessory muscles, paradoxical motion of the abdomen, or retraction of the intercostal spaces)

Indications for ICU admission

– Severe dyspnoea that responds inadequately to initial emergency therapy

– Changes in mental status– Persistent or worsening hypoxemia (PaO2 <

5.3 kPa, 40 mm Hg) and/or severe/worsening respiratory acidosis (PH <7.25) despite supplemental O2 & noninvasive ventilation

– Need for invasive mechanical ventilation– Need for vasopressors – hemodynamic

instability

Indications for invasive mechanical ventilation

– Unable to tolerate NIV or NIV failure– Respiratory or cardiac arrest– Respiratory pauses with loss of consciousness or gasping– Diminished consciousness, psychomotor agitation

inadequately controlled by sedation– Massive aspiration– Persistent inability to remove respiratory secretions – Heart rate <50 /min with loss of alertness– Severe hemodynamic instability without response to fluids

and vasoactive drugs– Severe ventricuar arrhythmia– Life threatening hypoxemia in patients unable to tolerate

NIV

Discharge criteria

• Able to use long acting bronchodilators with or without ICS

• Inhaled SABA therapy is required no more frequently than every 4 hrs

• Able to walk across room• Able to eat & sleep• Stable for 12-24 hrs• Fully understand correct use of medication• F/U & home care arrangement• Patient, family & physician are confident

Checklist at time of discharge

• Maintenance pharmacotherapy regimen• Reassessment of inhaler technique• Education regarding role of maintenance

regimen• Completion of steroid therapy & antibiotics• Need for LTOT• Follow up visit in 4-6 weeks• Management plan for comorbidities

Home management of exacerbation

• Nurse administered home care• Effective & practical alternative to

hospitalization in selected patient without acidotic respiratory failure (Evidence A)

68

Thank you