GOLD Slideset 2013 May15

8/10/2019 GOLD Slideset 2013 May15

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Global Initiative for Chronic Obstructive Lung Disease

GLOBAL INITIATIVE FOR CHRONIC

OBSTRUCTIVE LUNG DISEASE (GOLD):TEACHING SLIDE SET

January 2013This slide set is restricted for academic and educational

purposes only. Use of the slide set, or of individualslides, for commercial or promotional purposes requiresapproval from GOLD.


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lobal Initiative for Chronic

bstructive

ung

isease

GO

L

D

2013 Global Initiative for Chronic Obstructive Lung Disease


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GOLD Structure

GOLD Board of Directors

Marc Decramer, MDChair

Science Committee

Jrgen Vestbo, MD - Chair

Dissemination/Implementation

CommitteeJean Bourbeau, MD - Chair



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GOLD Board of Directors: 2013

J. Bourbeau, Canada

B. Celli, U..S.

D. Hui, Hong Kong PRCV. Lopez Varela, Uruguay

M. Nishimura, Japan

R. Rodriguez-Roisin,Spain

R. Stockley, U.K.J. Vestbo, Denmark, U.K.

C. Vogelmeier, Germany


M. Decramer,Chair, Belgium

J. Vestbo, Vice Chair, Denmark, U.K


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GOLD Science Committee - 2013

Jrgen Vestbo, MD, Chair

Alvar Agusti, MD

Antonio Anzueto, MD

Peter Barnes, MD

Leonardo Fabbri, MD

Paul Jones, MD

Fernando Martinez, MD

Nicolas Roche, MD

Roberto Rodriguez-Roisin, MD

Don Sin, MD

Robert Stockley, MDClaus Vogelmeier, MD



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EvidenceCategory

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



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GOLD Structure

GOLD Board of Directors

Marc Decramer, MDChair

Science Committee

Jrgen Vestbo, MD - Chair

Dissemination/Implementation

CommitteeJean Bourbeau, MD - Chair

GOLD National Leaders - GNL 2013 Global Initiative for Chronic Obstructive Lung Disease


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United States

United Kingdom

Argentina

Australia

Brazil

AustriaCanada

Chile

Belgium

China

Denmark

Colombia

Croatia

Egypt

Germany

Greece

Ireland

Italy

SyriaHong Kong ROC

Japan

Iceland

India

Korea

Kyrgyzstan

Uruguay

Moldova

Nepal

Macedonia

Malta

Netherlands

New Zealand

Poland

Norway

Portugal

Georgia

Romania

Russia

SingaporeSlovakia

Slovenia Saudi Arabia

South Afr ica

Spain

Sweden

Thailand

Switzerland

Ukraine

United Arab Emirates

Taiwan ROC

Venezuela

Vietnam

Peru

Yugoslavia

Bangladesh

France

Mexico

Turkey CzechRepublic

Pakistan

Israel

GOLD National Leaders

Philippines

Yeman

Kazakhstan

Mongolia

Albania



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GOLD Website Address

http://www.goldcopd.org



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lobal Initiative for Chronic

bstructive

ung

isease

GO

L

D 2013 Global Initiative for Chronic Obstructive Lung Disease


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GOLD Objectives

Increase awareness of COPD amonghealth professionals, health

authorities, and the general publicImprove diagnosis, management andprevention

Decrease morbidity and mortality

Stimulate research 2013 Global Initiative for Chronic Obstructive Lung Disease


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Global Strategy for Diagnosis, Management andPrevention of COPD, 2013: Chapters

Definition and Overview

Diagnosis and Assessment

Therapeutic Options

Manage Stable COPD

Manage Exacerbations

Manage ComorbiditiesUpdated 2013



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Therapeutic Options

Manage Stable COPD


Manage ComorbiditiesUpdated 2013



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Global Strategy for Diagnosis, Management and Prevention of COPD

Definition of COPD

COPD, a common preventable and treatabledisease, is characterized by persistent airflowlimitation that is usually progressive andassociated with an enhanced chronicinflammatory response in the airways and thelung to noxious particles or gases.

Exacerbations and comorbidities contribute tothe overall severity in individual patients.



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Mechanisms Underlying

Airflow Limitation in COPD

Small Airways Disease

Airway inflammationAirway fibrosis, luminal plugsIncreased airway resistance

Parenchymal Destruction

Loss of alveolar attachmentsDecrease of elastic recoil

AIRFLOW LIMITATION 2013 Global Initiative for Chronic Obstructive Lung Disease


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Burden of COPD

COPD is a leading cause of morbidity andmortality worldwide.

The burden of COPD is projected to increasein coming decades due to continuedexposure to COPD risk factors and the aging

of the worlds population.

COPD is associated with significant economicburden.



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Risk Factors for COPD

Lung growth and development

Gender

Age

Respiratory infections

Socioeconomic status

Asthma/Bronchial

hyperreactivityChronic Bronchitis

Genes

Exposure to particles

Tobacco smoke

Occupational dusts, organicand inorganic

Indoor air pollution fromheating and cooking with

biomass in poorly ventilateddwellings

Outdoor air pollution



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Risk Factors for COPD

Genes

Infections

Socio-economic

status

Aging Populations 2013 Global Initiative for Chronic Obstructive Lung Disease


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Therapeutic Options

Manage Stable COPD


Manage ComorbiditiesUPDATED 2013



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Diagnosis and Assessment: Key Points

A clinical diagnosis of COPD should beconsidered in any patient who has dyspnea,chronic cough or sputum production, and a

history of exposure to risk factors for thedisease.

Spirometry is requiredto make the diagnosis;

the presence of a post-bronchodilator FEV1/FVC< 0.70 confirms the presence of persistentairflow limitation and thus of COPD.



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Diagnosis and Assessment: Key Points

The goals of COPD assessment are to determinethe severity of the disease, including the severity ofairflow limitation, the impact on the patients health

status, and the risk of future events.

Comorbidities occur frequently in COPD patients,and should be actively looked for and treated

appropriately if present.



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SYMPTOMS

chronic cough

shortness of breath

EXPOSURE TO RISKFACTORS

tobacco

occupation

indoor/outdoor pollution

SPIROMETRY: Required to establishdiagnosis


Diagnosis of COPD

sputum


Gl b l S f i i d i f CO


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Assessment of Airflow Limitation:Spirometry

Spirometry should be performed after theadministration of an adequate dose of a short-

acting inhaled bronchodilator to minimizevariability.

A post-bronchodilator FEV1/FVC < 0.70 confirmsthe presence of airflow limitation.

Where possible, values should be compared toage-related normal values to avoid overdiagnosisof COPD in the elderly.



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Spirometry: Normal Trace ShowingFEV1and FVC

1 2 3 4 5 6

1

2

3

4

Volume,

lite

rs

Time, sec

FVC5

1

FEV1= 4LFVC = 5L

FEV1/FVC = 0.8



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Spirometry: Obstructive Disease

Volume,

lite

rs

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



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Determine the severity of the disease, itsimpact on the patients health status and therisk of future events (for example

exacerbations) to guide therapy. Consider thefollowing aspects of the disease separately:

current level of patients symptoms

severity of the spirometric abnormality frequency of exacerbations presence of comorbidities.


Assessment of COPD: Goals



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Assessment of COPD

Assess symptoms

Assess degree of airflowlimitation using spirometry

Assess risk of exacerbations

Assess comorbidities 2013 Global Initiative for Chronic Obstructive Lung Disease


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The characteristic symptoms of COPD are chronic andprogressive dyspnea, cough, and sputum productionthat can be variable from day-to-day.

Dyspnea: Progressive, persistent and characteristicallyworse with exercise.

Chronic cough: May be intermittent and may be

unproductive.

Chronic sputum production: COPD patients commonlycough up sputum.


Symptoms of COPD



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Assess symptoms

Assess degree of airflow limitation using

spirometry


Assess comorbidities

Use the COPD Assessment Test(CAT)or

mMRC Breathlessness scale

or

Clinical COPD Questionnaire (CCQ)


Assessment of COPD



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COPD Assessment Test (CAT):An 8-itemmeasure of health status impairment in COPD(http://catestonline.org).

Breathlessness Measurement using theModified British Medical Research Council

(mMRC) Questionnaire:relates well to othermeasures of health statusand predicts futuremortality risk.


Assessment of Symptoms



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Clinical COPD Questionnaire (CCQ): Self-administered questionnaire developed tomeasure clinical control in patients with COPD

(http://www.ccq.nl).


Assessment of Symptoms



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Modified MRC (mMRC)Questionnaire



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Assess symptoms

Assess degree of airflow limitation

usingspirometryAssess risk of exacerbations

Assess comorbidities

Use spirometry for grading severity

according to spirometry, using four

grades split at 80%, 50% and 30% ofpredicted value


Assessment of COPD




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Classification of Severity of AirflowLimitation 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 2013 Global Initiative for Chronic Obstructive Lung Disease


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Assess symptoms

Assess degree of airflow limitation

using spirometryAssess risk of exacerbations

Assess comorbiditiesUse 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


Assessment of COPD



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Assess Risk of Exacerbations

To assess risk of exacerbations usehistory of exacerbations and

spirometry:

Two or more exacerbations within

the last year oran FEV1 < 50 % ofpredicted value are indicators ofhigh risk.



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Combined Assessment of COPD

Assess symptoms

Assess degree of airflow limitation usingspirometry


Combine these assessments for thepurpose of improving management of COPD


Gl b l S f d f CO


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Risk

(GOLD

ClassificationofA

irflow

Limitation

)

Risk

(Exacerbation

history)

> 2

1

0

(C) (D)

(A) (B)

mMRC 0-1

CAT < 10

4

3

2

1

mMRC > 2

CAT > 10Symptoms

(mMRC or CAT score)) 2013 Global Initiative for Chronic Obstructive Lung Disease

Gl b l St t f Di i M t d P ti f COPD


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(C) (D)

(A) (B)mMRC 0-1

CAT < 10

mMRC > 2

CAT > 10

Symptoms(mMRC or CAT score))

If mMRC 0-1 or CAT < 10:

Less Symptoms (A or C)

If mMRC > 2 or CAT > 10:

More Symptoms (B or D)

Assess symptoms first




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Risk

(GOLD

Clas

sificationofAirflo

w

Limitation)

Risk

(E

xacerbationhistory)

> 2

1

0

(C) (D)

(A) (B)mMRC 0-1

CAT < 10

4

3

2

1

mMRC > 2

CAT > 10


If GOLD 1 or 2 and only0 or 1 exacerbations per year:

Low Risk (A or B)

If GOLD 3 or 4 ortwo ormore exacerbations per year:

High Risk (C or D)

(One or more hospitalizationsfor COPD exacerbationsshould be considered high

risk.)

Assess risk of exacerbations next




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Risk

(GOLD

Clas

sificationofAirflo

w

Limitation)

Risk

(E

xacerbationhistory)

> 2

1

0

(C) (D)

(A) (B)mMRC 0-1

CAT < 10

4

3

2

1

mMRC > 2

CAT > 10


Patient is now in one offour categories:

A: Les symptoms, low risk

B: More symptoms, low risk

C: Less symptoms, high risk

D: More symptoms, high risk

Use combined assessment




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Risk

(GOLD

ClassificationofA

irflow

Limitation

)

Risk

(Exacerbation

history)

> 2

1

0

(C) (D)

(A) (B)

mMRC 0-1

CAT < 10

4

3

2

1

mMRC > 2

CAT > 10Symptoms

(mMRC or CAT score))


Global Strategy for Diagnosis, Management and


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Patien

t

Characteristic Spirometric

Classification

Exacerbations

per year

mMRC CAT

ALow Risk

Less SymptomsGOLD 1-2 1 0-1 < 10

B

Low Risk

More Symptoms GOLD 1-2 1 > 2 10

CHigh Risk

Less SymptomsGOLD 3-4 >2 0-1 < 10

DHigh Risk

More SymptomsGOLD 3-4 > 2 > 2

10

Prevention of COPD

Combined Assessment

of COPDWhen assessing risk, choose the highestriskaccording to GOLD grade or exacerbation

history. One or more hospitalizations for COPD

exacerbations should be considered high risk.)



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Assess COPD Comorbidities

COPD patients are at increased risk for:

Cardiovascular diseases Osteoporosis Respiratory infections Anxiety and Depression Diabetes

Lung cancerThese comorbid conditions may influence

mortality and hospitalizations and should be

looked for routinely, and treated appropriately. 2013 Global Initiative for Chronic Obstructive Lung Disease



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Differential Diagnosis:COPD and Asthma

COPD

Onset in mid-life

Symptoms slowlyprogressive

Long smoking history

ASTHMA

Onset early in life (often

childhood) Symptoms vary from day to day

Symptoms worse at night/earlymorning

Allergy, rhinitis, and/or eczemaalso present

Family history of asthma



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Additional Investigations

Chest X-ray: Seldom diagnostic but valuable to excludealternative diagnoses and establish presence of significantcomorbidities.

Lung Volumes and Diffusing Capacity:Help to characterizeseverity, but not essential to patient management.

Oximetry and Arterial Blood Gases: Pulse oximetry can beused to evaluate a patients oxygen saturation and need for

supplemental oxygen therapy.Alpha-1 Antitrypsin Deficiency Screening: Perform when COPDdevelops in patients of Caucasian descent under 45 years orwith a strong family history of COPD.



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Exercise Testing: Objectively measured exerciseimpairment, assessed by a reduction in self-paced walkingdistance (such as the 6 min walking test) or duringincremental exercise testing in a laboratory, is a powerfulindicator of health status impairment and predictor ofprognosis.

Composite Scores: Several variables (FEV1, exercise

tolerance assessed by walking distance or peak oxygenconsumption, weight loss and reduction in the arterialoxygen tension) identify patients at increased risk formortality.


Additional Investigations


Gl b l St t f Di i M t d


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Therapeutic Options

Manage Stable COPD





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Therapeutic Options: Key Points

Smoking cessation has the greatest capacity toinfluence the natural history of COPD. Health careproviders should encourage all patients who smoketoquit.

Pharmacotherapy and nicotine replacement reliablyincrease long-term smoking abstinence rates.

All COPD patients benefit from regular physicalactivity and should repeatedly be encouraged toremain active.



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Appropriate pharmacologic therapy can reduce COPDsymptoms, reduce the frequency and severity of

exacerbations, and improve health status andexercise tolerance.

None of the existing medications for COPD has beenshown conclusively to modify the long-term decline

in lung function.

Influenza and pneumococcal vaccination should beoffered depending on local guidelines.


Therapeutic Options: Key Points




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Therapeutic Options: Smoking Cessation

Counseling delivered by physicians and other healthprofessionals significantly increases quit rates over self-initiated strategies. Even a brief (3-minute) period of

counseling to urge a smoker to quit results in smokingquit rates of 5-10%.

Nicotine replacement therapy (nicotine gum, inhaler,nasal spray, transdermal patch, sublingual tablet, orlozenge) as well as pharmacotherapy with varenicline,bupropion, and nortriptyline reliably increases long-term smoking abstinence rates and are significantlymore effective than placebo.


Brief Strategies to Help the


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Brief Strategies to Help thePatient Willing to Quit Smoking

ASK Systematically identify all

tobacco users at every visit

ADVISE Strongly urge all tobaccousers to quit

ASSESS Determine willingness to

make a quit attempt

ASSIST Aid the patient in quitting

ARRANGE Schedule follow-up contact. 2013 Global Initiative for Chronic Obstructive Lung Disease

Global Strategy for Diagnosis Management and Prevention of COPD


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Therapeutic Options: Risk Reduction

Encourage comprehensive tobacco-control policies with clear,consistent, and repeated nonsmoking messages.

Emphasize primary prevention, best achieved by elimination or

reduction of exposures in the workplace. Secondaryprevention, achieved through surveillance and early detection,is also important.

Reduce or avoid indoor air pollution from biomass fuel, burned

for cooking and heating in poorly ventilated dwellings.

Advise patients to monitor public announcements of air qualityand, depending on the severity of their disease, avoid vigorousexercise outdoors or stay indoors during pollution episodes.




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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

Methylxanthines

Inhaled corticosteroids

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

Systemic corticosteroids

Phosphodiesterase-4 inhibitors




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Bronchodilator medications are central to the

symptomatic management of COPD.

Bronchodilators are prescribed on an as-needed or on a

regular basis to prevent or reduce symptoms.

The principal bronchodilator treatments are beta2- agonists, anticholinergics, theophylline or combinationtherapy.

The choice of treatment depends on the availability of

medications and each patients individual response in

terms of symptom relief and side effects..


Therapeutic Options: Bronchodilators


Global Strategy for Diagnosis Management and Prevention of COPD


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Long-acting inhaled bronchodilators are

convenient and more effective for symptom reliefthan short-acting bronchodilators.

Long-acting inhaled bronchodilators reduceexacerbations and related hospitalizations andimprove symptoms and health status.

Combining bronchodilators of differentpharmacological classes may improve efficacy anddecrease the risk of side effects compared toincreasing the dose of a single bronchodilator.


Therapeutic Options: Bronchodilators




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Regular treatment with inhaled corticosteroids (ICS)

improves symptoms, lung function and quality of lifeand reduces frequency of exacerbations for COPD

patients with an FEV1< 60% predicted.

Inhaled corticosteroid therapy is associated with anincreased risk of pneumonia.

Withdrawal from treatment with inhaledcorticosteroids may lead to exacerbations in somepatients.

Therapeutic Options: InhaledCorticosteroids




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An inhaled corticosteroid combined with a long-acting

beta2-agonist is more effective than the individualcomponents in improving lung function and health

status and reducing exacerbations in moderate to verysevere COPD.

Combination therapy is associated with an increased riskof pneumonia.

Addition of a long-acting beta2-agonist/inhaledglucorticosteroid combination to an anticholinergic(tiotropium) appears to provide additional benefits.

Therapeutic Options: CombinationTherapy




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Chronic treatment with systemic

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

Therapeutic Options: SystemicCorticosteroids



The pe ti Option


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In patients with severe and very severeCOPD (GOLD 3 and 4) and a history ofexacerbations and chronic bronchitis, thephospodiesterase-4 inhibitor (PDE-4),roflumilast, reduces exacerbations treated

with oral glucocorticosteroids.

Therapeutic Options:Phosphodiesterase-4 Inhibitors




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gy g , g

Therapeutic Options: Theophylline

Theophylline is less effective and less well tolerated thaninhaled long-acting bronchodilators and is notrecommended if those drugs are available and affordable.

There is evidence for a modest bronchodilator effect andsome symptomatic benefit compared with placebo in stableCOPD. Addition of theophylline to salmeterol produces agreater increase in FEV1and breathlessness than

salmeterol alone.

Low dose theophylline reduces exacerbations but does notimprove post-bronchodilator lung function.



Therapeutic Options: Other


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Influenza vaccines can reduce serious illness.Pneumococcal polysaccharide vaccine is recommendedfor COPD patients 65 years and older and for COPDpatients younger than age 65 with an FEV1< 40%predicted.

The use of antibiotics, other than for treating infectious

exacerbations of COPD and other bacterial infections, iscurrently not indicated.

Therapeutic Options: OtherPharmacologic Treatments



Therapeutic Options: Other


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Alpha-1 antitrypsin augmentation therapy:notrecommended for patients with COPD that is unrelatedto the genetic deficiency.

Mucolytics: Patients with viscous sputum maybenefit from mucolytics; overall benefits are very small.

Antitussives: Not recommended.

Vasodilators: Nitric oxide is contraindicated in stableCOPD. The use of endothelium-modulating agents forthe treatment of pulmonary hypertension associatedwith COPD is not recommended.

Therapeutic Options: OtherPharmacologic Treatments




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All COPD patients benefit from exercise trainingprograms with improvements in exercise toleranceand symptoms of dyspnea and fatigue.

Although an effective pulmonary rehabilitationprogram is 6 weeks, the longer the programcontinues, the more effective the results.

If exercise training is maintained at home, thepatient's health status remains above pre-rehabilitation levels.


Therapeutic Options: Rehabilitation




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Oxygen Therapy: The long-term administration ofoxygen (> 15 hours per day) to patients with chronicrespiratory failure has been shown to increase

survival in patients with severe, resting hypoxemia.

Ventilatory Support: Combination of noninvasiveventilation (NIV) with long-term oxygen therapy may

be of some use in a selected subset of patients,particularly in those with pronounced daytimehypercapnia.


Therapeutic Options: Other Treatments



Th ti O ti S i l


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Lung volume reduction surgery (LVRS) is moreefficacious than medical therapy among patientswith upper-lobe predominant emphysema and low

exercise capacity.

LVRSis costly relative to health-care programs notincluding surgery.

In appropriately selected patients with very severeCOPD, lung transplantation has been shown toimprove quality of life and functional capacity.

Therapeutic Options: SurgicalTreatments




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Palliative Care, End-of-life Care, Hospice Care:

Communication with advanced COPD patients about

end-of-life care and advance care planning givespatients and their families the opportunity to makeinformed decisions.

G oba S a egy o ag os s, a age e a d e e o o CO

Therapeutic Options: Other Treatments


Global Strategy for Diagnosis Management and


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Global Strategy for Diagnosis, Management andPrevention of COPD, 2013: Major Chapters



Therapeutic Options

Manage Stable COPD






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Identification and reduction of exposure to risk factorsare important steps in prevention and treatment.

Individualized assessment of symptoms, airflow

limitation, and future risk of exacerbations should beincorporated into the management strategy.

All COPD patients benefit from rehabilitation andmaintenance of physical activity.

Pharmacologic therapy is used to reduce symptoms,reduce frequency and severity of exacerbations, andimprove health status and exercise tolerance.

Manage Stable COPD: Key Points



bl


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Long-acting formulations of beta2-agonists

and anticholinergics are preferred overshort-acting formulations. Based on efficacy

and side effects, inhaled bronchodilators arepreferred over oral bronchodilators.

Long-term treatment with inhaled

corticosteroids added to long-actingbronchodilators is recommended for patientswith high risk of exacerbations.




M S bl COPD K P i


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Long-term monotherapy with oral or inhaled

corticosteroids is not recommended inCOPD.

The phospodiesterase-4 inhibitor roflumilastmay be useful to reduce exacerbations forpatients with FEV1 < 50% of predicted,

chronic bronchitis, and frequentexacerbations.




M St bl COPD G l f Th


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Relieve symptoms

Improve exercise tolerance

Improve health status

Prevent disease progression

Prevent and treat exacerbations

Reduce mortality

Reduce

symptoms

Reducerisk

Manage Stable COPD: Goals of Therapy




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Avoidance of risk factors

- smoking cessation

- reduction of indoor pollution

- reduction of occupational exposureInfluenza vaccination

Manage Stable COPD: All COPD Patients



M St bl COPD N h l i


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Manage Stable COPD: Non-pharmacologic

Patient

Group

Essential Recommended Depending on local

guidelines

A

Smoking cessation (can

include pharmacologic

treatment)

Physical activity

Flu vaccination

Pneumococcal

vaccination

B, C, D

Smoking cessation (caninclude pharmacologic

treatment)

Pulmonary rehabilitation

Physical activity

Flu vaccination

Pneumococcal

vaccination



Manage Stable COPD: Pharmacologic Therapy


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Manage Stable COPD: Pharmacologic Therapy(Medications in each box are mentioned in alphabetical order, and

therefore not necessarily in order of preference.)

Patient RecommendedFirst choice

Alternative choice Other PossibleTreatments

A

SAMA prn

or

SABA prn

LAMA

or

LABA

or

SABA and SAMA

Theophylline

B

LAMA

or

LABA

LAMA and LABASABA and/orSAMA

Theophylline

C

ICS + LABA

or

LAMA

LAMA and LABA or

LAMA and PDE4-inh. or

LABA and PDE4-inh.

SABA and/orSAMA

Theophylline

D

ICS + LABA

and/or

LAMA

ICS + LABA and LAMA or

ICS+LABA and PDE4-inh. or

LAMA and LABA or

LAMA and PDE4-inh.

Carbocysteine

SABA and/orSAMA

Theophylline




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Exa

cerbationsperyear

> 2

1

0

mMRC 0-1

CAT < 10

GOLD 4

mMRC > 2

CAT > 10

GOLD 3

GOLD 2

GOLD 1

SAMAprn

orSABA prn

LABA

orLAMA

ICS + LABA

or

LAMA

g g py

RECOMMENDED FIRST CHOICE

A B

DC

ICS + LABA

and/or

LAMA





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> 2

1

0

mMRC 0-1

CAT < 10

GOLD 4

mMRC > 2

CAT > 10

GOLD 3

GOLD 2

GOLD 1

LAMA

or

LABA

or

SABA and SAMA

LAMA and LABA

or

LAMA and PDE4-inh

or

LABA and PDE4-inh

ICS + LABA and LAMA

or

ICS + LABA and PDE4-inh

or

LAMA and LABA

orLAMA and PDE4-inh.

LAMA and LABA

g g py

ALTERNATIVE CHOICE

A

DC

B

Exa

cerbationsperyear





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> 2

1

0

mMRC 0-1

CAT < 10

GOLD 4

mMRC > 2

CAT > 10

GOLD 3

GOLD 2

GOLD 1

Theophylline

SABA and/or SAMA

Theophylline

Carbocysteine

SABA and/or SAMA

Theophylline

SABA and/or SAMA

Theophylline

g g py

OTHER POSSIBLE TREATMENTS

A

DC

B

Exa

cerbationsperyear




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gy g , gPrevention of COPD, 2013: Chapters



Therapeutic Options

Manage Stable COPD





b


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An exacerbation of COPD is:

an acute event characterized by a

worsening of the patients respiratorysymptoms that is beyond normal day-to-day variations and leads to a

change in medication.




b i i


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The most common causes of COPD exacerbationsare viral upper respiratory tract infections andinfection of the tracheobronchial tree.

Diagnosis relies exclusively on the clinicalpresentation of the patient complaining of an acutechange of symptoms that is beyond normal day-to-day variation.

The goal of treatment is to minimize the impact ofthe current exacerbation and to prevent thedevelopment of subsequent exacerbations.

Manage Exacerbations: Key Points



M E b i K P i


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Short-acting inhaled beta2-agonists with or withoutshort-acting anticholinergics are usually thepreferred bronchodilators for treatment of an

exacerbation. Systemic corticosteroids and antibiotics can shorten

recovery time, improve lung function (FEV1) andarterial hypoxemia (PaO2),

and reduce the risk ofearly relapse, treatment failure, and length ofhospital stay.

COPD exacerbations can often be prevented.

Manage Exacerbations: Key Points


Consequences Of COPD Exacerbations


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Impact onsymptoms

and lung

function

Negativeimpact on

quality of life

Consequences Of COPD Exacerbations

Increased

economic

costs

Accelerated

lung function

decline

Increased

Mortality

EXACERBATIONS



M E b i A


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Arterial blood gas measurements (in hospital): PaO2< 8.0 kPawith or without PaCO2> 6.7 kPa when breathing room airindicates 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 sputumduring an exacerbation: indication to begin

empirical antibiotic treatment.Biochemical tests: detect electrolyte disturbances, diabetes, andpoor nutrition.

Spirometric tests: not recommended during an exacerbation.

Manage Exacerbations: Assessments



M E b ti T t t O ti


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Oxygen: titrate to improve the patients hypoxemia with atarget 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.

Manage Exacerbations: Treatment Options



M E b ti T t t O ti


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Antibiotics should be given to patients with:

Three cardinal symptoms: increased

dyspnea, increased sputum volume, andincreased sputum purulence.

Who require mechanical ventilation.

Manage Exacerbations: Treatment Options



Manage Exacerbations: Treatment


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Noninvasive ventilation (NIV) for patientshospitalized 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.GOLD Revision 2011

Options



Manage Exacerbations: Indications for


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Marked increase in intensity of symptoms

Severe underlying COPD

Onset of new physical signs

Failure of an exacerbation to respond to initialmedical management

Presence of serious comorbidities

Frequent exacerbations Older age

Insufficient home support

g

Hospital Admission




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Prevention of COPD, 2013: Major Chapters



Therapeutic Options

Manage Stable COPD





M C biditi


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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.

Manage Comorbidities



M C biditi


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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-blockertreatment in heart failure outweigh potential

risk even in patients with severe COPD.




M n ge Como biditie


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Osteoporosis andanxiety/depression: often under-diagnosed and associated with poor health status andprognosis.

Lung cancer: frequent in patients with COPD; the mostfrequent cause of death in patients with mild COPD.

Serious infections: respiratory infections are especially

frequent.Metabolic syndrome and manifest diabetes: morefrequent in COPD and the latter is likely to impact on

prognosis.





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Prevention of COPD, 2013: Chapters



Therapeutic Options

Manage Stable COPD




Global Strategy for Diagnosis, Management


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Prevention of COPD is to a large extent possibleand should have high priority

Spirometry is requiredto make the diagnosis ofCOPD; the presence of a post-bronchodilatorFEV1/FVC < 0.70 confirms the presence ofpersistent airflow limitation and thus of COPD

The beneficial effects of pulmonary rehabilitationand physical activity cannot be overstated

gy g , gand Prevention of COPD, 2013: Summary




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Assessment of COPD requiresassessment of symptoms, degree of

airflow limitation, risk ofexacerbations, and comorbidities

Combined assessment of symptoms

and risk of exacerbations is the basisfor non-pharmacologic andpharmacologic management of COPD

gy g gand Prevention of COPD, 2013: Summary




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Treat COPD exacerbations to minimizetheir impact and to prevent the

development of subsequentexacerbations

Look for comorbiditiesand if present

treat to the same extent as if thepatient did not have COPD

and Prevention of COPD, 2013: Summary


WORLD COPD DAY


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WORLD COPD DAY

November 20, 2013

Raising COPD Awareness Worldwide 2013 Global Initiative for Chronic Obstructive Lung Disease

United States Australia

Brazil

C dCroatia

Germany

Ireland

Slovenia Saudi Arabia

Yugoslavia

Bangladesh


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United States

United Kingdom

Argentina

AustraliaAustria

Canada

Chile

Belgium

China

Denmark

Colombia

Croatia

Egypt

Greece

Italy

SyriaHong Kong ROC

Japan

Iceland

India

Korea

Kyrgyzstan

Uruguay

Moldova

Nepal

Macedonia

Malta

Netherlands

New Zealand

Poland

Norway

Portugal

Georgia

Romania

Russia

SingaporeSlovakia

South Afr ica

SpainSweden

Thailand

Switzerland

Ukraine

United Arab Emirates

Taiwan ROC

Venezuela

Vietnam

Peru

ugos av a

France

Mexico

Turkey CzechRepublic

Pakistan

Israel

GOLD National Leaders

PhilippinesYeman

Kazakhstan

Mongolia

Albania




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http://www.goldcopd.org



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ADDITIONAL SLIDES PREPARED BY

PROFESSOR PETER J. BARNES, MD

NATIONAL HEART AND LUNG INSTITUTE

LONDON, ENGLAND


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Professor Peter J. Barnes, MD

National Heart and Lung Institute, London UK


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Professor P.J. Barnes, MD, National

Heart and Lung Institute, London UK


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GOLD Slideset 2013 May15

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Transcript of GOLD Slideset 2013 May15