GOLD Update 2011

Rabab A. El Wahsh, MD.

Lecturer of Chest Diseases and Tuberculosis

Minoufiya University

REVISED 2011

Global Initiative for chronic obstructive pulmonary disease

(GOLD)• Immediately following the release of the first

GOLD report in 2001, the GOLD board of directors appointed a science committee, charged with keeping the GOLD documents up to date.

• The first update to the GOLD report was in 2003, then annual updated documents were prepared and released on the GOLD website.

• A comprehensively updated version was released in 2006, then in 2010 and lastly in 2011.

What`s new in GOLD 2011?

• The definition of COPD was not significantly modified but has

been reworded for clarity.

• Assessment of COPD is based on the patient`s level of

symptoms, future risk of exacerbations, the severity of

spirometric abnormlity, and the identification of comorbidities.

• Management of stable COPD is based , not only on level of

FEV1 but on disease impact and future risk of disease

progression.

• More focusing on comorbidities.

COPD Definition

• GOLD 2010• Chronic obstructive pulmonary

disease (COPD) is a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases.

• GOLD 2011• Chronic obstructive pulmonary

disease (COPD), a common preventable and treatable disease is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. Exacerbations and comorbidities contribute to the overall severity in individual patients.

Risk Factors for COPD

GenesGenes

InfectionsInfections

Socio-economic Socio-economic statusstatus

Aging PopulationsAging Populations

Pathogenesis of COPDPathogenesis of COPD

NOXIOUS AGENT(tobacco smoke, pollutants, occupational agent)

COPD

Genetic factors

Respiratory infection

Other

Noxious particles

and gases

Lung inflammation

Host factors

COPD pathology

ProteinasesOxidative stress

Anti-proteinasesAnti-oxidants

Repair mechanisms

INFLAMMATION

Small airway diseaseAirway inflammationAirway remodeling

Parenchymal destructionLoss of alveolar attachments

Decrease of elastic recoil

AIRFLOW LIMITATION

Diagnosis and Assessment of COPDGOLD 2010 GOLD 2011

•While post-bronchodilator spirometry is required for the diagnosis and assessment of severity of COPD, the degree of reversibility of airflow limitation is no longer recommended. The degree of reversibility has never been shown to add to the diagnosis, differential diagnosis with asthma, or to predicting the response to long-term treatment with bronchodilators or corticosteroids.

•The use of a fixed ratio FEV1/FVC to define airflow limitation will result in more frequent diagnosis of COPD in the elderly, and less frequent diagnosis in adults younger than 45 years, especially of mild disease, compared to using a cutoff based on the lower limit of normal values for FEV1/FVC. From a scientific perspective it is difficult to determine which of these criteria is correct to diagnose COPD.

Diagnosis and Assessment of COPD

SYMPTOMS

chronic cough chronic coughshortness of breathshortness of breath

EXPOSURE TO RISKFACTORS

tobaccotobaccooccupationoccupation

indoor/outdoor pollutionindoor/outdoor pollution

SPIROMETRY: Required to establish diagnosis

SPIROMETRY: Required to establish diagnosis

Diagnosis of COPDDiagnosis of COPD

sputum sputum

Assessment of GOLD stage using spirometry (GOLD 2010)

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

Assess symptomsAssess degree of airflow limitation using

spirometryAssess risk of exacerbationsAssess comorbidities

Combined Assessment of COPD (GOLD 2011)

COPD Assessment Test (CAT): An 8-item measure of health status impairment in COPD.

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

Modified MRC (mMRC)Questionnaire

COPD Assessment Test (CAT):

Assessment of degree of airflow limitation using spirometry

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 risk of exacerbations

An exacerbation of COPD is defined as an acute event

characterized by a worsening of the patient`s respiratory

symptoms that is beyond normal day-to-day variations and

leads to change in medication.

Two exacerbations or more within the last year

or an FEV1 < 50 % of predicted value are

indicators of high risk of future exacerbations.

Combined Assessment of COPD

Ris

k (G

OLD

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Air

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imit

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Ris

k (E

xace

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> 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 of

four categories:

A: Less symptoms, low risk

B: More symtoms, low risk

C: Less symptoms, high risk

D: More Symtoms, high risk

Assessment of COPD Comorbidities

COPD patients are at increased risk for:

Cardiovascular diseasesOsteoporosisRespiratory infectionsAnxiety and DepressionDiabetesLung cancerThese comorbid conditions may influence mortality and

hospitalizations and should be looked for routinely, and treated appropriately.

Goals for treatment of stable COPD

Reduce symptoms by:•Relieving symptoms•Improving exercise tolerence•Improving health statusReduce risk by:•Preventing disease progression•Preventing and treatment of exacerbation•Reduction of mortality

Management of stable COPD

2010

Initial pharmacologic management of COPD (2011)Patient group First choice Second choice Alternative choice

A Short acting anticholinergic

Or

Short acting B2 agonist

Long acting anticholinergic

Or

Long acting B2 agonist

Or

Short acting B2 agonist and Short acting anticholinergic

Theophylline

B Long acting

Anticholinergic

Or

Long acting

B2 agonist

Long acting

Anticholinergic and

Long acting

B2 agonist

Short acting B2 agonist and/ or

Short acting anticholinergic

Theophylline

C Inhaled corticosteroid + Long acting

B2 agonist

Or

Long acting

anticholinergic

Long acting

Anticholinergic and

Long acting

B2 agonist

Phospodiesterase-4 inhibitor

Short acting B2 agonist and/ or

Short acting anticholinergic

Theophylline

D Inhaled corticosteroid + Long acting

B2 agonist

Or

Long acting

anticholinergic

Inhaled corticosteroid and Long acting

Anticholinergic

Or

inhaled corticosteroid+

Long acting

B2 agonist and long acting anticholinergic

Or

Inhaled corticosteroid + Long acting B2 agonist and phosphodiesterse-4 inhibitor

Or

Long acting Anticholinergic and long acting B2 agonist

Or

Long acting anticholinergic and phosphodiesterase-4 inhibitor

Carbocysteine

Short acting B2 agonist

And/or

Short acting anticholinergic

theophylline

Non-pharmacologic management of COPD (2011)

Patient group Essential Recommended Depending on local guidelines

A Smoking cessation

Physical activity Flu vaccine

Pneumococcal vaccine

B-D Smoking cessation

Pulmonary rehabilitation

Physical activity Flu vaccine

Pneumococcal vaccine