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© Global Initiative for Chronic Obstructive Lung Disease GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE (GOLD): TEACHING SLIDE SET December 2011 This slide set is restricted for academic and educational purposes only. Use of the slide set, or of individual slides, for commercial or promotional purposes requires approval from GOLD. lobal Initiative for Chronic bstructive ung isease G O L D © Global Initiative for Chronic Obstructive Lung Disease GOLD Structure GOLD Board of Directors Roberto Rodriguez-Roisin, MD Chair Science Committee Jørgen Vestbo, MD - Chair Dissemination/Implementation Committee Jean Bourbeau, MD - Chair GOLD Board of Directors: 2011 R. Rodriguez-Roisin, Chair, Spain A. Anzueto, U.S. ATS J. Bourbeau, Canada T. DeGuia, Philippines D. Hui, Hong Kong PRC F. Martinez, U.S. M. Mishima, Japan APSR D. Nugmanova, Kazakhstan WONCA A. Ramirez, Mexico ALAT R. Stockley, U.K. J. Vestbo, Denmark, U.K. Observer: J. Wedzica, UK ERS GOLD Science Committee - 2011 Jørgen Vestbo, MD, Chair Alvar Agusti, MD Antonio Anzueto, MD Peter Barnes, MD Leonardo Fabbri, MD Paul Jones, MD Fernando Martinez, MD Masaharu Nishimura, MD Roberto Rodriguez-Roisin, MD Don Sin, MD Robert Stockley, MD Claus Vogelmeier, MD 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 trials Observational studies. D Panel consensus judgment Description of Levels of Evidence GOLD Structure GOLD Board of Directors Roberto Rodriguez-Roisin, MD Chair Science Committee Jørgen Vestbo, MD - Chair Dissemination/Implementation Task Group Jean Bourbeau, MD - Chair GOLD National Leaders - GNL United States United Kingdom Argentina Australia Brazil Austria Canada Chile Belgium China Denmark Columbia Croatia Egypt Germany Greece Ireland Italy Syria Hong Kong ROC Japan Iceland India Korea Kyrgyzstan Uruguay Moldova Nepal Macedonia Malta Netherlands New Zealand Poland Norway Portugal Georgia Romania Russia Singapore Slovakia Slovenia Saudi Arabia South Africa Spain Sweden Thailand Switzerland Ukraine United Arab Emirates Taiwan ROC Venezuela Vietnam Peru Yugoslavia Albania Bangladesh France Mexico Turkey Czech Republic Pakistan Israel GOLD National Leaders Philippines Yeman Kazakhstan Mongolia GOLD Website Address http:/www.goldcopd.org lobal Initiative for Chronic bstructive ung isease G O L D © Global Initiative for Chronic Obstructive Lung Disease GOLD Objectives nIncrease awareness of COPD among health professionals, health authorities, and the general public nImprove diagnosis, management and prevention nDecrease morbidity and mortality nStimulate research Global Strategy for Diagnosis, Management and Prevention of COPD, 2011: Chapters nDefinition and Overview nDiagnosis and Assessment nTherapeutic Options nManage Stable COPD nManage Exacerbations nManage Comorbidities REVISED 2011 Global Strategy for Diagnosis, Management and Prevention of COPD, 2011: Chapters nDefinition and Overview nDiagnosis and Assessment nTherapeutic Options nManage Stable COPD nManage Exacerbations nManage Comorbidities REVISED 2011 Global Strategy for Diagnosis, Management and Prevention of COPD Definition of COPD nCOPD, 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. nExacerbations and comorbidities contribute to the overall severity in individual patients. Global Strategy for Diagnosis, Management and Prevention of COPD 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 Global Strategy for Diagnosis, Management and Prevention of COPD Burden of COPD COPD is a leading cause of morbidity and mortality worldwide. The burden of COPD is projected to increase in coming decades due to continued exposure to COPD risk factors and the aging of the worlds population. COPD is associated with significant economic burden. Global Strategy for Diagnosis, Management and Prevention of COPD 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 Global Strategy for Diagnosis, Management and Prevention of COPD Risk Factors for COPD GenesGenes InfectionsInfections Socio-economic Socio-economic statusstatus Aging PopulationsAging Populations Global Strategy for Diagnosis, Management and Prevention of COPD, 2011: Chapters nDefinition and Overview nDiagnosis and Assessment nTherapeutic Options nManage Stable COPD nManage Exacerbations nManage Comorbidities REVISED 2011 Global Strategy for Diagnosis, Management and Prevention of COPD Diagnosis and Assessment: Key Points § A clinical diagnosis of COPD should be considered in any patient who has dyspnea, chronic cough or sputum production, and/or a history of exposure to risk factors for the disease. § Spirometry is required to make the diagnosis; the presence of a post-bronchodilator FEV1/FVC 80% predicted GOLD 2: Moderate 50% 2 1 0 (C)(D) (A)(B) mMRC 0-1 CAT 2 CAT 10 Symptoms (mMRC or CAT score) Global Strategy for Diagnosis, Management and Prevention of COPD Combined Assessment of COPD (C)(D) (A)(B) mMRC 0-1 CAT 2 CAT 10 Symptoms (mMRC or CAT score) If mMRC 0-1 or CAT 2 or CAT 10: More Symptoms (B or D) Assess symptoms first Global Strategy for Diagnosis, Management and Prevention of COPD Combined Assessment of COPD Risk (GOLD Classification of Airflow Limitation) Risk (Exacerbation history) 2 1 0 (C)(D) (A)(B) mMRC 0-1 CAT 2 CAT 10 Symptoms (mMRC or CAT score) If GOLD 1 or 2 and only 0 or 1 exacerbations per year: Low Risk (A or B) If GOLD 3 or 4 or two or more exacerbations per year: High Risk (C or D) Assess risk of exacerbations next Global Strategy for Diagnosis, Management and Prevention of COPD Combined Assessment of COPD Risk (GOLD Classification of Airflow Limitation) Risk (Exacerbation history) 2 1 0 (C)(D) (A)(B) mMRC 0-1 CAT 2 CAT 10 Symptoms (mMRC or CAT score) Patient is now in one of four categories: A: Les symptoms, low risk B: More symtoms, low risk C: Less symptoms, high risk D: More Symtoms, high risk Use combined assessment Global Strategy for Diagnosis, Management and Prevention of COPD Combined Assessment of COPD Risk (GOLD Classification of Airflow Limitation) Risk (Exacerbation history) 2 1 0 (C)(D) (A)(B) mMRC 0-1 CAT 2 CAT 10 Symptoms (mMRC or CAT score) PatientCharacteristicSpirometric Classification Exacerbations per year mMRCCAT A Low Risk Less Symptoms GOLD 1-2 10-1 2 10 C High Risk Less Symptoms GOLD 3-4 20-1 2 2 10 Global Strategy for Diagnosis, Management and Prevention of COPD Combined Assessment of COPD When assessing risk, choose the highest risk according to GOLD grade or exacerbation history Global Strategy for Diagnosis, Management and Prevention of COPD Assess COPD Comorbidities COPD patients are at increased risk for: Cardiovascular diseases Osteoporosis Respiratory infections Anxiety and Depression Diabetes Lung cancer These comorbid conditions may influence mortality and hospitalizations and should be looked for routinely, and treated appropriately. Global Strategy for Diagnosis, Management and Prevention of COPD Differential Differential Diagnosis: Diagnosis: COPD COPD and Asthmaand Asthma COPD Onset in mid-life Symptoms slowly progressive Long smoking history ASTHMA Onset early in life (often childhood) Symptoms vary from day to day Symptoms worse at night/early morning Allergy, rhinitis, and/or eczema also present Family history of asthma Global Strategy for Diagnosis, Management and Prevention of COPD Additional Investigations Chest X-ray: Seldom diagnostic but valuable to exclude alternative diagnoses and establish presence of significant comorbidities. Lung Volumes and Diffusing Capacity: Help to characterize severity, but not essential to patient management. Oximetry and Arterial Blood Gases: Pulse oximetry can be used to evaluate a patients oxygen saturation and need for supplemental oxygen therapy. Alpha-1 Antitrypsin Deficiency Screening: Perform when COPD develops in patients of Caucasian descent under 45 years or with a strong family history of COPD. Exercise Testing: Objectively measured exercise impairment, assessed by a reduction in self-paced walking distance (such as the 6 min walking test) or during incremental exercise testing in a laboratory, is a powerful indicator of health status impairment and predictor of prognosis. Composite Scores: Several variables (FEV1, exercise tolerance assessed by walking distance or peak oxygen consumption, weight loss and reduction in the arterial oxygen tension) identify patients at increased risk for mortality. Global Strategy for Diagnosis, Management and Prevention of COPD Additional Investigations Global Strategy for Diagnosis, Management and Prevention of COPD, 2011: Chapters nDefinition and Overview nDiagnosis and Assessment nTherapeutic Options nManage Stable COPD nManage Exacerbations nManage Comorbidities REVISED 2011 Global Strategy for Diagnosis, Management and Prevention of COPD 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. § Appropriate pharmacologic therapy can reduce COPD symptoms, reduce the frequency and severity of exacerbations, and improve health status and exercise tolerance. § None of the existing medications for COPD has been shown conclusively to modify the long-term decline in lung function. § Influenza and pneumococcal vaccination should be offered depending on local guidelines. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Key Points Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Smoking Cessation § Counseling delivered by physicians and other health professionals significantly increases quit rates over self- initiated strategies. Even a brief (3-minute) period of counseling to urge a smoker to quit results in smoking quit rates of 5-10%. § 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. Brief Strategies to Help the Patient Willing to Quit Smoking ASK Systematically identify all tobacco users at every visit ADVISEStrongly urge all tobacco users to quit ASSESS Determine willingness to make a quit attempt ASSIST Aid the patient in quitting ARRANGESchedule follow-up contact. Global Strategy for Diagnosis, Management and Prevention of COPD 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. Secondary prevention, 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 quality and, depending on the severity of their disease, avoid vigorous exercise outdoors or stay indoors during pollution episodes. Global Strategy for Diagnosis, Management and Prevention of COPD 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 § 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 combination therapy. §The choice of treatment depends on the availability of medications and each patients individual response in terms of symptom relief and side effects Global Strategy for Diagnosis, Management and Prevention of COPD 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. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Bronchodilators §Regular treatment with inhaled corticosteroids (ICS) improves symptoms, lung function and quality of life and reduces frequency of exacerbations for COPD patients with an FEV1 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. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Other Treatments Lung volume reduction surgery (LVRS) is more efficacious than medical therapy among patients with upper-lobe predominant emphysema and low exercise capacity. LVRS is costly relative to health-care programs not including surgery. In appropriately selected patients with very severe COPD, lung transplantation has been shown to improve quality of life and functional capacity. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Surgical Treatments Global Strategy for Diagnosis, Management and Prevention of COPD, 2011: Major Chapters nDefinition and Overview nDiagnosis and Assessment nThera