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27.09.

2016

G lobal Initiative for Chronic


GLOBAL INITIATIVE FOR CHRONIC
OBSTRUCTIVE LUNG DISEASE (GOLD) 2015
O bstructive
L ung
Marcin Grabicki

Department of Pulmonology, Allergology and Respiratory Oncology


D isease
Poznan University of Medical Sciences

2015 Global Initiative for Chronic Obstructive Lung Disease

2015 Global Initiative for Chronic Obstructive Lung Disease

Definition of COPD Mechanisms Underlying Airflow


Limitation in COPD
COPD, a common preventable and treatable disease, is
characterized by persistent airflow limitation that is usually
progressive and associated with an enhanced chronic Small Airways Disease Parenchymal Destruction
inflammatory response in the airways and the lung to Airway inflammation Loss of alveolar attachments
noxious particles or gases. Airway fibrosis, luminal plugs Decrease of elastic recoil
Increased airway resistance

Exacerbations and comorbidities contribute to the overall


severity in individual patients.

2015 Global Initiative for Chronic Obstructive Lung Disease


AIRFLOW LIMITATION
2015 Global Initiative for Chronic Obstructive Lung Disease

Risk Factors for COPD Diagnosis of COPD

EXPOSURE TO RISK
Genes SYMPTOMS
FACTORS
shortness of breath
Infections tobacco
chronic cough occupation
Socio-economic
Socio- sputum
indoor/outdoor pollution
status

SPIROMETRY: Required to establish diagnosis


Aging Populations FEV1/FVC post < 0.7
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Additional Investigations Additional Investigations

Chest X-ray: Seldom diagnostic but valuable to exclude alternative diagnoses


Exercise Testing: Objectively measured exercise impairment, assessed
and establish presence of significant comorbidities.
by a reduction in self-paced walking distance (such as the 6 min walking
Lung Volumes and Diffusing Capacity: Help to characterize severity, but not
essential to patient management. test) or during incremental exercise testing in a laboratory, is a powerful

Oximetry and Arterial Blood Gases: Pulse oximetry can be used to evaluate a indicator of health status impairment and predictor of prognosis.
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.

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Differential Diagnosis: Assessment of COPD


COPD and Asthma
COPD ASTHMA Assess symptoms
Onset in mid-life Onset early in life (often childhood)
Assess degree of airflow limitation using
Symptoms slowly Symptoms vary from day to day
progressive
Symptoms worse at night/early morning spirometry
Long smoking history
Allergy, rhinitis, and/or eczema also
present Assess risk of exacerbations
Family history of asthma

Assess comorbidities

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Modified MRC (mMRC)


Assessment of COPD
Questionnaire
Assess symptoms
COPD Assessment Test (CAT)

or

Clinical COPD Questionnaire (CCQ)

or

mMRC Breathlessness scale


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CAT Questionnaire 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

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Assess Risk of Exacerbations Combined Assessment of COPD


Assess symptoms - first
To assess risk of exacerbations use history of exacerbations
and spirometry:
C D
Two or more exacerbations within the last year or an
FEV1 < 50 % of predicted value are indicators of high
risk.
A B
If CAT < 10 or mMRC 0-1:
less symptoms/breathlessness
CAT < 10 CAT > 10 (A or C)
One or more hospitalizations for COPD exacerbation
Symptoms
should be considered high risk. mMRC 01 mMRC > 2
If CAT > 10 or mMRC > 2:
more symptoms/breathlessness (B or D)
Breathlessness
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Combined Assessment of COPD Combined Assessment of COPD


Assess risk of exacerbations - next 2
(GOLD Classification of Airflow Limitation))

4
or
(GOLD Classification of Airflow Limitation)

If GOLD 3 or 4 or 2
C D > 1 leading
(Exacerbation history)

2
4 or exacerbations per year or to hospital
> 1 leading to hospital 3
(Exacerbation history)

C D > 1 leading
admission
Risk
Risk

to hospital admission:
3
admission High Risk (C or D)
Risk
Risk

2 1 (not leading
2 1 (not leading A B to hospital
A B to hospital
admission) If GOLD 1 or 2 and only
1
admission)
1 0 0 or 1 exacerbations per 0
year (not leading to
hospital admission): CAT < 10 CAT > 10
Low Risk (A or B) Symptoms
mMRC 01 mMRC > 2
Breathlessness
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Diagnosis and Assessment: Key Points Assess COPD Comorbidities


COPD patients are at increased risk for:
Comorbidities occur frequently in COPD patients, Cardiovascular diseases

and should be actively looked for and treated Osteoporosis


Respiratory infections
appropriately if present.
Anxiety and Depression
Diabetes
Lung cancer
Bronchiectasis
These comorbid conditions may influence mortality and hospitalizations
and should be looked for routinely, and treated appropriately.

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Therapeutic Options: Key Points Therapeutic Options:


Other Pharmacologic Treatments
Influenza vaccines can reduce serious illness.
Smoking cessation has the greatest capacity to influence
the natural history of COPD. Health care providers should Pneumococcal polysaccharide vaccine is recommended for
encourage all patients who smoke to quit. COPD patients 65 years and older and for COPD patients
younger than age 65 with an FEV1 < 40% predicted.
Pharmacotherapy and nicotine replacement reliably
increase long-term smoking abstinence rates. The use of antibiotics, other than for treating infectious
exacerbations of COPD and other bacterial infections, is
All COPD patients benefit from regular physical activity and
currently not indicated.
should repeatedly be encouraged to remain active.
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Therapeutic Options: Therapeutic Options:


Other Pharmacologic Treatments Other Treatments
Alpha-1 antitrypsin augmentation therapy: not recommended
for patients with COPD that is unrelated to the genetic Oxygen Therapy: The long-term administration of oxygen
deficiency. (> 15 hours per day) to patients with chronic respiratory
Mucolytics: Patients with viscous sputum may benefit from failure has been shown to increase survival in patients with
mucolytics; overall benefits are very small.
severe, resting hypoxemia.
Antitussives: Not recommended.

Systemic steroids: Not recommended. Ventilatory Support: Combination of noninvasive ventilation


(NIV) with long-term oxygen therapy may be of some use
Vasodilators: Nitric oxide is contraindicated in stable COPD.
The use of endothelium-modulating agents for the treatment of in a selected subset of patients, particularly in those with
pulmonary hypertension associated with COPD is not
pronounced daytime hypercapnia.
recommended.
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Therapeutic Options: Manage Stable COPD: Pharmacologic Therapy


RECOMMENDED FIRST CHOICE
Surgical Treatments

Lung volume reduction surgery (LVRS) is more efficacious C D

Exacerbations per year


GOLD 4 ICS + LABA ICS + LABA 2 or more
than medical therapy among patients with upper-lobe or and/or or
LAMA LAMA > 1 leading
predominant emphysema and low exercise capacity. GOLD 3 to hospital
admission

In appropriately selected patients with very severe COPD, A B


GOLD 2 1 (not leading
lung transplantation has been shown to improve quality of SAMA prn LABA to hospital
or or admission)
life and functional capacity. GOLD 1 SABA prn LAMA
0

CAT < 10 CAT > 10


mMRC 0-1 mMRC > 2
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Manage Stable COPD: Pharmacologic Therapy Manage Stable COPD: Pharmacologic Therapy
ALTERNATIVE CHOICE OTHER POSSIBLE TREATMENTS

C D C D
LAMA and LABA ICS + LABA and LAMA
Carbocysteine
Exacerbations per year

Exacerbations per year


GOLD 4 or GOLD 4 SABA and/or SAMA
or ICS + LABA and PDE4-inh
2 or more 2 or more
LAMA and PDE4-inh or N-acetylcysteine or
or Theophylline
or LAMA and LABA > 1 leading SABA and/or SAMA > 1 leading
GOLD 3 LABA and PDE4-inh or to hospital GOLD 3 to hospital
LAMA and PDE4-inh. admission Theophylline admission
A B A B
GOLD 2 LAMA 1 (not leading GOLD 2 1 (not leading
or LAMA and LABA to hospital SABA and/or SAMA to hospital
LABA Theophylline
admission) admission)
GOLD 1 or GOLD 1 Theophylline
SABA and SAMA 0 0

CAT < 10 CAT > 10 CAT < 10 CAT > 10


mMRC 0-1 mMRC > 2 mMRC 0-1 mMRC > 2
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