Global Initiative for Chronic Oung L isease D

bstructive

GOLD Structure
GOLD Executive Committee
Leonardo Fabbri, MD - Chair

GOLD Science Committee GOLD Dissemination Committee
Klaus Rabe, MD, PhD - Chair Peter Calverley, MD - Chair

GOLD Network Partners
 American Thoracic Society (ATS)  Asian Pacific Society of Respirology
(APSR)  GOLD National Leaders  International COPD Coalition (ICC) (Patient Organizations)  World Health Organization (WHO)  World Organization of Family Physicians (WONCA)

GOLD Executive Committee
L. Fabbri, Italy –Chair LAISION Representatives S. Buist, US P. Calverley, UK Y. Fukuchi, Japan (APSR) C. Jenkins, Australia N. Khaltaev, Switzerland (WHO) C. Lenfant, US C. van Weel, Netherlands (WONCA) E. Nizankowska, Poland K. Rabe, Netherlands R. Rodriguez-Roisin, Spain T. van der Molen, Netherlands

Rennard. Canada W. Australia D. Anthonisen. Calverley. Belgium Chair N. Spain N. US S. Clark. Italy Y. Fukuchi. US W. Rabe. Netherlands S. Canada C. Greece S. Postma. UK T. Barnes. US P. Fabbri. Hogg. Japan J. Tan. Jenkins. Buist. Sullivan. US R. Singapore . Netherlands K. UK S.GOLD Expert Panel: 1998 R. US P. Rodriguez-Roisin. Ramsey. Bailey. Pauwels. UK L. Siafakas.

Ltd Novartis Pfizer Zambon Group Boehringer-Ingelheim Schering-Plough International ..GOLD Sponsors: 2004 Altana Andi-Ventis AstraZeneca Aventis Bayer Chiesi Group GlaxoSmithKline Merck Sharp & Dohme Mitsubishi Pharma Corp Nikken Chemicals Co.

org .GOLD Website Address http://www.goldcopd.

cancer. s s .74 million deaths worldwide from COPD. In 2000. the WHO estimated 2. COPD was ranked 12th as a burden of disease. In 1990.Facts About COPD s COPD is the 4th leading cause of death in the United States (behind heart disease. and cerebrovascular disease). by 2020 it is projected to rank 5th.

6. 2.252 Pneumonia and influenza Alzheimer’s disease Nephritis Septicemia All other causes of death 62. 7.707 Diabetes 71. Number Heart Disease 699.251 Cerebrovascular disease (stroke) 163. 5. 10.123 53.679 26.697 Cancer 553.601 Respiratory Diseases (COPD) 123.Leading Causes of Deaths U.314 .295 32. 2001 Cause of Death 1. 9.974 Accidents 97. 8. 3. 4.275 469.S.

1965-1998 Proportion of 1965 Rate 3.1998 –35% 1965 .5 2.0 1.S.1998 –64% 1965 .1998 +163% 1965 . U.5 0 Coronary Heart Disease Stroke Other CVD COPD All Other Causes –59% 1965 .Percent Change in Age-Adjusted Death Rates.5 1.1998 Source: NHLBI/NIH/DHHS .0 2.1998 –7% 1965 .0 0..

U.COPD Age-Adjusted Death Rate. DHHS) . by year and sex (CDC.S.

000 60 50 40 30 20 10 0 1960 1965 1970 1975 1980 1985 1990 1995 2000 ..Age-Adjusted Death Rates for COPD. U. 1960-1998 Deaths per 100.S.

Future Mortality Worldwide 1990 2020 Ischemic heart disease Cerebrovascular disease Lower resp infection Diarrheal disease Perinatal disorders COPD 6th Tuberculosis Measles Road traffic accidents Lung cancer Murray & Lopez. Lancet 1997 3rd Stomach Cancer HIV Suicide .

s Between 1985 and 1995. the number of physician visits for COPD increased from 9.Facts About COPD: U. Medical expenditures in 2002 were estimated to be $18.000. The number of hospitalizations for COPD in 2000 was estimated to be 726.3 to16 million.S. s s .0 billion.

and middle-income countries. The WHO estimates 1.2 million people (28% of men and 23% of women) smoke. In low. In the US 47. increasing to 1.6 billion by 2025. rates are increasing at an alarming rate. .1 billion smokers worldwide.Facts About COPD    Cigarette smoking is the primary cause of COPD.

it is estimated that 400-550 thousand premature deaths can be attributed annually to use of biomass fuels.Facts About COPD  In India. In Algeria. placing indoor air pollution as a major risk factor in the country. an increase in COPD and asthma has been observed in the last decade. the prevalence of tuberculosis and acute respiratory infections has decreased since 1965.  .

Global Initiative for Chronic Oung L isease D bstructive .

GOLD Objectives s Increase awareness of COPD among health professionals. and the general public Improve diagnosis. and prevention Stimulate research s s . management. health authorities.

GOLD Documents s Workshop Report: Global Strategy for the Diagnosis. Management. and Prevention of COPD (updated 2004) Executive Summary (updated 2004) Pocket Guide for health care providers (updated 2004) s s s Guide for patients and their families .

GOLD Workshop Report Evidence-based s Implementation oriented   Diagnosis   Management   Prevention s Outcomes can be evaluated s .

GOLD Workshop Report Evidence category Sources of evidence A Randomized clinical trials Rich body of data B Randomized clinical trials Limited body of data C Non randomized trials Observational studies D Panel judgment consensus .

and pathophysiology Management Future research .GOLD Workshop Report: Contents s s s s s s s Introduction Definition and classification Burden of COPD Risk factors Pathogenesis. pathology.

.Definition of COPD Chronic obstructive pulmonary disease (COPD) is a disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases.

morbidity. and mortality vary appreciably across countries but in all countries where data are available. s .Burden of COPD Key Points s The burden of COPD is underestimated because it is not usually recognized and diagnosed until it is clinically apparent and moderately advanced. Prevalence. COPD is a significant health problem in both men and women.

.Burden of COPD Key Points  The global burden of COPD will increase enormously over the foreseeable future as the toll from tobacco use in developing countries becomes apparent.

the increasing prevalence of the disease. .Burden of COPD Key Points s The economic costs of COPD are high and will continue to rise in direct relation to the ever-aging population. and the cost of new and existing medical and public health interventions.

8 – – s Mortality related IDC Morbidity related IDC Total Cost $32. DHHS .1 Source: NHLBI.3 6.Direct and Indirect Costs of COPD.1 7. NIH.0 $ 14. 2002 (US $ Billions) s s Direct Medical Cost: Total Indirect Cost: $18.

g. alpha1-antitrypsin Hyperresponsiveness Lung growth Exposure Tobacco smoke Occupational dusts and chemicals Infections Socioeconomic status .Risk Factors for COPD Host Factors deficiency) Genes (e.

Pathogenesis of COPD (tobacco smoke. occupational agent) Genetic factors Respiratory infection Other NOXIOUS AGENT COPD . pollutants.

Noxious particles and gases Host factors Anti-oxidants Lung inflammation Anti-proteinases Oxidative stress Proteinases Repair mechanisms COPD pathology .

INFLAMMATION Small airway disease Airway inflammation Airway remodeling Parenchymal destruction Loss of alveolar attachments Decrease of elastic recoil AIRFLOW LIMITATION .

ASTHMA Sensitizing agent COPD Noxious agent Asthmatic airway inflammation CD4+ T-lymphocytes Eosinophils COPD airway inflammation CD8+ T-lymphocytes Macrophages Neutrophils Completely reversible Airflow limitation Completely irreversible .

Causes of Airflow Limitation s Irreversible   Fibrosis and narrowing of the airways   Loss of elastic recoil due to alveolar destruction   Destruction of alveolar support that maintains patency of small airways .

Causes of Airflow Limitation s Reversible   Accumulation of inflammatory cells. mucus. and plasma exudate in bronchi   Smooth muscle contraction in peripheral and central airways   Dynamic hyperinflation during exercise .

Manage stable COPD q q q Education Pharmacologic Non-pharmacologic 1. Assess and monitor disease 2.GOLD Workshop Report Four Components of COPD Management 1. Manage exacerbations . Reduce risk factors 3.

Objectives of COPD Management s s s s s s s s Prevent disease progression Relieve symptoms Improve exercise tolerance Improve health status Prevent and treat exacerbations Prevent and treat complications Reduce mortality Minimize side effects from treatment .

Manage stable COPD q q q Education Pharmacologic Non-pharmacologic 1.GOLD Workshop Report Four Components of COPD Management 1. Assess and monitor disease 2. Reduce risk factors 3. Manage exacerbations .

Reduce risk factors 3. Assess and monitor disease 2. Manage stable COPD q q q Education Pharmacologic Non-pharmacologic 1.GOLD Workshop Report Four Components of COPD Management 1. Manage exacerbations .

with or without the presence of symptoms. .Assess and Monitor Disease: Key Points s Diagnosis of COPD is based on a history of exposure to risk factors and the presence of airflow limitation that is not fully reversible.

even if they do not have dyspnea. .Assess and Monitor Disease: Key Points s Patients who have chronic cough and sputum production with a history of exposure to risk factors should be tested for airflow limitation.

Assess and Monitor Disease: Key Points For the diagnosis and assessment of COPD. s Health care workers involved in the diagnosis and management of COPD patients should have access to spirometry. spirometry is the gold standard. s .

Assess and Monitor Disease: Key Points s Measurement of arterial blood gas tension should be considered in all patients with FEV1 < 40% predicted or clinical signs suggestive of respiratory failure or right heart failure. .

Diagnosis of COPD SYMPTOMS cough sputum dyspnea EXPOSURE TO RISK FACTORS tobacco occupation indoor/outdoor pollution SPIROMETRY ² ² .

350 C P O D 4 5 1 2 F V E 1 F C V N orm al 3 4 F C V 5 6 S econ ds .Spirometry: Normal and COPD 0 1 2 Liter 3 F V E F V E 1 F C V 5.900 F V 1/ F C E V 80 % 60 % N rm o al C P O D 1 4.150 2.200 3.

Factors Determining Severity Of Chronic COPD  Severity of symptoms  Severity of airflow limitation  Frequency and severity of exacerbations  Presence of complications of COPD  Presence of respiratory insufficiency  Comorbidity  General health status  Number of medications needed to manage the disease .

dyspnea) II: Moderate III: Severe IV: Very Severe FEV1/FVC < 70%. sputum) FEV1/FVC < 70%. sputum. 50% ≤ FEV1 < 80% predicted With or without chronic symptoms (cough. dyspnea) FEV1/FVC < 70%. sputum. FEV1 ≥ 80% predicted With or without chronic symptoms (cough. sputum) FEV1/FVC < 70%.Classification by Severity Stage 0: At risk I: Mild Characteristics Normal spirometry Chronic symptoms (cough. 30% ≤ FEV1 < 50% predicted With or without chronic symptoms (cough. FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure .

Assess and monitor disease 2.GOLD Workshop Report Four Components of COPD Management 1. Reduce risk factors 3. Manage exacerbations . Manage stable COPD q q q Education Pharmacologic Non-pharmacologic 1.

intervention to reduce the risk of developing COPD and stop its progression (Evidence A). .and cost effective . • Smoking cessation is the single most effective . and indoor and outdoor air pollutants are important goals to prevent the onset and progression of COPD. occupational dusts and chemicals.Reduce Risk Factors Key Points • Reduction of total personal exposure to tobacco smoke.

. and every tobacco user should be offered at least this treatment at every visit to a health care provider.Reduce Risk Factors Key Points  Brief tobacco dependence treatment is effective (Evidence A). and social support arranged outside of treatment (Evidence A). social support as part of treatment.  Three types of counseling are especially effective: practical counseling.

and at least one of these medications should be added to counseling if necessary.Reduce Risk Factors Key Points  Several effective pharmacotherapies for tobacco dependence are available (Evidence A). . and in the absence of contraindications.

.Reduce Risk Factors Key Points  Progression of many occupationallyinduced respiratory disorders can be reduced or controlled through a variety of strategies aimed at reducing the burden of inhaled particles and gases (Evidence B).

Determine willingness to make a quit attempt. Strongly urge all tobacco users to quit.Brief Strategies To Help The Patient Willing To Quit Smoking • ASK • ADVISE • ASSESS • ASSIST Systematically identify all tobacco users at every visit. Aid the patient in quitting. . • ARRANGE Schedule follow-up contact.

Assess and monitor disease 2. Reduce risk factors 3.GOLD Workshop Report Four Components of COPD Management 1. Manage stable COPD q q q Education Pharmacologic Non-pharmacologic 1. Manage exacerbations .

health education can play a role in improving skills. ability to cope with illness. improving with respect to both exercise tolerance and symptoms of dyspnea and fatigue (Evidence A). and health status.  .Manage Stable COPD Key Points s For patients with COPD. All COPD-patients benefit from exercise training programs. It is effective in accomplishing certain goals. including smoking cessation (Evidence A).

s . Therefore. pharmacotherapy for COPD is used to decrease symptoms and/or complications. None of the existing medications for COPD has been shown to modify the long-term decline in lung function that is the hallmark of this disease (Evidence A). depending on the severity of the disease.Manage Stable COPD Key Points s The overall approach to managing stable COPD should be characterized by a stepwise increase in the treatment.

and a combination of these drugs (Evidence A). s . They are given on an as-needed basis or on a regular basis to prevent or reduce symptoms. anticholinergics. theophylline.Manage Stable COPD Key Points s Bronchodilator medications are central to the symptomatic management of COPD (Evidence A). The principal bronchodilator treatments are beta2agonists.

The choice between beta2-agonist. or combination therapy depends on availability and individual response in terms of symptom relief and side effects. s s .Bronchodilators in Stable COPD s Bronchodilator medications are central to symptom management in COPD. Inhaled therapy is preferred. theophylline. anticholinergic.

Combining bronchodilators may improve efficacy and decrease the risk of side effects compared to increasing the dose of a single bronchodilator.Bronchodilators in Stable COPD s Bronchodilators are prescribed on an as-needed or on a regular basis to prevent or reduce symptoms. but more expensive. Regular treatment with long-acting inhaled bronchodilators is more effective and convenient than treatment with short-acting bronchodilators. s s .

3 in the last three years (Evidence A). .g.Manage Stable COPD Key Points s s Regular treatment with inhaled glucocorticosteroids is appropriate for symptomatic COPD patients with an FEV1 < 50% predicted (Stage III: Severe COPD and Stage IV: Very Severe COPD) and repeated exacerbations e. Inhaled glucocorticosteroid combined with a longacting B2-agonist is more effective than the individual components (Evidence A).

.Manage Stable COPD Key Points s Chronic treatment with systemic glucocorticosteroids should be avoided because of an unfavorable benefit-to-risk ratio (Evidence A).

Manage Stable COPD Key Points s The long-term administration of oxygen (> 15 hours per day) to patients with chronic respiratory failure has been shown to increase survival (Evidence A). .

Management of COPD by Severity of Disease Stage 0: At risk Stage I: Mild COPD Stage II: Moderate COPD Stage III: Severe COPD Stage IV: Very Severe COPD .

smoking cessation .reduction of indoor pollution .reduction of occupational exposure s Influenza vaccination .Management of COPD: All stages s Avoidance of risk factors .

cough .sputum • No spirometric abnormalities Recommended Treatment .Management of COPD Stage 0: At Risk Characteristics • Chronic symptoms .

Management of COPD Stage I: Mild COPD Characteristics • FEV1/FVC < 70 % • FEV1 > 80 % predicted • With or without chronic symptoms Recommended Treatment • Short-acting bronchodilator as needed .

Management of COPD Stage II: Moderate COPD Characteristics • FEV1/FVC < 70% • 50% < FEV1< 80% predicted • With or without chronic symptoms Recommended Treatment • Short-acting bronchodilator as needed • Regular treatment with one or more long-acting bronchodilators • Rehabilitation .

Management of COPD Stage III: Severe COPD Characteristics • FEV1/FVC < 70% • 30% < FEV1 < 50% predicted • With or without chronic symptoms Recommended Treatment • Short-acting bronchodilator as needed • Regular treatment with one or more longacting bronchodilators • Inhaled glucocorticosteroids if repeated exacerbations • Rehabilitation .

Management of COPD Stage IV: Very Severe COPD Characteristics • FEV1/FVC < 70% • FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure Recommended Treatment • Short-acting bronchodilator as needed • Regular treatment with one or more long-acting bronchodilators • Inhaled glucocorticosteroids if repeated exacerbations • Treat complications • Rehabilitation • Long-term oxygen therapy if respiratory failure • Consider surgical options .

Therapy at Each Stage of COPD Old (2001) New (2003) Characteristics 0: At Risk 0: At Risk • Chronic Symptoms • Exposure to risk factors • Normal spirometry I: Mild I: Mild • FEV1/FVC < 70% • FEV1 ≥ 80% • With or without symptoms II: Moderate IIA IIB II: Moderate III: Severe III: Severe IV: Very Severe • FEV1/FVC < 70% • FEV1 < 30% or FEV1 < 50% predicted plus chronic respiratory failure • FEV1/FVC < 70% • FEV1/FVC < 70% • 50% < FEV1 < 80% • 30% < FEV1 < 50% • With or without symptoms • With or without symptoms Avoidance of risk factor(s). influenza vaccination Add short-acting bronchodilator when needed Add regular treatment with one or more long-acting bronchodilators Add rehabilitation Add inhaled glucocorticosteroids if repeated exacerbations Add long-term oxygen if chronic respiratory failure Consider surgical treatments .

Reduce risk factors 3. Manage exacerbations . Assess and monitor disease 2.GOLD Workshop Report Four Components of COPD Management 1. Manage stable COPD q q q Education Pharmacologic Non-pharmacologic 1.

Manage Exacerbations Key Points s Exacerbations of respiratory symptoms requiring medical intervention are important clinical events in COPD. but the cause of about one-third of severe exacerbations cannot be identified (Evidence B). The most common causes of an exacerbation are infection of the tracheobronchial tree and air pollution. s .

Manage Exacerbations Key Points
s

Inhaled bronchodilators (beta2-agonists and/or anticholinergics), theophylline, and systemic, preferably oral, glucocorticosteroids are effective for the treatment of COPD exacerbations (Evidence A).

Manage Exacerbations Key Points
s

Patients experiencing COPD exacerbations with clinical signs of airway infection (e.g., increased volume and change of color of sputum, and/or fever) may benefit from antibiotic treatment (Evidence B).

Manage Exacerbations Key Points
s

Noninvasive intermittent positive pressure ventilation (NIPPV) in exacerbations improves blood gases and pH, reduces in-hospital mortality, decreases the need for invasive mechanical ventilation and intubation, and decreases the length of hospital stay (Evidence A).

Management of COPD
s

In selecting a treatment plan, the benefits and risks to the individual, and the direct and indirect costs to the individual, his or her family, and the community must be considered.

2005 Raising COPD Awareness Worldwide .WORLD COPD DAY November 16.

6 1 6. 2 0 0 5 5 5 .

If COPD is found early. If you answer these questions. Take time to think about your lungs……Learn about COPD! .Could it be COPD? Do you know what COPD is? This chronic lung disease is a major cause of illness. Are you older than 40 years? 5. Are you a current smoker or an ex-smoker? Yes ___ No ___ Yes ___ No ___ Yes ___ No ___ Yes ___ No ___ 3. Do you cough several times most days? 2. Do you get out of breath more easily than others your age? Yes ___ No ___ If you answered yes to three or more of these questions. there are steps you can take to prevent further lung damage and make you feel better. 1. yet many people have it and don’t know it. it will help you find out if you could have COPD. ask your doctor if you might have COPD and should have a simple breathing test. Do you bring up phlegm or mucus most days? 4.

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GOLD Website Address http://www.org .goldcopd.

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