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Safaa Abbas

This slide set provides an overview of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines for chronic obstructive pulmonary disease (COPD). It defines COPD as a common lung disease characterized by airflow limitation caused by exposure to noxious particles or gases. The slide set outlines the GOLD board of directors and science committee, lists national leaders, and describes the objectives, evidence levels, and chapters covered in the 2017 GOLD report on defining, diagnosing, preventing, and managing COPD.

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GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE (GOLD): TEACHING SLIDE SET February 2017 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. © 2017 Global Initiative for Chronic Obstructive Lung Disease
© 2017 Global Initiative for Chronic Obstructive Lung Disease
GOLD Board of Directors 2017 Alvar Agusti, MD, Chair Respiratory Institute, Hospital Clinic, IDIBAPS Univ. Barcelona and Ciberes Barcelona, Spain Marc Decramer, MD, Chair (to 05/16) University of Leuven Leuven, Belgium Bartolome R. Celli, MD Brigham and Women’s Hospital Boston, Massachusetts, USA Rongchang Chen, MD Guangzhou Institute of Respiratory Disease Guangzhou, PRC Gerard Criner, MD Temple University School of Medicine Philadelphia, Pennsylvania, USA Peter Frith, MD Repatriation General Hospital, Adelaide, South Australia, Australia David Halpin, MD Royal Devon and Exeter Hospital Devon, UK M. Victorina López Varela, MD Universidad de la República Montevideo, Uruguay Masaharu Nishimura, MD Hokkaido University School of Medicine Sapporo, Japan Roberto Rodriguez-Roisin, MD Respiratory Institute, Hospital Clinic, IDIBAPS Univ. Barcelona and Ciberes Barcelona, Spain Claus Vogelmeier, MD University of Marburg Marburg, Germany © 2017 Global Initiative for Chronic Obstructive Lung Disease
GOLD Science Committee 2017 Claus Vogelmeier, MD, Chair University of Marburg Marburg, Germany Alvar Agusti, MD Respiratory Institute, Hospital Clinic, IDIBAPS Univ. Barcelona and Ciberes Barcelona, Spain Antonio Anzueto, MD University of Texas Health Science Center San Antonio, Texas, USA Peter Barnes, MD National Heart and Lung Institute London, United Kingdom Jean Bourbeau, MD McGill University Health Centre Montreal, Canada Gerard Criner, MD Temple University School of Medicine, Philadelphia, Pennsylvania, USA Leonardo M. Fabbri, MD University of Modena & Reggio Emilia Modena, Italy Fernando Martinez, MD, MS New York-Presbyterian Hospital/ Weill Cornell Medical Center New York, NY,USA Nicolas Roche, MD Hôpital Cochin Paris, France Roberto Rodriguez-Roisin, MD Respiratory Institut, Hospital Clinic, IDIBAPS, Univ. Barcelona and Ciberes, Barcelona, Spain Donald Sin, MD St. Paul’s Hospital, University of British Columbia Vancouver, Canada Dave Singh, MD University of Manchester Manchester, UK Robert Stockley, MD University Hospital Birmingham, UK Jørgen Vestbo, MD University of Manchester Manchester, England, UK Jadwiga A. Wedzicha, MD Imperial College London London, UK PROGRAM DIRECTOR Rebecca Decker, MSJ Fontana, Wisconsin, USA Suzanne Hurd, PhD (Director to 12/15) © 2017 Global Initiative for Chronic Obstructive Lung Disease
GOLD National Leaders Perlat Kapisyzi, Albania Eduardo A. Schiavi, Argentina Otto Chris Burghuber, Austria Mostafizur Rahman, Bangladesh Kazi S. BENNOOR, Bangladesh Wim Janssens, Belgium Jose Roberto Jardim, Brazil Aquiles Camelier, Brazil Fernando Lundgren, Brazil Yavor Ivanov, Bulgaria Kosta Kostov, Bulgaria Dennis E. O’Donnell, Canada Manuel Barros, Chile Nan-Shan Zhong, China Jiangtao Lin, China Chunxue Bai, China Fu-Qiang Wen, China Alejandro Casas, Colombia Neven Miculinic, Croatia Stanislav Kos, Czech Republic Jaromir Musil, Czech Republic Vladimir Vondra, Czech Republic Ejvind Frausing Hansen, Denmark Eduardo Gautreau de Windt, Dominican Republic Hisham Tarraf, Egypt Victor Castro Gòmez, El Salvador Gerard Huchon, France Maia Gotua, Georgia Klaus Rabe, Germany David S.C. Hui, Hong Kong Thorarinn Gislason, Iceland Gunnar Gudmundsson, Iceland Rohini V. Chowgule, India R.Narasimhan, India Faisal Yunus, Indonesia Masjedi Mohammad Reza, Iran Mohammad Ashkan Moslehi, Iran Timothy J. McDonnell, Ireland Zvi G. Fridlender, Israel Lorenzo Corbetta, Italy Takahide Nagase, Japan Michiaki Mishima, Japan Bashar Nsour, Jordan Jawad Hamad, Jordan Damilya Nugmanova, Kazakhstan Yeon-Mok Oh, Korea Mousa Khadadah, Kuwait Talant Sooronbaev, Kyrgyz Republic Joseph M Cacciottolo, Malta J. Javier Díaz Castañón, Mexico Alexandru Corlateanu, Moldova Dr Oyunchimeg, Mongolia Harold Rea, New Zealand Jorge Cuadra, Nicaragua Amund Gulsvik, Norway Ernst Omenaas, Norway Javaid Khan, Pakistan Jamil Ur Rehman Tahir, Pakistan Mohammad Osman Yusuf, Pakistan Teresita S. deGuia, Philippines Ewa Nizankowska-Mogilnicka, Poland Pawel Kuca, Poland Florin Mihaltan, Romania Ruxandra Ulmeanu, Romania Alexander Chuchalin, Russia Dmitri R. Rackita, Russia Professor Alexandre Vizel, Russia Professor Eugeny Shmelev, Russia Kian-Chung Ong, Singapore Wan-Cheng Tan, Singapore Ruzena Tkacova, Slovak Republic Stanislav Suskovic, Slovenia EM Irusen, South Africa Patricia Sobradillo, Spain Daiana Stolz, Switzerland Yousser Mohammad, Syria Professor Ali Kocabas, Turkey Hakan Gunen, Turkey Maria Montes de Oca, Venezuela Ngo Quy Chau, Vietnam Le Thi Tuyet Lan, Vietnam Sy Duong-Quy, Vietnam Khaled Al-Shair, Yemen © 2017 Global Initiative for Chronic Obstructive Lung Disease
GOLD Invited Contributors Prof. Richard Beasley Medical Research Institute of New Zealand Wellington, New Zealand Peter M A Calverley, MD University Hospital Aintree Liverpool, UK Ciro Casanova, MD Hospital Universitario Santa Cruz de Tenerife, Tenerife, Spain James Donohue, MD University of North Carolina Chapel Hill, NC, USA MeiLan Han, MD, MS University of Michigan Ann Arbor, MI, USA Nicola Hanania, MBBS, MS Baylor College of Medicine Houston, TX, USA Maria Montes de Oca, MD Hospital Universitario de Caracas, Universidad Central de Venezuela, Caracas, Venezuela Takahide Nagase, MD The University of Tokyo, Tokyo, Japan Alberto Papi, MD University of Ferarra Ferrara, Italy Ian Pavord, MD University of Oxford Oxford, UK David Price, FRCGP Observational and Pragmatic Research Institute, Singapore University of Aberdeen, Aberdeen, Scotland, UK © 2017 Global Initiative for Chronic Obstructive Lung Disease
GOLD Website Address © 2017 Global Initiative for Chronic Obstructive Lung Disease www.goldcopd.org
Chronic Obstructive Pulmonary Disease (COPD) © 2017 Global Initiative for Chronic Obstructive Lung Disease ► COPD is currently the fourth leading cause of death in the world.1 ► COPD is projected to be the 3rd leading cause of death by 2020.2 ► More than 3 million people died of COPD in 2012 accounting for 6% of all deaths globally. ► Globally, the COPD burden is projected to increase in coming decades because of continued exposure to COPD risk factors and aging of the population. 1. Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380(9859): 2095-128. 2. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med 2006; 3(11): e442.
GOLD Objectives © 2017 Global Initiative for Chronic Obstructive Lung Disease ► To provide a non-biased review of the current evidence for the assessment, diagnosis and treatment of patients with COPD. ► To highlight short-term and long-term treatment objectives organized into two groups:  Relieving and reducing the impact of symptoms, and  Reducing the risk of adverse health events that may affect the patient in the future. ► To guide symptoms assessment and health status measurement.
GOLD Levels of Evidence © 2017 Global Initiative for Chronic Obstructive Lung Disease
GOLD Levels of Evidence © 2017 Global Initiative for Chronic Obstructive Lung Disease ► Levels of evidence have been assigned to evidence- based recommendations where appropriate. ► Evidence levels are indicated in boldface type enclosed in parentheses after the relevant statement e.g., (Evidence A). ► The methodological issues concerning the use of evidence from meta-analyses were carefully considered. ► The evidence level scheme with categories A to D used throughout this document has been modified from that used in prior GOLD Reports and the evidence category definitions have been refined and updated.
GOLD 2017 Report: Chapters © 2017 Global Initiative for Chronic Obstructive Lung Disease 1. Definition and Overview 2. Diagnosis and Initial Assessment 3. Evidence Supporting Prevention & Maintenance Therapy 4. Management of Stable COPD 5. Management of Exacerbations 6. COPD and Comorbidities
GOLD 2017 Report: Chapters © 2017 Global Initiative for Chronic Obstructive Lung Disease 1. Definition and Overview 2. Diagnosis and Initial Assessment 3. Evidence Supporting Prevention & Maintenance Therapy 4. Management of Stable COPD 5. Management of Exacerbations 6. COPD and Comorbidities
COPD Definition © 2017 Global Initiative for Chronic Obstructive Lung Disease ► Chronic Obstructive Pulmonary Disease (COPD) is a common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases.
COPD Etiology, Pathobiology & Pathology © 2017 Global Initiative for Chronic Obstructive Lung Disease
Definition and Overview © 2017 Global Initiative for Chronic Obstructive Lung Disease
Definition and Overview © 2017 Global Initiative for Chronic Obstructive Lung Disease OVERALL KEY POINTS (1 of 2): ► Chronic Obstructive Pulmonary Disease (COPD) is a common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases. ► The most common respiratory symptoms include dyspnea, cough and/or sputum production. These symptoms may be under-reported by patients. ► The main risk factor for COPD is tobacco smoking but other environmental exposures such as biomass fuel exposure and air pollution may contribute.
Definition and Overview © 2017 Global Initiative for Chronic Obstructive Lung Disease OVERALL KEY POINTS (2 of 2): ► Besides exposures, host factors predispose individuals to develop COPD. These include genetic abnormalities, abnormal lung development and accelerated aging. ► COPD may be punctuated by periods of acute worsening of respiratory symptoms, called exacerbations. ► In most patients, COPD is associated with significant concomitant chronic diseases, which increase its morbidity and mortality.
Prevalence © 2017 Global Initiative for Chronic Obstructive Lung Disease Prevalence of COPD ► Systematic review and meta-analysis (Halbert et al, 2006) ► Included studies carried out in 28 countries between 1990 and 2004 ► Prevalence of COPD was higher in smokers and ex- smokers compared to non-smokers ► Higher ≥ 40 year group compared to those < 40 ► Higher in men than women.
Prevalence © 2017 Global Initiative for Chronic Obstructive Lung Disease Prevalence of COPD ► Estimated 384 million COPD cases in 2010. ► Estimated global prevalence of 11.7% (95% CI 8.4%– 15.0%). ► Three million deaths annually. ► With increasing prevalence of smoking in developing countries, and aging populations in high-income countries, the prevalence of COPD is expected to rise over the next 30 years. ► By 2030 predicted 4.5 million COPD related deaths annually.
Economic and Social Burden © 2017 Global Initiative for Chronic Obstructive Lung Disease Economic burden of COPD ► COPD is associated with significant economic burden. ► COPD exacerbations account for the greatest proportion of the total COPD burden. ► European Union:  Direct costs of respiratory disease ~6% of the total healthcare budget  COPD accounting for 56% (38.6 billion Euros) of the cost of respiratory disease. ► USA:  Direct costs of COPD are $32 billion  Indirect costs $20.4 billion.
Economic and Social Burden © 2017 Global Initiative for Chronic Obstructive Lung Disease ► Global Burden of Disease (GBD) study ► Disability-Adjusted Life Year (DALY) = sum of years lost because of premature mortality and years of life lived with disability, adjusted for the severity of disability. ► COPD is an increasing contributor to disability and mortality around the world. ► In 2013 COPD was 5th leading cause of DALYs lost. ► In the United States, COPD is the second leading cause of reduced DALYs, trailing only ischemic heart disease
Factors that influence disease progression © 2017 Global Initiative for Chronic Obstructive Lung Disease ► Genetic factors ► Age and gender ► Lung growth and development ► Exposure to particles ► Socioeconomic status ► Asthma & airway hyper-reactivity ► Chronic bronchitis ► Infections
Pathology, pathogenesis & pathophysiology © 2017 Global Initiative for Chronic Obstructive Lung Disease ► Pathology  Chronic inflammation  Structural changes ► Pathogenesis  Oxidative stress  Protease-antiprotease imbalance  Inflammatory cells  Inflammatory mediators  Peribronchiolar and interstitial fibrosis ► Pathophysiology  Airflow limitation and gas trapping  Gas exchange abnormalities  Mucus hypersecretion  Pulmonary hypertension
GOLD 2017 Report: Chapters © 2017 Global Initiative for Chronic Obstructive Lung Disease 1. Definition and Overview 2. Diagnosis and Initial Assessment 3. Evidence Supporting Prevention & Maintenance Therapy 4. Management of Stable COPD 5. Management of Exacerbations 6. COPD and Comorbidities
Diagnosis and Initial Assessment © 2017 Global Initiative for Chronic Obstructive Lung Disease OVERALL KEY POINTS (1 of 2): ► 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 < 0.70 confirms the presence of persistent airflow limitation. ► The goals of COPD assessment are to determine the level of airflow limitation, the impact of disease on the patient’s health status, and the risk of future events (such as exacerbations, hospital admissions, or death), in order to guide therapy.
Diagnosis and Initial Assessment © 2017 Global Initiative for Chronic Obstructive Lung Disease OVERALL KEY POINTS (2 of 2): ► Concomitant chronic diseases occur frequently in COPD patients, including cardiovascular disease, skeletal muscle dysfunction, metabolic syndrome, osteoporosis, depression, anxiety, and lung cancer. These comorbidities should be actively sought and treated appropriately when present as they can influence mortality and hospitalizations independently.
Diagnosis and Initial Assessment © 2017 Global Initiative for Chronic Obstructive Lung Disease
Diagnosis and Initial Assessment © 2017 Global Initiative for Chronic Obstructive Lung Disease
Diagnosis and Initial Assessment © 2017 Global Initiative for Chronic Obstructive Lung Disease ► Symptoms of COPD  Chronic and progressive dyspnea  Cough  Sputum production  Wheezing and chest tightness  Others – including fatigue, weight loss, anorexia, syncope, rib fractures, ankle swelling, depression, anxiety.
Diagnosis and Initial Assessment © 2017 Global Initiative for Chronic Obstructive Lung Disease
Medical History © 2017 Global Initiative for Chronic Obstructive Lung Disease ► Patient’s exposure to risk factors ► Past medical history ► Family history of COPD or other chronic respiratory disease. ► Pattern of symptom development ► History of exacerbations or previous hospitalizations for respiratory disorder ► Presence of comorbidities ► Impact of disease on patient’s life ► Social and family support available to the patient. ► Possibilities for reducing risk factors, especially smoking cessation.
Diagnosis and Initial Assessment © 2017 Global Initiative for Chronic Obstructive Lung Disease
Spirometry © 2017 Global Initiative for Chronic Obstructive Lung Disease
Classification of severity of airflow limitation © 2017 Global Initiative for Chronic Obstructive Lung Disease
Choice of thresholds © 2017 Global Initiative for Chronic Obstructive Lung Disease ► COPD Assessment Test (CAT TM ) ► Chronic Respiratory Questionnaire (CCQ® ) ► St George’s Respiratory Questionnaire (SGRQ) ► Chronic Respiratory Questionnaire (CRQ) ► Modified Medical Research Council (mMRC) questionnaire
Assessment of Exacerbation Risk © 2017 Global Initiative for Chronic Obstructive Lung Disease ► COPD exacerbations are defined as an acute worsening of respiratory symptoms that result in additional therapy. ► Classified as:  Mild (treated with SABDs only)  Moderate (treated with SABDs plus antibiotics and/or oral corticosteroids) or  Severe (patient requires hospitalization or visits the emergency room). Severe exacerbations may also be associated with acute respiratory failure. ► Blood eosinophil count may also predict exacerbation rates (in patients treated with LABA without ICS).
ABCD Assessment Tool © 2017 Global Initiative for Chronic Obstructive Lung Disease
ABCD Assessment Tool © 2017 Global Initiative for Chronic Obstructive Lung Disease Example ► Consider two patients:  Both patients with FEV1 < 30% of predicted  Both with CAT scores of 18  But, one with 0 exacerbations in the past year and the other with 3 exacerbations in the past year. ► Both would have been labelled GOLD D in the prior classification scheme. ► With the new proposed scheme, the subject with 3 exacerbations in the past year would be labelled GOLD grade 4, group D. ► The other patient, who has had no exacerbations, would be classified as GOLD grade 4, group B.
Summary © 2017 Global Initiative for Chronic Obstructive Lung Disease
Alpha-1 antitrypsin deficiency (AATD) © 2017 Global Initiative for Chronic Obstructive Lung Disease AATD screening ► The World Health Organization recommends that all patients with a diagnosis of COPD should be screened once especially in areas with high AATD prevalence. ► AATD patients are typically < 45 years with panlobular basal emphysema ► Delay in diagnosis in older AATD patients presents as more typical distribution of emphysema (centrilobular apical). ► A low concentration (< 20% normal) is highly suggestive of homozygous deficiency.
Differential Diagnosis © 2017 Global Initiative for Chronic Obstructive Lung Disease
GOLD 2017 Report: Chapters © 2017 Global Initiative for Chronic Obstructive Lung Disease 1. Definition and Overview 2. Diagnosis and Initial Assessment 3. Evidence Supporting Prevention & Maintenance Therapy 4. Management of Stable COPD 5. Management of Exacerbations 6. COPD and Comorbidities
Evidence Supporting Prevention & Maintenance Therapy © 2017 Global Initiative for Chronic Obstructive Lung Disease OVERALL KEY POINTS (1 of 3): ► Smoking cessation is key. Pharmacotherapy and nicotine replacement reliably increase long-term smoking abstinence rates. ► The effectiveness and safety of e-cigarettes as a smoking cessation aid is uncertain at present. ► Pharmacologic therapy can reduce COPD symptoms, reduce the frequency and severity of exacerbations, and improve health status and exercise tolerance. ► Each pharmacologic treatment regimen should be individualized and guided by the severity of symptoms, risk of exacerbations, side- effects, comorbidities, drug availability and cost, and the patient’s response, preference and ability to use various drug delivery devices. ► Inhaler technique needs to be assessed regularly.
Evidence Supporting Prevention & Maintenance Therapy © 2017 Global Initiative for Chronic Obstructive Lung Disease OVERALL KEY POINTS (2 of 3): ► Influenza vaccination decreases the incidence of lower respiratory tract infections. ► Pneumococcal vaccination decreases lower respiratory tract infections. ► Pulmonary rehabilitation improves symptoms, quality of life, and physical and emotional participation in everyday activities. ► In patients with severe resting chronic hypoxemia, long-term oxygen therapy improves survival. ► In patients with stable COPD and resting or exercise-induced moderate desaturation, long-term oxygen treatment should not be prescribed routinely. However, individual patient factors must be considered when evaluating the patient’s need for supplemental oxygen.
Evidence Supporting Prevention & Maintenance Therapy © 2017 Global Initiative for Chronic Obstructive Lung Disease OVERALL KEY POINTS (3 of 3): ► In patients with severe chronic hypercapnia and a history of hospitalization for acute respiratory failure, long-term non-invasive ventilation may decrease mortality and prevent re-hospitalization. ► In select patients with advanced emphysema refractory to optimized medical care, surgical or bronchoscopic interventional treatments may be beneficial. ► Palliative approaches are effective in controlling symptoms in advanced COPD.
Smoking Cessation © 2017 Global Initiative for Chronic Obstructive Lung Disease ► Smoking cessation has the greatest capacity to influence the natural history of COPD. ► If effective resources and time are dedicated to smoking cessation, long-term quit success rates of up to 25% can be achieved.
Vaccination © 2017 Global Initiative for Chronic Obstructive Lung Disease ► Influenza vaccination can reduce serious illness (such as lower respiratory tract infections requiring hospitalization)24 and death in COPD patients. ► Pneumococcal vaccinations, PCV13 and PPSV23, are recommended for all patients ≥ 65 years of age
Pharmacologic Therapy © 2017 Global Initiative for Chronic Obstructive Lung Disease
Pharmacologic Therapy © 2017 Global Initiative for Chronic Obstructive Lung Disease
Bronchodilators in Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease
Anti-inflammatory Therapy in Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease
The Inhaled Route © 2017 Global Initiative for Chronic Obstructive Lung Disease
Other Pharmacologic Treatments © 2017 Global Initiative for Chronic Obstructive Lung Disease
Rehabilitation, Education & Self- Management © 2017 Global Initiative for Chronic Obstructive Lung Disease
Palliative, End of Life & Hospice Care © 2017 Global Initiative for Chronic Obstructive Lung Disease ► In many patients, the disease trajectory in COPD is marked by a gradual decline in health status and increasing symptoms, punctuated by acute exacerbations that are associated with an increased risk of dying. ► Although mortality rates following hospitalization for an acute exacerbation of COPD are declining, reported rates still vary from 23% to 80%.
Oxygen Therapy & Ventilatory Support in Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease ► During exacerbations of COPD. Noninvasive ventilation (NIV) in the form of noninvasive positive pressure ventilation (NPPV) is the standard of care for decreasing morbidity and mortality in patients hospitalized with an exacerbation of COPD and acute respiratory failure
Oxygen Therapy & Ventilatory Support in Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease ► During exacerbations of COPD. Noninvasive ventilation (NIV) in the form of noninvasive positive pressure ventilation (NPPV) is the standard of care for decreasing morbidity and mortality in patients hospitalized with an exacerbation of COPD and acute respiratory failure
Interventional Therapy in Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease ► Lung volume reduction surgery (LVRS). LVRS is a surgical procedure in which parts of the lungs are resected to reduce hyperinflation,261 making respiratory muscles more effective pressure generators by improving their mechanical efficiency.
Interventional Therapy in Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease ► Lung volume reduction surgery (LVRS) is a surgical procedure in which parts of the lungs are resected to reduce hyperinflation,261 making respiratory muscles more effective pressure generators by improving their mechanical efficiency. ► Due to the morbidity and mortality associated with LVRS, less invasive bronchoscopic approaches to lung reduction have been examined.
GOLD 2017 Report: Chapters © 2017 Global Initiative for Chronic Obstructive Lung Disease 1. Definition and Overview 2. Diagnosis and Initial Assessment 3. Evidence Supporting Prevention & Maintenance Therapy 4. Management of Stable COPD 5. Management of Exacerbations 6. COPD and Comorbidities
Management of Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease OVERALL KEY POINTS: ► The management strategy for stable COPD should be predominantly based on the individualized assessment of symptoms and future risk of exacerbations. ► All individuals who smoke should be strongly encouraged and supported to quit. ► The main treatment goals are reduction of symptoms and future risk of exacerbations. ► Management strategies are not limited to pharmacologic treatments, and should be complemented by appropriate non-pharmacologic interventions.
Management of Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease ► Once COPD has been diagnosed, effective management should be based on an individualized assessment to reduce both current symptoms and future risks of exacerbations.
Management of Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease Identify and reduce exposure to known risk factors ► Identification and reduction of exposure to risk factors is important in the treatment and prevention of COPD. ► Cigarette smoking is the most commonly encountered and easily identifiable risk factor for COPD, and smoking cessation should be continually encouraged for all individuals who smoke. ► Reduction of total personal exposure to occupational dusts, fumes, and gases, and to indoor and outdoor air pollutants, should also be addressed.
Management of Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease
Treatment of Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease Pharmacologic treatment ► Pharmacologic therapies can reduce symptoms, and the risk and severity of exacerbations, as well as improve health status and exercise tolerance. ► Most of the drugs are inhaled so proper inhaler technique is of high relevance.
Treatment of Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease Pharmacologic treatment
Treatment of Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease Pharmacologic treatment
Treatment of Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease Pharmacologic treatment algorithms ► A proposed model for the initiation, and then subsequent escalation and/or de-escalation of pharmacologic management of COPD according to the individualized assessment of symptoms and exacerbation risk is shown. ► We suggest escalation (and de-escalation) strategies. ► The recommendations made are based on available efficacy as well as safety data. ► It should be noted that there is a lack of direct evidence supporting the therapeutic recommendations for patients in groups C and D. These recommendations will be re-evaluated as additional data become available.
Treatment of Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease
Pharmacologic treatment algorithms © 2017 Global Initiative for Chronic Obstructive Lung Disease Group A ► All Group A patients should be offered bronchodilator treatment based on its effect on breathlessness. This can be either a short- or a long-acting bronchodilator. ► This should be continued if symptomatic benefit is documented.
Pharmacologic treatment algorithms © 2017 Global Initiative for Chronic Obstructive Lung Disease Group B ► Initial therapy should consist of a long acting bronchodilator. Long-acting inhaled bronchodilators are superior to short-acting bronchodilators taken as needed i.e., pro re nata (prn) and are therefore recommended. ► There is no evidence to recommend one class of long-acting bronchodilators over another for initial relief of symptoms in this group of patients. In the individual patient, the choice should depend on the patient’s perception of symptom relief. ► For patients with persistent breathlessness on monotherapy the use of two bronchodilators is recommended.
Pharmacologic treatment algorithms © 2017 Global Initiative for Chronic Obstructive Lung Disease Group B (continued) ► For patients with severe breathlessness initial therapy with two bronchodilators may be considered. ► If the addition of a second bronchodilator does not improve symptoms, we suggest the treatment could be stepped down again to a single bronchodilator. ► Group B patients are likely to have comorbidities that may add to their symptomatology and impact their prognosis, and these possibilities should be investigated.
Pharmacologic treatment algorithms © 2017 Global Initiative for Chronic Obstructive Lung Disease Group C ► Initial therapy should consist of a single long acting bronchodilator. In two head-to head comparisons the tested LAMA was superior to the LABA regarding exacerbation prevention, therefore we recommend starting therapy with a LAMA in this group. ► Patients with persistent exacerbations may benefit from adding a second long acting bronchodilator (LABA/LAMA) or using a combination of a long acting beta2-agonist and an inhaled corticosteroid (LABA/ICS). As ICS increases the risk for developing pneumonia in some patients, our primary choice is LABA/LAMA.
Pharmacologic treatment algorithms © 2017 Global Initiative for Chronic Obstructive Lung Disease Group D ► We recommend starting therapy with a LABA/LAMA combination because:  In studies with patient reported outcomes as the primary endpoint LABA/LAMA combinations showed superior results compared to the single substances. If a single bronchodilator is chosen as initial treatment, a LAMA is preferred for exacerbation prevention based on comparison to LABAs (for details see GOLD 2017 Chapter 3).  A LABA/LAMA combination was superior to a LABA/ICS combination in preventing exacerbations and other patient reported outcomes in Group D patients (for details see GOLD 2017 Chapter 3).  Group D patients are at higher risk of developing pneumonia when receiving treatment with ICS.
Pharmacologic treatment algorithms © 2017 Global Initiative for Chronic Obstructive Lung Disease Group D (continued) ► In some patients initial therapy with LABA/ICS may be the first choice. These patients may have a history and/or findings suggestive of asthma-COPD overlap. High blood eosinophil counts may also be considered as a parameter to support the use of ICS, although this is still under debate (for details see Chapter 2 and Appendix). ► In patients who develop further exacerbations on LABA/LAMA therapy we suggest two alternative pathways:  Escalation to LABA/LAMA/ICS. Studies are underway comparing the effects of LABA/LAMA vs. LABA/LAMA/ICS for exacerbation prevention.  Switch to LABA/ICS. However, there is no evidence that switching from LABA/LAMA to LABA/ICS results in better exacerbation prevention. If LABA/ICS therapy does not positively impact exacerbations/symptoms, a LAMA can be added.
Pharmacologic treatment algorithms © 2017 Global Initiative for Chronic Obstructive Lung Disease Group D (continued) If patients treated with LABA/LAMA/ICS still have exacerbations the following options may be considered: ► Add roflumilast. This may be considered in patients with an FEV1 < 50% predicted and chronic bronchitis,13 particularly if they have experienced at least one hospitalization for an exacerbation in the previous year. ► Add a macrolide. The best available evidence exists for the use of azithromycin. Consideration to the development of resistant organisms should be factored into decision making. ► Stopping ICS. A reported lack of efficacy, an elevated risk of adverse effects (including pneumonia) and evidence showing no significant harm from withdrawal supports this recommendation (see Chapter 3 for further details).
Non-Pharmacologic Treatment © 2017 Global Initiative for Chronic Obstructive Lung Disease ►Education and self-management ►Physical activity ►Pulmonary rehabilitation programs ►Exercise training ►Self-management education ►End of life and palliative care ►Nutritional support ►Vaccination ►Oxygen therapy
Non-Pharmacologic Treatment © 2017 Global Initiative for Chronic Obstructive Lung Disease Education and self-management ► Self-management education and coaching by healthcare professionals should be a major component of the “Chronic Care Model” within the context of the healthcare delivery system. ► The aim of self-management education is to motivate, engage and coach the patients to positively adapt their health behavior(s) and develop skills to better manage their disease.
Non-Pharmacologic Treatment © 2017 Global Initiative for Chronic Obstructive Lung Disease Oxygen therapy Long-term oxygen therapy is indicated for stable patients who have: ►PaO2 at or below 7.3 kPa (55 mmHg) or SaO2 at or below 88%, with or without hypercapnia confirmed twice over a three week period; or ►PaO2 between 7.3 kPa (55 mmHg) and 8.0 kPa (60 mmHg), or SaO2 of 88%, if there is evidence of pulmonary hypertension, peripheral edema suggesting congestive cardiac failure, or polycythemia (hematocrit > 55%).
Non-Pharmacologic Treatment © 2017 Global Initiative for Chronic Obstructive Lung Disease
Non-Pharmacologic Treatment © 2017 Global Initiative for Chronic Obstructive Lung Disease Interventional bronchoscopy and surgery ►In selected patients with heterogeneous or homogenous emphysema and significant hyperinflation refractory to optimized medical care, surgical or bronchoscopic modes of lung volume reduction (e.g., endobronchial one-way valves or lung coils) may be considered. ►In selected patients with a large bulla, surgical bullectomy may be considered. ►In selected patients with very severe COPD and without relevant contraindications, lung transplantation may be considered.
© 2017 Global Initiative for Chronic Obstructive Lung Disease
Non-Pharmacologic Treatment - Summary © 2017 Global Initiative for Chronic Obstructive Lung Disease
Non-Pharmacologic Treatment – Summary (continued) © 2017 Global Initiative for Chronic Obstructive Lung Disease
Monitoring and Follow-up © 2017 Global Initiative for Chronic Obstructive Lung Disease Monitoring disease progression and development of complications and/or comorbidities ► Measurements. Decline in FEV1 can be tracked by spirometry performed at least once a year. ► Symptoms. At each visit, information on symptoms since the last visit should be collected, including cough and sputum, breathlessness, fatigue, activity limitation, and sleep disturbances. ► Exacerbations. The frequency, severity, type and likely causes of all exacerbations should be monitored. ► Imaging. If there is a clear worsening of symptoms, imaging may be indicated. ► Smoking status. At each visit, the current smoking status and smoke exposure should be determined followed by appropriate action.
Monitoring and Follow-up © 2017 Global Initiative for Chronic Obstructive Lung Disease Pharmacotherapy and other medical treatment In order to adjust therapy appropriately as the disease progresses, each follow-up visit should include a discussion of the current therapeutic regimen. Monitoring should focus on: ► Dosages of prescribed medications. ► Adherence to the regimen. ► Inhaler technique. ► Effectiveness of the current regime. ► Side effects. Treatment modifications should be recommended.
GOLD 2017 Report: Chapters © 2017 Global Initiative for Chronic Obstructive Lung Disease 1. Definition and Overview 2. Diagnosis and Initial Assessment 3. Evidence Supporting Prevention & Maintenance Therapy 4. Management of Stable COPD 5. Management of Exacerbations 6. COPD and Comorbidities
Management of Exacerbations © 2017 Global Initiative for Chronic Obstructive Lung Disease OVERALL KEY POINTS (1 of 3): ► An exacerbation of COPD is defined as an acute worsening of respiratory symptoms that results in additional therapy. ► Exacerbations of COPD can be precipitated by several factors. The most common causes are respiratory tract infections. ► The goal for treatment of COPD exacerbations is to minimize the negative impact of the current exacerbation and to prevent subsequent events. ► Short-acting inhaled beta2-agonists, with or without short-acting anticholinergics, are recommended as the initial bronchodilators to treat an acute exacerbation.
Management of Exacerbations © 2017 Global Initiative for Chronic Obstructive Lung Disease OVERALL KEY POINTS (2 of 3): ► Maintenance therapy with long-acting bronchodilators should be initiated as soon as possible before hospital discharge. ► Systemic corticosteroids can improve lung function (FEV1), oxygenation and shorten recovery time and hospitalization duration. Duration of therapy should not be more than 5-7 days. ► Antibiotics, when indicated, can shorten recovery time, reduce the risk of early relapse, treatment failure, and hospitalization duration. Duration of therapy should be 5-7 days. ► Methylxanthines are not recommended due to increased side effect profiles.
Management of Exacerbations © 2017 Global Initiative for Chronic Obstructive Lung Disease OVERALL KEY POINTS (3 of 3): ► Non-invasive mechanical ventilation should be the first mode of ventilation used in COPD patients with acute respiratory failure who have no absolute contraindication because it improves gas exchange, reduces work of breathing and the need for intubation, decreases hospitalization duration and improves survival. ► Following an exacerbation, appropriate measures for exacerbation prevention should be initiated (see GOLD 2017 Chapter 3 and Chapter 4).
Management of Exacerbations © 2017 Global Initiative for Chronic Obstructive Lung Disease COPD exacerbations are defined as an acute worsening of respiratory symptoms that result in additional therapy. ► They are classified as:  Mild (treated with short acting bronchodilators only, SABDs)  Moderate (treated with SABDs plus antibiotics and/or oral corticosteroids) or  Severe (patient requires hospitalization or visits the emergency room). Severe exacerbations may also be associated with acute respiratory failure.
Management of Exacerbations © 2017 Global Initiative for Chronic Obstructive Lung Disease Classification of hospitalized patients No respiratory failure: Respiratory rate: 20-30 breaths per minute; no use of accessory respiratory muscles; no changes in mental status; hypoxemia improved with supplemental oxygen given via Venturi mask 28-35% inspired oxygen (FiO2); no increase in PaCO2.
Management of Exacerbations © 2017 Global Initiative for Chronic Obstructive Lung Disease Classification of hospitalized patients Acute respiratory failure — non-life-threatening: Respiratory rate: > 30 breaths per minute; using accessory respiratory muscles; no change in mental status; hypoxemia improved with supplemental oxygen via Venturi mask 25- 30% FiO2; hypercarbia i.e., PaCO2 increased compared with baseline or elevated 50-60 mmHg.
Management of Exacerbations © 2017 Global Initiative for Chronic Obstructive Lung Disease Classification of hospitalized patients Acute respiratory failure — life-threatening: Respiratory rate: > 30 breaths per minute; using accessory respiratory muscles; acute changes in mental status; hypoxemia not improved with supplemental oxygen via Venturi mask or requiring FiO2 > 40%; hypercarbia i.e., PaCO2 increased compared with baseline or elevated > 60 mmHg or the presence of acidosis (pH < 7.25).
Management of Exacerbations © 2017 Global Initiative for Chronic Obstructive Lung Disease
Management of Exacerbations © 2017 Global Initiative for Chronic Obstructive Lung Disease
Management of Exacerbations - Summary © 2017 Global Initiative for Chronic Obstructive Lung Disease
Management of Exacerbations © 2017 Global Initiative for Chronic Obstructive Lung Disease Pharmacologic treatment The three classes of medications most commonly used for COPD exacerbations are: ►Bronchodilators  Although there is no high-quality evidence from RCTs, it is recommended that short-acting inhaled beta2-agonists, with or without short-acting anticholinergics, are the initial bronchodilators for acute treatment of a COPD exacerbation. ►Corticosteroids  Data from studies indicate that systemic glucocorticoids in COPD exacerbations shorten recovery time and improve lung function (FEV1). They also improve oxygenation, the risk of early relapse, treatment failure, and the length of hospitalization. ►Antibiotics
Management of Exacerbations © 2017 Global Initiative for Chronic Obstructive Lung Disease Respiratory support
Management of Exacerbations © 2017 Global Initiative for Chronic Obstructive Lung Disease Respiratory support
Management of Exacerbations © 2017 Global Initiative for Chronic Obstructive Lung Disease
Management of Exacerbations © 2017 Global Initiative for Chronic Obstructive Lung Disease
GOLD 2017 Report: Chapters © 2017 Global Initiative for Chronic Obstructive Lung Disease 1. Definition and Overview 2. Diagnosis and Initial Assessment 3. Evidence Supporting Prevention & Maintenance Therapy 4. Management of Stable COPD 5. Management of Exacerbations 6. COPD and Comorbidities
COPD and Comorbidities © 2017 Global Initiative for Chronic Obstructive Lung Disease OVERALL KEY POINTS (1 of 2): ► COPD often coexists with other diseases (comorbidities) that may have a significant impact on disease course. ► In general, the presence of comorbidities should not alter COPD treatment and comorbidities should be treated per usual standards regardless of the presence of COPD. ► Lung cancer is frequently seen in patients with COPD and is a main cause of death. ► Cardiovascular diseases are common and important comorbidities in COPD.
COPD and Comorbidities © 2017 Global Initiative for Chronic Obstructive Lung Disease OVERALL KEY POINTS (2 of 2): ► Osteoporosis and depression/anxiety are frequent, important comorbidities in COPD, are often under-diagnosed, and are associated with poor health status and prognosis. ► Gastroesophageal reflux (GERD) is associated with an increased risk of exacerbations and poorer health status. ► When COPD is part of a multimorbidity care plan, attention should be directed to ensure simplicity of treatment and to minimize polypharmacy.
COPD and Comorbidities © 2017 Global Initiative for Chronic Obstructive Lung Disease Some common comorbidities occurring in patients with COPD with stable disease include: ► Cardiovascular disease (CVD) ► Heart failure ► Ischaemic heart disease (IHD) ► Arrhythmias ► Peripheral vascular disease ► Hypertension ► Osteoporosis ► Anxiety and depression ► COPD and lung cancer ► Metabolic syndrome and diabetes ► Gastroesophageal reflux (GERD) ► Bronchiectasis ► Obstructive sleep apnea
COPD and Comorbidities © 2017 Global Initiative for Chronic Obstructive Lung Disease COPD as part of multimorbidity ► An increasing number of people in any aging population will suffer from multi- morbidity, defined as the presence of two or more chronic conditions, and COPD is present in the majority of multi-morbid patients. ► Multi-morbid patients have symptoms from multiple diseases and thus symptoms and signs are complex and most often attributable to several causes in the chronic state as well as during acute events. ► There is no evidence that COPD should be treated differently when part of multi-morbidity; however, it should be kept in mind that most evidence comes from trials in patients with COPD as the only significant disease. ► Treatments should be kept simple in the light of the unbearable polypharmacy that these patients are often exposed to.
GOLD Website www.goldcopd.org © 2017 Global Initiative for Chronic Obstructive Lung Disease
World COPD Day November, 2016 Keep updated here: http://goldcopd.org/world-copd-day/ © 2017 Global Initiative for Chronic Obstructive Lung Disease
Journals Publishing the GOLD 2017 Executive Summary  American Journal of Respiratory and Critical Care Medicine  European Respiratory Journal  Respirology  Archivos de Bronconeumología

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Gold slide set_2017

  • 1. GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE (GOLD): TEACHING SLIDE SET February 2017 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. © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 2. © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 3. GOLD Board of Directors 2017 Alvar Agusti, MD, Chair Respiratory Institute, Hospital Clinic, IDIBAPS Univ. Barcelona and Ciberes Barcelona, Spain Marc Decramer, MD, Chair (to 05/16) University of Leuven Leuven, Belgium Bartolome R. Celli, MD Brigham and Women’s Hospital Boston, Massachusetts, USA Rongchang Chen, MD Guangzhou Institute of Respiratory Disease Guangzhou, PRC Gerard Criner, MD Temple University School of Medicine Philadelphia, Pennsylvania, USA Peter Frith, MD Repatriation General Hospital, Adelaide, South Australia, Australia David Halpin, MD Royal Devon and Exeter Hospital Devon, UK M. Victorina López Varela, MD Universidad de la República Montevideo, Uruguay Masaharu Nishimura, MD Hokkaido University School of Medicine Sapporo, Japan Roberto Rodriguez-Roisin, MD Respiratory Institute, Hospital Clinic, IDIBAPS Univ. Barcelona and Ciberes Barcelona, Spain Claus Vogelmeier, MD University of Marburg Marburg, Germany © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 4. GOLD Science Committee 2017 Claus Vogelmeier, MD, Chair University of Marburg Marburg, Germany Alvar Agusti, MD Respiratory Institute, Hospital Clinic, IDIBAPS Univ. Barcelona and Ciberes Barcelona, Spain Antonio Anzueto, MD University of Texas Health Science Center San Antonio, Texas, USA Peter Barnes, MD National Heart and Lung Institute London, United Kingdom Jean Bourbeau, MD McGill University Health Centre Montreal, Canada Gerard Criner, MD Temple University School of Medicine, Philadelphia, Pennsylvania, USA Leonardo M. Fabbri, MD University of Modena & Reggio Emilia Modena, Italy Fernando Martinez, MD, MS New York-Presbyterian Hospital/ Weill Cornell Medical Center New York, NY,USA Nicolas Roche, MD Hôpital Cochin Paris, France Roberto Rodriguez-Roisin, MD Respiratory Institut, Hospital Clinic, IDIBAPS, Univ. Barcelona and Ciberes, Barcelona, Spain Donald Sin, MD St. Paul’s Hospital, University of British Columbia Vancouver, Canada Dave Singh, MD University of Manchester Manchester, UK Robert Stockley, MD University Hospital Birmingham, UK Jørgen Vestbo, MD University of Manchester Manchester, England, UK Jadwiga A. Wedzicha, MD Imperial College London London, UK PROGRAM DIRECTOR Rebecca Decker, MSJ Fontana, Wisconsin, USA Suzanne Hurd, PhD (Director to 12/15) © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 5. GOLD National Leaders Perlat Kapisyzi, Albania Eduardo A. Schiavi, Argentina Otto Chris Burghuber, Austria Mostafizur Rahman, Bangladesh Kazi S. BENNOOR, Bangladesh Wim Janssens, Belgium Jose Roberto Jardim, Brazil Aquiles Camelier, Brazil Fernando Lundgren, Brazil Yavor Ivanov, Bulgaria Kosta Kostov, Bulgaria Dennis E. O’Donnell, Canada Manuel Barros, Chile Nan-Shan Zhong, China Jiangtao Lin, China Chunxue Bai, China Fu-Qiang Wen, China Alejandro Casas, Colombia Neven Miculinic, Croatia Stanislav Kos, Czech Republic Jaromir Musil, Czech Republic Vladimir Vondra, Czech Republic Ejvind Frausing Hansen, Denmark Eduardo Gautreau de Windt, Dominican Republic Hisham Tarraf, Egypt Victor Castro Gòmez, El Salvador Gerard Huchon, France Maia Gotua, Georgia Klaus Rabe, Germany David S.C. Hui, Hong Kong Thorarinn Gislason, Iceland Gunnar Gudmundsson, Iceland Rohini V. Chowgule, India R.Narasimhan, India Faisal Yunus, Indonesia Masjedi Mohammad Reza, Iran Mohammad Ashkan Moslehi, Iran Timothy J. McDonnell, Ireland Zvi G. Fridlender, Israel Lorenzo Corbetta, Italy Takahide Nagase, Japan Michiaki Mishima, Japan Bashar Nsour, Jordan Jawad Hamad, Jordan Damilya Nugmanova, Kazakhstan Yeon-Mok Oh, Korea Mousa Khadadah, Kuwait Talant Sooronbaev, Kyrgyz Republic Joseph M Cacciottolo, Malta J. Javier Díaz Castañón, Mexico Alexandru Corlateanu, Moldova Dr Oyunchimeg, Mongolia Harold Rea, New Zealand Jorge Cuadra, Nicaragua Amund Gulsvik, Norway Ernst Omenaas, Norway Javaid Khan, Pakistan Jamil Ur Rehman Tahir, Pakistan Mohammad Osman Yusuf, Pakistan Teresita S. deGuia, Philippines Ewa Nizankowska-Mogilnicka, Poland Pawel Kuca, Poland Florin Mihaltan, Romania Ruxandra Ulmeanu, Romania Alexander Chuchalin, Russia Dmitri R. Rackita, Russia Professor Alexandre Vizel, Russia Professor Eugeny Shmelev, Russia Kian-Chung Ong, Singapore Wan-Cheng Tan, Singapore Ruzena Tkacova, Slovak Republic Stanislav Suskovic, Slovenia EM Irusen, South Africa Patricia Sobradillo, Spain Daiana Stolz, Switzerland Yousser Mohammad, Syria Professor Ali Kocabas, Turkey Hakan Gunen, Turkey Maria Montes de Oca, Venezuela Ngo Quy Chau, Vietnam Le Thi Tuyet Lan, Vietnam Sy Duong-Quy, Vietnam Khaled Al-Shair, Yemen © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 6. GOLD Invited Contributors Prof. Richard Beasley Medical Research Institute of New Zealand Wellington, New Zealand Peter M A Calverley, MD University Hospital Aintree Liverpool, UK Ciro Casanova, MD Hospital Universitario Santa Cruz de Tenerife, Tenerife, Spain James Donohue, MD University of North Carolina Chapel Hill, NC, USA MeiLan Han, MD, MS University of Michigan Ann Arbor, MI, USA Nicola Hanania, MBBS, MS Baylor College of Medicine Houston, TX, USA Maria Montes de Oca, MD Hospital Universitario de Caracas, Universidad Central de Venezuela, Caracas, Venezuela Takahide Nagase, MD The University of Tokyo, Tokyo, Japan Alberto Papi, MD University of Ferarra Ferrara, Italy Ian Pavord, MD University of Oxford Oxford, UK David Price, FRCGP Observational and Pragmatic Research Institute, Singapore University of Aberdeen, Aberdeen, Scotland, UK © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 7. GOLD Website Address © 2017 Global Initiative for Chronic Obstructive Lung Disease www.goldcopd.org
  • 8. Chronic Obstructive Pulmonary Disease (COPD) © 2017 Global Initiative for Chronic Obstructive Lung Disease ► COPD is currently the fourth leading cause of death in the world.1 ► COPD is projected to be the 3rd leading cause of death by 2020.2 ► More than 3 million people died of COPD in 2012 accounting for 6% of all deaths globally. ► Globally, the COPD burden is projected to increase in coming decades because of continued exposure to COPD risk factors and aging of the population. 1. Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380(9859): 2095-128. 2. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med 2006; 3(11): e442.
  • 9. GOLD Objectives © 2017 Global Initiative for Chronic Obstructive Lung Disease ► To provide a non-biased review of the current evidence for the assessment, diagnosis and treatment of patients with COPD. ► To highlight short-term and long-term treatment objectives organized into two groups:  Relieving and reducing the impact of symptoms, and  Reducing the risk of adverse health events that may affect the patient in the future. ► To guide symptoms assessment and health status measurement.
  • 10. GOLD Levels of Evidence © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 11. GOLD Levels of Evidence © 2017 Global Initiative for Chronic Obstructive Lung Disease ► Levels of evidence have been assigned to evidence- based recommendations where appropriate. ► Evidence levels are indicated in boldface type enclosed in parentheses after the relevant statement e.g., (Evidence A). ► The methodological issues concerning the use of evidence from meta-analyses were carefully considered. ► The evidence level scheme with categories A to D used throughout this document has been modified from that used in prior GOLD Reports and the evidence category definitions have been refined and updated.
  • 12. GOLD 2017 Report: Chapters © 2017 Global Initiative for Chronic Obstructive Lung Disease 1. Definition and Overview 2. Diagnosis and Initial Assessment 3. Evidence Supporting Prevention & Maintenance Therapy 4. Management of Stable COPD 5. Management of Exacerbations 6. COPD and Comorbidities
  • 13. GOLD 2017 Report: Chapters © 2017 Global Initiative for Chronic Obstructive Lung Disease 1. Definition and Overview 2. Diagnosis and Initial Assessment 3. Evidence Supporting Prevention & Maintenance Therapy 4. Management of Stable COPD 5. Management of Exacerbations 6. COPD and Comorbidities
  • 14. COPD Definition © 2017 Global Initiative for Chronic Obstructive Lung Disease ► Chronic Obstructive Pulmonary Disease (COPD) is a common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases.
  • 15. COPD Etiology, Pathobiology & Pathology © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 16. Definition and Overview © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 17. Definition and Overview © 2017 Global Initiative for Chronic Obstructive Lung Disease OVERALL KEY POINTS (1 of 2): ► Chronic Obstructive Pulmonary Disease (COPD) is a common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases. ► The most common respiratory symptoms include dyspnea, cough and/or sputum production. These symptoms may be under-reported by patients. ► The main risk factor for COPD is tobacco smoking but other environmental exposures such as biomass fuel exposure and air pollution may contribute.
  • 18. Definition and Overview © 2017 Global Initiative for Chronic Obstructive Lung Disease OVERALL KEY POINTS (2 of 2): ► Besides exposures, host factors predispose individuals to develop COPD. These include genetic abnormalities, abnormal lung development and accelerated aging. ► COPD may be punctuated by periods of acute worsening of respiratory symptoms, called exacerbations. ► In most patients, COPD is associated with significant concomitant chronic diseases, which increase its morbidity and mortality.
  • 19. Prevalence © 2017 Global Initiative for Chronic Obstructive Lung Disease Prevalence of COPD ► Systematic review and meta-analysis (Halbert et al, 2006) ► Included studies carried out in 28 countries between 1990 and 2004 ► Prevalence of COPD was higher in smokers and ex- smokers compared to non-smokers ► Higher ≥ 40 year group compared to those < 40 ► Higher in men than women.
  • 20. Prevalence © 2017 Global Initiative for Chronic Obstructive Lung Disease Prevalence of COPD ► Estimated 384 million COPD cases in 2010. ► Estimated global prevalence of 11.7% (95% CI 8.4%– 15.0%). ► Three million deaths annually. ► With increasing prevalence of smoking in developing countries, and aging populations in high-income countries, the prevalence of COPD is expected to rise over the next 30 years. ► By 2030 predicted 4.5 million COPD related deaths annually.
  • 21. Economic and Social Burden © 2017 Global Initiative for Chronic Obstructive Lung Disease Economic burden of COPD ► COPD is associated with significant economic burden. ► COPD exacerbations account for the greatest proportion of the total COPD burden. ► European Union:  Direct costs of respiratory disease ~6% of the total healthcare budget  COPD accounting for 56% (38.6 billion Euros) of the cost of respiratory disease. ► USA:  Direct costs of COPD are $32 billion  Indirect costs $20.4 billion.
  • 22. Economic and Social Burden © 2017 Global Initiative for Chronic Obstructive Lung Disease ► Global Burden of Disease (GBD) study ► Disability-Adjusted Life Year (DALY) = sum of years lost because of premature mortality and years of life lived with disability, adjusted for the severity of disability. ► COPD is an increasing contributor to disability and mortality around the world. ► In 2013 COPD was 5th leading cause of DALYs lost. ► In the United States, COPD is the second leading cause of reduced DALYs, trailing only ischemic heart disease
  • 23. Factors that influence disease progression © 2017 Global Initiative for Chronic Obstructive Lung Disease ► Genetic factors ► Age and gender ► Lung growth and development ► Exposure to particles ► Socioeconomic status ► Asthma & airway hyper-reactivity ► Chronic bronchitis ► Infections
  • 24. Pathology, pathogenesis & pathophysiology © 2017 Global Initiative for Chronic Obstructive Lung Disease ► Pathology  Chronic inflammation  Structural changes ► Pathogenesis  Oxidative stress  Protease-antiprotease imbalance  Inflammatory cells  Inflammatory mediators  Peribronchiolar and interstitial fibrosis ► Pathophysiology  Airflow limitation and gas trapping  Gas exchange abnormalities  Mucus hypersecretion  Pulmonary hypertension
  • 25. GOLD 2017 Report: Chapters © 2017 Global Initiative for Chronic Obstructive Lung Disease 1. Definition and Overview 2. Diagnosis and Initial Assessment 3. Evidence Supporting Prevention & Maintenance Therapy 4. Management of Stable COPD 5. Management of Exacerbations 6. COPD and Comorbidities
  • 26. Diagnosis and Initial Assessment © 2017 Global Initiative for Chronic Obstructive Lung Disease OVERALL KEY POINTS (1 of 2): ► 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 < 0.70 confirms the presence of persistent airflow limitation. ► The goals of COPD assessment are to determine the level of airflow limitation, the impact of disease on the patient’s health status, and the risk of future events (such as exacerbations, hospital admissions, or death), in order to guide therapy.
  • 27. Diagnosis and Initial Assessment © 2017 Global Initiative for Chronic Obstructive Lung Disease OVERALL KEY POINTS (2 of 2): ► Concomitant chronic diseases occur frequently in COPD patients, including cardiovascular disease, skeletal muscle dysfunction, metabolic syndrome, osteoporosis, depression, anxiety, and lung cancer. These comorbidities should be actively sought and treated appropriately when present as they can influence mortality and hospitalizations independently.
  • 28. Diagnosis and Initial Assessment © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 29. Diagnosis and Initial Assessment © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 30. Diagnosis and Initial Assessment © 2017 Global Initiative for Chronic Obstructive Lung Disease ► Symptoms of COPD  Chronic and progressive dyspnea  Cough  Sputum production  Wheezing and chest tightness  Others – including fatigue, weight loss, anorexia, syncope, rib fractures, ankle swelling, depression, anxiety.
  • 31. Diagnosis and Initial Assessment © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 32. Medical History © 2017 Global Initiative for Chronic Obstructive Lung Disease ► Patient’s exposure to risk factors ► Past medical history ► Family history of COPD or other chronic respiratory disease. ► Pattern of symptom development ► History of exacerbations or previous hospitalizations for respiratory disorder ► Presence of comorbidities ► Impact of disease on patient’s life ► Social and family support available to the patient. ► Possibilities for reducing risk factors, especially smoking cessation.
  • 33. Diagnosis and Initial Assessment © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 34. Spirometry © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 35. Classification of severity of airflow limitation © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 36. Choice of thresholds © 2017 Global Initiative for Chronic Obstructive Lung Disease ► COPD Assessment Test (CAT TM ) ► Chronic Respiratory Questionnaire (CCQ® ) ► St George’s Respiratory Questionnaire (SGRQ) ► Chronic Respiratory Questionnaire (CRQ) ► Modified Medical Research Council (mMRC) questionnaire
  • 37. Assessment of Exacerbation Risk © 2017 Global Initiative for Chronic Obstructive Lung Disease ► COPD exacerbations are defined as an acute worsening of respiratory symptoms that result in additional therapy. ► Classified as:  Mild (treated with SABDs only)  Moderate (treated with SABDs plus antibiotics and/or oral corticosteroids) or  Severe (patient requires hospitalization or visits the emergency room). Severe exacerbations may also be associated with acute respiratory failure. ► Blood eosinophil count may also predict exacerbation rates (in patients treated with LABA without ICS).
  • 38. ABCD Assessment Tool © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 39. ABCD Assessment Tool © 2017 Global Initiative for Chronic Obstructive Lung Disease Example ► Consider two patients:  Both patients with FEV1 < 30% of predicted  Both with CAT scores of 18  But, one with 0 exacerbations in the past year and the other with 3 exacerbations in the past year. ► Both would have been labelled GOLD D in the prior classification scheme. ► With the new proposed scheme, the subject with 3 exacerbations in the past year would be labelled GOLD grade 4, group D. ► The other patient, who has had no exacerbations, would be classified as GOLD grade 4, group B.
  • 40. Summary © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 41. Alpha-1 antitrypsin deficiency (AATD) © 2017 Global Initiative for Chronic Obstructive Lung Disease AATD screening ► The World Health Organization recommends that all patients with a diagnosis of COPD should be screened once especially in areas with high AATD prevalence. ► AATD patients are typically < 45 years with panlobular basal emphysema ► Delay in diagnosis in older AATD patients presents as more typical distribution of emphysema (centrilobular apical). ► A low concentration (< 20% normal) is highly suggestive of homozygous deficiency.
  • 42. Differential Diagnosis © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 43. GOLD 2017 Report: Chapters © 2017 Global Initiative for Chronic Obstructive Lung Disease 1. Definition and Overview 2. Diagnosis and Initial Assessment 3. Evidence Supporting Prevention & Maintenance Therapy 4. Management of Stable COPD 5. Management of Exacerbations 6. COPD and Comorbidities
  • 44. Evidence Supporting Prevention & Maintenance Therapy © 2017 Global Initiative for Chronic Obstructive Lung Disease OVERALL KEY POINTS (1 of 3): ► Smoking cessation is key. Pharmacotherapy and nicotine replacement reliably increase long-term smoking abstinence rates. ► The effectiveness and safety of e-cigarettes as a smoking cessation aid is uncertain at present. ► Pharmacologic therapy can reduce COPD symptoms, reduce the frequency and severity of exacerbations, and improve health status and exercise tolerance. ► Each pharmacologic treatment regimen should be individualized and guided by the severity of symptoms, risk of exacerbations, side- effects, comorbidities, drug availability and cost, and the patient’s response, preference and ability to use various drug delivery devices. ► Inhaler technique needs to be assessed regularly.
  • 45. Evidence Supporting Prevention & Maintenance Therapy © 2017 Global Initiative for Chronic Obstructive Lung Disease OVERALL KEY POINTS (2 of 3): ► Influenza vaccination decreases the incidence of lower respiratory tract infections. ► Pneumococcal vaccination decreases lower respiratory tract infections. ► Pulmonary rehabilitation improves symptoms, quality of life, and physical and emotional participation in everyday activities. ► In patients with severe resting chronic hypoxemia, long-term oxygen therapy improves survival. ► In patients with stable COPD and resting or exercise-induced moderate desaturation, long-term oxygen treatment should not be prescribed routinely. However, individual patient factors must be considered when evaluating the patient’s need for supplemental oxygen.
  • 46. Evidence Supporting Prevention & Maintenance Therapy © 2017 Global Initiative for Chronic Obstructive Lung Disease OVERALL KEY POINTS (3 of 3): ► In patients with severe chronic hypercapnia and a history of hospitalization for acute respiratory failure, long-term non-invasive ventilation may decrease mortality and prevent re-hospitalization. ► In select patients with advanced emphysema refractory to optimized medical care, surgical or bronchoscopic interventional treatments may be beneficial. ► Palliative approaches are effective in controlling symptoms in advanced COPD.
  • 47. Smoking Cessation © 2017 Global Initiative for Chronic Obstructive Lung Disease ► Smoking cessation has the greatest capacity to influence the natural history of COPD. ► If effective resources and time are dedicated to smoking cessation, long-term quit success rates of up to 25% can be achieved.
  • 48. Vaccination © 2017 Global Initiative for Chronic Obstructive Lung Disease ► Influenza vaccination can reduce serious illness (such as lower respiratory tract infections requiring hospitalization)24 and death in COPD patients. ► Pneumococcal vaccinations, PCV13 and PPSV23, are recommended for all patients ≥ 65 years of age
  • 49. Pharmacologic Therapy © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 50. Pharmacologic Therapy © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 51. Bronchodilators in Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 52. Anti-inflammatory Therapy in Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 53. The Inhaled Route © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 54. Other Pharmacologic Treatments © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 55. Rehabilitation, Education & Self- Management © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 56. Palliative, End of Life & Hospice Care © 2017 Global Initiative for Chronic Obstructive Lung Disease ► In many patients, the disease trajectory in COPD is marked by a gradual decline in health status and increasing symptoms, punctuated by acute exacerbations that are associated with an increased risk of dying. ► Although mortality rates following hospitalization for an acute exacerbation of COPD are declining, reported rates still vary from 23% to 80%.
  • 57. Oxygen Therapy & Ventilatory Support in Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease ► During exacerbations of COPD. Noninvasive ventilation (NIV) in the form of noninvasive positive pressure ventilation (NPPV) is the standard of care for decreasing morbidity and mortality in patients hospitalized with an exacerbation of COPD and acute respiratory failure
  • 58. Oxygen Therapy & Ventilatory Support in Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease ► During exacerbations of COPD. Noninvasive ventilation (NIV) in the form of noninvasive positive pressure ventilation (NPPV) is the standard of care for decreasing morbidity and mortality in patients hospitalized with an exacerbation of COPD and acute respiratory failure
  • 59. Interventional Therapy in Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease ► Lung volume reduction surgery (LVRS). LVRS is a surgical procedure in which parts of the lungs are resected to reduce hyperinflation,261 making respiratory muscles more effective pressure generators by improving their mechanical efficiency.
  • 60. Interventional Therapy in Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease ► Lung volume reduction surgery (LVRS) is a surgical procedure in which parts of the lungs are resected to reduce hyperinflation,261 making respiratory muscles more effective pressure generators by improving their mechanical efficiency. ► Due to the morbidity and mortality associated with LVRS, less invasive bronchoscopic approaches to lung reduction have been examined.
  • 61. GOLD 2017 Report: Chapters © 2017 Global Initiative for Chronic Obstructive Lung Disease 1. Definition and Overview 2. Diagnosis and Initial Assessment 3. Evidence Supporting Prevention & Maintenance Therapy 4. Management of Stable COPD 5. Management of Exacerbations 6. COPD and Comorbidities
  • 62. Management of Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease OVERALL KEY POINTS: ► The management strategy for stable COPD should be predominantly based on the individualized assessment of symptoms and future risk of exacerbations. ► All individuals who smoke should be strongly encouraged and supported to quit. ► The main treatment goals are reduction of symptoms and future risk of exacerbations. ► Management strategies are not limited to pharmacologic treatments, and should be complemented by appropriate non-pharmacologic interventions.
  • 63. Management of Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease ► Once COPD has been diagnosed, effective management should be based on an individualized assessment to reduce both current symptoms and future risks of exacerbations.
  • 64. Management of Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease Identify and reduce exposure to known risk factors ► Identification and reduction of exposure to risk factors is important in the treatment and prevention of COPD. ► Cigarette smoking is the most commonly encountered and easily identifiable risk factor for COPD, and smoking cessation should be continually encouraged for all individuals who smoke. ► Reduction of total personal exposure to occupational dusts, fumes, and gases, and to indoor and outdoor air pollutants, should also be addressed.
  • 65. Management of Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 66. Treatment of Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease Pharmacologic treatment ► Pharmacologic therapies can reduce symptoms, and the risk and severity of exacerbations, as well as improve health status and exercise tolerance. ► Most of the drugs are inhaled so proper inhaler technique is of high relevance.
  • 67. Treatment of Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease Pharmacologic treatment
  • 68. Treatment of Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease Pharmacologic treatment
  • 69. Treatment of Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease Pharmacologic treatment algorithms ► A proposed model for the initiation, and then subsequent escalation and/or de-escalation of pharmacologic management of COPD according to the individualized assessment of symptoms and exacerbation risk is shown. ► We suggest escalation (and de-escalation) strategies. ► The recommendations made are based on available efficacy as well as safety data. ► It should be noted that there is a lack of direct evidence supporting the therapeutic recommendations for patients in groups C and D. These recommendations will be re-evaluated as additional data become available.
  • 70. Treatment of Stable COPD © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 71. Pharmacologic treatment algorithms © 2017 Global Initiative for Chronic Obstructive Lung Disease Group A ► All Group A patients should be offered bronchodilator treatment based on its effect on breathlessness. This can be either a short- or a long-acting bronchodilator. ► This should be continued if symptomatic benefit is documented.
  • 72. Pharmacologic treatment algorithms © 2017 Global Initiative for Chronic Obstructive Lung Disease Group B ► Initial therapy should consist of a long acting bronchodilator. Long-acting inhaled bronchodilators are superior to short-acting bronchodilators taken as needed i.e., pro re nata (prn) and are therefore recommended. ► There is no evidence to recommend one class of long-acting bronchodilators over another for initial relief of symptoms in this group of patients. In the individual patient, the choice should depend on the patient’s perception of symptom relief. ► For patients with persistent breathlessness on monotherapy the use of two bronchodilators is recommended.
  • 73. Pharmacologic treatment algorithms © 2017 Global Initiative for Chronic Obstructive Lung Disease Group B (continued) ► For patients with severe breathlessness initial therapy with two bronchodilators may be considered. ► If the addition of a second bronchodilator does not improve symptoms, we suggest the treatment could be stepped down again to a single bronchodilator. ► Group B patients are likely to have comorbidities that may add to their symptomatology and impact their prognosis, and these possibilities should be investigated.
  • 74. Pharmacologic treatment algorithms © 2017 Global Initiative for Chronic Obstructive Lung Disease Group C ► Initial therapy should consist of a single long acting bronchodilator. In two head-to head comparisons the tested LAMA was superior to the LABA regarding exacerbation prevention, therefore we recommend starting therapy with a LAMA in this group. ► Patients with persistent exacerbations may benefit from adding a second long acting bronchodilator (LABA/LAMA) or using a combination of a long acting beta2-agonist and an inhaled corticosteroid (LABA/ICS). As ICS increases the risk for developing pneumonia in some patients, our primary choice is LABA/LAMA.
  • 75. Pharmacologic treatment algorithms © 2017 Global Initiative for Chronic Obstructive Lung Disease Group D ► We recommend starting therapy with a LABA/LAMA combination because:  In studies with patient reported outcomes as the primary endpoint LABA/LAMA combinations showed superior results compared to the single substances. If a single bronchodilator is chosen as initial treatment, a LAMA is preferred for exacerbation prevention based on comparison to LABAs (for details see GOLD 2017 Chapter 3).  A LABA/LAMA combination was superior to a LABA/ICS combination in preventing exacerbations and other patient reported outcomes in Group D patients (for details see GOLD 2017 Chapter 3).  Group D patients are at higher risk of developing pneumonia when receiving treatment with ICS.
  • 76. Pharmacologic treatment algorithms © 2017 Global Initiative for Chronic Obstructive Lung Disease Group D (continued) ► In some patients initial therapy with LABA/ICS may be the first choice. These patients may have a history and/or findings suggestive of asthma-COPD overlap. High blood eosinophil counts may also be considered as a parameter to support the use of ICS, although this is still under debate (for details see Chapter 2 and Appendix). ► In patients who develop further exacerbations on LABA/LAMA therapy we suggest two alternative pathways:  Escalation to LABA/LAMA/ICS. Studies are underway comparing the effects of LABA/LAMA vs. LABA/LAMA/ICS for exacerbation prevention.  Switch to LABA/ICS. However, there is no evidence that switching from LABA/LAMA to LABA/ICS results in better exacerbation prevention. If LABA/ICS therapy does not positively impact exacerbations/symptoms, a LAMA can be added.
  • 77. Pharmacologic treatment algorithms © 2017 Global Initiative for Chronic Obstructive Lung Disease Group D (continued) If patients treated with LABA/LAMA/ICS still have exacerbations the following options may be considered: ► Add roflumilast. This may be considered in patients with an FEV1 < 50% predicted and chronic bronchitis,13 particularly if they have experienced at least one hospitalization for an exacerbation in the previous year. ► Add a macrolide. The best available evidence exists for the use of azithromycin. Consideration to the development of resistant organisms should be factored into decision making. ► Stopping ICS. A reported lack of efficacy, an elevated risk of adverse effects (including pneumonia) and evidence showing no significant harm from withdrawal supports this recommendation (see Chapter 3 for further details).
  • 78. Non-Pharmacologic Treatment © 2017 Global Initiative for Chronic Obstructive Lung Disease ►Education and self-management ►Physical activity ►Pulmonary rehabilitation programs ►Exercise training ►Self-management education ►End of life and palliative care ►Nutritional support ►Vaccination ►Oxygen therapy
  • 79. Non-Pharmacologic Treatment © 2017 Global Initiative for Chronic Obstructive Lung Disease Education and self-management ► Self-management education and coaching by healthcare professionals should be a major component of the “Chronic Care Model” within the context of the healthcare delivery system. ► The aim of self-management education is to motivate, engage and coach the patients to positively adapt their health behavior(s) and develop skills to better manage their disease.
  • 80. Non-Pharmacologic Treatment © 2017 Global Initiative for Chronic Obstructive Lung Disease Oxygen therapy Long-term oxygen therapy is indicated for stable patients who have: ►PaO2 at or below 7.3 kPa (55 mmHg) or SaO2 at or below 88%, with or without hypercapnia confirmed twice over a three week period; or ►PaO2 between 7.3 kPa (55 mmHg) and 8.0 kPa (60 mmHg), or SaO2 of 88%, if there is evidence of pulmonary hypertension, peripheral edema suggesting congestive cardiac failure, or polycythemia (hematocrit > 55%).
  • 81. Non-Pharmacologic Treatment © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 82. Non-Pharmacologic Treatment © 2017 Global Initiative for Chronic Obstructive Lung Disease Interventional bronchoscopy and surgery ►In selected patients with heterogeneous or homogenous emphysema and significant hyperinflation refractory to optimized medical care, surgical or bronchoscopic modes of lung volume reduction (e.g., endobronchial one-way valves or lung coils) may be considered. ►In selected patients with a large bulla, surgical bullectomy may be considered. ►In selected patients with very severe COPD and without relevant contraindications, lung transplantation may be considered.
  • 83. © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 84. Non-Pharmacologic Treatment - Summary © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 85. Non-Pharmacologic Treatment – Summary (continued) © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 86. Monitoring and Follow-up © 2017 Global Initiative for Chronic Obstructive Lung Disease Monitoring disease progression and development of complications and/or comorbidities ► Measurements. Decline in FEV1 can be tracked by spirometry performed at least once a year. ► Symptoms. At each visit, information on symptoms since the last visit should be collected, including cough and sputum, breathlessness, fatigue, activity limitation, and sleep disturbances. ► Exacerbations. The frequency, severity, type and likely causes of all exacerbations should be monitored. ► Imaging. If there is a clear worsening of symptoms, imaging may be indicated. ► Smoking status. At each visit, the current smoking status and smoke exposure should be determined followed by appropriate action.
  • 87. Monitoring and Follow-up © 2017 Global Initiative for Chronic Obstructive Lung Disease Pharmacotherapy and other medical treatment In order to adjust therapy appropriately as the disease progresses, each follow-up visit should include a discussion of the current therapeutic regimen. Monitoring should focus on: ► Dosages of prescribed medications. ► Adherence to the regimen. ► Inhaler technique. ► Effectiveness of the current regime. ► Side effects. Treatment modifications should be recommended.
  • 88. GOLD 2017 Report: Chapters © 2017 Global Initiative for Chronic Obstructive Lung Disease 1. Definition and Overview 2. Diagnosis and Initial Assessment 3. Evidence Supporting Prevention & Maintenance Therapy 4. Management of Stable COPD 5. Management of Exacerbations 6. COPD and Comorbidities
  • 89. Management of Exacerbations © 2017 Global Initiative for Chronic Obstructive Lung Disease OVERALL KEY POINTS (1 of 3): ► An exacerbation of COPD is defined as an acute worsening of respiratory symptoms that results in additional therapy. ► Exacerbations of COPD can be precipitated by several factors. The most common causes are respiratory tract infections. ► The goal for treatment of COPD exacerbations is to minimize the negative impact of the current exacerbation and to prevent subsequent events. ► Short-acting inhaled beta2-agonists, with or without short-acting anticholinergics, are recommended as the initial bronchodilators to treat an acute exacerbation.
  • 90. Management of Exacerbations © 2017 Global Initiative for Chronic Obstructive Lung Disease OVERALL KEY POINTS (2 of 3): ► Maintenance therapy with long-acting bronchodilators should be initiated as soon as possible before hospital discharge. ► Systemic corticosteroids can improve lung function (FEV1), oxygenation and shorten recovery time and hospitalization duration. Duration of therapy should not be more than 5-7 days. ► Antibiotics, when indicated, can shorten recovery time, reduce the risk of early relapse, treatment failure, and hospitalization duration. Duration of therapy should be 5-7 days. ► Methylxanthines are not recommended due to increased side effect profiles.
  • 91. Management of Exacerbations © 2017 Global Initiative for Chronic Obstructive Lung Disease OVERALL KEY POINTS (3 of 3): ► Non-invasive mechanical ventilation should be the first mode of ventilation used in COPD patients with acute respiratory failure who have no absolute contraindication because it improves gas exchange, reduces work of breathing and the need for intubation, decreases hospitalization duration and improves survival. ► Following an exacerbation, appropriate measures for exacerbation prevention should be initiated (see GOLD 2017 Chapter 3 and Chapter 4).
  • 92. Management of Exacerbations © 2017 Global Initiative for Chronic Obstructive Lung Disease COPD exacerbations are defined as an acute worsening of respiratory symptoms that result in additional therapy. ► They are classified as:  Mild (treated with short acting bronchodilators only, SABDs)  Moderate (treated with SABDs plus antibiotics and/or oral corticosteroids) or  Severe (patient requires hospitalization or visits the emergency room). Severe exacerbations may also be associated with acute respiratory failure.
  • 93. Management of Exacerbations © 2017 Global Initiative for Chronic Obstructive Lung Disease Classification of hospitalized patients No respiratory failure: Respiratory rate: 20-30 breaths per minute; no use of accessory respiratory muscles; no changes in mental status; hypoxemia improved with supplemental oxygen given via Venturi mask 28-35% inspired oxygen (FiO2); no increase in PaCO2.
  • 94. Management of Exacerbations © 2017 Global Initiative for Chronic Obstructive Lung Disease Classification of hospitalized patients Acute respiratory failure — non-life-threatening: Respiratory rate: > 30 breaths per minute; using accessory respiratory muscles; no change in mental status; hypoxemia improved with supplemental oxygen via Venturi mask 25- 30% FiO2; hypercarbia i.e., PaCO2 increased compared with baseline or elevated 50-60 mmHg.
  • 95. Management of Exacerbations © 2017 Global Initiative for Chronic Obstructive Lung Disease Classification of hospitalized patients Acute respiratory failure — life-threatening: Respiratory rate: > 30 breaths per minute; using accessory respiratory muscles; acute changes in mental status; hypoxemia not improved with supplemental oxygen via Venturi mask or requiring FiO2 > 40%; hypercarbia i.e., PaCO2 increased compared with baseline or elevated > 60 mmHg or the presence of acidosis (pH < 7.25).
  • 96. Management of Exacerbations © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 97. Management of Exacerbations © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 98. Management of Exacerbations - Summary © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 99. Management of Exacerbations © 2017 Global Initiative for Chronic Obstructive Lung Disease Pharmacologic treatment The three classes of medications most commonly used for COPD exacerbations are: ►Bronchodilators  Although there is no high-quality evidence from RCTs, it is recommended that short-acting inhaled beta2-agonists, with or without short-acting anticholinergics, are the initial bronchodilators for acute treatment of a COPD exacerbation. ►Corticosteroids  Data from studies indicate that systemic glucocorticoids in COPD exacerbations shorten recovery time and improve lung function (FEV1). They also improve oxygenation, the risk of early relapse, treatment failure, and the length of hospitalization. ►Antibiotics
  • 100. Management of Exacerbations © 2017 Global Initiative for Chronic Obstructive Lung Disease Respiratory support
  • 101. Management of Exacerbations © 2017 Global Initiative for Chronic Obstructive Lung Disease Respiratory support
  • 102. Management of Exacerbations © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 103. Management of Exacerbations © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 104. GOLD 2017 Report: Chapters © 2017 Global Initiative for Chronic Obstructive Lung Disease 1. Definition and Overview 2. Diagnosis and Initial Assessment 3. Evidence Supporting Prevention & Maintenance Therapy 4. Management of Stable COPD 5. Management of Exacerbations 6. COPD and Comorbidities
  • 105. COPD and Comorbidities © 2017 Global Initiative for Chronic Obstructive Lung Disease OVERALL KEY POINTS (1 of 2): ► COPD often coexists with other diseases (comorbidities) that may have a significant impact on disease course. ► In general, the presence of comorbidities should not alter COPD treatment and comorbidities should be treated per usual standards regardless of the presence of COPD. ► Lung cancer is frequently seen in patients with COPD and is a main cause of death. ► Cardiovascular diseases are common and important comorbidities in COPD.
  • 106. COPD and Comorbidities © 2017 Global Initiative for Chronic Obstructive Lung Disease OVERALL KEY POINTS (2 of 2): ► Osteoporosis and depression/anxiety are frequent, important comorbidities in COPD, are often under-diagnosed, and are associated with poor health status and prognosis. ► Gastroesophageal reflux (GERD) is associated with an increased risk of exacerbations and poorer health status. ► When COPD is part of a multimorbidity care plan, attention should be directed to ensure simplicity of treatment and to minimize polypharmacy.
  • 107. COPD and Comorbidities © 2017 Global Initiative for Chronic Obstructive Lung Disease Some common comorbidities occurring in patients with COPD with stable disease include: ► Cardiovascular disease (CVD) ► Heart failure ► Ischaemic heart disease (IHD) ► Arrhythmias ► Peripheral vascular disease ► Hypertension ► Osteoporosis ► Anxiety and depression ► COPD and lung cancer ► Metabolic syndrome and diabetes ► Gastroesophageal reflux (GERD) ► Bronchiectasis ► Obstructive sleep apnea
  • 108. COPD and Comorbidities © 2017 Global Initiative for Chronic Obstructive Lung Disease COPD as part of multimorbidity ► An increasing number of people in any aging population will suffer from multi- morbidity, defined as the presence of two or more chronic conditions, and COPD is present in the majority of multi-morbid patients. ► Multi-morbid patients have symptoms from multiple diseases and thus symptoms and signs are complex and most often attributable to several causes in the chronic state as well as during acute events. ► There is no evidence that COPD should be treated differently when part of multi-morbidity; however, it should be kept in mind that most evidence comes from trials in patients with COPD as the only significant disease. ► Treatments should be kept simple in the light of the unbearable polypharmacy that these patients are often exposed to.
  • 109. GOLD Website www.goldcopd.org © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 110. World COPD Day November, 2016 Keep updated here: http://goldcopd.org/world-copd-day/ © 2017 Global Initiative for Chronic Obstructive Lung Disease
  • 111. Journals Publishing the GOLD 2017 Executive Summary  American Journal of Respiratory and Critical Care Medicine  European Respiratory Journal  Respirology  Archivos de Bronconeumología