lobal Initiative for Chronic bstructive ung isease

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lobal Initiative for Chronicbstructiveungisease
G OLD
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Global Initiative for Chronic Obstructive Lung
Disease

• In collaboration with
• National Heart, Lung, and Blood Institute, NIH
• and
• World Health Organization

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GOLD Executive Committee

• R. Pauwels, Belgium Chair
• S. Buist, US C. Jenkins,
  Australia
• P. Calverley, UK N. Khaltaev,
  Switzerland
• B. Celli, US C. Lenfant, US
• Y. Fukuchi, Japan J. Luna, Guatemala
• S. Hurd, US W. MacNee, UK
• L. Grouse, US N. Zhong, China

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Facts About COPD

• COPD is the 4th leading cause of death in the
  United States (behind heart disease, cancer, and
  cerebrovascular disease).
• In 2000, the WHO estimated 2.74 million deaths
  worldwide from COPD.
• In 1990, COPD was ranked 12th as a burden of
  disease by 2020 it is projected to rank 5th.

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Leading Causes of DeathsU.S. 1998
Cause of Death Number
Heart Disease
724,269
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Percent Change in Age-Adjusted Death Rates, U.S.,
1965-1998
Proportion of 1965 Rate
3.0
Coronary Heart Disease
Stroke
Other CVD
COPD
All Other Causes
2.5
2.0
1.5
1.0
0.5
59
64
35
163
7
0
1965 - 1998
1965 - 1998
1965 - 1998
1965 - 1998
1965 - 1998
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Age-Adjusted Death Rates for COPD, U.S., 1960-1995
Deaths per 100,000
60
50
40
30
20
10
0
1960
1965
1970
2000
1975
1980
1985
1990
1995
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Facts About COPD

• Between 1985 and 1995, the number of physician
  visits for COPD in the United States increased
  from 9.3 million to16 million.
• The number of hospitalizations for COPD in 1995
  was estimated to be 500,000. Medical
  expenditures amounted to an estimated 14.7
  billion.

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COPD 1990 Prevalence
Male/1000
Female/1000

• Established Market Economies 6.98 3.79
• Formerly Socialist Economies 7.35 3.45
• India 4.38 3.44
• China 26.20 23.70
• Other Asia and Islands 2.89 1.79
• Sub-Saharan Africa 4.41 2.49
• Latin America and Caribbean 3.36 2.72
• Middle Eastern Crescent 2.69 2.83
• World 9.34 7.33
• From Murray Lopez, 1996

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Facts About COPD

• Between 1985 and 1995, the number of physician
  visits for COPD in the United States increased
  from 9.3 million to16 million.
• The number of hospitalizations for COPD in 1995
  was estimated to be 500,000. Medical
  expenditures amounted to an estimated 14.7
  billion.

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Physician Office Visits for Chronicand
Unspecified Bronchitis, U.S.
Number (Millions)
15
10
5
0
1980
1985
1990
1995
1998
Year
Source National Ambulatory Medical Care Survey,
NCHS
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Facts About COPD

• Cigarette smoking is the primary cause of COPD.
• In the US 47.2 million people (28 of men and 23
  of women) smoke.
• The WHO estimates 1.1 billion smokers worldwide,
  increasing to 1.6 billion by 2025. In low- and
  middle-income countries, rates are increasing at
  an alarming rate.

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Facts About COPD

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

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lobal Initiative for Chronicbstructiveungisease
G OLD
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GOLD Objectives

• Increase awareness of COPD among health
  professionals, health authorities, and the
  general public
• Improve diagnosis, management, and prevention
• Stimulate research

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GOLD Documents

• Workshop Report Global Strategy for the
  Diagnosis, Management, and Prevention of COPD
• Executive Summary
• Pocket Guide for health care providers
• Guide for patients and their families(available
  late 2001)

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GOLD Workshop Report

• Evidence-based
• Implementation oriented
• Diagnosis
• Management
• Prevention
• Outcomes can be evaluated

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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
•  
•  
•  

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GOLD Workshop Report Contents

• Introduction
• Definition and classification
• Burden of COPD
• Risk factors
• Pathogenesis, pathology, and pathophysiology
• Management
• Future research

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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.

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Burden of COPD Key Points

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

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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.

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Burden of COPD Key Points

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

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Direct and Indirect Costs of COPD, 1993 (US
Billions)

• Direct Medical Cost 14.7
• Total Indirect Cost 9.2
• Mortality related IDC 4.5
• Morbidity related IDC 4.7
• Total Cost 23.9

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








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Pathogenesis of COPD
NOXIOUS AGENT(tobacco smoke, pollutants,
occupational agent)
COPD



Genetic factors Respiratory infection Other





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Causes of Airflow Limitation

• 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

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Causes of Airflow Limitation

• Reversible
• Accumulation of inflammatory cells, mucus, and
  plasma exudate in bronchi
• Smooth muscle contraction in peripheral and
  central airways
• Dynamic hyperinflation during exercise

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GOLD Workshop ReportFour Components of COPD
Management

• Assess and monitor disease
• Reduce risk factors
• Manage stable COPD
• Education
• Pharmacologic
• Non-pharmacologic
• Manage exacerbations

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Objectives of COPD Management

• 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

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GOLD Workshop ReportFour Components of COPD
Management

• Assess and monitor disease
• Reduce risk factors
• Manage stable COPD
• Education
• Pharmacologic
• Non-pharmacologic
• Manage exacerbations

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Assess and Monitor Disease Key Points

• Diagnosis of COPD is based on a history of
  exposure to risk factors and the presence of
  airflow limitation that is not fully reversible,
  with or without the presence of symptoms.

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Assess and Monitor Disease Key Points

• Patients who have chronic cough and sputum
  production with a history of exposure to risk
  factors should be tested for airflow limitation,
  even if they do not have dyspnea.

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Assess and Monitor Disease Key Points

• For the diagnosis and assessment of COPD,
  spirometry is the gold standard.
• Health care workers involved in the diagnosis and
  management of COPD patients should have access to
  spirometry.

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Assess and Monitor Disease Key Points

• Measurement of arterial blood gas tension should
  be considered in all patients with FEV1 lt 40
  predicted or clinical signs suggestive of
  respiratory failure or right heart failure.

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Diagnosis of COPD
EXPOSURE TO RISK FACTORS
SYMPTOMS
cough
tobacco
sputum
occupation
dyspnea
indoor/outdoor pollution
è
SPIROMETRY
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Spirometry Normal and COPD
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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

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Classification by Severity
Stage Characteristics 0 At risk Normal
spirometry Chronic symptoms (cough, sputum)  I
Mild FEV1/FVC lt 70 FEV1 ³ 80 predicted With
or without symptoms (cough, sputum) II
Moderate FEV1/FVC lt 70 30 FEV1 lt 80
predicted (IIA 50 FEV1 lt 80
predicted IIB 30 FEV1 lt 50 predicted)
With or without chronic symptoms (cough,
sputum, dyspnea) III Severe FEV1/FVC lt 70
FEV1 lt 30 predicted or FEV1 lt 50predicted
plus respiratory failure or clinical signs of
right heart failure
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GOLD Workshop ReportFour Components of COPD
Management

• Assess and monitor disease
• Reduce risk factors
• Manage stable COPD
• Education
• Pharmacologic
• Non-pharmacologic
• Manage exacerbations

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Reduce Risk FactorsKey Points

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

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Reduce Risk FactorsKey Points

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

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Reduce Risk FactorsKey Points

• Several effective pharmacotherapies for tobacco
  dependence are available (Evidence A), and at
  least one of these medications should be added to
  counseling if necessary, and in the absence of
  contraindications.

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Reduce Risk FactorsKey Points

• Progression of many occupationally-induced
  respiratory disorders can be reduced or
  controlled through a variety of strategies aimed
  at reducing the burden of inhaled particles and
  gases (Evidence B).

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Brief Strategies To Help The Patient Willing To
Quit Smoking

• ASK Systematically identify all tobacco
  users at every visit.
• ADVISE Strongly urge all tobacco users to
  quit.
• ASSESS Determine willingness to make a quit
  attempt.
• ASSIST Aid the patient in quitting.
• ARRANGE Schedule follow-up contact.

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GOLD Workshop ReportFour Components of COPD
Management

• Assess and monitor disease
• Reduce risk factors
• Manage stable COPD
• Education
• Pharmacologic
• Non-pharmacologic
• Manage exacerbations

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Manage Stable COPD Key Points

• The overall approach to managing stable COPD
  should be characterized by a stepwise increase in
  the treatment, depending on the severity of the
  disease.
• For patients with COPD, health education can play
  a role in improving skills, ability to cope with
  illness, and health status. It is effective in
  accomplishing certain goals, including smoking
  cessation (Evidence A).

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Manage Stable COPD Key Points

• 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). Therefore, pharmacotherapy
  for COPD is used to decrease symptoms and/or
  complications.

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Manage Stable COPD Key Points

• Bronchodilator medications are central to the
  symptomatic management of COPD (Evidence A).
  They are given on an as-needed basis or on a
  regular basis to prevent or reduce symptoms.
• The principal bronchodilator treatments are
  Beta2-agonists, anticholinergics, theophylline,
  and a combination of these drugs (Evidence A).

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Bronchodilators in Stable COPD

• Bronchodilator medications are central to symptom
  management in COPD.
• Inhaled therapy is preferred.
• The choice between Beta2-agonist,
  anticholinergic, theophylline or combination
  therapy depends on availability and individual
  response in terms of symptoms relief and side
  effects.

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Bronchodilators in Stable COPD

• Bronchodilators are prescribed on an as-needed or
  on a regular basis to prevent or reduce symptoms.
• Long-acting inhaled bronchodilators are more
  convenient.
• Combining bronchodilators may improve efficacy
  and decrease the risk of side effects compared to
  increasing the dose of a single bronchodilator.

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Manage Stable COPD Key Points

• Regular treatment with inhaled glucocortico-steroi
  ds should only be prescribed for symptomatic COPD
  patients with a documented spirometric response
  to glucocorticosteroids or in those with an FEV1
  lt 50 predicted and repeated exacerbations
  requiring treatment with antibiotics and/or oral
  glucocorticosteroids (Evidence B).

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Manage Stable COPD Key Points

• Chronic treatment with systemic
  glucocortico-steroids should be avoided because
  of an unfavorable benefit-to-risk ratio (Evidence
  A).
• All COPD-patients benefit from exercise training
  programs, improving with respect to both exercise
  tolerance and symptoms of dyspnea and fatigue
  (Evidence A).

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Manage Stable COPD Key Points

• The long-term administration of oxygen (gt 15
  hours per day) to patients with chronic
  respiratory failure has been shown to increase
  survival (Evidence A).

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Management of COPD by Severity of Disease

• Stage 0 At risk
• Stage 1 Mild COPD
• Stage 2 Moderate COPD
• Stage 3 Severe COPD

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Management of COPD All stages

• Avoidance of noxious agents
• - smoking cessation
• - reduction of indoor pollution- reduction of
  occupational exposure
• Influenza vaccination

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Management of COPD Stage 0 At Risk
Characteristics Recommended
Treatment

• Chronic symptoms- cough- sputum
• No spirometric abnormalities

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Management of COPD Stage I Mild COPD
Characteristics Recommended
Treatment

• FEV1/FVC lt 70
• FEV1 gt 80 predicted
• With or without symptoms

• bronchodilator as needed

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Management of COPD Stage IIA Moderate COPD
Characteristics Recommended
Treatment

• Regular treatment with one or more
  bronchodilators
• Rehabilitation
• Inhaled glucocortico-steroids if significant
  symptoms and lung function response

• FEV1/FVC lt 70
• 50 lt FEV1lt 80 predicted
• With or without symptoms

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Management of COPD Stage IIB Moderate COPD
Characteristics Recommended
Treatment

• Regular treatment with one or more
  bronchodilators
• Rehabilitation
• Inhaled glucocortico-steroids if significant
  symptoms and lung function response or if
  repeated exacerbations

• FEV1/FVC lt 70
• 30 lt FEV1 lt 50 predicted
• With or without symptoms

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Management of COPD Stage III Severe COPD
Characteristics Recommended
Treatment

• Regular treatment with one or more
  bronchodilators
• Inhaled glucocorticosteroids if significant
  symptoms and lung function response or if
  repeated exacerbations
• Treatment of complications
• Rehabilitation
• Long-term oxygen therapy if respiratory failure
• Consider surgical options

• FEV1/FVC lt 70
• FEV1 lt 30 predicted or presence of respiratory
  failure or right heart failure

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GOLD Workshop ReportFour Components of COPD
Management

• Assess and monitor disease
• Reduce risk factors
• Manage stable COPD
• Education
• Pharmacologic
• Non-pharmacologic
• Manage exacerbations

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Manage ExacerbationsKey Points

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

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Manage ExacerbationsKey Points

• Inhaled bronchodilators (Beta2-agonists and/or
  anticholinergics), theophylline, and systemic,
  preferably oral, glucocortico-steroids are
  effective for the treatment of COPD exacerbations
  (Evidence A).

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Manage ExacerbationsKey Points

• 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)

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Manage ExacerbationsKey Points

• Noninvasive intermittent positive pressure
  ventilation (NIIPPV) in acute 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).

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Management of COPD

• 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.