TO COPD DIAGNOSIS, MANAGEMENT,

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A Guide for Health Care Professionals

U P D AT ED 2 0 10

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POCKET GUIDE

AND PREVENTION

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Global Initiative for Chronic Obstructive Lung Disease

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GOLD Nat io n al L ead er s Representatives from many countries serve as a network for the dissemination and implementation of programs for diagnosis, management, and prevention of COPD. The GOLD Executive Committee is grateful to the many GOLD National Leaders who participated in discussions of concepts that appear in GOLD reports, and for their comments during the review of the 2006 Global Strategy for the Diagnosis, Management, and Prevention of COPD.

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Ob s er v er : Jadwiga Wedzicha, MD, UK (Representing ERS)

2010 Global Initiative for Chronic Obstructive Lung Disease, Inc.

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Roberto Rodriguez-Roisin, MD, Spain, Chair Antonio Anzueto, MD, US (representing ATS) Jean Bourbeau, MD, Canada Teresita S. DeGuia, MD, Philippines David Hui, MD, Hong Kong, ROC Christine Jenkins, MD, Australia Fernando Martinez, MD, US Michiaki Mishima, MD, Japan (representing APSR) Mara Montes de Oca, MD, PhD (representing ALAT) Robert Stockley, MD, UK Chris van Weel, MD, Netherlands (representing WONCA) Jorgen Vestbo, MD, Denmark

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GOLD Ex ecu t iv e Co m m it t ee

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Pocket Guide to COPD Diagnosis, Management, and Prevention

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Global Initiative for Chronic Obstructive L ung Disease

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TA B L E O F CON T EN T S
3 5 6 7 8 P R EFA CE K EY P O I N T S W H AT I S CH R O N I C OB S T R U CT I V E P U L M ON A R Y D I S EA S E ( CO P D ) ? R I S K FA CT OR S : WH AT CA U S ES CO P D ? D I A GN O S I N G COP D Figure 1: Key Indicators for Considering a COPD Diagnosis Figure 2: Normal Spirogram and Spirogram Typical of Patients with Mild to Moderate COPD Figure 3: Differential Diagnosis of COPD CO M P ON EN T S OF CA R E: A COP D M A N A G EM EN T P R O GR A M Co m p o n e n t 1 : A s s e s s a n d M o n i t o r D i s e a s e Co m p o n e n t 2 : R e d u ce R i s k F a ct o r s Figure 4: Strategy to Help a Patient Quit Smoking Co m p o n e n t 3 : M a n a g e S t a b l e COP D Patient Education Pharmacologic Treatment Figure 5: Commonly Used Formulations of Drugs for COPD Non-Pharmacologic Treatment Figure 6: Therapy at Each Stage of COPD Co m p o n e n t 4 : M a n a g e Ex a ce r b a t i o n s How to Assess the Severity of an Exacerbation Home Management Hospital Management Figure 7: Indications for Hospital Admission for Exacerbations A P P EN D I X I : S P I R OM ET R Y F OR D I A G N OS I S OF COP D

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PREFACE
Chronic Obstructive Pulmonary Disease (COPD) is a major cause of chronic morbidity and mortality throughout the world. The Globa l In it iat iv e f or Ch ro n ic Ob s t r u ct iv e L u n g Dis eas e was created to increase awareness of COPD among health professionals, public health authorities, and the general public, and to improve prevention and management through a concerted worldwide effort. The Initiative prepares scientific reports on COPD, encourages dissemination and adoption of the reports, and promotes international collaboration on COPD research.

The Glob al In it iat iv e f or Ch r on ic Ob s t r u ct iv e L u n g Dis eas e program includes the following publications:

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Pocket Guide to COPD Diagnosis, Management, and Prevention. Summary of patient care information for primary health care professionals. (Updated 2010) What You and Your Family Can Do About COPD. Information booklet for patients and their families.

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Executive Summary, Global Strategy for the Diagnosis, Management, and Prevention of COPD. (Updated 2010)

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Global Strategy for the Diagnosis, Management, and Prevention of COPD. Scientific information and recommendations for COPD programs. (Updated 2010)

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While COPD has been recognized for many years, public health officials are concerned about continuing increases in its prevalence and mortality, which are due in large part to the increasing use of tobacco products worldwide and the changing age structure of populations in developing countries. The Global In it iat iv e f or Ch r on ic Obs t r u ct iv e L u n g Dis eas e offers a framework for management of COPD that can be adapted to local health care systems and resources. Educational tools, such as laminated cards or computer-based learning programs, can be prepared that are tailored to these systems and resources.

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These publications are available on the Internet at www.goldcopd.org. This site provides links to other websites with information about COPD. This Pocket Guide has been developed from the Global Strategy for the Diagnosis, Management, and Prevention of COPD (2010). Technical discussions of COPD and COPD management, evidence levels, and specific citations from the scientific literature are included in that source document.

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A ck n o w l e d g e m e n t s : Grateful acknowledgement is given for the educational grants from Almirall, AstraZeneca, Boehringer Ingelheim, Chiesi, Dey, Forest Laboratories, GlaxoSmithKline, Novartis, Nycomed, Pfizer, Philips Respironics, and Schering-Plough. The generous contributions of these companies assured that the participants could meet together and publications could be printed for wide distribution. The participants, however, are solely responsible for the statements and conclusions in the publications.

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KEY POINTS
Ch r o n i c O b s t r u ct i v e P u l m o n a r y D i s e a s e ( COP D ) is a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases. Worldwide, the most commonly encountered r i s k f a ct o r for COPD is ci g a r e t t e s m o k i n g . A t e v e r y p o s s i b l e o p p o r t u n i t y i n d i v i d u a l s w h o s m o k e s h o u l d b e e n co u r a g e d t o q u i t . In many countries, air pollution resulting from the burning of wood and other biomass fuels has also been identified as a COPD risk factor. A d i a g n o s i s of COPD should be considered in any patient who has dyspnea, chronic cough or sputum production, and/or a history of exposure to risk factors for the disease. The diagnosis should be confirmed by spirometry. A CO P D m a n a g e m e n t p r o g r a m includes four components: assess and monitor disease, reduce risk factors, manage stable COPD, and manage exacerbations. P h a r m a co l o g i c t r e a t m e n t can prevent and control symptoms, reduce the frequency and severity of exacerbations, improve health status, and improve exercise tolerance. P a t i e n t e d u ca t i o n can help improve skills, ability to cope with illness, and health status. It is an effective way to accomplish smoking cessation, initiate discussions and understanding of advance directives and end-of-life issues, and improve responses to acute exacerbations.

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COPD is often associated with e x a ce r b a t i o n s of symptoms.

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Episodes of acute worsening of these symptoms often occur.

Ch r o n i c co u g h a n d s p u t u m p r o d u ct i o n o f t e n p r e ce d e t h e d e v e l o p m e n t o f a i r f l o w l i m i t a t io n b y m a n y y e a r s , a l t h o u g h n o t a l l i n d i v i d u a l s w i t h co u g h a n d s p u t u m p r o d u ct i o n g o o n t o d e v e l o p COP D .

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*Chronic bronchitis, defined as the presence of cough and sputum production for at least 3 months in each of 2 consecutive years, is not necessarily associated with airflow limitation. Emphysema, defined as destruction of the alveoli, is a pathological term that is sometimes (incorrectly) used clinically and describes only one of several structural abnormalities present in patients with COPD.

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Cough Sputum production Dyspnea on exertion

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S y m p t o m s o f CO P D i n cl u d e :

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This definition does not use the terms chronic bronchitis and emphysema* and excludes asthma (reversible airflow limitation).

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Ch r o n i c Ob s t r u ct i v e P u l m o n a r y D i s e a s e ( CO P D ) is a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases.

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WHAT IS CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)?

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In addition, any factor that affects lung growth during gestation and childhood (low birth weight, respiratory infections, etc.) has the potential for increasing an individuals risk of developing COPD.

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To b a cco s m o k e , including cigarette, pipe, cigar, and other types of tobacco smoking popular in many countries, as well as environmental tobacco smoke (ETS) Occu p a t i o n a l d u s t s a n d ch e m i ca l s (vapors, irritants, and fumes) when the exposures are sufficiently intense or prolonged I n d o o r a i r p o l l u t i o n from biomass fuel used for cooking and heating in poorly vented dwellings, a risk factor that particularly affects women in developing countries Ou t d o o r a i r p o l l u t i o n also contributes to the lungs total burden of inhaled particles, although it appears to have a relatively small effect in causing COPD

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COPD risk is related to the total burden of inhaled particles a person encounters over their lifetime:

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The genetic risk factor that is best documented is a severe hereditary deficiency of alpha-1 antitrypsin. It provides a model for how other genetic risk factors are thought to contribute to COPD.

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Wo r l d w i d e , ci g a r e t t e s m o k i n g i s t h e m o s t co m m o n l y e n co u n t e r e d r i s k f a ct o r f o r CO P D .

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RISK FACTORS: WHAT CAUSES COPD?

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*Where spirometry is unavailable, the diagnosis of COPD should be made using all available tools. Clinical symptoms and signs (abnormal shortness of breath and increased forced expiratory time) can be used to help with the diagnosis. A low peak flow is consistent with COPD but has poor specificity since it can be caused by other lung diseases and by poor performance. In the interest of improving the accuracy of a diagnosis of COPD, every effort should be made to provide access to standardized spirometry.

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T h e d i a g n o s i s s h o u l d b e co n f i r m e d b y s p i r o m e t r y * ( F i g u r e 2 , p a g e 9 a n d A p p e n d i x I, p a g e 2 4 ) .

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D y s p n e a that is: Progressive (worsens over time). Usually worse with exercise. Persistent (present every day). Described by the patient as an increased effort to breathe, heaviness, air hunger, or gasping. Ch r o n ic co u g h : May be intermittent and may be unproductive. Ch r o n ic s p u t u m p r o d u ct i o n : Any pattern of chronic sputum production may indicate COPD. H i s t o r y o f e x p o s u r e t o r i s k f a ct o r s : To b a cco s m o k e ( in cl u d in g p o p u l a r l o ca l p r e p a r a t io n s ) . Occupational dusts and chemicals. Smoke from home cooking and heating fuel.

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Consider COPD, and perform spirometry, if any of these indicators are present in an individual over age 40. These indicators are not diagnostic themselves, but the presence of multiple key indicators increases the probability of a diagnosis of COPD.

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F i g u r e 1 : K e y I n d i ca t o r s f o r Co n s id e r i n g a COP D D i a g n o s i s

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A diagnosis of COPD should be considered in any patient who has dyspnea, chronic cough or sputum production, and/or a history of exposure to risk F factors for the disease, especially cigarette smoking (F i g u r e 1 ).

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DIAGNOSING COPD

When performing spirometry, measure:

F i g u r e 2 : N o r m a l S p i r o g r a m a n d S p i r o g r a m Ty p i ca l o f P a t i e n t s w i t h M i l d t o M o d e r a t e CO P D *

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*Postbronchodilator FEV1 is recommended for the diagnosis and assessment of severity of COPD.
P a t i e n t s w i t h COP D t y p ica l l y s h o w a d e cr e a s e in b o t h F EV 1 a n d F EV 1 /F V C. T h e d e g r e e o f s p i r o m e t r ic a b n o r m a l i t y g e n e r a l l y r e f l e ct s t h e s e v e r i t y o f COP D . H o w e v e r, b o t h s y m p t o m s a n d s p ir o m e t r y s h o u l d b e c o n s i d e r e d w h e n d e v e l o p in g a n i n d i v id u a l i z e d m a n a g e m e n t s t r a t e g y f o r e a ch p a t i e n t .

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Spirometric results are expressed as % P r e d i ct e d using appropriate normal values for the persons sex, age, and height.

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Calculate the FEV1/FVC ratio.

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F F orced V ital Capacity (F V C) and F F orced Expiratory V olume in one second (F EV 1 ).

St a g es o f COP D
St a ge I: Mild COP D - Mild airflow limitation (FEV1/FVC < 70%; FEV1 80% predicted) and sometimes, but not always, chronic cough and sputum production.

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At this stage, quality of life is very appreciably impaired and exacerbations may be life-threatening. At R is k f or COP D

A major objective of GOLD is to increase awareness among health care providers and the general public of the significance of COPD symptoms. The classification of severity of COPD now includes four stages classified by spirometryStage I: Mild COPD; Stage II: Moderate COPD; Stage III: Severe COPD; Stage IV: Very Severe COPD. A fifth categoryStage 0: At Riskthat appeared in the 2001 report is no longer included as a stage of COPD, as there is incomplete evidence that the individuals who meet the definition of At Risk (chronic cough and sputum production, normal spirometry) necessarily progress on to Stage I: Mild COPD. Nevertheless, the importance of the public health message that chronic cough and sputum are not normal is unchanged and their presence should trigger a search for underlying cause(s).

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St a ge IV: Ver y Sev e r e COP D - Severe airflow limitation (FEV1/FVC < 70%; FEV1 < 30% predicted) or FEV1 < 50% predicted plus chronic respiratory failure. Patients may have Very Severe (Stage IV) COPD even if the FEV1 is > 30% predicted, whenever this complication is present.

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St a ge III: Sev er e COP D - Further worsening of airflow limitation (FEV1/FVC < 70%; 30% FEV1 < 50% predicted), greater shortness of breath, reduced exercise capacity, and repeated exacerbations which have an impact on patients quality of life.

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This is the stage at which patients typically seek medical attention because of chronic respiratory symptoms or an exacerbation of their disease.

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St a ge II: Mo de r at e COP D - Worsening airflow limitation (FEV1/FVC < 70%; 50% FEV1 < 80% predicted), with shortness of breath typically developing on exertion.

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At this stage, the individual may not be aware that his or her lung function is abnormal.

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D ia g n o s is
COPD

Su g g e s t iv e Fe a t u r e s *

Asthma

Bronchiectasis

Tuberculosis

Obliterative Bronchiolitis

Diffuse Panbronchiolitis

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*These features tend to be characteristic of the respective diseases, but do not occur in every case. For example, a person who has never smoked may develop COPD (especially in the developing world, where other risk factors may be more important than cigarette smoking); asthma may develop in adult and even elderly patients.

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Congestive Heart Failure

Onset in mid-life. Symptoms slowly progressive. Long smoking history. Dyspnea during exercise. Largely irreversible airflow limitation. Onset early in life (often childhood). Symptoms vary from day to day. Symptoms at night/early morning. Allergy, rhinitis, and/or eczema also present. Family history of asthma. Largely reversible airflow limitation. Fine basilar crackles on auscultation. Chest X-ray shows dilated heart, pulmonary edema. Pulmonary function tests indicate volume restriction, not airflow limitation. Large volumes of purulent sputum. Commonly associated with bacterial infection. Coarse crackles/clubbing on auscultation. Chest X-ray/CT shows bronchial dilation, bronchial wall thickening. Onset all ages. Chest X-ray shows lung infiltrate or nodular lesions. Microbiological confirmation. High local prevalence of tuberculosis. Onset in younger age, nonsmokers. May have history of rheumatoid arthritis or fume exposure. CT on expiration shows hypodense areas. Most patients are male and nonsmokers. Almost all have chronic sinusitis. Chest X-ray and HRCT show diffuse small centrilobular nodular opacities and hyperinflation.

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F i g u r e 3 : D i f f e r e n t i a l D i a g n o s i s o f CO P D

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D if f e r e n t ia l D i a g n o s i s : A major differential diagnosis is asthma. In some patients with chronic asthma, a clear distinction from COPD is not possible using current imaging and physiological testing techniques. In these patients, current management is similar to that of asthma. Other potential F diagnoses are usually easier to distinguish from COPD (F ig u r e 3 ).

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The goals of COPD management include: Relieve symptoms Prevent disease progression Improve exercise tolerance Improve health status Prevent and treat complications Prevent and treat exacerbations Reduce mortality Prevent or minimize side effects from treatment

1 . A s s e s s a n d M o n it o r D is e a s e 2 . R e d u ce R i s k F a ct o r s

3 . M a n a g e S t a b l e CO P D 4 . M a n a g e Ex a c e r b a t i o n s

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T H ES E GOA L S CA N B E A CH I EV ED T H R OU G H I M P L EM EN TAT I ON OF A COP D M A N A GEM EN T P R OG R A M WI T H F OU R COM P O N EN T S :

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Cessation of cigarette smoking should be included as a goal throughout the management program.

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COMPONENTS OF CARE: A COPD MANAGEMENT PROGRAM

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Component 1: Assess and Monitor Disease

A d e t a i l e d m e d i ca l h i s t o r y of a new patient known or thought to have COPD should assess: Exposure to risk factors, including intensity and duration.

Possibilities for reducing risk factors, especially smoking cessation.

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Social and family support available to the patient.

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Impact of disease on patients life, including limitation of activity; missed work and economic impact; effect on family routines; and feelings of depression or anxiety.

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Appropriateness of current medical treatments.

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Presence of comorbidities, such as heart disease, malignancies, osteoporosis, and musculoskeletal disorders, which may also contribute to restriction of activity.

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History of exacerbations or previous hospitalizations for respiratory disorder.

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Pattern of symptom development.

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Family history of COPD or other chronic respiratory disease.

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Past medical history, including asthma, allergy, sinusitis or nasal polyps, respiratory infections in childhood, and other respiratory diseases.

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COP D is u s u ally a p ro g r es s iv e dis ea s e. L u n g f u n ct io n ca n b e ex pect ed t o w o r s en o v er t im e, ev en w it h t h e b es t av aila ble car e. Sy m p t o m s a n d lu n g f u n ct io n s h o u ld be m o n it o r ed t o f o llo w t h e d ev elo p m en t o f co m plica t ion s , t o gu ide t r ea t m en t , an d t o f acilit a te d is cu s s io n o f m an a gem en t o pt io n s w it h pa t ien t s . Co m o r bidit ies a r e co m m o n in COP D an d s h o u ld b e a ct iv ely id en t if ied .

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Alph a - 1 an t it r y p s in def icie n cy s cr een in g: Perform when COPD develops in patients of Caucasian descent under 45 years or with a strong family history of COPD.

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Ar t er ia l blo od ga s m ea s u r em e n t : Perform in patients with FEV1 < 50% predicted or with clinical signs suggestive of respiratory failure or right heart failure. The major clinical sign of respiratory failure is cyanosis. Clinical signs of right heart failure include ankle edema and an increase in the jugular venous pressure. Respiratory failure is indicated by PaO2 < 8.0 kPa (60 mm Hg), with or without PaCO2 > 6.7 kPa (50 mm Hg) while breathing air at sea level.

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Ch es t X - r a y : Seldom diagnostic in COPD but valuable to exclude alternative diagnoses such as pulmonary tuberculosis, and identify comorbidities such as cardiac failure.

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B ro n ch od ilat o r r e v er s ibilit y t e s t in g: To rule out a diagnosis of asthma, particularly in patients with an atypical history (e.g., asthma in childhood and regular night waking with cough and wheeze).

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In addition to s piro m e t r y , the following ot h er t es t s may be considered for the assessment of a patient with Moderate (Stage II), Severe (Stage III), and Very Severe (Stage IV) COPD.

Component 2: Reduce Risk Factors

S m o k i n g ce s s a t i o n i s t h e s i n g l e m o s t e f f e ct i v e a n d co s t e f f e ct i v e i n t e r v e n t i o n t o r e d u ce t h e r i s k o f d e v e l o p i n g COP D a n d s l o w i t s p r o g r e s s i o n .

F ig u r e 4 : S t r a t e g y t o H e l p a P a t ie n t Qu it Sm o k in g
1. A S K : Systematically identify all tobacco users at every visit. Implement an office-wide system that ensures that, for EVERY patient at EVERY clinic visit, tobacco-use status is queried and documented. 2. A D V I S E: Strongly urge all tobacco users to quit. In a clear, strong, and personalized manner, urge every tobacco user to quit. 3. A S S ES S : Determine willingness to make a quit attempt. Ask every tobacco user if he or she is willing to make a quit attempt at this time (e.g., within the next 30 days). 4. A S S I S T: Aid the patient in quitting. Help the patient with a quit plan; provide practical counseling; provide intra-treatment social support; help the patient obtain extra-treatment social support; recommend use of approved pharmacotherapy if appropriate; provide supplementary materials. 5. A R R A NG E: Schedule follow-up contact. Schedule follow-up contact, either in person or via telephone.

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Pharmacotherapy (nicotine replacement, buproprion/nortryptiline, and/or varenicline) is recommended when counseling is not sufficient to help patients stop smoking. Special consideration should be given before using pharmacotherapy in people smoking fewer than 10 cigarettes per day, pregnant women, adolescents, and those with medical contraindications (unstable coronary artery disease, untreated peptic ulcer, and recent myocardial infarction or stroke for nicotine replacement; and history of seizures for buproprion).

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Even a brief, 3-minute period of counseling to urge a smoker to quit can be effective, and at a minimum this should be done for every smoker at every health care provider visit. More intensive F strategies increase the likelihood of sustained quitting (F i g u r e 4 ).

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I n d o o r a n d O u t d o o r A i r P o l l u t i o n : Implement measures to reduce or avoid indoor air pollution from biomass fuel, burned for cooking and heating in poorly ventilated dwellings. Advise patients to monitor public announcements of air quality and, depending on the severity of their disease, avoid vigorous exercise outdoors or stay indoors altogether during pollution episodes.

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Occu p a t i o n a l Ex p o s u r e s : Emphasize primary prevention, which is best achieved by elimination or reduction of exposures to various substances in the workplace. Secondary prevention, achieved through surveillance and early detection, is also important.

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S m o k i n g P r e v e n t i o n : Encourage comprehensive tobacco-control policies and programs with clear, consistent, and repeated nonsmoking messages. Work with government officials to pass legislation to establish smoke-free schools, public facilities, and work environments and encourage patients to keep smoke-free homes.

Component 3: Manage Stable COPD

P h a r m a co l o g i c t r e a t m e n t (F i g u r e 5 ) can control and prevent F symptoms, reduce the frequency and severity of exacerbations, improve health status, and improve exercise tolerance.

Inhaled therapy is preferred. Give as needed to relieve intermittent or worsening symptoms, and on a regular basis to prevent or reduce persistent symptoms. The choice between 2-agonists, anticholinergics, methylxanthines, and combination therapy depends on the availability of medications and each patients individual response in terms of both symptom relief and side effects. Regular treatment with long-acting bronchodilators, including nebulized formulations, is more effective and convenient than treatment with short-acting bronchodilators. Combining bronchodilators of different pharmacologic classes may improve efficacy and decrease the risk of side effects compared to increasing the dose of a single bronchodilator.

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B r o n ch o d i l a t o r s : These medications are central to symptom management in COPD.

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P a t i e n t e d u ca t i o n can help improve skills, ability to cope with illness, and health status. It is an effective way to accomplish smoking cessation, initiate discussions and understanding of advance directives and end-oflife issues, and improve responses to acute exacerbations.

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Determine disease severity on an individual basis by taking into account the patients symptoms, airflow limitation, frequency and severity of exacerbations, complications, respiratory failure, comorbidities, and general health status. Implement a stepwise treatment plan that reflects this assessment of disease severity. Choose treatments according to national and cultural preferences, the patients skills and preferences, and the local availability of medications.

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M a n a g e m e n t o f s t a b l e CO P D s h o u l d b e g u i d e d b y t h e f o l l o w i n g g e n e r a l p r i n ci p l e s :

Figure 5. Formulations and Typical Doses of COPD Medications*

Drug

Long-acting
Formoterol Arformoterol Indacaterol Salmeterol 4.5-12 (MDI & DPI) 150-300 (DPI) 25-50 (MDI & DPI) 0.01 0.0075

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Fenoterol Levalbuterol Salbutamol (albuterol) Terbutaline

100-200 (MDI) 45-90 (MDI) 100, 200 (MDI & DPI) 400, 500 (DPI)

1 0.21, 0.42 5

0.05% (Syrup) 5mg (Pill), 0.024%(Syrup) 2.5, 5 (Pill)

0.1, 0.5

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2-agonists Short-acting

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240 mg

Anticholinergics Short-acting
Ipratropium bromide Oxitropium bromide 20, 40 (MDI) 100 (MDI) 18 (DPI), 5 (SMI) 200/80 (MDI) 75/15 (MDI) 0.25-0.5 1.5

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Long-acting
Tiotropium Fenoterol/Ipratropium Salbutamol/Ipratropium

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Combination short-acting 2-agonists plus anticholinergic in one inhaler

1.25/0.5 0.75/0.5 6-8 6-8 Variable, up to 24 Variable, up to 24

Inhaled glucocorticosteroids
Beclomethasone Budesonide Fluticasone

50-400 (MDI & DPI) 100, 200, 400 (DPI) 50-500 (MDI & DPI)

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Aminophylline Theophylline (SR)

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Methylxanthines

200-600 mg (Pill) 100-600 mg (Pill)

0.2-0.4 0.20. 0.25, 0.5

Systemic glucocorticosteroids

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Prednisone Methyl-prednisolone Roflumilast

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Formoterol/Budesonide 4.5/160, 9/320 (DPI) Salmeterol/Fluticasone 50/100, 250. 500 (DPI) 25/50, 125, 250 (MDI)

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Combination long-acting 2-agonists plus glucocorticosteroids in one inhaler

5-60 mg (Pill) 4, 8, 16 mg (Pill) 500 mcg (Pill)

Phosphodiesterase-4 inhibitors
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MDI=metered dose inhaler; DPI=dry powder inhaler

*Not all formulations are available in all countries; in some countries, other formulations may be available. Formoterol nebulized solution is based on the unit dose vial containing 20 gm in a volume of 2.0ml

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4-6 6-8 4-6 4-6 12+ 12+ 24 12+ 6-8 7-9 24+

Inhaler (g)

Solution for Nebulizer (mg/ml)

Oral

Vials for Injection (mg)

Duration of Action (hours)

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An t ibiot ics : Not recommended except for treatment of infectious exacerbations and other bacterial infections. M u co ly t ic (Mu co k in et ic, Mu cor e gu lat or ) Agen t s: Patients with viscous sputum may benefit from mucolytics, but overall benefits are very small. Use is not recommended. An t it u s siv e s: Regular use contraindicated in stable COPD.
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Vaccines: Influenza vaccines reduce serious illness and death in COPD patients by 50%. Vaccines containing killed or live, inactivated viruses are recommended, and should be given once each year. Pneumococcal polysaccharide vaccine is recommended for COPD patients 65 years and older, and has been shown to reduce community-acquired pneumonia in those under age 65 with FEV1 < 40% predicted.

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Phosphodiesterase-4 inhibitors: In patients with Stage III: Severe COPD or Stage IV: Very Severe COPD and a history of exacerbations and chronic bronchitis, the phosphodiesterase-4 inhibitor, roflumilast, reduces exacerbations treated with oral glucocorticosteroids. These effects are also seen when roflumilast is added to long-acting bronchodilators; there are no comparison studies with inhaled glucocorticosteroids.

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Oral Glucocorticosteroids: Long-term treatment with oral glucocorticosteroids is not recommended.

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An inhaled glucocorticosteroid combined with a long-acting 2-agonist is more effective than the individual components in reducing exacerbations and improving lung function and health status. Combination therapy increases the likelihood of pneumonia and has no significant effects on mortality. In patients with an FEV1 less than 60%, pharmacotherapy with long-acting 2-agonist, inhaled glucocorticosteroid and its combination decreases the rate of decline of lung function. Addition of a long-acting -agonist/inhaled glucocorticosteroid to an anticholinergic (tiotropium) 2 appears to provide additional benefits.

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Inhaled Glucocorticosteroids: Regular treatment with inhaled glucocorticosteroids does not modify the long-term decline in FEV1 but has been shown to reduce the frequency of exacerbations and thus improve health status for symptomatic patients with an FEV1 < 50% predicted and repeated exacerbations (for example, 3 in the last three years). The dose-response relationships and long-term safety of inhaled glucocorticosteroids in COPD are not known. Treatment with inhaled glucocorticosteroids increases the likelihood of pneumonia and does not reduce overall mortality.

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Non - P h ar m acolo gic Tr e at m en t includes rehabilitation, oxygen therapy, and surgical interventions.

Initiate oxygen therapy for patients with Stage IV: Very Severe COPD if: PaO2 is at or below 7.3 kPa (55 mm Hg) or SaO2 is at or below 88%, with or without hypercapnia; or PO2 is between 7.3 kPa (55 mm Hg) and 8.0 kPa (60 mm Hg) or SaO2 is 88%, if there is evidence of pulmonary hypertension, peripheral edema suggesting congestive heart failure, or polycythemia (hematocrit > 55%).
Th e go a l o f lo n g- t er m o x y gen t h er a py is t o in cr ea s e t h e ba s elin e P a O2 a t r es t t o a t lea s t 8.0 k P a (60 m m Hg) a t s ea lev el, a n d/o r pr o du ce Sa O2 a t lea s t 90% , w h ich w ill p r es er v e v it al o r ga n f u n ct io n b y en s u r in g an ad equ at e d eliv er y of o x y gen .

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Su r gical Tr e at m en t s : Bullectomy and lung transplantation may be considered in carefully selected patients with Stage IV: Very Severe COPD. There is currently no sufficient evidence that would support the widespread use of lung volume reduction surgery (LVRS). Th er e is n o con v in cin g ev iden ce t h at m ech an ical v en t ilat or y su ppor t h as a role in t h e rou tin e m an agem en t of stable COP D.

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Ox y gen Th e r apy : The long-term administration of oxygen (>15 hours per day) to patients with chronic respiratory failure increases survival and has a beneficial impact on pulmonary hemodynamics, hematologic characteristics, exercise capacity, lung mechanics, and mental state.

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Th e go a ls of pu lm on a r y r eh ab ilit at io n a r e t o r ed u ce s y m pt o m s , im pr o v e qu a lit y o f life, a n d in cr ea s e pa r t icipa t io n in ev er y da y a ct iv at all Patients it ies . stages of disease benefit from exercise training programs,

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Rehabilitation: Patients at all stages of disease benefit from exercize training programs improvements in exercise tolerance and symptoms of dyspnea and fatigue. Benefits can be sustained even after a single pulmonary rehabilitation program. The minimum length of an effective rehabilitation program is 6 weeks; the longer the program continues, the more effective the results. Benefit does wane after a rehabilitation program ends, but if exercise training is maintained at home the patient's health status remains above pre-rehabilitation levels.

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I: Mild

II: Moderate

III: Severe

FEV1/FVC < 0.70

FEV1 8 0% predicted

50% FEV < 80% 1 predicted

Active reduction of risk factor(s); influenza vaccination

Add regular treatment with one or more long-acting bronchodilators

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(when needed); Add rehabilitation

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Add short-acting bronchodilator (when needed)

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Add inhaled glucocorticosteroids if

repeated exacerbations

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FEV1/FVC < 0.70

30% FEV < 50% 1 predicted

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*Postbronchodilator FEV1 is recommended for the diagnosis and assessment of severity of COPD.

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treatments

Add long term oxygen if

chronic respiratory failure

Consider surgical

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IV: Very Severe

FEV1/FVC < 0.70

FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure

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Figure 6: Therapy at Each Stage of COPD*

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A summary of characteristics and recommended treatment at each stage of COPD is shown in F i g u r e 6 .

Component 4: Manage Exacerbations

An exacerbation of COPD is defined as a n e v e n t in t h e n a t u r a l co u r s e o f t h e d i s e a s e ch a r a ct e r i z e d b y a ch a n g e i n t h e p a t i e n t s b a s e l i n e d y s p n e a , co u g h , a n d /o r s p u t u m t h a t i s b e y o n d n o r m a l d a y - t o - d a y v a r i a t i o n s , i s a cu t e i n o n s e t , a n d m a y w a r r a n t a ch a n g e i n r e g u l a r m e d i ca t i o n i n a p a t i e n t w i t h u n d e r l y i n g CO P D .

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. H o w t o A s s e s s t h e S e v e r i t y o f a n Ex a ce r b a t i o n

Chest X-ray: Chest radiographs (posterior/anterior plus lateral) identify alternative diagnoses that can mimic the symptoms of an exacerbation.

Other laboratory tests:

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Biochemical tests to detect electrolyte disturbances, diabetes, and poor nutrition. Whole blood count can identify polycythemia or bleeding.

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Sputum culture and antibiogram to identify infection if there is no response to initial antibiotic treatment.

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ECG: Aids in the diagnosis of right ventricular hypertrophy, arrhythmias, and ischemic episodes.

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Moderate-to-severe acidosis (pH < 7.36) plus hypercapnia (PaCO2 > 6-8 kPa, 45-60 mm Hg) in a patient with respiratory failure is an indication for mechanical ventilation.

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PaO2 < 8.0 kPa (60 mm Hg) and/or SaO2 < 90% with or without PaCO2 > 6.7 kPa, (50 mmHg) when breathing room air indicates respiratory failure.

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Arterial blood gas measurements (in hospital):

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Hom e Car e o r Ho s pit al Car e f o r En d - St a ge COP D P at ien t s ?

Th e r is k of dy in g f ro m a n ex acer ba t io n o f COP D is clos ely r ela t ed t o t h e dev elo p m en t o f r es pir a t o r y acido s is , t h e p r es en ce o f s er iou s com o r b idit ies , a n d t h e n eed f o r v en t ila t o r y s u pp o r t . P at ien t s lack in g t h es e f eat u r es a r e n o t at h igh r is k o f dy in g , bu t t h o s e w it h s ev er e u n der ly in g COP D o f ten r eq u ir e h o s p ita lizat io n in a n y ca s e. At t em p t s at m a n ag in g s u ch p at ien t s en t ir ely in t h e co m m u n it y h av e m et w it h lim it ed s u cces s , b u t r et u r n in g t h em t o t h eir h om es w it h in cr ea s ed s o cia l s u p po r t an d a s u p er v is ed m edica l car e p ro g r am af t er an in it ia l em er gen cy r o om as s es s m en t h as b een m u ch m o r e s u cces s f u l. Ho w ev er, d et ailed co s t - ben ef it a n a ly s es o f t h es e ap p ro a ch es h av e n o t b een r ep o r t ed .

H os pit a l Man agem en t

Figu r e 7: In dica t io n s fo r Ho s pit al Adm is s ion fo r Ex acerb at ion s

Marked increase in intensity of symptoms, such as sudden development of resting dyspnea Severe underlying COPD Onset of new physical signs (e.g., cyanosis, peripheral edema) Failure of exacerbation to respond to initial medical management Significant comorbidities Frequent exacerbations Newly occurring arrhythmias Diagnostic uncertainty Older age Insufficient home support

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An t ibio t ics: Antibiotics should be given to patients: With the following three cardinal symptoms: increased dyspnea, increased sputum volume, increased sputum purulence With increased sputum purulence and one other cardinal symptom Who require mechanical ventilation
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Patients with the characteristics listed in Figu r e 7 should be hospitalized. Indications for referral and the management of exacerbations of COPD in the hospital depend on local resources and the facilities of the local hospital.

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Glu cocor t ico st er oids : If baseline FEV1 < 50% predicted, add 30-40 mg oral prednisolone per day for 7-10 days to the bronchodilator regimen. Budesonide alone may be an alternative to oral glucocorticosteroids in the treatment of exacerbations and is associated with significant reduction of complications.

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H om e Ma n age m e n t B ron ch odila t o r s: Increase dose and/or frequency of existing shortacting bronchodilator therapy, preferably with 2-agonists. If not already used, add anticholinergics until symptoms improve.

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A s p i r o g r a m is a volume-time curve.

F EV 1 (Forced Expired Volume in one second): volume expired in the first second of maximal expiration after a maximal inspiration. This is a measure of how quickly the lungs can be emptied. F EV 1/F V C: FEV1 expressed as a percentage of the FVC, gives a clinically useful index of airflow limitation. The ratio FEV1/FVC is between 70% and 80% in normal adults; a value less than 70% indicates airflow limitation and the possibility of COPD. FEV1 is influenced by the age, sex, height and ethnicity, and is best considered as a percentage of the predicted normal value. There is a vast literature on normal values; those appropriate for local populations should be used1,2,3.

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F V C (Forced Vital Capacity): maximum volume of air that can be exhaled during a forced maneuver.

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Spirometry measurements used for diagnosis of COPD include (see Figure 2, page 9):

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A s p i r o m e t e r is a device used to measure how effectively, and how quickly, the lungs can be emptied.

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S p i r o m e t r y is a simple test to measure the amount of air a person can breathe out, and the amount of time taken to do so.

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Spirometry is as important for the diagnosis of COPD as blood pressure measurements are for the diagnosis of hypertension. Spirometry should be available to all health care professionals.

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APPENDIX I: SPIROMETRY FOR DIAGNOSIS OF COPD

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W h y d o S p i r o m e t r y f o r CO P D ?
Together with the presence of symptoms, spirometry helps stage COPD severity and can be a guide to specific treatment steps.

The lower the percentage predicted FEV1, the worse the subsequent prognosis.

Several types of spirometers are available: relatively large bellows or rolling-seal spirometers (usually only available in pulmonary function laboratories). Calibration should be checked against a known volume e.g. from a 3-litre syringe on a regular basis. smaller hand-held devices, often with electronic calibration systems. A hard copy of the volume time plot is very useful to check optimal performance and interpretation, and to exclude errors. Most spirometers require electrical power to permit operation of the motor and/or sensors. Some battery operated versions are available that can dock with a computer to provide hard copy.

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W h a t Yo u N e e d t o P e r f o r m S p i r o m e t r y

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FEV1 declines over time and faster in COPD than in healthy subjects. Spirometry can be used to monitor disease progression, but to be reliable the intervals between measurements must be at least 12 months.

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A normal value for spirometry effectively excludes the diagnosis of clinically relevant COPD.

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Spirometry is needed to make a firm diagnosis of COPD.

I t i s e s s e n t i a l t o l e a r n h o w y o u r m a ch i n e i s ca l i b r a t e d a n d w h e n a n d h o w t o cl e a n i t .

H o w t o P e r f o r m S p ir o m e t r y

Seal their lips around the mouthpiece.

Breathe in again and relax.

Those with chest pain or frequent cough may be unable to perform a satisfactory test and this should be noted.

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Like any test, spirometry results will only be of value if the expirations are performed satisfactorily and consistently. Both FVC and FEV1 should be the largest value obtained from any of 3 technically satisfactory curves and the FVC and FEV1 values in these three curves should vary by no more than 5% or 100 ml, whichever is greater. The FEV1/FVC is calculated using the maximum FEV1 and FVC from technically acceptable (not necessarily the same) curves.

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Exhalation must continue until no more air can be exhaled, must be at least 6 seconds, and can take up to 15 seconds or more.

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Force the air out of the chest as hard and fast as they can until their lungs are completely empty.

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Breathe in fully.

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Spirometry is best performed with the patient seated. Patients may be anxious about performing the tests properly, and should be reassured. Careful explanation of the test, accompanied by a demonstration, is very useful. The patient should:

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1 . A m e r i ca n T h o r a ci c S o ci e t y http://www.thoracic.org/adobe/statements/spirometry1-30.pdf

3. B r i t i s h T h o r a ci c S o ci e t y http://www.brit-thoracic.org.uk/copd/consortium.html

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4. GO L D A spirometry guide for general practitioners and a teaching slide set is available: http://www.goldcopd.org

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2. A u s t r a l i a n /N e w Z e a l a n d T h o r a ci c S o ci e t y http://www.nationalasthma.org.au/publications/spiro/index.htm

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Wh e r e t o f in d m o r e d e t a i l e d i n f o r m a t i o n o n s p ir o m e t r y

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NOTES

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The Global Initiative for Chronic Obstructive Lung Disease is supported by educational grants from:

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Copies of this document are available at www.us-health-network.com 2009 Medical Communications Resources, Inc.

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Visit the GOLD website at www.goldcopd.org www.goldcopd.org/application.asp

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