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Global initiative for chronic
Obstructive
Lung
Disease
GOLD MANAGEMENT PLAN FOR
CHRONIC OBSTRUCTIVE PULMONARY
DISEASE (COPD)
WHAT IS COPD?
“COPD is a disease state characterised 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.”
WHAT ARE THE CONSEQUENCES OF
COPD?
• Symptoms of COPD include: production of sputum,
chronic cough & dyspnoea (shortness of breath)
• Exacerbations are a major cause of disability and often
lead to a significant decrease in quality of life
• The disease cannot be fully reversed; however disease
progression can be slowed by smoking cessation
WHY TACKLE COPD?
• COPD is the fourth leading cause of death in the world
• An increase in prevalence/mortality is predicted for the
future
• A unified international effort is required to reverse
incidence trends
WHAT IS GOLD?
• GOLD is a collaborative project of the US National Heart,
Lung and Blood Institute & WHO
• “GOLD provides guidelines to achieve a global strategy for
the diagnosis, management and prevention of COPD”
• An international panel which consists of specialists in the
areas of respiratory medicine, epidemiology,
socioeconomics, public health & health education
• GOLD aims to increase awareness of COPD and decrease
morbidity and mortality
GOALS OF EFFECTIVE COPD
MANAGEMENT
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Prevent disease progression
Relieve symptoms
Improve exercise tolerance
Improve health status
Prevent and treat complications
Prevent and treat exacerbations
Reduce mortality
These goals should be reached with minimum
side effects from treatment
COMPONENTS OF COPD GUIDELINES
• Assess and monitor disease
• Decrease risk factors
• Manage stable COPD
• Manage exacerbations
EVIDENCE-BASED APPROACH
STATEMENTS SUPPORTED BY DEFINED LEVELS OF EVIDENCE
Evidence category
Sources of evidence
Evidence A
Randomised controlled
trials. Rich body of data
Evidence B
Randomised controlled
trials. Limited body of data
Evidence C
Non-randomised trials
Observational studies
Evidence D
Panel consensus
ASSESS & MONITOR DISEASE
• Diagnosis should be based on:
– a history of exposure to risk factors
– & presence of airflow limitation that is not fully reversible
– presence of symptoms
• Spirometry (FEV1; FEV1/VC) for diagnosis & assessment
– standardised, (reproducible), (objective tool)
• Annual assessment based on symptoms, spirometry and
presence of complications
• Even patients who do not show a significant FEV1 response to a
SAB test may benefit symptomatically from long-term
bronchodilator treatment
HOW SHOULD COPD BE DIAGNOSED
& ASSESSED?
KEY INDICATORS FOR CONSIDERING A DIAGNOSIS OF COPD
Dyspnoea
Progressive, persistent, worse on
exercise, worse during
respiratory infections
Chronic cough
Present intermittently / every day,
often present throughout the day
Chronic sputum
production
In any pattern
History of exposure to risk
factors, especially:
Tobacco smoke, occupational
dusts & chemicals, smoke from
home heating fuels
HOW CAN WE REDUCE THE RISK OF
DEVELOPING COPD?
• Smoking cessation is the single most effective/cost effective
intervention
– reduce risk of developing disease (A)
– stop progression of disease (A)
• Treating tobacco dependence is effective
• Every smoker should be offered
– counselling (A)
– smoking cessation medications where appropriate (A)
HOW SHOULD COPD BE MANAGED
IN PRACTICE?
• Stepwise increase in treatment recommended, dependent on
– severity of disease, response to treatments
• Exercise training programmes (pulmonary rehabilitation)
– improve exercise tolerance/symptoms of dyspnoea & fatigue (A)
• Health education
– Increase self-management skills, ability to cope with illness and health
status (patient well-being) (A)
• COPD lung damage is irreversible. Pharmacotherapy aims to
improve symptoms and/or decrease complications
HOW SHOULD COPD BE MANAGED
IN PRACTICE?
• Bronchodilators are central to managing symptoms (A)
– beta2-agonists
– anticholinergics
– theophylline (A)
• Choice of bronchodilator depends on:
– a patient’s response (symptom relief and side effects)
– availability
• Long-acting bronchodilators are more convenient for regular
therapy than short-acting agents
• The long-acting beta2-agonist, salmeterol has been shown to
improve health status significantly in doses of 50mcg b.d.1
• Similar data for short-acting beta2-agonists are not available
MANAGEMENT OF SYMPTOMS IN COPD
Bronchodilators
• Central to symptom management
• Prescribed to patients as needed
• LABs more convenient than SABs
• Benefit patient symptomatically
Beta2-agonists
Short-acting
Beta2-agonists
(duration of 4-6 hours)
- Fenoterol
- Salbutamol
- Terbutaline
Anticholinergics
(duration of 6-9 hours)
Long-acting
Beta2-agonists
(duration of >12 hours)
- Salmeterol
- Formoterol
- Ipratropium bromide
- Oxitropium bromide
Methylxanthines
(Theophyllines)
(duration <24 hours
- Aminophylline (SR)
- Theophylline (SR)
HOW SHOULD COPD BE MANAGED
IN PRACTICE?
• Regular inhaled corticosteroids are recommended for:
– patients with a response in FEV1 (B)
– patients with an FEV1 <50% predicted & repeated exacerbations
(B)
• A short course of oral corticosteroids (OCS) is a poor predictor
of the long-term response to inhaled glucocorticosteroids
• Chronic treatment with OCS should be avoided
– unfavourable benefit:risk ratio (A)
HOW SHOULD COPD
EXACERBATIONS BE MANAGED IN
PRACTICE?
• Characteristics of exacerbations:
– important clinical events
– causes largely unknown
– significant role of infection (B)
• Effective treatments:
– Inhaled bronchodilators (A)
– Oral corticosteroids (A)
– Antibiotic treatment for suspected infection (e.g. change of
colour of sputum) (B)
– Non-invasive positive pressure ventilation (A)
FUTURE RESEARCH
• Much about COPD is still unknown and further research
is needed in many areas:
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improved early detection/diagnosis
new approaches for interventions
means to identify the “susceptible” smoker
more effective means of managing exacerbations
standardise tracking = future planning
cost & burden analysis
GOALS OF EFFECTIVE COPD
MANAGEMENT
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Prevent disease progression
Relieve symptoms
Improve exercise tolerance
Improve health status
Prevent and treat complications
Prevent and treat exacerbations
Reduce mortality