Download Management of COPD

Global Initiative for Chronic
Obstructive
L ung
Disease
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.
Leading Causes of Deaths
U.S. 1998
Cause of Death
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Number
Heart Disease
724,269
Cancer
538,947
Cerebrovascular disease (stroke) 158,060
Respiratory Diseases (COPD)
114,381
Accidents
94,828
Pneumonia and influenza
93,207
Diabetes
64,574
Suicide
29,264
Nephritis
26,295
Chronic liver disease
24,936
All other causes of death
469,314
Percent Change in Age-Adjusted
Death Rates, U.S., 1965-1998
Proportion of 1965 Rate
3.0
3.0
2.5
2.5
Coronary
Heart
Disease
Stroke
Other CVD
COPD
All Other
Causes
–59%
–64%
–35%
+163%
–7%
1965 - 1998
1965 - 1998
1965 - 1998
1965 - 1998
1965 - 1998
2.0
2.0
1.5
1.5
1.0
1.0
0.5
0.5
0.0 0
Age-Adjusted Death Rates for
COPD, U.S., 1960-1995
Deaths per 100,000
6060
White Male
5050
4040
Black Male
3030
White Female
2020
Black Female
1010
00
1960
1960
1965
1965
1970
1970
1975
1975
1980
1980
1985
1985
1990
1990
1995
1995
2000
2000
Facts About COPD

Between 1985 and 1995, the number of
physician visits for COPD in the United
States increased from 9.3 million to
16 million.

The number of hospitalizations for COPD
in 1995 was estimated to be 500,000.
Medical expenditures amounted to an
estimated $14.7 billion.
COPD 1990 Prevalence
Male/1000


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
Established Market Economies
Formerly Socialist Economies
India
China
Other Asia and Islands
Sub-Saharan Africa
Latin America and Caribbean
Middle Eastern Crescent
World
*From Murray & Lopez, 1996
6.98
7.35
4.38
26.20
2.89
4.41
3.36
2.69
9.34
Female/1000
3.79
3.45
3.44
23.70
1.79
2.49
2.72
2.83
7.33
Facts About COPD

Between 1985 and 1995, the number of
physician visits for COPD in the United
States increased from 9.3 million to
16 million.

The number of hospitalizations for COPD
in 1995 was estimated to be 500,000.
Medical expenditures amounted to an
estimated $14.7 billion.
Physician Office Visits for Chronic
and Unspecified Bronchitis, U.S.
Number (Millions)
1515
1010
55
00
1980
1980
1985
1985
Source: National Ambulatory Medical Care Survey, NCHS
1990
1990
Year
Year
1995
1995
1998
1998
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.
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.
Global Initiative for Chronic
Obstructive
L ung
Disease
GOLD Objectives

Increase awareness of COPD among
health professionals, health authorities,
and the general public

Improve diagnosis, management, and
prevention

Stimulate research
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)
GOLD Workshop Report
Evidence-based
 Implementation oriented
 Diagnosis
 Management
 Prevention
 Outcomes can be evaluated

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
GOLD Workshop Report:
Contents







Introduction
Definition and classification
Burden of COPD
Risk factors
Pathogenesis, pathology,
and pathophysiology
Management
Future research
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.
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.
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.
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.
Direct and Indirect Costs of
COPD, 1993 (US $ Billions)

Direct Medical Cost:
$14.7

Total Indirect Cost:
– Mortality related IDC
– Morbidity related IDC
$ 9.2
Total Cost
$23.9

4.5
4.7
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
Pathogenesis of COPD
NOXIOUS AGENT
(tobacco smoke, pollutants, occupational agent)
Genetic factors
Respiratory
infection
Other
COPD
Noxious particles
and gases
Host factors
Lung inflammation
Anti-oxidants
Oxidative stress
Anti-proteinases
Proteinases
Repair mechanisms
COPD pathology
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
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
GOLD Workshop Report
Four Components of COPD
Management
1. Assess and monitor disease
2. Reduce risk factors
3. Manage stable COPD

Education

Pharmacologic

Non-pharmacologic
4. Manage exacerbations
Objectives of COPD
Management

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

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
GOLD Workshop Report
Four Components of COPD
Management
1. Assess and monitor disease
2. Reduce risk factors
3. Manage stable COPD

Education

Pharmacologic

Non-pharmacologic
4. Manage exacerbations
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.
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.
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.

Assess and Monitor
Disease: Key Points

Measurement of arterial blood gas
tension should be considered in all
patients with FEV1 < 40% predicted
or clinical signs suggestive of
respiratory failure or right heart
failure.
Diagnosis of COPD
EXPOSURE TO RISK
FACTORS
SYMPTOMS
cough
sputum
dyspnea
tobacco
occupation
indoor/outdoor pollution

SPIROMETRY
Spirometry: Normal and COPD
0
FEV1
Normal
COPD
1
Liter
2
FVC
FEV1/ FVC
4.150
5.200
80 %
2.350
3.900
60 %
FEV1
3
COPD
4
FVC
FEV1
Normal
5
1
2
3
FVC
4
5
6
Seconds
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
Classification by Severity
Stage
Characteristics
0: At risk
Normal spirometry
Chronic symptoms (cough, sputum)
I: Mild
FEV1/FVC < 70%; FEV1  80% predicted
With or without symptoms (cough, sputum)
II: Moderate
FEV1/FVC < 70%; 30% FEV1 < 80% predicted
(IIA: 50%  FEV1 < 80% predicted;
IIB: 30%  FEV1 < 50% predicted)
With or without chronic symptoms (cough, sputum, dyspnea)
III: Severe
FEV1/FVC < 70%; FEV1 < 30% predicted or FEV1
< 50%predicted plus respiratory failure or clinical signs of right
heart failure
Examples of individual patient histories
age
20
70
At risk
A
Mild
C
II
70
Stage
I
20
age
0
Moderate
III
Severe
B
III
Mild
70
II
Severe
At risk
20
I
Moderate
Stage
Stage
0
Stage
age
20
age
70
D
GOLD Workshop Report
Four Components of COPD
Management
1. Assess and monitor disease
2. Reduce risk factors
3. Manage stable COPD

Education

Pharmacologic

Non-pharmacologic
4. Manage exacerbations
Reduce Risk Factors
Key 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).
Reduce Risk Factors
Key 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).
Reduce Risk Factors
Key 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.
Reduce Risk Factors
Key Points
 Progression of many occupationallyinduced respiratory disorders can be
reduced or controlled through a variety
of strategies aimed at reducing the
burden of inhaled particles and gases
(Evidence B).
Brief Strategies To Help The
Patient Willing To Quit Smoking
• ASK
• ADVISE
• ASSESS
• ASSIST
Systematically identify all
tobacco users at every visit.
Strongly urge all tobacco
users to quit.
Determine willingness to
make a quit attempt.
Aid the patient in quitting.
• ARRANGE Schedule follow-up contact.
GOLD Workshop Report
Four Components of COPD
Management
1. Assess and monitor disease
2. Reduce risk factors
3. Manage stable COPD

Education

Pharmacologic

Non-pharmacologic
4. Manage exacerbations
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).
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.
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 Beta2agonists, anticholinergics, theophylline, and a
combination of these drugs (Evidence A).
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.
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.
Manage Stable COPD
Key Points

Regular treatment with inhaled glucocorticosteroids should only be prescribed for
symptomatic COPD patients with a
documented spirometric response to
glucocorticosteroids or in those with an FEV1
< 50% predicted and repeated exacerbations
requiring treatment with antibiotics and/or oral
glucocorticosteroids (Evidence B).
Manage Stable COPD
Key Points

Chronic treatment with systemic glucocorticosteroids 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).
Manage Stable COPD
Key Points

The long-term administration of oxygen
(> 15 hours per day) to patients with
chronic respiratory failure has been
shown to increase survival (Evidence A).
Management of COPD by
Severity of Disease
Stage 0: At risk
Stage 1: Mild COPD
Stage 2: Moderate COPD
Stage 3: Severe COPD
Management of COPD:
All stages

Avoidance of noxious agents
- smoking cessation
- reduction of indoor pollution
- reduction of occupational exposure

Influenza vaccination
Management of COPD
Stage 0: At Risk
Characteristics
• Chronic symptoms
- cough
- sputum
• No spirometric
abnormalities
Recommended Treatment
Management of COPD
Stage I: Mild COPD
Characteristics
• FEV1/FVC < 70 %
• FEV1 > 80 % predicted
• With or without
symptoms
Recommended Treatment
• Short-acting
bronchodilator as
needed
Management of COPD
Stage IIA: Moderate COPD
Characteristics
•FEV1/FVC < 70%
•50% < FEV1< 80% predicted
•With or without symptoms
Recommended Treatment
•Regular treatment with
one or more
bronchodilators
•Rehabilitation
•Inhaled glucocorticosteroids if significant
symptoms and lung
function response
Management of COPD
Stage IIB: Moderate COPD
Characteristics
•FEV1/FVC < 70%
•30% < FEV1 < 50% predicted
•With or without symptoms
Recommended Treatment
Regular treatment with
one or more
bronchodilators
•Rehabilitation
•Inhaled glucocorticosteroids if significant
symptoms and lung
function response or if
repeated exacerbations
Management of COPD
Stage III: Severe COPD
Characteristics
•FEV1/FVC < 70%
•FEV1 < 30% predicted or
presence of respiratory
failure or right heart
failure
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
GOLD Workshop Report
Four Components of COPD
Management
1. Assess and monitor disease
2. Reduce risk factors
3. Manage stable COPD

Education

Pharmacologic

Non-pharmacologic
4. Manage exacerbations
Manage Exacerbations
Key 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).
Manage Exacerbations
Key Points

Inhaled bronchodilators (Beta2-agonists
and/or anticholinergics), theophylline, and
systemic, preferably oral, glucocorticosteroids are effective for the treatment of
COPD exacerbations (Evidence A).
Manage Exacerbations
Key Points

Patients experiencing COPD
exacerbations with clinical signs of
airway infection (e.g., increased volume
and change of color of sputum, and/or
fever) may benefit from antibiotic
treatment (Evidence B)
Manage Exacerbations
Key Points

Noninvasive intermittent positive pressure
ventilation (NIIPPV) in acute exacerbations
improves blood gases and pH, reduces inhospital mortality, decreases the need for
invasive mechanical ventilation and
intubation, and decreases the length of
hospital stay (Evidence A).
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.
GOLD Website Address
http://www.goldcopd.com