1、 Global Initiative for Chronic Obstructive Lung DiseaseGLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE(GOLD):TEACHING SLIDE SETDecember 2019This slide set is restricted for academic and educational purposes only.Use of the slide set,or of individual slides,for commercial or promotional purpos
2、es requires approval from GOLD.lobal Initiative for ChronicbstructiveungiseaseG OLD Global Initiative for Chronic Obstructive Lung DiseaseGOLD StructureGOLD Board of DirectorsRoberto Rodriguez-Roisin,MD ChairScience CommitteeJrgen Vestbo,MD-ChairDissemination/ImplementationCommitteeJean Bourbeau,MD-
3、ChairGOLD Board of Directors:2019R.Rodriguez-Roisin,Chair,SpainA.Anzueto,U.S.ATSJ.Bourbeau,CanadaT.DeGuia,PhilippinesD.Hui,Hong Kong PRCF.Martinez,U.S.M.Mishima,Japan APSRD.Nugmanova,Kazakhstan WONCARamirez,Mexico ALATR.Stockley,U.K.J.Vestbo,Denmark,U.K.Observer:J.Wedzica,UK ERSGOLD Science Committe
4、e-2019Jrgen Vestbo,MD,Chair Alvar Agusti,MDAntonio Anzueto,MDPeter Barnes,MDLeonardo Fabbri,MDPaul Jones,MDFernando Martinez,MDMasaharu Nishimura,MDRoberto Rodriguez-Roisin,MDDon Sin,MDRobert Stockley,MDClaus Vogelmeier,MDEvidence Category Sources of Evidence ARandomized controlled trials(RCTs).Rich
5、 body of dataBRandomized controlled trials(RCTs).Limited body of dataCNonrandomized trialsObservational studies.DPanel consensus judgment Description of Levels of Evidence GOLD StructureGOLD Board of DirectorsRoberto Rodriguez-Roisin,MD ChairScience CommitteeJrgen Vestbo,MD-ChairDissemination/Implem
6、entationTask Group Jean Bourbeau,MD-ChairGOLD National Leaders-GNLUnited StatesUnited KingdomArgentinaAustraliaBrazilAustriaCanadaChileBelgiumChinaDenmarkColumbiaCroatiaEgyptGermanyGreeceIrelandItalySyriaHong Kong ROCJapanIcelandIndiaKoreaKyrgyzstanUruguayMoldovaNepalMacedoniaMaltaNetherlandsNew Zea
7、landPolandNorwayPortugalGeorgiaRomaniaRussiaSingaporeSlovakiaSloveniaSaudi ArabiaSouth AfricaSpainSwedenThailandSwitzerlandUkraineUnited Arab EmiratesTaiwan ROCVenezuelaVietnamPeruYugoslaviaAlbaniaBangladeshFranceMexicoTurkeyCzech RepublicPakistanIsraelGOLD National LeadersPhilippinesYemanKazakhstan
8、MongoliaGOLD Website Addressgoldcopd.orglobal Initiative for ChronicbstructiveungiseaseG OLD Global Initiative for Chronic Obstructive Lung DiseaseGOLD ObjectivesnIncrease awareness of COPD among health professionals,health authorities,and the general publicnImprove diagnosis,management and preventi
9、onnDecrease morbidity and mortalitynStimulate researchGlobal Strategy for Diagnosis,Management and Prevention of COPD,2019:Chapters nDefinition and Overview nDiagnosis and AssessmentnTherapeutic OptionsnManage Stable COPDnManage ExacerbationsnManage ComorbiditiesREVISED 2019Global Strategy for Diagn
10、osis,Management and Prevention of COPD,2019:Chapters nDefinition and Overview nDiagnosis and AssessmentnTherapeutic OptionsnManage Stable COPDnManage ExacerbationsnManage ComorbiditiesREVISED 2019Global Strategy for Diagnosis,Management and Prevention of COPDDefinition of COPDnCOPD,a common preventa
11、ble and treatable disease,is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases.nExacerbations and comorbidities contribute to the overall severity in indiv
12、idual patients.Global Strategy for Diagnosis,Management and Prevention of COPDMechanisms Underlying Airflow Limitation in COPDSmall Airways Disease Airway inflammation Airway fibrosis,luminal plugs Increased airway resistanceParenchymal Destruction Loss of alveolar attachments Decrease of elastic re
13、coilAIRFLOW LIMITATIONGlobal Strategy for Diagnosis,Management and Prevention of COPDBurden of COPD COPD is a leading cause of morbidity and mortality worldwide.The burden of COPD is projected to increase in coming decades due to continued exposure to COPD risk factors and the aging of the worlds po
14、pulation.COPD is associated with significant economic burden.Global Strategy for Diagnosis,Management and Prevention of COPDRisk Factors for COPDLung growth and development GenderAge Respiratory infectionsSocioeconomic statusAsthma/Bronchial hyperreactivityChronic BronchitisGenesExposure to particle
15、s Tobacco smoke Occupational dusts,organic and inorganic Indoor air pollution from heating and cooking with biomass in poorly ventilated dwellings Outdoor air pollutionGlobal Strategy for Diagnosis,Management and Prevention of COPDRisk Factors for COPDGlobal Strategy for Diagnosis,Management and Pre
16、vention of COPD,2019:Chapters nDefinition and Overview nDiagnosis and AssessmentnTherapeutic OptionsnManage Stable COPDnManage ExacerbationsnManage ComorbiditiesREVISED 2019Global Strategy for Diagnosis,Management and Prevention of COPDDiagnosis and Assessment:Key Points A clinical diagnosis of COPD
17、 should be considered in any patient who has dyspnea,chronic cough or sputum production,and/or a history of exposure to risk factors for the disease.Spirometry is required to make the diagnosis;the presence of a post-bronchodilator FEV1/FVC 0.70 confirms the presence of persistent airflow limitation
18、 and thus of COPD.Global Strategy for Diagnosis,Management and Prevention of COPDDiagnosis and Assessment:Key Points The goals of COPD assessment are to determine the severity of the disease,including the severity of airflow limitation,the impact on the patients health status,and the risk of future
19、events.Comorbidities occur frequently in COPD patients,and should be actively looked for and treated appropriately if present.SYMPTOMS chronic coughshortness of breathEXPOSURE TO RISKFACTORS tobaccooccupationindoor/outdoor pollutionSPIROMETRY:Required to establish diagnosisGlobal Strategy for Diagno
20、sis,Management and Prevention of COPDDiagnosis of COPD sputum Global Strategy for Diagnosis,Management and Prevention of COPDAssessment of Airflow Limitation:Spirometry Spirometry should be performed after the administration of an adequate dose of a short-acting inhaled bronchodilator to minimize va
21、riability.A post-bronchodilator FEV1/FVC 0.70 confirms the presence of airflow limitation.Where possible,values should be compared to age-related normal values to avoid overdiagnosis of COPD in the elderly.Spirometry:Normal Trace Showing FEV1 and FVC1234561234Volume,litersTime,secFVC51FEV1=4LFVC =5L
22、FEV1/FVC=0.8Spirometry:Obstructive DiseaseVolume,litersTime,seconds54321123456FEV1=1.8LFVC=3.2LFEV1/FVC=0.56Normal ObstructiveDetermine the severity of the disease,its impact on the patients health status and the risk of future events(for example exacerbations)to guide therapy.Consider the following
23、 aspects of the disease separately:current level of patients symptoms severity of the spirometric abnormality frequency of exacerbations presence of comorbidities.Global Strategy for Diagnosis,Management and Prevention of COPDAssessment of COPD:Goals Global Strategy for Diagnosis,Management and Prev
24、ention of COPDAssessment of COPDAssess symptomsAssess degree of airflow limitation using spirometryAssess risk of exacerbationsAssess comorbiditiesThe characteristic symptoms of COPD are chronic and progressive dyspnea,cough,and sputum production.Dyspnea:Progressive,persistent and characteristically
25、 worse with exercise.Chronic cough:May be intermittent and may be unproductive.Chronic sputum production:COPD patients commonly cough up sputum.Global Strategy for Diagnosis,Management and Prevention of COPDSymptoms of COPDAssess symptomsnAssess degree of airflow limitation using spirometrynAssess r
26、isk of exacerbationsnAssess comorbiditiesUse the COPD Assessment Test(CAT)or mMRC Breathlessness scale Global Strategy for Diagnosis,Management and Prevention of COPDAssessment of COPDCOPD Assessment Test(CAT):An 8-item measure of health status impairment in COPD(catestonline.org).Breathlessness Mea
27、surement using the Modified British Medical Research Council(mMRC)Questionnaire:relates well to other measures of health status and predicts future mortality risk.Global Strategy for Diagnosis,Management and Prevention of COPDAssessment of SymptomsGlobal Strategy for Diagnosis,Management and Prevent
28、ion of COPDModified MRC(mMRC)Questionnaire Assess symptoms Assess degree of airflow limitation using spirometryn Assess risk of exacerbationsn Assess comorbiditiesUse spirometry for grading severity according to spirometry,using four grades split at 80%,50%and 30%of predicted value Global Strategy f
29、or Diagnosis,Management and Prevention of COPDAssessment of COPDGlobal Strategy for Diagnosis,Management and Prevention of COPDClassification of Severity of Airflow Limitation in COPD*In patients with FEV1/FVC 80%predicted GOLD 2:Moderate 50%FEV1 80%predictedGOLD 3:Severe 30%FEV1 50%predictedGOLD 4:
30、Very Severe FEV1 30%predicted*Based on Post-Bronchodilator FEV1 Assess symptomsAssess degree of airflow limitation using spirometryAssess risk of exacerbationsn Assess comorbidities Use history of exacerbations and spirometry.Two exacerbations or more within the last year or an FEV1 50%of predicted
31、value are indicators of high risk Global Strategy for Diagnosis,Management and Prevention of COPDAssessment of COPDGlobal Strategy for Diagnosis,Management and Prevention of COPDAssess Risk of ExacerbationsTo assess risk of exacerbations use history of exacerbations and spirometry:Two or more exacer
32、bations within the last year or an FEV1 2 1 0(C)(D)(A)(B)mMRC 0-1CAT 2CAT 10 Symptoms(mMRC or CAT score)Global Strategy for Diagnosis,Management and Prevention of COPDCombined Assessment of COPD(C)(D)(A)(B)mMRC 0-1CAT 2CAT 10 Symptoms(mMRC or CAT score)If mMRC 0-1 or CAT 2 or CAT 10:More Symptoms(B
33、or D)Assess symptoms firstGlobal Strategy for Diagnosis,Management and Prevention of COPDCombined Assessment of COPDRisk(GOLD Classification of Airflow Limitation)Risk(Exacerbation history)2 1 0(C)(D)(A)(B)mMRC 0-1CAT 2CAT 10 Symptoms(mMRC or CAT score)If GOLD 1 or 2 and only 0 or 1 exacerbations pe
34、r year:Low Risk(A or B)If GOLD 3 or 4 or two ormore exacerbations per year:High Risk(C or D)Assess risk of exacerbations nextGlobal Strategy for Diagnosis,Management and Prevention of COPDCombined Assessment of COPDRisk(GOLD Classification of Airflow Limitation)Risk(Exacerbation history)2 1 0(C)(D)(
35、A)(B)mMRC 0-1CAT 2CAT 10 Symptoms(mMRC or CAT score)Patient is now in one offour categories:A:Les symptoms,low riskB:More symtoms,low riskC:Less symptoms,high riskD:More Symtoms,high riskUse combined assessmentGlobal Strategy for Diagnosis,Management and Prevention of COPDCombined Assessment of COPD
36、Risk(GOLD Classification of Airflow Limitation)Risk(Exacerbation history)2 1 0(C)(D)(A)(B)mMRC 0-1CAT 2CAT 10 Symptoms(mMRC or CAT score)PatientCharacteristicSpirometric ClassificationExacerbations per yearmMRCCATALow Risk Less SymptomsGOLD 1-2 10-1 2 10CHigh Risk Less SymptomsGOLD 3-4 20-1 2 2 10Gl
37、obal Strategy for Diagnosis,Management and Prevention of COPDCombined Assessment of COPDWhen assessing risk,choose the highest risk according to GOLD grade or exacerbation history Global Strategy for Diagnosis,Management and Prevention of COPDAssess COPD ComorbiditiesCOPD patients are at increased r
38、isk for:Cardiovascular diseasesOsteoporosisRespiratory infectionsAnxiety and DepressionDiabetesLung cancerThese comorbid conditions may influence mortality and hospitalizations and should be looked for routinely,and treated appropriately.Global Strategy for Diagnosis,Management and Prevention of COP
39、DCOPD Onset in mid-life Symptoms slowly progressive Long smoking history ASTHMAOnset early in life(often childhood)Symptoms vary from day to daySymptoms worse at night/early morningAllergy,rhinitis,and/or eczema also presentFamily history of asthmaGlobal Strategy for Diagnosis,Management and Prevent
40、ion of COPDAdditional InvestigationsChest X-ray:Seldom diagnostic but valuable to exclude alternative diagnoses and establish presence of significant comorbidities.Lung Volumes and Diffusing Capacity:Help to characterize severity,but not essential to patient management.Oximetry and Arterial Blood Ga
41、ses:Pulse oximetry can be used to evaluate a patients oxygen saturation and need for supplemental oxygen therapy.Alpha-1 Antitrypsin Deficiency Screening:Perform when COPD develops in patients of Caucasian descent under 45 years or with a strong family history of COPD.Exercise Testing:Objectively me
42、asured exercise impairment,assessed by a reduction in self-paced walking distance(such as the 6 min walking test)or during incremental exercise testing in a laboratory,is a powerful indicator of health status impairment and predictor of prognosis.Composite Scores:Several variables(FEV1,exercise tole
43、rance assessed by walking distance or peak oxygen consumption,weight loss and reduction in the arterial oxygen tension)identify patients at increased risk for mortality.Global Strategy for Diagnosis,Management and Prevention of COPDAdditional InvestigationsGlobal Strategy for Diagnosis,Management an
44、d Prevention of COPD,2019:Chapters nDefinition and Overview nDiagnosis and AssessmentnTherapeutic OptionsnManage Stable COPDnManage ExacerbationsnManage ComorbiditiesREVISED 2019Global Strategy for Diagnosis,Management and Prevention of COPDTherapeutic Options:Key Points Smoking cessation has the gr
45、eatest capacity to influence the natural history of COPD.Health care providers should encourage all patients who smoke to quit.Pharmacotherapy and nicotine replacement reliably increase long-term smoking abstinence rates.All COPD patients benefit from regular physical activity and should repeatedly
46、be encouraged to remain active.Appropriate pharmacologic therapy can reduce COPD symptoms,reduce the frequency and severity of exacerbations,and improve health status and exercise tolerance.None of the existing medications for COPD has been shown conclusively to modify the long-term decline in lung
47、function.Influenza and pneumococcal vaccination should be offered depending on local guidelines.Global Strategy for Diagnosis,Management and Prevention of COPDTherapeutic Options:Key PointsGlobal Strategy for Diagnosis,Management and Prevention of COPDTherapeutic Options:Smoking Cessation Counseling
48、 delivered by physicians and other health professionals significantly increases quit rates over self-initiated strategies.Even a brief(3-minute)period of counseling to urge a smoker to quit results in smoking quit rates of 5-10%.Nicotine replacement therapy(nicotine gum,inhaler,nasal spray,transderm
49、al patch,sublingual tablet,or lozenge)as well as pharmacotherapy with varenicline,bupropion,and nortriptyline reliably increases long-term smoking abstinence rates and are significantly more effective than placebo.Brief Strategies to Help the Patient Willing to Quit Smoking ASK Systematically identi
50、fy all tobacco users at every visit ADVISEStrongly urge all tobacco users to quit ASSESS Determine willingness to make a quit attempt ASSIST Aid the patient in quitting ARRANGESchedule follow-up contact.Global Strategy for Diagnosis,Management and Prevention of COPDTherapeutic Options:Risk Reduction
