229_GOLD 2010 Pocket Guide for COPD

Tai lieu y khoa

Global Initiative for Chronic Obstructive

GOLD Ex ecu tiv e Com m ittee

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

María Montes de Oca, MD, PhD (representing ALAT)

Chris van Weel, MD, Netherlands (representing WONCA)

Jorgen Vestbo, MD, Denmark

Obser v er:

Jadwiga Wedzicha, MD, UK (Representing ERS)

GOLD Nation al Leaders

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.

TTA AB BLL EE O OFF C CO ON NTTEEN NTTS S

PP RR EEFFAACCEE

K

K EEYY PP OOIINNTTSS

W

WHHAATT IISS CCHHRR OONNIICC OOBBSSTTRR UUCCTTIIVV EE

PP UULLMMOONNAARRYY DDIISSEEAASSEE ((CCOOPP DD))??

RR IISSKK FFAACCTTOORR SS:: WWHH AATT CCAAUU SSEESS CCOOPP DD??

D

DIIAAGGNNOOSSIINNGG CCOOPP DD

Figure 1: Key Indicators for Considering a

Coomm ppoonn eenn tt 22:: RR eedduu ccee RR iisskk FFaa cctt oo rr ss

Figure 4: Strategy to Help a Patient Quit Smoking

Coomm ppoonn eenn tt 44:: MMaann aa ggee EExx aacceerr bbaatt iioonn ss

How to Assess the Severity of an Exacerbation

Chronic Obstructive Pulmonary Disease (COPD) is a major cause ofchronic morbidity and mortality throughout the world The Global

Init iat iv e for Chronic Obst ru ct iv e Lu n g Disease was created toincrease awareness of COPD among health professionals, public healthauthorities, and the general public, and to improve prevention and

management through a concerted worldwide effort The Initiative

prepares scientific reports on COPD, encourages dissemination andadoption of the reports, and promotes international collaboration onCOPD research

While COPD has been recognized for many years, public health officialsare concerned about continuing increases in its prevalence and mortality,which are due in large part to the increasing use of tobacco productsworldwide and the changing age structure of populations in developingcountries The Global Initiativ e for Chronic Obstru ctiv e Lu ngDisease offers a framework for management of COPD that can beadapted to local health care systems and resources Educational tools,such as laminated cards or computer-based learning programs, can beprepared that are tailored to these systems and resources

The Global In itiat iv e for Chron ic Obst ru ct iv e Lu n g Diseaseprogram includes the following publications:

• Global Strategy for the Diagnosis, Management, and Prevention ofCOPD Scientific information and recommendations for COPD

programs (Updated 2010)

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

• Pocket Guide to COPD Diagnosis, Management, and Prevention

Summary of patient care information for primary health care

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 theDiagnosis, Management, and Prevention of COPD (2010) Technical discussions of COPD and COPD management, evidence levels, and specificcitations from the scientific literature are included in that source document.

A

Acckk nn o ow w lleed dg geem m eenn tt ss:: 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 distribu- tion The participants, however, are solely responsible for the statements and con- clusions in the publications.

KEY POINTS

• CChh rr oonn iicc OObbsstt rr uu cctt iivv ee PP uu llmm oonn aarr yy DDiiss eeaass ee ((CCOOPP DD) is a

preventable and treatable disease with some significant

extra-pulmonary effects that may contribute to the severity in individualpatients Its pulmonary component is characterized by airflow limitationthat is not fully reversible The airflow limitation is usually progressiveand associated with an abnormal inflammatory response of the lung

to noxious particles or gases

• Worldwide, the most commonly encountered rr iiss kk ff aacctt oorr for COPD

is cciiggaa rr eett tt ee ss mm oo kk iinn gg AAtt eevv eerr yy ppoo ssss iibbllee oopppp oorr tt uu nn iitt yy

iinn dd iivv iidduu aa llss ww hh oo ss mm oo kk ee sshh oouu lldd bbee eenn ccoouu rr aaggeedd tt oo qquu iitt Inmany countries, air pollution resulting from the burning of wood andother biomass fuels has also been identified as a COPD risk factor

• A ddiiaa ggnn oo ssiiss of COPD should be considered in any patient who hasdyspnea, chronic cough or sputum production, and/or a history ofexposure to risk factors for the disease The diagnosis should be confirmed by spirometry

• A CCOOPP DD mm aann aaggeemm eenn tt pp rrooggrr aamm includes four components:assess and monitor disease, reduce risk factors, manage stable

COPD, and manage exacerbations

• PP hh aa rr mm aa ccoolloo ggiicc tt rr eeaa tt mm eenn tt can prevent and control symptoms,reduce the frequency and severity of exacerbations, improve healthstatus, and improve exercise tolerance

• PP aatt iieenn tt eedd uu ccaa tt iioonn can help improve skills, ability to cope withillness, and health status It is an effective way to accomplish smokingcessation, initiate discussions and understanding of advance directivesand end-of-life issues, and improve responses to acute exacerbations

• COPD is often associated with eexx aacceerr bbaa tt iioo nn ss of symptoms

is characterized by airflow limitation that is not fully reversible The flow limitation is usually progressive and associated with an abnormalinflammatory response of the lung to noxious particles or gases

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

Episodes of acute worsening of these symptoms often occur

*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.

C

Chh rro onn iicc cco ouu g ghh a a nn d d ssp p uu ttuu m m p p rr o od d uu cctt iio onn o off tt eenn p p rr eecceed d ee tt hh ee

d

d eevv eello op pm m eenn tt o off a a iirr ff llo ow w lliim m iitt a a tt iio onn b byy m m a ann yy yy eea arr ss,, a a lltt hh o ouu g ghh

nn o ott a a llll iinn d diivv iid d uu a allss w w iitt hh cco ouu g ghh a ann d d ss p puu tt uu m m p prr o od duu ccttiio onn g go o o onn

tt o o d d eevv eello op p C CO OPP D D

RISK FACTORS:

WHAT CAUSES COPD?

W

Woo rr llddww iiddee,, cciiggaarr eett tt ee ssmm ookk iinn gg iiss tt hh ee mm oo sstt ccoomm mm oonn llyy

eenn ccoo uu nn tt eerr eedd rr iiss kk ff aacctt oorr ffoo rr CCOOPP DD

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

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

• TToobb aaccccoo ss mm oo kk ee, including cigarette, pipe, cigar, and other types

of tobacco smoking popular in many countries, as well as

environmental tobacco smoke (ETS)

• OOccccuu ppaa tt iioonn aall dd uu sstt ss aa nn dd cchh eemm iiccaallss (vapors, irritants, and

fumes) when the exposures are sufficiently intense or prolonged

• IInn ddoo oorr aa iirr ppoo lllluu tt iioonn from biomass fuel used for cooking and heating in poorly vented dwellings, a risk factor that particularlyaffects women in developing countries

• OOuu tt ddoooo rr aaiirr ppoolllluu tt iioo nn also contributes to the lungs’ total burden

of inhaled particles, although it appears to have a relatively smalleffect in causing COPD

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

DIAGNOSING

COPD

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 riskfactors for the disease, especially cigarette smoking (FFiigguu rr ee 11)

TThh ee dd iiaaggnn oo ssiiss ss hh oouu lldd bb ee ccoo nn ff iirr mm eedd bbyy sspp iirroomm eett rr yy **

((FFiigguu rr ee 22,, ppaa ggee 99 aann dd AApppp eenn dd iixx I,, pp aaggee 2244))

*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

FFiigguu rree 11:: KK eeyy IInn ddiiccaatt oorrss ffoorr CCoonn ss iiddeerriinn gg aa CCOOPP DD DDiiaaggnn oossiiss

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

• DDyy ss ppnn eeaa that is: Progressive (worsens over time)

Usually worse with exercise

Persistent (present every day)

Described by the patient as an “increasedeffort to breathe,” “heaviness,” “air hunger,”

or “gasping.”

• CChh rr oonn iicc ccoouu gghh :: May be intermittent and may be unproductive

• CChh rr oonn iicc ssppuu tt uu mm pprr oodduu cctt iioonn ::

Any pattern of chronic sputum production mayindicate COPD

• HHiisstt oorr yy ooff ee xx ppoossuu rr ee tt oo rr iisskk ff aaccttoo rr ss::

TToobbaaccccoo ssmm ookk ee ((iinn cclluu ddiinn gg ppooppuu llaarr llooccaall p

prr eeppaarr aatt iioo nn ss))

Occupational dusts and chemicals

Smoke from home cooking and heating fuel

When performing spirometry, measure:

• FForced VV ital CCapacity (FFVV CC) and

• FForced EExpiratory VV olume in one second (FFEEVV1)

Spirometric results are expressed as %% PP rr eeddiicctt eedd using

appropriate normal values for the person’s sex, age, and height

PP a a tt iieenn tt ss w w iitt hh C CO OPP D D ttyy p p iicca allllyy ss hh o ow w a a d deeccrr eea a ssee iinn b bo ott hh FFEEV V1a

a nn d d FFEEV V1/ /FFV V C C TThh ee d d eeg grr eeee o off ss p piirr o om m eett rr iicc a a b bnn o orr m m a a lliitt yy

g

g eenn eerr a allllyy rr eeff lleecctt ss tt hh ee sseevv eerr iitt yy o off C CO OPP D D H Ho ow w eevv eerr,, b b o ott hh

ss yy m m p p tt o om m ss a a nn d d ss p p iirr o om m eett rr yy ss hh o ouu lld d b b ee cco onn ss iid deerr eed d w w hh eenn

d

d eevv eello op p iinn g g a a nn iinn d diivv iid d uu a alliizzeed d m m a ann a a g geem m eenn tt sstt rr a att eeg gyy ffo orr

eea a cchh p pa a tt iieenn tt

FFiigguu rr ee 22:: NNoorr mm aall SSppiirr ooggrr aa mm aann dd SSppiirr ooggrr aa mm TTyy ppiiccaall ooff

PP aatt iieenn tt ss ww iitt hh MMiilldd tt oo MMoo ddeerr aatt ee CCOOPP DD**

*Postbronchodilator FEV 1 is recommended for the diagnosis and assessment of severity of COPD.

Stages of COP D

and sputum production

• At this stage, the individual may not be aware that his or her lungfunction is abnormal

Stage II: Moderate COP D - Worsening airflow limitation

of breath typically developing on exertion

• This is the stage at which patients typically seek medical attentionbecause of chronic respiratory symptoms or an exacerbation of theirdisease

Stage III: Sev er e COP D - Further worsening of airflow limitation

breath, reduced exercise capacity, and repeated exacerbations whichhave an impact on patients’ quality of life

Stage IV: Ver y Sev ere COP D - Severe airflow limitation

plus chronic respiratory failure Patients may have Very Severe (Stage IV)

is present

• At this stage, quality of life is very appreciably impaired and

exacerbations may be life-threatening

“ At R isk for 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 spirometry—Stage I: Mild COPD; Stage II: Moderate COPD; Stage III: Severe COPD; Stage IV: Very Severe COPD A fifth category—“Stage 0: At Risk”—that 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).Copyrighted

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Diiffffeerreenntt iiaall DDiiaaggnn oossiiss:: A major differential diagnosis is asthma Insome patients with chronic asthma, a clear distinction from COPD is not possible using current imaging and physiological testing techniques In thesepatients, current management is similar to that of asthma Other potentialdiagnoses are usually easier to distinguish from COPD (FFiigguu rree 33)

D

Diiaaggnnoossiiss SSuu ggggeessttiivv ee FFeeaattuurreess**

COPD Onset in mid-life.

Symptoms slowly progressive.

Long smoking history.

Dyspnea during exercise.

Largely irreversible airflow limitation.

Asthma 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.

Congestive Heart Failure Fine basilar crackles on auscultation.

Chest X-ray shows dilated heart, pulmonary edema.

Pulmonary function tests indicate volume restriction, not airflow limitation.

Bronchiectasis 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 Tuberculosis Onset all ages

Chest X-ray shows lung infiltrate or nodular lesions.

Microbiological confirmation.

High local prevalence of tuberculosis.

Obliterative Bronchiolitis Onset in younger age, nonsmokers.

May have history of rheumatoid arthritis or fume exposure.

CT on expiration shows hypodense areas.

Diffuse Panbronchiolitis Most patients are male and nonsmokers

Almost all have chronic sinusitis.

Chest X-ray and HRCT show diffuse small centrilobular nodular opacities and hyperinflation.

FFiigguu rr ee 33:: DDiiffff eerr eenn tt iiaall DDiiaagg nn ooss iiss ooff CCOOPP DD

*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 cigaretteCopyrighted

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• 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

Cessation of cigarette smoking should be included as a goal throughoutthe management program

TTHHEESSEE GGOOAALL SS CCAANN BBEE AACCHH IIEEVV EEDD TTHH RR OOUUGGHH

IIMMPP LL EEMMEENNTTAATTIIOONN OOFF AA CCOOPP DD MMAANNAAGGEEMMEENNTT PP RR OOGGRR AAMM

Component 1: Assess and Monitor Disease

In addition to spirom etr y , the following ot her tests may be consideredfor the assessment of a patient with Moderate (Stage II), Severe

(Stage III), and Very Severe (Stage IV) COPD

• Bronch odilator rev ersibilit y testing: To rule out a diagnosis ofasthma, particularly in patients with an atypical history (e.g., asthma

in childhood and regular night waking with cough and wheeze)

• Ch est X - ray : Seldom diagnostic in COPD but valuable to excludealternative diagnoses such as pulmonary tuberculosis, and identifycomorbidities such as cardiac failure

• Ar t erial blood gas m easu r em ent : Perform in patients with

failure or right heart failure The major clinical sign of respiratoryfailure is cyanosis Clinical signs of right heart failure include ankleedema and an increase in the jugular venous pressure Respiratory

• Alpha- 1 ant itr y psin deficiency screen ing: Perform whenCOPD develops in patients of Caucasian descent under 45 years orwith a strong family history of COPD

COP D is u su ally a progressiv e disease Lu n g fun ction

can be ex pected to w orsen ov er tim e, ev en w ith th e best

av ailable car e Sy m ptom s an d lun g fu n ction shou ld be

m on itored to follow th e dev elopm en t of com plication s, to

gu ide treatm en t, an d to facilitate discu ssion of m an agem en t option s w ith patients Com or bidities are com m on in COP D

an d shou ld be activ ely identified