1. health and fitness
2. disease
3. asthma

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Global Initiative for Chronic
Obstructive
Lung
Disease
POCKET GUIDE
AND PREVENTION
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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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Global Initiative for Chronic
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L ung
Disease
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Pocket Guide to COPD Diagnosis, Management,
and Prevention
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GOLD Ex ecu t iv e Co m m it t ee
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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)
María 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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Ob s er v er :
Jadwiga Wedzicha, MD, UK (Representing ERS)
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GOLD Nat io n al L ead er s
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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.
© 2010 Global Initiative for Chronic Obstructive Lung Disease, Inc.
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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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TA B L E O F CON T EN T S
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PREFACE
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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.
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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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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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• Global Strategy for the Diagnosis, Management, and Prevention of
COPD. Scientific information and recommendations for COPD
programs. (Updated 2010)
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• Executive Summary, Global Strategy for the Diagnosis, Management,
and Prevention of COPD. (Updated 2010)
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• Pocket Guide to COPD Diagnosis, Management, and Prevention.
Summary of patient care information for primary health care
professionals. (Updated 2010)
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• What You and Your Family Can Do About COPD. Information booklet
for patients and their families.
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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.
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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
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• 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.
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• 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.
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• 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.
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• 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.
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• 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.
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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-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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WHAT IS CHRONIC
OBSTRUCTIVE
PULMONARY DISEASE
(COPD)?
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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.
NO
This definition does not use the terms chronic bronchitis and emphysema*
and excludes asthma (reversible airflow limitation).
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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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Episodes of acute worsening of these symptoms often occur.
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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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RISK FACTORS:
WHAT CAUSES COPD?
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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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 person
encounters over their lifetime:
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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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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.
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DIAGNOSING
COPD
OR
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
factors for the disease, especially cigarette smoking (FF i g u r e 1 ).
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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
TA
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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• 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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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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*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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When performing spirometry, measure:
• F orced V ital Capacity (FF V C) and
• F orced Expiratory V olume in one second (FF EV 1 ).
Calculate the FEV1/FVC ratio.
OR
Spirometric results are expressed as % P r e d i ct e d using
appropriate normal values for the person’s sex, age, and height.
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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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and assessment of severity of COPD.
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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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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, the individual may not be aware that his or her lung
function is abnormal.
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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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• 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 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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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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• At this stage, quality of life is very appreciably impaired and
exacerbations may be life-threatening.
“ At R is k f or COP D”
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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).
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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
diagnoses are usually easier to distinguish from COPD (FF ig u r e 3 ).
OR
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
Su g g e s t iv e Fe a t u r e s *
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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D ia g n o s is
COPD
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Asthma
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Congestive Heart Failure
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Bronchiectasis
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Tuberculosis
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Obliterative Bronchiolitis
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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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COMPONENTS OF CARE:
A COPD MANAGEMENT
PROGRAM
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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
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•
•
•
•
•
•
•
•
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Cessation of cigarette smoking should be included as a goal throughout
the management program.
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T H ES E G OA 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 :
1 . A s s e s s a n d M o n it o r D is e a s e
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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
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4 . M a n a g e Ex a c e r b a t i o n s
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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:
OR
• Exposure to risk factors, including intensity and duration.
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• Past medical history, including asthma, allergy, sinusitis or nasal
polyps, respiratory infections in childhood, and other respiratory
diseases.
• Pattern of symptom development.
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• Family history of COPD or other chronic respiratory disease.
NO
• History of exacerbations or previous hospitalizations for
respiratory disorder.
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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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• Appropriateness of current medical treatments.
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• Impact of disease on patient’s life, including limitation of activity;
missed work and economic impact; effect on family routines; and
feelings of depression or anxiety.
• Social and family support available to the patient.
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• Possibilities for reducing risk factors, especially smoking cessation.
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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.
• 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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• 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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• 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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• 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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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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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 .
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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
strategies increase the likelihood of sustained quitting (FF i g u r e 4 ).
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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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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
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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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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.
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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.
CO
PY
RI
GH
TE
D
MA
T
ER
IAL
-D
O
NO
TA
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.
16
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Component 3: Manage Stable COPD
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 :
LT
ER
OR
• Determine disease severity on an individual basis by taking into
account the patient’s 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 patient’s skills and preferences, and the local availability of
medications.
NO
TA
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.
-D
O
P h a r m a co l o g i c t r e a t m e n t (FF i g u r e 5 ) can control and prevent
symptoms, reduce the frequency and severity of exacerbations, improve
health status, and improve exercise tolerance.
ER
IAL
B r o n ch o d i l a t o r s : These medications are central to symptom
management in COPD.
CO
PY
RI
GH
TE
D
MA
T
• 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 patient’s 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.
17
Long-acting
Formoterol
Arformoterol
Indacaterol
Salmeterol
Anticholinergics
Short-acting
1
0.21, 0.42
5
0.05% (Syrup)
4.5-12 (MDI & DPI)
0.01±
0.0075
Ipratropium bromide
Oxitropium bromide
20, 40 (MDI)
100 (MDI)
Long-acting
Tiotropium
0.25-0.5
1.5
5mg (Pill), 0.024%(Syrup)
2.5, 5 (Pill)
18 (DPI), 5 (SMI)
0.1, 0.5
Aminophylline
Theophylline (SR)
O
ER
Inhaled glucocorticosteroids
50-400 (MDI & DPI)
100, 200, 400 (DPI)
50-500 (MDI & DPI)
Formoterol/Budesonide
Salmeterol/Fluticasone
propionate
4.5/160, 9/320 (DPI)
50/100, 250. 500 (DPI)
25/50, 125, 250 (MDI)
MA
T
Beclomethasone
Budesonide
Fluticasone propionate
6-8
6-8
-D
Methylxanthines
200-600 mg (Pill)
100-600 mg (Pill)
12+
12+
24
12+
24+
1.25/0.5
0.75/0.5
IAL
200/80 (MDI)
75/15 (MDI)
4-6
6-8
4-6
4-6
6-8
7-9
Combination short-acting β2-agonists plus anticholinergic in one inhaler
Fenoterol/Ipratropium
Salbutamol/Ipratropium
Duration of
Action (hours)
RE
PR
OD
100-200 (MDI)
45-90 (MDI)
100, 200 (MDI & DPI)
400, 500 (DPI)
150-300 (DPI)
25-50 (MDI & DPI)
Vials for
Injection
(mg)
OR
Fenoterol
Levalbuterol
Salbutamol (albuterol)
Terbutaline
Oral
LT
ER
β2-agonists
Short-acting
Solution for
Nebulizer
(mg/ml)
TA
Inhaler
(µg)
UC
E
Figure 5. Formulations and Typical Doses of COPD Medications*
NO
Drug
240 mg
Variable, up to 24
Variable, up to 24
0.2-0.4
0.20. 0.25, 0.5
D
Combination long-acting β2-agonists plus glucocorticosteroids in one inhaler
TE
Systemic glucocorticosteroids
GH
Prednisone
Methyl-prednisolone
Phosphodiesterase-4 inhibitors
RI
Roflumilast
PY
MDI=metered dose inhaler; DPI=dry powder inhaler
5-60 mg (Pill)
4, 8, 16 mg (Pill)
500 mcg (Pill)
24
CO
*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 µgm in a volume of 2.0ml
18
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OR
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OD
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.
NO
TA
LT
ER
An inhaled glucocorticosteroid combined with a long-acting β2-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 β2-agonist, inhaled glucocorticosteroid and its combination
decreases the rate of decline of lung function. Addition of a long-acting
β2-agonist/inhaled glucocorticosteroid to an anticholinergic (tiotropium)
appears to provide additional benefits.
O
Oral Glucocorticosteroids: Long-term treatment with oral glucocorticosteroids
is not recommended.
ER
IAL
-D
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.
TE
D
MA
T
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.
GH
An t ibiot ics : Not recommended except for treatment of infectious
exacerbations and other bacterial infections.
PY
RI
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.
CO
An t it u s siv e s: Regular use contraindicated in stable COPD.
19
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PR
OD
Non - P h ar m acolo gic Tr e at m en t includes rehabilitation, oxygen
therapy, and surgical interventions.
OR
Rehabilitation: Patients at all stages of disease benefit from exercise
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.
LT
ER
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 itaties
Patients
all. stages of disease benefit from exercise training programs,
NO
TA
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.
O
Initiate oxygen therapy for patients with Stage IV: Very Severe COPD if:
MA
T
ER
IAL
-D
• 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%).
TE
D
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 .
PY
RI
GH
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).
CO
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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A summary of characteristics and recommended treatment at each stage
of COPD is shown in F i g u r e 6 .
Figure 6: Therapy at Each Stage of COPD*
•
FEV1/FVC < 0.70
•
50% ≤ FEV1 < 80%
predicted
FEV1/FVC < 0.70
FEV1 ≥ 8 0% predicted
•
FEV1/FVC < 0.70
•
30% ≤ FEV1 < 50%
predicted
•
FEV1/FVC < 0.70
•
FEV1 < 30% predicted
or FEV1 < 50%
predicted plus chronic
respiratory failure
NO
Active reduction of risk factor(s); influenza vaccination
IV: Very Severe
OR
III: Severe
LT
ER
•
•
II: Moderate
TA
I: Mild
Add short-acting bronchodilator (when needed)
O
Add regular treatment with one or more long-acting bronchodilators
Add inhaled glucocorticosteroids if
repeated exacerbations
Add long term oxygen if
chronic respiratory
failure
Consider surgical
treatments
MA
T
ER
IAL
-D
(when needed); Add rehabilitation
CO
PY
RI
GH
TE
D
*Postbronchodilator FEV1 is recommended for the diagnosis and
assessment of severity of COPD.
21
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OD
Component 4: Manage Exacerbations
OR
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 .
LT
ER
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.
TA
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
NO
Arterial blood gas measurements (in hospital):
-D
O
• 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.
IAL
• 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.
MA
T
ER
Chest X-ray: Chest radiographs (posterior/anterior plus lateral) identify
alternative diagnoses that can mimic the symptoms of an exacerbation.
ECG: Aids in the diagnosis of right ventricular hypertrophy, arrhythmias,
and ischemic episodes.
D
Other laboratory tests:
GH
TE
• Sputum culture and antibiogram to identify infection if there is
no response to initial antibiotic treatment.
RI
• Biochemical tests to detect electrolyte disturbances, diabetes,
and poor nutrition.
CO
PY
• Whole blood count can identify polycythemia or bleeding.
22
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PR
OD
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 ?
LT
ER
OR
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 .
TA
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.
-D
H os pit a l Man agem en t
O
NO
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.
ER
IAL
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.
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
GH
TE
D
MA
T
• 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
CO
PY
RI
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
23
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APPENDIX I:
SPIROMETRY FOR
DIAGNOSIS OF COPD
LT
ER
OR
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.
Wh a t is S p i r o m e t r y ?
TA
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.
NO
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.
O
A s p i r o g r a m is a volume-time curve.
-D
Spirometry measurements used for diagnosis of COPD include
(see Figure 2, page 9):
ER
IAL
• F V C (Forced Vital Capacity): maximum volume of air that
can be exhaled during a forced maneuver.
MA
T
• 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.
D
• F EV 1/F V C: FEV1 expressed as a percentage of the FVC,
gives a clinically useful index of airflow limitation.
GH
TE
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.
CO
PY
RI
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.
24
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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 ?
• Spirometry is needed to make a firm diagnosis of COPD.
• Together with the presence of symptoms, spirometry helps stage
COPD severity and can be a guide to specific treatment steps.
OR
• A normal value for spirometry effectively excludes the diagnosis
of clinically relevant COPD.
LT
ER
• The lower the percentage predicted FEV1, the worse the
subsequent prognosis.
TA
• 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.
NO
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
O
Several types of spirometers are available:
IAL
-D
• 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.
ER
• smaller hand-held devices, often with electronic calibration
systems.
MA
T
A hard copy of the volume time plot is very useful to check
optimal performance and interpretation, and to exclude errors.
CO
PY
RI
GH
TE
D
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.
25
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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
OR
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:
LT
ER
• Breathe in fully.
• Seal their lips around the mouthpiece.
NO
• Breathe in again and relax.
TA
• Force the air out of the chest as hard and fast as they can
until their lungs are completely “empty.”
O
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.
MA
T
ER
IAL
-D
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.
CO
PY
RI
GH
TE
D
Those with chest pain or frequent cough may be unable to
perform a satisfactory test and this should be noted.
26
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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
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
OR
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
LT
ER
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
CO
PY
RI
GH
TE
D
MA
T
ER
IAL
-D
O
NO
TA
4. G O L D
A spirometry guide for general practitioners and a teaching slide
set is available:
http://www.goldcopd.org
27
D
TE
GH
RI
PY
CO
ER
MA
T
IAL
O
-D
LT
ER
TA
NO
OR
28
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UC
E
NOTES
UC
E
CO
PY
RI
GH
TE
D
MA
T
ER
IAL
-D
O
NO
TA
LT
ER
OR
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The Global Initiative for Chronic Obstructive Lung Disease
is supported by unrestricted educational grants from:
Visit the GOLD website at www.goldcopd.org