Presented on november, 2012

1. Global Strategy for Diagnosis,
Management and Prevention of
Chronic Obstructive Pulmonary Disease
Revised 2011
Dr. Mashfiqul Hasan
Resident, Phase A
Respiratory wing, Dept of Medicine
BSMMU
1

2. G lobal Initiative for Chronic
O bstructive
L ung
D isease
© Global Initiative for Chronic Obstructive Lung Disease
2

3. WORLD COPD DAY
November 14, 2012
Raising COPD Awareness Worldwide

4. “It’s Not Too Late.”
4

5. Description of Levels of Evidence
Evidence Sources of Evidence
Category
A Randomized controlled trials
(RCTs). Rich body of data
B Randomized controlled trials
(RCTs). Limited body of data
C Nonrandomized trials
Observational studies.
D Panel consensus judgment
5

6. Global Strategy for Diagnosis, Management and
Prevention of COPD, 2011: Chapters
 Definition and Overview
 Diagnosis and Assessment
 Therapeutic Options
 Manage Stable COPD
 Manage Exacerbations
REVISED 2011
 Manage Comorbidities
6

7. Definition of COPD
 COPD, a common preventable 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.
 Exacerbations and comorbidities
7

8. Mechanisms Underlying
Airflow Limitation in COPD
Small Airways Disease Parenchymal Destruction
• Airway inflammation • Loss of alveolar attachments
• Airway fibrosis, luminal plugs • Decrease of elastic recoil
• Increased airway resistance
AIRFLOW LIMITATION 8

9. Emphysema & chronic bronchitis
 Not included in the definition
 Emphysema
 Pathological term
 Only one of several structural abnormalities
 Chronic bronchitis
 Independent disease entity
 May precede or follow development of
airflow limitation 9

10. Burden of COPD
 Leading cause of morbidity and mortality
worldwide
 6th leading cause of death in 1990
 Will be the 3rd leading cause of death by the
year 2020

11. Risk Factors for COPD
• Genes
• Lung growth and
• Exposure to particles
development
 Tobacco smoke
• Gender
 Occupational dusts, organic
• Age
and inorganic
• Respiratory infections
 Indoor air pollution from
heating and cooking with • Socioeconomic status
biomass in poorly ventilated • Asthma/Bronchial
dwellings hyperreactivity
 Outdoor air pollution • Chronic Bronchitis

12. Risk Factors for COPD
Genes
Infections
Socio-economic
status
Aging Populations

13. Global Strategy for Diagnosis, Management and
Prevention of COPD, 2011: Chapters
 Definition and Overview
 Diagnosis and Assessment
 Therapeutic Options
 Manage Stable COPD
 Manage Exacerbations
REVISED 2011
 Manage Comorbidities

14. Diagnosis of COPD
EXPOSURE TO RISK
SYMPTOMS FACTORS
shortness of breath tobacco
chronic cough occupation
sputum indoor/outdoor pollution
SPIROMETRY : Required to establish
diagnosis

15. Spirometry: Normal Trace Showing FEV1
and FVC
5 FVC
4
Volume, liters
FEV1 = 4L
3
FVC = 5L
2
FEV1/FVC = 0.8
1
1 2 3 4 5 6
Time, sec

16. Spirometry: Obstructive Disease
5 Normal
4
Volume, liters
3
FEV1 = 1.8L
2 FVC = 3.2L
Obstructive
FEV1/FVC = 0.56
1
1 2 3 4 5 6
Time, seconds

17. Assessment of COPD
1. Assess symptoms
2. Assess degree of airflow limitation
using spirometry
3. Assess risk of exacerbations
4. Assess comorbidities

18. Assessment of COPD
1. Assess symptoms
Assess degree of airflow limitation using spirometry
Assess risk of exacerbations Test (CAT)
COPD Assessment
Assess comorbidities
or
mMRC Breathlessness scale

19. Modified MRC (mMRC)Questionnaire

21. 21

22. Assessment of COPD
1. Assess symptoms
2. Assess degree of airflow limitation
Spirometry for grading severity

23. Classification of Severity of Airflow
Limitation in COPD*
In patients with FEV1/FVC < 0.70:
GOLD 1: Mild FEV1> 80% predicted
GOLD 2: Moderate 50% < FEV1< 80% predicted
GOLD 3: Severe 30% < FEV1< 50% predicted
GOLD 4: Very Severe FEV1< 30% predicted
*Based on Post-Bronchodilator FEV1

24. Assessment of COPD
1. Assess symptoms
2. Assess degree of airflow limitation
using spirometry
3. Assess risk of exacerbations
Assess comorbidities
1. History of exacerbations and
2. Spirometry

25. Combined Assessment of COPD
(GOLD Classification of Airflow Limitation)
4
(C) (D) >2
(Exacerbation history)
3
Risk
Risk
2
1
(A) (B)
1 0
mMRC 0-1 mMRC>2
CAT < 10 CAT >10
Symptoms
(mMRC or CAT score))

26. (GOLD Classification of Airflow Limitation) Combined Assessment of COPD
Patient is now in one of
4
Four categories:
(C) (D)
(Exacerbation history)
>2
3 A: Les symptoms, low risk
Risk
Risk
B: More symtoms, low risk
2 1
(A) (B) C: Less symptoms, high risk
1 0
D: More symptoms, high risk
mMRC 0-1 mMRC>2
CAT < 10 CAT >10
Symptoms
(mMRC or CAT score))

27. Assess COPD Comorbidities
• Cardiovascular diseases
• Skeletal muscle dysfunction
• Osteoporosis
• Anxiety and Depression
• Metabolic syndrome
• Lung cancer
May influence mortality and hospitalizations
Should be looked for routinely and treated appropriately

28. Additional Investigations
•Chest X-ray
•Lung Volumes and Diffusing Capacity
•Oximetry and Arterial Blood Gases
•Alpha-1 Antitrypsin Deficiency Screening
•Exercise Testing

29. Global Strategy for Diagnosis, Management and
Prevention of COPD, 2011: Chapters
 Definition and Overview
 Diagnosis and Assessment
 Therapeutic Options
 Manage Stable COPD
 Manage Exacerbations
REVISED 2011
 Manage Comorbidities

30. Smoking cessation
• Greatest capacity to influence the natural
history of COPD
30

31. Treating tobacco use &
dependence
• Warrants repeated treatment
• Effective treatment exist & should be
offered
• Smoking cessation counseling
• Pharmacotherapies : varenicline,
bupropion, nicotine gum, inhaler, nasal
spray, patch
• Cost effective
31

32. Brief Strategies to Help the
Patient Willing to Quit Smoking
1. ASK Systematically identify all
tobacco users at every visit
2. ADVISE Strongly urge all tobacco
users to quit
3. ASSESS Determine willingness to
make a quit attempt
4. ASSIST Aid the patient in quitting
5. ARRANGE Schedule follow-up contact

33. Pharmacological therapy for stable
COPD
Beta2-agonists
Short-acting beta2-agonists
Long-acting beta2-agonists
Anticholinergics
Short-acting anticholinergics
Long-acting anticholinergics
Combination short-acting beta2-agonists + anticholinergic in one inhaler
Methylxanthines
Inhaled corticosteroids
Combination long-acting beta2-agonists + corticosteroids in one inhaler
Systemic corticosteroids
Phosphodiesterase-4 inhibitors

34. Bronchodilators in COPD
• Central to the symptom management
• Inhaled : preferred
• Choice depends on availability & individual
patient response
• As needed or regular
• Long acting : convenient, more effective
• Combination
34

35. ICS in COPD
• Controversial
• Limited to specific indications
• Regular treatment with ICS improves
symptoms, lung function and quality of life in
patients with FEV1 <60% predicted
(Evidence A)
• Does not modify the long term decline of
FEV1 nor mortality (Evidence A)
• Adverse effects
35

36. Other pharmacological
treatments
• Phosphodiesterase 4 inhibitors: Roflumilast
• Vaccines
• Antibiotics
• Mucolytic & antioxidant agents
• Immunoregulators
• Antitussive
• Vasodilators
• Narcotics
• Nedocromil & leukotriene modifier
36

37. Non-pharmacologic therapies :
pulmonary rehabilitation
 Improvements in exercise tolerance and
symptoms of dyspnea and fatigue
 Effective pulmonary rehabilitation
program duration: 6 weeks
 If exercise training is maintained at home
the patient's health status remains above
pre-rehabilitation levels

38. Other treatments
• O2 therapy
• Ventilatory support
• Surgical treatments
– Lung volume reduction surgery
– Bronchoscopic lung volume reduction
– Lung transplantation
– Bullectomy
38

39. Global Strategy for Diagnosis, Management and
Prevention of COPD, 2011: Major Chapters
 Definition and Overview
 Diagnosis and Assessment
 Therapeutic Options
 Manage Stable COPD
 Manage Exacerbations
REVISED 2011
 Manage Comorbidities

40. Goals of Therapy
 Relieve symptoms
 Improve exercise tolerance Reduce
symptoms
 Improve health status
 Prevent disease progression
 Prevent and treat exacerbations Reduce
risk
 Reduce mortality

41. Identify & reduce exposure
to risk factors
• Tobacco smoke
– Key intervention (Evidence A)
• Occupational exposures
– Avoid continued exposures (Evidence D)
• Indoor & outdoor air pollution
– Biomass fuel
– Efficient ventilation, non polluting cooking
device (Evidence B)
41

42. Manage Stable COPD: Non-pharmacologic
Patient Essential Recommended Depending on
local guidelines
Smoking cessation (can Flu vaccination
A include pharmacologic Physical activity Pneumococcal
treatment) vaccination
Smoking cessation (can
Flu vaccination
include pharmacologic
B, C, D Physical activity Pneumococcal
treatment)
vaccination
Pulmonary rehabilitation

43. Manage Stable COPD: Pharmacologic
Patient First choice Second choice Alternative Choices
LAMA
SAMA prn or
A or LABA Theophylline
SABA prn or
SABA and SAMA
LAMA
SABA and/or SAMA
B or LAMA and LABA
Theophylline
LABA
ICS + PDE4-inh.
C LABA or LAMA and LABA SABA and/or SAMA
LAMA Theophylline
ICS + ICS andLAMA or
ICS + LABA and LAMA or Carbocysteine
LABA or
D ICS+LABA and PDE4-inh.or SABA and/or SAMA
LAMA LAMA and LABA or Theophylline
LAMA and PDE4-inh.

44. FIRST CHOICE
C D
GOLD 4
Exacerbations per year
ICS + LABA ICS + LABA
>2
or or
LAMA LAMA
GOLD 3
A B
GOLD 2
SAMA prn LABA 1
or or
GOLD 1 SABA prn LAMA
0
mMRC 0-1 mMRC>2
CAT < 10 CAT >10

45. SECOND CHOICE
C D
GOLD 4
Exacerbations per year
LAMA and LABA ICS and LAMA or
ICS + LABA and LAMA or >2
ICS + LABA and PDE4-inh or
GOLD 3 LAMA and LABA or
LAMA and PDE4-inh.
A B
GOLD 2
LAMA or LAMA and LABA 1
LABA or
GOLD 1 SABA and SAMA
0
mMRC 0-1 mMRC> 2
CAT < 10 CAT > 10

46. ALTERNATIVE CHOICES
C D
GOLD 4 PDE4-inh. Carbocysteine
Exacerbations per year
SABA and/or SAMA SABA and/or SAMA >2
Theophylline Theophylline
GOLD 3
GOLD 2 A B
SABA and/or SAMA 1
Theophylline Theophylline
GOLD 1
0
mMRC 0-1 mMRC> 2
CAT < 10 CAT >10

47. Monitoring & follow up
• Disease progression & development of
complications
• Monitor pharmacotherapy
• Exacerbation history
• Comorbidities
47

48. Global Strategy for Diagnosis, Management and
Prevention of COPD, 2011: Chapters
 Definition and Overview
 Diagnosis and Assessment
 Therapeutic Options
 Manage Stable COPD
 Manage Exacerbations
REVISED 2011
 Manage Comorbidities

49. Acute Exacerbation
• an acute event
• characterized by a worsening of the
patient’s respiratory symptoms
• that is beyond normal day-to-day
variations and
• leads to a change in medication

50. Consequences Of COPD Exacerbations
Negative Impact on
impact on symptoms
quality of life and lung
function
EXACERBATIONS
Accelerated Increased
lung function economic
decline costs
Increased
Mortality

51. Precipitating factors
• Respiratory tract infection (Bacterial
or viral)
• Exposure to pollutants
• Interruption of maintenance therapy
• Overlaping

52. Investigation for acute exacerbation
• Pulse oxymetry, ABG
• Chest radiograph
• ECG
• CBC
• Sputum for CS
• Biochemical tests
• Spirometry : Not recommended

53. Potential indications for hospital
assessment and admission
• Marked increase in the intensity of symptoms
• Onset of new physical signs
• Failure to respond to initial medical management
• Severe underlying COPD
• Frequent exacerbations
• Serious comorbidities
• Older age
• Insufficeint home support

54. Treatment of exacerbation
• Pharmacologic treatment
• Respiratory support

55. Pharmacologic treatment
• Short acting bronchodilators
• Systemic corticosteroid
• Antibiotics

56. Pharmacologic treatment
• Short acting bronchodilators
• Short acting inhaled β2 agonist with or
without short acting anticholinergic
(Evidence C)
• No significant difference betweent MDI with
or without spacer and nebuliser
• IV methylxanthines only to be used in
selected cases (Evidence B)

57. Pharmacologic treatment: Coticosteroids
• Shorten recovery time, improve FEV1 &
PaO2, reduce the risk of early relapse,
treatment failure & length of hospital stay
(Evidence A)
• 30-40 mg prednisolone for 10-14 days
(Evidence D)
• Nebulised budesonide may be an alternative

58. Pharmacologic treatment: Antibiotics
• Indications
• Increased dyspoea, sputum purulence, sputum
volume (Evidence B)
• Increased sputum purulence with one other cardinal
symptoms (Evidence C)
• Mechanical ventilation (Evidence B)
• Length of antibiotic therapy : 5-10 days (Evidence D)
• The choice of antibiotic
• Route of administration

59. Pharmacologic treatment: others
• Appropriate fluid balance
• Diuretics
• Anticoagulants
• Treatment of comorbidities
• Nutrition

60. Respiratory support
• Oxygen therapy
– Key component of hospital treatment
– Target saturation of 88-92%
– ABG should be checked 30-60 minutes later
– Venturi masks for accurate & controlled delivery

61. Ventilatory support
• Non-invasive
• Invasive

62. Indications for NIV
At least one of following:
• Respiratory acidosis
• Severe dyspnea with clinical signs suggestive
of respiratory muscle fatigue, increased work
of breathing or both (Use of respiratory
accessory muscles, paradoxical motion of the
abdomen, or retraction of the intercostal
spaces)

63. Indications for ICU admission
– Severe dyspnoea that responds inadequately
to initial emergency therapy
– Changes in mental status
– Persistent or worsening hypoxemia (PaO2 <
5.3 kPa, 40 mm Hg) and/or severe/worsening
respiratory acidosis (PH <7.25) despite
supplemental O2 & noninvasive ventilation
– Need for invasive mechanical ventilation
– Need for vasopressors – hemodynamic
instability

64. Indications for invasive mechanical
ventilation
– Unable to tolerate NIV or NIV failure
– Respiratory or cardiac arrest
– Respiratory pauses with loss of consciousness or
gasping
– Diminished consciousness, psychomotor agitation
inadequately controlled by sedation
– Massive aspiration
– Persistent inability to remove respiratory secretions
– Heart rate <50 /min with loss of alertness
– Severe hemodynamic instability without response to
fluids and vasoactive drugs
– Severe ventricuar arrhythmia
– Life threatening hypoxemia in patients unable to
tolerate NIV

65. Discharge criteria
• Able to use long acting bronchodilators with or
without ICS
• Inhaled SABA therapy is required no more
frequently than every 4 hrs
• Able to walk across room
• Able to eat & sleep
• Stable for 12-24 hrs
• Fully understand correct use of medication
• F/U & home care arrangement
• Patient, family & physician are confident

66. Checklist at time of discharge
• Maintenance pharmacotherapy regimen
• Reassessment of inhaler technique
• Education regarding role of maintenance
regimen
• Completion of steroid therapy & antibiotics
• Need for LTOT
• Follow up visit in 4-6 weeks
• Management plan for comorbidities

67. Home management of
exacerbation
• Nurse administered home care
• Effective & practical alternative to
hospitalization in selected patient without
acidotic respiratory failure (Evidence A)

68. 68