COPD:Epidemiology,%20Pathophysiology,%20

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GOLD Update 2011

• Rabab A. El Wahsh, MD.
• Lecturer of Chest Diseases and Tuberculosis
• Minoufiya University

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Global Initiative for chronic obstructive
pulmonary disease (GOLD)

• Immediately following the release of the first
  GOLD report in 2001, the GOLD board of directors
  appointed a science committee, charged with
  keeping the GOLD documents up to date.
• The first update to the GOLD report was in 2003,
  then annual updated documents were prepared and
  released on the GOLD website.
• A comprehensively updated version was released in
  2006, then in 2010 and lastly in 2011.

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Whats new in GOLD 2011?

• The definition of COPD was not significantly
  modified but has been reworded for clarity.
• Assessment of COPD is based on the patients
  level of symptoms, future risk of exacerbations,
  the severity of spirometric abnormlity, and the
  identification of comorbidities.
• Management of stable COPD is based , not only on
  level of FEV1 but on disease impact and future
  risk of disease progression.
• More focusing on comorbidities.

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COPD Definition

• GOLD 2010
• Chronic obstructive pulmonary disease (COPD) 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 is usually
  progressive and associated with an abnormal
  inflammatory response of the lungs to noxious
  particles or gases.

• GOLD 2011
• Chronic obstructive pulmonary disease (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 contribute
  to the overall severity in individual patients.

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Risk Factors for COPD
Genes
Infections
Socio-economic status
Aging Populations
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Diagnosis and Assessment of COPD
GOLD 2010
GOLD 2011
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Diagnosis and Assessment of COPD

• While post-bronchodilator spirometry is required
  for the diagnosis and assessment of severity of
  COPD, the degree of reversibility of airflow
  limitation is no longer recommended. The degree
  of reversibility has never been shown to add to
  the diagnosis, differential diagnosis with
  asthma, or to predicting the response to
  long-term treatment with bronchodilators or
  corticosteroids.
• The use of a fixed ratio FEV1/FVC to define
  airflow limitation will result in more frequent
  diagnosis of COPD in the elderly, and less
  frequent diagnosis in adults younger than 45
  years, especially of mild disease, compared to
  using a cutoff based on the lower limit of normal
  values for FEV1/FVC. From a scientific
  perspective it is difficult to determine which of
  these criteria is correct to diagnose COPD.

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Diagnosis of COPD
EXPOSURE TO RISK FACTORS
SYMPTOMS
shortness of breath
tobacco
chronic cough
occupation
sputum
indoor/outdoor pollution
SPIROMETRY Required to establish diagnosis
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Assessment of GOLD stage using spirometry (GOLD
2010)
In patients with FEV1/FVC lt 0.70 GOLD 1 Mild
FEV1 gt 80 predicted GOLD 2
Moderate 50 lt FEV1 lt 80 predicted GOLD 3
Severe 30 lt FEV1 lt 50 predicted GOLD
4 Very Severe FEV1 lt 30 predicted Based on
Post-Bronchodilator FEV1
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Combined Assessment of COPD (GOLD 2011)

• Assess symptoms
• Assess degree of airflow limitation using
  spirometry
• Assess risk of exacerbations
• Assess comorbidities

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Assessment of Symptoms
COPD Assessment Test (CAT) An 8-item measure of
health status impairment in COPD. Breathlessness
Measurement using the Modified British Medical
Research Council (mMRC) Questionnaire relates
well to other measures of health status and
predicts future mortality risk.
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Modified MRC (mMRC)Questionnaire
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COPD Assessment Test (CAT)
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Assessment of degree of airflow limitation using
spirometry
In patients with FEV1/FVC lt 0.70 GOLD 1 Mild
FEV1 gt 80 predicted GOLD 2
Moderate 50 lt FEV1 lt 80 predicted GOLD 3
Severe 30 lt FEV1 lt 50 predicted GOLD
4 Very Severe FEV1 lt 30 predicted Based on
Post-Bronchodilator FEV1
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Assessment of risk of exacerbations
An exacerbation of COPD is defined as an acute
event characterized by a worsening of the
patients respiratory symptoms that is beyond
normal day-to-day variations and leads to change
in medication. Two exacerbations or more within
the last year or an FEV1 lt 50 of predicted
value are indicators of high risk of future
exacerbations.
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Combined Assessment of COPD
Patient is now in one of four categories A
Less symptoms, low risk B More symtoms, low
risk C Less symptoms, high risk D More
Symtoms, high risk
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(C)
(D)
gt 2
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Risk (Exacerbation history)
Risk (GOLD Classification of Airflow Limitation)
2
(B)
1
(A)
1
0

mMRC 0-1 CAT lt 10
mMRC gt 2 CAT gt 10
Symptoms (mMRC or CAT score))
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Assessment of COPD Comorbidities

• COPD patients are at increased risk for
• Cardiovascular diseases
• Osteoporosis
• Respiratory infections
• Anxiety and Depression
• Diabetes
• Lung cancer
• These comorbid conditions may influence mortality
  and hospitalizations and should be looked for
  routinely, and treated appropriately.

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Goals for treatment of stable COPD

• Reduce symptoms by
• Relieving symptoms
• Improving exercise tolerence
• Improving health status
• Reduce risk by
• Preventing disease progression
• Preventing and treatment of exacerbation
• Reduction of mortality

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Management of stable COPD
2010
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Initial pharmacologic management of COPD (2011)
Patient group First choice Second choice Alternative choice
A Short acting anticholinergic Or Short acting B2 agonist Long acting anticholinergic Or Long acting B2 agonist Or Short acting B2 agonist and Short acting anticholinergic Theophylline
B Long acting Anticholinergic Or Long acting B2 agonist Long acting Anticholinergic and Long acting B2 agonist Short acting B2 agonist and/ or Short acting anticholinergic Theophylline
C Inhaled corticosteroid Long acting B2 agonist Or Long acting anticholinergic Long acting Anticholinergic and Long acting B2 agonist Phospodiesterase-4 inhibitor Short acting B2 agonist and/ or Short acting anticholinergic Theophylline
D Inhaled corticosteroid Long acting B2 agonist Or Long acting anticholinergic Inhaled corticosteroid and Long acting Anticholinergic Or inhaled corticosteroid Long acting B2 agonist and long acting anticholinergic Or Inhaled corticosteroid Long acting B2 agonist and phosphodiesterse-4 inhibitor Or Long acting Anticholinergic and long acting B2 agonist Or Long acting anticholinergic and phosphodiesterase-4 inhibitor Carbocysteine Short acting B2 agonist And/or Short acting anticholinergic theophylline
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Non-pharmacologic management of COPD (2011)
Patient group Essential Recommended Depending on local guidelines
A Smoking cessation Physical activity Flu vaccine Pneumococcal vaccine
B-D Smoking cessation Pulmonary rehabilitation Physical activity Flu vaccine Pneumococcal vaccine
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THANK YOU