G lobal initiative for chronic O bstructive L ung D isease

1. Global initiative for chronic Obstructive Lung Disease GOLD MANAGEMENT PLAN FOR CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

2. WHAT IS COPD? “COPD is a disease state characterised by airflow limitation that is not fully reversible. The airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases.”

3. WHAT ARE THE CONSEQUENCES OF COPD? • Symptoms of COPD include:production of sputum, chronic cough & dyspnoea (shortness of breath) • Exacerbationsare a major cause of disability and often lead to a significant decrease in quality of life • The disease cannot be fully reversed; however disease progression can be slowed by smoking cessation

4. WHY TACKLE COPD? • COPD is the fourth leading cause of death in the world • An increase in prevalence/mortality is predicted for the future • A unified international effort is required to reverse incidence trends

5. WHAT IS GOLD? • GOLD is a collaborative project of the US National Heart, Lung and Blood Institute & WHO • “GOLD provides guidelines to achieve a global strategy for the diagnosis, management and prevention of COPD” • An international panel which consists of specialists in the areas of respiratory medicine, epidemiology, socioeconomics, public health & health education • GOLD aims to increase awareness of COPD and decrease morbidity and mortality

6. GOALS OF EFFECTIVE COPD MANAGEMENT • Prevent disease progression • Relieve symptoms • Improve exercise tolerance • Improve health status • Prevent and treat complications • Prevent and treat exacerbations • Reduce mortality • These goals should be reached with minimumside effects from treatment

7. COMPONENTS OF COPD GUIDELINES • Assess and monitor disease • Decrease risk factors • Manage stable COPD • Manage exacerbations

8. EVIDENCE-BASED APPROACHSTATEMENTS SUPPORTED BY DEFINED LEVELS OF EVIDENCE Evidence category Sources of evidence Evidence A Randomised controlled trials. Rich body of data Randomised controlled trials. Limited body of data Evidence B Non-randomised trials Observational studies Evidence C Evidence D Panel consensus

9. ASSESS & MONITOR DISEASE • Diagnosis should be based on: • a history of exposure to risk factors • & presence of airflow limitation that is not fully reversible • presence of symptoms • Spirometry (FEV1; FEV1/VC) for diagnosis & assessment • standardised, (reproducible), (objective tool) • Annual assessment based on symptoms, spirometry and presence of complications • Even patients who do not show a significant FEV1 response to a SAB test may benefit symptomatically from long-term bronchodilator treatment

10. HOW SHOULD COPD BE DIAGNOSED & ASSESSED?KEY INDICATORS FOR CONSIDERING A DIAGNOSIS OF COPD Dyspnoea Progressive, persistent, worse on exercise, worse during respiratory infections Chronic cough Present intermittently / every day, often present throughout the day Chronic sputum production In any pattern Tobacco smoke, occupational dusts & chemicals, smoke from home heating fuels History of exposure to risk factors, especially:

11. HOW CAN WE REDUCE THE RISK OF DEVELOPING COPD? • Smoking cessation is the single most effective/cost effective intervention • reduce risk of developing disease (A) • stop progression of disease (A) • Treating tobacco dependence is effective • Every smoker should be offered • counselling (A) • smoking cessation medications where appropriate (A)

12. HOW SHOULD COPD BE MANAGED IN PRACTICE? • Stepwise increase in treatment recommended, dependent on • severity of disease, response to treatments • Exercise training programmes (pulmonary rehabilitation) • improve exercise tolerance/symptoms of dyspnoea & fatigue (A) • Health education • Increase self-management skills, ability to cope with illness and health status (patient well-being) (A) • COPD lung damage is irreversible. Pharmacotherapy aims to improve symptoms and/or decrease complications

13. HOW SHOULD COPD BE MANAGED IN PRACTICE? • Bronchodilators are central to managing symptoms (A) • beta2-agonists • anticholinergics • theophylline (A) • Choice of bronchodilator depends on: • a patient’s response (symptom relief and side effects) • availability • Long-acting bronchodilators are more convenient for regular therapy than short-acting agents • The long-acting beta2-agonist, salmeterol has been shown to improve health status significantly in doses of 50mcg b.d.1 • Similar data for short-acting beta2-agonists are not available

14. MANAGEMENT OF SYMPTOMS IN COPD Bronchodilators • Central to symptom management • Prescribed to patients as needed • LABs more convenient than SABs • Benefit patient symptomatically Methylxanthines (Theophyllines) (duration <24 hours Anticholinergics (duration of 6-9 hours) Beta2-agonists Short-acting Beta2-agonists (duration of 4-6 hours) • Fenoterol • Salbutamol • Terbutaline Long-acting Beta2-agonists (duration of >12 hours) • Salmeterol • Formoterol • Ipratropium bromide • Oxitropium bromide • Aminophylline (SR) • Theophylline (SR)

15. HOW SHOULD COPD BE MANAGED IN PRACTICE? • Regular inhaled corticosteroids are recommended for: • patients with a response in FEV1 (B) • patients with an FEV1 <50% predicted & repeated exacerbations (B) • A short course of oral corticosteroids (OCS) is a poor predictor of the long-term response to inhaled glucocorticosteroids • Chronic treatment with OCS should be avoided • unfavourable benefit:risk ratio (A)

16. HOW SHOULD COPD EXACERBATIONS BE MANAGED IN PRACTICE? • Characteristics of exacerbations: • important clinical events • causes largely unknown • significant role of infection (B) • Effective treatments: • Inhaled bronchodilators (A) • Oral corticosteroids (A) • Antibiotic treatment for suspected infection (e.g. change of colour of sputum) (B) • Non-invasive positive pressure ventilation (A)

17. FUTURE RESEARCH • Much about COPD is still unknown and further research is needed in many areas: • improved early detection/diagnosis • new approaches for interventions • means to identify the “susceptible” smoker • more effective means of managing exacerbations • standardise tracking = future planning • cost & burden analysis

18. GOALS OF EFFECTIVE COPD MANAGEMENT • Prevent disease progression • Relieve symptoms • Improve exercise tolerance • Improve health status • Prevent and treat complications • Prevent and treat exacerbations • Reduce mortality