lobal Initiative for Chronic bstructive ung isease

1. lobal Initiative for Chronicbstructiveungisease GOLD

2. Global Initiative for Chronic Obstructive Lung Disease In collaboration with: National Heart, Lung, and Blood Institute, NIH and World Health Organization

3. GOLD Executive Committee R. Pauwels, Belgium – Chair S. Buist, US C. Jenkins, Australia P. Calverley, UK N. Khaltaev, Switzerland B. Celli, US C. Lenfant, US Y. Fukuchi, Japan J. Luna, Guatemala S. Hurd, US W. MacNee, UK L. Grouse, US N. Zhong, China

4. Facts About COPD • COPD is the 4th leading cause of death in the United States (behind heart disease, cancer, and cerebrovascular disease). • In 2000, the WHO estimated 2.74 million deaths worldwide from COPD. • In 1990, COPD was ranked 12th as a burden of disease; by 2020 it is projected to rank 5th.

5. 1. 2. Cancer 538,947 3. Cerebrovascular disease (stroke) 158,060 4. Respiratory Diseases (COPD) 114,381 5. Accidents 94,828 Pneumonia and influenza 93,207 6. Diabetes 64,574 7. Suicide 29,264 8. Nephritis 26,295 9. 10. Chronic liver disease 24,936 All other causes of death 469,314 Leading Causes of DeathsU.S. 1998 Cause of Death Number Heart Disease 724,269

6. Percent Change in Age-Adjusted Death Rates, U.S., 1965-1998 Proportion of 1965 Rate 3.0 Coronary Heart Disease Stroke Other CVD COPD All Other Causes 2.5 2.0 1.5 1.0 0.5 –59% –64% –35% +163% –7% 0 1965 - 1998 1965 - 1998 1965 - 1998 1965 - 1998 1965 - 1998

7. Age-Adjusted Death Rates for COPD, U.S., 1960-1995 Deaths per 100,000 60 50 40 30 20 10 0 1960 1965 1970 1975 1980 1985 1990 1995 2000

8. Facts About COPD • Between 1985 and 1995, the number of physician visits for COPD in the United States increased from 9.3 million to16 million. • The number of hospitalizations for COPD in 1995 was estimated to be 500,000. Medical expenditures amounted to an estimated $14.7 billion.

9. COPD 1990 Prevalence Male/1000 Female/1000 • Established Market Economies 6.98 3.79 • Formerly Socialist Economies 7.35 3.45 • India 4.38 3.44 • China 26.20 23.70 • Other Asia and Islands 2.89 1.79 • Sub-Saharan Africa 4.41 2.49 • Latin America and Caribbean 3.36 2.72 • Middle Eastern Crescent 2.69 2.83 • World 9.34 7.33 *From Murray & Lopez, 1996

10. Facts About COPD • Between 1985 and 1995, the number of physician visits for COPD in the United States increased from 9.3 million to16 million. • The number of hospitalizations for COPD in 1995 was estimated to be 500,000. Medical expenditures amounted to an estimated $14.7 billion.

11. Physician Office Visits for Chronicand Unspecified Bronchitis, U.S. Number (Millions) 15 10 5 0 1980 1985 1990 1995 1998 Year Source: National Ambulatory Medical Care Survey, NCHS

12. Facts About COPD • Cigarette smoking is the primary cause of COPD. • In the US 47.2 million people (28% of men and 23% of women) smoke. • The WHO estimates 1.1 billion smokers worldwide, increasing to 1.6 billion by 2025. In low- and middle-income countries, rates are increasing at an alarming rate.

13. Facts About COPD • In India, it is estimated that 400-550 thousand premature deaths can be attributed annually to use of biomass fuels, placing indoor air pollution as a major risk factor in the country. • In Algeria, the prevalence of tuberculosis and acute respiratory infections has decreased since 1965; an increase in COPD and asthma has been observed in the last decade.

14. lobal Initiative for Chronicbstructiveungisease GOLD

15. GOLD Objectives • Increase awareness of COPD among health professionals, health authorities, and the general public • Improve diagnosis, management, and prevention • Stimulate research

16. GOLD Documents • Workshop Report: Global Strategy for the Diagnosis, Management, and Prevention of COPD • Executive Summary • Pocket Guide for health care providers • Guide for patients and their families(available late 2001)

17. GOLD Workshop Report • Evidence-based • Implementation oriented • Diagnosis • Management • Prevention • Outcomes can be evaluated

18. GOLD Workshop Report Evidence category Sources of evidence A Randomized clinical trials Rich body of data B Randomized clinical trials Limited body of data C Non randomized trials Observational studies  D Panel judgment consensus

19. GOLD Workshop Report: Contents • Introduction • Definition and classification • Burden of COPD • Risk factors • Pathogenesis, pathology, and pathophysiology • Management • Future research

20. Definition of COPD Chronic obstructive pulmonary disease (COPD) is a disease state characterized 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.

21. Burden of COPD Key Points • The burden of COPD is underestimated because it is not usually recognized and diagnosed until it is clinically apparent and moderately advanced. • Prevalence, morbidity, and mortality vary appreciably across countries but in all countries where data are available, COPD is a significant health problem in both men and women.

22. Burden of COPD Key Points • The global burden of COPD will increase enormously over the foreseeable future as the toll from tobacco use in developing countries becomes apparent.

23. Burden of COPD Key Points • The economic costs of COPD are high and will continue to rise in direct relation to the ever-aging population, the increasing prevalence of the disease, and the cost of new and existing medical and public health interventions.

24. Direct and Indirect Costs of COPD, 1993 (US $ Billions) • Direct Medical Cost: $14.7 • Total Indirect Cost: $ 9.2 • Mortality related IDC 4.5 • Morbidity related IDC 4.7 • Total Cost $23.9

25. Risk Factors for COPD Host FactorsGenes (e.g. alpha1-antitrypsin deficiency) Hyperresponsiveness Lung growth ExposureTobacco smoke Occupational dusts and chemicals Infections Socioeconomic status

26. Pathogenesis of COPD NOXIOUS AGENT(tobacco smoke, pollutants, occupational agent) COPD Genetic factors Respiratory infection Other

30. Causes of Airflow Limitation • Irreversible • Fibrosis and narrowing of the airways • Loss of elastic recoil due to alveolar destruction • Destruction of alveolar support that maintains patency of small airways

31. Causes of Airflow Limitation • Reversible • Accumulation of inflammatory cells, mucus, and plasma exudate in bronchi • Smooth muscle contraction in peripheral and central airways • Dynamic hyperinflation during exercise

32. GOLD Workshop ReportFour Components of COPD Management • Assess and monitor disease • Reduce risk factors • Manage stable COPD • Education • Pharmacologic • Non-pharmacologic • Manage exacerbations

33. Objectives of COPD Management • Prevent disease progression • Relieve symptoms • Improve exercise tolerance • Improve health status • Prevent and treat exacerbations • Prevent and treat complications • Reduce mortality • Minimize side effects from treatment

34. GOLD Workshop ReportFour Components of COPD Management • Assess and monitor disease • Reduce risk factors • Manage stable COPD • Education • Pharmacologic • Non-pharmacologic • Manage exacerbations

35. Assess and Monitor Disease: Key Points • Diagnosis of COPD is based on a history of exposure to risk factors and the presence of airflow limitation that is not fully reversible, with or without the presence of symptoms.

36. Assess and Monitor Disease: Key Points • Patients who have chronic cough and sputum production with a history of exposure to risk factors should be tested for airflow limitation, even if they do not have dyspnea.

37. Assess and Monitor Disease: Key Points • For the diagnosis and assessment of COPD, spirometry is the gold standard. • Health care workers involved in the diagnosis and management of COPD patients should have access to spirometry.

38. Assess and Monitor Disease: Key Points • Measurement of arterial blood gas tension should be considered in all patients with FEV1 < 40% predicted or clinical signs suggestive of respiratory failure or right heart failure.

39. Diagnosis of COPD EXPOSURE TO RISK FACTORS SYMPTOMS cough tobacco sputum occupation dyspnea indoor/outdoor pollution è SPIROMETRY

40. Spirometry: Normal and COPD

41. Factors Determining Severity Of Chronic COPD • Severity of symptoms • Severity of airflow limitation • Frequency and severity of exacerbations • Presence of complications of COPD • Presence of respiratory insufficiency • Comorbidity • General health status • Number of medications needed to manage the disease

42. Classification by Severity Stage Characteristics 0: At riskNormal spirometry Chronic symptoms (cough, sputum)  I: MildFEV1/FVC < 70%; FEV1 ³ 80% predicted With or without symptoms (cough, sputum) II: ModerateFEV1/FVC < 70%; 30% £ FEV1 < 80% predicted (IIA: 50% £ FEV1 < 80% predicted; IIB: 30% £ FEV1 < 50% predicted) With or without chronic symptoms (cough, sputum, dyspnea) III: SevereFEV1/FVC < 70%; FEV1 < 30% predicted or FEV1 < 50%predicted plus respiratory failure or clinical signs of right heart failure

44. GOLD Workshop ReportFour Components of COPD Management • Assess and monitor disease • Reduce risk factors • Manage stable COPD • Education • Pharmacologic • Non-pharmacologic • Manage exacerbations

45. Reduce Risk FactorsKey Points • Reduction of total personal exposure to tobacco smoke, occupational dusts and chemicals, and indoor and outdoor air pollutants are important goals to prevent the onset and progression of COPD. • Smoking cessation is the single most effective-and cost-effective- intervention to reduce the risk of developing COPD and stop its progression (Evidence A).

46. Reduce Risk FactorsKey Points • Brief tobacco dependence treatment is effective (Evidence A), and every tobacco user should be offered at least this treatment at every visit to a health care provider. • Three types of counseling are especially effective: practical counseling, social support as part of treatment, and social support arranged outside of treatment (Evidence A).

47. Reduce Risk FactorsKey Points • Several effective pharmacotherapies for tobacco dependence are available (Evidence A), and at least one of these medications should be added to counseling if necessary, and in the absence of contraindications.

48. Reduce Risk FactorsKey Points • Progression of many occupationally-induced respiratory disorders can be reduced or controlled through a variety of strategies aimed at reducing the burden of inhaled particles and gases (Evidence B).

49. Brief Strategies To Help The Patient Willing To Quit Smoking • ASKSystematically identify all tobacco users at every visit. • ADVISEStrongly urge all tobacco users to quit. • ASSESSDetermine willingness to make a quit attempt. • ASSIST Aid the patient in quitting. • ARRANGESchedule follow-up contact.

50. GOLD Workshop ReportFour Components of COPD Management • Assess and monitor disease • Reduce risk factors • Manage stable COPD • Education • Pharmacologic • Non-pharmacologic • Manage exacerbations