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Alvar G. Agusti, MD
Thorax Institute, Hospital Clinic
Univ. Barcelona, Ciberes, Barcelona, Spain
Jean Bourbeau, MD
McGill University Health Centre
Montreal, Quebec, Canada
Antonio Anzueto, MD
University of Texas Health Science Center
San Antonio, Texas, USA
Bartolome R. Celli, MD
Brigham and Womens Hospital
Boston, Massachusetts USA
Marc Decramer, MD
Katholieke Universiteit Leuven
Leuven, Belgium
Leonardo M. Fabbri, MD
University of Modena & Reggio Emilia
Modena, Italy
Paul Jones, MD
St Georges Hospital Medical School
London, England, UK
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Nicolas Roche, MD
Htel-Dieu
Paris, France
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Roberto Rodriguez-Roisin, MD
Thorax Institute, Hospital Clinic
Univ. Barcelona, Barcelona, Spain
Donald Sin, MD
St. Pauls Hospital
Vancouver, Canada
AT
Claus Vogelmeier, MD
University of Gieen and Marburg
Marburg, Germany
Robert Stockley, MD
University Hospital
Birmingham, UK
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Fernando Martinez, MD
University of Michigan School of Medicine
Ann Arbor, Michigan, USA
Masaharu Nishimura, MD
Hokkaido University School of Medicine
Sapporo, Japan
Claus Vogelmeier, MD
University of Giessen and Marburg
Marburg, Germany
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Jadwiga A. Wedzicha, MD
Univ College London
London, UK
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*Disclosure forms for GOLD Committees are posted on the GOLD Website, www.goldcopd.org
ii
INVITED REVIEWERS
Joan-Albert Barbera, MD
Hospital Clinic, Universitat de Barcelona
Barcelona Spain
A. Sonia Buist, MD
Oregon Health Sciences University
Portland, OR, USA
Sanjay Sethi, MD
State University of New York
Buffalo, NY, USA
OR
Peter Calverley, MD
University Hospital Aintree
Liverpool, England, UK
Bart Celli, MD
Brigham and Womens Hospital
Boston, MA, USA
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Lorenzo Corbetta, MD
University of Florence
Florence, Italy
M. W. Elliott, MD
St. Jamess University Hospital
Leeds, England, UK
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Yoshinosuke Fukuchi, MD
Juntendo University
Tokyo, Japan
NO
Masakazu Ichinose, MD
Wakayama Medical University
Kimiidera, Wakayama, Japan
-D
Fernando Lundgren, MD
Pernambuco, Brazil
E. M. Irusen, MD
University of Stellenbosch
South Africa
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Christine Jenkins, MD
Woolcock Institute of Medical Research
Camperdown. NSW, Australia
H. A. M. Kerstjens, MD
University of Groningen
Groningen, The Netherlands
Timothy J. MacDonald, MD
St. Vincents University Hospital
Dublin, Ireland
Takahide Nagase, MD
University of Tokyo
Tokyo, Japan
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Peter Lange, MD
Hvidovre University Hospital
Copenhagen, Denmark
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Mostafizur Rahman, MD
NIDCH
Mohakhali, Dhaka, Bangladesh
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Atsushi Nagai, MD
Tokyo Womens Medical University
Tokyo, Japan
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Dennis Niewoehner, MD
Veterans Affairs Medical Center
Minneapolis, MN, USA
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David Price, MD
University of Aberdeen
Aberdeen, Scotland, UK
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PREFACE
In 2011, the Global Initiative for Chronic Obstructive Lung
Disease (GOLD) released a consensus report, Global
Strategy for the Diagnosis, Management, and Prevention of
COPD. It recommended a major revision in the management
strategy for COPD that was presented in the original 2001
document. Updated reports released in January 2013 and
OR
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Marc Decramer, MD
Chair, GOLD Board of Directors
Professor of Medicine
Chief of the Respiratory Division
University Hospital
Katholieke Universiteit, Leuven Belgium
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Jrgen Vestbo, MD
Vice-Chair, GOLD Board of Directors
Chair, GOLD Science Committee
Professor of Respiratory Medicine
Odense University Hospital
Odense, Denmark (and)
The University of Manchester
Manchester Academic Health Science
University Hospital of South Manchester
NHS Foundation Trust, Manchester, UK
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iv
Preface.............................................................. .iv
Methodology and Summary of New
Recommendations
viii
Introduction.....................................................xiv
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20
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21
21
24
25
25
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26
27
28
28
29
29
29
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Key Points
3. Therapeutic Options
Key Points
Smoking Cessation
Pharmacotherapies for Smoking Cessation
Pharmacologic Therapy for Stable COPD
Overview of the Medications
Bronchodilators
Corticosteroids
Phosphodiesterase-4 Inhibitors
Other Pharmacologic Treatments
Non-Pharmacologic Therapies
Rehabilitation
Components of Pulmonary Rehabilitation
Programs
Other Treatments
Oxygen Therapy
Ventilatory Support
Surgical Treatments
Palliative Care, End-of-life Care, Hospice Care
Burden Of COPD
Prevalence
Morbidity
Mortality
Economic Burden
Social Burden
1
2
2
2
3
3
3
3
4
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9
10
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11
12
12
12
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15
15
16
17
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53
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in COPD
2
Figure 2.1A. Spirometry - Normal Trace
13
Figure 2.1B. Spirometry - Obstructive Disease
13
Figure 2.2. Relationship Between Health-Related
and
1
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Exacerbations
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COPD
26
Table 4.1. Goals for Treatment of Stable COPD 32
Table 4.2. Model of Symptom/Risk of Evaluation of
COPD
33
Table 4.3. Non-pharmacologic Management
of COPD
34
Table 4.4. Initial Pharmacologic Management
of COPD
36
Table 5.1. Assessment of COPD Exacerbations:
Medical History
41
Table 5.2. Assessment of COPD Exacerbations:
Signs of Severity
41
Table 5.3. Potential Indications for Hospital
Assessment or Admission
41
Table 5.4. Management of Severe but Not
Life-Threatening Exacerbations
42
Table 5.5. Therapeutic Components of Hospital
Management
42
Table 5.6. Indications for ICU Admission
43
Table 5.7. Indications for Noninvasive Mechanical
Ventilation
43
Figures
21
AT
References
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(ACOS)
12
OR
47
48
48
48
49
50
50
50
50
50
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Diagnosis
Assessment
Treatment Options
Treatment Setting
Pharmacologic Treatment
Respiratory Support
Hospital Discharge and Follow-up
Home Management of Exacerbations
Prevention of COPD Exacerbations
39
40
40
40
41
41
41
41
43
44
45
45
5. Management of Exacerbations
Key Points
Tables
Table A. Description of Levels of Evidence
Table 2.1. Key Indicators for Considering
a Diagnosis of COPD
Table 2.2. Causes of Chronic Cough
Table 2.3. Considerations in Performing
Spirometry
NO
37
37
38
15
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44
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Global Strategy
for Diagnosis, Management and Prevention of COPD
was issued in 2001. In 2006 and again in 2011 a
complete revision was prepared based on published
research. These reports, and their companion
documents, have been widely distributed and
translated into many languages and can be found on
the GOLD website (www.goldcopd.org).
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1
The Global Strategy for Diagnosis, Management and Prevention of COPD (updated 2014),
the Pocket Guide (updated 2014) and the complete list of references examined by the
Committee are available on the GOLD website www.goldcopd.org.
2
Chair; A. Agusti, A. Anzueto, L. Fabbri, P. Jones, F.
viii
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tiotropium in
patients with COPD: the GLOW2 study. Eur Respir J
2012 Nov;40(5):1106-14.
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previous recommendations
Page 26, left column, line 11, after reference 297,
insert:
Reference 562: Tse HN, Raiteri L, Wong KY, Yee
KS, Ng LY, Wai KY, Loo CK, Chan MH. High-dose
N-acetylcysteine in stable COPD: the 1-year, doubleblind, randomized, placebo-controlled HIACE study.
Chest 2013 Jul;144(1):106-18.
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Assessment of Symptoms.
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xii
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xiii
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BACKGROUND
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INTRODUCTION
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xiv
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METHODOLOGY
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LEVELS OF EVIDENCE
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Nonrandomized trials.
Observational studies.
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Definition
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Evidence is from endpoints of intervention studies that include only a limited number
general, Category B pertains when few randomized trials exist, they are small in size,
they were undertaken in a population that differs from the target population of the
recommendation, or the results are somewhat inconsistent.
Evidence is from outcomes of uncontrolled or nonrandomized trials or from
observational studies
This category is used only in cases where the provision of some guidance was deemed
justify placement in one of the other categories. The Panel Consensus is based on
xvi
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CHAPTER
1
DEFINITION
AND
OVERVIEW
OR
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DEFINITION
AIRFLOW LIMITATION
NO
Parenchymal destruction
Loss of alveolar attachments
Decrease of elastic recoil
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BURDEN OF COPD
COPD is a leading cause of morbidity and mortality
worldwide and results in an economic and social
burden that is both substantial and increasing2,5. COPD
prevalence, morbidity, and mortality vary across countries
and across different groups within countries. COPD is the
result of cumulative exposures over decades. Often, the
prevalence of COPD is directly related to the prevalence
of tobacco smoking, although in many countries, outdoor,
occupational and indoor air pollution the latter resulting
from the burning of wood and other biomass fuels are
major COPD risk factors6. The prevalence and burden of
COPD are projected to increase in the coming decades
due to continued exposure to COPD risk factors and the
changing age structure of the worlds population (with more
people living longer and therefore expressing the long-term
effects of exposure to COPD risk factors)5. Information
on the burden of COPD can be found on international
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diagnosis of COPD9.
Despite the complexities, data are emerging that
enable some conclusions to be drawn regarding COPD
prevalence, not least because of increasing data quality
control. A systematic review and meta-analysis of studies
carried out in 28 countries between 1990 and 20048, and
an additional study from Japan10, provide evidence that
the prevalence of COPD is appreciably higher in smokers
and ex-smokers than in nonsmokers, in those over 40
years of age than those under 40, and in men than in
women. The Latin American Project for the Investigation
of Obstructive Lung Disease (PLATINO)11 examined the
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Morbidity
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Economic Burden
the European Union, the total direct costs of respiratory
disease are estimated to be about 6% of the total health
care budget, with COPD accounting for 56% (38.6 billion
Euros) of this cost of respiratory disease17. In the United
States the estimated direct costs of COPD are $29.5 billion
and the indirect costs $20.4 billion18. COPD exacerbations
account for the greatest proportion of the total COPD
burden on the health care system. Not surprisingly, there is
a striking direct relationship between the severity of COPD
and the cost of care, and the distribution of costs changes
as the disease progresses. For example, hospitalization
and ambulatory oxygen costs soar as COPD severity
increases. Any estimate of direct medical expenditures for
home care under-represents the true cost of home care to
society, because it ignores the economic value of the care
provided to those with COPD by family members.
In developing countries, direct medical costs may be less
important than the impact of COPD on workplace and
home productivity. Because the health care sector might
not provide long-term supportive care services for severely
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Genes
Social Burden
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Socioeconomic Status
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Exposure to Particles
Across the world, cigarette smoking is the most commonly
encountered risk factor for COPD. Cigarette smokers
have a higher prevalence of respiratory symptoms and
lung function abnormalities, a greater annual rate of
decline in FEV1, and a greater COPD mortality rate than
nonsmokers44. Other types of tobacco (e.g., pipe, cigar,
water pipe45) and marijuana46 are also risk factors for
COPD47,48. Passive exposure to cigarette smoke (also
known as environmental tobacco smoke or ETS) may
also contribute to respiratory symptoms49 and COPD50 by
increasing the lungs total burden of inhaled particles and
gases51,52. Smoking during pregnancy may also pose a risk
for the fetus, by affecting lung growth and development in
utero and possibly the priming of the immune system53,54.
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NO
71
, and in a longitudinal study self-reported
asthma was associated with excess loss of FEV1 in
the general population72. In the European Community
Respiratory Health Survey, bronchial hyperresponsiveness
was second only to cigarette smoking as the leading risk
factor for COPD, responsible for 15% of the population
attributable risk (smoking had a population attributable
risk of 39%)73
in asthmatic nonsmokers and non-asthmatic smokers is
markedly different, suggesting that the two disease entities
may remain different even when presenting with similarly
reduced lung function74. However, clinically separating
asthma from COPD may not be easy.
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PATHOLOGY, PATHOGENESIS
AND PATHOPHYSIOLOGY
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Pathology
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Pathogenesis
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The extent of
OR
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gas exchange101
may contribute to skeletal muscle wasting and cachexia,
and may initiate or worsen comorbidities such as ischemic
heart disease, heart failure, osteoporosis, normocytic
anemia, diabetes, metabolic syndrome, and depression.
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Gas exchange
abnormalities result in hypoxemia and hypercapnia,
and have several mechanisms in COPD. In general,
gas transfer for oxygen and carbon dioxide worsens as
the disease progresses. Reduced ventilation may also
be due to reduced ventilatory drive. This may lead to
carbon dioxide retention when it is combined with reduced
ventilation due to a high work of breathing because
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CHAPTER
2
DIAGNOSIS
AND
OR
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KEY POINTS:
OR
Chronic cough:
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DIAGNOSIS
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. Thus, GOLD
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Symptoms
OR
Intrathoracic
Chronic obstructive pulmonary disease
Asthma
Lung cancer
Tuberculosis
Bronchiectasis
Left heart failure
Interstitial lung disease
Idiopathic cough
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Extrathoracic
Chronic allergic rhinitis
Upper Airway Cough Syndrome (UACS)
-D
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110
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Fatigue, weight
loss and anorexia are common problems in patients with
severe and very severe COPD115. They are prognostically
important116 and can also be a sign of other diseases (e.g.,
tuberculosis, lung cancer), and therefore should always
be investigated. Cough syncope occurs due to rapid
increases in intrathoracic pressure during prolonged attacks
of coughing. Coughing spells may also cause rib fractures,
which are sometimes asymptomatic. Ankle swelling may
be the only symptomatic pointer to the development of cor
pulmonale. Symptoms of depression and/or anxiety merit
common in COPD117 and are associated with increased risk
of exacerbations and poorer health status.
Medical History
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Preparation
Spirometers need calibration on a regular basis.
Spirometers should produce hard copy or have a digital display of the
expiratory curve to permit detection of technical errors or have an automatic
prompt to identify an unsatisfactory test and the reason for it.
The supervisor of the test needs training in its effective performance.
Maximal patient effort in performing the test is required to avoid
underestimation of values and hence errors in diagnosis and management.
Bronchodilation
Possible dosage protocols are 400 mcg beta2
or the two combined122. FEV1
NO
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Physical Examination
AT
anticholinergic or a combination.
Performance
Spirometry should be performed using techniques that meet published
standards .
The expiratory volume/time traces should be smooth and free from irregularities.
The recording should go on long enough for a volume plateau to be reached,
which may take more than 15 seconds in severe disease.
Both FVC and FEV1
technically satisfactory curves and the FVC and FEV1 values in these three
curves should vary by no more than 5% or 150 ml, whichever is greater.
The FEV1/FVC ratio should be taken from the technically acceptable curve with
the largest sum of FVC and FEV1.
TE
Spirometry
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ASSESSMENT OF DISEASE
The goals of COPD assessment are to determine the severity
of the disease, its impact on the patients health status and
the risk of future events (such as exacerbations, hospital
admissions or death), in order to, eventually, guide therapy.
Volume, liters
Volume, liters
4
4
FEV1 = 4L
FVC = 5L
FEV1/FVC = 0.8
FEV1 = 1.8L
FVC = 3.2L
FEV1/FVC = 0.56
1
1
Time, seconds
Obstructive
OR
Time, seconds
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Assessment of Symptoms
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AT
mMRC Grade 2. I walk slower than people of the same age on the
level because of breathlessness, or I have to stop for breath when
walking on my own pace on the level.
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GOLD 4:
Mild
FEV1
Very Severe
Spirometric Assessment
80% predicted
1
Table 2.5
OR
GOLD 1:
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?
11%*
Moderate
Risk
15%*
Severe
24%*
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Very severe
(C)
(D)
(A)
(B)
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1 (not leading
to hospital
admission)
Assessment of Comorbidities
2
or
1 leading
to hospital
admission
Risk
(Exacrbation History)
3-year
Mortality*
OR
Hospitalizations
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Exacerbations
GOLD
spirometric
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CAT < 10
CAT 10
Symptoms
mMRC 0-1
mMRC 2
Breathlessness
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2.3
with the mMRC) and determine if the patient belongs to the
boxes on the left side Less Symptoms (CAT < 10) or Less
Breathlessness (mMRC grade 0-1); or belongs to boxes
or
AL
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or
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OR
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COPD patients
exhibit gas trapping (a rise in residual volume) from
AL
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The World
Health Organization recommends that COPD patients
from areas with a particularly high prevalence of alpha-1
DIFFERENTIAL DIAGNOSIS
NO
Pulse
oximetry can be used to evaluate a patients oxygen
saturation and need for supplemental oxygen therapy.
Pulse oximetry should be used to assess all stable
patients with FEV1 < 35% predicted or with clinical signs
suggestive of respiratory failure or right heart failure. If
peripheral saturation is < 92% arterial blood gases should
be assessed147.
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use157,158.
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COPD
OR
Asthma
Tuberculosis
NO
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Diffuse Panbronchiolitis
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Obliterative Bronchiolitis
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(especially in the developing world where other risk factors may be more important than cigarette smoking); asthma may develop in adult and even in elderly patients.
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CHAPTER
3
OPTIONS
OR
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4.
AT
Evaluation of the smoking cessation component in a longterm, multicenter study indicates that if effective resources
and time are dedicated to smoking cessation, 25% longterm quit rates can be achieved159.
Effective treatments for tobacco dependence exist and all tobacco users should
be offered these treatments.
visit.
Brief smoking cessation counseling is effective and every tobacco user should
be offered such advice at every contact with health care providers.
dependence counseling and its effectiveness.
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SMOKING CESSATION
NO
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8.
are effective and at least one of these medications should be prescribed in the
absence of contraindications.
Tobacco dependence treatments are cost effective relative to other medical
and disease prevention interventions.
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therapy in any form (nicotine gum, inhaler, nasal spray,
transdermal patch, sublingual tablet, or lozenge) reliably
increases long-term smoking abstinence rates160-162 and is
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20 THERAPEUTIC OPTIONS
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OR
2.
ADVISE
In a clear, strong, and
personalized manner, urge every tobacco user to quit.
ASSESS
Ask every tobacco
user if he or she is willing to make a quit attempt at this time (e.g., within the
NO
ARRANGE
in person or via telephone.
5.
ASSIST
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PHARMACOLOGIC THERAPY
FOR STABLE COPD
-D
4.
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Implement an
1.
3.
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THERAPEUTIC OPTIONS 21
Inhaler (mcg)
Solution for
Nebulizer (mg/ml)
Oral
0.05% (Syrup)
Vials for
Injection (mg)
Fenoterol
Levalbuterol
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Beta2-agonists
0.21, 0.42
100, 200 (MDI & DPI)
Terbutaline
5 mg (Pill),
0.024%(Syrup)
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Salbutamol (albuterol)
0.1, 0.5
2.5, 5 mg (Pill)
Formoterol
0.01
Salmeterol
Tulobuterol
Oxitropium bromide
100 (MDI)
1.5
20, 40 (MDI)
44 (DPI)
Tiotropium
24
12
24
12
NO
Aclidinium bromide
Glycopyrronium bromide
12
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Anticholinergics
Ipratropium bromide
12
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2 mg (transdermal)
OR
Arformoterol
Indacaterol
Duration of
Action (hours)
18 (DPI), 5 (SMI)
24
24
Fenoterol/Ipratropium
1.25/0.5
-D
200/80 (MDI)
Salbutamol/Ipratropium
Theophylline (SR)
Inhaled corticosteroids
Beclomethasone
Budesonide
AT
ER
IA
L
Methylxanthines
Aminophylline
240
Variable, up to 24
Variable, up to 24
Fluticasone
GH
Salmeterol/Fluticasone
TE
Formoterol/mometasone
Formoterol/Budesonide
25/100 (DPI)
RI
Vilanterol/Fluticasone
furoate
Systemic corticosteroids
PY
Prednisone
4, 8, 16 mg (Pill)
CO
Phosphodiesterase-4 inhibitors
22 THERAPEUTIC OPTIONS
24
OR
RE
PR
O
DU
CE
AL
ER
IA
L
-D
bronchodilators.
Combining bronchodilators of different pharmacological classes may
NO
TE
R
GH
TE
AT
RI
CO
PY
THERAPEUTIC OPTIONS 23
DU
CE
RE
PR
O
placebo in a meta-analysis519
the TIOSPIR trial showed that there was no difference
in mortality or rates of exacerbation when comparing
tiotropium in a dry-powder inhaler to the Respimat
inhaler559. Use of solutions with a face mask has been
reported to precipitate acute glaucoma, probably by a direct
effect of the solution on the eye.
TE
R
AL
NO
-D
OR
Combining
bronchodilators with different mechanisms and durations
of action may increase the degree of bronchodilation
for equivalent or lesser side effects230. For example,
a combination of a short-acting beta2-agonist and an
anticholinergic produces greater and more sustained
improvements in FEV1 than either drug alone and does
not produce evidence of tachyphylaxis over 90 days of
treatment191,231,232. The combination of a beta2-agonist,
an anticholinergic, and/or theophylline may produce
additional improvements in lung function191,224,228,231-235
and health status191,236. Short-term combination therapy
using formoterol and tiotropium has been shown to have
a bigger impact on FEV1 than the single components237,238
(
). Combinations of short-acting beta2-agonists
and anticholinergics are also superior compared to either
medication alone in improving FEV1 and symptoms231
(
). Combinations of a long-acting beta2agonist and a long-acting anticholinergic have shown a
Corticosteroids
The dose-response
relationships and long-term safety of inhaled corticosteroids
in COPD are not known. Only moderate to high doses
and side effects of inhaled corticosteroids in asthma are
dependent on the dose and type of corticosteroid239, but
whether this is also the case in COPD is unclear. The
effects of corticosteroids on pulmonary and systemic
their role in the management of stable COPD is limited to
AT
ER
IA
L
GH
TE
CO
PY
RI
24 THERAPEUTIC OPTIONS
DU
CE
RE
PR
O
TE
R
NO
AL
Vaccines.
illness (such as lower respiratory tract infections requiring
hospitalization267) and death in COPD patients268-270
(
). Vaccines containing killed or live,
inactivated viruses are recommended271 as they are more
effective in elderly patients with COPD272. The strains
are adjusted each year for appropriate effectiveness
and should be given once each year273. Pneumococcal
polysaccharide vaccine is recommended for COPD
patients 65 years and older, and also in younger patients
-D
OR
An inhaled corticosteroid combined with a longacting beta2-agonist is more effective than the individual
components in improving lung function and health status
and reducing exacerbations in patients with moderate
(
) to very severe COPD195,240,243,244,246,251-253,521,522
(
). A large prospective clinical trial failed to
AT
ER
IA
L
TE
PY
RI
GH
CO
Young
patients with severe hereditary alpha-1 antitrypsin
for alpha-1 antitrypsin augmentation therapy (
).
However, this therapy is very expensive, is not available in
most countries, and is not recommended for patients with
Antibiotics. In older studies prophylactic, continuous use
of antibiotics was shown to have no effect on the frequency
of exacerbations in COPD278-280, and a study that examined
Phosphodiesterase-4 Inhibitors
266
THERAPEUTIC OPTIONS 25
DU
CE
RE
PR
O
T
NO
-D
GH
TE
AT
ER
IA
L
RI
CO
PY
26 THERAPEUTIC OPTIONS
OR
Rehabilitation
AL
NON-PHARMACOLOGIC THERAPIES
TE
R
from mucolytics290,291
very small; the widespread use of these agents cannot
be recommended at present (
). Drugs like
N-acetylcysteine may have antioxidant effects, leading to
speculation that these medications could have a role in the
treatment of patients with recurrent exacerbations292-295,562
(
). There is some evidence that in COPD
patients not receiving inhaled corticosteroids, treatment
with mucolytics such as carbocysteine and N-acetylcysteine
may reduce exacerbations296,297,562 (
) although
a Cochrane review showed little or no effect on the overall
quality of life523.
).
).
Reduces the number of hospitalizations and days in the hospital
(
).
Reduces anxiety and depression associated with COPD (
Strength and endurance training of the upper limbs improves arm
function (
).
).
(
).
Improves survival (
).
RE
PR
O
DU
CE
OR
TE
R
AL
NO
-D
AT
ER
IA
L
CO
PY
RI
GH
TE
).
THERAPEUTIC OPTIONS 27
OR
depressed patients.
TE
R
AL
ER
IA
L
-D
NO
RE
PR
O
DU
CE
Oxygen Therapy
The long-term administration of oxygen (> 15 hours per day)
to patients with chronic respiratory failure has been shown to
increase survival in patients with severe resting hypoxemia359
(
). Long-term oxygen therapy is indicated for
patients who have:
TE
PY
RI
GH
CO
28 THERAPEUTIC OPTIONS
AT
OTHER TREATMENTS
); or
In
a post-hoc analysis, BLVR in COPD patients with severe
15-45% predicted), heterogeneous
1
DU
CE
of at least 6.7 kPa (50 mmHg). Studies indicate that this can
be achieved in those with moderate to severe hypoxemia
at sea level by supplementary oxygen at 3 L/min by nasal
cannulae or 31% by Venturi facemask361. Those with a
resting PaO2 at sea level > 9.3 kPa (70 mmHg) are likely to
362,363
, although
it is important to emphasize that a resting PaO2 > 9.3 kPa
(70 mmHg) at sea level does not exclude the development
of severe hypoxemia when travelling by air (
).
Careful consideration should be given to any comorbidity
that may impair oxygen delivery to tissues (e.g., cardiac
impairment, anemia). Also, walking along the aisle may
profoundly aggravate hypoxemia364.
RE
PR
O
AL
NO
Ventilatory Support
TE
R
OR
-D
Surgical Treatments
ER
IA
L
. LVRS is a
surgical procedure in which parts of the lung are resected to
367
, making respiratory muscles more
effective pressure generators by improving their mechanical
AT
CO
PY
RI
GH
TE
THERAPEUTIC OPTIONS 29
AT
ER
IA
L
-D
CO
PY
RI
GH
TE
30 THERAPEUTIC OPTIONS
DU
CE
RE
PR
O
OR
TE
R
AL
NO
TE
GH
RI
PY
CO
M
ER
IA
L
AT
O
-D
T
NO
TE
R
AL
CHAPTER
4
OR
DU
CE
RE
PR
O
DU
CE
KEY POINTS:
GH
TE
OR
TE
R
NO
AL
Relieve symptoms
Improve exercise tolerance
Improve health status
-D
ER
IA
L
AT
INTRODUCTION
CO
PY
RI
RE
PR
O
and
DU
CE
Occupational Exposures
AL
TE
R
OR
RE
PR
O
Tobacco Smoke
NO
(FEV1
has often been used as an entry criterion for clinical trials.
(D)
TE
(A)
GH
CAT < 10
Risk
1 (not leading
to hospital
admission)
(B)
RI
Low Risk, Less Symptoms
B
C
D
CO
PY
Characteristics
mMRC 2
Breathlessness
Patient
Category
A
CAT 10
Symptoms
mMRC 0-1
(Exacrbation History)
AT
2
or
1 leading
to hospital
admission
(C)
Risk
).
ER
IA
L
-D
Spirometric
Classification
GOLD 1-2
GOLD 1-2
GOLD 3-4
GOLD 3-4
Exacerbations
per year
>2
>2
CAT
mMRC
< 10
0-1
< 10
0-1
FEV1 after one year382. Thus, this common clinical trial entry
criterion has limited impact on the reliability of therapeutic
recommendations.
DU
CE
NON-PHARMACOLOGIC TREATMENT
Smoking Cessation
RE
PR
O
OR
TE
R
AL
Rehabilitation
Although more information is needed on criteria for
patient selection for pulmonary rehabilitation programs, all
ER
IA
L
-D
NO
AT
TE
GH
RI
Essential
Recommended
Physical activity
Flu vaccination
Pneumococcal vaccination
CO
PY
Patient Group
Pulmonary rehabilitation
Pneumococcal vaccination
OR
RE
PR
O
DU
CE
TE
R
PHARMACOLOGIC TREATMENT
AL
NO
ER
IA
L
-D
PY
RI
GH
TE
AT
CO
Patient Group
or
or
2
RE
PR
O
or
Theophylline
or
TE
R
OR
AL
Inhaled corticosteroid +
NO
-D
ER
IA
L
Inhaled corticosteroid +
D
Theophylline
and/or
inhibitor
or
Theophylline
2
inhibitor
Inhaled corticosteroid +
2
or
Inhaled corticosteroid +
and/or
Carbocysteine
2
or
Theophylline
or
TE
AT
and/or
or
and/or
or
DU
CE
CO
PY
RI
GH
*Medications in each box are mentioned in alphabetical order, and therefore not necessarily in order of preference.
**Medications in this column can be used alone or in combination with other options in the Recommended First Choice and Alternative Choice columns.
RE
PR
O
OR
-D
NO
TE
R
AL
DU
CE
ER
IA
L
AT
TE
practice566.
GH
Complications
RI
CO
PY
DU
CE
RE
PR
O
OR
AL
T
NO
TE
R
-D
AT
ER
IA
L
TE
CO
PY
RI
GH
TE
GH
RI
PY
CO
M
ER
IA
L
AT
O
-D
T
NO
TE
R
AL
CHAPTER
5
OF
OR
DU
CE
RE
PR
O
DU
CE
OR
TE
R
AL
NO
ER
IA
L
-D
AT
DEFINITION
TE
PY
RI
CO
GH
RE
PR
O
40 MANAGEMENT OF EXACERBATIONS
DIAGNOSIS
Currently, the diagnosis of an exacerbation relies
exclusively on the clinical presentation of the patient
complaining of an acute change of symptoms (baseline
dyspnea, cough, and/or sputum production) that is beyond
normal day-to-day variation. In the future, a biomarker or
panel of biomarkers that allows a more precise etiologic
diagnosis would be desirable.
AL
PY
CO
RI
GH
TE
AT
ER
IA
L
-D
NO
Treatment Setting
OR
TREATMENT OPTIONS
TE
R
RE
PR
O
DU
CE
ASSESSMENT
Pharmacologic Treatment
The three classes of medications most commonly
used for exacerbations of COPD are bronchodilators,
corticosteroids, and antibiotics.
Although there
are no controlled trials, short-acting inhaled beta2agonists with or without short-acting anticholinergics
are usually the preferred bronchodilators for treatment
MANAGEMENT OF EXACERBATIONS 41
DU
CE
RE
PR
O
OR
TE
R
arrhythmias)
AL
RESPIRATORY SUPPORT
NO
Oxygen therapy
Ventilatory support
Noninvasive ventilation
Invasive ventilation
PHARMACOLOGIC TREATMENT
ER
IA
L
-D
Bronchodilators
Corticosteroids
Antibiotics
Adjunct therapies
TE
AT
of an exacerbation290,291 (
). There are no
clinical studies that have evaluated the use of inhaled
long-acting bronchodilators (either beta2-agonists or
anticholinergics) with or without inhaled corticosteroids
during an exacerbation. A systematic review of the
route of delivery of short-acting bronchodilators found no
between metered-dose
1
inhalers (with or without a spacer device) and nebulizers420,
although the latter can be more convenient for sicker
patients. Intravenous methylxanthines (theophylline or
aminophylline) are considered second-line therapy, only
GH
RI
CO
PY
42 MANAGEMENT OF EXACERBATIONS
OR
AL
TE
R
The indications
for initiating invasive mechanical ventilation during an
exacerbation are shown in Table 5.8, and include failure of an
NO
Respiratory Support
AT
TE
RI
GH
PY
The use of
noninvasive mechanical ventilation (NIV) has increased
acute exacerbations of COPD. NIV has been studied
Mechanical Ventilation291,445,451,452
ER
IA
L
-D
RE
PR
O
CO
DU
CE
mm Hg)
Severe dyspnea with clinical signs suggestive of respiratory muscle
fatigue, increased work of breathing, or both, such as use of respiratory
accessory muscles, paradoxical motion of the abdomen, or retraction of
the intercostal spaces
MANAGEMENT OF EXACERBATIONS 43
-D
ER
IA
L
AT
GH
TE
RI
PY
NO
AL
CO
TE
R
44 MANAGEMENT OF EXACERBATIONS
OR
RE
PR
O
HOSPITAL DISCHARGE
AND FOLLOW-UP
DU
CE
PREVENTION OF COPD
EXACERBATIONS
DU
CE
RE
PR
O
OR
disability.
NO
AL
TE
R
HOME MANAGEMENT
OF EXACERBATIONS
-D
TE
AT
ER
IA
L
CO
PY
RI
GH
MANAGEMENT OF EXACERBATIONS 45
TE
GH
RI
PY
CO
M
ER
IA
L
AT
O
-D
T
NO
TE
R
AL
OR
DU
CE
RE
PR
O
TE
GH
RI
PY
CO
M
ER
IA
L
AT
O
-D
T
NO
TE
R
AL
CHAPTER
6
AND
OR
DU
CE
RE
PR
O
RE
PR
O
KEY POINTS:
OR
TE
R
AL
IHD is increased in
COPD, to some extent because of an unfavourable IHD
478,479
. There is evidence that
myocardial injury is overlooked and IHD is therefore underdiagnosed in COPD patients480.
-D
ER
IA
L
AT
GH
TE
RI
PY
INTRODUCTION
CO
NO
DU
CE
DU
CE
RE
PR
O
. However, as in
IHD, treatment with selective beta1-blockers is considered
safe for heart failure patients who also have COPD481,579,580.
Studies have shown that treatment with bisoprolol in HF
with concomitant COPD decreased FEV1 but without
deleterious effects on symptoms and quality of life488 and
that a selective beta1-blocker is indeed preferable to a nonselective beta-blocker in HF with COPD489. In a study of
TE
R
AL
NO
-D
AT
ER
IA
L
TE
PY
RI
GH
CO
Osteoporosis
OR
487
117,499
RE
PR
O
DU
CE
OR
AL
TE
R
Lung Cancer
Bronchiectasis
-D
NO
ER
IA
L
AT
TE
Infections
GH
CO
PY
RI
TE
GH
RI
PY
CO
M
ER
IA
L
AT
O
-D
T
NO
TE
R
AL
CHAPTER
7
OR
DU
CE
RE
PR
O
DU
CE
RE
PR
O
OR
AL
T
NO
TE
R
ER
IA
L
-D
AT
RI
GH
TE
CO
PY
statistics.htm; 2000.
2.
RE
PR
O
1.
DU
CE
12.
REFERENCES
Lancet
Eur Respir J
14.
6.
18.
-D
AT
Eur Respir J
ER
IA
L
8.
OR
16.
TE
R
AL
15.
NO
5.
4.
21.
GH
10.
TE
Harvard University
CO
PY
RI
11.
Press
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22.
Lancet
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CE
24.
RE
PR
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Lancet
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R
Respiratory Physiology
AL
NO
ER
IA
L
-D
28.
40.
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42.
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Wilk JB, Chen TH, Gottlieb DJ, Walter RE, Nagle MW,
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54 REFERENCES
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ER
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L
51.
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-D
NO
48.
52.
RI
smokers.
GH
TE
64.
65.
PY
54.
TE
R
OR
45.
DU
CE
55.
RE
PR
O
44.
CO
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REFERENCES 80
TE
GH
RI
PY
CO
M
ER
IA
L
AT
O
-D
T
NO
TE
R
AL
OR
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CE
RE
PR
O
NOTES
81
82
TE
GH
RI
PY
CO
M
ER
IA
L
AT
O
-D
T
NO
TE
R
AL
OR
DU
CE
RE
PR
O
NOTES
TE
GH
RI
PY
CO
M
ER
IA
L
AT
O
-D
T
NO
TE
R
AL
OR
DU
CE
RE
PR
O
NOTES
83
84
TE
GH
RI
PY
CO
M
ER
IA
L
AT
O
-D
T
NO
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R
AL
OR
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CE
RE
PR
O
NOTES
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The Global Initiative for Chronic Obstructive Lung Disease is supported by unrestricted educational grants from:
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OR
Almirall
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Chiesi
Forest Laboratories
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Merck Sharp and Dohme
Mylan
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Pearl Therapeutics
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