Escolar Documentos
Profissional Documentos
Cultura Documentos
GOLD Structure
GOLD Board of Directors
Marc Decramer, MD Chair
Science Committee
Claus Vogelmeier, MD - Chair
Dissemination/Implementation
Committee
Jean Bourbeau, MD Chair
M. Victorina Lpez, MD Vice Chair
D. Halpin, UK
J. Bourbeau, Canada
P. Jones, UK
B. Celli, US
R. C. Chen, PRC
M. Nishimura, Japan
G. Criner, US
C. Vogelmeier, Germany
P. Frith, Australia
2014 Global Initiative for Chronic Obstructive Lung Disease
Roberto Rodriguez-Roisin, MD
Antonio Anzueto, MD
Don Sin, MD
Leonardo Fabbri, MD
Dave Singh, MD
Paul Jones, MD
Robert Stockley, MD
Jadwiga A. Wedzicha, MD
Sources of Evidence
Randomized controlled trials
(RCTs). Rich body of data
Nonrandomized trials
Observational studies.
GOLD Structure
GOLD Board of Directors
Marc Decramer, MD Chair
Science Committee
Claus Vogelmeier, MD - Chair
Dissemination/Implementation
Committee
Jean Bourbeau, MD Chair
M. Victorina Lpez, MD Vice Chair
Slovenia
Germany
Saudi Arabia
Bangladesh
Brazil Ireland
Yugoslavia Croatia
United States Australia
Canada
Austria
Taiwan ROC
Mongolia
Portugal
Philippines
Yeman
Thailand
Malta
Norway
Moldova
Greece
South Africa
China
Kazakhstan
United Kingdom Syria
Hong Kong ROC
Italy
New Zealand
Nepal Chile Israel
Argentina
Mexico
Pakistan Russia
Poland Korea
Peru
Japan
Netherlands
Egypt France
Venezuela
KyrgyzstanGeorgia
Macedonia Albania
Iceland
Denmark
Turkey Czech
Belgium
Slovakia
Republic
Singapore Spain
Columbia
Ukraine
Romania
Sweden
Uruguay
2014 Global Initiative for Chronic Obstructive Lung Disease
Vietnam
Switzerland India
http://www.goldcopd.org
GOLD Objectives
Increase awareness of COPD among
health professionals, health
authorities, and the general public
Definition of COPD
Mechanisms Underlying
Airflow Limitation in COPD
Small Airways Disease
Parenchymal Destruction
Airway inflammation
Airway fibrosis, luminal plugs
Increased airway resistance
AIRFLOW LIMITATION
2014 Global Initiative for Chronic Obstructive Lung Disease
Burden of COPD
Genes
Infections
Socio-economic
status
Aging Populations
2014 Global Initiative for Chronic Obstructive Lung Disease
Diagnosis of COPD
SYMPTOMS
shortness of breath
chronic cough
sputum
EXPOSURE TO RISK
FACTORS
tobacco
occupation
indoor/outdoor pollution
Volume, liters
FEV1 = 4L
FVC = 5L
2
FEV1/FVC = 0.8
1
Time, sec
2014 Global Initiative for Chronic Obstructive Lung Disease
Volume, liters
4
3
FEV1 = 1.8L
2
FVC = 3.2L
FEV1/FVC = 0.56
Time, seconds
2014 Global Initiative for Chronic Obstructive Lung Disease
Obstructive
Assessment of COPD
Assess symptoms
Assess degree of airflow
limitation using spirometry
Assess risk of exacerbations
Assess comorbidities
2014 Global Initiative for Chronic Obstructive Lung Disease
Symptoms of COPD
Assessment of COPD
Assess symptoms
Assess degree of airflow limitation using
spirometry
COPD Assessment Test (CAT)
Assess risk of exacerbations
Assess comorbidities or
or
mMRC Breathlessness scale
2014 Global Initiative for Chronic Obstructive Lung Disease
Assessment of Symptoms
Assessment of Symptoms
Assessment of COPD
Assess symptoms
Assess degree of airflow limitation
using spirometry
Assess
risk of exacerbations
Use spirometry
for grading severity
Assess
comorbidities
according
to spirometry, using four
grades split at 80%, 50% and 30% of
predicted value
2014 Global Initiative for Chronic Obstructive Lung Disease
GOLD 2: Moderate
GOLD 3: Severe
Assessment of COPD
Assess symptoms
Assess degree of airflow limitation
using spirometry
Assess risk of exacerbations
Assess
comorbidities
Use history
of exacerbations and spirometry.
Two exacerbations or more within the last year
or an FEV1 < 50 % of predicted value are
indicators of high risk. Hospitalization for a COPD
exacerbation associated with increased risk of death.
2014 Global Initiative for Chronic Obstructive Lung Disease
(C)
(D)
3
2
(A)
(B)
or
> 1 leading
to hospital
admission
1 (not leading
to hospital
admission)
0
CAT < 10
CAT > 10
Symptoms
mMRC > 2
mMRC 01
Breathlessness
2014 Global Initiative for Chronic Obstructive Lung Disease
(Exacerbation history)
Risk
Risk
(D)
(A)
(B)
CAT < 10
CAT > 10
Symptoms
4
3
(C)
(D)
or
> 1 leading
to hospital
admission
(B)
1 (not leading
to hospital
admission)
0
(A)
1
CAT < 10
(Exacerbation history)
Risk
Risk
CAT > 10
Symptoms
mMRC 01
mMRC > 2
Breathlessness
(C)
(D)
3
2
(A)
(B)
or
> 1 leading
to hospital
admission
1 (not leading
to hospital
admission)
0
CAT < 10
CAT > 10
Symptoms
mMRC > 2
mMRC 01
Breathlessness
2014 Global Initiative for Chronic Obstructive Lung Disease
(Exacerbation history)
Risk
Risk
Characteristic
Spirometric
Classification
Exacerbations
per year
CAT
mMRC
Low Risk
Less Symptoms
GOLD 1-2
< 10
0-1
Low Risk
More Symptoms
GOLD 1-2
> 10
>2
High Risk
Less Symptoms
GOLD 3-4
>2
< 10
0-1
High Risk
More Symptoms
GOLD 3-4
>2
> 10
>2
Cardiovascular diseases
Osteoporosis
Respiratory infections
Anxiety and Depression
Diabetes
Lung cancer
Bronchiectasis
Differential Diagnosis:
COPD and Asthma
COPD
ASTHMA
Onset in mid-life
Symptoms slowly
progressive
Additional Investigations
Additional Investigations
Exercise Testing: Objectively measured exercise
ADVISE
ASSESS
Determine willingness to
make a quit attempt
ASSIST
ARRANGE
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
2014 Global Initiative for Chronic Obstructive Lung Disease
Therapeutic Options:
Phosphodiesterase-4 Inhibitors
Mucolytics:
Relieve symptoms
Improve exercise tolerance
Improve health status
Reduce
symptoms
Reduce
risk
- smoking cessation
- reduction of indoor pollution
- reduction of occupational exposure
Influenza vaccination
2014 Global Initiative for Chronic Obstructive Lung Disease
Patient
Group
Essential
B, C, D
Recommended
Depending on local
guidelines
Physical activity
Flu vaccination
Pneumococcal
vaccination
Physical activity
Flu vaccination
Pneumococcal
vaccination
Patient
Recommended
First choice
Alternative choice
Other Possible
Treatments
SAMA prn
or
SABA prn
LAMA
or
LABA
or
SABA and SAMA
Theophylline
LAMA
or
LABA
ICS + LABA
or
LAMA
ICS + LABA
and/or
LAMA
Carbocysteine
SABA and/or SAMA
Theophylline
C
GOLD 4
ICS + LABA
or
LAMA
GOLD 3
GOLD 2
GOLD 1
D
2 or more
or
> 1 leading
to hospital
admission
ICS + LABA
and/or
LAMA
B
SAMA prn
or
SABA prn
LABA
or
LAMA
1 (not leading
to hospital
admission)
0
CAT < 10
mMRC 0-1
CAT > 10
mMRC > 2
GOLD 4
GOLD 3
A
GOLD 2
GOLD 1
LAMA
or
LABA
or
SABA and SAMA
CAT < 10
mMRC 0-1
2 or more
or
> 1 leading
to hospital
admission
B
LAMA and LABA
1 (not leading
to hospital
admission)
0
CAT > 10
mMRC > 2
GOLD 4
Theophylline
Carbocysteine
SABA and/or SAMA
Theophylline
GOLD 3
A
2 or more
or
> 1 leading
to hospital
admission
GOLD 2
Theophylline
Theophylline
GOLD 1
1 (not leading
to hospital
admission)
0
CAT < 10
mMRC 0-1
CAT > 10
mMRC > 2
Manage Exacerbations
An exacerbation of COPD is:
an acute event characterized by a
Impact on
symptoms
and lung
function
EXACERBATIONS
Accelerated
lung function
decline
Increased
economic
costs
Increased
Mortality
Manage Comorbidities
COPD often coexists with other diseases
Manage Comorbidities
Cardiovascular disease (including ischemic
heart disease, heart failure, atrial fibrillation,
and hypertension) is a major comorbidity in
COPD and probably both the most frequent
and most important disease coexisting with
COPD. Benefits of cardioselective beta-blocker
treatment in heart failure outweigh potential
risk even in patients with severe COPD.
2014 Global Initiative for Chronic Obstructive Lung Disease
Manage Comorbidities
Osteoporosis and anxiety/depression: often under-
Slovenia
Germany
Saudi Arabia
Bangladesh
Brazil Ireland
Yugoslavia Croatia
United States Australia
Canada
Austria
Taiwan ROC
Mongolia
Portugal
Philippines
Yeman
Thailand
Malta
Norway
Moldova
Greece
South Africa
China
Kazakhstan
United Kingdom Syria
Hong Kong ROC
Italy
New Zealand
Nepal Chile Israel
Argentina
Mexico
Pakistan Russia
Poland Korea
Peru
Japan
Netherlands
Egypt France
Venezuela
KyrgyzstanGeorgia
Macedonia Albania
Iceland
Denmark
Turkey Czech
Belgium
Slovakia
Republic
Singapore Spain
Columbia
Ukraine
Romania
Sweden
Uruguay
2014 Global Initiative for Chronic Obstructive Lung Disease
Vietnam
Switzerland India
http://www.goldcopd.org