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lobal Initiative for Chronic bstructive ung isease. G O L D. GOLD Structure. GOLD Executive Committee Sonia Buist, MD – Chair Roberto Rodriguez-Roisin, MD – Co-Chair. Dissemination/Implementation Task Group Christine Jenkins, MD - Chair. Science Committee Klaus Rabe, MD, PhD - Chair.

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Lobal initiative for chronic bstructive ung isease

lobal Initiative for Chronicbstructiveungisease

GOLD


Gold structure

GOLD Structure

GOLD Executive Committee

Sonia Buist, MD – Chair

Roberto Rodriguez-Roisin, MD – Co-Chair

Dissemination/Implementation

Task Group

Christine Jenkins, MD - Chair

Science Committee

Klaus Rabe, MD, PhD - Chair


Gold executive committee

GOLD Executive Committee

S. Buist,Chair, US

A. Anzueto,US ATS

P. Calverley,UK

T. DeGuia,Philippines

Y. Fukuchi,Japan APSR

C. Jenkins,Australia

J. Kiley,US NHLBI

A. Kocabas,Turkey

N. Khaltaev,Switzerland WHO

M. Lopez,Uruguay ALAT

E. Nizankowska, Poland

K. Rabe,Netherlands

R. Rodriguez-Roisin, Spain

T. van der Molen, Netherlands

C. Van Weel, Netherlands WONCA


Gold science committee

GOLD Science Committee

K. Rabe, Chair

A. Agusti,

A. Anzueto

P. Barnes

S. Buist

P. Calverley

M. Decramer

Y. Fukuchi

P. Jones

R. Rodriguez-Roisin

J. Vestbo

J. Zielinski


Lobal initiative for chronic bstructive ung isease

Description of Levels of Evidence


Gold structure1

GOLD National Leaders - GNL

GOLD Structure

GOLD Executive Committee

Sonia Buist, MD – Chair

Roberto Rodriguez-Roisin, MD – Co-Chair

Dissemination/Implementation

Task Group

Christine Jenkins, MD - Chair

Science Committee

Klaus Rabe, MD, PhD - Chair


Lobal initiative for chronic bstructive ung isease

Bangladesh

Saudi Arabia

Slovenia

Ireland

Germany

Australia

Yugoslavia

Croatia

Canada

Brazil

Philippines

Austria

Taiwan ROC

United States

Portugal

Thailand

Malta

Norway

Greece

Moldova

China

Syria

South Africa

United Kingdom

Hong Kong ROC

Italy

New Zealand

Israel

Chile

Nepal

Argentina

Mexico

Russia

Pakistan

United Arab Emirates

Japan

Peru

GOLD National Leaders

Korea

Poland

Netherlands

Egypt

Venezuela

Switzerland

India

Georgia

France

Macedonia

Iceland

Czech Republic

Denmark

Turkey

Belgium

Slovakia

Singapore

Spain

Ukraine

Columbia

Romania

Uruguay

Sweden

Vietnam

Kyrgyzstan

Albania


Lobal initiative for chronic bstructive ung isease

GOLD Website Address

http://www.goldcopd.org


Lobal initiative for chronic bstructive ung isease

lobal Initiative for Chronicbstructiveungisease

GOLD


Lobal initiative for chronic bstructive ung isease

GOLD Objectives

  • Increase awareness of COPD among health professionals, health authorities, and the general public.

  • Improve diagnosis, management and prevention of COPD.

  • Stimulate research in COPD.


Lobal initiative for chronic bstructive ung isease

Global Strategy for Diagnosis, Management and Prevention of COPD

  • Definition, Classification

  • Burden of COPD

  • Risk Factors

  • Pathogenesis, Pathology, Pathophysiology

  • Management

  • Practical Considerations


Lobal initiative for chronic bstructive ung isease

Definition of COPD

  • 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 that is not fully reversible.

  • The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases.


Lobal initiative for chronic bstructive ung isease

Classification of COPD Severity

by Spirometry

Stage I: Mild FEV1/FVC < 0.70

FEV1> 80% predicted

Stage II: Moderate FEV1/FVC < 0.70

50% < FEV1 < 80% predicted

Stage III: Severe FEV1/FVC < 0.70

30% < FEV1 < 50% predicted

Stage IV: Very Severe FEV1/FVC < 0.70

FEV1 < 30% predicted or

FEV1 < 50% predicted plus chronic respiratory failure


Lobal initiative for chronic bstructive ung isease

“At Risk” for COPD

  • COPD includes four stages of severity classified by spirometry.

  • A fifth category--Stage 0: At Risk--that appeared in the 2001 report is no longer included as a stage of COPD, as there is incomplete evidence that the individuals who meet the definition of “At Risk” (chronic cough and sputum production, normal spirometry) necessarily progress on to Stage I: Mild COPD.

  • The public health message is that chronic cough and sputum are not normal remains important - their presence should trigger a search for underlying cause(s).


Lobal initiative for chronic bstructive ung isease

Global Strategy for Diagnosis, Management and Prevention of COPD

  • Definition, Classification

  • Burden of COPD

  • Risk Factors

  • Pathogenesis, Pathology, Pathophysiology

  • Management

  • Practical Considerations


Burden of copd key points

Burden of COPD: Key Points

  • COPD is a leading cause of morbidity and mortality worldwide and results in an economic and social burden that is both substantial and increasing.

  • COPD prevalence, morbidity, and mortality vary across countries and across different groups within countries.

  • The burden of COPD is projected to increase in the coming decades due to continued exposure to COPD risk factors and the changing age structure of the world’s population.


Burden of copd prevalence

Burden of COPD: Prevalence

  • Many sources of variation can affect estimates of COPD prevalence, including e.g., sampling methods, response rates and quality of spirometry.

  • Data are emerging to provide evidence that prevalence of Stage I: Mild COPD and higher is appreciably higher in:

    - smokers and ex-smokers

    - people over 40 years of age

    - males


Lobal initiative for chronic bstructive ung isease

COPD Prevalence Study in Latin America

The prevalence of post-bronchodilator FEV1/FVC < 0.70 increases steeply with age in 5 Latin American Cities

Source: Menezes AM et al. Lancet 2005


Burden of copd mortality

Burden of COPD: Mortality

  • COPD is a leading cause of mortality worldwide and projected to increase in the next several decades.

  • COPD mortality trends generally track several decades behind smoking trends.

  • In the US and Canada, COPD mortality for both men and women have been increasing.

  • In the US in 2000, the number of COPD deaths was greater among women than men.


Percent change in age adjusted death rates u s 1965 1998

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

Source: NHLBI/NIH/DHHS


Lobal initiative for chronic bstructive ung isease

Of the six leading causes of death in the United States, only COPD has been increasing steadily since 1970

Source:Jemal A. et al. JAMA 2005


Copd mortality by gender u s 1980 2000

COPD Mortality by Gender,U.S., 1980-2000

Number Deaths x 1000

Source: US Centers for Disease Control and Prevention, 2002


Lobal initiative for chronic bstructive ung isease

Global Strategy for Diagnosis, Management and Prevention of COPD

  • Definition, Classification

  • Burden of COPD

  • Risk Factors

  • Pathogenesis, Pathology, Pathophysiology

  • Management

  • Practical Considerations


Lobal initiative for chronic bstructive ung isease

Risk Factors for COPD

  • Genes

  • Exposure to particles

  • Tobacco smoke

  • Occupational dusts, organic and inorganic

  • Indoor air pollution from heating and cooking with biomass in poorly ventilated dwellings

  • Outdoor air pollution

Lung growth and development

Oxidative stress

Gender

Age

Respiratory infections

Socioeconomic status

Nutrition

Comorbidities


Lobal initiative for chronic bstructive ung isease

Risk Factors for COPD

Nutrition

Infections

Socio-economic status

Aging Populations


Lobal initiative for chronic bstructive ung isease

Global Strategy for Diagnosis, Management and Prevention of COPD

  • Definition, Classification

  • Burden of COPD

  • Risk Factors

  • Pathogenesis, Pathology, Pathophysiology

  • Management

  • Practical Considerations


Lobal initiative for chronic bstructive ung isease

Pathogenesis of COPD

Cigarette smoke

Biomass particles

Particulates

Host factors

Amplifying mechanisms

LUNG INFLAMMATION

Anti-oxidants

Anti-proteinases

Oxidative

stress

Proteinases

Repair

mechanisms

COPD PATHOLOGY

Source: Peter J. Barnes, MD


Lobal initiative for chronic bstructive ung isease

Changes in Lung Parenchyma in COPD

Alveolar wall destruction

Loss of elasticity

Destruction of pulmonary

capillary bed

↑ Inflammatory cells

macrophages, CD8+ lymphocytes

Source: Peter J. Barnes, MD


Lobal initiative for chronic bstructive ung isease

Pulmonary Hypertension in COPD

Chronic hypoxia

Pulmonary vasoconstriction

Muscularization

Intimal

hyperplasia

Fibrosis

Obliteration

Pulmonary hypertension

Cor pulmonale

Edema

Death

Source: Peter J. Barnes, MD


Lobal initiative for chronic bstructive ung isease

COPD

Cigarette smoke

Y

Y

Y

Alv macrophage

Ep cells

CD8+ cell

(Tc1)

Neutrophil

Small airway narrowing

Alveolar destruction

ASTHMA

Allergens

Ep cells

Mast cell

CD4+ cell

(Th2)

Eosinophil

Bronchoconstriction

AHR

Airflow Limitation

Reversible

Irreversible

Source: Peter J. Barnes, MD


Lobal initiative for chronic bstructive ung isease

Global Strategy for Diagnosis, Management and Prevention of COPD

  • Definition, Classification

  • Burden of COPD

  • Risk Factors

  • Pathogenesis, Pathology, Pathophysiology

  • Management

  • Practical Considerations


Four components of copd management

Four Components of COPD Management

  • Assess and monitor disease

  • Reduce risk factors

  • Manage stable COPD

    • Education

    • Pharmacologic

    • Non-pharmacologic

  • Manage exacerbations


Lobal initiative for chronic bstructive ung isease

GOALS of COPD MANAGEMENT

VARYING EMPHASIS WITH DIFFERING SEVERITY

  • Relieve symptoms

  • Prevent disease progression

  • • Improve exercise tolerance

  • • Improve health status

  • • Prevent and treat complications

  • • Prevent and treat exacerbations

  • • Reduce mortality


Four components of copd management1

Four Components of COPD Management

  • Assess and monitor disease

  • Reduce risk factors

  • Manage stable COPD

    • Education

    • Pharmacologic

    • Non-pharmacologic

  • Manage exacerbations


Lobal initiative for chronic bstructive ung isease

Management of Stable COPD

Assess and Monitor COPD: Key Points

  • A clinical diagnosis of COPD should be considered in any patient who has dyspnea, chronic cough or sputum production, and/or a history of exposure to risk factors for the disease.

  • The diagnosis should be confirmed by spirometry. A post-bronchodilator FEV1/FVC < 0.70 confirms the presence of airflow limitation that is not fully reversible.

  • Comorbidities are common in COPD and should be actively identified.


Lobal initiative for chronic bstructive ung isease

Diagnosis of COPD

EXPOSURE TO RISK

FACTORS

SYMPTOMS

cough

tobacco

sputum

occupation

shortness of breath

indoor/outdoor pollution

è

è

è

SPIROMETRY


Lobal initiative for chronic bstructive ung isease

Management of Stable COPD

Assess and Monitor COPD: Spirometry

  • Spirometry should be performed after the administration of an adequate dose of a short-acting inhaled bronchodilator to minimize variability.

  • A post-bronchodilator FEV1/FVC < 0.70 confirms the presence of airflow limitation that is not fully reversible.

  • Where possible, values should be compared to age-related normal values to avoid overdiagnosis of COPD in the elderly.


Lobal initiative for chronic bstructive ung isease

Spirometry: Normal and Patients with COPD


Lobal initiative for chronic bstructive ung isease

Differential Diagnosis: COPD and Asthma

COPD

ASTHMA

  • Onset early in life (often childhood)

  • Symptoms vary from day to day

  • Symptoms at night/early morning

  • Allergy, rhinitis, and/or eczema also present

  • Family history of asthma

  • Largely reversible airflow limitation

  • Onset in mid-life

  • Symptoms slowly progressive

  • Long smoking history

  • Dyspnea during exercise

  • Largely irreversible airflow

  • limitation


Copd and co morbidities

COPD and Co-Morbidities

COPD patients are at increased risk for:

  • Myocardial infarction, angina

  • Osteoporosis

  • Respiratory infection

  • Depression

  • Diabetes

  • Lung cancer


Copd and co morbidities1

COPD and Co-Morbidities

COPD has significant extrapulmonary

(systemic) effects including:

  • Weight loss

  • Nutritional abnormalities

  • Skeletal muscle dysfunction


Four components of copd management2

Four Components of COPD Management

  • Assess and monitor disease

  • Reduce risk factors

  • Manage stable COPD

    • Education

    • Pharmacologic

    • Non-pharmacologic

  • Manage exacerbations


Lobal initiative for chronic bstructive ung isease

Management of Stable COPD

Reduce Risk Factors: Key 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 in most people to reduce the risk of developing COPD and stop its progression (Evidence A).


Lobal initiative for chronic bstructive ung isease

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.

  • ASSISTAid the patient in quitting.

  • ARRANGESchedule follow-up contact.


Lobal initiative for chronic bstructive ung isease

Management of Stable COPD

Reduce Risk Factors: Smoking Cessation

  • Counseling delivered by physicians and other health professionals significantly increases quit rates over self-initiated strategies. Even a brief

    (3-minute) period of counseling to urge a smoker to quit results in smoking cessation rates of 5-10%.

  • Numerous effective pharmacotherapies for smoking cessation are available and pharmacotherapy is recommended when counseling is not sufficient to help patients quitsmoking.


Lobal initiative for chronic bstructive ung isease

Management of Stable COPD

Reduce Risk Factors: Indoor/Outdoor Air Pollution

  • Reducing the risk from indoor and outdoor air pollution is feasible and requires a combination of public policy and protective steps taken by individual patients.

  • Reduction of exposure to smoke from biomass fuel, particularly among women and children, is a crucial goal to reduce the prevalence of COPD worldwide.


Four components of copd management3

Four Components of COPD Management

  • Assess and monitor disease

  • Reduce risk factors

  • Manage stable COPD

    • Education

    • Pharmacologic

    • Non-pharmacologic

  • Manage exacerbations


Lobal initiative for chronic bstructive ung isease

Management of Stable COPD

Manage Stable COPD: Key Points

  • The overall approach to managing stable COPD should be individualized to address symptoms and improve quality of life.

  • For patients with COPD, health education plays an important role in smoking cessation (Evidence A) and can also play a role in improving skills, ability to cope with illness and health status.

  • None of the existing medications for COPD have been shown to modify the long-term decline in lung function that is the hallmark of this disease (Evidence A). Therefore, pharmacotherapy for COPD is used to decrease symptoms and/or complications.


Lobal initiative for chronic bstructive ung isease

Management of Stable COPD

Pharmacotherapy: Bronchodilators

  • Bronchodilator medications are central to the symptomatic management of COPD (Evidence A). They are given on an as-needed basis or on a regular basis to prevent or reduce symptoms and exacerbations.

  • The principal bronchodilator treatments are ß2-agonists, anticholinergics, and methylxanthines used singly or in combination (Evidence A).

  • Regular treatment with long-acting bronchodilators is more effective and convenient than treatment with short-acting bronchodilators (Evidence A).


Lobal initiative for chronic bstructive ung isease

Management of Stable COPD

Pharmacotherapy: Glucocorticosteroids

  • The addition of regular treatment with inhaled

    glucocorticosteroids to bronchodilator treatment is appropriate for symptomatic COPD patients with an FEV1 < 50% predicted (Stage III: Severe COPD and Stage IV: Very Severe COPD) and repeated exacerbations (Evidence A).

  • An inhaled glucocorticosteroid combined with a long-acting ß2-agonist is more effective than the individual components (Evidence A).


Lobal initiative for chronic bstructive ung isease

Management of Stable COPD

Pharmacotherapy: Glucocorticosteroids

  • The dose-response relationships and long-term safety of inhaled glucocorticosteroids in COPD are not known.

  • Chronic treatment with systemic glucocorticosteroids should be avoided because of an unfavorable benefit-to-risk ratio (Evidence A).


Lobal initiative for chronic bstructive ung isease

Management of Stable COPD

Pharmacotherapy: Vaccines

  • In COPD patients influenza vaccines can reduce serious illness (Evidence A).

  • Pneumococcal polysaccharide vaccine is recommended for COPD patients 65 years and older and for COPD patients younger than age 65 with an FEV1 < 40% predicted (Evidence B).


Management of stable copd all stages of disease severity

Management of Stable COPDAll Stages of Disease Severity

  • Avoidance of risk factors

    - smoking cessation

    - reduction of indoor pollution

    - reduction of occupational exposure

  • Influenza vaccination


Lobal initiative for chronic bstructive ung isease

Active reduction of risk factor(s); influenza vaccination

Addshort-acting bronchodilator (when needed)

I: Mild

II: Moderate

III: Severe

IV: Very Severe

Addregular treatment with one or more long-acting bronchodilators (when needed); Addrehabilitation

Addinhaled glucocorticosteroids if repeated exacerbations

Addlong term oxygenif chronic respiratory failure. Considersurgical treatments


Lobal initiative for chronic bstructive ung isease

Management of Stable COPD

Other Pharmacologic Treatments

  • Antibiotics: Only used to treat infectious exacerbations of COPD

  • Antioxidant agents: No effect of n-acetylcysteine on frequency of exacerbations, except in patients not treated with inhaled glucocorticosteroids

  • Mucolytic agents, Antitussives, Vasodilators: Not recommended in stable COPD


Lobal initiative for chronic bstructive ung isease

Management of Stable COPD

Non-Pharmacologic Treatments

  • Rehabilitation: All COPD patients benefit from exercise training programs, improving with respect to both exercise tolerance and symptoms of dyspnea and fatigue (Evidence A).

  • Oxygen Therapy: The long-term administration of oxygen (> 15 hours per day) to patients with chronic respiratory failure has been shown to increase survival (Evidence A).


Four components of copd management4

Revised 2006

Four Components of COPD Management

  • Assess and monitor disease

  • Reduce risk factors

  • Manage stable COPD

    • Education

    • Pharmacologic

    • Non-pharmacologic

  • Manage exacerbations


Lobal initiative for chronic bstructive ung isease

Management COPD Exacerbations

Key Points

An exacerbation of COPD is defined as:

“An event in the natural course of the disease characterized by a change in the patient’s baseline dyspnea, cough, and/or sputum that is beyond normal day-to-day variations, is acute in onset, and may warrant a change in regular medication in a patient with underlying COPD.”


Lobal initiative for chronic bstructive ung isease

Management COPD Exacerbations

Key Points

  • The most common causes of an exacerbation are infection of the tracheobronchial tree and air pollution, but the cause of about one-third of severe exacerbations cannot be identified (Evidence B).

  • Patients experiencing COPD exacerbations with clinical signs of airway infection (e.g., increased sputum purulence) may benefit from antibiotic treatment (Evidence B).


Lobal initiative for chronic bstructive ung isease

Manage COPD Exacerbations

Key Points

  • Inhaled bronchodilators (particularly inhaled ß2-agonists with or without anticholinergics) and oral glucocortico-steroids are effective treatments for exacerbations of COPD (Evidence A).


Lobal initiative for chronic bstructive ung isease

Management COPD Exacerbations

Key Points

  • Noninvasive mechanical ventilation in exacerbations improves respiratory acidosis, increases pH, decreases the need for endotracheal intubation, and reduces PaCO2, respiratory rate, severity of breathlessness, the length of hospital stay, and mortality (Evidence A).

  • Medications and education to help prevent future exacerbations should be considered as part of follow-up, as exacerbations affect the quality of life and prognosis of patients with COPD.


Global strategy for diagnosis management and prevention of copd

Global Strategy for Diagnosis, Management and Prevention of COPD

  • Definition, Classification

  • Burden of COPD

  • Risk Factors

  • Pathogenesis, Pathology, Pathophysiology

  • Management

  • Practical Considerations


Translating copd guidelines into primary care key points

Better dissemination of COPD guidelines and their effective implementation in a variety of health care settings is urgently required.

In many countries, primary care practitioners treat the vast majority of patients with COPD and may be actively involved in public health campaigns and in bringing messages about reducing exposure to risk factors to both patients and the public.

Translating COPD Guidelines into Primary CareKEY POINTS


Translating copd guidelines into primary care key points1

Spirometric confirmation is a key component of the diagnosis of COPD and primary care practitioners should have access to high quality spirometry.

Older patients frequently have multiple chronic health conditions. Comorbidities can magnify the impact of COPD on a patient’s health status, and can complicate the management of COPD.

Translating COPD Guidelines into Primary CareKEY POINTS


Global strategy for diagnosis management and prevention of copd summary

Global Strategy for Diagnosis, Management and Prevention of COPDSUMMARY

  • Definition, Classification

  • Burden of COPD

  • Risk Factors

  • Pathogenesis, Pathology, Pathophysiology

  • Management

  • Practical Considerations


Lobal initiative for chronic bstructive ung isease

Global Strategy for Diagnosis, Management and Prevention of COPD: Summary

  • COPD is increasing in prevalence in many countries of the world.

  • COPD is treatable and preventable.

  • The GOLD program offers a strategy to identify patients and to treat them according to the best medications available.


Lobal initiative for chronic bstructive ung isease

Global Strategy for Diagnosis, Management and Prevention of COPD: Summary

  • COPD can be prevented by avoidance of risk factors, the most notable being tobacco smoke.

  • Patients with COPD have multiple other conditions (comorbidities) that must be taken into consideration.

  • GOLD has developed a global network to raise awareness of COPD and disseminate information on diagnosis and treatment.


Lobal initiative for chronic bstructive ung isease

Bangladesh

Saudi Arabia

Slovenia

Ireland

Germany

Australia

Yugoslavia

Croatia

Canada

Brazil

Philippines

Austria

Taiwan ROC

United States

Portugal

Thailand

Malta

Norway

Greece

Moldova

China

Syria

South Africa

United Kingdom

Hong Kong ROC

Italy

New Zealand

Israel

Chile

Nepal

Argentina

Mexico

Russia

Pakistan

United Arab Emirates

Japan

Peru

GOLD National Leaders

Korea

Poland

Netherlands

Egypt

Venezuela

Switzerland

India

Georgia

France

Macedonia

Iceland

Czech Republic

Denmark

Turkey

Belgium

Slovakia

Singapore

Spain

Ukraine

Columbia

Romania

Uruguay

Sweden

Vietnam

Kyrgyzstan

Albania


Lobal initiative for chronic bstructive ung isease

WORLD COPD DAY

November 14, 2007

Raising COPD Awareness Worldwide


Lobal initiative for chronic bstructive ung isease

GOLD Website Address

http://www.goldcopd.org


Lobal initiative for chronic bstructive ung isease

ADDITIONAL SLIDES WITH NOTES PREPARED BY:

PROFESSOR PETER J. BARNES, MD

NATIONAL HEART AND LUNG INSTITUTE

LONDON, ENGLAND


Lobal initiative for chronic bstructive ung isease

Changes in Large Airways of COPD Patients

Mucus hypersecretion

Neutrophils in sputum

Squamous metaplasia of epithelium

No basement membrane thickening

Goblet cell

hyperplasia

↑ Macrophages

↑ CD8+ lymphocytes

Mucus gland hyperplasia

Little increase in

airway smooth muscle

Source: Peter J. Barnes, MD


Lobal initiative for chronic bstructive ung isease

Changes in Small Airways in COPD Patients

Inflammatory exudate in lumen

Disrupted alveolar attachments

Thickened wall with inflammatory cells

- macrophages, CD8+ cells, fibroblasts

Peribronchial fibrosis

Lymphoid follicle

Source: Peter J. Barnes, MD


Lobal initiative for chronic bstructive ung isease

Changes in the Lung Parenchyma in COPD Patients

Alveolar wall destruction

Loss of elasticity

Destruction of pulmonary

capillary bed

↑ Inflammatory cells

macrophages, CD8+ lymphocytes

Source: Peter J. Barnes, MD


Lobal initiative for chronic bstructive ung isease

Changes in Pulmonary Arteries in COPD Patients

Endothelial dysfunction

Intimal hyperplasia

Smooth muscle hyperplasia

↑ Inflammatory cells

(macrophages, CD8+ lymphocytes)

Source: Peter J. Barnes, MD


Lobal initiative for chronic bstructive ung isease

Pathogenesis of COPD

Cigarette smoke

Biomass particles

Particulates

Host factors

Amplifying mechanisms

LUNG INFLAMMATION

Anti-oxidants

Anti-proteinases

Oxidative

stress

Proteinases

Repair

mechanisms

COPD PATHOLOGY

Source: Peter J. Barnes, MD


Lobal initiative for chronic bstructive ung isease

Inflammatory Cells Involved in COPD

Cigarette smoke

(and other irritants)

Alveolar macrophage

Epithelial

cells

Chemotactic factors

CD8+

lymphocyte

Fibroblast

Neutrophil

Monocyte

Neutrophil elastase

Cathepsins

MMPs

PROTEASES

Mucus hypersecretion

Fibrosis

(Obstructive

bronchiolitis)

Alveolar wall destruction

(Emphysema)

Source: Peter J. Barnes, MD


Lobal initiative for chronic bstructive ung isease

Oxidative Stress in COPD

Macrophage

Neutrophil

Anti-proteases

NF-B

SLPI

1-AT

Proteolysis

IL-8

TNF-

↓ HDAC2

↑Inflammation

Steroid

resistance

O2-, H202

OH., ONOO-

Neutrophil

recruitment

Isoprostanes

Bronchoconstriction

Plasma leak

 Mucus secretion

Source: Peter J. Barnes, MD


Lobal initiative for chronic bstructive ung isease

COPD

Cigarette smoke

Y

Y

Y

Alv macrophage

Ep cells

CD8+ cell

(Tc1)

Neutrophil

Small airway narrowing

Alveolar destruction

Differences in Inflammation and its Consequences: Asthma and COPD

ASTHMA

Allergens

Ep cells

Mast cell

CD4+ cell

(Th2)

Eosinophil

Bronchoconstriction

AHR

Airflow Limitation

Irreversible

Reversible

Source: Peter J. Barnes, MD


Lobal initiative for chronic bstructive ung isease

Air Trapping in COPD

Mild/moderateCOPD

Normal

Severe COPD

Inspiration

small

airway

alveolar attachments

loss of elasticity

loss of alveolar attachments

Expiration

closure

Dyspnea

↓ Exercise capacity

Air trapping

Hyperinflation

↓ Health

status

Source: Peter J. Barnes, MD


Lobal initiative for chronic bstructive ung isease

Pulmonary Hypertension in COPD

Chronic hypoxia

Pulmonary vasoconstriction

Muscularization

Intimal

hyperplasia

Fibrosis

Obliteration

Pulmonary hypertension

Cor pulmonale

Edema

Death

Source: Peter J. Barnes, MD


Lobal initiative for chronic bstructive ung isease

Inflammation in COPD Exacerbations

Bacteria Viruses Non-infective

Pollutants

Macrophages

Epithelialcells

TNF-

IL-8

IL-6

Neutrophils

Oxidative stress

Source: Peter J. Barnes, MD


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