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Chronic Obstructive Lung Disease: GOLD Guidelines. Baylor College of Medicine Combined Med-Peds Program Anoop Agrawal, M.D. COPD - Definition. Global Obstructive Lung Disease Guidelines (GOLD) : first published in 2001

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chronic obstructive lung disease gold guidelines
Chronic Obstructive Lung Disease:GOLD Guidelines
  • Baylor College of Medicine
  • Combined Med-Peds Program
  • Anoop Agrawal, M.D.
copd definition
COPD - Definition
  • Global Obstructive Lung DiseaseGuidelines (GOLD) : first published in 2001
    • “Disease state characterized by airflow limitation that is no longer fully reversible and is usually progressive... This results in a chronic inflammatory response in the walls and lumen of the airways.”
  • GOLD guidelines were recently updated in 2006
copd prevalence
COPD - Prevalence
  • Affects 15 million Americans
  • Fourth leading cause of mortality (100,000/year)
  • Only major health problem for which mortality has been increasing for past 20 years
  • Results in 500,000 hospitalizations/year
  • Second leading cause of missed work days
  • There are numerous published guidelines - GOLD being the most prominent (www.goldcopd.com)
copd risk factors
COPD - Risk Factors
  • Hereditary - Alpha-1 Antitrypsin Deficiency
  • Environmental
    • Cigarette Smoking
      • What percent of smokers will develop COPD?
        • 15-20% (~1 in 5) - this implies a genetic predisposition to developing COPD; tends to cluster in families
    • Occupational exposures to dust, chemicals
copd diagnosis
COPD - Diagnosis
  • Symptoms
    • chronic cough - intermittent, nonproductive
    • cough with sputum production, ‘smoker’s cough’
    • dyspnea on exertion, usually progressive and indolent
  • Spirometry
    • Should spirometry screening be performed on the general population?
      • No, but in those with higher risk - i.e. all current and former smokers over the age of 40 years with any of the above symptoms of disease
the importance of screening for copd
The Importance of Screening for COPD
  • The Rule of 50s
    • 50% of COPD patients are undiagnosed (or approximately 12 million patients in U.S.)
    • COPD is evident by age 50
    • At time of diagnosis, FEV1 is <50% predicted
    • 50% 5-year survival rate
raising copd awareness
Raising COPD Awareness

November is National COPD Awareness Month

World COPD Day took place on November 19th, 2008.

copd staging
COPD Staging
  • Based upon the GOLD Guidelines - 2006 update
    • Classified into 4 stages
  • Staging is based primarily upon FEV1:
    • FEV1 < 80%
    • FEV1:FVC < 70%
  • The lower the FEV1 the more severe the disease classification.
copd management and therapies
COPD Management and Therapies
  • Vaccination - pneumococcal and influenza
  • Regular Assessment of lung function - annually
  • Cessation of tobacco use
  • Drug Therapy:
    • short acting vs. long acting bronchodilators
    • inhaled vs. oral corticosteroids
copd management of stable disease
COPD - Management of Stable Disease
  • Smoking cessation: rate of FEV1 deterioration will slow to near normal (20 ml /yr vs. 65 ml /yr for active smokers) if patient stops smoking
copd drug therapy
COPD - Drug Therapy
  • Therapy recommendations based on their effect on FEV1.
  • First Line therapy:
    • Beta agonists - short and long acting
    • Anticholinergics - short and long acting
  • Second Line therapy:
    • Steroids - inhaled vs. oral
    • Supplemental therapies
beta agonists
Beta agonists
  • Mechanism of Action - bronchodilate by stimulating Beta-2 receptors
  • Studies show that COPD patients do not develop tolerance to short acting or long acting beta agonists
  • Asthmatics tend to develop tolerance to short acting agonists
  • Can Salmeterol be used as monotherapy?

YES, salmeterol monotherapy had adverse outcomes in asthma study, note copd.

anticholinergics
Anticholinergics
  • Mechanism of action- bronchodilation by decreasing airway smooth muscle tone
  • Also reduces sputum production
  • Combination of an anticholinergic + B2-agonist produces greater and more sustained rise in FEV1 than either drug alone.
tiotropium spiriva
Tiotropium (Spiriva)
  • Studies show that once daily tiotropium has resulted in a lasting increase in FEV1 out to one year.
    • 174 ml above baseline in good short-term responders
    • 56 ml increase in poor short-term responders

Special delivery device.

Tashkin,D. Chest 2003 May; 123:1441-9

inhaled corticosteroids ics
Inhaled Corticosteroids (ICS)
  • Have not been shown to slow the progression of disease or provide long term benefit
  • ISOLDE trial - patients with FEV1 of 50% predicted value had a 25% reduction of exacerbations
  • Combination with salmeterol more effective in reducing exacerbations than either drug alone
  • Unfortunately, recently published trial failed to demonstrate statistically significant reduction in mortality with salmeterol/fluticasone combo.
  • Use of ICS increases likelihood of pneumonia.
new copd treatment data
New COPD Treatment Data
  • INSPIRE - study published in Jan 2008
    • compared salmeterol/fluticasone head to head with tiotropium
    • No difference in exacerbation rate although more in tiotropium group had higher drop out rate.
    • More patients in salmeterol/fluticasone developed pneumonia.
oral corticosteroids
Oral Corticosteroids
  • They have no proven benefit in stable COPD
  • Oral steroids are useful for acute exacerbations
    • What is the recommended duration of therapy?
      • Maximum benefit obtained during first 2 weeks of therapy.
supplemental therapies
Supplemental Therapies
  • Supplemental oxygen for hypoxemia (worn for more than 15 hrs/day) has been shown to reduce moratality
    • What are the qualification parameters for oxygen therapy?
      • PaO2 of 55mmHg or less, or pulse oximetry of 88% or less
  • Pulmonary Rehabilitation
  • Lung reduction and lung transplantation surgeries
summary
Summary
  • Early diagnosis, disease prevention, smoking cessation and vaccination are important.
  • Initiate bronchodilator therapy early in disease course, combination of albuterol with ipratropium most effective
  • Inhaled corticosteroids may be useful in patients with severe disease or with objective responses on spirometry.
  • Will likely see inflammatory modulators (TNF-α) in the future