GOLD Update 2011
Rabab A. El Wahsh, MD.
Lecturer of Chest Diseases and Tuberculosis
Minoufiya University
REVISED 2011
Global Initiative for chronic obstructive pulmonary disease
(GOLD)• Immediately following the release of the first
GOLD report in 2001, the GOLD board of directors appointed a science committee, charged with keeping the GOLD documents up to date.
• The first update to the GOLD report was in 2003, then annual updated documents were prepared and released on the GOLD website.
• A comprehensively updated version was released in 2006, then in 2010 and lastly in 2011.
What`s new in GOLD 2011?
• The definition of COPD was not significantly modified but has
been reworded for clarity.
• Assessment of COPD is based on the patient`s level of
symptoms, future risk of exacerbations, the severity of
spirometric abnormlity, and the identification of comorbidities.
• Management of stable COPD is based , not only on level of
FEV1 but on disease impact and future risk of disease
progression.
• More focusing on comorbidities.
COPD Definition
• GOLD 2010• Chronic obstructive pulmonary
disease (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 is usually progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases.
• GOLD 2011• Chronic obstructive pulmonary
disease (COPD), a common preventable and treatable disease is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. Exacerbations and comorbidities contribute to the overall severity in individual patients.
Risk Factors for COPD
GenesGenes
InfectionsInfections
Socio-economic Socio-economic statusstatus
Aging PopulationsAging Populations
Pathogenesis of COPDPathogenesis of COPD
NOXIOUS AGENT(tobacco smoke, pollutants, occupational agent)
COPD
Genetic factors
Respiratory infection
Other
Noxious particles
and gases
Lung inflammation
Host factors
COPD pathology
ProteinasesOxidative stress
Anti-proteinasesAnti-oxidants
Repair mechanisms
INFLAMMATION
Small airway diseaseAirway inflammationAirway remodeling
Parenchymal destructionLoss of alveolar attachments
Decrease of elastic recoil
AIRFLOW LIMITATION
Diagnosis and Assessment of COPDGOLD 2010 GOLD 2011
•While post-bronchodilator spirometry is required for the diagnosis and assessment of severity of COPD, the degree of reversibility of airflow limitation is no longer recommended. The degree of reversibility has never been shown to add to the diagnosis, differential diagnosis with asthma, or to predicting the response to long-term treatment with bronchodilators or corticosteroids.
•The use of a fixed ratio FEV1/FVC to define airflow limitation will result in more frequent diagnosis of COPD in the elderly, and less frequent diagnosis in adults younger than 45 years, especially of mild disease, compared to using a cutoff based on the lower limit of normal values for FEV1/FVC. From a scientific perspective it is difficult to determine which of these criteria is correct to diagnose COPD.
Diagnosis and Assessment of COPD
SYMPTOMS
chronic cough chronic coughshortness of breathshortness of breath
EXPOSURE TO RISKFACTORS
tobaccotobaccooccupationoccupation
indoor/outdoor pollutionindoor/outdoor pollution
SPIROMETRY: Required to establish diagnosis
SPIROMETRY: Required to establish diagnosis
Diagnosis of COPDDiagnosis of COPD
sputum sputum
Assessment of GOLD stage using spirometry (GOLD 2010)
In patients with FEV1/FVC < 0.70:
GOLD 1: Mild FEV1 > 80% predicted
GOLD 2: Moderate 50% < FEV1 < 80% predicted
GOLD 3: Severe 30% < FEV1 < 50% predicted
GOLD 4: Very Severe FEV1 < 30% predicted
*Based on Post-Bronchodilator FEV1
Assess symptomsAssess degree of airflow limitation using
spirometryAssess risk of exacerbationsAssess comorbidities
Combined Assessment of COPD (GOLD 2011)
COPD Assessment Test (CAT): An 8-item measure of health status impairment in COPD.
Breathlessness Measurement using the Modified British Medical Research Council (mMRC) Questionnaire: relates well to other measures of health status and predicts future mortality risk.
Assessment of Symptoms
Modified MRC (mMRC)Questionnaire
COPD Assessment Test (CAT):
Assessment of degree of airflow limitation using spirometry
In patients with FEV1/FVC < 0.70:
GOLD 1: Mild FEV1 > 80% predicted
GOLD 2: Moderate 50% < FEV1 < 80% predicted
GOLD 3: Severe 30% < FEV1 < 50% predicted
GOLD 4: Very Severe FEV1 < 30% predicted
*Based on Post-Bronchodilator FEV1
Assessment of risk of exacerbations
An exacerbation of COPD is defined as an acute event
characterized by a worsening of the patient`s respiratory
symptoms that is beyond normal day-to-day variations and
leads to change in medication.
Two exacerbations or more within the last year
or an FEV1 < 50 % of predicted value are
indicators of high risk of future exacerbations.
Combined Assessment of COPD
Ris
k (G
OLD
Cla
ssifi
catio
n of
Air
flo
w L
imit
atio
n)
Ris
k (E
xace
rbat
ion
hist
ory)
> 2
1
0
(C) (D)
(A) (B)
mMRC 0-1CAT < 10
4
3
2
1
mMRC > 2CAT > 10
Symptoms(mMRC or CAT score))
Patient is now in one of
four categories:
A: Less symptoms, low risk
B: More symtoms, low risk
C: Less symptoms, high risk
D: More Symtoms, high risk
Assessment of COPD Comorbidities
COPD patients are at increased risk for:
Cardiovascular diseasesOsteoporosisRespiratory infectionsAnxiety and DepressionDiabetesLung cancerThese comorbid conditions may influence mortality and
hospitalizations and should be looked for routinely, and treated appropriately.
Goals for treatment of stable COPD
Reduce symptoms by:•Relieving symptoms•Improving exercise tolerence•Improving health statusReduce risk by:•Preventing disease progression•Preventing and treatment of exacerbation•Reduction of mortality
Management of stable COPD
2010
Initial pharmacologic management of COPD (2011)Patient group First choice Second choice Alternative choice
A Short acting anticholinergic
Or
Short acting B2 agonist
Long acting anticholinergic
Or
Long acting B2 agonist
Or
Short acting B2 agonist and Short acting anticholinergic
Theophylline
B Long acting
Anticholinergic
Or
Long acting
B2 agonist
Long acting
Anticholinergic and
Long acting
B2 agonist
Short acting B2 agonist and/ or
Short acting anticholinergic
Theophylline
C Inhaled corticosteroid + Long acting
B2 agonist
Or
Long acting
anticholinergic
Long acting
Anticholinergic and
Long acting
B2 agonist
Phospodiesterase-4 inhibitor
Short acting B2 agonist and/ or
Short acting anticholinergic
Theophylline
D Inhaled corticosteroid + Long acting
B2 agonist
Or
Long acting
anticholinergic
Inhaled corticosteroid and Long acting
Anticholinergic
Or
inhaled corticosteroid+
Long acting
B2 agonist and long acting anticholinergic
Or
Inhaled corticosteroid + Long acting B2 agonist and phosphodiesterse-4 inhibitor
Or
Long acting Anticholinergic and long acting B2 agonist
Or
Long acting anticholinergic and phosphodiesterase-4 inhibitor
Carbocysteine
Short acting B2 agonist
And/or
Short acting anticholinergic
theophylline
Non-pharmacologic management of COPD (2011)
Patient group Essential Recommended Depending on local guidelines
A Smoking cessation
Physical activity Flu vaccine
Pneumococcal vaccine
B-D Smoking cessation
Pulmonary rehabilitation
Physical activity Flu vaccine
Pneumococcal vaccine