sandra g. adams, md, ms pulmonary diseases / critical care medicine university of texas health...

Sandra G. Adams, MD, MS

Pulmonary Diseases / Critical Care Medicine

University of Texas Health Science Center at San Antonio

South Texas Veterans Healthcare System

GOLD Assessment

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FE

VF

EV

11/F

VC

<70

%/F

VC

<70

%

III: SevereFEV1

30% to 49%

IV: Very SevereFEV1 <30%

Worse obstruction

Global initiative for chronic obstructive lung disease. GOLD Website. http://www.goldcopd.com. Updated December 2011

I: MildFEV1 ≥80%

II: ModerateFEV1

50% to 79%

FEV1 = Forced expiratory volume in one second; FVC = Forced vital capacity

High Risk

http://www.goldcopd.com/

Modified Medical Research Council (MMRC) Dyspnea Scale

Grade Description of Breathlessness

0 I only get breathless with strenuous exercise

1 I get short of breath when hurrying on level ground or walking up a slight hill

2 On level ground, I walk slower than people of the same age because of breathlessness, or have to stop for breath when walking at my own pace

3 I stop for breath after walking about 100 yards or after a few minutes on level ground

4 I am too breathless to leave the house or I am breathless when dressing

Global initiative for chronic obstructive lung disease. GOLD Website. http://www.goldcopd.com. Updated December 2011


GOLD Assessment

Worse obstruction

GOLD Website. http://www.goldcopd.com. Updated December 2011

I: MildFEV1 ≥80%

II: ModerateFEV1

50% to 79%

SymptomsSymptoms

More severe

High

High

Risk

Risk0 1 2 3 4

Modified Medical Research Council Dyspnea ScoreModified Medical Research Council Dyspnea Score

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VF

EV

11/F

VC

<70

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VC

<70

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III: SevereFEV1

30% to 49%



GOLD Assessment

Worse obstruction


⌘May consider “high risk” if develops 1 severe exacerbation or has been hospitalized for exacerbation (not part of GOLD report)

I: MildFEV1 ≥80%

II: ModerateFEV1

50% to 79%

More severe

Exa

cerb

atio

ns

Exa

cerb

atio

ns

≥ 2 or more

per year⌘See below

1 per year

Frequent exacerbations

None

High

High

HighRisk

Risk

Risk

SymptomsSymptoms SymptomsSymptoms

0 1 2 3 4


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FE

VF

EV

11/F

VC

<70

%/F

VC

<70

%

III: SevereFEV1

30% to 49%



GOLD Assessment

Worse obstruction

I: MildFEV1 ≥80%

II: ModerateFEV1

50% to 79%

More severe

Exa

cerb

atio

ns

Exa

cerb

atio

ns

1 per year


AMild-Mod Obstruction

Minimal Symptoms

Few ExacerbationsNone

High

High

HighRisk

Risk

Risk

SymptomsSymptoms

0 1 2 3 4


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FE

VF

EV

11/F

VC

<70

%/F

VC

<70

%


≥ 2 or more

per year⌘III: Severe

FEV1 30% to 49%



GOLD Assessment

Worse obstruction

I: MildFEV1 ≥80%

II: ModerateFEV1

50% to 79%

More severe

Exa

cerb

atio

ns

Exa

cerb

atio

ns

1 per year


None

High

High

HighRisk

Risk

Risk

SymptomsSymptoms

0 1 2 3 4


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FE

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EV

11/F

VC

<70

%/F

VC

<70

%

BMild-Mod Obstruction

Severe Symptoms

Few Exacerbations


Minimal Symptoms

Few Exacerbations

≥ 2 or more

per year⌘


III: SevereFEV1

30% to 49%



GOLD Assessment

Worse obstruction

I: MildFEV1 ≥80%

II: ModerateFEV1

50% to 79%

More severe

Exa

cerb

atio

ns

Exa

cerb

atio

ns

≥ 2 or more

per year⌘

1 per year


None

CSevere Obstruction

Minimal Symptoms

++ Exacerbations

High

High

HighRisk

Risk

Risk

SymptomsSymptoms

0 1 2 3 4


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FE

VF

EV

11/F

VC

<70

%/F

VC

<70

%


Minimal Symptoms

Few Exacerbations


Severe Symptoms

Few Exacerbations


III: SevereFEV1

30% to 49%



GOLD Assessment

Worse obstruction

I: MildFEV1 ≥80%

II: ModerateFEV1

50% to 79%

More severe

Exa

cerb

atio

ns

Exa

cerb

atio

ns

1 per year


DSevere Obstruction

Severe Symptoms

++ Exacerbations

None

High

High

HighRisk

Risk

Risk

SymptomsSymptoms

0 1 2 3 4


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FE

VF

EV

11/F

VC

<70

%/F

VC

<70

%

CSevere Obstruction

Minimal Symptoms

++ Exacerbations


Minimal Symptoms

Few Exacerbations


Severe Symptoms

Few Exacerbations

≥ 2 or more

per year⌘


III: SevereFEV1

30% to 49%



GOLD Assessment

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S

ever

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Air

flo

w

Ob

stru

ctio

nO

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Worse obstruction

More severe

Exa

cerb

atio

ns

Exa

cerb

atio

ns


DSevere Obstruction

Severe Symptoms

++ Exacerbations

High

High

HighRisk

Risk

Risk

SymptomsSymptoms

CSevere Obstruction

Minimal Symptoms

++ Exacerbations


Minimal Symptoms

Few Exacerbations


Severe Symptoms

Few Exacerbations



Management: GOLD Overview

Stage: Mild-Moderate

Minimal Symptoms

Exacerbations (0-1/yr)


Severe symptoms


Stage: Severe-Very Severe

Minimal Symptoms

Exacerbations( ≥2/yr)


Severe Symptoms

Exacerbations (≥2/yr)

Active reduction of risk factors and administer vaccinations (influenza/pneumococcal)

Increase physical activity

Add short-acting bronchodilator (as needed)

Add one or more long-acting bronchodilator(s): scheduled

Add pulmonary rehabilitation

Consider adding inhaled corticosteroid***

Consider PDE4-inhibitor

PDE4-inhibitor = phosphodiesterase4 inhibitor

A B C D

***Never use an inhaled corticosteroid as a single agent in patients with COPD

(inhaled corticosteroids are not approved by the FDA as a single agent for COPD

and they should always be prescribed with a long-acting bronchodilator)



Pharmacotherapy: Overview


Minimal Symptoms



Severe symptoms



Minimal Symptoms



Severe Symptoms


Short-acting bronchodilator (prn)

Long-acting bronchodilator(s): scheduled

Consider adding inhaled corticosteroid***


PDE4-inhibitor = phosphodiesterase4 inhibitor

A B C D

***Never use an inhaled corticosteroid as a single agent in patients with COPD

(inhaled corticosteroids are not approved by the FDA as a single agent for COPD

and they should always be prescribed with a long-acting bronchodilator)


First Choice Pharmacotherapy


Minimal Symptoms


SABA (prn) Albuterol: ProAir®

Proventil®

Reli-On®

Ventolin®

Levalbuterol: Xopenex®

Pirbuterol: Maxair®

OR

SAMA (prn)Ipratropium: Atrovent®


Severe symptoms



Minimal Symptoms



Severe Symptoms


SABA = short-acting beta2-agonist

SAMA = short-acting muscarinic antagonist (anticholinergic)



Consider adding inhaled corticosteroid


A B C D




Minimal Symptoms


SABA or SAMA (prn)


Severe symptoms


LABA (scheduled) Arformoterol: Brovana®

Formoterol: Foradil®

Perforomist®

Indacaterol: Arcapta®

Salmeterol: Serevent®

OR

LAMA (scheduled)Tiotropium: Spiriva®


Minimal Symptoms



Severe Symptoms


LABA = long-acting beta2-agonist

LAMA = long-acting muscarinic antagonist (anticholinergic)





A B C D




Minimal Symptoms


SABA or SAMA (prn)


Severe symptoms


LABA or LAMA

(scheduled)


Minimal Symptoms


ICS/LABA*Budesonide/Formoterol

(Symbicort®)

Fluticasone/Salmeterol

(Advair®)

OR

LAMATiotropium

(Spiriva®)


Severe Symptoms


ICS = inhaled corticosteroid







A B C D

*Mometasone/Formoterol (Dulera®) is another ICS/LABA agent available in the US, but is not yet FDA-approved for COPD




Minimal Symptoms


SABA or SAMA (prn)


Severe symptoms


LABA or LAMA

(scheduled)


Minimal Symptoms


ICS/LABA or LAMA

(scheduled)


Severe Symptoms


ICS/LABA or LAMA

(scheduled) ICS = inhaled corticosteroid







A B C D


Pharmacotherapy (Second Choice)


Minimal Symptoms


First choice:

SABA or SAMA (prn)

Second choice:

SABA + SAMA (scheduled)

or

LABA or LAMA (scheduled)


Severe symptoms


First choice:



Minimal Symptoms


First choice:

ICS/LABA or LAMA

(scheduled)


Severe Symptoms


First Choice:

ICS/LABA or LAMA

(scheduled)





A B C D



Minimal Symptoms


First choice:

SABA or SAMA (prn)


Severe symptoms


First choice:

LABA or LAMA

Second choice:

LABA + LAMA


Minimal Symptoms


First choice:

ICS/LABA or LAMA


Severe Symptoms


First Choice:

ICS/LABA or LAMA





A B C D




Minimal Symptoms


First choice:

SABA or SAMA (prn)


Severe symptoms


First choice:

LABA or LAMA


Minimal Symptoms


First choice:

ICS/LABA or LAMA

Second choice:

LABA + LAMA

or

ICS + LAMA


Severe Symptoms


First Choice:

ICS/LABA or LAMA





A B C D




Minimal Symptoms


First choice:

SABA or SAMA (prn)


Severe symptoms


First choice:

LABA or LAMA


Minimal Symptoms


First choice:

ICS/LABA or LAMA


Severe Symptoms


First Choice:

ICS/LABA or LAMA

Second choice:

ICS/LABA + LAMA

or

ICS/LABA + PDE4-inh

or

LAMA + PDE4-inh





A B C D


PDE4-inhibitor = phosphodiesterase4 inhibitor: Roflumilast (Daliresp®)


Pharmacotherapy (1st & 2nd Choices)


Minimal Symptoms


First choice:

SABA or SAMA (prn)

Second choice:


or



Severe symptoms


First choice:

LABA or LAMA

Second choice:

LABA + LAMA


Minimal Symptoms


First choice:

ICS/LABA or LAMA

Second choice:

LABA + LAMA

or

ICS + LAMA


Severe Symptoms


First Choice:

ICS/LABA or LAMA

Second choice:

ICS/LABA + LAMA

or

ICS/LABA + PDE4-inh

or

LAMA + PDE4-inh





A B C D


Pharmacotherapy (Summary)


Minimal Symptoms


First choice:

SABA or SAMA (prn)

Second choice:


or


Consider Theophylline


Severe symptoms


First choice:

LABA or LAMA

Second choice:

LABA + LAMA



Minimal Symptoms


First choice:

ICS/LABA or LAMA

Second choice:

LABA + LAMA

or

ICS + LAMA

Consider PDE4-inh

or



Severe Symptoms


First Choice:

ICS/LABA or LAMA

Second choice:

ICS/LABA + LAMA

or

ICS/LABA + PDE4-inh

or

LAMA + PDE4-inh






A B C D



Minimal Symptoms



Severe symptoms



Minimal Symptoms



Severe Symptoms


Active reduction of risk factors

Administer vaccinations (influenza/pneumococcal)

Increase physical activity

Add pulmonary rehabilitation

A B C D


Consider evaluation for need for supplemental oxygen

Non-pharmacological Management: GOLD Overview

Consider surgical eval

sandra g. adams, md, ms pulmonary diseases / critical care medicine university of texas health...

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