sandra g. adams, md, ms pulmonary diseases / critical care medicine

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

Seve

rity

of O

bstr

uctio

nSe

verit

y of

Obs

truc

tion

Post

-bro

ncho

dila

tor

Post

-bro

ncho

dila

tor

FEV

FEV 11/F

VC <

70%

/FVC

<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 Breathlessness0 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 Seve

rity

of O

bstr

uctio

nSe

verit

y of

Obs

truc

tion

Post

-bro

ncho

dila

tor

Post

-bro

ncho

dila

tor

FEV

FEV 11/F

VC <

70%

/FVC

<70

%

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

Exac

erba

tions

Exac

erba

tions≥ 2 or more

per year⌘See below

1 per year

Frequent exacerbations

None

High

High

High

Risk

Risk

Risk

SymptomsSymptoms SymptomsSymptoms

0 1 2 3 4


rity

of O

bstr

uctio

nSe

verit

y of

Obs

truc

tion

Post

-bro

ncho

dila

tor

Post

-bro

ncho

dila

tor

FEV

FEV 11/F

VC <

70%

/FVC

<70

%

III: SevereFEV1

30% to 49%



GOLD Assessment

Worse obstruction

I: MildFEV1 ≥80%

II: ModerateFEV1

50% to 79%

More severe

Exac

erba

tions

Exac

erba

tions

1 per year


AMild-Mod ObstructionMinimal SymptomsFew Exacerbations

None

High

High

High

Risk

Risk

Risk

SymptomsSymptoms

0 1 2 3 4


rity

of O

bstr

uctio

nSe

verit

y of

Obs

truc

tion

Post

-bro

ncho

dila

tor

Post

-bro

ncho

dila

tor

FEV

FEV 11/F

VC <

70%

/FVC

<70

%


≥ 2 or more per year⌘

III: SevereFEV1

30% to 49%



GOLD Assessment

Worse obstruction

I: MildFEV1 ≥80%

II: ModerateFEV1

50% to 79%

More severe

Exac

erba

tions

Exac

erba

tions

1 per year


None

High

High

High

Risk

Risk

Risk

SymptomsSymptoms

0 1 2 3 4


rity

of O

bstr

uctio

nSe

verit

y of

Obs

truc

tion

Post

-bro

ncho

dila

tor

Post

-bro

ncho

dila

tor

FEV

FEV 11/F

VC <

70%

/FVC

<70

%

BMild-Mod Obstruction

Severe SymptomsFew Exacerbations




III: SevereFEV1

30% to 49%



GOLD Assessment

Worse obstruction

I: MildFEV1 ≥80%

II: ModerateFEV1

50% to 79%

More severe

Exac

erba

tions

Exac

erba

tions≥ 2 or more

per year⌘

1 per year


None

CSevere ObstructionMinimal Symptoms++ Exacerbations

High

High

High

Risk

Risk

Risk

SymptomsSymptoms

0 1 2 3 4


rity

of O

bstr

uctio

nSe

verit

y of

Obs

truc

tion

Post

-bro

ncho

dila

tor

Post

-bro

ncho

dila

tor

FEV

FEV 11/F

VC <

70%

/FVC

<70

%





III: SevereFEV1

30% to 49%



GOLD Assessment

Worse obstruction

I: MildFEV1 ≥80%

II: ModerateFEV1

50% to 79%

More severe

Exac

erba

tions

Exac

erba

tions

1 per year


DSevere ObstructionSevere Symptoms++ Exacerbations

None

High

High

High

Risk

Risk

Risk

SymptomsSymptoms

0 1 2 3 4


rity

of O

bstr

uctio

nSe

verit

y of

Obs

truc

tion

Post

-bro

ncho

dila

tor

Post

-bro

ncho

dila

tor

FEV

FEV 11/F

VC <

70%

/FVC

<70

%







III: SevereFEV1

30% to 49%



GOLD Assessment

Seve

rity

of A

irflo

w

Seve

rity

of A

irflo

w

Obs

truc

tion

Obs

truc

tion

Worse obstruction

More severe

Exac

erba

tions

Exac

erba

tions


DSevere ObstructionSevere Symptoms++ Exacerbations

High

High

High

Risk

Risk

Risk

SymptomsSymptoms







Management: GOLD Overview

Stage: Mild-ModerateMinimal Symptoms

Exacerbations (0-1/yr)

Stage: Mild-ModerateSevere symptoms


Stage: Severe-Very SevereMinimal Symptoms

Exacerbations( ≥2/yr)

Stage: Severe-Very SevereSevere Symptoms

Exacerbations (≥2/yr)

Active reduction of risk factors and administer vaccinations (influenza/pneumococcal)Increase physical activityAdd short-acting bronchodilator (as needed)

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









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



SABA (prn) Albuterol: ProAir®

Proventil®

Reli-On® Ventolin®

Levalbuterol: Xopenex® Pirbuterol: Maxair®

OR

SAMA (prn)Ipratropium: Atrovent®







SABA = short-acting beta2-agonist

SAMA = short-acting muscarinic antagonist (anticholinergic)



Consider adding inhaled corticosteroid


A B C D





SABA or SAMA (prn)



LABA (scheduled) Arformoterol: Brovana®

Formoterol: Foradil® Perforomist®

Indacaterol: Arcapta®

Salmeterol: Serevent®

OR

LAMA (scheduled)Tiotropium: Spiriva®





LABA = long-acting beta2-agonist

LAMA = long-acting muscarinic antagonist (anticholinergic)





A B C D





SABA or SAMA (prn)



LABA or LAMA(scheduled)

Stage: Severe-Very SevereMinimal SymptomsExacerbations( ≥2/yr)

ICS/LABA*Budesonide/Formoterol (Symbicort®)Fluticasone/Salmeterol(Advair®)

OR

LAMATiotropium(Spiriva®)



ICS = inhaled corticosteroidLABA = long-acting beta2-agonist






A B C D

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





SABA or SAMA (prn)



LABA or LAMA(scheduled)



ICS/LABA or LAMA(scheduled)



ICS/LABA or LAMA(scheduled) ICS = inhaled corticosteroid

LABA = long-acting beta2-agonist






A B C D


Pharmacotherapy (Second Choice)



First choice:SABA or SAMA (prn)

Second choice:SABA + SAMA

(scheduled)or

LABA or LAMA (scheduled)



First choice:LABA or LAMA

(scheduled)

Stage: Severe-Very SevereMinimal SymptomsExacerbations( ≥2/yr)

First choice:ICS/LABA or LAMA(scheduled)



First Choice:ICS/LABA or LAMA

(scheduled)





A B C D








Second choice:LABA + LAMA



First choice:ICS/LABA or LAMA








A B C D













or

ICS + LAMA








A B C D















Second choice:ICS/LABA + LAMA

orICS/LABA + PDE4-inh

orLAMA + PDE4-inh





A B C D


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


Pharmacotherapy (1st & 2nd Choices)





(scheduled)or










or

ICS + LAMA






orLAMA + PDE4-inh





A B C D


Pharmacotherapy (Summary)





(scheduled)or


Consider Theophylline










or

ICS + LAMA

Consider PDE4-inhor







orLAMA + PDE4-inh






A B C D










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

Documents

gold reporti

level ground4i

short of breath

slight hill2on level

severe exacerbation

strenuous exercise1i

yearsee below1

high risk