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Global Initiative for Chronic Obstructive Lung Disease (2006) Global Initiative for Chronic Obstructive Lung Disease GLOBAL STRATEGY FOR THE DIAGNOSIS, MANAGEMENT, AND PREVENTION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE 2006 Copyright © 2006 MCR VISION, Inc. All Rights Reserved GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE GLOBAL STRATEGY FOR THE DIAGNOSIS, MANAGEMENT, AND PREVENTION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE (2006) © 2006 Global Initative for Chronic Obstructive Lung Disease i Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2006) GOLD EXECUTIVE COMMITTEE* Roberto Rodriguez Roisin, MD Hospital Clinic A. Sonia Buist, MD, Chair Barcelona, Spain Oregon Health & Science University Portland, Oregon, USA Thys van der Molen, MD University of Groningen Antonio Anzueto, MD Groningen, The Netherlands (Representing the American Thoracic Society) University of Texas Health Science Center Chris van Weel, MD San Antonio, Texas, USA (Representing the World Organization of Family Doctors (WONCA)) Peter Calverley, MD University of Nijmegen University Hospital Aintree Nijmegen, The Netherlands Liverpool, UK GOLD SCIENCE COMMITTEE* Teresita S. deGuia, MD Philippine Heart Center Klaus F. Rabe, MD, PhD, Chair Quezon City, Philippines Leiden University Medical Center Leiden, The Netherlands Yoshinosuke Fukuchi, MD (Representing the Asian Pacific Society for Respirology) A. G. Agusti, MD (Effective June 2006) Tokyo, Japan Hospital Universitari Son Dureta Palma de Mallorca, Spain Christine Jenkins, MD Woolcock Institute of Medical Research Antonio Anzueto, MD Sydney, NSW, Australia University of Texas Health Science Center San Antonio, Texas, USA Nikolai Khaltaev, MD (Representing the World Health Organization) Peter J. Barnes, MD Geneva, Switzerland National Heart and Lung Institute London, UK James Kiley, PhD (Representing the National Heart, Lung, and Blood Institute, A. Sonia Buist, MD National Institutes of Health, Oregon Health & Science University Department of Health and Human Services) Portland, Oregon, USA Bethesda, Maryland, USA Peter Calverley, MD Ali Kocabas, MD University Hospital Aintree Cukurova University School of Medicine Liverpool, UK Balcali, Adana, Turkey Marc Decramer, MD (Effective June 2006) Mará Victorina López, MD University Hospital (Representing the Latin American Thoracic Society) Leuven, Belgium Montevideo, URUGUAY Yoshinosuke Fukuchi, MD Ewa Nizankowska-Mogilnicka, MD President University School of Medicine Asian Pacific Society for Respirology Krakow, Poland Tokyo, Japan Klaus F. Rabe, MD, PhD Paul Jones, MD (Effective June 2006) Leiden University Medical Center St. George's Hospital Medical School Leiden, The Netherlands London, UK *Disclosure forms for GOLD Committees are posted on the GOLD Website, www.goldcopd.org ii Roberto Rodriguez Roisin, MD Carlos M. Luna, MD Hospital Clinic President, ALAT Barcelona, Spain Buenos Aires, Argentina Jorgen Vestbo, MD (Effective June 2006) Dennis Niewoehner, MD Hvidovre University Hospital University of Minnesota Hvidovre, Denmark Minneapolis, Minnesota, USA Jan Zielinski, MD Jim Reid, MD Institute of TB and Lung Diseases Dunedin School of Medicine Warsaw, Poland University of Otago Dunedin, New Zealand CHAPTER CONTRIBUTORS Sanjay Sethi, MD Leonardo Fabbri, MD VA Medical Research University of Modena & Reggio Emilia Buffalo, New York, USA Modena, Italy Peter Sterk, MD James C. Hogg, MD Leiden University Medical Center St. Paul’s Hospital Leiden, The Netherlands Vancouver, British Columbia, Canada GOLD NATIONAL LEADERS WHO SUBMITTED Christine Jenkins, MD COMMENTS Woolcock Institute of Medical Research Sydney, NSW, Australia Lorenzo Corbetta, MD Università di Firenze Ewa Nizankowska-Mogilnicka, MD Firenze, Italy University School of Medicine Krakow, Poland Maia Gotua, MD, PhD Center of Allergy & Immunology Sean Sullivan, MD Tbilisi, Georgia University of Washington Seattle, Washington, USA Gérard Huchon, MD University of Paris Thys van der Molen, MD Paris, France University of Groningen Groningen, The Netherlands Prof. E.M. Irusen South Africa Thoracic Society Chris van Weel, MD University of Stellenbosch University of Nijmegen Cape Town, South Africa Nijmegen, The Netherlands Yousser Mohammad, MD REVIEWERS Tishreen University School of Medicine Lattakia, Syria Bart Celli, MD Caritas St. Elizabeth's Medical Center Jaromir Musil, PhD Brighton, Massachusetts, USA Stanislav Kos, MD, PhD F. Salajka, PhD M.W. Elliott, MD Vladimir Vondra, MD, PhD St. James's University Hospital Czech Association Against COPD West Yorkshire, UK Prague, Czech Republic H.A.M. Kerstjens, MD, PhD Vesna Petrovic, MD University Medical Center Groningen JUDAH Association for Asthma and COPD Groningen, The Netherlands Serbia Peter Lange, MD Hvidovre Hospital Hvidovre, Denmark iii PREFACE Chronic Obstructive Pulmonary Disease (COPD) remains In spite of the achievements in the five years since the a major public health problem. It is the fourth leading GOLD report was originally published, considerable cause of chronic morbidity and mortality in the United additional work is ahead of all of us if we are to control States, and is projected to rank fifth in 2020 in burden this major public health problem. The GOLD initiative will of disease caused worldwide, according to a study continue to bring COPD to the attention of governments, published by the World Bank/World Health Organization. public health officials, health care workers, and the Furthermore, although COPD has received increasing general public, but a concerted effort by all involved in attention from the medical community in recent years, it health care will be necessary. is still relatively unknown or ignored by the public as well as public health and government officials. I would like to acknowledge the work of the members of the GOLD Science Committee who prepared this revised In 1998, in an effort to bring more attention to COPD, its report. We look forward to our continued work with management, and its prevention, a committed group of interested organizations and the GOLD National Leaders scientists encouraged the US National Heart, Lung, and to meet the goals of this initiative. Blood Institute and the World Health Organization to form the Global Initiative for Chronic Obstructive Lung Disease We are most appreciative of the unrestricted educational (GOLD). Among the important objectives of GOLD are to grants from Altana, AstraZeneca, Boehringer Ingelheim, increase awareness of COPD and to help the millions of Chiesi, GlasoSmithKline, Mitsubishi Pharma Corporation, people who suffer from this disease and die prematurely Nikken Chemicals, Co,. Ltd., Novartis, and Pfizer that from it or its complications. enabled development of this report. The first step in the GOLD program was to prepare a consensus report, Global Strategy for the Diagnosis, Management, and Prevention of COPD, which was published in 2001. The report was written by an Expert Panel, which was chaired by Professor Romain Pauwels A. Sonia Buist, MD of Belgium and included a distinguished group of health Portland, Oregon, USA professionals from the fields of respiratory medicine, Chair, GOLD Executive Committee epidemiology, socioeconomics, public health, and health education. The Expert Panel reviewed existing COPD guidelines and new information on pathogenic mechanisms of COPD, bringing all of this material together in the consensus document. The present, newly revised document follows the same format as the original consensus report, but has been updated to reflect the many publications on COPD that have appeared since 2001. Since the original consensus report was published in 2001, a network of international experts known as GOLD National Leaders has been formed to implement the report’s recommendations. Many of these experts have initiated investigations of the causes and prevalence of COPD in their countries, and developed innovative approaches for the dissemination and implementation of COPD management guidelines. We appreciate the enormous amount of work the GOLD National Leaders have done on behalf of their patients with COPD. iv TABLE OF CONTENTS Introduction . 4. Pathology, Pathogenesis, and Pathophysiology . Key Points . 1. Definition . Introduction . Key Points . Pathology . Definition . Pathogenesis Airflow limitation in COPD Inflammatory Cells . COPD and Co-morbidities Inflammatory Mediators . Natural History . Oxidative Spirometric Classification of Severity Protease-Antiprotease Imbalance Stages of COPD Differences in Inflammation Between COPD Scope of the Report . and Asthma . Asthma and COPD . Pathophysiology . Pulmonary Tuberculosis and COPD . Airflow Limitation and Air Trapping References . Gas Exchange Abnormalities . Mucus Hypersecretion 2. Burden of COPD . Pulmonary Hypertension Key Points . Systemic Features . Exacerbations . Introduction . References . Epidemiology . Prevalence . 5. Management of COPD Morbidity . Introduction . Mortality . Economic and Social Burden of COPD . Component 1: Assess and Monitor Disease . Economic Burden . Key Points . Social Burden . Initial Diagnosis . References . Assessment of Symptoms . Dyspnea 3. Risk Factors . Cough Key Points . Sputum production Introduction . Wheezing and chest tightness Risk Factors . Additional features in severe disease Genes . Medical History . Inhalational Exposures . Physical Examination . Tobacco smoke Inspection Occupational dusts and chemicals Palpation and percussion Indoor air pollution Auscultation Outdoor air pollution Measurement of Airflow Limitation . Lung Growth and
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