DISTRIBUTE OR COPY NOT DO - MATERIAL COPYRIGHT POCKET GUIDE TO COPD DIAGNOSIS, MANAGEMENT, AND PREVENTION A Guide for Health Care Professionals 2020 REPORT GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE POCKET GUIDE TO COPD DIAGNOSIS, MANAGEMENT, AND PREVENTION A Guide for Health Care Professionals 2020 EDITION DISTRIBUTE OR COPY NOT DO - MATERIAL COPYRIGHT © 2020 Global Initiative for Chronic Obstructive Lung Disease, Inc. i GOLD BOARD OF DIRECTORS GOLD SCIENCE COMMITTEE* (2019) (2019) Alvar Agusti, MD, Chair Claus Vogelmeier, MD, Chair Maria Montes de Oca, MD Respiratory Institute, University of Marburg Hospital Universitario de Caracas Hospital Clinic, IDIBAPS Marburg, Germany Universidad Central de Venezuela Univ. Barcelona and Ciberes Caracas, Venezuela Barcelona, Spain Alvar Agusti, MD Respiratory Institute, Hospital Alberto Papi, MD Richard Beasley, MD Clinic, IDIBAPS University of Ferrara Medical Research Institute of NZ, Univ. Barcelona and Ciberes Ferrara, Italy Wellington, New Zealand Barcelona, Spain Ian Pavord, MA DM Bartolome R. Celli, MD Antonio Anzueto, MD Respiratory Medicine Unit and Oxford Brigham and Women’s Hospital South Texas Veterans Health Care System, Respiratory NIHR Biomedical Research Boston, Massachusetts, USA University of Texas, Health Centre San Antonio, Texas, USA Nuffield Department of Medicine Rongchang Chen, MD University of Oxford Guangzhou Institute of Respiratory Peter Barnes, DM, FRS Oxford, UK Disease National Heart & Lung Institute, Guangzhou, PRC Imperial College Nicolas Roche, MD London, United Kingdom University Paris Descartes Gerard Criner, MD Hôpital Cochin APHP Temple University School of Medicine Jean Bourbeau, MD Paris, France Philadelphia, Pennsylvania, USA McGill University Health Centre Montreal, Canada Don D. Sin, MD Peter Frith, MD St. Paul’s Hospital, University of British Flinders University Gerard Criner, MD DISTRIBUTEColumbia Adelaide, Australia Temple University School of Medicine Vancouver, Canada Philadelphia, Pennsylvania, USA OR David Halpin, MD Dave Singh, MD Royal Devon and Exeter Hospital Peter Frith, MD (retired 2019) University of Manchester Devon, UK Flinders University COPY Manchester, UK Adelaide, Australia M. Victorina López Varela, MD Robert Stockley, MD Universidad de la República David Halpin, MD NOT University Hospital Montevideo, Uruguay Royal Devon and ExeterDO Hospital Birmingham, UK Devon, UK - Maria Montes de Oca, MD M. Victorina López Varela, MD Hospital Universitario de Caracas MeiLan Han, MD MS Universidad de la República Universidad Central de Venezuela University of Michigan Hospital Maciel Caracas, Venezuela Ann Arbor, MI, USA Montevideo, Uruguay MATERIAL Kevin Mortimer, MD Fernando J. Martinez, MD MS Jørgen Vestbo, MD Liverpool School of Tropical Medicine New York-Presbyterian Hospital/ University of Manchester Liverpool, UK Weill Cornell Medical Center Manchester, England, UK New York, NY, USA Sundeep Salvi, MD Jadwiga A. Wedzicha, MD Chest Research Foundation Imperial College London Pune, India COPYRIGHT London, UK Claus Vogelmeier, MD University of Marburg Marburg, Germany GOLD EXECUTIVE GOLD PROJECT MANAGER EDITORIAL ASSISTANCE DIRECTOR Rebecca Decker, MSJ Katie Langefeld, BS Ruth Hadfield, PhD Fontana, Wisconsin, USA Illinois, USA Sydney, Australia Michael Hess, MPH, RRT, RPFT, Kalamazoo, MI, USA * Disclosure forms for GOLD Committees are posted on the GOLD Website, www.goldcopd.org ii TABLE OF CONTENTS TABLE OF CONTENTS ................................................................. III MANAGEMENT OF STABLE COPD ..............................................28 GLOBAL STRATEGY FOR THE DIAGNOSIS, MANAGEMENT, AND OVERALL KEY POINTS: ......................................................... 28 PREVENTION OF COPD ............................................................... 1 IDENTIFY AND REDUCE EXPOSURE TO RISK FACTORS ............... 29 INTRODUCTION ......................................................................... 1 TREATMENT OF STABLE COPD: PHARMACOLOGICAL TREATMENT ............................................................................. 30 DEFINITION AND OVERVIEW ...................................................... 1 Algorithms for the assessment, initiation and follow-up OVERALL KEY POINTS: .......................................................... 1 management of pharmacological treatment ..................... 32 WHAT IS CHRONIC OBSTRUCTIVE PULMONARY DISEASE TREATMENT OF STABLE COPD: NON-PHARMACOLOGICAL (COPD)? ..................................................................................... 1 TREATMENT ............................................................................. 36 WHAT CAUSES COPD? ............................................................... 2 Oxygen therapy .................................................................. 38 MONITORING AND FOLLOW-UP .............................................. 40 DIAGNOSIS AND ASSESSMENT OF COPD ..................................... 3 MANAGEMENT OF EXACERBATIONS .........................................40 OVERALL KEY POINTS: .......................................................... 3 DIAGNOSIS ................................................................................ 4 OVERALL KEY POINTS: ......................................................... 40 DIFFERENTIAL DIAGNOSIS ......................................................... 4 TREATMENT OPTIONS .............................................................. 42 ASSESSMENT ............................................................................. 7 Treatment setting ............................................................... 42 Classification of severity of airflow limitation ...................... 8 Respiratory support ............................................................ 44 Assessment of symptoms ..................................................... 8 Hospital discharge and follow-up ....................................... 46 Combined COPD assessment .............................................. 10 Prevention of exacerbations ............................................... 47 EVIDENCE SUPPORTING PREVENTION AND MAINTENANCE COPD AND COMORBIDITIESDISTRIBUTE ...................................................... 48 THERAPY .................................................................................. 12 OVERALLOR KE Y POINTS: ......................................................... 48 OVERALL KEY POINTS: ........................................................ 12 REFERENCES ............................................................................. 48 SMOKING CESSATION .............................................................. 12 VACCINATIONS ........................................................................ 13 COPY PHARMACOLOGICAL THERAPY FOR STABLE COPD .................. 15 Overview of the medications .............................................. 15 NOT Bronchodilators .................................................................. 15 DO Antimuscarinic drugs .......................................................... 15 - Methylxanthines ................................................................ 16 Combination bronchodilator therapy ................................. 16 Anti-inflammatory agents .................................................. 17 Inhaled corticosteroids (ICS) ...............................................MATERIAL 17 Triple inhaled therapy ........................................................ 21 Oral glucocorticoids ........................................................... 21 Phosphodiesterase-4 (PDE4) inhibitors .............................. 21 Antibiotics .......................................................................... 22 Mucolytic (mucokinetics, mucoregulators) and antioxidant COPYRIGHT agents (NAC, carbocysteine) .............................................. 22 Issues related to inhaled delivery ....................................... 23 Other pharmacological treatments .................................... 23 REHABILITATION, EDUCATION & SELF-MANAGEMENT ........... 23 Pulmonary rehabilitation ................................................... 23 SUPPORTIVE, PALLIATIVE, END-OF-LIFE & HOSPICE CARE........ 24 Symptom control and palliative care ................................. 24 OTHER TREATMENTS ............................................................... 25 Oxygen therapy and ventilatory support ........................... 25 Ventilatory Support ............................................................ 25 Surgical Interventions ......................................................... 25 iii GLOBAL STRATEGY FOR THE DIAGNOSIS, MANAGEMENT, AND PREVENTION OF COPD INTRODUCTION Chronic Obstructive Pulmonary Disease (COPD) is currently the fourth leading cause of death in the world1 but is projected to be the 3rd leading cause of death by 2020. More than 3 million people died of COPD in 2012 accounting for 6% of all deaths globally. COPD represents an important public health challenge that is both preventable and treatable. COPD is a major cause of chronic morbidity and mortality throughout the world; many people suffer from this disease for years and die prematurely from it or its complications. Globally, the COPD burden is projected to increase in coming decades because of continued exposure to COPD risk factors and aging of the population.2 This Pocket Guide has been developed from the Global Strategy for the Diagnosis, Management, and Prevention of COPD (2020 Report), which aims to provide a