GlobalGlobal InitiativeInitiative forfor ChronicChronic ObstructiveObstructive LungLung DiseaseDisease DISTRIBUTE OR COPY NOT DO MATERIAL- COPYRIGHTEDPOCKET GUIDE TO COPD DIAGNOSIS, MANAGEMENT, AND PREVENTION A Guide for Health Care Professionals 2018 REPORT GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE POCKET GUIDE TO COPD DIAGNOSIS, MANAGEMENT, AND PREVENTION A Guide for Health Care Professionals 2018 EDITION DISTRIBUTE OR COPY NOT DO MATERIAL- COPYRIGHTED © 2018 Global Initiative for Chronic Obstructive Lung Disease, Inc. ii GOLD BOARD OF DIRECTORS GOLD SCIENCE COMMITTEE* (2017) (2017) Alvar Agusti, MD, Chair Claus Vogelmeier, MD, Chair Respiratory Institute, University of Marburg Hospital Clinic, IDIBAPS Marburg, Germany Univ. Barcelona and Ciberes Barcelona, Spain Alvar Agusti, MD Nicolas Roche, MD Respiratory Institute, Hospital Hôpital Cochin Bartolome R. Celli, MD Clinic, IDIBAPS Paris, France Brigham and Women’s Hospital Boston, Univ. Barcelona and Ciberes Massachusetts, USA Barcelona, Spain Donald Sin, MD St. Paul’s Hospital, University of Rongchang Chen, MD Antonio Anzueto, MD British Columbia Guangzhou Institute of Respiratory University of Texas Vancouver, Canada Disease Health Science Center Guangzhou, PRC San Antonio, Texas, USA Dave Singh, MD University of Manchester Gerard Criner, MD Peter Barnes, MD Manchester, UK Temple University School of Medicine National Heart and Lung Institute Philadelphia, Pennsylvania, USA London, United Kingdom Robert Stockley, MD University Hospital Peter Frith, MD Jean Bourbeau, MD DISTRIBUTEBirmingham, UK Repatriation General Hospital, Adelaide, McGill University Health Centre South Australia, Australia Montreal, Canada OR Jørgen Vestbo, MD University of Manchester David Halpin, MD Gerard Criner, MD Manchester, England, UK Royal Devon and Exeter Hospital Temple University School of Medicine Devon, UK Philadelphia, Pennsylvania,COPY USA Jadwiga A. Wedzicha, MD Imperial College London M. Victorina López Varela, MD Peter Frith, MD London, UK Universidad de la República Repatriation GeneralNOT Hospital, Montevideo, Uruguay Adelaide, M. Victorina López South Australia,AustraliaDO Varela,MDUniversidad de la Masaharu Nishimura, MD República Hokkaido University School of Medicine David Halpin, MD Hospital Maciel Sapporo, Japan Royal Devon and Exeter Hospital, Montevideo, Uruguay Devon, United Kingdom Claus Vogelmeier, MD University of Marburg MATERIAL-Fernando J. Martinez, MD, MS Marburg, Germany New York-Presbyterian Hospital/ Weill Cornell Medical Center New York, NY USA GOLD PROGRAM DIRECTOR Rebecca Decker,COPYRIGHTED MSJ Fontana, Wisconsin, USA * Disclosure forms for GOLD Committees are posted on the GOLD Website, www.goldcopd.org TABLE OF CONTENTS TABLE OF CONTENTS ......................................... IV SUPPORTIVE, PALLIATIVE, END-OF-LIFE & HOSPICE CARE ................................................. 18 GLOBAL STRATEGY FOR THE DIAGNOSIS, Symptom control and palliative care .......... 18 MANAGEMENT, AND PREVENTION OF COPD ...... 1 OTHER TREATMENTS ....................................... 19 INTRODUCTION ................................................. 1 Oxygen therapy and ventilatory support .... 19 DEFINITION AND OVERVIEW ............................... 1 MANAGEMENT OF STABLE COPD ...................... 21 OVERALL KEY POINTS: .................................. 1 OVERALL KEY POINTS: ................................ 21 WHAT IS CHRONIC OBSTRUCTIVE PULMONARY IDENTIFY AND REDUCE EXPOSURE TO RISK DISEASE (COPD)? ............................................... 2 FACTORS .......................................................... 22 WHAT CAUSES COPD? ....................................... 2 TREATMENT OF STABLE COPD ......................... 23 DIAGNOSIS AND ASSESSMENT OF COPD ............. 4 PHARMACOLOGIC TREATMENT .................. 23 Pharmacologic treatment algorithms ........ 24 OVERALL KEY POINTS: .................................. 4 MONITORING AND FOLLOW-UP ...................... 28 DIAGNOSIS ........................................................ 4 DISTRIBUTE DIFFERENTIAL DIAGNOSIS ................................. 5 MANAGEMENT OF EXACERBATIONS ................. 28 OR ASSESSMENT ..................................................... 6 OVERALL KEY POINTS: ................................ 28 Classification of severity of airflow TREATMENT OPTIONS ..................................... 29 obstruction ................................................... 6 TreatmentCOPY Setting ....................................... 29 Assessment of symptoms ............................. 6 HOSPITAL DISCHARGE AND FOLLOW-UP ......... 33 Combined COPD assessment ........................ 8 NOTCOPD AND COMORBIDITIES .............................. 34 EVIDENCE SUPPORTING PREVENTION AND DO OVERALL KEY POINTS: ................................. 34 MAINTENANCE THERAPY ................................... 9 REFERENCES .................................................... 35 OVERALL KEY POINTS: ..................................9 SMOKING CESSATION ..................................... 10 VACCINATIONS ................................................ 10 Influenza vaccine ................................MATERIAL-........ 10 Pneumococcal vaccine ............................... 10 PHARMACOLOGIC THERAPY FOR STABLE COPD ........................................................................ 11 Bronchodilators .......................................... 11 Beta2-agonists ............................................ 11 Antimuscarinic drugs .................................. 12 COPYRIGHTED Methylxanthines......................................... 12 Combination bronchodilator therapy ......... 12 Anti-inflammatory agents .......................... 14 Inhaled corticosteroids (ICS) ....................... 14 Issues related to inhaled delivery ............... 16 Other pharmacologic treatments ............... 17 REHABILITATION, EDUCATION & SELF- MANAGEMENT ............................................... 18 Pulmonary rehabilitation ........................... 18 iv GLOBAL STRATEGY FOR THE DIAGNOSIS, MANAGEMENT, AND PREVENTION OF COPD INTRODUCTION Chronic Obstructive Pulmonary Disease (COPD) represents an important public health challenge and is a major cause of chronic morbidity and mortality throughout the world. 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. 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 (2018 Report), which aims to provide a non-biased review of the current evidence for the assessment, diagnosis and treatment of patients withDISTRIBUTE COPD that can aid the clinician. Discussions of COPD and COPD management, evidence levels,OR and specific citations from the scientific literature are included in that source document, which is available from www.goldcopd.org. The tables and figures in this Pocket Guide follow the numbering of the 2018 COPY Global Strategy Report for reference consistency. NOT DEFINITION AND OVERVIEW DO OVERALL KEY POINTS: • Chronic Obstructive Pulmonary Disease (COPD) is a common, preventable and treatable disease that is characterizedMATERIAL- by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases. • The most common respiratory symptoms include dyspnea, cough and/or sputum production. These symptoms may be under-reported by patients. • The mainCOPYRIGHTED risk factor for COPD is tobacco smoking but other environmental exposures such as biomass fuel exposure and air pollution may contribute. Besides exposures, host factors predispose individuals to develop COPD. These include genetic abnormalities, abnormal lung development and accelerated aging. • COPD may be punctuated by periods of acute worsening of respiratory symptoms, called exacerbations. • In most patients, COPD is associated with significant concomitant chronic diseases, which increase its morbidity and mortality. 1 1 WHAT IS CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)? Chronic Obstructive Pulmonary Disease (COPD) is a common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases. The chronic airflow limitation that is characteristic of COPD is caused by a mixture of small airways disease (e.g., obstructive bronchiolitis) and parenchymal destruction (emphysema), the relative contributions of which vary from person to person (Figure 1.1). Figure 1.1. Etiology, pathobiology and pathology of COPD leading to airflow limitation and clinical manifestations Etiology Smoking and pollutants DISTRIBUTE Host factors OR COPY Pathobiology Impaired lung growth Accelerated declineNOT Lung injury DO Lung & systemic inflammation MATERIAL- Pathology Small airway disorders or abnormalities Emphysema Systemic effects COPYRIGHTEDAirflow limitation Clinical manifestations Persistent airflow Symptoms limitation Exacerbations Comorbidities WHAT CAUSES COPD? Worldwide, the most commonly encountered risk factor for COPD is tobacco smoking. Other types