Gold Guideline for COPD

1. GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE
LUNG DISEASE (GOLD)
2022
. Dr. Sujan Kafle
MD in Emergency Medicine / General Practice
PG Year 1

2. DEFINITION OF COPD

3. • 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 and influenced by host factors including abnormal lung
development.
• Many previous definitions of COPD have emphasized the terms
“emphysema” and “chronic bronchitis”, which are not included in the
definition used in this or earlier GOLD reports

4. Burden of COPD
• The prevalence and burden of COPD are projected to increase over
the coming decades due to continued exposure to COPD risk factors
and aging of the world’s population; as longevity increases more
people will express the long-term effects of exposure to COPD risk
factors

5. FACTORS THAT INFLUENCE DISEASE DEVELOPMENT
AND PROGRESSION

6. • Most well studied COPD risk factor
• Compared to smokers with COPD, never smokers with chronic airflow
limitation have fewer symptoms, milder disease and lower burden of
systemic inflammation.
• Never smokers with chronic airflow limitation do not appear to have an
increased risk of lung cancer, or cardiovascular comorbidities,
compared to those without chronic airflow limitation.
• However, there is evidence that non smokers with COPD have an
increased risk of pneumonia and mortality from respiratory failure
SMOKING
FACTORS THAT INFLUENCE DISEASE DEVELOPMENT AND PROGRESSION

7. GENETICS
• alpha-1 antitrypsin
• A significant familial risk of airflow limitation has been observed in
people who smoke and are siblings of patients with severe COPD,
suggesting that genetics together with environmental factors could
influence this susceptibility.
FACTORS THAT INFLUENCE DISEASE DEVELOPMENT AND PROGRESSION

8. AGE AND SEX
• It is unclear if healthy aging as such leads to COPD or if age reflects
the sum of cumulative exposures throughout life
• Although controversial, some studies have suggested that women
may be more susceptible to the harmful effects of smoking than men,
leading to more severe disease for the equivalent quantity of
cigarettes consumed.
FACTORS THAT INFLUENCE DISEASE DEVELOPMENT AND PROGRESSION

9. LUNG GROWTH AND DEVELOPMENT
• Processes occurring during gestation, birth, and exposures during
childhood and adolescence affect lung growth
• Any factor that affects lung growth during gestation and childhood
has the potential for increasing an individual’s risk of developing
COPD
• Smoking during pregnancy may pose a risk for the fetus, by affecting
lung growth and development in utero, and possibly the priming of
the immune system
FACTORS THAT INFLUENCE DISEASE DEVELOPMENT AND PROGRESSION

10. EARLY COPD
• Biological “early” related to the initial mechanisms that eventually
lead to COPD should be differentiated from a clinical “early”, which
reflects the initial perception of symptoms, functional limitation
and/or structural abnormalities noted.
• Thus, the guidelines propose to use the term “early COPD” only to
discuss “biological early”, when appropriate
FACTORS THAT INFLUENCE DISEASE DEVELOPMENT AND PROGRESSION

11. MILD COPD
• GOLD proposes that “mild” should not be used to identify clinical
“early” COPD.
• Some patients may never suffer “mild” disease in terms of “severity”
of airflow limitation. Further, “mild” disease can occur at any age and
may progress or not over time
FACTORS THAT INFLUENCE DISEASE DEVELOPMENT AND PROGRESSION

12. COPD in young people
• “COPD in young people” for those patients included in the 20–50 year
age range.
• COPD in young people may have a substantial impact on health and is
frequently not diagnosed or treated.
• There may be significant structural and functional lung abnormalities.
• A family history of respiratory diseases and/or early-life events
(including hospitalizations before the age of 5 years) is reported by a
significant proportion of young people with COPD, further supporting
the possibility of early-life origins of COPD
FACTORS THAT INFLUENCE DISEASE DEVELOPMENT AND PROGRESSION

13. Pre-COPD
• This term has been recently proposed to identify individuals
(importantly, of any age) who have respiratory symptoms with or
without detectable structural and/or functional abnormalities, in the
absence of airflow limitation, and who may (or not) develop
persistent airflow limitation (i.e., COPD) over time
FACTORS THAT INFLUENCE DISEASE DEVELOPMENT AND PROGRESSION

14. FACTORS THAT INFLUENCE DISEASE DEVELOPMENT AND PROGRESSION

15. EXPOSURES TO PARTICLES
• Smoking and Environmental Tobacco smoke
• Pesticides
• Sculpters, Gardeners and warehouse workers
• Wood, animal dung, crop residues, and coal, typically burned in open
fires or poorly functioning stoves  Indoor air pollution;
FACTORS THAT INFLUENCE DISEASE DEVELOPMENT AND PROGRESSION

16. ASTHMA AND AIRWAY HYPERACTIVITY
FACTORS THAT INFLUENCE DISEASE DEVELOPMENT AND PROGRESSION
• Some studies suggested Asthma is commonly encountered risk factor
for COPD after smoking
• Airway hyper-responsiveness can exist without a clinical diagnosis of
asthma and has been shown to be an independent predictor of COPD
and respiratory mortality in population studies as well as an indicator
of risk of excess decline in lung function in patients with mild COPD

17. INFECTIONS
FACTORS THAT INFLUENCE DISEASE DEVELOPMENT AND PROGRESSION
• A history of severe childhood respiratory infections has been
associated with reduced lung function and increased respiratory
symptoms in adulthood.
• There is evidence that HIV patients are at increased risk of COPD
compared to HIV negative controls (11 studies; pooled odds ratio for
1.14 (95% CI 1.05,1.25));
• Tuberculosis (TB) has also been identified as a risk factor for COPD (23
studies; pooled odds ratio 2.59 (95% CI 2.12,3.15))
• Tuberculosis is both a differential diagnosis for COPD and a potential
comorbidity

18. PATHOLOGY
Pathological changes characteristic of COPD are found in the airways,
lung parenchyma, and pulmonary vasculature.
• Chronic inflammation,
• Increased numbers of specific inflammatory cell types in different
parts of the lung,
• Structural changes resulting from repeated injury and repair

19. PATHOGENESIS
• Oxidative Stress
• Protease-antiprotease imbalance
• Inflammatory Cells and mediators
• Peribronchiolar and Interstitial Fibrosis
• Telomere Shortening
Accelerated telomere shortening (marker for aging)

20. PATHOPHYSIOLOGY
• Airflow limitation and gas trapping
• Gaseous Exchange abnormalities
• Mucus Hypersecretion
• Pulmonary Hypertension

21. DIAGNOSIS AND INITIAL MANAGMENT

22. DIAGNOSIS AND INITIAL MANAGMENT

23. DIAGNOSIS AND INITIAL MANAGMENT

24. DIAGNOSIS AND INITIAL MANAGMENT

25. DIAGNOSIS AND INITIAL MANAGMENT

26. SPIROMETRY
• Non Invasive
• Reproducible and Objective measurement of airflow limitation
• Spirometry should measure the volume of air forcibly exhaled from
the point of maximal inspiration (forced vital capacity, FVC) and the
volume of air exhaled during the first second of this maneuver (forced
expiratory volume in one second, FEV1), and the ratio of these two
measurements (FEV1/FVC) should be calculated
DIAGNOSIS AND INITIAL MANAGMENT

27. SPIROMETRY
• Simple and independent criterion of FEV1/FVC<0.70
• Lower Limit of Normal  adjusted to age, height and sex
• LLN is used in order to avoid more frequent diagnosis of COPD in
elderly and less frequent among age <45 years especially in cases of
mild COPD.
DIAGNOSIS AND INITIAL MANAGMENT

28. DIAGNOSIS AND INITIAL MANAGMENT

29. CHEST XRAY
• More than to diagnose it is used to exclude alternative diagnosis
• Radiological changes associated with COPD include signs of lung
hyperinflation (flattened diaphragm and an increase in the volume of
the retrosternal air space), hyperlucency of the lungs, and rapid
tapering of the vascular markings
DIAGNOSIS AND INITIAL MANAGMENT

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DIAGNOSIS AND INITIAL MANAGMENT

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DIAGNOSIS AND INITIAL MANAGMENT

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DIAGNOSIS AND INITIAL MANAGMENT

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DIAGNOSIS AND INITIAL MANAGMENT

36. PREVENTION
• Smoking Cessation
• Vaccinations

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64. Thank You