Guias GOLD de EPOC

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Guias GOLD de EPOC

  1. 1. Global Initiative for ChronicObstructive CO PYL ung RI GHD isease TE D MA TE RI AL , DO NO TA LT ER OR RE PR OD CEU . GLOBAL STRATEGY FOR THE DIAGNOSIS, MANAGEMENT, AND PREVENTION OFCHRONIC OBSTRUCTIVE PULMONARY DISEASE UPDATED 2008
  2. 2. GLOBAL INITIATIVE FOR CO CHRONIC OBSTRUCTIVE LUNG DISEASE PY GLOBAL STRATEGY FOR THE DIAGNOSIS, MANAGEMENT, AND RIPREVENTION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE GH (UPDATED 2008) TE D MA TE RI AL ,DO NO TA LT ER OR RE PR OD U CE . © 2008 Medical Communications Resources, Inc i
  3. 3. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (UPDATED 2007)GOLD EXECUTIVE COMMITTEE* Observers: Alvaro Cruz, MDRoberto Rodriguez Roisin, MD, Chair (Representing World Health Organization)University of Barcelona Geneva, SwitzerlandBarcelona, Spain CO Mark Woodhead, MDKlaus F. Rabe MD, PhD, Vice-Chair (Representing European Respiratory Society) PYLeiden University Medical Center Manchester Royal InfirmaryLeiden, The Netherlands Manchester England, UK RIAntonio Anzueto, MD GOLD SCIENCE COMMITTEE* GH(Representing American Thoracic Society)University of Texas Health Science Center Peter Calverley, MD, Chair TESan Antonio, Texas, USA University Hospital Aintree Liverpool, England, UK DJean Bourbeau, MDMcGill University Health Centre A. G. Agusti, MD MAMontreal, Quebec, Canada Hospital University Son Dureta Palma de Mallorca, Spain TEPeter Calverley, MDUniversity Hospital Aintree Antonio Anzueto, MD RILiverpool, England, UK University of Texas Health Science Center AL San Antonio, Texas, USAAlejandro Casas, MD ,(Representing Latin American Thoracic Society) Peter J. Barnes, MD DOFundación Neumológica Colombiana National Heart and Lung InstituteBogotá, Colombia SA London, England, UK NOTeresita S. deGuia, MD Marc Decramer, MDPhilippine Heart Center University Hospitals TAQuezon City, Philippines Leuven, BelgiumYoshinosuke Fukuchi, MD Yoshinosuke Fukuchi, MD LT(Representing Asian Pacific Society for Respirology) Tokyo, Japan ERTokyo, Japan Paul Jones, MDDavid S.C. Hui, MD St Georges Hospital Medical School ORThe Chinese University of Hong London, England, UKHong Kong, ROC Fernando Martinez, MD REChristine Jenkins, MD University of Michigan School of MedicineWoolcock Institute of Medical Research Ann Arbor, Michigan, USA PRSydney NSW, Australia Klaus F. Rabe MD, PhD, Vice-Chair ODAli Kocabas, MD Leiden University Medical CenterCukurova University School of Medicine Leiden, The Netherlands UAdana, Turkey Roberto Rodriguez Roisin, MD CEFernando Martinez, MD University of BarcelonaUniversity of Michigan School of Medicine Barcelona, Spain .Ann Arbor, Michigan, USA Jorgen Vestbo, MDChris van Weel, MD Hvidovre University Hospital(Representing the World Organization of Family Doctors) Hvidore, DenmarkUniversity of NijmegenNijmegen, The Netherlands Jan Zielinski, MD Institute of TB and Lung DiseasesJorgen Vestbo, MD Warsaw, PolandHvidovre University HospitalHvidore, Denmark*Disclosure forms for GOLD Committees are posted on the GOLD Website, www.goldcopd.org ii
  4. 4. PREFACEChronic Obstructive Pulmonary Disease (COPD) remains In spite of the achievements since the GOLD report wasa major public health problem. It is the fourth leading originally published, considerable additional work is COcause of chronic morbidity and mortality in the United ahead of all of us if we are to control this major publicStates, and is projected to rank fifth in 2020 in burden health problem. The GOLD initiative will continue to PYof disease caused worldwide, according to a study bring COPD to the attention of governments, publicpublished by the World Bank/World Health Organization. health officials, health care workers, and the general RIFurthermore, although COPD has received increasing public, but a concerted effort by all involved in health GHattention from the medical community in recent years, it care will be necessary.is still relatively unknown or ignored by the public as well TEas public health and government officials. I would like to acknowledge the work of the members of D the GOLD Science Committee who prepared this revisedIn 1998, in an effort to bring more attention to COPD, its report. We look forward to our continued work with MAmanagement, and its prevention, a committed group of interested organizations and the GOLD National Leadersscientists encouraged the US National Heart, Lung, and TE to meet the goals of this initiative.Blood Institute and the World Health Organization to form RIthe Global Initiative for Chronic Obstructive Lung Disease We are most appreciative of the unrestricted educational AL(GOLD). Among the important objectives of GOLD are to grants from Almirall, AstraZeneca, Boehringer Ingelheim,increase awareness of COPD and to help the millions of Chiesi, Dey, Forest Laboratories, GlaxoSmithKline, ,people who suffer from this disease and die prematurely Mitsubishi Tanabe Pharma, Novartis, Nycomed, Pfizer, DOfrom it or its complications. and Schering-Plough that enabled development of this report. NOThe first step in the GOLD program was to prepare aconsensus report, Global Strategy for the Diagnosis, TAManagement, and Prevention of COPD, which waspublished in 2001. The report was written by an Expert LTPanel, which was chaired by Professor Romain Pauwels ERof Belgium and included a distinguished group of health Roberto Rodriguez Roisin, MDprofessionals from the fields of respiratory medicine, Chair, GOLD Executive Committee, 2007 - 2008 ORepidemiology, socioeconomics, public health, and health Professor of Medicineeducation. The Expert Panel reviewed existing COPD Hospital Clínic, Universitat de Barcelona REguidelines and new information on pathogenic mechanisms Villarroel, Barcelona, Spainof COPD, bringing all of this material together in the PRconsensus document. The present, newly revised documentfollows the same format as the original consensus report, ODbut has been updated to reflect the many publications onCOPD that have appeared since 2001. U CESince the original consensus report was published in .2001, a network of international experts known as GOLDNational Leaders has been formed to implement thereports recommendations. Many of these experts haveinitiated investigations of the causes and prevalence ofCOPD in their countries, and developed innovativeapproaches for the dissemination and implementationof COPD management guidelines. We appreciate theenormous amount of work the GOLD National Leadershave done on behalf of their patients with COPD. iii
  5. 5. TABLE OF CONTENTSMethodology and Summary of New 4. Pathology, Pathogenesis, and Pathophysiology . .23Recommendations: 2007 Update . . . . . . . . . . . . . . . .vii Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xii Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 CO Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .241. Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Pathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 PYKey Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 Inflammatory Cells . . . . . . . . . . . . . . . . . . . . . . . . . .25 RIDefinition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 Inflammatory Mediators . . . . . . . . . . . . . . . . . . . . . .25 Oxidative Stress . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 GH Airflow limitation in COPD . . . . . . . . . . . . . . . . . . . . . .2 COPD and Comorbidities . . . . . . . . . . . . . . . . . . . . . .3 Protease-Antiprotease Imbalance . . . . . . . . . . . . . .26 TENatural History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 Differences in Inflammation Between COPD Spirometric Classification of Severity . . . . . . . . . . . . .3 and Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 D Stages of COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 MAScope of the Report . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 Airflow Limitation and Air Trapping . . . . . . . . . . . . . .26 Asthma and COPD . . . . . . . . . . . . . . . . . . . . . . . . . . .5 Gas Exchange Abnormalities . . . . . . . . . . . . . . . . . .26 TE Pulmonary Tuberculosis and COPD . . . . . . . . . . . . . .5 Mucus Hypersecretion . . . . . . . . . . . . . . . . . . . . . . .26 RIReferences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 Pulmonary Hypertension . . . . . . . . . . . . . . . . . . . . .28 Systemic Features . . . . . . . . . . . . . . . . . . . . . . . . . .28 AL2. Burden of COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Exacerbations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 ,Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 DOIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 5. Management of COPD . . . . . . . . . . . . . . . . . . . . . .31 NOPrevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 Morbidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 TA Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Component 1: Assess and Monitor Disease . . . . . .33 Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33 LTEconomic and Social Burden of COPD . . . . . . . . . . . .11 Economic Burden . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Initial Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33 ER Social Burden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Assessment of Symptoms . . . . . . . . . . . . . . . . . . . .33References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Dyspnea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34 OR Cough . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .343. Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 Sputum production . . . . . . . . . . . . . . . . . . . . . . . .34 REKey Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 Wheezing and chest tightness . . . . . . . . . . . . . . .34Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 Additional features in severe disease . . . . . . . . . .35 PRRisk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 Medical History . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 OD Genes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 Physical Examination . . . . . . . . . . . . . . . . . . . . . . . .35 Inhalational Exposures . . . . . . . . . . . . . . . . . . . . . . .17 Inspection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 U Tobacco smoke . . . . . . . . . . . . . . . . . . . . . . . . . . .17 Palpation and percussion . . . . . . . . . . . . . . . . . . .35 CE Occupational dusts and chemicals . . . . . . . . . . . .17 Auscultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 Indoor air pollution . . . . . . . . . . . . . . . . . . . . . . . . .17 Measurement of Airflow Limitation . . . . . . . . . . . . . .36 . Outdoor air pollution . . . . . . . . . . . . . . . . . . . . . . .18 Assessment of COPD Severity . . . . . . . . . . . . . . . . .37 Lung Growth and Development . . . . . . . . . . . . . . . .18 Additional Investigations . . . . . . . . . . . . . . . . . . . . . .37 Oxidative Stress . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 Bronchodilator reversibility testing . . . . . . . . . . . . .37 Gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 Chest X-ray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38 Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 Arterial blood gas measurement . . . . . . . . . . . . . .38 Socioeconomic Status . . . . . . . . . . . . . . . . . . . . . . .18 Alpha-1 antitrypsin deficiency screening . . . . . . . .38 Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . .38 Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 Ongoing Monitoring and Assessment . . . . . . . . . . . . . .39References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 iv
  6. 6. Monitor Disease Progression and Pharmacologic Therapy by Disease Severity . . . . . .54 Development of Complications . . . . . . . . . . . . . . . .40 Other Pharmacologic Treatments . . . . . . . . . . . . . . .55 Pulmonary function . . . . . . . . . . . . . . . . . . . . . .40 Vaccines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55 Arterial blood gas measurement . . . . . . . . . . . .40 Alpha-1 antitrypsin augmentation therapy . . . .55 Assessment of pulmonary hemodynamics . . . .40 Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55 Diagnosis of right heart failure or cor pulmonale . .40 Mucolytic agents . . . . . . . . . . . . . . . . . . . . . . . .55 CT and ventilation-perfusion scanning . . . . . . .40 Antioxidant agents . . . . . . . . . . . . . . . . . . . . . . .55 CO Hematocrit . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40 Immunoregulators . . . . . . . . . . . . . . . . . . . . . . .55 Respiratory muscle function . . . . . . . . . . . . . . .40 Antitussives . . . . . . . . . . . . . . . . . . . . . . . . . . . .55 PY Sleep studies . . . . . . . . . . . . . . . . . . . . . . . . . .40 Vasodilators . . . . . . . . . . . . . . . . . . . . . . . . . . . .55 RI Exercise testing . . . . . . . . . . . . . . . . . . . . . . . . .40 Narcotics (morphine) . . . . . . . . . . . . . . . . . . . . .55 Monitor Pharmacotherapy and Others . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56 GH Other Medical Treatment . . . . . . . . . . . . . . . . . . .40 Non-Pharmacologic Treatment . . . . . . . . . . . . . . . . . . .56 TE Monitor Exacerbation History . . . . . . . . . . . . . . . . .41 Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56 Monitor Comorbidities . . . . . . . . . . . . . . . . . . . . . . .41 Patient selection and program design . . . . . . .56 D Components of pulmonary rehabilitation MAComponent 2: Reduce Risk Factors . . . . . . . . . . . . .42 programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42 Assessment and follow-up . . . . . . . . . . . . . . . .58 TEIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42 Economic cost of rehabilitation programs . . . . .58 RITobacco Smoke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42 Oxygen Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . .58 Smoking Prevention . . . . . . . . . . . . . . . . . . . . . . . . .42 Cost considerations . . . . . . . . . . . . . . . . . . . . .59 AL Smoking Cessation . . . . . . . . . . . . . . . . . . . . . . . . . .43 Oxygen use in air travel . . . . . . . . . . . . . . . . . .59 , The role of health care providers in Ventilatory Support . . . . . . . . . . . . . . . . . . . . . . . . . .60 DO smoking cessation . . . . . . . . . . . . . . . . . . . . .43 Surgical Treatments . . . . . . . . . . . . . . . . . . . . . . . . .60 Counseling . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 Bullectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60 NO Pharmacotherapy . . . . . . . . . . . . . . . . . . . . . . .45 Lung volume reduction surgery . . . . . . . . . . . .60Occupational Exposures . . . . . . . . . . . . . . . . . . . . . . . .45 Lung transplantation . . . . . . . . . . . . . . . . . . . . .60 TAIndoor/Outdoor Air Pollution . . . . . . . . . . . . . . . . . . . . .46 Special Considerations . . . . . . . . . . . . . . . . . . . . . . .61 Regulation of Air Quality . . . . . . . . . . . . . . . . . . . . . .46 Surgery in COPD . . . . . . . . . . . . . . . . . . . . . . .61 LT Steps for Health Care Providers/Patients . . . . . . . . .46 ER Component 4: Manage Exacerbations . . . . . . . . . . .62Component 3: Manage Stable COPD . . . . . . . . . . . .47 Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62 ORKey Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47 Diagnosis and Assessment of Severity . . . . . . . . . . . . .62 REEducation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47 Medical History . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62 Goals and Educational Strategies . . . . . . . . . . . . . .48 Assessment of Severity . . . . . . . . . . . . . . . . . . . . . .63 PR Components of an Education Program . . . . . . . . . .48 Spirometry and PEF . . . . . . . . . . . . . . . . . . . . .63 OD Cost Effectiveness of Education Pulse oximetry/Arterial blood gases . . . . . . . . .63 Programs for COPD Patients . . . . . . . . . . . . . . .49 Chest X-ray and ECG . . . . . . . . . . . . . . . . . . . .63 UPharmacologic Treatment . . . . . . . . . . . . . . . . . . . . . . .49 Other laboratory tests . . . . . . . . . . . . . . . . . . . .63 CE Overview of the Medications . . . . . . . . . . . . . . . . . .49 Differential Diagnoses . . . . . . . . . . . . . . . . . . . . . . .63 Bronchodilators . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 Home Management . . . . . . . . . . . . . . . . . . . . . . . . . . . .64 . ␤2-agonists . . . . . . . . . . . . . . . . . . . . . . . . . . . .51 Bronchodilator Therapy . . . . . . . . . . . . . . . . . . . . . .64 Anticholinergics . . . . . . . . . . . . . . . . . . . . . . . . .52 Glucocorticosteroids . . . . . . . . . . . . . . . . . . . . . . . . .64 Methylxanthines . . . . . . . . . . . . . . . . . . . . . . . .52 Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64 Combination bronchodilator therapy . . . . . . . . .53 Hospital Management . . . . . . . . . . . . . . . . . . . . . . . . . .64 Glucocorticosteroids . . . . . . . . . . . . . . . . . . . . . . . . .53 Emergency Department or Hospital . . . . . . . . . . . . .65 Oral glucocorticosteroids: short-term . . . . . . . .53 Controlled oxygen therapy . . . . . . . . . . . . . . . .65 Oral glucocorticosteroids: long-term . . . . . . . . .53 Bronchodilator therapy . . . . . . . . . . . . . . . . . . .65 Inhaled glucocorticosteroids . . . . . . . . . . . . . . .53 Glucocorticosteroids . . . . . . . . . . . . . . . . . . . . .66 v
  7. 7. Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66 Respiratory Stimulants . . . . . . . . . . . . . . . . . . .67 Ventilatory support . . . . . . . . . . . . . . . . . . . . . .67 Other measures . . . . . . . . . . . . . . . . . . . . . . . .69 Hospital Discharge and Follow-Up . . . . . . . . . . . . . .69References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69 CO6. Translating Guideline Recommendations to the Context of (Primary) Care . . . . . . . . . . . . . . . . . . .85 PYKey Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .86 RIIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .86Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .86 GH Respiratory Symptoms . . . . . . . . . . . . . . . . . . . . . . .86 TE Spirometry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .86Comorbidities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87 DReducing Exposure to Risk Factors . . . . . . . . . . . . . . .87 MAImplementation of COPD Guidelines . . . . . . . . . . . . . .87References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .88 TE RI AL , DO NO TA LT ER OR RE PR OD CE U . vi
  8. 8. METHODOLOGY AND SUMMARY OF NEW RECOMMENDATIONS GLOBAL STRATEGY FOR DIAGNOSIS, MANAGEMENT AND PREVENTION OF COPD: 2008 UPDATE CO PY RIWhen the Global Initiative for Chronic Obstructive Lung offered the opportunity to provide an opinion on anyDisease (GOLD) program was initiated in 1998, a goal abstract. Members evaluated the abstract or, up to GHwas to produce recommendations for management of her/his judgment, the full publication, by answering spe- TECOPD based on the best scientific information available. cific written questions from a short questionnaire, and toThe first report, Global Strategy for Diagnosis, indicate if the scientific data presented impacted on rec- DManagement and Prevention of COPD was issued in ommendations in the GOLD report. If so, the member MA2001 and in 2006 a complete revision was prepared was asked to specifically identify modifications thatbased on research published through June, 2006. These should be made. The entire GOLD Science Committee TEreports, and their companion documents, have been met on a regular basis to discuss each individual publica-widely distributed and translated into many languages tion that was indicated to have an impact on COPD man- RIand can be found on the GOLD website agement and prevention by at least 1 member of the AL(www.goldcopd.org). Committee, and to reach a consensus on the changes in the report. Disagreements were decided by vote. ,The GOLD Science Committee¦ was established in 2002 DOto review published research on COPD management and Summary of Recommendations in the 2008 Update: Between July 1, 2007 and June 30, 2008, 226 articles NOprevention, to evaluate the impact of this research onrecommendations in the GOLD documents related to met the search criteria. Of the 138 reviewed, 27 papers TAmanagement and prevention, and to post yearly updates were identified to have an impact on the GOLD reporton the GOLD website. The first update of the 2006 report that was posted on the website in December 2008 either LTincluded the impact of publications from July 1, 2006 by: 1) confirming, that is, adding or replacing an existingthrough June 30, 2007; this second update includes the reference, or 2) modifying, that is, changing the text or ERimpact of publications from July 1, 2007 through June 30, introducing a concept requiring a new recommendation to2008. the report. The summary (below) is reported in three OR segments: A) Modifications in the text; B) ReferencesMethods: The process to produce this 2008 update that provided confirmation or an update of previous rec- REincluded a Pub Med search using search fields estab- ommendations; and C) Changes to the text for clarifica-lished by the Committee: 1) COPD OR chronic bronchitis tion or to correct errors. PROR emphysema, All Fields, All Adult: 19+ years, only Evidence Reviews: In preparation of GOLD reports, ODitems with abstracts, Clinical Trial, Human; and 2) COPDOR chronic bronchitis OR emphysema AND systematic, including this 2008 update, grading of evidence has been UAll Fields, only items with abstracts, human. Publications completed using four categories as described on page xi. CEin peer review journals not captured by Pub Med could However, new GRADE technology has been described1be submitted to individual members of the Committee and is being widely adopted. Thus, during the 2008 peri- .providing an abstract and the full paper were submitted in od, GOLD has been developing a system to make a tran-(or translated into) English. sition to the GRADE technology to identify key recom- mendations that require more in-depth evaluation, and toAll members of the Committee received a summary of implement the creation and evaluation of evidencecitations and all abstracts. Each abstract was assigned to tables. The 2009 update will begin to reflect this work.two Committee members, although all members were (See section D.)*The Global Strategy for Diagnosis, Management and Prevention of COPD (updated 2008), the Executive Summary (updated 2008), the Pocket Guide(updated 2008) and the complete list of references examined by the Committee are available on the GOLD website www.goldcopd.org.¦Members (2007-2008): P. Calverley, Chair; A. Agusti, A. Anzueto, P. Barnes, M. Decramer, Y. Fukuchi, P. Jones, K. Rabe, R. Rodriguez-Roisin, J.Vestbo, J. Zielinski. vii
  9. 9. A. Modifications in the text: INSPIRE Investigators. The prevention of chronic obstructive pulmonary disease exacerbations by salme-Page 16, Figure 3-1, insert (after Respiratory infections): terol/fluticasone propionate or tiotropium bromide. Am JPrevious tuberculosis Respir Crit Care Med. 2008 Jan 1;177(1):19-26. Epub 2007 Oct 4.Page 18, right column, insert line 11: "In patients withsevere COPD, women, relative to men, exhibit anatomi- Page 55, right column at end of paragraph 1, insert: COcally smaller airway lumens with disproportionately thick- "There is some evidence, however, that in COPD patientser airway walls, and emphysema that is less extensive who have not been treated with inhaled glucocorticos- PYand characterized by smaller hole size and less peripher- teroids, treatment with mucolytics such as carbocisteineal involvement62." may reduce exacerbations426." RIReference 62: Martinez FJ, Curtis JL, Sciurba F, Reference 426: Zheng JP, Kang J, Huang SG, Chen P, GHMumford J, Giardino ND, Weinmann G, Kazerooni E, Yao WZ, Yang L, Bai CX, Wang CZ, Wang C, Chen BY,Murray S, Criner GJ, Sin DD, Hogg J, Ries AL, Han M, Shi Y, Liu CT, Chen P, Li Q, Wang ZS, Huang YJ, Luo ZY, TEFishman AP, Make B, Hoffman EA, Mohsenifar Z, Wise Chen FP, Yuan JZ, Yuan BT, Qian HP, Zhi RC, ZhongR; National Emphysema Treatment Trial Research NS. Effect of carbocisteine on acute exacerbation of DGroup. Sex differences in severe pulmonary emphyse- chronic obstructive pulmonary disease (PEACE Study): a MAma. Am J Respir Crit Care Med 2007 Aug 1;176(3):243- randomised placebo-controlled study. Lancet. 2008 Jun52. Epub 2007 Apr 12. 14;371(9629):2013-8. TE RIPage 18, right column, insert line 28: "A history of tuber- Page 57, right column, line 14, delete "or use of pursedculosis has been found to be associated with airflow lip breathing." At end of sentence add: "There is some ALobstruction in adults older than 40 years63." evidence to suggest that pursed lip breathing may pro- ,Reference 63: Menezes AM, Hallal PC, Perez-Padilla R, vide sustained improvement in exertional dyspnea and DOJardim JR, Muiño A, Lopez MV, Valdivia G, Montes de physical function427."Oca M, Talamo C, Pertuze J, Victora CG; Latin American Reference 427: Nield MA, Soo Hoo GW, Roper JM, NOProject for the Investigation of Obstructive Lung Disease Santiago S. Efficacy of pursed-lips breathing: a breath-(PLATINO) Team. Tuberculosis and airflow obstruction: ing pattern retraining strategy for dyspnea reduction. J TAevidence from the PLATINO study in Latin America. Eur Cardiopulm Rehabil Prev. 2007 Jul-Aug;27(4):237-44.Respir J 2007 Dec;30(6):1180-5. Epub 2007 Sep 5. LT Page 57, right column, line 35, modify to read: "…..of ERPage 52, left column, insert line 25: "Meaningful increas- respiratory muscle weakness242. In contrast, inspiratoryes in lung function can be achieved following administra- muscle training appears to provide additional benefitstion of inhaled anticholinergic plus sympathomimetic when used as part of a comprehensive pulmonary reha- ORbronchodilators even in patients with moderate to severe bilitation program243, 428, 429COPD423. Treatment with long-acting anticholinergic drug Reference 428: Magadle R, McConnell AK, Beckerman REimproves the effectiveness of pulmonary rehabilitation424." M, Weiner P. Inspiratory muscle training in pulmonary PRReference 423: Tashkin DP, Celli B, Decramer M, Liu rehabilitation program in COPD patients. Respir Med.D, Burkhart D, Cassino C, Kesten S. Bronchodilator 2007 Jul;101(7):1500-5. Epub 2007 Feb 27. ODresponsiveness in patients with COPD. Eur Respir J. Reference 429: OBrien K, Geddes EL, Reid WD, Brooks2008 Apr;31(4):742-50. Epub 2008 Feb 6. D, Crowe J. Inspiratory muscle training compared with UReference 424: Kesten S, Casaburi R, Kukafka D, other rehabilitation interventions in chronic obstructive CECooper CB. Improvement in self-reported exercise partic- pulmonary disease: a systematic review update. Jipation with the combination of tiotropium and rehabilita- Cardiopulm Rehabil Prev. 2008 Mar-Apr;28(2):128-41. .tive exercise training in COPD patients. Int J ChronObstruct Pulmon Dis. 2008;3(1):127-36. Page 60, left column, first paragraph, modify last two lines to read: "...strength, or quality of life in COPDPage 53, left column, insert at end of paragraph 1: "In a patients with chronic respiratory failure282, 430."large study, combination therapy compared to tiotropium Reference 430: Kolodziej MA, Jensen L, Rowe B, Sinshowed no difference in exacerbation rate although more D. Systematic review of noninvasive positive pressurepatients randomized to combination treatment completed ventilation in severe stable COPD. Eur Respir J. 2007the study425." Aug;30(2):293-306. Epub 2007 Apr 25.Reference 425: Wedzicha JA, Calverley PM,Seemungal TA, Hagan G, Ansari Z, Stockley RA; viii
  10. 10. Page 60, right column, line 20, delete "In addition" and practitioners with practice nurses in one model had amodify line 22 to read: "… quality of life293, and surgery positive effect on patient compliance12. An integratedreduced the frequency of COPD exacerbations and care intervention including education, coordinationincreased the time to first exacerbation431." among levels of care, and improved accessibility,Reference 431: Washko GR, Fan VS, Ramsey SD, reduced hospital readmissions in chronic obstructive pul-Mohsenifar Z, Martinez F, Make BJ, Sciurba FC, Criner monary disease (COPD) after 1 year13."GJ, Minai O, Decamp MM, Reilly JJ; for the National Reference 12: Meulepas MA, Jacobs JE, Smeenk FW, COEmphysema Treatment Trial Research Group. The effect Smeele I, Lucas AE, Bottema BJ, Grol RP. Effect of anof lung volume reduction surgery on chronic obstructive integrated primary care model on the management of PYpulmonary disease exacerbations. Am J Respir Crit middle-aged and old patients with obstructive lungCare Med. 2008 Jan 15;177(2):164-9. Epub 2007 Oct 25. diseases. Scand J Prim Health Care. 2007 RI Sep;25(3):186-92. GHPage 64, right column, add after references 346, 349, Reference 13: Garcia-Aymerich J, Hernandez C,350. "Therapy with oral prednisolone is preferable432." Alonso A, Casas A, Rodriguez-Roisin R, Anto JM, Roca TEReference 432: de Jong YP, Uil SM, Grotjohan HP, J. Effects of an integrated care intervention on risk fac-Postma DS, Kerstjens HA, van den Berg JW. Oral or IV tors of COPD readmission. Respir Med 2007 Dprednisolone in the treatment of COPD exacerbations: a Jul;101(7):1462-9. Epub 2007 Mar 6. MArandomized, controlled, double-blind study. Chest. 2007Dec;132(6):1741-7. Epub 2007 Jul 23. B. References that provided confirmation or update of TE previous recommendations. RIPage 68, left column, last paragraph after reference 324add: "Despite this, there is evidence that patients who Pg 3: Reference 25. Fan VS, Ramsey SD, Giardino ALmight otherwise survive may be denied admission to ND, Make BJ, Emery CF, Diaz PT, Benditt JO, Mosenifar ,intensive care for intubation because of unwarranted Z, McKenna R Jr, Curtis JL, Fishman AP, Martinez FJ; DOprognostic pessimism434." National Emphysema Treatment Trial (NETT) ResearchReference 434: Wildman MJ, Sanderson C, Groves J, Group. Sex, depression, and risk of hospitalization and NOReeves BC, Ayres J, Harrison D, Young D, Rowan K. mortality in chronic obstructive pulmonary disease. ArchImplications of prognostic pessimism in patients with Intern Med. 2007 Nov 26;167(21):2345-53. TAchronic obstructive pulmonary disease (COPD) or asth-ma admitted to intensive care in the UK within the COPD Pg 46: Reference 421: Harber P, Tashkin DP, Simmons LTand asthma outcome study (CAOS): multicentre observa- M, Crawford L, Hnizdo E, Connett J; Lung Health Study ERtional cohort study. BMJ 2007 Dec 1;335(7630):1132. Group. Effect of occupational exposures on decline ofEpub 2007 Nov 1. lung function in early chronic obstructive pulmonary dis- OR ease. Am J Respir Crit Care Med 2007 NovPage 69, left column, third paragraph, after spirometric 15;176(10):994-1000. Epub 2007 Jul 12.paramaters 355 add: "Prior hospital admission, oral gluco- REcorticosteroids, use of long term oxygen therapy, poor Page 51: Reference 422: Al-Showair RA, Tarsin WY, PRhealth related quality of life, and lack of routine physical Assi KH, Pearson SB, Chrystyn H. Can all patients withactivity have been found to be predictive of readmis- COPD use the correct inhalation flow with all inhalers ODsion435." and does training help? Respir Med. 2007Reference 435: Bahadori K, FitzGerald JM. Risk factors Nov;101(11):2395-401. Epub 2007 Jul 12. Uof hospitalization and readmission of patients with COPD CEexacerbation--systematic review. Int J Chron Obstruct Page 66: Reference 433: Murphy TF, Brauer AL,Pulmon Dis 2007;2(3):241-51. Eschberger K, Lobbins P, Grove L, Cai X, Sethi S. . Pseudomonas aeruginosa in chronic obstructive pul-Page 88, move last paragraph from page 88 to page 87 monary disease. Am J Respir Crit Care Med 2008 Aprand insert (before section on implementation of COPD 15;177(8):853-60. Epub 2008 Jan 17.Guidelines): "Integrative Care in the Management ofCOPD. Evidence is increasing that a chronic diseasemanagement program for COPD patients that incorpo-rates a variety of interventions, includes pulmonary reha-bilitation, and is implemented by primary care reducehospital admissions and bed days11. Combining general ix
  11. 11. C. The committee recommended changes to text:Page 50, Figure 5.3-4: Modification in entry for leval-buterol to include MDI formulation.Page 51, Figure 5.3-5: To clarify the "one or more long-acting bronchodilators" statement in Figure 5.3-7, modify COthe last statement in Figure 5.3-5 to read: "Combiningbronchodilators of different pharmacological classes may PYimprove efficacy and decrease the risk of side effectscompared to increasing the dose of a single bronchodila- RItor." GHPage 58: Line 38: After references 261 and 262, add TEEvidence A DD. Grading Evidence: The GOLD document Global MAStrategy for Diagnosis, Management and Prevention ofCOPD will continue to include background information TEand will eventually include a series of specific recommen- RIdations based on evidence tables1 (included as an ALappendix to the volume and/or on the GOLD website.)The GOLD Science Committee will develop a system to ,identify recommendations that are relatively controversial DOand have a less robust evidence base, to assemble andanalyze the evidence, and to routinely update the evi- NOdence. Three questions that have been identified tobegin the work include: TA1. Should glucocorticosteroid and long-acting beta-ago- LTnist in one inhaler vs inhaled long-acting beta-agonist ERalone be used in patients with moderate or severe chron-ic obstructive pulmonary disease? OR2. Should glucocorticosteroid and long-acting beta-ago-nist in one inhaler vs no treatment be used for moderate REand severe chronic obstructive pulmonary disease?3. Should glucocorticosteroid and long-acting beta-ago- PRnist in one inhaler vs inhaled steroids alone be used inpatients with moderate and severe chronic obstructive ODpulmonary disease? UThe analysis of the data from these questions is under CEreview and will be available in the 2009 update. .REFERENCES1. Guyatt GH, Oxman AD, Kunz R, et al. Going from evi-dence to recommendations. BMJ 2008;336:1049-51. x
  12. 12. GLOBAL STRATEGY FOR THE DIAGNOSIS, MANAGEMENT, AND PREVENTION OF COPD One strategy to help achieve the objectives of GOLD isINTRODUCTION to provide health care workers, health care authorities, and the general public with state-of-the-art information COChronic Obstructive Pulmonary Disease (COPD) is amajor cause of chronic morbidity and mortality throughout about COPD and specific recommendations on the most appropriate management and prevention strategies. PYthe world. Many people suffer from this disease for yearsand die prematurely from it or its complications. COPD is The GOLD report, Global Strategy for the Diagnosis, RIthe fourth leading cause of death in the world1, and further Management, and Prevention of COPD, is based on the best-validated current concepts of COPD pathogenesis GHincreases in its prevalence and mortality can be predictedin the coming decades2. and the available evidence on the most appropriate TE management and prevention strategies. The report,The goals of the Global Initiative for Chronic Obstructive developed by individuals with expertise in COPD research DLung Disease (GOLD) are to increase awareness of and patient care and reviewed by many additional experts, MACOPD and decrease morbidity and mortality from the provides state-of-the-art information about COPD fordisease. GOLD aims to improve prevention and manage- pulmonary specialists and other interested physicians. TEment of COPD through a concerted worldwide effort of The document serves as a source for the production of various communications for other audiences, including RIpeople involved in all facets of health care and health carepolicy, and to encourage an expanded level of research an Executive Summary, a Pocket Guide for Health Care ALinterest in this highly prevalent disease. A nihilistic Professionals, and a Patient Guide2. ,attitude toward COPD continues among some health DOcare providers, due to the relatively limited success of The GOLD report is not intended to be a comprehensiveprimary and secondary prevention (i.e., avoidance of textbook on COPD, but rather to summarize the current state of the field. Each chapter starts with Key Points NOfactors that cause COPD or its progression), the prevailingnotion that COPD is largely a self-inflicted disease, and that crystallize current knowledge. The chapters on the TAdisappointment with available treatment options. Another Burden of COPD and Risk Factors demonstrate the globalimportant goal of the GOLD initiative is to work toward importance of COPD and the various causal factors LTcombating this nihilistic attitude by disseminating information involved. The chapter on Pathology, Pathogenesis, and Pathophysiology documents the current understanding ERabout available treatments (both pharmacologic andnonpharmacologic), and by working with a network of of, and remaining questions about, the mechanism(s) that lead to COPD, as well as the structural and functional ORexperts—the GOLD National Leaders—to implementeffective COPD management programs developed in abnormalities of the lung that are characteristic ofaccordance with local health care practices. the disease. RE A major part of the GOLD report is devoted to the clinical PRTobacco smoking continues to be a major cause ofCOPD, as well as of many other diseases. A worldwide Management of COPD and presents a management plan with four components: (1) Assess and Monitor Disease; ODdecline in tobacco smoking would result in substantialhealth benefits and a decrease in the prevalence of (2) Reduce Risk Factors; (3) Manage Stable COPD; (4) UCOPD and other smoking-related diseases. There is an Manage Exacerbations. CEurgent need for improved strategies to decrease tobaccoconsumption. However, tobacco smoking is not the only Management recommendations are presented according .cause of COPD, and it may not even be the major cause to the severity of the disease, using a simple classificationin some parts of the world. Furthermore, not all smokers of severity to facilitate the practical implementation ofdevelop clinically significant COPD, which suggests the available management options. Where appropriate,that additional factors are involved in determining each information about health education for patients is includ-individuals susceptibility. Thus, investigations of COPD ed. A new chapter at the end of the document will assistrisk factors, ways to reduce exposure to these factors, readers in Translating Guideline Recommendations to theand the molecular and cellular mechanisms involved in Context of (Primary) Care.COPD pathogenesis continue to be important areas ofresearch to develop more effective treatments that slowor halt the course of the disease. xi
  13. 13. A large segment of the worlds population lives in areas All members of the committee received a summary ofwith inadequate medical facilities and meager financial citations and all abstracts. Each abstract was assignedresources, and fixed international guidelines and rigid to two committee members (members were not assignedscientific protocols will not work in many locations. Thus, papers they had authored), although any member wasthe recommendations found in this report must be adapted offered the opportunity to provide an opinion on anyto fit local practices and the availability of health care abstract. Each member evaluated the assigned abstractsresources. As the individuals who participate in the or, where s/he judged necessary, the full publication, by COGOLD program expand their work, every effort will be answering specific written questions from a shortmade to interact with patient and physician groups at questionnaire, and indicating whether the scientific data PYnational, district, and local levels, and in multiple health presented affected recommendations in the GOLD report.care settings, to continuously examine new and innovative If so, the member was asked to specifically identify RIapproaches that will ensure the delivery of the best care modifications that should be made. The GOLD Science GHpossible to COPD patients, and the initiation of programs Committee met on a regular basis to discuss eachfor early detection and prevention of this disease. GOLD individual publication indicated by at least one member of TEis a partner organization in a program launched in March the committee to have an impact on COPD management,2006 by the World Health Organization, the Global and to reach a consensus on the changes needed in the DAlliance Against Chronic Respiratory Diseases (GARD). report. Disagreements were decided by vote. MAThrough the work of the GOLD committees, and incooperation with GARD initiatives, progress toward better The publications that met the search criteria for each TEcare for all patients with COPD should be substantial in yearly update (between 100 and 200 articles per year) RIthe next decade. mainly affected Chapter 5, Management of COPD. Lists AL of the publications considered by the Science CommitteeMETHODOLOGY each year, along with the yearly updated reports, are , posted on the GOLD Website, www.goldcopd.org. DOA. Preparation of yearly updates: Immediately followingthe release of the first GOLD report in 2001, the GOLD B. Preparation of the New 2006 Report: In January NOExecutive Committee appointed a Science Committee, 2005, the GOLD Science Committee initiated its work oncharged with keeping the GOLD documents up-to-date a comprehensively updated version of the GOLD report. TAby reviewing published research, evaluating the impact During a two-day meeting, the committee established thatof this research on the management recommendations the report structure should remain the same as in the LTin the GOLD documents, and posting yearly updates of 2001 document, but that each chapter would be carefully ERthese documents on the GOLD Website. The first update reviewed and modified in accordance with new publishedto the GOLD report was posted in July 2003, based on literature. The committee met in May and Septemberpublications from January 2001 through December 2002. OR 2005 to evaluate progress and to reach consensus on theA second update appeared in July 2004, and a third in messages to be provided in each chapter. Throughout itsJuly 2005, each including the impact of publications from work, the committee made a commitment to develop a REJanuary through December of the previous year. document that would reach a global audience, be based PR on the most current scientific literature, and be as conciseProducing the yearly updates began with a PubMed as possible, while at the same time recognizing that one OD(http://www.nlm.nih.gov) search using search fields of the values of the GOLD report has been to provideestablished by the Science Committee: 1) COPD OR background information on COPD management and the Uchronic bronchitis OR emphysema, All Fields, All Adult, scientific principles on which management recommendations CE19+ years, only items with abstracts, Clinical Trial, are based.Human, sorted by Author; and 2) COPD OR chronic .bronchitis OR emphysema AND systematic, All Fields, In January 2006, the Science Committee met with theAll Adult, 19+ years, only items with abstracts, Human, Executive Committee for a two-day session during whichsorted by Author. In addition, publications in peer- another in-depth evaluation of each chapter was conducted.reviewed journals not captured by PubMed could be sub- At this meeting, members reviewed the literature thatmitted to individual members of the Science Committee, appeared in 2005—using the same criteria developedprovided that an abstract and the full paper were submitted for the update process. The list of 2005 publications thatin (or translated into) English. were considered is posted on the GOLD website. At the January meeting, it was clear that work remaining would xii
  14. 14. permit the report to be finished during the summer of production, normal spirometry) necessarily progress on to2006, and the Science Committee requested that, as Stage I. Nevertheless, the importance of the publicpublications appeared throughout early 2006, they be health message that chronic cough and sputum are notreviewed carefully for their impact on the recommenda- normal is unchanged.tions. At the committees next meeting, in May 2006,publications meeting the search criteria were considered 4. The spirometric classification of severity continues toand incorporated into the current drafts of the chapters recommend use of the fixed ratio, postbronchodilator COwhere appropriate. A final meeting of the committee was FEV1/FVC < 0.7, to define airflow limitation. Using theheld in September 2006, at which time publications that fixed ratio (FEV1/FVC) is particularly problematic in PYappeared prior to July 31, 2006 were considered for their milder patients who are elderly as the normal process ofimpact on the document. aging affects lung volumes. Postbronchodilator reference RI values in this population are urgently needed to avoid GHPeriodically throughout the preparation of this report potential overdiagnosis.(May and September 2005, May and September 2006), TErepresentatives from the GOLD Science Committee met 5. Chapter 2, Burden of COPD, provides references towith the GOLD National Leaders to discuss COPD man- published data from prevalence surveys carried out in a Dagement and issues specific to each of the chapters. number of countries, using standardized methods and MAThe GOLD National Leaders include representatives from including spirometry, to estimate that about 15 to 25%over 50 countries and many participated in these interim of adults aged 40 years and older may have airflow TEdiscussions. In addition, GOLD National Leaders were limitation classified as Stage I: Mild COPD or higher. RIinvited to submit comments on a DRAFT document and Evidence is also provided that the prevalence of COPDtheir comments were considered by the committee. (Stage I: Mild COPD and higher) is appreciably higher in ALWhen the committee completed its work, several other smokers and ex-smokers than in nonsmokers, in those ,individuals were invited to submit comments on the over 40 years than those under 40, and higher in men DOdocument as reviewers. The names of reviewers and than in women. The chapter also provides new data onGOLD National Leaders who submitted comments are COPD morbidity and mortality. NOin the front material. 6. Throughout it is emphasized that cigarette smoke is TANEW ISSUES PRESENTED IN THIS REPORT the most commonly encountered risk factor for COPD and elimination of this risk factor is an important step LT1. Throughout the document, emphasis has been made toward prevention and control of COPD. However, other ERthat COPD is characterized by chronic airflow limitation risk factors for COPD should be taken into account whereand a range of pathological changes in the lung, some possible. These include occupational dusts and ORsignificant extrapulmonary effects, and important chemicals, and indoor air pollution from biomass cookingcomorbidities that may contribute to the severity of the and heating in poorly ventilated dwellings—the latterdisease in individual patients. especially among women in developing countries. RE PR2. In the definition of COPD, the phrase “preventable 7. Chapter 4, Pathology, Pathogenesis, andand treatable” has been incorporated following the Pathophysiology, continues with the theme that inhaled ODATS/ERS recommendations to recognize the need to cigarette smoke and other noxious particles cause lungpresent a positive outlook for patients, to encourage the inflammation, a normal response which appears to be Uhealth care community to take a more active role in amplified in patients who develop COPD. The chapter CEdeveloping programs for COPD prevention, and to has been considerably updated and revised.stimulate effective management programs to treat those .with the disease. 8. Management of COPD continues to be presented in four components: (1) Assess and Monitor Disease; (2)3. The spirometric classification of severity of COPD Reduce Risk Factors; (3) Manage Stable COPD; (4)now includes four stages—Stage I: Mild; Stage II: Manage Exacerbations. All components have beenModerate; Stage III: Severe; Stage IV: Very Severe. A updated based on recently published literature. Throughoutfifth category - “Stage 0: At Risk,” - that appeared in the the document, it is emphasized that the overall approach2001 report is no longer included as a stage of COPD, to managing stable COPD should be individualized toas there is incomplete evidence that the individuals who address symptoms and improve quality of life.meet the definition of “At Risk” (chronic cough and sputum xiii
  15. 15. 9. In Component 4, Manage Exacerbations, a COPD LEVELS OF EVIDENCEexacerbation is defined as: an event in the naturalcourse of the disease characterized by a change in the Levels of evidence are assigned to managementpatients baseline dyspnea, cough, and/or sputum that is recommendations where appropriate in Chapter 5,beyond normal day-to-day variations, is acute in onset, Management of COPD. Evidence levels are indicated inand may warrant a change in regular medication in a boldface type enclosed in parentheses after the relevantpatient with underlying COPD. statement–e.g., (Evidence A). The methodological CO issues concerning the use of evidence from meta-analy-10. It is widely recognized that a wide spectrum of health ses were carefully considered3. PYcare providers are required to assure that COPD isdiagnosed accurately, and that individuals who have This evidence level scheme (Figure A) has been used in RICOPD are treated effectively. The identification of effective previous GOLD reports, and was in use throughout the GHhealth care teams will depend on the local health care preparation of this document. The GOLD Sciencesystem, and much work remains to identify how best to Committee was recently introduced to a new approach to TEbuild these health care teams. A chapter on COPD evidence levels4 and plans to review and consider theimplementation programs and issues for clinical practice possible introduction of this approach in future reports. Dhas been included but it remains a field that requires MAconsiderable attention. TE Figure A. Description of Levels of Evidence RI Evidence AL Sources of Evidence Definition Category , A Randomized controlled Evidence is from endpoints of well-designed RCTs that provide a consistent DO trials (RCTs). Rich body of data. pattern of findings in the population for which the recommendation is made. Category A requires substantial numbers of studies involving substantial numbers of participants. NO B Randomized controlled trials Evidence is from endpoints of intervention studies that include only a limited TA (RCTs). Limited body of data. number of patients, posthoc or subgroup analysis of RCTs, or meta-analysis of RCTs. In general, Category B pertains when few randomized trials exist, LT they are small in size, they were undertaken in a population that differs from the target population of the recommendation, or the results are somewhat ER inconsistent. C Nonrandomized trials. Evidence is from outcomes of uncontrolled or nonrandomized trials or from OR Observational studies. observational studies. D Panel Consensus Judgment. This category is used only in cases where the provision of some guidance RE was deemed valuable but the clinical literature addressing the subject was deemed insufficient to justify placement in one of the other categories. The PR Panel Consensus is based on clinical experience or knowledge that does not meet the above-listed criteria. ODREFERENCES U CE1. World Health Report. Geneva: World Health Organization. Available from URL: http://www.who.int/whr/2000/en/statistics.htm; 2000. .2. Lopez AD, Shibuya K, Rao C, Mathers CD, Hansell AL, Held LS, et al. Chronic obstructive pulmonary disease: current burden and future projections. Eur Respir J 2006;27(2):397-412.3. Jadad AR, Moher M, Browman GP, Booker L, Sigouin C, Fuentes M, et al. Systematic reviews and meta-analyses on treatment of asthma: critical evaluation. BMJ 2000;320(7234):537-40.4. Guyatt G, Vist G, Falck-Ytter Y, Kunz R, Magrini N, Schunemann H. An emerging consensus on grading recommendations? ACP J Club 2006;144(1):A8-9. Available from URL: http://www.evidence-basedmedicine.com. xiv
  16. 16. DEFINITION CHAPTER . U CE 1 OD PR RE OR ER LT TA NO , DO AL RI TE MA D TE GH RI PYCO
  17. 17. CHAPTER 1: DEFINITION Based on current knowledge, a working definition is: KEY POINTS: • Chronic Obstructive Pulmonary Disease (COPD) Chronic Obstructive Pulmonary Disease (COPD) is a is a preventable and treatable disease with some preventable and treatable disease with some significant CO significant extrapulmonary effects that may extrapulmonary effects that may contribute to the contribute to the severity in individual patients. severity in individual patients. Its pulmonary component PY Its pulmonary component is characterized by is characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive RI airflow limitation that is not fully reversible. The airflow limitation is usually progressive and and associated with an abnormal inflammatory response GH associated with an abnormal inflammatory response of the lung to noxious particles or gases. of the lung to noxious particles or gases. TE Worldwide, cigarette smoking is the most commonly encountered risk factor for COPD, although in many D • The chronic airflow limitation characteristic of countries, air pollution resulting from the burning of wood MA COPD is caused by a mixture of small airway and other biomass fuels has also been identified as a COPD risk factor. TE disease (obstructive bronchiolitis) and parenchymal destruction (emphysema), the relative contributions RI of which vary from person to person. Airflow Limitation in COPD AL The chronic airflow limitation characteristic of COPD is , • COPD has a variable natural history and not all caused by a mixture of small airway disease (obstructive DO individuals follow the same course. However, bronchiolitis) and parenchymal destruction (emphysema), COPD is generally a progressive disease, the relative contributions of which vary from person to NO especially if a patients exposure to noxious person (Figure 1-1). Chronic inflammation causes agents continues. structural changes and narrowing of the small airways. TA Destruction of the lung parenchyma, also by inflammatory processes, leads to the loss of alveolar attachments to LT • The impact of COPD on an individual patient the small airways and decreases lung elastic recoil; in ER depends on the severity of symptoms (especially turn, these changes diminish the ability of the airways to breathlessness and decreased exercise capacity), remain open during expiration. Airflow limitation is best OR systemic effects, and any comorbidities the measured by spirometry, as this is the most widely patient may have—not just on the degree of available, reproducible test of lung function. airflow limitation. RE PR Figure 1-1. Mechanisms Underlying AirflowDEFINITION Limitation in COPD ODChronic obstructive pulmonary disease (COPD) is INFLAMMATION Ucharacterized by chronic airflow limitation and a range CEof pathological changes in the lung, some significantextra-pulmonary effects, and important comorbidities .which may contribute to the severity of the disease inindividual patients. Thus, COPD should be regarded as Small airway disease Parenchymal destructiona pulmonary disease, but these significant comorbidities Airway inflammation Loss of alveolar attachments Airway remodeling Decrease of elastic recallmust be taken into account in a comprehensivediagnostic assessment of severity and in determiningappropriate treatment. AIRFLOW LIMITATION2 DEFINITION

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