Global Initiative For Dr.

Diptta Bhattacharjee
Chronic Obstructive IMO ,medicine dept
Pulmonary Disease. CIMCH
 What's new !
The GOLD report is revised annually and has been used worldwide by healthcare professionals as a tool to implement
effective management programs based on local healthcare systems.

i.Chapter 3 and Chapter 4 have been consolidated into one chapter to reduce repetitive information

ii. Some tables have been consolidated to remove repetition; all table and figure numbers have been changed to
consecutive figure numbers only.

iii. Information about PRISm (preserved ratio but impaired spirometry) has been expanded

iv. In the Spirometry section further clarification about pre-bronchodilator spirometry has been added.

v. The section on Smoking Cessation has been revised

vi. Vaccination Recommendations for people with COPD have been updated in line with current guidance from the US
Centers for Disease Control (CDC).

vii. Managing Inhaled Therapy has been expanded and includes information on a patient’s Ability to use the Delivery
System Correctly and Choice of Inhaler Device

viii. A new section on Pharmacotherapies for Smoking Cessation has been added
DEFINITION:

Chronic obstructive pulmonary disease is a heterogenous lung condition

characterized by chronic respiratory symptoms (dyspnea, cough, sputum
production and/or exacerbations) due to abnormalities of airways (bronchitis ,
bronchiolitis) and/or alveoli (emphysema) that cause persistent, often progressive,
airflow obstruction.
Taxonomy :
DIAGNOSTIC CRITERIA:

The presence of non-fully reversible airflow obstruction

( FEV1/FVC < 0.7 post bronchodilation measured by
spirometry confirm the diagnosis of COPD.
COPD results from gene(G) – environment(E) interaction occurring over the lifetime (T) of the individual that can
damage the lungs and/or alter their normal developmental/ ageing processes.

• Tobacco smoking
• Toxic particles and gases from house
RISK FACTORS INCLUDE: • Outdoor air pollution
• Host factors- abnormal lung development

Accelerated lung ageing • Genetic risk factor – alpha-1 antitrypsin deficiency.

 Some individuals may present with structural lung
lesions ( eg: emphysema ) and or physiological
abnormalities ( including low FEV1 , gas trapping ,
hyperinflation , reduced lung diffusing capacity
and/or rapid FEV1 decline ) without airflow
obstruction ( FEV1 / FVC >= 0.7 post
bronchodilation.

 These subjects are labelled as Pre – COPD .

 The term PRISm ( preserved ratio impaired
spirometry ) implies to those with normal ratio but
abnormal spirometry.
 Pre bronchodilator spirometry can be used as an
initial test to investigate whether symptomatic
patient have air flow obstruction

Post BDR not essential if pre is normal unless

Pre bronchodilator very high clinical suspicion (FEV1/FVC < 0.7

Spirometry
Repeat spirometry at interval

if PRE obstruction, confirm diagnosis

with post BDR
 Clinical indicators:
Dyspnea
Wheezing
Chest tightness
Fatigue
Activity limitations
Cough with or without sputum production
Acute events characterized by increased respiratory
symptoms called exacerbation that influence their
health status and prognosis.
Diagnosis and assessment :
Screening and case finding:

In asymptomatic individuals without any

significant exposures to tobacco or other risk
factors, screening spirometry is probably not
The role of screening by spirometry for the indicated; whereas in those with symptoms or risk
diagnosis of COPD in the general population is factors (e.g., > 20 pack-years of smoking,
controversial. recurrent chest infections, early life events), the
diagnostic yield for COPD is relatively high and
spirometry should be considered as a method for
early case finding.
Initial assessment:

Once the diagnosis of COPD has been confirmed by spirometry , in

order to guide therapy COPD assessment must focus on
determining the following five fundamental aspects:
• Severity of airflow obstruction
• Nature and magnitude of current symptoms
• Previous history of moderate and severe exacerbations
• Blood eosinophil count
• Presence and type of other diseases ( multimorbidity).
Severity assessment tools:

Some assessment tools are used to assess the

severity of COPD symptoms
• mMRC scale
• multidimensional questionnaires like :

CAT assessment

SGRQ- saint George respiratory questionnaire

CRQ- chronic respiratory questionnaire

• Multidimensional questionnaires are most efficient tool to Assess
the severity of symptoms according to guideline.
Additional tests:
 Physiological tests : lung volumes
Dlco ( carbon monoxide diffusing capacity of the lungs)
Oximetry and arterial blood gas measurement
Exercise testing and assessment of physical activity
 Imaging : chest X-ray
Computed tomography
Interstitial lung abnormalities
 Alpha 1 anti-trypsin deficiency
 Composite score
 Biomarkers
 Treatable traits
Prevention and management of COPD.
Smoking
cessation:
Pharmacological treatments for smoking
cessation include controller medications
aimed at achieving long term abstinence
( nortryptilin ,nicotine patch , bupropion
and varenicline) and those that rapidly
relieve acute withdrawal symptoms.
Vaccination recommendation:
Pharmacological management of stable COPD:
Non-pharmacological treatment for stable COPD
PATIENT GROUP ESSENTIAL RECOMMENDED DEPENDING ON
LOCAL GUIDELINES

A Smoking cessation Physical activity Influenza vaccination

(can include COVID-19 vaccination
pharmacological treatment ) Pneumococcal vaccination
Pertussis vaccination
Shingles vaccination
RSV vaccination

B and E Smoking cessation Physical activity Influenza vaccination

(can include COVID-19 vaccination
pharmacological treatment ) Pneumococcal vaccination
Pertussis vaccination
Pulmonary rehabilitation Shingles vaccination
RSV vaccination
Rehabilitation, education and self-management

PULMONARY REHABILITATION:

Assessment and follow-up of pulmonary rehabilitation: Assessment should include:

• Detail history and physical examination
• Measurement of post-bronchodilator spirometry
• Assessment of exercise capacity
• Measurement of health status and impact of breathlessness
• Assessment of inspiratory and expiratory muscle strength and lower limb strength in
patients who suffer from muscle wasting
• Discussion about individual patient goals and expectations .
OXYGEN
THERAPY AND
VENTILATORY
SUPPORT
Oxygen Therapy and Ventilatory Support in Stable COPD:
OXYGEN THERAPY • The long term administration of oxygen Increases survival in patients with severe chronic
resting hypoxemia .

• In patients with stable COPD and Moderate resting or exercise induced arterial
desaturation, prescription of long- term oxygen therapy does not lengthen time to death or
first hospitalization or provide sustained benefit in health status.
• Resting oxygenation at sea level does not exclude the development of severe hypoxemia
during travelling by air .

VENTILATORY SUPPORT NPPV may improve hospitalization free survival in selected patients after recent
hospitalization, particularly in
those with pronounced persistent daytime hypercapnia (PaCO2> 53 mmhg)

In patients with severe chronic hypercapnia and a history of hospitalization for acute
respiratory failure, long term
noninvasive ventilation may be considered.
Long term
oxygen therapy
LTOT is indicated for stable patients who have :

• PaO2 at or below 55 mmHg ( 7.3 kPa ) and 60

mmHg ( 8 kPa) , or SaO2 at or below 88% with or
without hypercapnia confirmed twice over a 3
weeks period.
• PaO2 between 55 mmHg (7.3 kPa) and 60mmHg
(8 kPa) , or SaO2 of 88% if there is evidence of
pulmonary HTN, peripheral odema suggesting
congestive cardiac failure , or polycythemia (HCT
> 55%) .
Therapeutic interventions that
reduce COPD mortality
Pharmacotherapy :

LABA+LAMA+ICS

Non- Pharmacological Therapy:

• Smoking cessation
• Pulmonary rehabilitation
• Long term oxygen therapy(LTOT)
• Non- invasive positive pressure ventilation
(NPPV)
• Lung volume reduction surgery
Bronchodilators in stable COPD
• Inhaled bronchodilators in COPD are central to symptom management and commonly given on a regular basis to prevent
or reduce symptoms .
• Inhaled bronchodilators are recommended over oral bronchodilators .
• Regular and as needed use of SABA or SAMA improves FEV1 and symptoms .
• Combinations of SABA and SAMA are superior compared to either medication alone in improving FEV1 and symptoms.
• LABA and LAMA are preferred over short acting agents except for patients with only occasional dyspnea and for
immediate relief of symptoms in patients already on long -acting bronchodilators for maintenance therapy.
• LABA and LAMA significantly improve lung function , dyspnea , health status , and reduce exacerbation rates .
• LAMAs have a greater evidence of on exacerbation reduction compared with LABAs and decrease hospitalizations.
• When initiating treatment with long -acting bronchodilators the preferred choice is a combination of LABA + LAMA. In
patients with persistence dyspnea on a single long -acting bronchodilator treatment should be escalated to two .
• Combination treatment with a LABA and a LAMA increases FEV1 and reduces symptoms compared to monotherapy .
• Combination treatment with LABA+ LAMA reduces exacerbations compared to monotherapy.
 Anti-inflammatory
therapy in stable
COPD
• Inhaled corticosteroids
• Oral glucocorticoids
• PDE4 inhibitors ( Roflumilast)
• Antibiotics
• Mucoregulators and anti-oxidant agents
• Other anti-inflammatory – statin therapy
 Alpha -1 anti-trypsin augmentation
therapy
Antitussives

Other
Vasodilators
pharmacological
treatments
Opioids

Pulmonary HTN therapy

Interventional and surgical therapies for COPD
SYMPTOMS CHRONIC MUCUS EXACERBATIONS DYSPNEA
PRODUCTION
DISORDERS • Chronic bronchitis • Acute and chronic • Bulla
bronchitis • Emphysema
• Bulla • Tracheobronchomalacia
• Emphysema
• Tracheobronchomalacia

SURGICAL AND • Nitrogen cryospray • Targeted lung denervation • Giant bullectomy

BRONCOSCOPIC • Rheoplasty • Large airways stenting
INTERVENTIONS • EBV
• Coil
• Thermal vapor ablation
• Lung sealants
• LVRS
• Lung transplantation
Management of Exacerbations
Definition:

An exacerbation of COPD is defined as an

event characterized by dypnea and /or cough
and sputum that worsen over less than 14
days. Exacerbations of COPD are often
associated with increased local and systemic
inflammation caused by airway infection ,
pollution, or other insults to the lungs.
Confounders or contributors to be considered in patients presenting
with suspected COPD exacerbations:

MOST FREQUENT : Pneumonia

Pulmonary embolism
Heart failure

LESS FREQUENT: Pneumothorax

Pleural effusion
Myocardial infarction and/or cardiac arrythmias
Indications for Respiratory or Medical
Intensive Care Unit Admission :
Persistent and worsening
Severe dyspnea that hypoxemia ( PaO2 <5.3 kPa
Changes in mental status ( or <40 mmHg and/or
responds inadequately
confusion , lethargy , severe/worsening respiratory
to initial emergency coma). acidosis( pH<7.25) despite
therapy. supplemental oxygen and
noninvasive ventilation.

Hemodynamic
Need for invasive
instability – need for
mechanical ventilation.
vasopressors.
Indications for Noninvasive Mechanical Ventilation
(NIV)
At least one of the following :

• Respiratory acidosis (PaCO2 >=6.0kPa or 45 mmHg and arterial pH

<= 7.35)
• Severe dyspnea with clinical signs suggestive of respiratory muscle
fatigue , increased work of breathing , or both, such as use of
respiratory accessory muscles, paradoxical motion of the abdomen , or
retraction of the intercostal spaces.
• Persistent hypoxemia despite supplemental oxygen therapy.
Indications for Invasive Mechanical Ventilation
Unable to tolerate NIV or NIV failure.

Status post-respiratory or cardiac arrest.

Diminished consciousness , psychomotor agitation inadequately controlled by sedation.

Massive aspiration or persistent vomiting.

Persistent inability to remove respiratory secretions.

Severe hemodynamic instability without response to fluids and vasoactive drugs.

Severe ventricular or supraventricular arrythmias.

Life-threatening hypoxemia in patients unable to tolerate NIV.

COPD and Comorbidities
 COPD AND COMORBIDITIES:

Cardiovascular
Ischaemic heart Peripheral vascular
diseases (CVD) Heart failure Arrythmias Hypertension Lung cancer
disease (IHD) disease

Metabolic
Gastroesophageal Periodontitis and Obstructive sleep
Anemia Osteoporosis
reflux (GERD)
syndrome and
dental hygiene apnea and insomnia
Bronchiectasis
diabetes

Other considerations- consider

Anxiety and Cognitive COPD as part of
Polycythemia Frailty checking for vitamin D
depression impairment multimorbidity
deficiency in COPD patients .
COVID 19 & COPD
 COPD is a common, preventable, and
treatable disease, but extensive under-
diagnosis and misdiagnosis leads to patients
receiving no treatment or incorrect treatment.

Take home Appropriate and earlier diagnosis of COPD

can have a very significant public-health

message. impact.

The realization that environmental factors other than tobacco

smoking can contribute to COPD, that it can start early in life
and affect young individuals, and that there are precursor
conditions (Pre-COPD, PRISm), opens new windows of
opportunity for its prevention, early diagnosis, and prompt
and appropriate therapeutic intervention.
Thank you