Báo cáo của Hội nghị khoa học “Bệnh hô hấp”

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COPD Assessment and Treatment

Strategies Based on the Latest

GOLD Guidelines

Steven E. Lommatzsch, M.D.
Pulmonary and Critical Care

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Learning Objectives

 Describe the GOLD recommendations for the
combined assessment of COPD

 Differentiate high risk COPD patients from low risk
patients in your practice

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Background

 In 1998 the Global Initiative for Chronic
Obstructive Lung Disease (GOLD) was
implemented to increase diagnosis and
improve management and prevention of
COPD

 In 2001 GOLD released ‘Global Strategy

for the Diagnosis, Management and 
Prevention of COPD’

 Various updates have taken into account
new concepts and emerging research

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How to Diagnose COPD

 Symptoms

 Shortness of breath

 Chronic cough

 Chronic sputum

 History of exposure to risk factors

 Tobacco smoke

 Home cooking/biomass fuels

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Perform Spirometry

 The diagnosis of COPD relies on the demonstration of
airflow limitation with post bronchodilator FEV1/FVC
< 0.7

 FEV1 = Forced expiratory volume in 1st second
 GOLD severity based on FEV1

GOLD 1 Mild FEV1 ≥ 80% predicted

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Is FEV

1

the Best Marker for Severity

Assessment of COPD?

Jones et al. COPD 2009;6:59-63

Poor Health

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Combined Assessment of COPD

Severity



Assessment of airflow limitation



Assessment of symptoms

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Combined COPD Assessment*
Risk
(GO
LD
 S
ta
ge 
of 
A
irflow
 Li
mi
ta
tion)
Risk
(Exa
c
erba

tion 
hi
st
ory
)
> 2
0-1

(C)

(D)

(A)

(B)

mMRC 0-1
CAT < 10 
4

mMRC > 2
CAT > 10

*Choose the highest risk according to GOLD stage or exacerbation history

___________Symptoms________

50<FEV1<80
30<FEV1<50

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 There are several validated questionnaires available to

assess symptoms

 GOLD recommends:

 Modified British Medical Research Council

Questionnaire (easier to use)

 COPD Assessment Test (broader coverage of impact)

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Assessment of Symptoms

Modified British Medical Research Council Questionnaire 
(MMRC) dyspnea score

0 No shortness of breath except for strenuous exercise

1 Short of breath hurrying on level or walking up a hill

2 Have to stop when walking on level

3 Stop for breath after 100m or few minutes on level
4 Too breathless to leave the house or to perform daily

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Assessment of Symptoms

COPD Assessment test (CAT)

 8 item measure of health

status

 Score 0 -5 
 Impact

 <10 – low

 11-20 – medium
 21-30 – high

 31 - 40 – very high

0 Cough 5

0 Phlegm 5

0 Chest tightness 5
0 Short of breath on hill or

flight of stairs

0 Limitation in home
activities

5
0 Confidence leaving home 5

0 Sleep 5

0 Energy 5

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Assessment of Exacerbation Risk

 Exacerbations increase decline in lung function,

health status and the risk of death.

 Greatest risk factor for future exacerbations is a 
history of previous exacerbations.

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From OLD to New Classification

 The old GOLD system of classification and

treatment made recommendations based only on
the severity of lung dysfunction from spirometry
(GOLD stages I – IV).

 The new GOLD system of classification and

treatment is based on an integrated approach, and
considers all three: spirometry, symptoms, and

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Example: Combined COPD Assessment*
Risk
(GO
LD
 S
ta

ge 
of 
A
irflow
 Li
mi
ta
tion)
Risk
(Exa
c
erba
tion 
hi
st
ory
)
> 2
0-1

(C)

(D)

(A)

(B)

mMRC 0-1
CAT < 10 
4

mMRC > 2

CAT > 10

*Choose the highest risk according to GOLD stage or exacerbation history

___________Symptoms________

50<FEV1<80

30<FEV1<50

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www.goldcopd.org

• Relieve symptoms

• Prevent disease progression
• Improve exercise tolerance
• Improve health status

• Prevent and treat complications
• Prevent and treat exacerbations
• Reduce mortality

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Treatment of Stable COPD

1 - Smoking Cessation

2 - Pharmacologic Treatment

3 - Pulmonary Rehabilitation
4 - Oxygen Therapy

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1 - Smoking Cessation
- Smoking cessation is a key

component to preserving lung
function, and no other therapy
impacts the natural disease
progression more.

- The most proven therapy for
smoking cessation is a

multifaceted approach of support
networks, nicotine replacement,
and agents like bupropion and
varenicline.

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Adapted from Fletcher CM, Peto R. Br Med J. 1977;1:1645
0
20
Age (years)
Death
Disability
Symptoms
Not Susceptible
Susceptible
Smokers

Stopped smoking
at 45 (mild COPD)

Stopped smoking
at 65 (severe COPD)

30 40 50 60 70 80 90
20

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Smoking Cessation Therapy

Varenicline 2mg/day
Buproprion SR

NRT Nasal Spray
NRT Patch

NRT Gum

NRT Patch + Buproprion SR
NRT Patch +Spray

NRT – nicotine replacement therapy

USPHS 2008 meta-analysis

33.2%
24.2%
26.7%
23.4%

19.0%
28.9%
25.8%

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2 - Pharmacologic Treatment

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2 - Pharmacologic Treatment

- The GOLD recommendations are guided
by assessing lung function, symptoms,
and exacerbations.

- Appropriate therapy is dependent upon
each patient’s needs and responses to

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Treatment based on Combined COPD 
Assessment*
Ris
k 
(GO
LD
 Classific
at
ion
 of 
A
irflow
Lim
ita
tion)

Risk
(Exa
ce
rbat
ion
history
)
> 2
0-1

(C)

(D)

(A)

(B)

mMRC 0-1
CAT < 10 
4

mMRC > 2
CAT > 10

*Choose the highest risk according to GOLD stage or exacerbation history

SAMA prn
or

SABA prn

___________Symptoms________

50<FEV1<80
30<FEV1<50

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Category A : Pharmacologic Treatment

- Short acting bronchodilators are integral to
management of symptoms.

- Short acting agents alone are not

recommended for patients with more

sustained daily symptoms or experiencing
more frequent exacerbations.

- Combination therapy results in synergistic

effects.

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Treatment based on Combined COPD 
Assessment*
Ris
k 
(GO
LD
 Classific
at

ion
 of 
A
irflow
Lim
ita
tion)
Risk
(Exa
ce
rbat
ion
history
)
> 2
0-1

(C)

(D)

(A)

(B)

mMRC 0-1
CAT < 10 
4

mMRC > 2
CAT > 10

*Choose the highest risk according to GOLD stage or exacerbation history

SAMA prn
or

SABA prn

___________Symptoms________

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Category B : Pharmacologic Treatment

- Long acting bronchodilators are

recommended for all patients with daily
symptoms.

- They are more effective for symptom relief
than short-acting bronchodilators.

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Treatment based on Combined COPD 
Assessment*
Ris
k 
(GO
LD
 Classific
at
ion
 of

A
irflow
Lim
ita
tion)
Risk
(Exa
ce
rbat
ion
history
)
> 2
0-1

(C)

(D)

(A)

(B)

mMRC 0-1
CAT < 10 
4

mMRC > 2
CAT > 10

*Choose the highest risk according to GOLD stage or exacerbation history

SAMA prn
or

SABA prn

___________Symptoms________

50<FEV1<80
30<FEV1<50

FEV1>80%

FEV1<30% ICS + LABA

and/or

LAMA

LABA

or

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Category C & D : Pharmacologic

Treatment

- These two groups are treated similarly

because of the increased exacerbation risk in
both. Thus, therapy attempts to decrease risk

of exacerbations.

- As the distinguishing feature between C and
D is symptoms, the chosen therapy should be
that which best relieves the patient’s

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Additional Choice – Medical Management

1 - Roflumilast (phosphodiesterase-4 inhibitor) is

approved in chronic bronchitic patients with
frequent exacerbations, and an FEV1 < 50%, to
help decrease the exacerbation rates.

Lancet. 2009 Aug 29;374(9691):685-94

2 - Chronic daily Azithromycin has also been
proven to decrease exacerbation rates.

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Chronic Azithromycin Therapy*

*Albert et al. N Engl J Med. 2011 Aug 25; 365:689-698

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3 - Pulmonary Rehabilitation

- Physical therapy has been underutilized by
providers, and it is one of the most proven
interventions to help with dyspnea.

- Therapy typically consist of exercise training,

education, nutritional interventions, and

psychosocial support.

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n=93

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4 - OxygenTherapy

- Oxygen therapy is the most well established
intervention to afford greater survival to the
COPD patient.

- It is indicated once PaO2 is less than 55 mmHg,
and the goal is keep sats > 88% during rest, sleep,
and exertion.

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Oxygen Improves Survival in COPD
Oxygen Improves Survival in COPD

Flenley DC. Chest 1985:87:99.

Lancet 1981:1:681

NOTT Trial Group. Ann Intern Med

1980:16936:391

NOTT study:

COT – Continuous oxygen (17.7hr)

NOT – Nocturnal oxygen

MRC trial:

O2 – “nocturnal” oxygen (15hr)
Controls – no oxygen

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Mortality in subjects with:
Upper lobe disease and low
exercise capacity

1218 severe COPD patients
Assessment

– CT distribution

– Exercise performance
Randomize

– Surgery

– Medical management
Re-evaluate: 6 months, yearly
Assess

– Survival
– Exercise

Fishman A, et al. N Engl J Med. 2003;348:2059-2073.

Lung Volume Reduction Surgery in Emphysema:
NETT trial

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- The National Emphysema Treatment Trial (NETT )
- Volume Reduction Surgery (LVRS) with upper lobe
predominate emphysema, FEV1 < 45% of predicted, gas
trapping, no significant pulmonary hypertension, and
DLCO and FEV1 values of greater than 20%.

- LVRS improved functional status, physiologic parameters,
and quality of life as compared to the medically managed
group.

- Lung Volume Reduction Surgery was shown to offer

substantial survival to those patients who had low exercise
tolerance post rehabilitation.

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- Lung transplantation is a consideration for those
patients with considerable disability despite maximal
medical therapy.

- Factors Include:

Age < 65 years No cancer in the last 5 years
No Hepatitis B, C, HIV No tobacco in last 6 months
No severe osteoporosis No substances abuse

Reliable support network No major organ dysfunction
BMI in range (<30) No advanced coronary

disease

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Treatment of Comorbidities

- It is important to remember these disorders and
treat accordingly.

- Cardiovascular disease (most common)

- Diabetes (especially with frequent steroid use)
- Lung cancer (close to 10-fold greater in subjects

with severe COPD)
- Osteoporosis

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- Brief Summary of Medical

Management-- Assess symptoms, spirometry, and exacerbation risk to
characterize each patient and individualize therapy.

- Use frequency of exacerbations (> 2/yr) and/or an FEV1 <
50% of predicted to indicate higher risk patients that

should be on combination inhaled steroids/long acting b
-agonist and/or long acting antimuscarinic, or a

combination.

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Báo cáo của Hội nghị khoa học “Bệnh hô hấp”

<b>COPD Assessment and Treatment </b>

<b>Strategies Based on the Latest </b>

<b>GOLD Guidelines</b>

Learning Objectives

Background

How to Diagnose COPD

Perform Spirometry

Is FEV

the Best Marker for Severity

Assessment of COPD?

Combined Assessment of COPD

Severity



Assessment of airflow limitation



<sub>Assessment of symptoms</sub>

<b>(C)</b>

<b><sub>(D)</sub></b>

<b>(A)</b>

<b>(B)</b>

Assessment of Symptoms

Assessment of Symptoms

Assessment of Exacerbation Risk

From OLD to New Classification

<b>(C)</b>

<b><sub>(D)</sub></b>

<b>(A)</b>

<b>(B)</b>

<b>Treatment of Stable COPD</b>

<b>Smoking Cessation Therapy</b>

<b>2 - Pharmacologic Treatment</b>

<b>2 - Pharmacologic Treatment</b>

<b>(C)</b>

<b>(D)</b>

<b>(A)</b>

<b><sub>(B)</sub></b>

<b>Category A : Pharmacologic Treatment</b>

<b>(C)</b>

<b>(D)</b>

<b>(A)</b>

<b><sub>(B)</sub></b>

<b>Category B : Pharmacologic Treatment</b>

<b>(C)</b>

<b>(D)</b>

<b>(A)</b>

<b><sub>(B)</sub></b>

<b>Category C & D : Pharmacologic </b>

<b>Treatment</b>

<b>Additional Choice – Medical Management</b>

Chronic Azithromycin Therapy*

<b>3 - Pulmonary Rehabilitation</b>

<b>4 - OxygenTherapy </b>

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