GOLD Update 2011

2. GOLD Update 2011 Rabab A. El Wahsh, MD. Lecturer of Chest Diseases and Tuberculosis Minoufiya University REVISED 2011

3. Global Initiative for chronic obstructive pulmonary disease (GOLD) • Immediately following the release of the first GOLD report in 2001, the GOLD board of directors appointed a science committee, charged with keeping the GOLD documents up to date. • The first update to the GOLD report was in 2003, then annual updated documents were prepared and released on the GOLD website. • A comprehensively updated version was released in 2006, then in 2010 and lastly in 2011.

4. What`s new in GOLD 2011? • The definition of COPD was not significantly modified but has been reworded for clarity. • Assessment of COPD is based on the patient`s level of symptoms, future risk of exacerbations, the severity of spirometric abnormlity, and the identification of comorbidities. • Management of stable COPD is based , not only on level of FEV1 but on disease impact and future risk of disease progression. • More focusing on comorbidities.

5. GOLD 2010 Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases. GOLD 2011 Chronic obstructive pulmonary disease (COPD), a common preventable and treatable disease is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lungto noxious particles or gases. Exacerbations and comorbidities contribute to the overall severity in individual patients. COPD Definition

6. Risk Factors for COPD Genes Infections Socio-economic status Aging Populations

10. Diagnosis and Assessment of COPD GOLD 2010 GOLD 2011

11. Diagnosis and Assessment of COPD • While post-bronchodilator spirometry is required for the diagnosis and assessment of severity of COPD, the degree of reversibility of airflow limitation is no longer recommended. The degree of reversibility has never been shown to add to the diagnosis, differential diagnosis with asthma, or to predicting the response to long-term treatment with bronchodilators or corticosteroids. • The use of a fixed ratio FEV1/FVC to define airflow limitation will result in more frequent diagnosis of COPD in the elderly, and less frequent diagnosis in adults younger than 45 years, especially of mild disease, compared to using a cutoff based on the lower limit of normal values for FEV1/FVC. From a scientific perspective it is difficult to determine which of these criteria is correct to diagnose COPD.

12. Diagnosis of COPD EXPOSURE TO RISK FACTORS SYMPTOMS shortness of breath tobacco chronic cough occupation sputum indoor/outdoor pollution SPIROMETRY: Required to establish diagnosis

13. Assessment of GOLD stage using spirometry (GOLD 2010) In patients with FEV1/FVC < 0.70: GOLD 1: MildFEV1> 80% predicted GOLD 2: Moderate50% < FEV1 < 80% predicted GOLD 3: Severe30% < FEV1 < 50% predicted GOLD 4: Very SevereFEV1 < 30% predicted *Based on Post-Bronchodilator FEV1

14. Combined Assessment of COPD (GOLD 2011) • Assess symptoms • Assess degree of airflow limitation using spirometry • Assess risk of exacerbations • Assess comorbidities

15. Assessment of Symptoms COPD Assessment Test (CAT): An 8-item measure of health status impairment in COPD. Breathlessness Measurement using the Modified British Medical Research Council (mMRC) Questionnaire: relates well to other measures of health statusand predicts future mortality risk.

16. Modified MRC (mMRC)Questionnaire

17. COPD Assessment Test (CAT):

18. Assessment of degree of airflow limitation using spirometry In patients with FEV1/FVC < 0.70: GOLD 1: MildFEV1> 80% predicted GOLD 2: Moderate50% < FEV1 < 80% predicted GOLD 3: Severe30% < FEV1 < 50% predicted GOLD 4: Very SevereFEV1 < 30% predicted *Based on Post-Bronchodilator FEV1

19. Assessment of risk of exacerbations An exacerbation of COPD is defined as an acute event characterized by a worsening of the patient`s respiratory symptoms that is beyond normal day-to-day variations and leads tochange in medication. Two exacerbations or more within the last year or an FEV1 < 50 % of predicted value are indicators of high risk of future exacerbations.

20. Combined Assessment of COPD Patient is now in one of four categories: A: Less symptoms, low risk B: More symtoms, low risk C: Less symptoms, high risk D: More Symtoms, high risk 4 (C) (D) > 2 3 Risk (Exacerbation history) Risk (GOLD Classification of Airflow Limitation) 2 (B) 1 (A) 1 0 mMRC 0-1 CAT < 10 mMRC > 2 CAT >10 Symptoms (mMRC or CAT score))

21. Assessment of COPD Comorbidities COPD patients are at increased risk for: Cardiovascular diseases Osteoporosis Respiratory infections Anxiety and Depression Diabetes Lung cancer These comorbid conditions may influence mortality and hospitalizations and should be looked for routinely, and treated appropriately.

22. Goals for treatment of stable COPD • Reduce symptoms by: • Relieving symptoms • Improving exercise tolerence • Improving health status • Reduce risk by: • Preventing disease progression • Preventing and treatment of exacerbation • Reduction of mortality

23. Management of stable COPD 2010

24. Initial pharmacologic management of COPD (2011)

25. Non-pharmacologic management of COPD (2011)

26. THANK YOU